Direct diagnosis and management of emotional factors in chronic headache patients

Effectiveness of intensive short-term dynamic psychotherapy for Tension-Type Headache (TTH): A randomized controlled trial of effects on emotion regulation, anger, anxiety, and TTH symptom severity

Research has demonstrated the potential efficacy of intensive short-term dynamic psychotherapy (ISTDP) in addressing medically unexplained symptoms (MUS). However, the specific application of ISTDP for tension-type headache (TTH), a prevalent and common MUS, has not been extensively studied. In light of this gap in the literature, the current study investigated the effectiveness of intensive short-term dynamic psychotherapy (ISTDP) in treating TTH. The study assessed ISTDP's impact on emotion regulation (ER) capacities, levels of anxiety and anger, and TTH symptoms. 30 patients from the neurology clinic at Hazrat Rasool Hospital in Tehran were randomly assigned to either the intervention (n = 15) or control (n = 15) group. Pre- and post-treatment evaluations were conducted, followed by a ten-week follow-up assessment. Data were analyzed using repeated measures analyses of variance. The results indicated that ISTDP led to significant improvements in ER, reductions in anxiety and anger levels, and a significant decrease in TTH symptoms (ps < 0.001). Findings underscore the effectiveness of ISTDP as a valuable therapeutic approach for addressing TTH.

Understanding the gaps in headache and migraine treatment with psychological and behavioral interventions: A narrative review

OBJECTIVE

In this narrative review, we summarize relevant literature pertaining to psychosocial risk factors for headache and migraine progression, current behavioral and psychological treatments, and consider promising treatments.

BACKGROUND

Headache and migraine are common and associated with significant burden and disability. Current treatments targeting psychosocial risk factors show modest outcomes and do not directly address the impact of early life adversity, including the development of maladaptive emotional processing. An intervention that could address these factors and include components of current evidence-based interventions may lead to improved outcomes.

METHODS

We searched PubMed and Google Scholar for articles through December 2022. Search terms included headache, migraine, psychological interventions, behavioral interventions, cognitive-behavioral therapy, mindfulness, psychiatric comorbidities, adverse childhood experiences, trauma, and emotional processing.

RESULTS

Trauma and childhood adversity show a correlation with headache and migraine progression. Developmental adversity and trauma interfere with adaptive emotional processing, which may worsen headache and migraine symptoms, while adaptive ways of experiencing emotions are shown to improve symptoms. Current behavioral and psychological interventions, such as cognitive-behavioral and mindfulness therapies, are effective treatments for headache, but they produce small to medium effect sizes and do not directly address the impact of trauma and emotional conflicts-common factors that contribute to chronicity and disability, especially among certain subpopulations of headache patients such as those with migraine. Thus, there exists a gap in current treatment.

CONCLUSION

There is a gap in headache and migraine treatment for those patients who have a history of trauma, childhood adversity, and maladaptive emotional processing. We suggest that an integrated psychological treatment that includes components of current evidence-based interventions and addresses gaps by focusing on processing trauma-related emotions may improve chronic and debilitating symptoms.

The Effects of Emotion Regulation on Physical and Psychological Wellbeing in University Students: The Role of Depersonalization and Attachment Style

Our ability to regulate our emotions plays a key protective role against psychological distress and somatic symptoms, with most of the literature focusing on the role of cognitive reappraisal in interventions such as cognitive behavioral therapy (CBT). This study seeks to examine the relationship between emotion dysregulation and psychological and physical distress in university students through the role of depersonalization (DP) and insecure attachment. This study will try to explain the deployment of DP as a defense mechanism to insecure attachment fears and overwhelming stress, developing a maladaptive emotion responding strategy, which affects wellbeing later in life. A cross-sectional design was used on a sample (N = 313) of university students over the age of 18 which consisted of an online survey of 7 questionnaires. Hierarchical multiple regression and mediation analysis were conducted on the results. The results showed that emotion dysregulation and DP predicted each variable of psychological distress and somatic symptoms. Both insecure attachment styles were found to predict psychological distress and somatization, mediated through higher levels of DP, whereby DP may be deployed as a defense mechanism to insecure attachment fears and overwhelming stress, which affects our wellbeing. Clinical implications of these findings highlight the importance of screening for DP in young adults and university students.

