Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomised controlled trial

Trust, belief and transitions: people's experiences of multidisciplinary inpatient treatment for persistent physical symptoms. A qualitative study

PURPOSE

People with Persistent Physical Symptoms experience physical symptoms that are not wholly explained by a medical disorder or disease. Multidisciplinary treatment is recommended for people with severe difficulties and is provided in a small number of specialist centres in the UK. Only brief descriptions of this treatment are available, and the experiences of people receiving this treatment as an inpatient have not been explored. This study aimed to explore how people with persistent physical symptoms experience inpatient treatment from a specialist multidisciplinary team, and to identify which factors facilitated their engagement in the rehabilitation.

MATERIALS AND METHODS

18 people who had received inpatient multidisciplinary treatment for persistent physical symptoms participated in semi-structured interviews. The transcripts were analysed using reflexive thematic analysis.

RESULTS

Participants' experiences were influenced by whether they felt believed by the healthcare team, and whether they could place their own trust and belief in the staff team and the treatment approach. Their experiences involved a series of transitions; both in environment and understanding.

CONCLUSIONS

Improvements are possible for people receiving inpatient multidisciplinary treatment for severe PPS. Trusting relationships between patients and staff members take time to develop but play a major role in patients' experiences of treatment.

Understanding the Role of Therapist Quality in Accounting for Heterogeneity of Patient Outcomes in Psychosocial Chronic Pain Treatments

A variety of evidence-based psychosocial treatments now exist for chronic pain. However, on average, effect sizes have tended to be modest and there is a high degree of heterogeneity in treatment response. In this focus article, we explore the potential role that therapist quality in delivering treatment may have in accounting for a degree of this variability in outcome. Therapist quality refers to the skillful delivery of treatment, harnessing both specific and common therapeutic factors during sessions. While recognized as important to assess and report in clinical trials by some reporting guidelines, few randomized controlled trials evaluating psychosocial treatments for chronic pain have reported on therapist factors. We reviewed the clinical trials included in three systematic reviews and meta-analyses of trials of cognitive-behavioral therapy (mainly), mindfulness-based interventions, and acceptance and commitment therapy. We found that of the 134 trials included, only nine assessed and reported therapist quality indicators, with a variety of procedures used. This is concerning as without knowledge of the quality in which treatments are delivered, the estimates of effect sizes reported may be misrepresented. We contextualize this finding by drawing on the broader psychotherapy literature which has shown that more skillful, effective therapists demonstrated ten times better patient response rates. Examination of the characteristics associated with these more effective therapists tends to indicate that skillful engagement of common factors in therapy sessions represents a distinguishing feature. We conclude by providing recommendations for assessing and reporting on therapist quality within clinical trials evaluating psychosocial treatments for chronic pain. PERSPECTIVE: Therapist quality in the delivery of psychosocial treatments for chronic pain has rarely been assessed in clinical trials. We propose that therapist quality indicators are an under-studied mechanism that potentially contributes to the heterogeneity of treatment outcomes. We provide recommendations for assessing and reporting on therapist quality in future trials.

[Integrated Care for Patients with Somatic Symptom Disorder in Primary Care - A Qualitative Participatory Evaluation of a Randomised Feasibility Trial]

OBJECTIVE

The VISION intervention is a manualized short-term treatment for people with somatic symptom disorder, integrated into the primary care and delivered by psychotherapists via video consultations. As an innovative technology-based approach, the intervention was most recently piloted in a randomized feasibility trial. During the qualitative accompanying study presented here, the intervention was evaluated and optimised from the user perspective of patients who participated in the feasibility study.

METHODS

We interviewed a total of N=10 patients included in the intervention group in three semi structured focus group discussions focusing on how they (1) assess the intervention in terms of acceptance and individual benefit and (2) which adjustments are necessary from the user perspective for further optimization of the intervention. We performed a qualitative content analysis using MAXQDA Plus 2022.

RESULTS

Respondents reported initial reservations on their part regarding care via video consultation. After a brief period of habituation, the intervention was universally accepted. Main suggestions for improvement included a stronger focus on supporting patients find follow-up psychotherapy (if indicated) more flexible settings (e. g., location of video consultation), and a stronger integration of treatment into primary care.

DISCUSSION AND CONCLUSION

The study provides systematically elaborated comprehensive findings on participants' practical experiences with the intervention. The model is appropriate for treating people with somatic symptom disorder. Before implementation, important suggestions for improvement should be thoroughly considered with continued patient and public involvement.

Beliefs about emotions predict psychological stress related to somatic symptoms

BACKGROUND

Previous research has shown that the more people believe their emotions are controllable and useful (BECU), the less they generally report psychological distress. Psychological distress, in turn, impacts health outcomes, and is among the most frequently reported complaints in psychotherapeutic and psychosomatic practice.

OBJECTIVE

We aimed to examine how BECU predicts psychological distress related to somatic symptoms in a prospective sample from the general population and to replicate this association in two cross-sectional samples of psychosomatic patients.

METHODS

We applied a panel design with an interval of 2 weeks between T1 and T2 in general-population panel-participants (N = 310), assessing BECU and psychological distress related to somatic symptoms via validated self-report measures. Moreover, we cross-sectionally replicated the relationship between BECU and psychological distress in a clinical sample of psychosomatic outpatients diagnosed with somatoform disorders (n = 101) or without somatoform disorders (n = 628).

RESULTS

BECU predicted over and above the lagged criterion panel-participants' psychological distress related to somatic symptoms, β = -.18, p < .001. BECU was also cross-sectionally related to psychological distress in our clinical replication-sample of psychosomatic outpatients diagnosed with somatoform disorders, rS (87) = -.33, p = .002 and in those without, rS (557) = -.21, p < .001.

CONCLUSIONS

BECU as a malleable way of thinking about emotions predicted psychological distress related to somatic symptoms in general-population panel-participants and correlated with the same in two clinical replication samples. BECU thus becomes a promising treatment target in psychotherapeutic approaches.

A Clinical Trial of Psychodynamic-Interactional and Body Therapy in Somatoform Pain Disorders - Positive Interpersonal Experiences for Patients with Early Trauma

Objectives: The aim of this clinical trial was to explore whether psychodynamic-interactional therapy leads to a better outcome in the treatment of somatoform pain disorders when combined with body therapy. Methods: 30 patients diagnosed with this disorder took part in outpatient group therapies with 25 sessions. In the intervention condition, sessions based on psychodynamic-interactional and body therapy took place in weekly change, while in the control condition all sessions were based on psychodynamic-interactional therapy. Data were collected with self-report measures at the beginning and end of therapy and at the 6-months follow-up. Results: Under both conditions somatic and psychological symptoms merely remained stable from the first to the third measurement time. However, patients expressed a high level of satisfaction with the relationships in the group. Conclusions: Contrary to the assumptions, the two therapy conditions did not differ in the treatment outcome. Both conditions proved successful in providing patients with supporting interpersonal experiences.

