Warten, Entspannung oder Verhaltenstherapie

Cognitive and emotional variables predicting treatment outcome of cognitive behavior therapies for patients with medically unexplained symptoms: A meta-analysis

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).

Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults

BACKGROUND

Medically unexplained physical symptoms (MUPS) are physical symptoms for which no adequate medical explanation can be found after proper examination. The presence of MUPS is the key feature of conditions known as 'somatoform disorders'. Various psychological and physical therapies have been developed to treat somatoform disorders and MUPS. Although there are several reviews on non-pharmacological interventions for somatoform disorders and MUPS, a complete overview of the whole spectrum is missing.

OBJECTIVES

To assess the effects of non-pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform disorders unspecified, somatoform autonomic dysfunction, pain disorder, and alternative somatoform diagnoses proposed in the literature) and MUPS in adults, in comparison with treatment as usual, waiting list controls, attention placebo, psychological placebo, enhanced or structured care, and other psychological or physical therapies.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to November 2013. This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library, EMBASE, MEDLINE, and PsycINFO. We ran an additional search on the Cochrane Central Register of Controlled Trials and a cited reference search on the Web of Science. We also searched grey literature, conference proceedings, international trial registers, and relevant systematic reviews.

SELECTION CRITERIA

We included RCTs and cluster randomised controlled trials which involved adults primarily diagnosed with a somatoform disorder or an alternative diagnostic concept of MUPS, who were assigned to a non-pharmacological intervention compared with usual care, waiting list controls, attention or psychological placebo, enhanced care, or another psychological or physical therapy intervention, alone or in combination.

DATA COLLECTION AND ANALYSIS

Four review authors, working in pairs, conducted data extraction and assessment of risk of bias. We resolved disagreements through discussion or consultation with another review author. We pooled data from studies addressing the same comparison using standardised mean differences (SMD) or risk ratios (RR) and a random-effects model. Primary outcomes were severity of somatic symptoms and acceptability of treatment.

MAIN RESULTS

We included 21 studies with 2658 randomised participants. All studies assessed the effectiveness of some form of psychological therapy. We found no studies that included physical therapy.Fourteen studies evaluated forms of cognitive behavioural therapy (CBT); the remainder evaluated behaviour therapies, third-wave CBT (mindfulness), psychodynamic therapies, and integrative therapy. Fifteen included studies compared the studied psychological therapy with usual care or a waiting list. Five studies compared the intervention to enhanced or structured care. Only one study compared cognitive behavioural therapy with behaviour therapy.Across the 21 studies, the mean number of sessions ranged from one to 13, over a period of one day to nine months. Duration of follow-up varied between two weeks and 24 months. Participants were recruited from various healthcare settings and the open population. Duration of symptoms, reported by nine studies, was at least several years, suggesting most participants had chronic symptoms at baseline.Due to the nature of the intervention, lack of blinding of participants, therapists, and outcome assessors resulted in a high risk of bias on these items for most studies. Eleven studies (52% of studies) reported a loss to follow-up of more than 20%. For other items, most studies were at low risk of bias. Adverse events were seldom reported.For all studies comparing some form of psychological therapy with usual care or a waiting list that could be included in the meta-analysis, the psychological therapy resulted in less severe symptoms at end of treatment (SMD -0.34; 95% confidence interval (CI) -0.53 to -0.16; 10 studies, 1081 analysed participants). This effect was considered small to medium; heterogeneity was moderate and overall quality of the evidence was low. Compared with usual care, psychological therapies resulted in a 7% higher proportion of drop-outs during treatment (RR acceptability 0.93; 95% CI 0.88 to 0.99; 14 studies, 1644 participants; moderate-quality evidence). Removing one outlier study reduced the difference to 5%. Results for the subgroup of studies comparing CBT with usual care were similar to those in the whole group.Five studies (624 analysed participants) assessed symptom severity comparing some psychological therapy with enhanced care, and found no clear evidence of a difference at end of treatment (pooled SMD -0.19; 95% CI -0.43 to 0.04; considerable heterogeneity; low-quality evidence). Five studies (679 participants) showed that psychological therapies were somewhat less acceptable in terms of drop-outs than enhanced care (RR 0.93; 95% CI 0.87 to 1.00; moderate-quality evidence).

AUTHORS' CONCLUSIONS

When all psychological therapies included this review were combined they were superior to usual care or waiting list in terms of reduction of symptom severity, but effect sizes were small. As a single treatment, only CBT has been adequately studied to allow tentative conclusions for practice to be drawn. Compared with usual care or waiting list conditions, CBT reduced somatic symptoms, with a small effect and substantial differences in effects between CBT studies. The effects were durable within and after one year of follow-up. Compared with enhanced or structured care, psychological therapies generally were not more effective for most of the outcomes. Compared with enhanced care, CBT was not more effective. The overall quality of evidence contributing to this review was rated low to moderate.The intervention groups reported no major harms. However, as most studies did not describe adverse events as an explicit outcome measure, this result has to be interpreted with caution.An important issue was that all studies in this review included participants who were willing to receive psychological treatment. In daily practice, there is also a substantial proportion of participants not willing to accept psychological treatments for somatoform disorders or MUPS. It is unclear how large this group is and how this influences the relevance of CBT in clinical practice.The number of studies investigating various treatment modalities (other than CBT) needs to be increased; this is especially relevant for studies concerning physical therapies. Future studies should include participants from a variety of age groups; they should also make efforts to blind outcome assessors and to conduct follow-up assessments until at least one year after the end of treatment.