The Effectiveness of Mindful Hypnotherapy on Psychological Inflexibility, Pain Acceptance, Headache Disability and Intensity in Females with Chronic Migraine Headache: A Randomized Clinical Trial

This study was a randomized controlled design and examined the feasibility and effectiveness of mindful hypnotherapy on psychological inflexibility, pain acceptance, headache disability, and headache intensity in patients with chronic migraine headaches. The sample consisted of 38 females with chronic migraine who were randomly assigned to mindful hypnotherapy and medical treatment as usual groups. Psychological inflexibility pain scale (PIPS), chronic pain acceptance questionnaire-revised (CPAQ-R), headache disability inventory (HDI), diary scale for headache, and short-form McGill pain questionnaire 2 (SF-MPQ-2) were administered at baseline and post-treatment in both groups. The psychological inflexibility mean (SD) score was 81.00 (12.15) at baseline, which significantly decreased to 53.28 (17.06) after the intervention (p < 0.001). Additionally, the mean (SD) score of the pain acceptance was 46.44 (11.16), which significantly increased to 73.61 (15.65) in post-intervention (p < 0.001). Furthermore, the mean (SD) score of headache disability was 73.55 (19.48), which significantly decreased to 23.33 (19.88) in post-intervention (p < 0.001). Finally, headache intensity was 7.33 (0.98) and 5.78 (1.83), which significantly decreased to 2.77 (2.04), and 1.38 (1.48) after the intervention based on the Diary Scale for Headache and McGill Pain Questionnaire (SF-MPQ-2), respectively (p < 0.001). In conclusion, the results show that mindful hypnotherapy is a feasible and effective treatment for chronic migraine.

A review of the treatment of functional neurological disorder with intensive short-term dynamic psychotherapy

The purpose of this article was to raise awareness of an under-recognized but well-supported treatment for Functional Neurological Disorders (FND) termed Intensive Short-term Dynamic Psychotherapy (ISTDP). There has been significant interest in the role of psychological mechanisms in FND onset and maintenance with specific evidence for maladaptive emotional processing. We outline how this supports the theoretical basis for ISTDP as an option in FND treatment and undertake a literature review of the current evidence base. We describe the application of ISTDP to FND illustrated through direct therapy transcripts. We conclude with reflections on the strengths and limitations of ISTDP as well as recommendations regarding future research.

Short-term psychodynamic psychotherapy for functional somatic disorders: A systematic review and meta-analysis of within-treatment effects

OBJECTIVE

A recent meta-analysis of 17 randomized, controlled trials (RCTs) showed that Short-term Psychodynamic Psychotherapy (STPP) for functional somatic disorders (FSD) reduced somatic symptoms compared to wait list, minimal treatment, and treatment-as-usual controls. A clinically important yet unanswered question is how much improvement patients experience within STPP treatment.

METHODS

Following a systematic search, we identified STPP trials presenting data at baseline and post-treatment/follow-up. Meta-analyses determined the magnitude of changes in somatic symptoms and other outcomes from before to after STPP, and analyses examined effect sizes as a function of study, therapy, and patient variables.

RESULTS

We identified 37 trials (22 pre-post studies and 15 RCTs) totaling 2094 patients treated an average of 13.34 sessions for a range of FSD. Across all studies, somatic symptoms improved significantly from pre-treatment to short-term follow-up with a large effect size (SMD = -1.07), which was maintained at long-term follow-up (SMD = -0.90). After excluding two outlier studies, effects at short- and medium-term follow-up remained significant but were somewhat reduced in magnitude (e.g., short-term SMD = -0.73). Secondary outcomes including anxiety, depression, disability, and interpersonal problems had medium to large effects. Effects were larger for studies of STPP that were longer than 12 sessions or used an emotion-focused type of STPP, and for chronic pain or gastrointestinal conditions than for functional neurological disorders.