Utility and optimal cut-off point of the Somatic Symptom Scale-8 for central sensitization syndrome among outpatients with somatic symptoms and related disorders

BACKGROUND

Central sensitization syndrome (CSS) involves severe functional symptoms due to central sensitization. for patients with severe somatic symptoms and related disorders (SSRDs), central sensitization may be responsible for their functional symptoms. We hypothesized that screening for CSS in patients with SSRDs would identify those with severe disease. The Somatic Symptom Scale-8 (SSS-8) is a simple tool to assess medical conditions related to SSRDs, but the cut-off point to identify severe cases of comorbid CSS is unknown. This study aimed to determine the optimal cut-off point of SSS-8 for screening the CSS of patients with severe SSRDs.

METHODS

In total, 143 patients with SSRDs attending outpatient clinics of a university hospital in Japan were included in the study. The participants were evaluated using the SSS-8 for somatic symptoms, Hospital Anxiety and Depression Scale (HADS) for anxiety and depressive symptoms, Pain Catastrophizing Scale (PCS) for catastrophic thoughts, and Central Sensitization Inventory (CSI-A, B) for CSS. Receiver operating characteristic (ROC) curve analysis was performed using the propensity score. The area under the curve (AUC) was calculated using a propensity score considering PCS, age, sex, HADS, and CSI-B as confounders of SSS-8 and CSS to evaluate differences in diagnostic accuracy between patients with and without SSS-8. The sensitivity and specificity of the ROC analysis were then used to determine the cut-off point for discriminating severe cases of SSS-8.

RESULTS

Of the 143 participants, 126 responded (51 CSS group and 75 non-CSS group), with a valid response rate of 88.1 percent. In the ROC analysis, the propensity score including SSS-8 was statistically more accurate. The optimal cut-off point was 13, with an AUC of 0.88, sensitivity of 84.3 percent, and specificity of 77.3 percent.

CONCLUSIONS

The SSS-8 is a useful tool for discriminating severe cases of SSRDs comorbid with CSS.

Migraine in the context of chronic primary pain, chronic overlapping pain disorders, and functional somatic disorders: A narrative review

OBJECTIVE

To contextualize migraine as the most common primary headache disorder in relation to other chronic primary pain and non-pain functional somatic and mental conditions.

BACKGROUND

Migraine is increasingly understood as a sensory processing disorder within a broader spectrum of symptom disorders. This has implications for diagnosis and treatment.

METHOD

Narrative review based on a search of the literature of the last 15 years on the overlap of migraine with other symptom disorders.

RESULTS

Migraine as the prototypical primary headache disorder not only comprises many non-headache symptoms in itself, it also shows high comorbidity with other chronic pain and non-pain conditions (e.g., fibromyalgia syndrome, irritable bowel syndrome, functional non-epileptic seizures, depression, anxiety, and posttraumatic stress disorder). Such "symptom disorders" share several etiological factors (e.g., female preponderance, psychological vulnerability) and psychophysiological mechanisms (e.g., altered sensory processing, pain expectancy). These facts are acknowledged by several recent integrative conceptualizations such as chronic primary pain, chronic overlapping pain conditions, or functional somatic disorders. Accordingly, migraine management increasingly addresses the total symptom burden and individual contributors to symptom experience, and thus incorporates centrally acting pharmacological and non-pharmacological, that is, psychological and behavioral, treatment approaches.

CONCLUSIONS

Migraine and also other primary headache disorders should be seen as particular phenotypes within a broader spectrum of symptom perception and processing disorders that require integrative diagnostics and treatment. A harmonization of classifications and better interdisciplinary collaboration are desirable.

A systematic review of economic analyses of psychological interventions and therapies in health-related settings

Background

This review aims to synthesise evidence on the economic impact of psychological interventions and therapies when applied to a broad range of physical health conditions.

Methods

The following bibliographic databases were searched for relevant articles: MEDLINE (Ovid), EMBASE (Ovid) and PsycINFO (Ebsco). As this review was intended to update an earlier review, the date range for the search was restricted to between January 2012 and September 2018. Reference lists from the review articles were also searched for relevant articles. Study quality was evaluated using the Scottish Intercollegiate Network Guidelines (SIGN) appraisal checklists for both economic studies and Randomised Controlled Trials (RCTs). When the economic analyses did not provide sufficient detail for quality evaluation, the original RCT papers were sought and these were also evaluated. Half of the papers were quality rated by a second author. Initial agreement was high and all disagreements were resolved by discussion.

Results

This yielded 1408 unique articles, reduced to 134 following screening of the title and abstract. The full texts of the remaining articles were reviewed by at least one team member and all exclusions were discussed and agreed by the team. This left 46 original research articles, alongside five systematic reviews. Fifty-seven per cent of the articles were deemed to be of high quality, with the remainder of acceptable quality. Fifteen different medical conditions were covered, with chronic pain (10 articles) and cancer (9 articles) being the two most investigated health conditions. Three quarters of the papers reviewed showed evidence for the cost-effectiveness of psychological interventions in physical health, with the clearest evidence being in the field of chronic pain and cancer.

Conclusions

This paper provides a comprehensive integration of the research on the cost-effectiveness of psychological therapies in physical health. Whilst the evidence for cost-effectiveness in chronic pain and cancer is encouraging, some health conditions require further study. Clearly, as the primary research is international, and was therefore conducted across varying health care systems, caution must be exercised when applying the results to counties outside of those covered. Despite this, the results are of potential relevance to service providers and funders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08158-0.

The interplay of chronic stress and genetic traits discriminates between patients suffering from multisomatoform disorder with pain as the leading symptom and matched controls

OBJECTIVE

Somatoform disorders and functional somatic syndromes (FSS) with symptoms that are not sufficiently explained by physical or technical examination are among the most challenging underlying causes. Many different somatoform disorders and FSS have overlapping symptoms, often with pain as the most prevalent one, leading to a high burden of disease. The concept of multisomatoform disorder (MSD) has been developed to acknowledge that fact. We analyzed a group of 151 patients and 149 matched controls to identify interactions of genetic and environmental factors with a possible influence on the development of MSD.

DESIGN

In a retrospective case-control study, we performed a statistical analysis on 151 patients and 149 matched controls using logistic regression and a Classification and Regression Tree (CART) analysis.

