Leg pain: somatic or psychogenic?

Angiologie Graubünden
Amsler Consulting, Basel

Leg pain: somatic or psychogenic?

by W. Blättler and F. Amsler, Switzerland

The authors’ studies on an eventual psychic cause of venous-type leg symptoms are reviewed. Construction of the nine-item psychic vs somatic venous disease questionnaire (PsySoVDQ) is described. The instrument has been applied to participants of the population-based Bonn Vein Study (BVS) II and found able to group 77.3% of the 962 subjects with symptoms according to the presence of a psychic cause or a somatic cause of the symptoms. The groups showed different demographic and disease-related characteristics. Elevated scores in the psychic component (PC) were correlated with the absence of true venous disease. Elevated scores in the somatic component (SC) showed high sensitivity and specificity for true venous disease. The PsySoVDQ clearly recognizes the particularities of subjects with a somatic and a psychic condition behind their symptoms. However, it has a limited discriminatory power. This is due to the fact that subjects with an emotional or psychic problem use the same expressions for their feelings as those with clear organic venous disease. This is an inalterable phenomenon implying that questionnaires may not be appropriate tools to assess feelings.

Medicographia. 2015;37:26-31 (see French abstract on page 31)

Data of studies on symptoms of leg swelling, heaviness, tension, and pain

The hallmark of venous-type leg symptoms are feelings of swelling and heaviness, and poorly located pain that is difficult to explain. In addition, a wide spectrum of individual complaints are brought up by afflicted persons.1-4 The various symptoms show a high inter-item consistency and a strong correlation of each with the core symptoms.5 The symptoms are poorly associated with venous disease severity and clearly have a good prognosis. This is discordant with the impaired quality of life readily observed in individual patients and documented in many observational studies.

We studied the many aspects of the disorder in four cohorts: (i) patients who consulted because of symptoms, with no objective signs and laboratory findings of venous or any other disease; (ii) healthy persons at a presumed elevated risk of becoming symptomatic because of their occupation; (iii) healthy subjects who served as controls in a study on normal anatomy of veins; and (iv) subjects from the general population.

Figure 1
Figure 1. Medical compression stockings and lower limb symptoms.

(A) Pain and feeling of leg swelling and (B) change of lower leg volumeduring
the period of awaiting the designated use of low-strength medical compression
stockings (in dotted lines) and during the period of wearing them (in plain lines).
Data of a crossover trial in hairdressers.
Adapted from reference 5: Blazek C et al. Phlebology. 2013;28(5):239-247.
© 2013, SAGE Publications.

Figure 2
Figure 2. Correlating symptoms and disease.

Feelings of leg swelling and heaviness in healthy volunteers with a fear of developing
varicose veins (bar 3); with reflux in the great saphenous vein (GSV) unknown
at the time of the study (bar 2); with both features (bar 4); with neither
feature (bar 1); and in patients with GSV varicose disease (bar 5).
Abbreviation: SD, standard deviation.
Adapted from reference 10: Blättler W et al. Phlebology. 2013;28(7):347-352.
© 2013, SAGE Publications.

♦ Symptoms only
In-depth psychiatric work-up of patients showed a high incidence of feelings of heaviness of legs, tiredness, and sleeplessness (73%, 88%, and 65%, respectively) and no other somatic symptoms of above normal prevalence or intensity. The “psychic syndrome” featured hypochondria, anxiety, disturbance of vital feelings (85%, 77%, and 73%, respectively) and depression (84% overall, 42% severe depression). Psychiatric analysis revealed a low self-esteem, high dependence on the opinion of others, a wish to run away, and the inability to attribute to the legs their libidinous role, among others.6-9

We conclude that leg symptoms can be associated with characteristic and comprehensible psychiatric symptoms and frank depression.