CONCLUSIONS

STPP results in moderate to large improvements in multiple outcome domains that are sustained in long-term follow-up. STPP is an effective treatment option for FSD and should be included in treatment guidelines.

Psychological Therapy for Centralized Pain: An Integrative Assessment and Treatment Model

OBJECTIVE

Chronic pain is a significant health problem that is increasing in prevalence, and advances in treatment are needed.

METHODS

We briefly review the leading evidence-based psychological therapies for chronic pain-cognitive-behavioral and acceptance/mindfulness-based therapies-and examine several limitations and missing perspectives of these approaches. We review six lesser-known interventions that address these limitations, and we describe our integrative model for psychological assessment and treatment of centralized pain. We present a typical patient and describe how we apply this approach, along with challenges to its implementation and possible solutions to these challenges.

RESULTS

Greater pain treatment efficacy may be possible if clinicians: (a) distinguish patients with primarily centralized (i.e., somatoform or nociplastic) pain from those with primarily peripheral (nociceptive, inflammatory, or neuropathic) pain; (b) acknowledge the capacity of the brain not only to modulate pain but also generate as well as attenuate or eliminate centralized pain; (c) consider the powerful role that adverse life experiences and psychological conflicts play in centralized pain; and (d) integrate emotional processing and interpersonal changes into treatment. Our integrative treatment involves delivering a progression of interventions, as needed, to achieve pain reduction: tailored pain neuroscience education, cognitive and mindfulness skills to decrease the pain danger alarm mechanism, behavioral engagement in avoided painful and other feared activities, emotional awareness and expression to reverse emotional avoidance and overcome trauma or psychological conflict, and adaptive communication to decrease interpersonal stress.

CONCLUSIONS

This integrative assessment and treatment model has the potential to substantially reduce and sometimes eliminate centralized pain by changing the cognitive, behavioral, emotional, and interpersonal processes that trigger and maintain centralized pain.

Parallel Pains and Dynamic Dilemmas: Psychodynamic Considerations in Approaching and Managing Chronic Physical Pain

Chronic physical pain is prevalent condition and has gained considerable attention in the wake of the opioid crisis and epidemic. As a medical phenomenon, it has highlighted significant gaps in healthcare training, finances, clinical service, and administration. The psychodynamic determinants of pain symptoms or the need for analgesia are rarely considered in the medical management of this problem. The specific objective of this article is to offer a general psychodynamic understanding of chronic physical pain. As a psychodynamically oriented, medically informed psychiatrist practicing in a multidisciplinary pain management program, I propose a clinical construct of psychologically rich "parallel pains" to chronic physical pain, and that these pains inform important interpersonal issues dubbed "dynamic dilemmas." Chronic physical pain is defined, clinical examples are provided, and general implications are considered.

Identifying attachment ruptures underlying severe music performance anxiety in a professional musician undertaking an assessment and trial therapy of Intensive Short-Term Dynamic Psychotherapy (ISTDP)

Introduction

Kenny has proposed that severe music performance anxiety that is unresponsive to usual treatments such as cognitive-behaviour therapy may be one manifestation of unresolved attachment ruptures in early life. Intensive Short-Term Dynamic Psychotherapy specifically targets early relationship trauma. Accordingly, a trial of Intensive Short-Term Dynamic Psychotherapy with severely anxious musicians was implemented to assess whether resolution of attachment ruptures resulted in clinically significant relief from music performance anxiety.

Methods

Volunteer musicians participating in a nationally funded study were screened for MPA severity. Those meeting the critical cut-off score on the Kenny Music Performance Anxiety Inventory were offered a trial of Intensive Short-Term Dynamic Psychotherapy. In this paper, we present the theoretical foundations and rationale for the treatment approach, followed by sections of a verbatim transcript and process analysis of the assessment phase of treatment that comprised a 3-h trial therapy session.

