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Jespersen CP, Pedersen HF, Kleinstäuber M, Fink P, Wellnitz KB, Ørnbøl E, Schröder A, Agger JL, Vase L, Finnerup NB, Gormsen LK. Efficacy of patient education and duloxetine, alone and in combination, for patients with multisystem functional somatic disorder: Study protocol for the EDULOX trial. Contemp Clin Trials 2024; 141:107524. [PMID: 38604496 DOI: 10.1016/j.cct.2024.107524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/28/2024] [Accepted: 04/08/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Multisystem functional somatic disorder is characterized by specific patterns of persistent physical symptoms with a complex biopsychosocial etiology. The disorder can lead to disability and personal suffering. Current treatment options require specialized settings, therefore patients often wait a long time to receive specific treatment. Patient education is considered important in most treatment programs, but has only been investigated sparsely as a stand-alone treatment. Pharmacological treatment is limited to tricyclic antidepressants in low doses with no antidepressant properties. Duloxetine has been found effective in single organ functional disorders. As a treatment for multisystem functional somatic disorder, duloxetine could reduce symptoms and treat comorbid anxiety and depression. It may furthermore enhance the effect of patient education through a hypothesized effect on cognitive functioning. The purpose of the EDULOX trial is to study psycho-EDUcation and duLOXetine alone and in combination. METHODS This is a nested study design. The parent trial "EDULOX1" (n = 424) will compare a patient education program with enhanced usual care in an open-labelled, randomized controlled trial. In addition to this, eligible participants will furthermore receive either duloxetine or active placebo in the nested, double-blinded, randomized controlled trial, "EDULOX2" (n = 212). Patient and clinician reported outcomes will be collected through questionnaires. CONCLUSION The EDULOX trial may establish evidence for treatments applicable for the majority of patients with multisystem functional somatic disorder. If effective, duloxetine would be a more tolerable pharmacological treatment option that can target comorbid depression and anxiety, and potentially boost the effect of patient education. Trial registration number The study is registered at www. CLINICALTRIALS gov (NCT06232473) and the internal list of research projects at the Region of Central Denmark (Case number 1-16-02-305-23). Approval from the Danish Medical Research Ethics Committees (Case number: 2212291) and the Danish Medicines Agency was obtained under EudraCT Number: 2022-002780-30 and Sponsor's Protocol Code Number: 9515.
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Affiliation(s)
- Cecilia Pihl Jespersen
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Heidi Frølund Pedersen
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Kleinstäuber
- Department of Psychology, Emma Eccles Jones College of Education and Human Services, Utah State University, Logan, UT, USA
| | - Per Fink
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kaare Bro Wellnitz
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Eva Ørnbøl
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Schröder
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark
| | - Johanne Liv Agger
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark
| | - Lene Vase
- Department of Psychology and Behavioral Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Nanna Brix Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Kirstine Gormsen
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Huth D, Bräscher AK, Tholl S, Fiess J, Birke G, Herrmann C, Jöbges M, Mier D, Witthöft M. Cognitive-behavioral therapy for patients with post-COVID-19 condition (CBT-PCC): a feasibility trial. Psychol Med 2024; 54:1122-1132. [PMID: 37842765 DOI: 10.1017/s0033291723002921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND The post-COVID-19 condition describes the persistence or onset of somatic symptoms (e.g. fatigue) after acute COVID-19. Based on an existing cognitive-behavioral treatment protocol, we developed a specialized group intervention for individuals with post-COVID-19 condition. The present study examines the feasibility, acceptance, and effectiveness of the program for inpatients in a neurological rehabilitation setting. METHODS The treatment program comprises eight sessions and includes psychoeducational and experience-based interventions on common psychophysiological mechanisms of persistent somatic symptoms. A feasibility trial was conducted using a one-group design in a naturalistic setting. N = 64 inpatients with a history of mild COVID-19 that fulfilled WHO criteria for post-COVID-19 condition were enrolled. After each session, evaluation forms were completed and psychometric questionnaires on somatic and psychopathological symptom burden were collected pre- and post-intervention. RESULTS The treatment program was well received by participants and therapists. Each session was rated as comprehensible and overall satisfaction with the sessions was high. Pre-post effect sizes (of standard rehabilitation incl. new treatment program; intention-to-treat) showed significantly reduced subjective fatigue (p < 0.05, dav = 0.33) and improved disease coping (ps < 0.05, dav = 0.33-0.49). CONCLUSIONS Our results support the feasibility and acceptance of the newly developed cognitive-behavioral group intervention for individuals with post-COVID-19 condition. Yet, findings have to be interpreted cautiously due to the lack of a control group and follow-up measurement, the small sample size, and a relatively high drop-out rate.
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Affiliation(s)
- Daniel Huth
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Anne-Kathrin Bräscher
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sarah Tholl
- Department of Clinical Psychology and Psychotherapy, University of Konstanz, Konstanz, Germany
| | - Johanna Fiess
- Department of Clinical Psychology and Psychotherapy, University of Konstanz, Konstanz, Germany
| | - Gunnar Birke
- Kliniken Schmieder Gailingen, Gailingen, Germany
| | | | | | - Daniela Mier
- Department of Clinical Psychology and Psychotherapy, University of Konstanz, Konstanz, Germany
| | - Michael Witthöft
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg University Mainz, Mainz, Germany
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Staton A, Dawson D, Merdian H, Tickle A, Walker T. Functional neurological disorder: A qualitative study exploring individuals' experiences of psychological services. Psychol Psychother 2024; 97:138-156. [PMID: 37800641 DOI: 10.1111/papt.12504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/27/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVES Individuals with a diagnosis of FND report experiencing stigma in medical settings, however, there is a paucity of research exploring their experiences in psychological services. The aim of this research was to explore experiences of accessing UK psychological services, from the perspective of those with FND. METHODS This study utilised a qualitative approach with data collected from semi-structured interviews (n = 15) and analysed using reflexive thematic analysis. RESULTS One superordinate theme, 'the stigmatised self within the therapeutic relationship', and five interrelated subthemes were identified: 'internalised stigma and self-doubt', 'selective disclosure to professionals', 'perceptions of psychological explanations', 'having to educate the professionals' and 'attunement and trust within the therapeutic relationship'. Positive therapeutic relationships were perceived to mitigate the impact of these perceived barriers. The conceptualisation of FND and the perception of how this was responded to by services and professionals was a central tenet throughout the related themes. CONCLUSIONS Intra-personal, interpersonal and organisational stigma impact access and engagement to psychological treatment. The findings of this study highlight the need for increased training provision for practitioners with a focus on actively challenging FND stigma within services at both an individual and systemic level.
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Affiliation(s)
- Amelia Staton
- University of Nottingham, Nottingham, UK
- University of Lincoln, Lincoln, UK
| | | | | | | | - Tammy Walker
- Defence Medical Rehabilitation Centre, Loughborough, UK
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Lerario MP, Fusunyan M, Stave CD, Roldán V, Keuroghlian AS, Turban J, Perez DL, Maschi T, Rosendale N. Functional neurological disorder and functional somatic syndromes among sexual and gender minority people: A scoping review. J Psychosom Res 2023; 174:111491. [PMID: 37802674 DOI: 10.1016/j.jpsychores.2023.111491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE To describe the current literature on functional neurological disorder and functional somatic syndromes among sexual and gender minority people (SGM). METHODS A search string with descriptors of SGM identity and functional disorders was entered into PubMed, Embase, Web of Science, PsycInfo, and CINAHL for articles published before May 24, 2022, yielding 3121 items entered into Covidence, where 835 duplicates were removed. A neurologist and neuropsychiatrist screened titles and abstracts based on predefined criteria, followed by full-text review. A third neurologist adjudicated discrepancies. Eligible publications underwent systematic data extraction and statistical description. RESULTS Our search identified 26 articles on functional disorders among SGM people. Most articles were case (13/26, 46%) or cross-sectional (4/26, 15%) studies. Gender minority people were represented in 50% of studies. Reported diagnoses included fibromyalgia (n = 8), functional neurological disorder (n = 8), somatic symptom disorder (n = 5), chronic fatigue syndrome (n = 3), irritable bowel syndrome (n = 2), and other functional conditions (n = 3). Three cohort studies of fibromyalgia or somatic symptom disorder reported an overrepresentation of gender minority people compared to cisgender cohorts or general population measures. Approximately half of case studies reported pediatric or adolescent onset (7/13, 54%), functional neurological disorder diagnosis (7/13, 54%), and symptom improvement coinciding with identity-affirming therapeutic interventions (7/13, 58%). CONCLUSION Despite a methodologically rigorous literature search, there are limited data on functional neurological disorder and functional somatic syndromes among SGM people. Several studies reported increased prevalence of select conditions among transgender people. More observational studies are needed regarding the epidemiology and clinical course of functional disorders among SGM people.
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Affiliation(s)
- Mackenzie P Lerario
- Fordham Graduate School of Social Service, New York, NY, United States of America; Greenburgh Pride, Westchester, NY, United States of America.
| | - Mark Fusunyan
- Department of Psychiatry, Santa Clara Valley Medical Center, San Jose, CA, United States of America
| | - Christopher D Stave
- Lane Medical Library, Stanford University, Stanford, CA, United States of America.
| | - Valeria Roldán
- Facultad de Medicina Alberto Hurtado, La Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Alex S Keuroghlian
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States of America; The Fenway Institute, Boston, MA, United States of America.
| | - Jack Turban
- Division of Child & Adolescent Psychiatry, University of California San Francisco, United States of America.
| | - David L Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Tina Maschi
- Fordham Graduate School of Social Service, New York, NY, United States of America; Greenburgh Pride, Westchester, NY, United States of America.
| | - Nicole Rosendale
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States of America; Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, United States of America.
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Boecking B, Brueggemann P, Rose M, Mazurek B. [Chronic tinnitus: An interplay between somatic and psychological factors]. HNO 2023; 71:719-730. [PMID: 37702794 DOI: 10.1007/s00106-023-01370-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/14/2023]
Abstract
Chronic tinnitus is a common, sometimes highly distressing phenomenon that can be triggered and maintained by an interplay of physical and psychological factors. Partnering with clinical psychology and psychosomatic medicine, modern otolaryngology integrates both medical (e.g., hearing loss) and psychological influences (e.g., interactions between biographical experiences, personality traits, subjective evaluation of intrapsychic and interpersonal stimuli, emotional states, and intrapsychic or interpersonal emotion regulation strategies). Both groups of variables can influence the intensity and course of chronic tinnitus symptomatology both directly and indirectly, whereby the quality and relative degrees of psychological and physical components in a person's self-experience can fluctuate. With this in mind, the present article distinguishes between chronic tinnitus symptomatology with or without hearing loss-and strongly advocates for an integrated understanding of the symptomatology within a holistic psychological frame of reference. After a brief introduction to the principles of psychosomatic medicine and psychotherapy, the article discusses psychological case conceptualization using a vulnerability-stress-coping (VSC) model as an example, outlines clinical aspects and diagnostics of chronic tinnitus symptomatology, and concludes with a conceptualization of chronic tinnitus-related distress as a function of person-centered VSC interactions.
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Affiliation(s)
- Benjamin Boecking
- Tinnituszentrum, Charité - Universitätsmedizin Berlin, Luisenstraße 13, 10117, Berlin, Deutschland
| | - Petra Brueggemann
- Tinnituszentrum, Charité - Universitätsmedizin Berlin, Luisenstraße 13, 10117, Berlin, Deutschland
| | - Matthias Rose
- Medizinische Klinik mit Schwerpunkt für Psychosomatik und Psychotherapie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Birgit Mazurek
- Tinnituszentrum, Charité - Universitätsmedizin Berlin, Luisenstraße 13, 10117, Berlin, Deutschland.
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Sauer KS, Witthöft M, Rief W. Somatic Symptom Disorder and Health Anxiety: Assessment and Management. Neurol Clin 2023; 41:745-758. [PMID: 37775202 DOI: 10.1016/j.ncl.2023.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Somatic Symptom Disorder (SSD) and Illness Anxiety Disorder (IAD) replaced the diagnostic entities of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) somatoform disorders and hypochondriasis. SSD turns away from specifying the presence or absence of a medical condition for presented symptoms and instead focuses on excessive symptom-related affects, cognitions, and behaviors. People with pathological health anxiety can be diagnosed with SSD or IAD, depending on the intensity of accompanying somatic symptoms. Cognitive-behavioral therapy shows the best empirical evidence for an effective treatment of SSD and IAD.