RESULTS

The logistic regression analysis of genes and environmental factors demonstrated significant differences in the results of the Trier Inventory of Chronic Stress (TICS) questionnaire, the single nucleotide polymorphism rs1800955 of the dopamine receptor D4 and the single nucleotide polymorphism rs4818 of the enzyme catechol-O-methyltransferase between patients with MSD and healthy controls. The resulting decision tree of the CART analysis determined that the TICS questionnaire was able to differentiate patients and controls most accurately, followed by certain genotypes of the 5-hydroxytryptamine receptor 2A and a single nucleotide polymorphism of the enzyme catechol-O-methyltransferase.

CONCLUSIONS

The results of the statistical analysis identified a gene-environmental interaction possibly leading to MSD. The resulting identifiers could be used as a reference to inform diagnostic algorithms to easier identify patients suffering from MSD.

Neurohumoral Profiles and Childhood Adversity of Patients with Multisomatoform Disorder and Pain as the Leading Bodily Symptom

Objective

Patients suffering from chronic pain often present with multifactorial underlying conditions, sometimes without concrete pathological physical findings. Functional somatic syndromes (FSS) and somatoform disorders show a high prevalence of 8-20% and are often associated with adverse childhood experiences (ACE) and chronic stress. As many different FSS have overlapping symptoms, the concept of multisomatoform disorder (MSD) has been introduced as an encompassing concept. We hypothesize that a common neurohumoral profile is present in patients with MSD that is distinct from gender- and age-matched controls and thus provides insight into possible common underlying mechanisms.

Design

In 151 patients with MSD (138 females) and 149 matched controls (131 females), we determined ACE by the Childhood Trauma Questionnaire (CTQ) and chronic stress by the Trier Inventory for Chronic Stress (TICS). Furthermore, the serum levels of leptin, FSH, LH, cortisol, DHEA-S, and IGF-1 have been assessed.

Results

There were significant differences in the levels of leptin, FSH, IGF-1, and cortisol between patients and controls, mainly driven by female participants. Levels of leptin were significantly correlated with BMI in patients, in controls, and in the female subgroup. This correlation was exaggerated in female patients when compared to female controls. Both CTQ and TICS predicted MSD directly and indirectly through the levels of leptin.

Conclusion

There is evidence of a distinct neurohumoral profile in female patients with MSD when compared to matched healthy controls, similar to what has been demonstrated in other chronic pain states. The observed profile can be taken as possible evidence for a dysregulated response to chronic stress and metabolic balance as well as a state of hypocortisolism and HPA-axis dysfunction. ACE and chronic stress play a major role in the development of MSD and altered neurohumoral profile.

Interpersonal Emotion Dynamics in Couples With Somatic Symptom Disorder: Dyadic Coherence in Facial Temperature During Emotional Interactions

OBJECTIVE

Disturbances in emotional processes are commonly reported in patients with a somatic symptom disorder (SSD). Although emotions usually occur in social interactions, little is known about interpersonal emotion dynamics of SSD patients during their actual emotional encounters. This study examined physiological coherence (linkage) between SSD patients and their partners, and in healthy couples during their emotional interactions. Secondarily, we explored group-level relationships between participants' and their partners' subjective affect.

METHODS

Twenty-nine romantic couples (16 healthy and 13 SSD patient-couples) underwent a dyadic conversation task with neutral and anger-eliciting topics followed by a guided relaxation. Partners' cutaneous facial temperature was recorded simultaneously by functional infrared thermal imaging. Immediately after each condition, participants reported on their pain intensity, self-affect, and perceived partner-affect.

RESULTS

Emotional conditions and having a partner with an SSD significantly affected coherence amplitude on the forehead (F(2,54) = 4.95, p = .011) and nose tip temperature (F(2,54) = 3.75, p = .030). From baseline to anger condition, coherence amplitude significantly increased in the patient-couples, whereas it decreased in the healthy couples. Correlation changes between partners' subjective affect comparably accompanied the changes in physiological coherence in healthy and patient-couples.

CONCLUSIONS

Inability to reduce emotional interdependence in sympathetic activity and subjective affect during a mutual conflict observed in SSD patient-couples seems to capture emotion co-dysregulation. Interventions should frame patients' emotional experiences as embodied and social. Functional infrared thermal imaging confirms to be an ecological and reliable method for examining autonomic changes in interpersonal contexts.Registration Page: https://osf.io/8eyjr.

Leptin promoter methylation in female patients with painful multisomatoform disorder and chronic widespread pain

Background

Different functional somatic syndromes (FSS), fibromyalgia (FMS) and other unexplained painful conditions share many common clinical traits and are characterized by troubling and functionally disabling somatic symptoms. Chronic pain is most frequently reported and at the center of patients’ level of disease burden. The construct of multisomatoform disorder (MSD) allows to subsume severely impaired patients suffering from FSS, FMS and other unexplained painful conditions to be examined for common underlying processes. Altered leptin levels and a pathological response of the HPA-axis as a result of chronic stress and childhood trauma have been suggested as one of the driving factors of disease development and severity. Previous studies have demonstrated that methylation of the leptin promoter can play a regulatory role in addiction. In this study, we hypothesized that methylation of the leptin promoter is influenced by the degree of childhood traumatization and differs between patients with MSD and controls. A cohort of 151 patients with MSD and 149 matched healthy volunteers were evaluated using clinical and psychometric assessment while methylation level analysis of the leptin promoter was performed using DNA isolated from whole blood.

Results

In female controls, we found CpG C-167 to be negatively correlated with leptin levels, whereas in female patients CpG C-289, C-255, C-193, C-167 and methylation cluster (C-291 to C-167) at putative bindings sites for transcription factors Sp1 and c/EBPalpha were negatively correlated with leptin levels. Methylation levels were significantly lower in female patients CpG C-289 compared with controls. When looking at female patients with chronic widespread pain methylation levels were significantly lower at CpG C-289, C-255 and methylation cluster (C-291 to C-167).

Conclusion

Our findings support the hypothesis that epigenetic regulation of leptin plays a role in the regulation of leptin levels in patients with MSD. This effect is more pronounced in patients with chronic widespread pain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13148-022-01235-5.

Perceived working mechanisms of psychosomatic therapy in patients with persistent somatic symptoms in primary care: a qualitative study

OBJECTIVES

To explore the perceived working mechanisms of psychosomatic therapy according to patients with persistent somatic symptoms (PSS) and their psychosomatic therapists.

DESIGN

Qualitative study using semistructured face-to-face interviews and focus groups. All interviews were audiorecorded, transcribed verbatim and analysed, by two researchers independently, based on the thematic analysis.