Case description

The ‘case’ was a professional orchestral musician (male, aged 55) who had suffered severe music performance anxiety over the course of his entire career, which spanned more than 30 years at the time he presented for treatment following his failure to secure a position at audition.

Discussion and evaluation

The participant was able to access the pain, rage and grief associated with unresolved attachment ruptures with both parents that demonstrated the likely nexus between early attachment trauma and severe music performance anxiety.

Conclusion

Intensive Short-Term Dynamic Psychotherapy is a potentially cost-effective treatment for severe music performance anxiety. Further research using designs with higher levels of evidence are required before clinical recommendations can be made for the use of this therapy with this population.

Telemedicine vs. in-person delivery of intensive short-term dynamic psychotherapy for patients with medically unexplained pain: A 12-month randomized, controlled trial

Introduction This study examined the effectiveness of telemedicine in providing psychotherapy to patients with medically unexplained pain (MUP) who may not have access to in-person treatment. The impact of Internet-delivered intensive short-term dynamic psychotherapy (ID-ISTDP) was investigated for MUP via video teleconferencing (Skype™). Methods A randomized, controlled trial of ISTDP, an evidence-based intervention for MUP, was conducted to compare delivery modalities on variations in MUP symptoms. Eighty-one participants with MUP were randomized to either ID-ISTDP ( n = 39) or in-person ISTDP ( n = 42). Outcome variables included the Numeric Pain Rating Scale, Depression Anxiety Stress Scale-21, Emotion Regulation Questionnaire, Mindful Attention Awareness Scale and the Quality of Life Inventory. In addition, exploratory analyses were used to examine acceptability, satisfaction and compliance in both conditions. Participants were assessed prior to intervention, immediately following the intervention, and 12 months after. Results In the intention-to-treat analysis, in-person ISTDP participants had significantly lower pain intensity than ID-ISTDP participants, both immediately following the intervention ( d = 0.97) and at the 12-month follow-up ( d = 0.82). Moreover, there were significant decreases in depression, anxiety and stress as well as a greater increase in emotion regulation functioning, mindfulness and quality of life observed in the in-person ISTDP group at the end of the intervention and 12 months after the treatment when compared to the ID-ISTDP group. Participants rated both treatment conditions as equally credible and satisfying. Conclusion ISTDP seems most effective when delivered in person in treating MUP patients with highly comorbid conditions with benefits maintained over 12 months.

A Randomized Double-Blind Controlled Trial Comparing Davanloo Intensive Short-Term Dynamic Psychotherapy as Internet-Delivered Vs Treatment as Usual for Medically Unexplained Pain: A 6-Month Pilot Study

BACKGROUND

Research has shown that Intensive Short-Term Dynamic Psychotherapy (ISTDP) can effectively decrease pain intensity and improve quality of life in patients with medically unexplained pain.

OBJECTIVE

Understanding that not all patients with medically unexplained pain have access to in-person ISTDP, this study aims to investigate the efficacy of an Internet-delivered ISTDP for individuals with medically unexplained pain using Skype in comparison with treatment as usual.

METHOD

In this randomized controlled trial, 100 patients were randomly allocated into Internet-delivered ISTDP (n = 50) and treatment-as- usual (n = 50) groups. Treatment intervention consisted of 16 weekly, hour-long therapy sessions. The primary outcome was perceived pain assessed using the Numeric Pain Rating Scale. The secondary outcome included Depression Anxiety Stress Scale-21, Emotion Regulation Questionnaire, Mindful Attention Awareness Scale, and Quality-of-Life Inventory. Blind assessments were conducted at the baseline, posttreatment, and at a 6-month follow-up.

RESULTS

In the intention-to-treat analysis, pain symptoms in the intervention group were significantly reduced (p < 0.001), whereas a reduction was not observed in the treatment as usual group (p = 0.651). Moreover, there were significant decreases in depression, anxiety, and stress, as well as a greater increase in emotion regulation functioning, mindfulness, and quality of life observed in the intervention group 6 months after the treatment compared with the treatment as usual condition.