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Affiliation(s)
- Karoline S Sauer
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University of Mainz, Wallstraße 3, Mainz 55122, Germany.
| | - Michael Witthöft
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University of Mainz, Wallstraße 3, Mainz 55122, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
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Fischer S, Kleinstäuber M, Fiori LM, Turecki G, Wagner J, von Känel R. DNA Methylation Signatures of Functional Somatic Syndromes: Systematic Review. Psychosom Med 2023; 85:672-681. [PMID: 37531610 DOI: 10.1097/psy.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
OBJECTIVE Functional somatic syndromes (FSS) are highly prevalent across all levels of health care. The fact that they are characterized by medically unexplained symptoms, such as fatigue and pain, raises the important question of their underlying pathophysiology. Psychosocial stress represents a significant factor in the development of FSS and can induce long-term modifications at the epigenetic level. The aim of this review was to systematically review, for the first time, whether individuals with FSS are characterized by specific alterations in DNA methylation. METHODS MEDLINE and PsycINFO were searched from the first available date to September 2022. The inclusion criteria were as follows: a) adults fulfilling the research diagnostic criteria for chronic fatigue syndrome, fibromyalgia syndrome, and/or irritable bowel syndrome; b) healthy control group; and c) candidate-gene or genome-wide study of DNA methylation. RESULTS Sixteen studies ( N = 957) were included. In candidate-gene studies, specific sites within NR3C1 were identified, which were hypomethylated in individuals with chronic fatigue syndrome compared with healthy controls. In genome-wide studies in chronic fatigue syndrome, a hypomethylated site located to LY86 and hypermethylated sites within HLA-DQB1 were found. In genome-wide studies in fibromyalgia syndrome, differential methylation in sites related to HDAC4 , TMEM44 , KCNQ1 , SLC17A9 , PRKG1 , ALPK3 , TFAP2A , and LY6G5C was found. CONCLUSIONS Individuals with chronic fatigue syndrome and fibromyalgia syndrome seem to be characterized by altered DNA methylation of genes regulating cellular signaling and immune functioning. In chronic fatigue syndrome, there is preliminary evidence for these to be implicated in key pathophysiological alterations, such as hypocortisolism and low-grade inflammation, and to contribute to the debilitating symptoms these individuals experience. PREREGISTRATION PROSPERO identifier: CRD42022364720.
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Affiliation(s)
- Susanne Fischer
- From the Institute of Psychology (Fischer), Clinical Psychology and Psychotherapy, University of Zurich, Zurich, Switzerland; Department of Psychology, Emma Eccles Jones College of Education and Human Services (Kleinstäuber), Utah State University, Logan, Utah; McGill Group for Suicide Studies, Douglas Hospital Research Center (Fiori, Turecki), Montréal, Canada; Department of Psychiatry (Turecki), McGill University, Montréal, Canada; and Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine (Wagner, von Känel). University Hospital Zurich, Zurich, Switzerland
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Imperiale MN, Lieb R, Meinlschmidt G. Treatment-associated network dynamics in patients with globus sensations: a proof-of-concept study. Sci Rep 2023; 13:15615. [PMID: 37730963 PMCID: PMC10511470 DOI: 10.1038/s41598-023-42186-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 09/06/2023] [Indexed: 09/22/2023] Open
Abstract
In this proof-of-concept study, we used a systems perspective to conceptualize and investigate treatment-related dynamics (temporal and cross-sectional associations) of symptoms and elements related to the manifestation of a common functional somatic syndrome (FSS), Globus Sensations (GS). We analyzed data from 100 patients (M = 47.1 years, SD = 14.4 years; 64% female) with GS who received eight sessions of group psychotherapy in the context of a randomized controlled trial (RCT). Symptoms and elements were assessed after each treatment session. We applied a multilevel graphical vector-autoregression (ml GVAR) model approach resulting in three separate, complementary networks (temporal, contemporaneous, and between-subject) for an affective, cognitive, and behavioral dimension, respectively. GS were not temporally associated with any affective, cognitive, and behavioral elements. Temporally, catastrophizing cognitions predicted bodily weakness (r = 0.14, p < 0.01, 95% confidence interval (CI) [0.04-0.23]) and GS predicted somatic distress (r = 0.18, p < 0.05, 95% CI [0.04-0.33]). Potential causal pathways between catastrophizing cognitions and bodily weakness as well as GS and somatic distress may reflect treatment-related temporal change processes in patients with GS. Our study illustrates how dynamic NA can be used in the context of outcome research.
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Affiliation(s)
- Marina N Imperiale
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Missionsstrasse 62a, 4055, Basel, Switzerland
| | - Roselind Lieb
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Missionsstrasse 62a, 4055, Basel, Switzerland
| | - Gunther Meinlschmidt
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Missionsstrasse 62a, 4055, Basel, Switzerland.
- Department of Clinical Psychology and Cognitive Behavioral Therapy, International Psychoanalytic University (IPU) Berlin, Stromstrasse 1, 10555, Berlin, Germany.
- Department of Digital and Blended Psychosomatics and Psychotherapy, Psychosomatic Medicine, University Hospital Basel and University of Basel, Hebelstrasse 2, 4031, Basel, Switzerland.
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9
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Weigel A, Hüsing P, Junge M, Löwe B. Helpful explanatory models for persistent somatic symptoms (HERMES): Results of a three-arm randomized-controlled pilot trial. J Psychosom Res 2023; 172:111419. [PMID: 37352693 DOI: 10.1016/j.jpsychores.2023.111419] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE This three-arm randomized controlled trial aimed to test the efficacy of an etiological model for persistent somatic symptoms (PSS) translated into video-animated explanatory models in comparison to a control group, and to examine additional value of personalization of the explanatory models (i.e. possibility to choose information based on mechanisms of symptom persistence). METHODS Outpatients with PSS were shown one of three 15-min video animations: a) explanatory model without personalization, b) explanatory model with personalization, c) no explanatory model control group. Changes in somatic symptom severity (PHQ-15) and psychological burden related to somatic symptoms or associated health concerns (SSD-12) from baseline to one-month follow-up were the primary outcome. Health-related quality of life (SF-12) and perceived usefulness (USE) were also assessed. RESULTS Seventy-five patients with PSS were allocated to the study arms (Mage = 44.2 ± 13.3 years, 56% female). The study arms did not differ significantly on the primary outcomes. However, no explanatory model participants reported significantly greater mental quality of life improvements than explanatory model without personalization participants (Mdiff = 7.50 [0.43; 14.56]). Further, explanatory model with personalization participants rated the individual fit of the intervention significantly higher than no explanatory model participants (Mdiff = 2.05 [0.17; 3.93]). All groups rated credibility of the intervention as very high. CONCLUSION The HERMES materials seemed to have been too brief to improve symptom related outcomes. However, all three interventions were positively evaluated regarding their usefulness, particularly in case of additional personalization. Future studies should investigate potential effects of an increased intervention dose. TRIAL REGISTRATION DRKS00018803.
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Affiliation(s)
- Angelika Weigel
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
| | - Paul Hüsing
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
| | - Magdalena Junge
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
| | - Bernd Löwe
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
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Hüsing P, Smakowski A, Löwe B, Kleinstäuber M, Toussaint A, Shedden-Mora MC. The framework for systematic reviews on psychological risk factors for persistent somatic symptoms and related syndromes and disorders (PSY-PSS). Front Psychiatry 2023; 14:1142484. [PMID: 37091694 PMCID: PMC10113674 DOI: 10.3389/fpsyt.2023.1142484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/16/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Numerous psychological factors are believed to play a pivotal role in the development and maintenance of persistent somatic symptoms (PSS) in all fields of medicine. However, very few of these factors have been empirically investigated in relation to PSS. The aim of this study is firstly to propose a framework and define search terms for systematic reviews on the empirical evidence and diagnostic value of psychological risk factors for PSS and PSS-related outcomes (PSY-PSS). Secondly, the application of the framework is illustrated using the example of a systematic review on the relevance of psychological factors in somatic symptom disorders (SSD; DSM-5) and bodily distress disorders (BDD; ICD-11). Methods Following a narrative review approach, two comprehensive lists of search terms to identify studies in (1) relevant patient groups with PSS and (2) relevant psychological factors were generated by reviewing the current literature and employing an iterative process of internal revision and external expert feedback. Results We identified 83 relevant symptoms, syndromes and disorders for which we defined a total of 322 search terms (list 1). We further comprised 120 psychological factors into 42 subcategories and 7 main categories (list 2). The introduced lists can be combined to conduct systematic reviews on one or more specific psychological factors in combination with any symptom, syndrome or disorder of interest. A protocol of the application of this framework in a systematic review and meta-analysis on psychological etiological factors of SSD and BDD is presented following the PRISMA guidelines. Discussion This framework will help to gather systematic evidence on psychological factors in order to improve the understanding of the etiology of PSS, to refine future diagnostic conceptualizations of PPS, and to develop optimized mechanism-based interventions for individuals with PPS and related syndromes and disorders.
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Affiliation(s)
- Paul Hüsing
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Abigail Smakowski
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Kleinstäuber
- Department of Psychology, Utah State University, Logan, UT, United States
| | - Anne Toussaint
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Selinheimo S, Keinonen K, Vuokko A, Liesto S, Sainio M, Lappalainen R, Paunio T. A randomized controlled trial protocol for persistent physical symptoms associated with indoor environment or chronic fatigue: Effectiveness of video-based functional case conceptualization and web-program for improving quality of life. Front Psychol 2023; 13:923532. [PMID: 36687807 PMCID: PMC9853541 DOI: 10.3389/fpsyg.2022.923532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 12/15/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction Persistent physical symptoms (PPS) refer to symptoms that cannot be fully explained by structural bodily pathology or by environmental factors. Their impact on daily functioning varies from mild to severe disability. So far, evidence-based treatments for PPS have resulted in only small to moderate effects. Treatment protocols with a stronger orientation toward personalized approaches are needed to improve the efficacy and applicability of treatment. In this study, we aim to assess the effect of an online individual case conceptualization with web-based program for PPS. This study is conducted among two focus groups: patients with indoor air-related symptoms and patients with chronic fatigue syndrome. Methods and analyses Using a randomized controlled design (RCT) with two parallel groups in a 1:1 ratio, we will compare individual video-based case conceptualization with a web-based program based on Acceptance and Commitment Therapy (ACT), combined with treatment as usual, with treatment as usual only. The web-based program consists of ten modules, each lasting 1 week and including training. The planned sample size is 124 eligible patients without attrition. The primary outcome will be the health-related quality of life as measured by the 15D questionnaire. The secondary outcome measures will include questionnaires on psychiatric and physical symptoms, illness perceptions, psychological flexibility, and work ability. We will also use national registers to obtain information on the use of healthcare and social benefits to complete patient-reported outcomes. Data collection began in August 2020 and will continue until 2023. Discussion This trial will provide information on the effects and usefulness of an online administrated individual case conceptualization and an ACT-based web-program on PPS. Ethics and dissemination The Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland, has granted approval for the study. The results will be published in peer-reviewed journals. Clinical Trial Registration Clinicaltrials.gov, identifier NCT04532827 preresults.
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Affiliation(s)
- Sanna Selinheimo
- Finnish Institute of Occupational Health, Helsinki, Finland,*Correspondence: Sanna Selinheimo,
| | | | - Aki Vuokko
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Sanna Liesto
- Outpatient Clinic for Functional Disorders, HUS Helsinki University Hospital, Helsinki, Finland
| | - Markku Sainio
- Finnish Institute of Occupational Health, Helsinki, Finland,Outpatient Clinic for Functional Disorders, HUS Helsinki University Hospital, Helsinki, Finland
| | - Raimo Lappalainen
- Department of Psychology, University of Jyväskylä, Jyväskylä, Finland
| | - Tiina Paunio
- Finnish Institute of Occupational Health, Helsinki, Finland,Department of Psychiatry and SleepWell Research Program, Faculty of Medicine, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
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12
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Čevelíček M, Roubal J, Hytych R, Řiháček T. What works in the treatment of medically unexplained physical symptoms? The psychotherapist perspective. COUNSELLING PSYCHOLOGY QUARTERLY 2023. [DOI: 10.1080/09515070.2022.2123785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Michal Čevelíček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czechia
| | - Jan Roubal
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czechia
| | - Roman Hytych
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czechia
| | - Tomáš Řiháček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czechia
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13
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Maas genannt Bermpohl F, Hülsmann L, Martin A. Efficacy of mindfulness- and acceptance-based cognitive-behavioral therapies for bodily distress in adults: a meta-analysis. Front Psychiatry 2023; 14:1160908. [PMID: 37151971 PMCID: PMC10157071 DOI: 10.3389/fpsyt.2023.1160908] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
Objective Bodily distress, i.e., somatoform disorders and associated functional somatic syndromes, is highly prevalent, often persistent and highly disabling. It has been proposed that "third wave" therapies may be beneficial variants of cognitive behavioral treatments. However, evidence on their efficacy is scarce. This meta-analysis examines the efficacy of "third wave" psychotherapies (mindfulness-based cognitive therapy [MBCT], mindfulness-based stress reduction [MBSR], and acceptance and commitment therapy [ACT]) in adults with bodily distress. Method We included randomized controlled trials (RCTs) treating adults with bodily distress using MBCT, MBSR, and ACT compared to inactive and non-specific control groups. A random effects model was used. The primary outcome was somatic symptom severity. Secondary outcomes were degrees of depression and of anxiety, health anxiety, perceived health status, mindfulness, psychological inflexibility, and pain acceptance. Results Sixteen RCTs with 1,288 participants were included in the analysis (k = 4 MBCT, k = 7 MBSR, k = 5 ACT; k = 7 fibromyalgia, k = 5 irritable bowel syndrome, k = 1 chronic fatigue syndrome, k = 2 bodily distress, k = 1 medically unexplained symptoms). However, not all studies provided data for each of the relevant outcomes. The analyses revealed that "third wave" therapies were more effective than control conditions in reducing somatic symptom severity (k = 15, n = 1,100, g = -0.51, 95%CI -0.69; -0.32). Heterogeneity was moderate (I 2 = 52.8%, 95%CI 15.1 to 73.8). Effects for secondary outcomes were small to moderate with varying degrees of heterogeneity. We did not find differences between the different therapy approaches (mindfulness- vs. acceptance-based therapies); neither therapy dosis (i.e., total duration of therapy sessions) nor number of sessions were significant moderators of efficacy. Conclusions The therapies addressing mindfulness and acceptance proved to be more effective than control conditions. Hence, they are promising treatment approaches for bodily distress. However, there is still need for research on which patient groups may benefit from these psychological approaches. Systematic review registration https://osf.io/g7hby, identifier: 10.17605/OSF.IO/4RZGC.