SETTING

Alongside a randomised controlled trial to establish the (cost-)effectiveness of psychosomatic therapy in patients with PSS in primary care, we conducted a process evaluation with a qualitative study. Patients were recruited in general practice in three regions in the Netherlands.

PARTICIPANTS

Interviews were conducted with twenty patients with PSS who received psychosomatic therapy and 25 psychosomatic therapists. In addition, two focus groups were conducted with six and seven psychosomatic therapists, respectively.

INTERVENTION

Psychosomatic therapy, delivered by specialised exercise and physical therapists, is a multimodal and tailored treatment based on the biopsychosocial model.

OUTCOME MEASURES

Experiences, opinions and views from patients' and therapists' perspective on psychosomatic therapy were identified.

RESULTS

A total of 37 interviews with patients, 25 interviews and two focus groups with therapists were analysed. Three main themes emerged from the data of the patients: (1) continuous alternation of psychosocial conversations and body-oriented exercises; (2) awareness of body-mind connection and (3) good relationship with therapist. Four main themes emerged from the data of the therapists (1) building rapport; (2) continuously searching for common ground; (3) making patients aware of the interaction between body and mind; and (4) continuous alternation between exploration and treatment.

CONCLUSION

According to patients as well as therapists, the continuous alternation of psychosocial conversations and body-oriented exercises to provide awareness of the interaction between body and mind are the perceived working mechanism of psychosomatic therapy. Therapeutic alliance and finding common ground between patient and therapist are prerequisites for the success of psychosomatic therapy.

TRIAL REGISTRATION NUMBER

NL7157 (NTR7356).

The Validity of Somatic Symptom Disorder in Patients With Gastrointestinal Complaints

BACKGROUND AND GOAL

The current diagnostic concept of somatic symptom disorder (SSD) aims to capture psychological burden due to bodily complaints independent of the medical cause. The aim of this study was to compare patients with chronic gastrointestinal (GI) complaints with SSD (SSD+) and without SSD (SSD-) along sociodemographic, clinical, and psychological characteristics.

STUDY

This cross-sectional study included 199 patients (n=92 SSD+ and n=107 SSD-) with distressing and chronic abdominal/lower GI complaints (≥6 mo) recruited from several primary, secondary, and tertiary medical care units. SSD+ patients were separated from SSD- patients by psychobehavioral positive criteria. Psychological distress (somatization, depression, anxiety, and illness anxiety) and risk factors (adverse childhood experiences, insecure attachment, mentalizing capacity, and levels of personality functioning) were measured. Nonparametric group comparisons were performed to analyze the differences of sociodemographic, clinical, and psychological characteristics between SSD+ and SSD- patients.

RESULTS

About half of the SSD+ patients had a functional GI disorder and a third had an inflammatory bowel disease. SSD+ patients reported higher GI pain severity, higher health-related and work-related impairment, and higher psychological distress, especially illness anxiety, as well as higher mentalizing and personality functioning deficits.

CONCLUSIONS

Overall, psychobehavioral positive criteria of SSD seem to be a valid identifier of patients exhibiting a high psychological burden, independent of the medical explanation of the GI complaints. There is a substantial overlap of SSD and general mental burden, but also evidence for a specific disease entity.

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.

A Randomized Controlled Trial Evaluating Integrative Psychotherapeutic Group Treatment Compared to Self-Help Groups in Functional Vertigo/Dizziness

We tested the efficacy of an integrative psychotherapeutic group treatment (IPGT) in reducing vertigo/dizziness-related impairment along with depression, anxiety, and somatization by conducting a randomized controlled superiority trial comparing IPGT to self-help groups moderated by a clinical psychologist (SHG). Adult patients with functional vertigo and dizziness symptoms were randomly allocated to either the IPGT or SHG as active control group. Outcomes were assessed at baseline (t0), after treatment lasting 16 weeks (t1), and 12 months after treatment (t2). A total of 81 patients were assigned to IPGT and 78 patients were assigned to SHG. Vertigo-related impairment was reduced in both conditions (IPGT: t0–t1: d = 1.10, t0–t2: d = 1.06; SHG: t0–t1: d = 0.86, t0–t2: d = 1.29), showing the efficiency of both IPGT and SHG. Clinically relevant improvements were also obtained for depression in both groups. Linear mixed model analyses revealed no differences between groups for all outcomes (effect of group for the primary outcome: b = −1.15, SE = 2.13, t = −0.54, p = 0.59). Attrition rates were higher in SHG (52.6%) than in IPGT (28.4%). Both conditions improved primary and secondary outcomes while IPGT was better accepted by patients than SHG. Trial registration: ClinicalTrials.gov, Identifier: NCT02320851.

Different Dimensions of Affective Processing in Patients With Irritable Bowel Syndrome: A Multi-Center Cross-Sectional Study

Objective: Deficits in affective processing are associated with impairments in both mental and physical health. The role of affective processing in patients with functional somatic complaints such as irritable bowel syndrome (IBS) remains unclear. Most studies have focused on the capacity for emotional awareness and expression, but neglect other dimensions of affective processing. Therefore, this study aimed to systematically analyze differences in six different dimensions of affective processing between patients with IBS and healthy controls (HCs). Additionally, we exploratively investigated the impact of IBS symptom severity, psychological distress, and attachment styles on affective processing in IBS. Methods: A controlled cross-sectional multi-center study was conducted. Overall, 127 patients with IBS were compared with 127 matched HCs using multivariate analysis of variances. Affective processing was operationalized in line with the affect cascade model on six specific dimensions: emotional experience, emotional awareness, affect tolerance, affect differentiation, affect regulation, and emotional communication. They were measured using two subscales of the Mentalizing Questionnaire (MZQ) and four subscales of the Operationalized Psychodynamic Diagnosis-Structure Questionnaire (OPD-SQ). Linear regression analysis was used to investigate the influence of IBS symptom severity (IBS-Severity Scoring System, IBS-SSS), depression (Patient Health Questionnaire, PHQ-9), anxiety (General Anxiety Disorder, GAD-7), and anxious and avoidant attachment styles (Experiences in Close Relationships Scale, ECR-RD12) on the different dimensions of affective processing in IBS. Results: Patients with IBS compared to HCs showed deficits in all six dimensions of affective processing. Deficits were largest for affect tolerance (d = 0.849) and lowest for emotional experience (d = 0.222) and emotional awareness (d = 0.420). Moderate effect sizes were found for affect differentiation (d = 0.773), emotional communication (d = 0.665), and affect regulation (d = 0.552). Moreover, explorative analyses indicated that affective processing in patients with IBS was significantly influenced by levels of anxiety and insecure attachment. Conclusion: The results indicate a specific pattern of affective processing abilities in patients with IBS. The deficits in affective processing are more prominent in the area of understanding and tolerating difficult affective states than experiencing affective states. This opens interesting perspectives for the development of specific psychotherapeutic interventions. Clinical Trial Registration: DRKS00011685.