♦ At-risk population
The most interesting finding gathered from persons at risk of developing venous leg symptoms was the response to wearing light compression stockings for three weeks in a randomized crossover trial.5 The stockings not only reduced feelings of heaviness and pain in the legs, but also reduced sleep disturbance, depression, and the feeling of having unattractive legs. This improvement was accompanied by a reduction of lower-leg volume (Figure 1).5 We also found that both the psychic and somatic end points were improved at the end of the period during which the persons were not wearing compression stockings, but were looking forward to using them. The phenomenon was understood as a Hawthorne effect. The term labels the pervasive phenomenon that any promise of change for the better results in feelings of hope and faith, and thereby leads to an improvement in the symptoms.

We conclude that leg symptoms are related to leg volume and can be prevented with light leg compression. The expectation of such treatment already exerts a positive effect on both somatic and psychic phenomena.

♦ Healthy controls
The examination of healthy volunteers participating in a population- based cross-sectional study on normal vein anatomy revealed that leg symptoms were equally prevalent in subjects with fears of one day developing varicose veins, in subjects with a refluxing great saphenous vein that was only uncovered during the study, and in patients who consulted a vein clinic for overt venous disease (Figure 2).10

We conclude that leg symptoms of similar intensity can be caused by specific fears, the presence of a previously unknown and clinically undetectable varicose great saphenous vein, and a varicose disorder for which treatment is deemed necessary.

♦ General population
♦ The psychic vs somatic venous disease questionnaire (PsySoVDQ)
Based on both our psychometric and psychoanalytical data6-9 and in due consideration of the literature, we worked out a comprehensive questionnaire (62 items) and used it in a previous study.5 A version shortened to 12 items was applied to participants in the Bonn Vein Study (BVS) II,11 the follow up of the BVS I.12 Finally, a nine-item questionnaire was constructed with the data gathered in this large population-based study. The statistical methods applied were a factor analysis of principal components with varimax® rotation and Cronbach α calculation to assess inter-item consistency. This version was labeled the PsySoVDQ and used to distinguish between a psychic and a somatic cause of the symptoms on the basis of symptoms alone (Table I).11 The BVS symptom score, used for comparison, took the presence of signs into account.

The PsySoVDQ was administered to 1 800 subjects of which 962 (53.4%) had an elevated BVS symptom score and 1 111 (61.7%) had an elevated PsySoVDQ score. The psychic component (PC) score alone was elevated in 437 subjects (24.3%) and not correlated with an elevated BVS symptom score. Subjects with CEAP (clinical, etiological, anatomical, pathophysiological) class C0 or C1 showed higher PC scores than those with C2 or C3; indeed, an elevated PC score showed a negative predictive value for the presence of C2 or C3 disease (P<0.001). The somatic component (SC) score alone was elevated in 395 subjects (21.9%). It showed the same predictive value for the presence of C2 or C3 as the BVS symptom score (receiver operating characteristic [ROC] analysis, area under the curve 0.604 and 0.627 respectively, both P<0.001). Elevation of the SC score did not depend on the presence of varices, but on the presence of edema (P<0.001). The use of the questionnaire as an algorithm to identify the cause of the symptoms was reasonably limited in subjects who experienced symptoms in the recent past (Figure 3).11 Of the 607 subjects with an elevated SC score, 59% had a normal PC score, while 41% had an elevated PC score at the same time. The concomitant increase of the PC score reduced the likelihood of a somatic origin (C2/C3) of the symptoms from 58% to 45%. Of the 355 subjects with a normal SC score, 39% had an elevated PCscore. Thus, 58% had a psychic origin of their symptoms, while 42% had a somatic origin. In the subjects with normal SC and PC scores, the origin of the symptoms remained unexplained in 61% and were attributed to a somatic condition in 39%.

The personal and disease-specific data of subjects scoring high on either component of the PsySoVDQ differed significantly from the data obtained from asymptomatic study participants and formed two distinct groups (Table II).11 The typical interviewees with an elevated PC score were younger, slim women, with a higher education and social status, who felt that their general health was jeopardized and that their psychic quality of life reduced. The symptoms were of the same type as those reported by the subjects scoring high in the SC, but were much less intense.