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Entwistle N, Polnay A, Russ TC. Service impact: how patients use mental health and medical services before and after psychodynamic psychotherapy. PSYCHOANALYTIC PSYCHOTHERAPY 2022. [DOI: 10.1080/02668734.2022.2147580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Naomi Entwistle
- Psychotherapy Department, Royal Edinburgh Hospital, Edinburgh, UK
| | - Adam Polnay
- Psychotherapy Department, Royal Edinburgh Hospital, Edinburgh, UK
- Medical Division, The State Hospital, Carstairs, UK
- Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Tom C. Russ
- Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Alzheimer Scotland Dementia Research Centre, University of Edinburgh, Edinburgh, UK
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15
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Polakovská L, Čevelíček M, Roubal J, Řiháček T. Changes after multicomponent group-based treatment in patients with medically unexplained physical symptoms. COUNSELLING PSYCHOLOGY QUARTERLY 2022. [DOI: 10.1080/09515070.2022.2142200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lucia Polakovská
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czechia
| | - Michal Čevelíček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czechia
| | - Jan Roubal
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czechia
| | - Tomáš Řiháček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czechia
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16
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Interoceptive accuracy and bias in somatic symptom disorder, illness anxiety disorder, and functional syndromes: A systematic review and meta-analysis. PLoS One 2022; 17:e0271717. [PMID: 35980959 PMCID: PMC9387777 DOI: 10.1371/journal.pone.0271717] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/06/2022] [Indexed: 12/03/2022] Open
Abstract
Somatic symptom disorder, illness anxiety disorder, and functional syndromes are characterized by burdensome preoccupation with somatic symptoms. Etiological models propose either increased interoceptive accuracy through hypervigilance to the body, or decreased and biased interoception through top-down predictions about sensory events. This systematic review and meta-analysis summarizes findings of 68 studies examining interoceptive accuracy and 8 studies examining response biases in clinical or non-clinical groups. Analyses yielded a medium population effect size for decreased interoceptive accuracy in functional syndromes, but no observable effect in somatic symptom disorder and illness anxiety disorder. The overall effect size was highly heterogeneous. Regarding response bias, there was a small significant effect in somatic symptom disorder and illness anxiety disorder. Our findings strengthen the notion of top-down factors that result in biased rather than accurate perception of body signals in somatic symptom disorder and illness anxiety disorder.
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17
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Kaur T, Ranjan P, Sarkar S, Kaloiya GS, Khan M, Aakansha, Bhatia H. Psychological interventions for medically unexplained physical symptoms: A systematic review and meta-analysis. Gen Hosp Psychiatry 2022; 77:92-101. [PMID: 35580397 DOI: 10.1016/j.genhosppsych.2022.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/18/2022] [Accepted: 04/13/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Individuals seeking treatment for physical symptoms having unknown etiology are common in the primary healthcare setup. Factors such as biomedical, environmental, social, and psychological ones are expected to play an important role in the treatment of Medically Unexplained Physical Symptoms (MUPS). Therefore, this systematic review and meta-analysis aimed to investigate the efficacy of psychological interventions for the treatment of MUPS. METHOD Studies were selected using different electronic databases (PubMed, Wiley, Cochrane), to identify RCTs published in the last 11 years on psychological interventions to treat MUPS. A total of 12 studies were finalized for systematic review and 7 for meta-analysis based on the inclusion criteria. The risk of bias was assessed by the two reviewers independently using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. OpenMeta[Analyst] was used to perform meta-analysis. RESULTS The findings revealed that psychological interventions can possibly be effective in treating patients with MUPS. Somatic symptom severity and depression improved in the intervention groups as compared to controls, while anxiety, and physical and mental component summary of Short-Form General Health Survey 36 did not significantly improve in the intervention group. CONCLUSION A tailored module including psychological interventions to deal with these patients in primary care may be useful in improving the overall functioning of the individuals.
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Affiliation(s)
- Tanveer Kaur
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Piyush Ranjan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India.
| | - Siddharth Sarkar
- Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Gauri Shanker Kaloiya
- Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Munnoo Khan
- Morarji Desai National Institute of Yoga, New Delhi, India
| | - Aakansha
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Harpreet Bhatia
- Department of Psychology, University of Delhi, New Delhi, India
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18
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Sarter L, Heider J, Witthöft M, Rief W, Kleinstäuber M. Using clinical patient characteristics to predict treatment outcome of cognitive behavior therapies for individuals with medically unexplained symptoms: A systematic review and meta-analysis. Gen Hosp Psychiatry 2022; 77:11-20. [PMID: 35390568 DOI: 10.1016/j.genhosppsych.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE For individuals with medically unexplained symptoms (MUS), cognitive behavioral therapy (CBT) is the best-evaluated treatment. This systematic review and meta-analyses identify clinical patient characteristics associated with the treatment outcome of CBT for MUS. METHODS A systematic literature search (PubMed, PsycInfo, Web of Science) resulted in 53 eligible studies; of these 32 studies could be included in meta-analyses. Pooled correlation coefficients between predictors and treatment outcome were calculated with a random-effects model. Moderator analyses were conducted to examine differences between subgroups of MUS and different levels of methodological study quality. RESULTS Meta-analyses demonstrated that individuals with higher symptom intensity (r = 0.38; p < 0.001), lower physical functioning (r = -0.29; p < 0.001), lower emotional and social functioning (r = -0.37; p < 0.001), more potential symptom-related incentives (r = -0.15; p = 0.001), or longer symptom duration (r = 0.10; p = 0.033) at the beginning of treatment reported less change of symptom severity until the end of therapy or higher end-of-treatment symptom severity. The pooled effect sizes did not differ between certain subgroups of MUS or between different levels of methodological quality. CONCLUSION Our findings indicated that clinical characteristics of MUS patients are associated with treatment outcome of CBT. We discuss how the results can be used to optimize and personalize future treatments for MUS.
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Affiliation(s)
- Lena Sarter
- Philipps-University Marburg, Department of Clinical Psychology and Psychotherapy, Gutenbergstraße 18, 35037 Marburg, Germany.
| | - Jens Heider
- University Koblenz-Landau, Department of Clinical Psychology and Psychotherapy, Ostbahnstraße 10, 76829 Landau, Germany.
| | - Michael Witthöft
- Johannes Gutenberg-University Mainz, Department of Clinical Psychology, Psychotherapy and Experimental Psychopathology, Wallstraße 3, 55122 Mainz, Germany.
| | - Winfried Rief
- Philipps-University Marburg, Department of Clinical Psychology and Psychotherapy, Gutenbergstraße 18, 35037 Marburg, Germany.
| | - Maria Kleinstäuber
- Department of Psychology, Emma Eccles Jones College of Education and Human Services, Utah State University, Logan, USA.
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Řiháček T, Čevelíček M, Boehnke JR, Pourová M, Roubal J. Mechanisms of change in multicomponent group-based treatment for patients suffering from medically unexplained physical symptoms. Psychother Res 2022; 32:1016-1033. [PMID: 35436163 DOI: 10.1080/10503307.2022.2061874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Understanding psychological mechanisms of change is essential to advance treatments for patients suffering from medically unexplained physical symptoms (MUPS). This study aimed to test the role of selected change mechanisms (incl. interoceptive awareness, emotional regulation skills, symptom acceptance, relational needs satisfaction, clarification of meaning, working alliance, and group cohesion) in the modification of patients' somatic symptom intensity and well-being. N = 290 patients suffering from MUPS participated in a multi-component group-based treatment at seven clinical sites. Data were collected weekly. Multi-level modeling was used to test cross-lagged relationships between the hypothesized mechanisms and outcomes in terms of Granger causality (with lags of 1, 2, and 3 weeks). None of the mechanisms predicted a time-lagged change in outcomes in the expected direction. In fact, there was a consistent pattern of negative time-lagged relationships (i.e., an increase in a mechanism predicted worsening of the outcome). Findings consistent with the hypothesized role of the mechanisms were found only in concurrent relationships between mechanisms and outcomes. This study did not support time-lagged relationships under the condition of weekly measurement and many methodological factors remain to be considered (e.g., a finer time resolution).
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Affiliation(s)
- Tomáš Řiháček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
| | - Michal Čevelíček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
| | - Jan R Boehnke
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Martina Pourová
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
| | - Jan Roubal
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
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20
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Berezowski L, Ludwig L, Martin A, Löwe B, Shedden-Mora MC. Early Psychological Interventions for Somatic Symptom Disorder and Functional Somatic Syndromes: A Systematic Review and Meta-Analysis. Psychosom Med 2022; 84:325-338. [PMID: 34524264 PMCID: PMC8983947 DOI: 10.1097/psy.0000000000001011] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/20/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Psychological treatments for somatic symptom disorder and functional somatic syndromes (SSD/FSS) achieve moderate effects only, potentially because of the high chronicity in these patients. Therefore, we aimed to evaluate whether early treatment, that is, treatment in populations at risk or with recent onset, improves outcome. METHODS We conducted a systematic review and meta-analysis of (cluster-)randomized controlled trials evaluating early psychological interventions in the prevention and treatment of SSD/FSS in adults compared with inactive control conditions, standard care, or placebo. Individuals at risk for SSD/FSS, suffering from subthreshold symptoms or new onsets of SSD/FSS, or presenting with SSD/FSS for the first time were included. RESULTS We identified 30 eligible studies, mostly examining pain-related conditions. Interventions were diverse, ranging from bibliotherapy to cognitive-behavioral therapy. We found positive effects on depression post-treatment (Hedges' g = 0.12 [95% confidence interval = 0.03-0.2], k = 5) as well as on somatic symptom severity (g = 0.25 [0.096-0.41], k = 17) and health care utilization (g = 0.31 [0.18-0.44], k = 3) at follow-up. However, because of a high risk of bias, sensitivity to corrections for meta-bias, and missing outcome data, findings should be interpreted cautiously. CONCLUSIONS Our review shows that targeting SSD/FSS at an early stage represents a conceptual and practical challenge. Readily accessible interventions addressing transsymptomatic processes of SSD/FSS development and consolidation are highly needed. Future studies are needed to evaluate individuals with diverse symptoms, examine symptom history thoroughly, use placebo controls, and report outcomes completely to determine the efficacy of early psychological interventions for SSD/FSS.PROSPERO Registration:CRD42020140122.