Stress, depression, and the therapeutic alliance as mediators on the outcome of brief psychodynamic-interpersonal psychotherapy for multisomatoform disorder

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.

Psychodynamic Psychotherapy for Patients With Functional Somatic Disorders and the Road to Recovery

Patients with functional somatic disorders (FSDs) are commonly encountered in clinical practice and are often considered difficult to treat. This article summarizes recent advances in the understanding of these disorders that have opened new avenues for treatment. Findings concerning the role of three related key biobehavioral systems (attachment, mentalizing, and impairments in epistemic trust) that seem to be centrally involved in FSDs, as viewed from a psychodynamic perspective, are discussed as well as empirical evidence supporting the efficacy of psychodynamic psychotherapy for patients with FSDs. Finally, the basic treatment principles of dynamic interpersonal therapy, an integrative psychodynamic treatment adapted for patients with FSDs, are outlined through a description of the treatment of a woman with chronic widespread pain and irritable bowel syndrome.

[Validation of the Short-Form-Health-Survey-12 (SF-12 Version 2.0) assessing health-related quality of life in a normative German sample]

Validation of the Short-Form-Health-Survey-12 (SF-12 Version 2.0) assessing health-related quality of life in a normative German sample Objectives: Convergent and divergent validation of the Short-Form-Health-Survey-12 assessing HRQoL by analyzing its associations with depressiveness (PHQ-9), social support (OSS-3) and satisfaction with life (SWLS). Methods: A normative German sample (N = 2.524) was analyzed using correlation, regression as well as confirmatory factor analysis and structural equation modelling for ordinal data. Results: The SF-12-scale Mental Health is associated most strongly with the validation criteria (PHQ: r[scales/constructs] = -.73/-.88, OSS-3: r = .35/.55, SWLS: r = .47/.62). Mental Health (β = .36) and Social Support (OSS-3; β = .25) allow to explain a significant amount of variance of the SWLS (R2 = .28). On construct level Emotional Role Functioning (β = .28) proved to be significant additionally. Conclusions: The SF-12 scales are associated with the validation criteria as expected. The SF- 12 proved to be suitable for modelling core components of HRQoL within a biopsychosocial framework aiming at predicting satisfaction with life.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012.

OBJECTIVES

To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU).

SEARCH METHODS

We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials.

SELECTION CRITERIA

RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end.

DATA COLLECTION AND ANALYSIS

Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment.

MAIN RESULTS

We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned.

AUTHORS' CONCLUSIONS

We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT.

Multimodal psychotherapy in the management of somatization disorder

BACKGROUND

Somatization is the presentation of physical symptoms without an objective and identifiable cause, and the condition is among the most common and challenging problems in primary medical care. Several modal of psychotherapy modal is being practiced but effective treatment in rarely delivered.

AIM

The aim of this study is to evaluate the efficacy and durability of multimodal psychotherapy in the management of somatization disorder.

MATERIALS AND METHODS

This is a hospital-based study using the pre-post design with control group. Thirty outpatient department patients with somatization disorder were selected and divided into two groups, i.e., intervention group and control group using the purposive sampling method. Intervention group was given 12 sessions of management package, i.e., symptoms monitoring form, scheduling of daily activity, sleep hygiene, diaphragmatic breathing, psycho-social intervention, psychodynamic individual psychotherapy, and cognitive restructuring (approximately 3-4 months). Efficacy and durability were measured by the Bradford somatic inventory, general health questionnaire-28 (GHQ-28), defense mechanism inventory (DMI), and Sack's sentence completion test (SSCT).

RESULTS

The results reveal that there are significant differences found among intervention group in comparisons to the control group in the context of somatic complaints (BSI), general health functioning (GHQ-28), life conflict (SSCT), and in defense mechanism (DMI). Significant improvement also found between postintervention and follow-up of the intervention group on different study variables.

CONCLUSION

The present study findings indicate that multimodal psychotherapy program is effective in the Indian context in the management of somatization disorder.

Psychological Interventions for Health Anxiety and Somatic Symptoms

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.

Quantitative Sensory Testing in Patients with Multisomatoform Disorder with Chronic Pain as the Leading Bodily Symptom-a Matched Case-Control Study

OBJECTIVE

Chronic pain is a debilitating condition of multifactorial origin, often without physical findings to explain the presenting symptoms. Of the possible etiologies of persisting painful symptoms, somatoform disorders and functional somatic syndromes (FSS) are among the most challenging, with a prevalence of 8-20%. Many different somatoform disorders and FSS have overlapping symptoms, with pain being the most prevalent one. The concept of multisomatoform disorder (MSD) has been developed to acknowledge that fact. We hypothesized that the concept of MSD will be reflected in a distinct sensory profile of patients compared with healthy controls and possibly provide insight into the type and pathophysiology of the pain commonly experienced by patients.

DESIGN

We performed comprehensive quantitative sensory testing (QST) in 151 patients and 149 matched controls.

RESULTS

There were significant differences in the sensory profiles of patients compared with controls. Patients with MSD showed a combination of tactile and thermal hypesthesia combined with mechanical and cold hyperalgesia. This was true for measurements at test and control sites, with the exception of vibration detection threshold and mechanical pain threshold. Among the observed changes, a marked sensory loss of function, as evidenced by an increase in cold detection threshold, and a marked gain of function, as evidenced by a decrease of pressure pain threshold, were most notable. There was no evidence of concurrent medication influencing QST results.

CONCLUSIONS

The observed somatosensory profile of patients with MSD resembles that of patients suffering from neuropathic pain with evidence of central sensitization.

Childhood traumatization is associated with differences in TRPA1 promoter methylation in female patients with multisomatoform disorder with pain as the leading bodily symptom

Background

The construct of multisomatoform disorder (MSD) is a common point of reference for patients in different somatic and psychosomatic specialties and therefore useful in studying large well-characterized cohorts of a prototype of a somatoform disorder and in parallel as a functional somatic syndrome (FSS). This disorder is characterized by distressing and functionally disabling somatic symptoms with chronic pain as the most frequent and clinically relevant complaint. Pain is perceived by nociceptive nerve fibers and transferred through the generation of action potentials by different receptor molecules known to determine pain sensitivity in pathophysiological processes. Previous studies have shown that for the transient receptor potential ankyrin 1 (TRPA1), receptor methylation of a particular CpG dinucleotide in the promoter region is inversely associated with both heat pain and pressure pain thresholds. In this study, we hypothesized that TRPA1 promoter methylation regulates pain sensitivity of patients with multisomatoform disorder (MSD). A cohort of 151 patients with MSD and 149 matched healthy volunteers were evaluated using quantitative sensory testing, clinical and psychometric assessment, and methylation analysis using DNA isolated from whole blood.

