The body speaks its mind: The BodyMind Approach® for patients with medically unexplained symptoms in primary care in England

Stress, subjective wellbeing and self-knowledge in higher education teachers: A pilot study through bodyfulness approaches

Work-related stress is a major cause of health problems worldwide. Faculty in educational institutions, including universities, also face high levels of stress, which undoubtedly affects their performance, level of personal satisfaction and wellbeing, and the relationship with students. Training interventions based on embodied learning can promote self-knowledge, emotional regulation and stress reduction, thereby increasing levels of psychological well-being. The present pilot study analyzed the impact of body awareness training in 31 university teachers using a controlled, randomized pre-post experimental design, with two experimental groups and a control group (n = 10). The two interventions were: Hatha Yoga (n = 11) and Dance Movement Therapy/Body Mind Centering (n = 10), which we have termed Body Movement Awareness. Variables related to body awareness, mindfulness, wellbeing, life satisfaction and stress were measured using self-perception tests. Cortisol levels, heart rate variability and sleep quality were also analyzed. Finally, participants' reflections were analyzed according to a qualitative approach. The results showed significant differences between the control group and the Hatha Yoga group in terms of stress reduction and wellbeing. The Body Movement Awareness group exhibited evidence of contributions on self-knowledge, communication and kinesthetic empathy, key elements in the educational field. Despite the inherent limitations of the study, the conclusions are encouraging and open new lines of research from embodied approaches that introduce creative movement and group experience as part of the process of emotional regulation and self-knowledge.

Embodied Learning for Well-Being, Self-Awareness, and Stress Regulation: A Randomized Trial with Engineering Students Using a Mixed-Method Approach

The continuous changes in our society require adapted training that encompasses both technical and competency knowledge. There is a high level of demand, especially in areas such as engineering, which can affect the mental health of students, producing high levels of stress and psychological distress, hindering self-efficacy and academic performance. Embodied learning working on self-awareness, stress reduction and self-knowledge can help to generate healthier environments. Creative therapies can be a tool to promote the prevention of health problems in this group of the population. In particular, Dance Movement Therapy has demonstrated its effectiveness in improving health in clinical and non-clinical settings. In this work, a body awareness program based on Dance Movement Therapy is developed and implemented in engineering students. Through a mixed pre-post methodology, its impact is evaluated and analyzed in an experimental group of engineering students. Psychometric tests, physiological variables and reflective diaries are used as data sources. The results show that the experimental group, compared with the control group, increased their levels of body awareness and connectedness, well-being and life satisfaction and reduced their stress levels. The results were supported by cortisol measures. Likewise, the students acknowledged having increased their levels of self-awareness and self-knowledge and considered the inclusion of these bodily approaches in higher education to be necessary.

The acceptability of primary care or community-based behavioural interventions for persistent physical symptoms: Qualitative systematic review

PURPOSE

Persistent physical symptoms (PPS) are often associated with profound physical disability and psychological distress. Interventions for PPS that promote behavioural change aim to reduce levels of symptoms and improve overall functioning in patients. The evidence for these interventions is mixed, with effective relationships between patients and health practitioners (HPs) reported as the key to the success of primary care interventions. The objectives of this systematic review were to synthesize the qualitative evidence and to evaluate the acceptability of behavioural interventions for PPS in primary care, from the perspective of both patients and HPs.

METHODS

A comprehensive literature search was conducted in seven major electronic bibliographic databases, to February 2019. The aim was to identify a broad range of literature including, qualitative research, mixed methods research, and qualitative data embedded in trial reports or process evaluations. Fifty-eight full papers were screened against the inclusion criteria. Nine studies were included and quality-assessed. A qualitative evidence synthesis was conducted using thematic synthesis.

RESULTS

Some patients and HPs reported positive gains from taking part in or delivering interventions, with appropriate support and explanation of their symptoms important for patients. Barriers appeared to be underpinned by the relationship between the patients and HPs, and by beliefs and attitudes held by both parties.