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Affiliation(s)
- Lukas Berezowski
- From the Clinical Psychology and Psychotherapy, Institute of Psychology, Faculty of Psychology and Movement Sciences (Berezowski, Ludwig), University of Hamburg, Hamburg; Department of Clinical Psychology and Psychotherapy (Martin), University of Wuppertal, Wuppertal; Department of Psychosomatic Medicine and Psychotherapy (Löwe, Shedden-Mora), University Medical Center Hamburg-Eppendorf; and Department of Psychology (Shedden-Mora), University Medical Center Hamburg-Eppendorf & Medical School Hamburg, Hamburg, Germany
| | - Lea Ludwig
- From the Clinical Psychology and Psychotherapy, Institute of Psychology, Faculty of Psychology and Movement Sciences (Berezowski, Ludwig), University of Hamburg, Hamburg; Department of Clinical Psychology and Psychotherapy (Martin), University of Wuppertal, Wuppertal; Department of Psychosomatic Medicine and Psychotherapy (Löwe, Shedden-Mora), University Medical Center Hamburg-Eppendorf; and Department of Psychology (Shedden-Mora), University Medical Center Hamburg-Eppendorf & Medical School Hamburg, Hamburg, Germany
| | - Alexandra Martin
- From the Clinical Psychology and Psychotherapy, Institute of Psychology, Faculty of Psychology and Movement Sciences (Berezowski, Ludwig), University of Hamburg, Hamburg; Department of Clinical Psychology and Psychotherapy (Martin), University of Wuppertal, Wuppertal; Department of Psychosomatic Medicine and Psychotherapy (Löwe, Shedden-Mora), University Medical Center Hamburg-Eppendorf; and Department of Psychology (Shedden-Mora), University Medical Center Hamburg-Eppendorf & Medical School Hamburg, Hamburg, Germany
| | - Bernd Löwe
- From the Clinical Psychology and Psychotherapy, Institute of Psychology, Faculty of Psychology and Movement Sciences (Berezowski, Ludwig), University of Hamburg, Hamburg; Department of Clinical Psychology and Psychotherapy (Martin), University of Wuppertal, Wuppertal; Department of Psychosomatic Medicine and Psychotherapy (Löwe, Shedden-Mora), University Medical Center Hamburg-Eppendorf; and Department of Psychology (Shedden-Mora), University Medical Center Hamburg-Eppendorf & Medical School Hamburg, Hamburg, Germany
| | - Meike C. Shedden-Mora
- From the Clinical Psychology and Psychotherapy, Institute of Psychology, Faculty of Psychology and Movement Sciences (Berezowski, Ludwig), University of Hamburg, Hamburg; Department of Clinical Psychology and Psychotherapy (Martin), University of Wuppertal, Wuppertal; Department of Psychosomatic Medicine and Psychotherapy (Löwe, Shedden-Mora), University Medical Center Hamburg-Eppendorf; and Department of Psychology (Shedden-Mora), University Medical Center Hamburg-Eppendorf & Medical School Hamburg, Hamburg, Germany
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21
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Hennemann S, Witthöft M, Kleinstäuber M, Böhme K, Baumeister H, Ebert DD, Probst T. Somatosensory amplification moderates the efficacy of internet-delivered CBT for somatic symptom distress in emerging adults: Exploratory analysis of a randomized controlled trial. J Psychosom Res 2022; 155:110761. [PMID: 35182889 DOI: 10.1016/j.jpsychores.2022.110761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE While studies mainly provide positive evidence for the efficacy of internet-delivered cognitive-behavioral therapy (ICBT) for various persistent somatic symptoms, it remains largely unclear for whom these interventions work or not. This exploratory analysis aimed to identify moderators for the outcome between ICBT for somatic symptom distres and a waitlist control group (WL) in a vulnerable target group of emerging adults. METHODS Based on data from a randomized controlled trial on 156 university students with varying degrees of somatic symptom distress who were allocated to either an eight-week, therapist guided ICBT (iSOMA) or to the WL, we examined pretreatment demographic characteristics, health-related variables (e.g., somatic symptom duration), mental distress (e.g., depression, anxiety) and cognitive-emotional factors (emotional reactivity, somatosensory amplification) as candidate moderators of the outcome, somatic symptom distress (assessed by the Patient Health Questionnaire, PHQ-15) from pre- to posttreatment. RESULTS Somatosensory amplification (assessed by the Somatosensory Amplification Scale, SSAS) moderated the outcome in favor of iSOMA (B = -0.17, SE = 0.08, p = 0.031), i.e., higher pretreatment somatosensory amplification was associated with better outcome in the active compared to the control intervention. No significant moderation effects were found among demographic characteristics, health-related variables, or mental distress. CONCLUSION Our findings suggest that an internet-delivered CBT for somatic symptom distress should be preferred over no active treatment particularly in individuals with moderate to high levels of somatosensory amplification, which as a next step should be tested against further treatments and in clinical populations. TRIAL REGISTRATION German Clinical Trials Register (DRKS00014375).
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Affiliation(s)
- Severin Hennemann
- Johannes Gutenberg University Mainz, Department of Clinical Psychology, Psychotherapy and Experimental Psychopathology, Mainz, Germany.
| | - Michael Witthöft
- Johannes Gutenberg University Mainz, Department of Clinical Psychology, Psychotherapy and Experimental Psychopathology, Mainz, Germany
| | - Maria Kleinstäuber
- Utah State University, Emma Eccles Jones College of Education and Human Services, Department of Psychology, Logan (Utah), USA
| | - Katja Böhme
- Johannes Gutenberg University Mainz, Department of Clinical Psychology, Psychotherapy and Experimental Psychopathology, Mainz, Germany
| | - Harald Baumeister
- Ulm University, Department of Clinical Psychology and Psychotherapy, Ulm, Germany
| | - David Daniel Ebert
- Technical University of Munich, Department of Sport and Health Sciences, München, Germany
| | - Thomas Probst
- Danube University Krems, Department for Psychotherapy and Biopsychosocial Health, Krems, Austria
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22
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Watson D, Levin-Aspenson HF, Waszczuk MA, Conway CC, Dalgleish T, Dretsch MN, Eaton NR, Forbes MK, Forbush KT, Hobbs KA, Michelini G, Nelson BD, Sellbom M, Slade T, South SC, Sunderland M, Waldman I, Witthöft M, Wright AGC, Kotov R, Krueger RF. Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): III. Emotional dysfunction superspectrum. World Psychiatry 2022; 21:26-54. [PMID: 35015357 PMCID: PMC8751579 DOI: 10.1002/wps.20943] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.
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Affiliation(s)
- David Watson
- Department of Psychology, University of Notre Dame, South Bend, IN, USA
| | | | - Monika A Waszczuk
- Department of Psychiatry, Stony Brook University, Stony Brook, NY, USA
| | | | - Tim Dalgleish
- Medical Research Council, Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Michael N Dretsch
- US Army Medical Research Directorate - West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, WA, USA
| | - Nicholas R Eaton
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | - Miriam K Forbes
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Kelsie T Forbush
- Department of Psychology, University of Kansas, Lawrence, KS, USA
| | - Kelsey A Hobbs
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
| | - Giorgia Michelini
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA, USA
| | - Brady D Nelson
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | - Martin Sellbom
- Department of Psychology, University of Otago, Dunedin, New Zealand
| | - Tim Slade
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
| | - Susan C South
- Department of Psychological Sciences, Purdue University, West Lafayette, IN, USA
| | - Matthew Sunderland
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
| | - Irwin Waldman
- Department of Psychology, Emory University, Atlanta, GA, USA
| | - Michael Witthöft
- Department for Clinical Psychology, Psychotherapy, and Experimental Psychopathology, University of Mainz, Mainz, Germany
| | - Aidan G C Wright
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Roman Kotov
- Department of Psychiatry, Stony Brook University, Stony Brook, NY, USA
| | - Robert F Krueger
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
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23
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Senger K, Heider J, Kleinstäuber M, Sehlbrede M, Witthöft M, Schröder A. Network Analysis of Persistent Somatic Symptoms in Two Clinical Patient Samples. Psychosom Med 2022; 84:74-85. [PMID: 34428004 DOI: 10.1097/psy.0000000000000999] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Previous attempts to group persistent somatic symptoms (PSSs) with factor-analytic approaches have obtained heterogeneous results. An alternative approach that seems to be more suitable is the network theory. Compared with factor analysis, which focuses on the underlying factor of symptoms, network analysis focuses on the dynamic relationships and interactions among different symptoms. The main aim of this study is to apply the network approach to examine the heterogeneous structure of PSS within two clinical samples. METHODS The first data set consisted of n = 254 outpatients who were part of a multicenter study. The second data set included n = 574 inpatients, both with somatoform disorders. Somatic symptom severity was assessed with the Screening of Somatoform Disorder (SOMS-7T). RESULTS Results indicate that there are five main symptom groups that were found in both samples: neurological, gastrointestinal, urogenital, cardiovascular, and musculoskeletal symptoms. Although patterns of symptoms with high connection to each other look quite similar in both networks, the order of the most central symptoms (e.g., symptoms with a high connection to other symptoms in the network) differs. CONCLUSIONS This work is the first to estimate the structure of PSS using network analysis. A next step could be first to replicate our findings before translating them into clinical practice. Second, results may be useful for generating hypotheses to be tested in future studies, and the results open new opportunities for a better understanding for etiology, prevention, and intervention research.
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Affiliation(s)
- Katharina Senger
- From the Department of Psychology (Senger, Heider, Schröder), University of Koblenz-Landau, Landau, Germany; Department of Psychology (Kleinstäuber), Emma Eccles Jones College of Education and Health Services, Utah State University, Logan, Utah; Section of Health Care Research and Rehabilitation Research, Faculty of Medicine and Medical Centre (Sehlbrede), University of Freiburg, Freiburg im Breisgau; and Division of Clinical Psychology and Psychotherapy (Witthöft), Johannes Gutenberg University of Mainz, Mainz, Germany
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Roubal J, Hytych R, Čevelíček M, Řiháček T. Personal therapeutic approach in Gestalt therapists working with clients suffering from medically unexplained psychosomatic symptoms. RESEARCH IN PSYCHOTHERAPY (MILANO) 2021; 24:535. [PMID: 35047424 PMCID: PMC8715264 DOI: 10.4081/ripppo.2021.535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 10/20/2021] [Indexed: 12/04/2022]
Abstract
Treatment specificity and adherence to treatment manuals represent essential components of the medical model in psychotherapy. The model assumes that psychotherapists who work with the same type of clients and who identify with the same theoretical approach work very similarly. This study illustrates the shortcomings of that assumption and explores how therapists' individuality forms and shapes their unique approaches that resonate with their own personalities, inclinations, and worldviews. Semi-structured interviews with eight Gestalt therapists working with clients who experienced medically unexplained physical symptoms were analysed using the grounded theory method. Considerable differences were found among the therapists within four domains of the personal therapeutic approach, namely Case Conceptualization, Therapeutic Task, Therapist's Position, and Alternative Strategy. However, regardless of the differences, all the therapists endeavoured, either implicitly or explicitly, to convey to the clients what they considered to be healthy functioning. There is considerable diversity in the way therapists work even when they subscribe to the same psychotherapeutic approach and work with the same type of clients. The exploration of psychotherapists' usual strategies, as well as the alternative strategies they use when their usual strategies do not work, appears helpful for capturing their personal therapeutic approaches.
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Affiliation(s)
- Jan Roubal
- Department of Psychology, Masaryk University, Brno, Czech Republic
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Somatic Symptoms and Sleep Disorders: A Literature Review of Their Relationship, Comorbidities and Treatment. Healthcare (Basel) 2021; 9:healthcare9091128. [PMID: 34574901 PMCID: PMC8465276 DOI: 10.3390/healthcare9091128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/19/2021] [Accepted: 08/27/2021] [Indexed: 12/02/2022] Open
Abstract
This study aimed to investigate the relationship between somatic symptom disorder (SSD) and sleep disorders, following three research questions: (1) How are these disorders correlated? (2) What are the comorbidities reported in these patients? and (3) What are the most effective pharmacological and non-pharmacological treatments for both conditions? PubMed, Scopus, OVID, Medline, and ProQuest databases were searched for relevant articles published between 1957–2020. Search terms included “somatic symptoms disorder”, “sleep disorders”, “insomnia”, “somatoform”, “somatization”, “therapeutic”, “psychotherapy”, and alternative, formerly used terms for SSD. Forty papers were finally included in the study. Prevalence of insomnia in SSD patients ranged between 20.4–48%, with this being strongly correlated to somatic symptoms and psychosocial disability. The most relevant comorbidities were generalized anxiety disorder, depression, fatigue, negative mood, substance use, orthorexia, alexithymia, anorexia, weight loss, poor eating habits, and acute stress disorder. Patients receiving antidepressant therapy reported significant improvements in insomnia and somatic symptoms. In terms of non-pharmacological interventions, cognitive-behavioral therapy (CBT) showed improvements in sleep outcomes, while the Specialized Treatment for Severe Bodily Distress Syndromes (STreSS) may represent an additional promising option. Future research could include other medical and psychosocial variables to complete the picture of the relationship between sleep disorders and somatic symptoms.