Results

We found CpG -628 to be correlated with mechanical pain threshold and CpG -411 to be correlated with mechanical pain threshold in female volunteers, i.e., higher methylation levels lead to higher pain thresholds. A novel finding is that methylation levels were significantly different between patients with no and severe levels of childhood trauma. CpG methylation also correlated with psychometric assessment of pain and pain levels rated on a visual analog scale.

Conclusion

Our findings support the hypothesis that epigenetic regulation of TRPA1 plays a role in mechanical pain sensitivities in healthy volunteers. They further provide evidence for the possible influence of childhood traumatic experiences on the epigenetic regulation of TRPA1 in patients with MSD.

Electronic supplementary material

The online version of this article (10.1186/s13148-019-0731-0) contains supplementary material, which is available to authorized users.

Emotion regulation in patients with somatic symptom and related disorders: A systematic review

Background

Somatic symptoms and related disorders (SSD) are prevalent phenomena in the health-care system. Disturbances in emotion regulation (ER) are commonly observed in patients suffering from SSD.

Objectives

This review aimed to examine ER processes that characterize SSD by a systematic analysis of the available empirical studies.

Data sources

PsycINFO and PubMed databases for the articles published between January 1985 and June 2018.

Search terms

“emotion/al regulation” or “affect regulation” and various forms of SSD.

Study eligibility criteria

Empirical studies that a) assigned adolescent or adult patients suffering from SSD based on a clinical diagnosis, and b) examined the relationship between ER and SSD, were included.

Study synthesis methods

A tabular summary of the articles was generated according to study characteristics, study quality, variables, and findings. The findings were organized based on ER variables used in the articles and diagnoses of SSD, which were then re-organized under the main constituents of ER (attention, body, and knowledge).

Results

The findings of the 64 articles largely supported the association between SSD and disturbances in ER, which are usually shared by different diagnoses of SSD. The results indicate that patients show a reduced engagement with cognitive content of emotions. On the other hand, bodily constituents of ER seem to depict an over-reactive pattern. Similarly, the patients tend to encounter difficulties in flexibly disengaging their (spontaneous) attention from emotional material.

Limitations

There is a scarcity of longitudinal designs, randomized controlled trials, experiments, and diary studies suited to investigate the short- and long-term causal relationship between ER and SSD. Symptoms of SSD and measures to assess emotion regulation are heterogeneous.

Conclusions and implications

Assessment of ER processes is potentially useful to understand SSD and for treatment planning. Furthermore, a concurrent investigation of the dynamic interaction of the ER modalities promises insights for better understanding of the role of ER in development, course, and maintenance of SSD.

Group body psychotherapy for the treatment of somatoform disorder - a partly randomised-controlled feasibility pilot study

BACKGROUND

Clinical outcomes for patients with heterogeneous somatoform disorder (bodily distress disorder, including medically unexplained symptoms) are suboptimal, new treatments are required to improve acceptance. Body-oriented psychological therapy approaches have been identified as potentially beneficial additions to the portfolio of treatments. This study was aiming to assess the acceptability, the potential benefits, and associated change processes of manualised group body psychotherapy (BPT) for outpatients with Somatoform Disorder.

METHODS

A randomized controlled feasibility trial was carried out with follow-up at 6 months after baseline assessments using the Primary Health Questionnaire (PHQ), Somatic Symptom Screening Scale (SOMS-7), quality of life ratings (Short-Form Health Survey-36; SF-36) and body image measures (Dresden Body Image Questionnaire). Acceptance was assessed with the Helping Alliance Scale (HAS).

RESULTS

A total of 24 patients were recruited to participate. Sixteen patients were randomly assigned to receive either manualised BPT or TAU, eight patients were directly assigned to BPT. Drop-out rates were acceptable, patients reported to be highly satisfied with the group intervention. Somatic symptom levels reduced significantly in the BPT group. Additionally, a significant effect on self-acceptance and the mental component of quality of life was observed.

CONCLUSION

Group body psychotherapy is a feasible and acceptable treatment for patients with somatoform disorder and a larger trial studying the effectiveness of BPT in these patients should be conducted.

TRIAL REGISTRATION

Retrospectively registered SRCTN12277345 ; Trial Registraton Date: 27/03/2019.

Potential effects of multimodal psychosomatic inpatient treatment for patients with functional vertigo and dizziness symptoms - A pilot trial

OBJECTIVES

Functional vertigo and dizziness (VD) are frequent and severely distressing complaints that are often described as hard to treat. Our aim was to provide preliminary data on potential effects of multimodal psychosomatic inpatient therapy for patients with functional VD symptoms in reducing vertigo-related handicap and related psychopathology, and to evaluate the role of symptom burden and body-related locus of control in predicting vertigo-related handicap at follow-up.

DESIGN

We conducted an uncontrolled clinical pilot trial.

METHODS

We included data of n = 72 inpatients with functional VD as a primary symptom and various psychopathological and/or physical comorbidities admitted for multimodal psychosomatic inpatient treatment. Patients completed self-report questionnaires assessing vertigo-related handicap (VHQ), somatization (PHQ-15), depression (BDI-II), anxiety (BAI), health-related quality of life (HRQOL; SF-36), and body-related locus of control (KLC) at admission (T0), discharge (T1), and 6 months after discharge (T2).

RESULTS

We observed medium effects for the change of vertigo-related handicap (T0-T1: g = -0.60, T0-T2: g = -0.67) and small effects for the change of somatization (T0-T1: g = -0.29, T0-T2: g = -0.24), mental HRQOL (T0-T1: g = 0.43, T0-T2: g = 0.49), and depression (T0-T1: g = -0.41, T0-T2: g = -0.28) from admission to discharge and admission to follow-up. Body-related locus of control did not predict vertigo-related handicap at follow-up.

CONCLUSIONS

Findings provide preliminary evidence for the beneficial role of psychosomatic inpatient treatment for patients with functional VD symptoms. Potentially relevant predictors of outcome at follow-up are discussed.