CONCLUSION

The results of this pilot trial demonstrate that 16 weeks of ISTDP delivered by Skype can significantly improve pain intensity and clinical symptoms of medically unexplained pain.

The Emergence of Psychodynamic Psychotherapy for Treatment Resistant Patients: Intensive Short-Term Dynamic Psychotherapy

Intensive short-term dynamic psychotherapy (ISTDP) was developed out of the need for relatively short psychodynamic psychotherapeutic treatment approaches to complex and resistant patient populations so common in public health systems. Based on extensive study of video recordings, Habib Davanloo discovered, and other researchers have validated, some important clinical ingredients that align the therapist with healthy aspects of the patient striving for resolution of chronic neurotic disorders and fragile character structure. In the case of character neurotic highly resistant patients, these approaches including "pressure," "clarification," "challenge to defenses," and "head on collision" can be used in a tailored and properly timed way to help the chronically suffering patient to overcome his or her own resistance and access core drivers of these pathologies. In this article the meta-psychological basis of ISTDP is reviewed and illustrated with an extended case vignette.

Defining the Role of Cognitive Behavioral Therapy in Treating Chronic Low Back Pain: An Overview

Study Design Narrative review of the literature. Objectives Determine if the term cognitive behavioral therapy (CBT) is useful in clinical care and research. What literature supports these variables being relevant to the experience of chronic pain? What effects of CBT in treating these factors have been documented? What methods and platforms are available to administer CBT? Methods Chronic low back pain (CLBP) is a complex neurologic disorder with many components. CBT refers to a broad family of therapies that address both maladaptive thoughts and behaviors. There are several ways to deliver it. CLBP was broken into five categories that affect the perception of pain, and the literature was reviewed to see the effects of CBT on these variables. Results The term cognitive behavioral therapy has little use in future research because it covers such a wide range of therapies. CBT should always be defined by the problem it is intended to solve. The format and method of delivery should be defined because they have implications for outcomes. They are readily available even at the primary care level. The effectiveness of CBT is unquestioned regarding its effectiveness in treating each of the variables that affect CLBP. It is unclear why it is not more widely implemented. Conclusions CBT represents a family of therapies that are effective for a wide range of problems, many of which coexist with and influence CLBP. Each of the variables can be improved with focused CBT. Early, widespread adoption of CBT in treating and preventing CLBP is recommended. Future research and clinical care should focus on strategies to operationalize these well-documented treatments utilizing a public health approach.

Long-term healthcare cost reduction with Intensive Short-term Dynamic Psychotherapy in a tertiary psychiatric service

OBJECTIVE

To evaluate whether a mixed population of patients treated with Intensive Short-term Dynamic Psychotherapy (ISTDP) would exhibit reduced healthcare costs in long-term follow-up.

METHODS

A quasi-experimental design was employed in which data on pre- and post-treatment healthcare cost were compared for all ISTDP cases treated in a tertiary care service over a nine year period. Observed cost changes were compared with those of a control group of patients referred but never treated. Physician and hospital costs were compared to treatment cost estimates and normal population cost figures.

RESULTS

1082 patients were included; 890 treated cases for a broad range of somatic and psychiatric disorders and 192 controls. The treatment averaged 7.3 sessions and measures of symptoms and interpersonal problems significantly improved. The average cost reduction per treated case was $12,628 over 3 follow-up years: this compared favorably with the estimated treatment cost of $708 per patient. Significant differences were seen between groups for follow-up hospital costs.

CONCLUSIONS

ISTDP in this setting appears to facilitate reductions in healthcare costs, supporting the notion that brief dynamic psychotherapy provided in a tertiary setting can be beneficial to health care systems overall. CLINICALTRIALS.

GOV IDENTIFIER NUMBER

NCT01924715.