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Broddadóttir E, Flóvenz SÓ, Gylfason HF, Þormar Þ, Einarsson H, Salkovskis P, Sigurðsson JF. "I'm So Tired": Fatigue as a Persistent Physical Symptom among Working People Experiencing Exhaustion Disorder. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8657. [PMID: 34444405 PMCID: PMC8392333 DOI: 10.3390/ijerph18168657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/13/2021] [Accepted: 08/14/2021] [Indexed: 11/16/2022]
Abstract
Fatigue is widespread in the population, particularly among working people. Exhaustion disorder (ED), a clinical manifestation of burnout, is common, but, after treatment, about one-third still experience fatigue and other physical symptoms. We propose that in some instances, fatigue as a persistent physical symptom (PPS) might be a more appropriate formulation of ED patients' fatigue problems, and we suggest that ED patients who meet fatigue PPS criteria will differ from other ED patients in terms of psychological distress, non-fatigue PPSs and functional impairment. Questionnaires were sent to 10,956 members of a trade union of which 2479 (22.6%) responded. Of 1090 participants who met criteria for ED, 106 (9.7%) met criteria for fatigue as a PPS. Participants who met fatigue PPS criteria scored on average higher on measures of depression, anxiety and functional impairment and were more likely to have clinically significant scores. Moreover, they had 27 times higher odds of meeting other PPS subtypes and reported more non-fatigue PPS subtypes, suggesting a more complex health problem. Specific evidence-based interventions are available for both ED and PPSs, and therefore, it is crucial to accurately formulate the fatigue problem reported by patients to provide appropriate treatment.
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Affiliation(s)
- Elín Broddadóttir
- Department of Psychology, Reykjavik University, 102 Reykjavik, Iceland; (S.Ó.F.); (Þ.Þ.); (J.F.S.)
| | | | | | - Þórey Þormar
- Department of Psychology, Reykjavik University, 102 Reykjavik, Iceland; (S.Ó.F.); (Þ.Þ.); (J.F.S.)
| | - Hjalti Einarsson
- Stett.is, Icelandic Confederation of University Graduates, 105 Reykjavik, Iceland;
| | - Paul Salkovskis
- Oxford Centre for Psychological Health, Oxford Institute of Clinical Psychology Training and Oxford Cognitive Therapy Center, Warneford Hospital, Oxford University, Oxford OX3 7JX, UK;
| | - Jón Friðrik Sigurðsson
- Department of Psychology, Reykjavik University, 102 Reykjavik, Iceland; (S.Ó.F.); (Þ.Þ.); (J.F.S.)
- Faculty of Medicine, School of Health Sciences, University of Iceland, 102 Reykjavik, Iceland
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Sarter L, Heider J, Kirchner L, Schenkel S, Witthöft M, Rief W, Kleinstäuber M. Cognitive and emotional variables predicting treatment outcome of cognitive behavior therapies for patients with medically unexplained symptoms: A meta-analysis. J Psychosom Res 2021; 146:110486. [PMID: 33879330 DOI: 10.1016/j.jpsychores.2021.110486] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/19/2021] [Accepted: 04/02/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Cognitive behavior therapy (CBT) is the best-evaluated psychological approach to treat patients with medically unexplained symptoms (MUS). We still need a better understanding of what characterizes patients with MUS who benefit more or less from CBT. This systematic review aimed to identify patients' cognitive-emotional characteristics predicting the outcome of CBT for MUS. METHODS A systematic literature search (PubMed, PsycINFO, Web of Science) revealed 37 eligible studies, 23 of these provided data for meta-analyses. Mean correlation coefficients between predictor variables and the outcomes (symptom intensity, physical or social-emotional functioning) were calculated using a random-effects model. Differences between syndromes of MUS were investigated with moderator analyses. RESULTS Meta-analyses showed that patients with a comorbid mood disorder (r = 0.32, p < .01) or anxiety disorder (r = 0.18, p < .01), symptom catastrophizing and worries (r = 0.34, p < .01), tendencies of somatosensory amplification (r = 0.46, p = .04), and low symptom acceptance or self-efficacy (r = 0.25, p < .01) have a less favorable CBT outcome. Moderator analyses revealed that these associations between predictors and treatment outcome are pronounced in patients with chronic fatigue syndrome and irritable bowel syndrome. CONCLUSIONS Our results show that pre-treatment differences in patients' cognitive-emotional characteristics predict patients' outcome in CBT. Patient-tailored CBT could be a promising approach to address MUS patients' widely varying needs more effectively. PROTOCOL REGISTRATION The protocol of this systematic review and meta-analysis was registered in the PROSPERO registry (CRD 42018098649).
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Affiliation(s)
- Lena Sarter
- Philipps-University Marburg, Department of Clinical Psychology and Psychotherapy, Marburg, Germany.
| | - Jens Heider
- University Koblenz-Landau, Department of Clinical Psychology and Psychotherapy, Landau, Germany.
| | - Lukas Kirchner
- Philipps-University Marburg, Department of Clinical Psychology and Psychotherapy, Marburg, Germany.
| | - Sandra Schenkel
- Johannes Gutenberg-University Mainz, Department of Clinical Psychology, Psychotherapy and Experimental Psychopathology, Mainz, Germany.
| | - Michael Witthöft
- Johannes Gutenberg-University Mainz, Department of Clinical Psychology, Psychotherapy and Experimental Psychopathology, Mainz, Germany.
| | - Winfried Rief
- Philipps-University Marburg, Department of Clinical Psychology and Psychotherapy, Marburg, Germany.
| | - Maria Kleinstäuber
- University of Otago, Otago Medical School - Dunedin Campus, Department of Psychological Medicine, Dunedin, New Zealand.
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Nazzal Z, Maraqa B, Abu Zant M, Qaddoumi L, Abdallah R. Somatic symptom disorders and utilization of health services among Palestinian primary health care attendees: a cross-sectional study. BMC Health Serv Res 2021; 21:615. [PMID: 34182995 PMCID: PMC8240383 DOI: 10.1186/s12913-021-06671-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/22/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many primary health care (PHC) clients come in with medically unexplained complaints, leading to frequent consultations and high usage of services and healthcare costs. This study aimed to determine the prevalence of somatic symptom disorder (SSD) among PHC attendees and explore its relation to other mental conditions and risk factors. METHODS A cross-sectional design was used to interview 400 attendees. Men and women aged over 18 years old without a psychiatric diagnosis were invited to participate. The Somatization scale of the Four-Dimensional Symptom Questionnaire was used to assess somatic symptom disorders. It is a valid tool to be used in a PHC setting. We used the Chi-square test and multivariable logistic regression to explore determinant variables. RESULTS Prevalence of SSD was 32.5% (95%CI = 27.9-37.1%). The most common symptoms were painful muscles (61.5%) followed by back pain (52.3%). Female gender [adjusted OR = 2.1 (95% CI = 1.2-3.7)], chronic diseases [adjusted OR = 2.4 (95%CI = 1.3-4.5)], depression [adjusted OR = 3.3 (95%CI = 2.0-5.5)], and anxiety [adjusted OR = 2.1 (95%CI = 1.2-3.6)] were all associated with SSD. In addition, frequent primary health care attendance was found to be associated with SSD [adjusted OR = 2.4 (95%CI = 1.4-4.1)]. CONCLUSIONS SSD significantly higher among females, patients with chronic diseases, clients with anxiety and depressive disorders, and patients with frequent doctors' visits. Painful muscles and back pain are the most common symptom presented by patients, and this could be used initially by PHC physicians as a signal to consider for screening.
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Affiliation(s)
- Zaher Nazzal
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Beesan Maraqa
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
- Primary Healthcare Directorate, Palestinian Ministry of Health, Ramallah, Palestine
| | - Marah Abu Zant
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Layali Qaddoumi
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Rana Abdallah
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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Cathébras P. Patient-Centered Medicine: A Necessary Condition for the Management of Functional Somatic Syndromes and Bodily Distress. Front Med (Lausanne) 2021; 8:585495. [PMID: 33987188 PMCID: PMC8110699 DOI: 10.3389/fmed.2021.585495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 03/10/2021] [Indexed: 12/02/2022] Open
Abstract
This paper argues that “functional,” “medically unexplained,” or “somatoform” symptoms and disorders necessarily require a patient-centered approach from the clinicians. In the first part, I address the multiple causes of the patients' suffering and I analyze the unease of the doctors faced with these disorders. I emphasize the iatrogenic role of medical investigations and the frequent failure in attempting to reassure the patients. I stress the difficulties in finding the right terms and concepts, despite overabundant nosological categories, to give a full account of psychosomatic complexity. Finally, I discuss the moral dimension attached to assigning a symptom, at times arbitrarily, to a psychogenic origin. The following part presents a brief reminder of the patient-centered approach (PCA) in medicine. In the last part, I aim to explain why and how patient-centered medicine should be applied in the context of functional disorders. First, because PCA focuses on the patients' experience of illness rather than the disease from the medical point of view, which is, indeed, absent. Second, because PCA is the only way to avoid sterile attribution conflicts. Last, because PCA allows doctors and patients to collaboratively create plausible and non-stigmatizing explanations for the symptoms, which paves the way toward effective management.
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Affiliation(s)
- Pascal Cathébras
- Department of Internal Medicine, Jean-Monnet University, Saint-Etienne, France
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Humer E, Sattel H, Gündel H, Henningsen P, Kruse J, Schneider G, Lahmann C, Pieh C, Probst T. Stress, depression, and the therapeutic alliance as mediators on the outcome of brief psychodynamic-interpersonal psychotherapy for multisomatoform disorder. Psychother Res 2021; 31:1012-1021. [PMID: 33550930 DOI: 10.1080/10503307.2021.1882711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The aim of this study was to identify and explore mediators of psychodynamic-interpersonal psychotherapy (PIT) on treatment outcome in multisomatoform disorders (MSD). Data from 164 patients with MSD who took part in a randomized control trial of PIT (n = 88) vs. enhanced medical care (EMC; n = 76) were re-analyzed. A parallel mediation analysis was performed to investigate whether the beneficial effect of PIT vs. EMC on physical quality of life (physical component summary (PCS) of the SF-36 Health Survey) nine months post-treatment is mediated by post-treatment scores of stress, depression, and therapeutic alliance. The potential mediators were operationalized with the Helping Alliance Questionnaire (HAQ; therapeutic alliance), the Patient Health Questionnaire (PHQ)-stress module (perceived stress) and the PHQ-depression module (PHQ-9; depression). Stress partially mediated the effect of PIT vs. EMC on the follow-up outcome. PIT (as compared to EMC) led to lower post-treatment stress-levels, which in turn led to higher physical quality of life at follow-up. Neither depression nor the alliance had a mediating effect. Stress mediated the outcome of PIT for MSD. Future studies are needed to extend the scope of research regarding which specific psychotherapeutic mechanisms of change are beneficial in PIT treatment of MSD patients.
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Affiliation(s)
- Elke Humer
- Department for Psychotherapy and Biopsychosocial Health, Danube University Krems, Krems, Austria
| | - Heribert Sattel
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Harald Gündel
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University, Ulm, Germany
| | - Peter Henningsen
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johannes Kruse
- Department of Psychosomatic Medicine and Psychotherapy, University of Giessen, Giessen, Germany.,Department of Psychosomatic Medicine and Psychotherapy, University of Marburg, Marburg, Germany
| | - Gudrun Schneider
- Department of Psychosomatic Medicine and Psychotherapy, Department of Mental Health, University Hospital Münster, Münster, Germany
| | - Claas Lahmann
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany
| | - Christoph Pieh
- Department for Psychotherapy and Biopsychosocial Health, Danube University Krems, Krems, Austria
| | - Thomas Probst
- Department for Psychotherapy and Biopsychosocial Health, Danube University Krems, Krems, Austria
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Vogel A, Comtesse H, Nocon A, Kersting A, Rief W, Steil R, Rosner R. Feasibility of Present-Centered Therapy for Prolonged Grief Disorder: Results of a Pilot Study. Front Psychiatry 2021; 12:534664. [PMID: 33935813 PMCID: PMC8081969 DOI: 10.3389/fpsyt.2021.534664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/15/2021] [Indexed: 12/26/2022] Open
Abstract
Present-centered therapy (PCT) was originally developed as a strong comparator for the non-specific effects of psychotherapy in the treatment of posttraumatic stress disorder. PCT qualifies as a not strictly supportive treatment as it is structured and homework is assigned between sessions. It does not focus on cognitive restructuring or exposure. A growing body of literature supports its beneficial effects. For example, it demonstrated only slightly inferior effect sizes and lower dropout rates compared to that of trauma-focused cognitive behavioral therapy in several trials with patients suffering from posttraumatic stress disorder. The current study is the first to evaluate the feasibility and the treatment effects of PCT in adults with prolonged grief disorder (PGD). Meta-analyses on psychotherapy for PGD have yielded moderate effect sizes. N = 20 individuals suffering from PGD were treated with PCT by novice therapists as part of a preparation phase for an upcoming RCT in an outpatient setting. Treatment consisted of 20-24 sessions á 50 min. All outcomes were assessed before treatment, at post-treatment, and at the 3-month follow-up. The primary outcome, PGD symptom severity, was assessed using the Interview for Prolonged Grief-13. Secondary outcomes were self-reported PGD severity, depression, general psychological distress, and somatic symptom severity. Furthermore, therapists evaluated their experiences with their first PCT patient and the treatment manual. In intent-to-treat analyses of all patients we found a significant decrease in interview-based PGD symptom severity at post-treatment (d = 1.26). Decreases were maintained up to the 3-month follow-up assessment (d = 1.25). There were also significant decreases in self-reported PGD symptoms, depression, and general psychological distress. No changes were observed for somatic symptoms. The completion rate was 85%. Therapists deemed PCT to be a learnable treatment program that can be adapted to the patient's individual needs. The preliminary results of PCT as a treatment for PGD demonstrate large effects and indicate good feasibility in outpatient settings. The treatment effects were larger than those reported in meta-analyses. Thus, PCT is a promising treatment for PGD. Possible future research directions are discussed.