PRACTITIONER POINTS

The change of vertigo-related handicap and related variables through multimodal psychosomatic inpatient treatment was evaluated in a clinical pilot trial in patients with functional vertigo and dizziness. We observed medium effects for the change of vertigo-related handicap and small effects for the change of somatization, mental health-related quality of life, and depression. Internal body-related locus of control at admission did not predict vertigo-related handicap at follow-up.

Fronto-Insular Connectivity during Pain Distraction Is Impaired in Patients with Somatoform Pain

BACKGROUND AND PURPOSE

Somatoform pain disorder is characterized by chronic pain and various psychological symptoms including increased attention to mental and physical processes. Given that the medial prefrontal cortex (mPFC) of the default mode network (DMN) and the anterior insula of the salience network are critically involved in intrinsic and attentional processes, we investigated the involvement of these networks during the distraction from physical pain in somatoform pain patients.

METHODS

During painful and nonpainful heat stimulation, attentional distraction from physical processes was modulated with a Stroop task. Thirteen patients were investigated with functional magnetic resonance imaging (fMRI) and compared to 13 controls. Main outcomes were spatial maps of coherent fMRI activity based on independent component analysis and functional connectivity (FC) resulting from psychophysiological interaction analysis.

RESULTS

Behavioral pain intensity ratings were reduced during the distraction task in both groups. At brain level, we found deviant network activities in the DMN (particularly in the mPFC) and in the salience network (bilaterally in the anterior insula) in patients. During pain stimulation, Stroop-induced distraction decreased the FC between the mPFC and anterior insula in controls but not in patients.

CONCLUSIONS

Modulating the FC between the mPFC and the insula may be highly relevant for shifting the attention away from external stimuli, including nociceptive input. The observed alterations in somatoform pain patients may foster new strategies in cognitive behavioral training tools for these patients.

Pilot-RCT of an integrative group therapy for patients with refractory irritable bowel syndrome (ISRCTN02977330)

OBJECTIVE

Different forms of psychotherapeutic treatments have been proven effective in irritable bowel syndrome (IBS), but disorder-oriented and integrative concepts are still rare. Therefore, we implemented and evaluated an integrative group therapeutic concept within an interdisciplinary tertiary care clinic for functional gastrointestinal disorders (FGIDs).

AIMS

present our integrative group concept, assess feasibility issues, and evaluate efficacy.

METHODS

A pilot-RCT with a randomized controlled wait-listed group design was conducted. The treatment concept was a disorder-oriented multicomponent group therapy (12 90-min weekly sessions) integrating interactive psychoeducation, gut-directed hypnotherapy, and open group phases. All patients received enhanced medical care and completed a short online diary as an active wait-listed control condition.

INCLUSION CRITERIA

refractory IBS diagnosed as somatoform autonomic dysfunction of the lower gastrointestinal tract (SAD).

PRIMARY OUTCOME

IBS symptom severity (IBS-SSS).

RESULTS

Of 294 patients, 220 had IBS (ROME III), 144 were diagnosed as SAD (ICD-10), 51 were eligible regarding inclusion/exclusion criteria, and 30 consented to participate (group intervention: n=16, wait-listed control condition: n=14). Only 1 patient dropped out. Intention-to-treat-analysis with repeated-measures mixed ANOVA showed that the group intervention was not significantly superior to the wait-listed control condition. Nevertheless, the calculated effect size for the between-group difference in IBS-SSS at the end of treatment (post) was moderate (d=0.539).

CONCLUSION

Our disorder-oriented integrative group intervention for IBS proved to be acceptable and feasible in an interdisciplinary tertiary care setting. There is promise in this intervention, but a larger RCT may be needed to investigate efficacy.

Changes in Emotion Processing following Brief Augmented Psychodynamic Interpersonal Therapy for Functional Neurological Symptoms

Background: Functional neurological symptoms (FNS) are considered non-volitional and often very disabling, but are not explainable by neurological disease or structural abnormalities. Brief Augmented Psychodynamic Interpersonal Therapy (BAPIT) was adapted to treat the putative emotion processing deficits thought to be central to FNS aetiology and maintenance. BAPIT for FNS has previously been shown to improve levels of distress and functioning, but it is unknown whether improvements on such measures correlate with changes in emotion processing ‒ which this treatment focuses on. Aim: To determine (a) whether the recently developed Emotional Processing Scale-25 can be used to demonstrate BAPIT-associated changes in patients with FNS, and (b) whether changes in the EPS-25 are associated with changes in previously validated outcome measures. Method: 44 patients with FNS completed questionnaires including the EPS-25 and measures of clinical symptomology (health-related quality of life (SF-36), somatic symptoms (PHQ-15), psychological distress (CORE-10) and illness understanding (BIPQ)) pre- and post-therapy. Results: At group level, emotion processing improved following therapy (p = .049). Some measures of clinical symptomology also improved, namely health-related quality of life (p = .02) and illness understanding (p = .01). Improvements in the EPS-25 correlated with improvements in mental health-related quality of life and psychological distress. Conclusions: Emotion processing and some measures of clinical symptomology improved in patients with FNS following BAPIT. The EPS-25 demonstrated changes that correlated with previously validated outcome measures. The EPS-25 is a suitable measure of psychotherapy-associated change in the FNS patient population.

History, aims and present structure of psychosomatic medicine in Germany

Combining its two traditions of integrated psychosomatics in internal medicine and focusing on psychotherapeutic/psychiatric methods in many clinical fields, German psychosomatic medicine has developed well over the last decades. It benefits from its institutional independence and the progressive changes in health care. Clinically, disorder-oriented psychotherapy is a core method integrated with other modes of therapy. As a conceptual base for empirical research, non-reductionist accounts of the interactions of (sick) persons with their environment are most important. Germany has developed a model of Psychosomatic Medicine that has conceptualized and integrated psychotherapeutic methods into clinical practice and realized one way to practice bio-psycho-social medicine in the health care system of the country.

[Bio-psycho-socio or psychotherapeutic medicine - actual development of psychosomatics in clinical practice]

In Germany a model of Psychosomatic Medicine has developed, which integrated several psychotherapeutic methods in clinical practice. The concept, which focused on disease mechanisms in the human body and the interaction between diseased individuals and their environment became a basic psychosomatic research strategy and was imlemented in medical care. In this paper the result of a psychosomatic development in clinical health care and research and possible deficiences are described. Perspectives of development and future tasks of Psychosomatic Medicine will be reviewed.