CONCLUSIONS

Patients should be provided with adequate information to make an informed decision about whether an intervention is appropriate for them, and interventions should not end suddenly or without adequate follow-up. HPs should receive training and supervision to address their lack of confidence, and improve their knowledge of PPS.

Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation

BACKGROUND

The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms.

OBJECTIVES

An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis.

DATA SOURCES

Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019.

PARTICIPANTS

Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes.

INTERVENTIONS

Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes.

RESULTS

Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000.

LIMITATIONS

Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points.

CONCLUSIONS

Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study).

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015025520.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.

Medically Unexplained Symptoms and Attachment Theory: The BodyMind Approach®

This article discusses how The BodyMind Approach^® (TBMA) addresses insecure attachment styles in medically unexplained symptoms (MUS). Insecure attachment styles are associated with adverse childhood experiences (ACEs) and MUS (Adshead and Guthrie, 2015) and affect sufferers’ capacity to self-manage. The article goes on to make a new hypothesis to account for TBMA’s effectiveness (Payne and Brooks, 2017), that is, it addresses insecure attachment styles, which may be present in some MUS sufferers, leading to their capacity to self-manage. Three insecure attachment styles (dismissive, pre-occupied and fearful) associated with MUS are discussed. TBMA is described and explanations provided of how TBMA has been specifically designed to support people’s insecure attachment styles. Three key concepts to support insecure attachment styles involved in the content of TBMA are identified and debated: (a) emotional regulation; (b) safety; and (c) bodymindfulness. There is a rationale for the design of TBMA as opposed to psychological interventions for this population. The programme’s structure, facilitation and content, takes account of the three insecure attachment styles above. Examples of how TBMA works with their specific characteristics are presented. TBMA has been tested and found to be effective during delivery in the United Kingdom National Health Service (NHS). Improved self-management has potential to reduce costs for the NHS and in General Practitioner time and resources.

Explanation of somatic symptoms by mental health and personality traits: application of Bayesian regularized quantile regression in a large population study

BACKGROUND

Somatic syndrome is one of the remarkably prevalent issues in primary health care and subspecialty settings. We aimed to elucidate multidimensional associations between somatic symptoms with major mental problems and personality traits in the framework of the quantile regression model with a Bayesian approach.

METHODS

A total of 4763 employees at Isfahan University of Medical Sciences and Health Services in Isfahan province, Iran, filled out four validated questionnaires including Hospital Anxiety and Depression Scale (HADS), NEO Questionnaire, General Health Questionnaire (GHQ) and PHQ-15 for somatic symptom severity. In addition, Functional Gastrointestinal Disorders (FGIDs) were determined using Rome IV criteria. Exploratory Factor Analysis (EFA) and Bayesian regularized quantile regression with adaptive LASSO penalization were applied for reduced dimension of somatic symptoms and variable selection and parameter estimation, respectively.

RESULTS

The 25 major somatic symptoms were grouped into four factors including general, upper gastrointestinal, lower gastrointestinal and respiratory by EFA. Stress, depression, and anxiety had significant effects on all of the four extracted factors. The effect of anxiety in each four extracted factors was more than stress and depression. Neuroticism and agreeableness had significant effects on all of the four extracted factors, generally (p < 0.05).

CONCLUSIONS

Given the high prevalence of somatic symptoms and psychosomatic complaints in correlation with the diverse range of mental co-morbidities, developing more detailed diagnostic tools and methods is crucial; nonetheless, it seems that providing better interdisciplinary approaches in general medical practice is groundwork.