Effectiveness of psychotherapy for severe somatoform disorder: meta-analysis

BACKGROUND

Patients with severe somatoform disorder (in secondary and tertiary care) typically experience functional impairment associated with physical symptoms and mental distress. Although psychotherapy is the preferred treatment, its effectiveness remains to be demonstrated.

AIMS

To examine the effectiveness of psychotherapy for severe somatoform disorder in secondary and tertiary care compared with treatment as usual (TAU) but not waiting-list conditions.

METHOD

Main inclusion criteria were presence of a somatoform disorder according to established diagnostic criteria and receiving psychotherapy for somatoform disorder in secondary and tertiary care. Both randomised and non-randomised trials were included. The evaluated outcome domains were physical symptoms, psychological symptoms (depression, anxiety, anger, general symptoms) and functional impairment (health, life satisfaction, interpersonal problems, maladaptive cognitions and behaviour).

RESULTS

Ten randomised and six non-randomised trials were included, comprising 890 patients receiving psychotherapy and 548 patients receiving TAU. Psychotherapy was more effective than TAU for physical symptoms (d = 0.80 v. d = 0.31, P<0.05) and functional impairment (d = 0.45 v. d = 0.15, P<0.01), but not for psychological symptoms (d = 0.75 v. d = 0.51, P = 0.21). These effects were maintained at follow-up.

CONCLUSIONS

Overall findings suggest that psychotherapy is effective in severe somatoform disorder. Future randomised controlled studies should examine specific interventions and mechanisms of change.

Specific collaborative group intervention for patients with medically unexplained symptoms in general practice: a cluster randomized controlled trial

BACKGROUND

Patients with medically unexplained symptoms (MUS) are frequent in primary care and substantially impaired in their quality of life (QoL). Specific training of general practitioners (GPs) alone did not demonstrate sustained improvement at later follow-up in current reviews. We evaluated a collaborative group intervention.

METHODS

We conducted a cluster randomized controlled trial. Thirty-five GPs recruited 304 MUS patients (intervention group: 170; control group: 134). All GPs were trained in diagnosis and management of MUS (control condition). Eighteen randomly selected intervention GPs participated in training for a specific collaborative group intervention. They conducted 10 weekly group sessions and 2 booster meetings in their practices, together with a psychosomatic specialist. Six and 12 months after baseline, QoL was assessed with the Short-Form 36. The primary outcome was the physical composite score (PCS), and the secondary outcome was the mental composite score (MCS).

RESULTS

At 12 months, intention-to-treat analyses showed a significant between-group effect for the MCS (p = 0.023) but not for the PCS (p = 0.674). This effect was preceded by a significant reduction of somatic symptom severity (15-item somatic symptom severity scale of the Patient Health Questionnaire, PHQ-15) at 6 months (p = 0.008) that lacked significance at 12 months (p = 0.078). As additional between-group effects at 12 months, per-protocol analyses showed less health anxiety (Whiteley-7; p = 0.038) and less psychosocial distress (PHQ; p = 0.024); GP visits were significantly (p = 0.042) reduced in the intervention group.

CONCLUSIONS

Compared to pure GP training, collaborative group intervention achieved a progressive, clinically meaningful improvement in mental but not physical QoL. It could bridge gaps between general practice and mental health care.

[Psychotherapeutic approaches for patients with somatoform disorders]

Patients with somatoform symptoms are considered to be difficult to treat. Clinical studies on treatment of this condition are underrepresented compared to other mental and psychosomatic disorders. Cognitive-behavioral treatment for patients with somatoform symptoms was found to have a significant effect; additionally, some evidence of recently published findings supports psychodynamic therapy. This report provides information on how to effectively deal with those patients. Furthermore it describes transtherapeutic targets and explains three therapeutic phases: establishing a therapeutic relationship, developing a model of the disorder and establishing coping strategies. As a last point a cognitive-behavioral treatment study, a psychodynamically-oriented study, a group intervention study and a new approach, a combination of cognitive-behavioral therapy and emotion regulation training, are presented.

Auswertung von Längsschnittdaten mit hierarchisch-linearen Modellen

Zusammenfassung. Hintergrund: Bislang werden im Bereich der klinischen Psychologie zur Analyse von Längsschnittdaten vor allem Varianzanalysen mit Messwiederholung (RM-ANOVA) verwendet. Mehrebenenmodelle für Längsschnittdaten sind demgegenüber in ihren Voraussetzungsannahmen weniger restriktiv und in ihren Analysemöglichkeiten weitaus flexibler. Fragestellung: Wie können Mehrebenenmodelle für Längsschnittdaten in der Psychotherapieforschung sinnvoll eingesetzt werden? Methode: Aufbauend auf dem Beitrag von Keller (2003) werden Probleme klassischer Verfahren der Datenauswertung am Beispiel der Wirksamkeitsevaluation einer kognitiv-verhaltenstherapeutischen Gruppentherapie erläutert und alternativen Modellen gegenübergestellt. Ergebnisse: Es wird gezeigt, wie lineare und nichtlineare Veränderungen beschrieben und getestet sowie eine zusätzliche Analyseebene im Gesamtmodell integriert werden können. Schlussfolgerung: Mehrebenenmodelle für Längsschnittdaten bieten eine adäquate Strategie, um typischen Anwendungsfällen der klinisch-psychologischen Forschung in optimaler Weise Rechnung zu tragen.