Table I
Table I. Items
of the psychic
component (PC)
and somatic
component (SC)
of the PsySoVDQ.

Factor analysis with
varimax rotation
Abbreviations: SD,
standard deviation;
PsySoVDQ, psychic
vs somatic venous
disease questionnaire.
Adapted from reference
: Amsler et al.
Eur J Vasc Endovasc
Surg. 2013;46(2):255-
262. © 2013, European
Society for
Vascular Surgery.
Published by Elsevier
Ltd. All Rights

Figure 3
Figure 3. Use of the PsySoVDQ as an
algorithm to explain the cause of symptoms
in participants of the Bonn Vein
Study (BVS) II.

Use: Symptomatic subjects, consider somatic
component (SC) first and consider psychic component
(PC) second. Interpretation: SC+/PC+, no
separation of the two components possible (the
SC is less strong); SC+/PC-, elevation of the SC
score with no elevation of the PC score speaks
for the presence of an organic venous condition;
SC-/PC+, elevation of the PC score with no elevation
of the SC score speaks for the presence of a
psychic condition; SC-/PC-, normal values of both
components mean that the PsySoVDQ cannot identify
the cause of the symptoms in these subjects.
Some subjects have asymptomatic C2/C3 disease.
Abbreviation: PsySoVDQ, psychic vs somatic venous
disease questionnaire.
Adapted from reference 11: Amsler et al. Eur J
Vasc Endovasc Surg. 2013;46(2):255-262.
© 2013, European Society for Vascular Surgery.
Published by Elsevier Ltd. All Rights Reserved.

Table II. Univariate correlations of the psychic component (PC)and
somatic component (SC) with personal and disease-related findings
(n=1800). *P<0.05; **P<0.01; ***P<0.001; ****P<0.0001.

Abbreviations: BMI, body mass index; BVS, Bonn Vein Study; CEAP, clinical,
etiological, anatomical, pathophysiological; CIVIQ, ChronIc Venous Insufficiency
Questionnaire; ns, nonsignificant; PsySoVDQ, psychic vs somatic venous disease
questionnaire; VCSS, Venous Clinical Severity Score.
Adapted from reference 11: Amsler et al. Eur J Vasc Endovasc Surg. 2013;46(2):
255-262. © 2013, European Society for Vascular Surgery. Published by Elsevier
Ltd. All Rights Reserved.

We conclude that the PC of the PsySoVDQ identified subjects with the psychiatric syndrome, as described in the previous studies. Thus, this particular dysfunction is present subconsciously in some healthy subjects with venous-type leg symptoms. The SC identified the subjects with C2/C3 disease aswell as the comprehensive BVS questionnaire administered separately and serving for comparison. However, the discriminatory power of the two components is low, as many subjects had both an elevated PC and SC (858 of 962; 89%). As will be discussed below, many subjects take certain notice of phenomena going on in their peripheral veins. The intensity of the bodily signal depends on the shape of the venous system and its environment, while the intensity of the mental reaction depends on momentary emotions and the individual’s psychic condition. The PsySoVDQ covers the two extremes of this continuum. Other questionnaires will undoubtedly encounter the same facts.

The PsySoVDQ was administered to the whole BVS cohort, and not only to the symptomatic participants. Under this condition, its potential to diagnose a venous disorder with a psychic or somatic origin was found to be very low. We conclude that the PsySoVDQ is of no use to assess a cohort that includes asymptomatic patients.

A hypothesis on the origins of symptoms of leg swelling and heaviness

Venous leg symptoms investigated in multiple studies worldwide and in all imaginable situations turned out to be the same everywhere, and merit the label of a somatoform or functional disorder as they are capable of affecting the subjects’ self. Often dismissed as “just feelings,” the symptoms mimic true venous disease, but remain medically unexplained in manycases.13,14 Feelings are the highest manifestation of the homeostatic control, clearly a mental endeavor providing awareness of something potentially noxious threatening the body from inside or out.15 A hypothesis shall be set forth on how venous function is connected with the emergence of feelings. Involved in the process are the venous circulation, where the bodily signal is produced, the peripheral nervous system, which carries the message, and the central nervous system, which modifies the information on its way to the insular cortex, from where the feelings are expressed.

