Cognitive behavioral therapy for somatic symptom disorders in later life: a prospective comparative explorative pilot study in two clinical populations

Cognitive-behavioral therapy for patients with post-COVID-19 condition (CBT-PCC): a feasibility trial

BACKGROUND

The post-COVID-19 condition describes the persistence or onset of somatic symptoms (e.g. fatigue) after acute COVID-19. Based on an existing cognitive-behavioral treatment protocol, we developed a specialized group intervention for individuals with post-COVID-19 condition. The present study examines the feasibility, acceptance, and effectiveness of the program for inpatients in a neurological rehabilitation setting.

METHODS

The treatment program comprises eight sessions and includes psychoeducational and experience-based interventions on common psychophysiological mechanisms of persistent somatic symptoms. A feasibility trial was conducted using a one-group design in a naturalistic setting. N = 64 inpatients with a history of mild COVID-19 that fulfilled WHO criteria for post-COVID-19 condition were enrolled. After each session, evaluation forms were completed and psychometric questionnaires on somatic and psychopathological symptom burden were collected pre- and post-intervention.

RESULTS

The treatment program was well received by participants and therapists. Each session was rated as comprehensible and overall satisfaction with the sessions was high. Pre-post effect sizes (of standard rehabilitation incl. new treatment program; intention-to-treat) showed significantly reduced subjective fatigue (p < 0.05, dav = 0.33) and improved disease coping (ps < 0.05, dav = 0.33-0.49).

CONCLUSIONS

Our results support the feasibility and acceptance of the newly developed cognitive-behavioral group intervention for individuals with post-COVID-19 condition. Yet, findings have to be interpreted cautiously due to the lack of a control group and follow-up measurement, the small sample size, and a relatively high drop-out rate.

A cognitive behavioural group treatment for somatic symptom disorder: a pilot study

BACKGROUND

Somatic symptom disorder (SSD) presents challenges to the healthcare system, including frequent medical visits, lack of symptom relief experienced by individuals with this condition, high associated medical costs, and patient dissatisfaction. This study examined the utility of a novel, low-barrier, brief cognitive behavioural therapy (CBT) group intervention for individuals with SSD.

METHODS

Participants were referred by their mental health providers or self-referral. Each participant underwent a telephone screen and in-person psychological and neuropsychological screen. Two cycles of the CBT-based group (n = 30), each consisting of six weekly two-hour sessions, were facilitated at a large outpatient mental healthcare facility in Ontario, Canada. The final sample consisted of 13 individuals of whom 11 completed the treatment. Clinical outcome measures were administered pre-, mid- and post-group, including the Generalized Anxiety Disorder-7, Perceived Stress Scale-4, Pain Self-Efficacy Questionnaire, Pain Disability Index, Revised Illness Perception Questionnaire, and sections of the Patient Health Questionnaire. Six healthcare utilization metrics were collected from electronic medical records at six months pre- and post-group. Paired samples t-tests were used to examine pre- to post-group differences in participants' somatic symptoms, psychological functioning, health, and degree of healthcare utilization.

RESULTS

When comparing pre- and post- group, we observed reductions in the mean scores for somatic symptom severity, depressive symptomatology, anxiety, perceived stress, and perceived disability related to pain. The change in depressive symptomatology yielded a small effect size (d = 0.30). Further, we observed downward trends across participants' pre- to post-group healthcare utilization, with small effect sizes observed for hospital admission (d = 0.36), days admitted to hospital (d = 0.47), and inpatient consults (d = 0.42). Differences between pre- and post-group measures of somatic symptom severity, psychological functioning, health, or healthcare utilization did not reach significance.

CONCLUSIONS

Current findings provide support for the potential effectiveness of an abbreviated CBT group for individuals with SSD in reducing psychiatric symptomatology. Further research is recommended, including randomized control trials, cost-benefit analyses, and comparisons between abbreviated versus longer-duration treatment programs for SSD.

TRIAL REGISTRATION

Not applicable.

Relations between criteria for somatic symptom disorder and quality of life in asylum seekers living in Germany

OBJECTIVE

Asylum seekers often suffer from medically unexplained symptoms that affect their quality of life (QoL). The present study is the first to investigate the extent to which somatic symptoms and the B criteria for the DSM-5 somatic symptom disorder (SSD) are associated with the QoL of asylum seekers living in Germany.