Effects of anger awareness and expression training versus relaxation training on headaches: a randomized trial

BACKGROUND AND PURPOSE

Stress contributes to headaches, and effective interventions for headaches routinely include relaxation training (RT) to directly reduce negative emotions and arousal. Yet, suppressing negative emotions, particularly anger, appears to augment pain, and experimental studies suggest that expressing anger may reduce pain. Therefore, we developed and tested anger awareness and expression training (AAET) on people with headaches.

METHODS

Young adults with headaches (N = 147) were randomized to AAET, RT, or a wait-list control. We assessed affect during sessions, and process and outcome variables at baseline and 4 weeks after treatment.

RESULTS

On process measures, both interventions increased self-efficacy to manage headaches, but only AAET reduced alexithymia and increased emotional processing and assertiveness. Yet, both interventions were equally effective at improving headache outcomes relative to controls.

CONCLUSIONS

Enhancing anger awareness and expression may improve chronic headaches, although not more than RT. Researchers should study which patients are most likely to benefit from an emotional expression or emotional reduction approach to chronic pain.

Davanloo's Intensive Short-Term Dynamic Psychotherapy in a tertiary psychotherapy service: overall effectiveness and association between unlocking the unconscious and outcome

Background. Intensive Short-Term Dynamic Psychotherapy (ISTDP), as developed by Habib Davanloo, is an intensive emotion-focused psychodynamic therapy with an explicit focus on handling resistance in treatment. A core assumption in ISTDP is that psychotherapeutic effects are dependent on in-session emotional processing in the form of rise in complex transference feelings that occurs when treatment resistance is challenged. Recent research indicates that an unlocking of the unconscious, a powerful emotional breakthrough achieved at a high rise in complex transference feelings, can potentially enhance ISTDP's effectiveness. While ISTDP has a growing evidence base, most of the research conducted has used small samples and has tested therapy delivered by expert therapists. The aims of this study were to evaluate the overall effectiveness of ISTDP when delivered in a tertiary psychotherapy service, and to investigate if having an unlocking of the unconscious during therapy predicted enhanced treatment effectiveness. Methods. A total of 412 patients were included in the analyses. The average length of treatment was 10.2 sessions (SD 13.3). Multilevel growth curve modeling was used to evaluate treatment effectiveness and the association between unlocking the unconscious and outcome. A number of control predictors including type of treatment resistance were selected and included in the analyses. Outcome measures were the Brief Symptom Inventory (BSI) and the Inventory of Interpersonal Problems (IIP). About half of the patients in the study were treated by therapists in training and the other half by more experienced therapists. Results. Growth curve analyses using the full intention-to-treat sample revealed significant within-group effects of ISTDP on both the BSI and the IIP. Effect sizes were large (>0.80). Unlocking the unconscious during therapy was associated with significantly larger treatment outcome. The relationship was further moderated by type of treatment resistance. Conclusion. This study adds to the empirical base of Davanloo's ISTDP with confirmed treatment effectiveness in a large-scale patient sample when ISTDP was delivered by therapists with a range of experience. Furthermore, emotional mobilization in the form of unlocking the unconscious was confirmed as a process factor enhancing the effectiveness of ISTDP.

Psychotherapy versus usual care in pediatric migraine and tension-type headache: a single-blind controlled pilot study

Background

Despite growing interest in psychotherapy in child and adolescent headache, efficacy studies in this research field have focused mainly on cognitive-behavioral therapies. Whereas relaxation and cognitive-behavioral techniques, in particular, have been found to reduce the intensity and frequency of headache in children and adolescents, data on psychodynamic psychotherapy in this population are lacking.

Our aim was to explore the effectiveness of a brief psychodynamic psychotherapy program in the treatment of idiopathic headache in childhood and adolescence.

Methods

Thirty-three newly diagnosed idiopathic headache sufferers aged 6–18 years, consecutively referred to our outpatient services, were randomized to receive either a brief cycle of psychodynamic psychotherapy (eight sessions administered at two-week intervals) or usual care (clinical interview, neurological examination, counselling, symptomatic therapy).