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Affiliation(s)
- Anna Vogel
- Department of Psychology, Catholic University Eichstaett-Ingolstadt, Eichstaett, Germany
| | - Hannah Comtesse
- Department of Psychology, Catholic University Eichstaett-Ingolstadt, Eichstaett, Germany
| | - Agnes Nocon
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Anette Kersting
- Department of Psychosomatic Medicine and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Marburg, Germany
| | - Regina Steil
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University, Frankfurt, Germany
| | - Rita Rosner
- Department of Psychology, Catholic University Eichstaett-Ingolstadt, Eichstaett, Germany
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O'Leary D. A concerning display of medical indifference: reply to 'Chronic fatigue syndrome and an illness-focused approach to care: controversy, morality and paradox'. MEDICAL HUMANITIES 2020; 46:e4. [PMID: 32601171 DOI: 10.1136/medhum-2019-011743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/18/2020] [Indexed: 06/11/2023]
Abstract
In 'Chronic fatigue syndrome and an illness-focused approach to care: controversy, morality and paradox', authors Michael Sharpe and Monica Greco begin by characterising myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) as illness-without-disease. On that basis they ask why patients reject treatments for illness-without-disease, and they answer with a philosophical idea. Whitehead's 'bifurcation of nature', they suggest, still dominates public and professional thinking, and that conceptual confusion leads patients to reject the treatment they need. A great deal has occurred, however, since Whitehead characterised his culture's confusions 100 years ago. In our time, I suggest, experience is no longer construed as an invalid second cousin of bodily states in philosophy, in medicine or in the culture at large. More importantly, we must evaluate medical explanations before we reach for philosophical alternatives. The National Institutes of Health and the Institute of Medicine have concluded that ME/CFS is, in fact, a biomedical disease, and all US governmental health organisations now agree. Although it would be productive for Sharpe and Greco to state and support their disagreement with the other side of the disease debate, it is no longer tenable, or safe, to ignore the possibility of disease in patients with ME/CFS, or to recommend that clinicians should do so. When we find ourselves in a framework that suggests the possibility of medical need is somehow beside the point for medical providers, it is time to reconsider our conceptual foundations.
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Affiliation(s)
- Diane O'Leary
- Rotman Institute of Philosophy, Western University, London, ON N6A 5B7, Canada
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Weigel A, Maehder K, Witt M, Löwe B. Psychotherapists' perspective on the treatment of patients with somatic symptom disorders. J Psychosom Res 2020; 138:110228. [PMID: 32896756 DOI: 10.1016/j.jpsychores.2020.110228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/30/2020] [Accepted: 08/25/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Guidelines recommend psychotherapy in addition to primary care for patients with moderate to severe somatic symptom disorders. While general practitioners' experiences have been well studied, psychotherapists' experiences with this patient group and the explanatory models psychotherapists use in psychotherapy are unknown. METHODS Semi-structured qualitative interviews were conducted between April and July 2018 with 20 German licensed outpatient psychotherapists with either a medical or a psychological background, using the label "somatoform disorders". Interviews were analyzed applying thematic analysis. RESULTS Psychotherapists experienced management of affected patients as challenging and partly frustrating, mainly due to the difficult diagnostic process and the "somatic fixation" of some patients. Diagnostic labelling was considered a delicate issue, with some psychotherapists using the term "somatoform", while others preferred either "functional" or vague descriptions like "psychosomatic". The explanatory process was deemed essential for treatment, as was the adaptation of explanations to both a patient's biography and language. As main explanatory factors, psychotherapists referred to generic vulnerability factors, previous somatic illness and health care system influences. CONCLUSIONS Explanatory models used in psychotherapy are patient-centred, processual and constitute a major component of the psychotherapeutic process. However, this process might be impeded if patients are confronted with different diagnostic labels and explanatory models during their pathways through care.
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Affiliation(s)
- Angelika Weigel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Germany.
| | - Kerstin Maehder
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Germany.
| | - Marie Witt
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Germany.
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Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R, White P. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020; 24:1-490. [PMID: 32975190 PMCID: PMC7548871 DOI: 10.3310/hta24460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alison Scope
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London Medical School, London, UK
| | | | - Peter White
- Barts and The London School of Medicine and Dentistry, London, UK
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Kleinstäuber M, Allwang C, Bailer J, Berking M, Brünahl C, Erkic M, Gitzen H, Gollwitzer M, Gottschalk JM, Heider J, Hermann A, Lahmann C, Löwe B, Martin A, Rau J, Schröder A, Schwabe J, Schwarz J, Stark R, Weiss FD, Rief W. Cognitive Behaviour Therapy Complemented with Emotion Regulation Training for Patients with Persistent Physical Symptoms: A Randomised Clinical Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 88:287-299. [PMID: 31430755 DOI: 10.1159/000501621] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/20/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Persistent medically unexplained symptoms (MUS) are a major burden for health care. Cognitive behaviour therapy (CBT) is efficacious for patients with MUS, with small to medium effects. The current study investigates whether therapy outcomes of a CBT for MUS patients can be improved by complementing it with emotion regulation training. METHODS In a multicentre trial 255 patients with at least three persisting MUS were randomised to 20 sessions of either conventional CBT (n = 128) or CBT complemented with emotion regulation training (ENCERT; n = 127). Somatic symptom severity and secondary outcomes were assessed at pre-treatment, therapy session 8, end of therapy, and 6-month follow-up. RESULTS Linear mixed-effect models revealed medium to large effects in both study arms for almost all outcomes at the end of therapy and 6-month follow-up. ENCERT and CBT did not differ in their effect on the primary outcome (d = 0.20, 95% CI: -0.04 to 0.44). Significant time × group cross-level interactions suggested ENCERT to be of more benefit than conventional CBT for a few secondary outcomes. Moderator analyses revealed higher effects of ENCERT in patients with co-morbid mental disorders. DISCUSSION/CONCLUSIONS Current findings are based on a representative sample. Results demonstrate that both CBT and ENCERT can achieve strong effects on primary and secondary outcomes in MUS patients. Our results do not indicate that adding a training in emotion regulation skills generally improves the effect of CBT across all patients with MUS. Large effect sizes of both treatments and potential specific benefits of ENCERT for patients with co-morbid mental disorders are discussed.
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Affiliation(s)
- Maria Kleinstäuber
- Department of Clinical Psychology and Psychotherapy, Philipps University, Marburg, Germany,
| | - Christine Allwang
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Josef Bailer
- Department of Clinical Psychology, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Friedrich Alexander University, Erlangen, Germany
| | - Christian Brünahl
- Institute and Outpatients Clinic for Psychosomatic Medicine and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Maja Erkic
- Department of Clinical Psychology, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Harald Gitzen
- School of Human and Social Sciences, University of Wuppertal, Wuppertal, Germany
| | - Mario Gollwitzer
- Department of Social Psychology, Ludwig Maximilian University, Munich, Germany
| | | | - Jens Heider
- Outpatient Clinic for Psychotherapy, University of Koblenz-Landau, Landau, Germany
| | - Andrea Hermann
- Department of Psychotherapy and Systems Neuroscience, Justus Liebig University of Giessen, Giessen, Germany
| | - Claas Lahmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bernd Löwe
- Institute and Outpatients Clinic for Psychosomatic Medicine and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Martin
- School of Human and Social Sciences, University of Wuppertal, Wuppertal, Germany
| | - Jörn Rau
- Coordinating Centre for Clinical Trials, Philipps University, Marburg, Germany
| | - Annette Schröder
- Department of Clinical Psychology and Psychotherapy, University of Koblenz-Landau, Landau, Germany
| | - Johannes Schwabe
- Department of Social Psychology, Ludwig Maximilian University, Munich, Germany
| | - Jeanine Schwarz
- Department of Clinical Psychology and Psychotherapy, Philipps University, Marburg, Germany
| | - Rudolf Stark
- Department of Psychotherapy and Systems Neuroscience, Justus Liebig University of Giessen, Giessen, Germany
| | - Frauke Dorothee Weiss
- Department of Clinical Psychology and Psychotherapy, Philipps University, Marburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps University, Marburg, Germany
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Pourová M, Klocek A, Řiháček T, Čevelíček M. Therapeutic change mechanisms in adults with medically unexplained physical symptoms: A systematic review. J Psychosom Res 2020; 134:110124. [PMID: 32348898 DOI: 10.1016/j.jpsychores.2020.110124] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although psychological treatments for patients suffering from medically unexplained physical symptoms (MUPS) show promising results, evidence for their effectiveness is still limited. The aim of this study was to review the existing empirical support for change mechanisms that explain treatment effect in terms of symptom intensity and symptom interference in the daily lives of patients. METHODS A systematic database search was conducted. Sixty-seven eligible studies were found, and change mechanism effects were extracted from them. The data were subjected to a systematic review. RESULTS Fifteen change mechanisms were identified. Those receiving the most consistent support included Increasing symptom acceptance, Development of coping strategies, and Positive treatment expectations, although the last mechanism was investigated in only two studies. Almost all mechanisms received support for at least one type of outcome, either at post-treatment or at follow-up. CONCLUSIONS Although some empirical support exists for many mechanisms, some of them have received only marginal attention in empirical studies. These limitations prevented us from deriving more definite conclusions.
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Affiliation(s)
- Martina Pourová
- Department of Psychology, Faculty of Social Studies, Masaryk University, Czech Republic.
| | - Adam Klocek
- Department of Psychology, Faculty of Social Studies, Masaryk University, Czech Republic
| | - Tomáš Řiháček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Czech Republic
| | - Michal Čevelíček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Czech Republic
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Balabanovic J, Hayton P. Engaging patients with "medically unexplained symptoms" in psychological therapy: An integrative and transdiagnostic approach. Psychol Psychother 2020; 93:347-366. [PMID: 30618182 DOI: 10.1111/papt.12213] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 11/26/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Patients with "medically unexplained symptoms" or "MUS" experience subjectively compelling and distressing somatic symptoms that are not fully explained by underlying physical pathology. Effective treatment of these patients has been impeded by multiple barriers. Problems with patient engagement have been highlighted in the clinical and research literature, yet few exploratory studies have been conducted in this area. This research explores how experienced psychological therapists in a specialist MUS service work to engage these patients. DESIGN An in-depth qualitative study was conducted to explore the process of engaging patients with MUS in psychological therapy. METHOD Semi-structured depth interviews were conducted with psychological therapists who work with complex patients with MUS. The therapists interviewed were recruited from an NHS primary care psychological therapy service that specializes in working with this patient group. Data were analysed using grounded theory to develop a model of this process. RESULTS The analysis identified how multiple interacting layers of systemic, interpersonal, and intrapsychic disconnections impede engagement. The research introduces a new theoretical framework 'Negotiating disconnection' that conceptualizes the process of engagement in terms of a series of stages, namely 'Drawing in' (negotiating systemic disconnection), 'Meeting' (connecting in the disconnection), and 'Nudging Forward' (cultivating new connections), and illustrates how these are negotiated by therapists. CONCLUSIONS The model shows that it is critical for therapists to collaborate closely with GPs to engage these patients while also highlighting barriers to doing this, reflecting the complexities of organizational and cultural change. Clinically, the model illustrates the importance of adopting a flexible, pluralistic, and integrative approach that is person-centred and process-led. Doctors and therapists should embrace a holistic, biopsychosocial stance towards MUS and be sensitively attuned to its complex phenomenology. PRACTITIONER POINTS To engage patients with MUS psychological therapists should be person-centred and process-led rather than theory- or protocol-led. A pluralistic and integrative mindset facilitates this by enhancing clinicians' flexibility. A multidisciplinary approach is essential. Clinicians should embrace a biopsychosocial stance towards MUS and work closely with medical colleagues to help them do the same. Structural and cultural change is needed to tackle this issue effectively.