METHODS

In 144 asylum seekers, somatic symptoms (PHQ-15), B criteria for SSD, symptoms of posttraumatic stress (PDS), depressive symptoms (PHQ-9), post-migration living difficulties (PMLD), and QoL (EUROHIS) were assessed cross-sectionally. Multiple regressions in the total sample and in groups of somatic symptom severity (mild/moderate and severe) were conducted to examine the associations between somatic symptoms and B criteria with QoL.

RESULTS

Sleep problems and pain were the most frequently reported somatic symptoms. Sixteen (11%) participants met one B criterion, 24 (17%) met two, and 84 (58%) met all three criteria. QoL correlated negatively with somatic symptoms (r = -0.56, p < .001) and with the existence of at least one B criterion (r = -0.24, p < .001). In the total sample, stronger depressive and somatic symptoms were related to lower QoL (adjusted R² = 0.53) while the B criteria were not. In persons with severe somatic symptom severity, the B criterion behavior was associated with lower QoL.

CONCLUSION

In addition to stronger somatic and depressive symptoms, the psychological B criterion behavior seems to play an important role in the lower QoL of asylum seekers with severe somatic symptoms.

The association of childhood maltreatment, somatization and health-related quality of life in adult age: Results from a population-based cohort study

BACKGROUND

Population-based data regarding the relationship between childhood maltreatment (CM), somatization and health-related quality of life (HRQoL) in adults are limited.

OBJECTIVE

To investigate the association of CM history (emotional and physical abuse and neglect, sexual abuse) with somatization and with physical and mental HRQoL in adults.

PARTICIPANTS AND SETTING

Data from 2305 participants from the population-based Study of Health in Pomerania were analyzed (aged 20 to 80 years).

METHODS

We applied the Childhood Trauma Questionnaire. Somatoform disorders were diagnosed according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) in a clinical interview. Using a self-administered questionnaire, we assessed the number of somatic symptoms and physical and mental HRQoL.

RESULTS

Sexual abuse was related to the diagnosis of a somatoform disorder (odds ratio [OR] 1.87; 95% confidence interval [CI] 1.29, 2.69). Emotional abuse and physical neglect were associated with the number of somatic symptoms (B = 0.93; 95% CI 0.42, 1.45 and B = 0.50; 95% CI 0.17, 1.83, respectively). Sexual abuse and physical neglect were related to lower physical HRQoL (B = -1.87; 95% CI -3.17, -0.57 and B = -1.26; 95% CI -2.02, -0.49, respectively), and emotional abuse was associated with lower mental HRQoL (B = -2.83; 95% CI -4.03, -1.62).

CONCLUSIONS

A history of CM, in particular sexual abuse, emotional abuse and physical neglect, is a risk factor for somatization and impaired HRQoL in adults. Individuals with somatic symptoms are an important target group for CM screening. Addressing HRQoL might be significant in psychotherapy for individuals with CM experience.

T4+T3 Combination Therapy: An Unsolved Problem of Increasing Magnitude and Complexity

Thyroxine (T4)+triiodothyronine (T3) combination therapy can be considered in case of persistent symptoms despite normal serum thyroid stimulating hormone in levothyroxine (LT4)-treated hypothyroid patients. Combination therapy has gained popularity in the last two decades, especially in countries with a relatively high gross domestic product. The prevalence of persistent symptoms has also increased; most frequent are complaints about energy levels and fatigue (80% to 90%), weight management (70% to 75%), memory (60% to 80%), and mood (40% to 50%). Pathophysiological explanations for persistent problems are unrealistic patient expectations, comorbidities, somatic symptoms, related disorders (Diagnostic and Statistical Manual of Mental Disorders [DSM-5]), autoimmune neuroinflammation, and low tissue T3. There is fair circumstantial evidence for the latter cause (tissue and specifically brain T3 content is normalized by T4+T3, not by T4 alone), but the other causes are viewed as more relevant in current practice. This might be related to the 'hype' that has emerged surrounding T4+T3 therapy. Although more and better-designed trials are needed to validate the efficacy of T4+T3 combination, the management of persistent symptoms should also be directed towards alternative causes. Improving the doctor-patient relationship and including more and better information is crucial. For example, dissatisfaction with the outcomes of T4 treatment for subclinical hypothyroidism can be anticipated as recent trials have demonstrated that LT4 is hardly effective in improving symptoms associated with subclinical hypothyroidism.