Different Strokes for Different Folks: The BodyMind Approach as a Learning Tool for Patients With Medically Unexplained Symptoms to Self-Manage

Medically unexplained symptoms (MUS) are common and costly in both primary and secondary health care. It is gradually being acknowledged that there needs to be a variety of interventions for patients with MUS to meet the needs of different groups of patients with such chronic long-term symptoms. The proposed intervention described herewith is called The BodyMind Approach (TBMA) and promotes learning for self-management through establishing a dynamic and continuous process of emotional self-regulation. The problem is the mismatch between the patient's mind-set and profile and current interventions. This theoretical article, based on practice-based evidence, takes forward the idea that different approaches (other than cognitive behavioural therapy) are required for people with MUS. The mind-set and characteristics of patients with MUS are reflected upon to shape the rationale and design of this novel approach. Improving services for this population in primary care is crucial to prevent the iterative spiraling downward of frequent general practitioner (GP) visits, hospital appointments, and accident and emergency attendance (A&E), all of which are common for these patients. The approach derives from embodied psychotherapy (authentic movement in dance movement psychotherapy) and adult models of learning for self-management. It has been developed from research and practice-based evidence. In this article the problem of MUS in primary care is introduced and the importance of the reluctance of patients to accept a psychological/mental health referral in the first instance is drawn out. A description of the theoretical underpinnings and philosophy of the proposed alternative to current interventions is then presented related to the design, delivery, facilitation, and educational content of the program. The unique intervention is also described to give the reader a flavor.

Moving on: the BodyMind ApproachTM for medically unexplained symptoms

Purpose

The purpose of this paper is to summarise practice-based evidence from an analysis of outcomes from a county-wide pilot study of a specialised primary care clinic employing an original approach for patients with medically unexplained symptoms (MUS). Conditions with persistent bodily symptoms for which tests and scans come back negative are termed MUS. Patients are generic, high health-utilising and for most there is no effective current treatment pathway. The solution is a proven service based on proof of concept, cost-effectiveness and market research studies together with practice-based evidence from early adopters. The research was transferred from a university into a real-world primary care clinical service which has been delivering in two clinical commissioning groups in a large county in England.

Design/methodology/approach

Clinical data calculated as reliable change from the various clinics were aggregated as practice-based evidence pre- and post-intervention via standardised measurements on anxiety, depression, symptom distress, functioning/activity, and wellbeing. It is not a research paper.

Findings

At post-course the following percentages of people report reliable improvement when compared to pre-course: reductions in symptom distress 63 per cent (39/62), anxiety 42 per cent (13/31) and depression 35 per cent (11/31); increases in activity levels 58 per cent (18/31) and wellbeing 55 per cent (17/31) and 70 per cent felt that they had enough help to go forward resulting in the self-management of their symptoms which decreases the need to visit the GP or hospital.

Research limitations/implications

Without a full clinical trial the outcomes must be interpreted with caution. There may be a possible Hawthorne or observer effect.

Practical implications

Despite the small numbers who received this intervention, preliminary observations suggest it might offer a feasible alternative for many patients with MUS who reject, or try and find unsatisfying, cognitive behaviour therapy.

Social implications

Many patients suffering MUS feel isolated and that they are the only one for whom their doctor cannot find an organic cause for their condition. The facilitated group has a beneficial effect on this problem, for example they feel a sense of belonging and sharing of their story.

Originality/value

The BodyMind Approach is an original intervention mirroring the new wave of research in neuroscience and philosophy which prides embodiment perspectives over solely cognitive ones preferred in the “talking” therapies. There is a sea change in thinking about processes and models for supporting people with mental ill-health where the need to include the lived body experience is paramount to transformation.

Transferring research from a university to the United Kingdom National Health Service: the implications for impact

The aim of this article is to inform readers of the author’s reflections on the experience of transferring university-based research into the commercial sector, and of the processes and strategies employed when preparing for impact in so doing. Concepts for the transfer are illustrated by the author’s reflection on aspects that arose during the birthing and subsequent start-up of a university spin-off, Pathways2Wellbeing, a form of reflection-on-action. This is the vehicle for the adaption required to transfer research into the delivery of a specialised clinic in the United Kingdom National Health Service for people with medically unexplained, persistent, bodily symptoms such as fibromyalgia, chronic fatigue and chronic pain. It is hoped that the article will provide readers with an insight into how knowledge transfer can take place through engagement with stakeholders to create an exchange of knowledges to result in impact on health service policy for service users, despite the challenges, and the enablers that facilitated this process. The reflections on the process of knowledge transfer and the implications for impact are underpinned by relevant theory.