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Maass U, Kühne F, Maas J, Unverdross M, Weck F. Psychological Interventions for Health Anxiety and Somatic Symptoms. ZEITSCHRIFT FUR PSYCHOLOGIE-JOURNAL OF PSYCHOLOGY 2020. [DOI: 10.1027/2151-2604/a000400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. This study examined the effectiveness of psychological interventions for severe health anxiety (SHA) regarding somatic symptoms (SS) and health anxiety (HA). The databases Web of Science, EBSCO, and CENTRAL were searched on May 15, 2019, May 16, 2019, and August 5, 2019, respectively. Eighteen randomized controlled trials ( N = 2,050) met the inclusion criteria (i.e., hypochondriasis, illness anxiety disorder or somatic symptom disorder with elevated HA being assessed with validated interviews; use of standardized outcome measures). Two reviewers independently evaluated the studies’ risk of bias using the Revised Cochrane Risk-of-Bias Tool for randomized trials (RoB-2) tool. Overall, psychological interventions were significantly more effective than waitlist, treatment-as-usual, or placebo post-treatment ( gSS = 0.70, gHA = 1.11) and at follow-up ( gSS = 0.33, gHA = 0.70). CBT outperformed other psychological interventions or pharmacotherapy for HA post-treatment (Hedge’s gHA = 0.81). The number of sessions did not significantly predict the effect sizes. In sum, psychological interventions were effective for SHA, but the generalizability of the results for SS is limited, because only two high-quality trials contributed to the comparisons.
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Affiliation(s)
- Ulrike Maass
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
| | - Franziska Kühne
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
| | - Jana Maas
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
| | - Maria Unverdross
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
| | - Florian Weck
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
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Witthöft M, Bräscher AK, Jungmann SM, Köteles F. Somatic Symptom Perception and Interoception. ZEITSCHRIFT FUR PSYCHOLOGIE-JOURNAL OF PSYCHOLOGY 2020. [DOI: 10.1027/2151-2604/a000403] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Abstract. Models of chronic somatic symptoms assume that abnormalities in interoception are related to the development and maintenance of symptom distress. Different models, however, disagree on the exact nature of the assumed abnormality: cognitive-behavioral models stress a hypervigilant cognitive style (predicting higher interoceptive accuracy) whereas predictive processing models assume a less detailed sensory processing (predicting lower interoceptive accuracy). This study aimed at testing the relationship between interoception and symptom perception. Using structural equation modeling, associations between cardiac interoception and symptom perception were tested in a sample of students ( n = 316) and a second heterogeneous sample ( n = 340, including 63 patients with either pathological health anxiety or a somatoform disorder according to DSM-IV). Stronger sensory symptom perceptions in the cardiorespiratory system were associated with lower interoceptive accuracy in sample 2. The findings are more in line with the predictive processing approach, suggesting less detailed and more biased interoception being associated with chronic somatic symptom distress.
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Affiliation(s)
- Michael Witthöft
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University of Mainz, Germany
| | - Anne-Kathrin Bräscher
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University of Mainz, Germany
| | - Stefanie M. Jungmann
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University of Mainz, Germany
| | - Ferenc Köteles
- Institute of Health Promotion and Sport Sciences, ELTE Eötvös Loránd University, Budapest, Hungary
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Gol JM, Rosmalen JGM, Gans ROB, Voshaar RCO. The importance of contextual aspects in the care for patients with functional somatic symptoms. Med Hypotheses 2020; 142:109731. [PMID: 32335457 DOI: 10.1016/j.mehy.2020.109731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/01/2020] [Accepted: 04/08/2020] [Indexed: 12/30/2022]
Abstract
Functional somatic symptoms refer to physical symptoms that cannot be (bio) medically explained. The pattern or clustering of such symptoms may lead to functional syndromes like chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, among many others. Since the underlying pathophysiology remains unknown, several explanatory models have been proposed, nearly all including social and psychological parameters. These models have stimulated effectiveness studies of several psychological and psychopharmacological therapies. While the evidence for their effectiveness is steadily growing, effect-sizes are at most moderate and many patients do not benefit. We hypothesize that the context in which interventions for functional somatic symptoms are delivered substantially influences their effectiveness. Although this hypothesis is in line with explanatory models of functional somatic symptoms, to our knowledge, studies primarily focusing on the influence of contextual aspects on treatment outcome are scarce. Contextual research in the field of somatic symptoms has (irrespective whether these symptoms can be medically explained or not), however, just begun and already yielded some valuable results. These findings can be organized according to Duranti's and Goodwin's theoretical approach to context in order to substantiate our hypothesis. Based on this approach, we categorized empirical findings in three contextual aspects, i.e. 1) the setting, 2) the behavioural environment, and 3) the language environment. Collectively, some support is found for the fact that early identification of patients with functional somatic symptoms, starting treatment as soon as possible, having a neat appearance and an organized office interior, a warm and friendly nonverbal approach and a language use without defensiveness are contextual parameters which enhance the assessment by the patient of the physician's competence to help. Nonetheless, in vivo studies addressing the most aspects, i.e. nonverbal behaviour and language, are needed for better understanding of these contextual aspect. Moreover, future research should address to what extent optimizing contextual aspects improve care for functional somatic symptoms.
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Affiliation(s)
- J M Gol
- University of Groningen & University Medical Center Groningen, Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), PO Box 30.001 (CC72), 9700 RB Groningen, the Netherlands.
| | - J G M Rosmalen
- University of Groningen & University Medical Center Groningen, Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), PO Box 30.001 (CC72), 9700 RB Groningen, the Netherlands
| | - R O B Gans
- University of Groningen & University Medical Center Groningen, Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), PO Box 30.001 (CC72), 9700 RB Groningen, the Netherlands
| | - R C Oude Voshaar
- University of Groningen & University Medical Center Groningen, Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), PO Box 30.001 (CC72), 9700 RB Groningen, the Netherlands
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Selinheimo S, Vuokko A, Hublin C, Järnefelt H, Karvala K, Sainio M, Suojalehto H, Paunio T. Psychosocial treatments for employees with non-specific and persistent physical symptoms associated with indoor air: A randomised controlled trial with a one-year follow-up. J Psychosom Res 2020; 131:109962. [PMID: 32078837 DOI: 10.1016/j.jpsychores.2020.109962] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Persistent physical symptoms (PPS) associated with indoor air without an adequate pathophysiological- or environmental-related explanation may lead to work disability and decreased health-related quality of life (HRQoL). We attempted to assess the effect of cognitive behavioural therapy (CBT) for PPS and also psychoeducation (PE) on these symptoms involving disability. METHOD The intention-to-treat (ITT) sample included 52 employees recruited from an occupational healthcare service randomised as either controls undergoing treatment as usual (TAU) or TAU enhanced with CBT or PE. The primary outcome was HRQoL measuring the severity of symptoms and restrictions in everyday life caused by them. Secondary outcomes included depressive, anxiety and insomnia symptoms, and intolerance to environmental factors, assessed at baseline and at 3-, 6- and 12-month follow-ups. RESULTS At the 12-month follow-up assessment point, no statistically significant differences between treatments emerged following adjustment for gender, age, and HRQoL before the waiting period in the ITT analysis [F(2,46)=2.89, p=.07]. The secondary analysis revealed a significant improvement in HRQoL in the combined intervention group as compared with controls [F(1,47)=5.06, p=.03, g=0.41]. In total, 15% of participants dropped out during follow-up. CONCLUSIONS The results suggest that CBT for PPS or PE might not have a robust effect on HRQoL in PPS associated with indoor air, but the study did not achieve the planned power. Despite difficulties during the recruitment process, the final dropout rates remained low, and participants positively evaluated CBT, suggesting that it represents an acceptable treatment to them. Trial status This study was registered at the ClinicalTrials.gov registry (NCT02069002).
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Affiliation(s)
- Sanna Selinheimo
- Finnish Institute of Occupational Health, Helsinki, Finland; Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland.
| | - Aki Vuokko
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | - Christer Hublin
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | - Heli Järnefelt
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | - Kirsi Karvala
- Finnish Institute of Occupational Health, Helsinki, Finland; Insurance Medicine and Rehabilitation Unit, Keva, Finland.
| | - Markku Sainio
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | | | - Tiina Paunio
- Finnish Institute of Occupational Health, Helsinki, Finland; Department of Health, National Institute for Health and Welfare, Helsinki, Finland; Department of Psychiatry and the SleepWell Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Kube T, Rozenkrantz L, Rief W, Barsky A. Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts. Clin Psychol Rev 2020; 76:101829. [PMID: 32062101 DOI: 10.1016/j.cpr.2020.101829] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 01/11/2023]
Abstract
Persistent physical symptoms (PPS) are distressing, difficult to treat, and pose a major challenge to health care providers and systems. In this article, we review two disparate bodies of literature on PPS to provide a novel integrative model of this elusive condition. First, we draw on the clinical-psychological literature on the role of expectations to suggest that people with PPS develop dysfunctional expectations about health and disease that become increasingly immune to disconfirmatory information (such as medical reassurance) through cognitive reappraisal. Second, we invoke neuroscientific predictive processing accounts and propose that the psychological process of 'cognitive immunization' against disconfirmatory evidence corresponds, at the neurobiological and computational level, to too much confidence (i.e. precision) afforded to prior predictions. This can lead to an attenuation of disconfirming sensory information so that strong priors override benign bodily signals and make people believe that something serious is wrong with the body. Combining these distinct accounts provides a unifying framework for persistent physical symptoms and shifts the focus away from their causes to the sustaining mechanisms that prevent symptoms from subsiding spontaneously. Based on this integrative model, we derive new avenues for future research and discuss implications for treating people with PPS in clinical practice.
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Affiliation(s)
- Tobias Kube
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Gutenbergstr. 18, 35032 Marburg, Germany; Pain and Psychotherapy Research Lab, University of Koblenz-Landau, Ostbahnstr. 10, 76829 Landau, Germany.
| | - Liron Rozenkrantz
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Gutenbergstr. 18, 35032 Marburg, Germany
| | - Arthur Barsky
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Psychiatry, Harvard Medical School, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
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Agarwal V, Nischal A, Praharaj SK, Menon V, Kar SK. Clinical Practice Guideline: Psychotherapies for Somatoform Disorders. Indian J Psychiatry 2020; 62:S263-S271. [PMID: 32055068 PMCID: PMC7001354 DOI: 10.4103/psychiatry.indianjpsychiatry_775_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- Vivek Agarwal
- Department of Psychiatry, King George Medical College, Lucknow, Uttar Pradesh, India
| | - Anil Nischal
- Department of Psychiatry, King George Medical College, Lucknow, Uttar Pradesh, India
| | - Samir Kumar Praharaj
- Department of Psychiatry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vikas Menon
- Department of Psychiatry, JIPMER, Puducherry, India
| | - Sujita Kumar Kar
- Department of Psychiatry, King George Medical College, Lucknow, Uttar Pradesh, India
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Managing fibromyalgia syndrome in pregnancy no bridges between USA and EU. Arch Womens Ment Health 2019; 22:711-721. [PMID: 30607517 DOI: 10.1007/s00737-018-0933-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
The first aim of this article is to analyze the risk/benefit ratio of using psychotropic drugs approved in some countries for treating fibromyalgia syndrome (FMS) during pregnancy. Assessing the effectiveness of non-pharmacological interventions is the second scope of this article, in order to help clinicians to manage FMS in pregnancy in those countries were no drugs are approved for treating the disease. Following the PRISMA guidelines for systematic reviews, a literature search was conducted on PubMed and Google Scholar. Separate literature searches were performed for the three psychotropic drugs approved in the USA for treating FMS, psychotherapy, and transcranial magnetic stimulation (TMS). Perinatal duloxetine exposure is associated with increased risk of gestational and perinatal complications. With regards pregabalin, available information suggests that the drug is not devoid of structural teratogenicity potential. No data are available for milnacipran. Duloxetine and pregabalin should be only given to pregnant women diagnosed with severe forms of FMS after carefully weighing the benefits and risks for the mother-fetus dyad. On the other hand, we have to consider that the proportion of women who discontinue psychotropic drugs during pregnancy is as high as 85.4%. This figure raises further questions about adequate alternative treatment of FMS during the perinatal period. Moreover, neither duloxetine nor milnacipran or pregabalin have been approved by the EMEA for the treatment of FMS. Unfortunately, psychological treatment of FMS in perinatal women are not yet tested and data on TMS are conflicting.