Figure 4
Figure 4.
Sketch of
the hypothesis
of how a
volume overload
of veins
may cause
feelings of
swelling and

In a resting person, venous return stagnates because of inactivity of the muscle pump. Although arterial inflow is reduced simultaneously because of low demand, increase of blood volume in the legs inevitably occurs. Standing immobile after rising from the supine or sitting position leads to an increase of leg volume by an average of 30 mL within a few seconds16 and by about 150 mL, or 2.5%, within 9 minutes (Figure 3).11,17,18 The rapid and readily reversible volume load is attributed to dilatation of veins rather than to fluid extravasation.19 Vein distension or wall stretch can activate vegetative sensory nerves (unmyelinated C fibers, sympathetic nerve fibers) whose endings are located within the vein wall.20 Prolonged venous stasis can activate leukocytes, which release nociceptive substances.21 Chronic venous hypertension will occur when the venous capacity reaches its limits regularly or permanently. These phenomena are associated with feelings of discomfort illustrating the fact that the information is transported to the central nervous system. On their way to the brain, bodily signals are subject to continuous modification by interoperception, until they ultimately arrive at the specific somatosensory areas of the brain cortex that are mainly located in the insula.15,23 The primarily unconscious process is subject to much interference from other sources as well (exteroperception) and to comparisons with the body image created by somatoperception. Interference can bring about defensive reactions, from repetitive leg movements to polite excuses like “I have to move my legs for a moment.” Reasons for (mis)perceptions contributing to negative feelings can be either amplified bodily signals (as in physical deconditioning) or decreased filter activity (as in anxiety and depressive moods). Feelings conveyed with words like heaviness and tension, rightly put emphasis on the somatic origin of the problem, and not on their aggravating modification by emotions and psychic conditions. In some cases, however, patients may well use expressions that allow one to elucidate the autobiographic context of their complaints (such as the feeling to have to run away). The hypothetical concept of venoneuronal coupling is depicted in Figure 4.

Recognition of the venoneuronal coupling has therapeutic implications

Feelings of venous origin are empathized if they are reported in association with a visible venous pathology. If no somatic problem can be identified, the model of venoneuronal coupling can offer an explanation that even low-strength signals from the peripheral venous system can be perceived as noxious and described with appropriate terms. Using a colloquial expression, one could say that these persons “hear the grass grow.” Successful therapeutic intervention with this oversensitivity requires an in-depth diagnosis, which includes both a venous workup and the search for the presence of a psychic problem. Treatment with light compression stockings allevi- ates the symptoms reliably by reducing the venous distension and/or by direct action on the afferent nerves that control the input from the venous milieu. Empathy of the consulted person toward the symptomatic subject plays an important role. The fact that anticipation of a benefit can give relief already shows that changing emotions (eg, from fears to hope) can be a worthwhile strategy. Never again, should a symptomatic patient be dismissed with the information “nothing is wrong, just feelings!” Prescribing compression stockings or a venotropic drug should be accompanied with good words. As demonstrated, the Hawthorne effect adds to the effect of the prescribed treatment. Clearly, neither the nature of the venous signal is sufficiently understood nor is the neuropsychological interpretation backed by hard facts. The hypothesis is a clarion call for the cooperation of two sciences that have not knowingly interacted so far. Awaiting results, we are left with the modest message of this review, which lays emphasis on the complexity of the intrinsically coherent venous leg symptoms that may herald a severe psychiatric condition or a yet to be diagnosed venous disorder, but in many cases will remain medically unexplained. Acceptation of the fact that feelings originating in the body are meaningful, and should help to ward off misunderstandings of the cause of the symptoms and overestimations of the efficacy of interventions on veins.

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Keywords: chronic venous disease; chronic venous disorder; PsySoVDQ; venoneuronal coupling; venous symptom