The two groups were evaluated at baseline (T0) and at six months (T1) to be assessed for headache characteristics (i.e. frequency, intensity and duration), quality of life (i.e. the EuroQoL score), patient’s global health status (i.e. the Clinical Global Impression score), and emotional-behavioral symptoms (i.e. Child Behavior Checklist scores).

Results

The two groups were fairly similar with reference to the main demographic and clinical variables. The T0/T1 comparison showed a statistically significant improvement in headache frequency (p = 0.005), intensity (p < 0.001) and duration (p = 0.002), a statistically significant improvement in the CGI score (p = 0.018), and a borderline improvement in the EuroQoL score (p = 0.053) in the group receiving psychotherapy.

Conclusions

According to our pilot findings, a brief psychodynamic psychotherapy program may be more effective than usual care in children and adolescents with idiopathic headache.

Anxiety related to sexual abuse: A case of recurrent priapism

Recurrent priapism is notoriously difficult to treat and very distressing to the sufferer. There is little literature about emotional contributors to this condition. We report a case of a man with sexual abuse and severe anxiety who responded acutely to emotion-focused treatment with persistent cessation of severe recurrent priapism episodes. A second case treated with the same method had a similar response to treatment. Emotional factors may be relevant in certain cases of recurrent priapism and these factors warrant clinical management and formal study.

Intensive short-term dynamic psychotherapy: a systematic review and meta-analysis of outcome research

Habib Davanloo has spent his career developing and teaching methods to accelerate dynamic psychotherapy, including his technique of intensive short-term dynamic psychotherapy (ISTDP). Over the past 20 years, outcome studies using this treatment have been conducted and published. We performed a systematic review of the literature to obtain studies presenting ISTDP outcome data. We found 21 studies (10 controlled, and 11 uncontrolled) reporting the effects of ISTDP in patients with mood, anxiety, personality, and somatic disorders. Using the random-effects model, we performed meta-analyses including 13 of these studies and found pre- to post-treatment effect sizes (Cohen's d) ranging from 0.84 (interpersonal problems) to 1.51 (depression). Post-treatment to follow-up effect sizes suggested that these gains were maintained at follow-up. Based on post-treatment effect sizes, ISTDP was significantly more efficacious than control conditions (d = 1.18; general psychopathology measures). Study quality was highly variable, and there was significant heterogeneity in some analyses. Eight studies using various measures suggested ISTDP was cost-effective. Within limitations of study methodologies, this evidence supports the application of ISTDP across a broad range of populations. Further rigorous and targeted research into this method is warranted.

Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre-post intervention study

OBJECTIVE

Somatization of emotions accounts for excess emergency department (ED) visits in the form of medically unexplained symptoms (MUS). Intensive short-term dynamic psychotherapy (ISTDP) has been used to diagnose and manage somatization. We examined the effectiveness of this procedure for ED patients with MUS.

METHODS

We implemented a service that included staff education, timely access to consultation and gathering of outcome data.

RESULTS

Patients were assessed and treated shortly after referral. There was a mean reduction of 3.2 (69.0%) ED visits per patient (standard deviation [SD] 6.4) the year afterward (95% confidence interval [CI] 1.3-5.0, p< 0.001). In comparison revisit rates during the same time interval for 3 available ED populations (i.e., those matched by visit rates, those with matching complaints and all patients referred to the service but never seen) showed either smaller reductions or higher ED use (ranging from a 15% reduction to a 43% increase). Treatments averaged 3.8 sessions per patient (SD 5.3). Self reported symptoms improved significantly with the Brief Symptom Inventory global rating, which changed from a mean of 1.21 (SD 0.58) before assessment to 0.86 (SD 0.63) ( p< 0.01) at the end of contact with the service. The service appeared acceptable to both emergency physicians and patients.

CONCLUSION

This emotion-focused assessment and treatment method appeared to be feasible and may be effective in reducing both symptoms and repeat ED use.