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Abstract
Somatic symptom disorder (SSD) is a diagnosis that was introduced with publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013. It eliminated the diagnoses of somatisation disorder, undifferentiated somatoform disorder, hypochondriasis and pain disorder; most of the patients who previously received these diagnoses are now diagnosed in DSM-5 with SSD. The main feature of this disorder is a patient's concern with physical symptoms for which no biological cause is found. It requires psychiatric assessment to exclude comorbid psychiatric disease. Failure to recognise this disorder may lead the unwary physician or surgeon to embark on investigations or diagnostic procedures which may result in iatrogenic complications. It also poses a significant financial burden on the healthcare service. Patients with non-specific abdominal pain have a poor symptomatic prognosis with continuing use of medical services. Proven treatments include cognitive behavioural therapy, mindfulness therapy and pharmacological treatment using selective serotonin reuptake inhibitors or tricyclic antidepressants. The authors describe the case of a 31-year-old woman with an emotionally unstable personality disorder and comorbid disease presenting to the emergency department with a 3-week history of left-sided abdominal and leg pain. Despite a plethora of investigations, no organic cause for her pain was found. She was reviewed by the multidisciplinary team including surgeons, physicians, neurologists and psychiatrists. A diagnosis of somatoform symptom disorder was subsequently rendered. As patients with SSD will present to general practice and the emergency department rather than psychiatric settings, this case provides a cautionary reminder of furthering the need for appropriate recognition of this condition.
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Affiliation(s)
- Louise Dunphy
- Department of General Surgery, Wexham Park Hospital, Slough, UK
| | - Marta Penna
- Department of General Surgery, Wexham Park Hospital, Slough, UK
| | - Jihene El-Kafsi
- Department of General Surgery, Wexham Park Hospital, Slough, UK
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Chalder T, Patel M, James K, Hotopf M, Frank P, Watts K, McCrone P, David A, Ashworth M, Husain M, Garrood T, Moss-Morris R, Landau S. Persistent physical symptoms reduction intervention: a system change and evaluation in secondary care (PRINCE secondary) - a CBT-based transdiagnostic approach: study protocol for a randomised controlled trial. BMC Psychiatry 2019; 19:307. [PMID: 31640632 PMCID: PMC6805658 DOI: 10.1186/s12888-019-2297-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 09/20/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Persistent physical symptoms (PPS), also known as medically unexplained symptoms (MUS), affect approximately 50% of patients in secondary care and are often associated with disability, psychological distress and increased health care costs. Cognitive behavioural therapy (CBT) has demonstrated both short- and long-term efficacy with small to medium effect sizes for PPS, with larger treatment effects for specific PPS syndromes, including non-cardiac chest pain, irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS). Research indicates that PPS conditions share similar cognitive and behavioural responses to symptoms, such as avoidance and unhelpful beliefs. This suggests that a transdiagnostic approach may be beneficial for patients with PPS. METHODS A randomised controlled trial (RCT) will be conducted to evaluate the efficacy and cost-effectiveness of a transdiagnostic CBT-based intervention for PPS. 322 participants with PPS will be recruited from secondary care clinics. Participants stratified by clinic and disability level will be randomised to CBT plus standard medical care (SMC) versus SMC alone. The intervention consists of 8 CBT sessions delivered by a qualified therapist over a period of 20 weeks. Outcomes will be assessed at 9, 20, 40- and 52-weeks post randomisation. Efficacy will be assessed by examining the difference between arms in the primary outcome Work and Social Adjustment Scale (WSAS) at 52 weeks after randomisation. Secondary outcomes will include mood, symptom severity and clinical global impression at 9, 20, 40 and 52 weeks. Cost-effectiveness will be evaluated by combining measures of health service use, informal care, loss of working hours and financial benefits at 52 weeks. DISCUSSION This trial will provide a powered evaluation of the efficacy and cost-effectiveness of a transdiagnostic CBT approach versus SMC for patients with PPS. It will also provide valuable information about potential healthcare pathways for patients with PPS within the National Health Service (NHS). TRIAL REGISTRATION ClinicalTrials.gov NCT02426788. Registered 27 April 2015. Overall trial status: Ongoing; Recruitment status: No longer recruiting.
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Affiliation(s)
- Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK.
| | - Meenal Patel
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
| | - Kirsty James
- 0000 0001 2322 6764grid.13097.3cDepartment of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Matthew Hotopf
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
| | - Philipp Frank
- 0000000121901201grid.83440.3bDepartment of Behavioural Science and Health, University College London, London, UK
| | - Katie Watts
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
| | - Paul McCrone
- 0000 0001 2322 6764grid.13097.3cHealth Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anthony David
- 0000000121901201grid.83440.3bDivision of Psychiatry, University College London, London, UK
| | - Mark Ashworth
- 0000 0001 2322 6764grid.13097.3cPopulation Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Mujtaba Husain
- 0000 0000 9439 0839grid.37640.36South London and Maudsley NHS Foundation Trust, London, UK
| | - Toby Garrood
- grid.420545.2Department of Rheumatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Rona Moss-Morris
- 0000 0001 2322 6764grid.13097.3cSchool of Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sabine Landau
- 0000 0001 2322 6764grid.13097.3cDepartment of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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van Gils A, Hanssen D, van Asselt A, Burger H, Rosmalen J. Personalized, Web-Based, Guided Self-Help for Patients With Medically Unexplained Symptoms in Primary Care: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e13738. [PMID: 31596246 PMCID: PMC6913687 DOI: 10.2196/13738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/09/2019] [Accepted: 06/15/2019] [Indexed: 12/22/2022] Open
Abstract
Background Medically unexplained symptoms (MUS) constitute a major health problem because of their high prevalence, the suffering and disability they cause, and the associated medical costs. Web-based interventions may provide an accessible and convenient tool for managing MUS. We developed a personalized, Web-based, guided self-help intervention for MUS in primary care (Grip self-help) and would compare its effectiveness with that of usual care. Objective This paper aims to describe the rationale, objectives, and design of a pragmatic randomized controlled trial (RCT) assessing the effectiveness of Grip self-help. Methods For a pragmatic multicenter RCT, 165 adult patients with mild to moderate MUS will be recruited through general practices in the Netherlands. Randomization will be performed at general practice level. Over the course of several months, patients in the intervention group will receive a personalized set of Web-based self-help exercises, targeting the unhelpful cognitions, emotions, behaviors, and social factors that are relevant to them. The intervention is guided by a general practice mental health worker. The control group will receive care-as-usual. Primary outcome is physical health-related quality of life (RAND-36 or 36-item general health survey, physical component score). Secondary outcomes include severity of physical and psychological symptoms, mental health–related quality of life, cost-effectiveness, and acceptability. Assessments will take place at baseline, end of treatment, and at 16-, 26-, and 52-week follow-ups. Results Recruitment started in December 2018, and enrolment is ongoing. The first results are expected to be submitted for publication in December 2021. Conclusions To our knowledge, this is the first study to combine the concepts of electronic health, self-help, and personalized medicine in the treatment of MUS. By improving the quality of life and reducing symptoms of patients with MUS, Grip self-help has the potential to reduce costs and conserve scarce health care resources. Trial Registration Dutch Trial Register NTR7390; https://www.trialregister.nl/trial/7390. International Registered Report Identifier (IRRID) PRR1-10.2196/13738
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Affiliation(s)
- Anne van Gils
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Denise Hanssen
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Antoinette van Asselt
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Huibert Burger
- Department of General Practice, University Medical Center Groningen, University of Groningen,, Groningen, Netherlands
| | - Judith Rosmalen
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Řiháček T, Čevelíček M. Common therapeutic strategies in psychological treatments for medically unexplained somatic symptoms. Psychother Res 2019; 30:532-545. [PMID: 31345126 DOI: 10.1080/10503307.2019.1645370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: Medically unexplained somatic symptoms (MUSS) represent a frequent complaint in health care services. While psychological treatments have demonstrated some effect in patients with MUSS, further progress may be achieved by a synthesis of clinical strategies used in diverse treatment models. The aim of this study was to identify clinical strategies shared across multiple psychological treatments intended for the treatment of adult patients with MUSS. Method: Descriptions of psychological treatments for patients with MUSS were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. N = 135 resources met inclusion criteria and were subjected to qualitative analysis. Results: Similarities across treatments were captured in 8 broad categories and 18 subcategories that covered aspects of the therapeutic relationship, specific skills (bodily, emotional, and relational) for patients to develop, search for the meaning of symptoms, and the orientation on life beyond symptoms. Conclusions: Despite the differences in technique, it was possible to identify common therapeutic strategies in psychological treatments for patients with MUSS. These overarching treatment strategies, many of which have already obtained empirical support, may inspire further research and the development of comprehensive treatments with enhanced efficacy. Limitations of the present study include the lack of focus on specific syndromes.
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Affiliation(s)
- Tomáš Řiháček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
| | - Michal Čevelíček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
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Patel M, James K, Moss-Morris R, Husain M, Ashworth M, Frank P, Ferreira N, Mosweu I, McCrone P, Hotopf M, David A, Landau S, Chalder T. Persistent physical symptoms reduction intervention: a system change and evaluation (PRINCE)-integrated GP care for persistent physical symptoms: protocol for a feasibility and cluster randomised waiting list, controlled trial. BMJ Open 2019; 9:e025513. [PMID: 31340956 PMCID: PMC6661663 DOI: 10.1136/bmjopen-2018-025513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Persistent physical symptoms (PPS), also known as medically unexplained symptoms are associated with profound physical disability, psychological distress and high healthcare costs. England's annual National Health Service costs of attempting to diagnose and treat PPS amounts to approximately £3 billion. Current treatment relies on a positive diagnosis, life-style advice and drug therapy. However, many patients continue to suffer from ongoing symptoms and general practitioners (GPs) are challenged to find effective treatments. Training GPs in basic cognitive behavioural skills and providing self-help materials to patients could be useful, but availability in primary care settings is limited. METHODS AND ANALYSIS A cluster randomised waiting list, controlled trial will be conducted to assess the feasibility of an integrated approach to care in general practice. Approximately 240 patients with PPS will be recruited from 8 to 12 GP practices in London. GP practices will be randomised to 'integrated GP care plus treatment as usual' or waiting list control. Integrated GP care plus treatment as usual will include GP training in cognitive behavioural skills, GP supervision and written and audio visual materials for both GPs and participants. The primary objectives will be assessment of trial and intervention feasibility. Secondary objectives will include estimating the intracluster correlation coefficient for potential outcome measures for cluster effects in a sample size calculation. Feasibility parameters and identification of suitable primary and secondary outcomes for future trial evaluations will be assessed prerandomisation and at 12 and 24 weeks' postrandomisation, using a mixed-methods approach. ETHICS AND DISSEMINATION Ethical approval was granted by the Camberwell St Giles Ethics Committee. Results will be disseminated via peer-reviewed publications and conference presentations. This trial will inform researchers, clinicians, patients and healthcare providers about the feasibility and potential cost-effectiveness of an integrated approach to managing PPS in primary care. TRIAL REGISTRATION NUMBER NCT02444520; Pre-results.
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Affiliation(s)
- Meenal Patel
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Kirsty James
- Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rona Moss-Morris
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Mujtaba Husain
- Persistent Physical Symptoms Research and Treatment Unit, South London and Maudsley NHS Foundation Trust, London, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Philipp Frank
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nicola Ferreira
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Iris Mosweu
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Paul McCrone
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Matthew Hotopf
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anthony David
- Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sabine Landau
- Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Trudie Chalder
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Health-related quality among life of employees with persistent nonspecific indoor-air-associated health complaints. J Psychosom Res 2019; 122:112-120. [PMID: 30935665 DOI: 10.1016/j.jpsychores.2019.03.181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/24/2019] [Accepted: 03/24/2019] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Nonspecific health complaints associated with indoor air are common in work environments. In some individuals, symptoms become persistent without an adequate explanation. The aim was to study factors that associate with the health-related quality of life (HRQoL) of employees with persistent, nonspecific indoor-air-related symptomatology. METHODS We present baseline results of a randomized controlled trial of interventions targeted on the HRQoL of the employees with indoor-air-associated nonspecific symptoms. The main participant-inclusion criterion was the presence of persistent indoor-air-related multiorgan symptoms with no known pathophysiological or environment-related explanation. As a comparison for participants´ HRQoL (n = 52) we used data from the general-population Health 2011 study (BRIF8901) including information on subjects matched to the participants´ working status and age and subjects with asthma, anxiety or depressive disorder, or other chronic conditions with work disability. RESULTS The participants showed greater and a clinically significant impairment of HRQoL [M = 0.83, SE = 0.013] than individuals from the general population [M = 0.95, SE = 0.001, p < .001, Hedges´ g = 2.33] and those with asthma [M = 0.93, SE = 0.005, p < .001, Hedges´ g = 1.46], anxiety and depressive disorder [M = 0.89, SE = 0.006, p < .001, Hedges´ g = 0.73], or a chronic condition with work disability [M = 0.91, SE = 0.003, p < .001, Hedges´ g = 1.11]. Prevalent symptoms of depression, anxiety, and insomnia and poor recovery from work were associated with a poor HRQoL. CONCLUSIONS Individuals with nonspecific indoor-air-associated symptoms have a poorer HRQoL than individuals in the general population with a globally burdensome disease. Psychological distress associated with a poor HRQoL should be considered in the making of decisions about the treatment of these patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT02069002.
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