Psychotherapie im höheren Lebensalter in der Psychotherapieausbildung

Zusammenfassung. Theoretischer Hintergrund: Psychotherapie im höheren Lebensalter (PihL) gewinnt in Deutschland in den letzten Jahrzehnten zunehmend an Bedeutung. Dennoch ist dieses Feld trotz des großen Bedarfs weiterhin unterrepräsentiert. Fragestellung: Wie werden angehende Psychotherapeut_innen aktuell in Bezug auf die psychotherapeutische Behandlung älterer Menschen ausgebildet? Methode: Sämtliche Ausbildungsinstitute in Deutschland mit dem Schwerpunkt Verhaltenstherapie sowie Dozierende mit Seminaren zu PihL wurden im Jahr 2018 zu einer Befragung eingeladen. Ergebnisse: Von 48 Instituten boten zum Zeitpunkt der Befragung 64.6 % gerontopsychlogische Unterrichtsstunden (M = 13.03 h) an (2.2 % des Theorieunterrichts). In den ausfindig gemachten Seminaren zeigen sich zu einem großen Teil die von Knight et al. (2009 ) vorgeschlagenen Themenschwerpunkte von allgemeinen und pathologischen Alterungsprozessen über diagnostische Besonderheiten bis hin zu konkreten Interventionsmethoden. Diskussion: Sowohl die Weiterbildungsstudiengänge als auch die neuen psychotherapeutischen Bachelor- und Masterstudiengänge sollten mehr Inhalte zum Thema PihL ähnlich wie die hier ausfindig gemachten Seminare berücksichtigen. Eine Orientierung für eine Basiswissensvermittlung bieten die vorgeschlagenen Themenschwerpunkte.

Functioning and quality of life in patients with somatic symptom disorder: The association with comorbid depression

OBJECTIVES

Patients with somatic symptoms often have impaired functioning and reduced quality of life (QOL), but the factors identified as responsible for these impairments vary between studies. We examined functioning and QOL in patients with somatic symptom disorder (SSD), exploring their associations with demographic factors, personality traits and psychological features.

METHODS

The sample comprised 107 SSD patients and 100 healthy controls. Several types of self-report instrument were administered. Group differences were assessed with independent t-tests. We used multiple linear regression to examine relationships between the independent variables and functioning and QOL. Finally, we used structural equation modeling (SEM) to perform path analysis and examine the fit of a model based on the earlier results.

RESULTS

Most function scores were lower in SSD patients than in healthy controls. In SSD patients overall WHO Quality of Life-BREF (WHOQOL-BREF) score was correlated with exercise level and Beck Depression Inventory-II (BDI-II) score. There were also associations between Sheehan Disability Scale (SDS) score and age, novelty seeking, Cognitions About Body and Health Questionnaire (CABAH) score and BDI-II score. Family APGAR score was only related to BDI-II score. Path analysis revealed that BDI-II score was related to all three indices of functioning.

CONCLUSIONS

Depression is associated with functioning and QOL in SSD patients.

TRIAL REGISTRATION INFORMATION

The Research Ethics Committee of National Taiwan University National Taiwan University Hospital approved this study (approval number: 201507007RINB).

Predictors of Persistent Medically Unexplained Physical Symptoms: Findings From a General Population Study

Objective: To explore the persistency of Medically Unexplained Symptoms (MUS) and its prognostic factors in the general adult population. Knowledge of prognostic factors of MUS may indicate possible avenues for intervention development. Methods: Data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a nationally representative face-to-face cohort study among the Dutch general population aged 18-64 years. We selected subjects with MUS at baseline and who participated at follow-up (N = 324) and reassessed those subjects for having MUS at 3 year follow-up. Logistic regression analyses were used to determine risk factors for persistency of MUS. Results: 36.4% of the subjects had persistent MUS at follow-up. In logistic regression analyses adjusted for sex and age, persistency of MUS was predicted by the number of comorbid chronic medical disorder(s), lower education, female sex, not having a paid job, parental psychopathology as well as lower functioning. In the logistic regression analysis in which all significant variables adjusted for sex and age were entered simultaneously, three variables predicted persistent MUS: parental psychopathology, the number of comorbid chronic medical disorder(s) and physical functioning, with odds ratios of 2.01 (1.20-3.38), 1.19 (1.01-1.40), and 0.99 (0.97-1.00), respectively. Conclusion: In the adult general population, MUS were persistent in over one third of the subjects with MUS at baseline. Persistency was significantly predicted by parental psychopathology, number of comorbid chronic medical disorders, and physical functioning. These findings warrant further research into early intervention and treatment options for persons with an increased risk of persistent MUS.