The CIPRUS study, a nurse-led psychological treatment for patients with undifferentiated somatoform disorder in primary care: study protocol for a randomised controlled trial

BACKGROUND

Up to a third of patients presenting medically unexplained physical symptoms in primary care may have a somatoform disorder, of which undifferentiated somatoform disorder (USD) is the most common type. Psychological interventions can reduce symptoms associated with USD and improve functioning. Previous research has either been conducted in secondary care or interventions have been provided by general practitioners (GPs) or psychologists in primary care. As efficiency and cost-effectiveness are imperative in primary care, it is important to investigate whether nurse-led interventions are effective as well. The aim of this study is to examine the effectiveness and cost-effectiveness of a short cognitive behavioural therapy (CBT)-based treatment for patients with USD provided by mental health nurse practitioners (MHNPs), compared to usual care.

METHODS

In a cluster randomised controlled trial, 212 adult patients with USD will be assigned to the intervention or care as usual. The intervention group will be offered a short, individual CBT-based treatment by the MHNP in addition to usual GP care. The main goal of the intervention is that patients become less impaired by their physical symptoms and cope with symptoms in a more effective way. In six sessions patients will receive problem-solving treatment. The primary outcome is improvement in physical functioning, measured by the physical component summary score of the RAND-36. Secondary outcomes include health-related quality of life measured by the separate subscales of the RAND-36, somatization (PHQ-15) and symptoms of depression and anxiety (HADS). Problem-solving skills, health anxiety, illness perceptions, coping, mastery and working alliance will be assessed as potential mediators. Assessments will be done at 0, 2, 4, 8 and 12 months. An economic evaluation will be conducted from a societal perspective with quality of life as the primary outcome measure assessed by the EQ-5D-5L. Health care, patient and lost productivity costs will be assessed with the Tic-P.

DISCUSSION

We expect that the intervention will improve physical functioning and is cost-effective compared to usual care. If so, more patients might successfully be treated in general practice, decreasing the number of referrals to specialist care.

TRIAL REGISTRATION

Dutch Trial Registry, identifier: NTR4686 , Registered on 14 July 2014.

Moderating Effects of Alexithymia on Associations between the Therapeutic Alliance and the Outcome of Brief Psychodynamic-Interpersonal Psychotherapy for Multisomatoform Disorder

This secondary analysis of a trial on brief psychodynamic-interpersonal therapy (PIT) for patients with multisomatoform disorder investigated whether alexithymia moderates the associations between the therapeutic alliance and the outcome of PIT and whether moderating effects of alexithymia remain significant when controlling for depression. Eighty-three patients with multisomatoform disorder receiving PIT were statistically analyzed. Moderation analyses were performed with the SPSS macro PROCESS. The primary outcome (Y), self-reported physical quality of life at 9-month after the end of PIT, was measured with the physical component summary (PCS) of the SF-36 Health Survey. The potential moderator (M) alexithymia was operationalized with the Toronto Alexithymia Scale (TAS-20) at pre-treatment and the predictor (X) the therapeutic alliance was rated by both patients and therapists via the Helping Alliance Questionnaire (HAQ) at the end of PIT. Moreover, the PCS at pre-treatment functioned as covariate in all moderation models. When the patients' alliance ratings were analyzed, alexithymia did not moderate associations between the alliance and the outcome. When the therapists' alliance ratings were evaluated, alexithymia moderated the relationship between the alliance and the outcome (p < 0.05): a stronger alliance in the therapists' perspective was beneficial for the outcome only for patients scoring above 61 on the TAS-20. This moderating effect of alexithymia was, however, not statistically significant anymore when adding the pre-treatment depression scores (PHQ-9) as a covariate to the moderation model. The results underline the importance of a good therapists' view of the alliance when treating alexithymic patients and highlight the complex interaction between alexithymia and depression. Future studies are needed to extend the scope of research regarding which psychotherapeutic mechanisms of change are beneficial for which patients.

Developmental study of treatment fidelity, safety and acceptability of a Symptoms Clinic intervention delivered by General Practitioners to patients with multiple medically unexplained symptoms

BACKGROUND

There is a need for primary care interventions for patients with multiple medically unexplained symptoms (MUS). We examined whether GPs could be taught to deliver one such intervention, the Symptoms Clinic Intervention (SCI), to patients. The intervention includes recognition and validation of patients' symptoms, explanation of symptoms and actions to manage symptoms.

METHODS

We conducted an uncontrolled observational study in Northeast Scotland. GPs were recruited and received two days of structured training. Patients were identified via a two stage process (database searching followed by postal questionnaire) and received the SCI intervention from a GP in their practice. Treatment fidelity was assessed by applying a coding framework to consultation transcripts. Safety was assessed by examining changes in patient symptoms (PHQ-15) and checking for unexpected events. Acceptability was primarily assessed by patient interview.

RESULTS

Four GPs delivered the SCI to 23 patients. GPs delivered all core components of the SCI, and used the components flexibly across the consultations and between patients. They spent more time on recognition than either explanation or actions components. 10 out of 17 patients interviewed described feeling validated, receiving useful explanation and learning actions. 9 out of 20 patients (45%) reported an improvement in PHQ-15 of between 3 and 8 points. Patients who reported the most improvement also described receiving all three components of the intervention.

CONCLUSIONS

GPs can be taught to deliver the SCI with reasonable fidelity, safety and acceptability, although some items were inconsistently delivered: further training would be needed before use.

Heart rate variability predicts therapy outcome in pain-predominant multisomatoform disorder

BACKGROUND

Autonomic imbalance establishes an important model to understand organically unexplained physical complaints. Our study aimed to investigate whether the functioning of the autonomous nervous system corresponds with somatoform symptoms and predicts the outcome of brief psychotherapy in these patients.

METHOD

As a part of multicenter study assessing effects of brief psychodynamic interpersonal therapy on multisomatoform disorder (PISO-study), 106 patients participated in a stress experiment investigating autonomic reactivity during application of the Stroop-test. Patients were randomized receiving either enhanced medical care (EMC, N=49) or psychotherapy (N=57). Autonomic baseline functioning as well as stress reactivity of heart rate (HR) and heart rate variability (HRV) were analyzed in their relation to symptom measures and as potential predictors of the primary outcome (Physical Component Score of the SF-36) during 9-month follow-up.

RESULTS

After therapy patients markedly and sustainably improved in physical quality of life, and this long-term improvement was predicted by baseline HR and HRV. HRV also predicted change in pain symptoms following psychotherapy. A responder analysis revealed a significant better treatment outcome in patients with high pre-treatment HRV (OR 3.4, CI: 1.2-9.9, p=.0035). No significant associations between HR or HRV and outcome measures were found in the EMC group.

CONCLUSION

In our study, the adaptability of the autonomous nervous system as indicated by low pretreatment HR and high HRV was associated with a more pronounced benefit from psychotherapy. This finding can be explained by a possible association between autonomic self-regulation and emotional learning capacities.