Mindfulness-Based Cognitive Therapy as a Treatment for Chronic Tinnitus: A Randomized Controlled Trial

BACKGROUND

Tinnitus is experienced by up to 15% of the population and can lead to significant disability and distress. There is rarely a medical or surgical target and psychological therapies are recommended. We investigated whether mindfulness-based cognitive therapy (MBCT) could offer an effective new therapy for tinnitus.

METHODS

This single-site randomized controlled trial compared MBCT to intensive relaxation training (RT) for chronic, distressing tinnitus in adults. Both treatments involved 8 weekly, 120-min sessions focused on either relaxation (RT) or mindfulness meditation (MBCT). Assessments were completed at baseline and at treatment commencement 8 weeks later. The primary outcomes were tinnitus severity (Tinnitus Questionnaire) and psychological distress (Clinical Outcomes in Routine Evaluation - Non-Risk, CORE-NR), 16 weeks after baseline. The analysis utilized a modified intention-to-treat approach.

RESULTS

A total of 75 patients were randomly allocated to MBCT (n = 39) or RT (n = 36). Both groups showed significant reductions in tinnitus severity and loudness, psychological distress, anxiety, depression, and disability. MBCT led to a significantly greater reduction in tinnitus severity than RT, with a mean difference of 6.3 (95% CI 1.3-11.4, p = 0.016). Effects persisted 6 months later, with a mean difference of 7.2 (95% CI 2.1-2.3, p = 0.006) and a standardized effect size of 0.56 (95% CI 0.16-0.96). Treatment was effective regardless of initial tinnitus severity, duration, or hearing loss.

CONCLUSIONS

MBCT is effective in reducing tinnitus severity in chronic tinnitus patients compared to intensive RT. It also reduces psychological distress and disability. Future studies should explore the generalizability of this approach and how outcome relates to different aspects of the intervention.

Medically Unexplained Symptoms: an acceptable term?

BACKGROUND

The term 'Medically Unexplained Symptoms' (MUS) is used by health professionals and researchers to refer to persistent bodily complaints, including pain and discomfort.

AIMS

This study explores the views held by a lay sample on the clinical terminology used to describe 'MUS', to ascertain reasons for particular preferences and whether preferences differ between individuals who experience more somatic symptoms.

DESIGN AND METHODS

A sample (n = 844) of healthy adults completed an online survey, which included a questionnaire measuring somatic symptoms (Patient Health Questionnaire-15 (PHQ-15)) and a question about their preferences for terminology used to describe MUS.

RESULTS

Of 844 participants, 698 offered their preferences for terminology. The most popular terms were 'Persistent Physical Symptoms' (20%) and 'Functional Symptoms' (17%). 'MUS' (15%), 'Body Distress Disorder' (13%) and 'Complex Physical Symptoms' (5%) were less popular. And 24% indicated no preference, but high PHQ-15 scorers were more likely to express preferences than low scorers.

CONCLUSION

Persistent Physical Symptoms and Functional Symptoms are more acceptable to this sample of healthy adults than the more commonly used term 'MUS'.

A multidisciplinary, biopsychosocial treatment for non-cardiac chest pain

BACKGROUND

Non-cardiac chest pain (NCCP) affects up to 80% of patients attending chest pain clinics, but its treatment is suboptimal.

AIM

To describe the outcomes of a pilot, stepped care, biopsychosocial management programme in terms of improvements in chest pain, psychosocial scores and use of healthcare resources.

METHODS

Of 198 referrals, 77 patients were suitable for the clinic and received a one hour biopsychosocial assessment. Stepped care consisted of assessment only, low intensity Cognitive Behaviour Therapy (CBT), or high intensity CBT.

RESULTS

The proportion with pain occurring more than once monthly fell from 100% at baseline to 61% at 3 months (p < 0.001). Pain interference reduced significantly (p < 0.001) from 5.9 [SD 2.2] at baseline to 3.2 [SD 2.6] at 3 months. Depression scores improved from a mean 8.8 to 5.4 (p < 0.05) and anxiety from 6.9 to 4.6 (p < 0.05). Use of healthcare resources improved with a fall in consultations for chest pain over 6 months from a mean 2.6 to 0.1 (p < 0.05). The impact on work and social functioning reduced from 10.4 [SD 10.4] to 3.9 [SD 7.5]: [t (70) = 6.3, p < 0.001). Further improvements occurred at 6 months for chest pain frequency (which fell to 51%, p = 0.003), interference (2.6 [SD 2.1], p < 0.05) and avoidance of exercise (p = 0.03). Otherwise improvements were maintained between 3 and 6 months.

CONCLUSION

A stepped-care biopsychosocial approach to NCCP is effective in reducing chest pain frequency and improving behaviour and wellbeing. It can be delivered in part by a nurse allowing integration into any chest pain clinic.

The rapid access chest pain clinic: unmet distress and disability

AIMS

To determine the characteristics, clinical needs and level of health-care use of patients with non-cardiac (NCCP) and cardiac-chest pain (CCP) attending a Rapid Access Chest Pain Clinic in an inner-London Hospital.

METHODS

A cross-sectional comparison of NCCP and CCP patients on measures of pain, mood, beliefs, somatic symptoms and use of services completed by patients attending the Rapid Access Chest Pain Clinic over an 18-month period.

RESULTS

There were no significant differences between NCCP and CCP patients in terms of chest pain frequency, duration or severity or associated distress; however, NCCP were younger (53 vs. 60, OR = 1.05) and reported 'atypical' pain more frequently (82% vs. 50%, OR = 3.72). The NCCP group reported more panic-type beliefs about chest pain (5.8 vs. 4.3, P < 0.05) and lower 'illness coherence' (a patient's belief that the illness 'makes sense') (3.5 vs. 4.7, P < 0.05). Anxiety and depression scores were similar in both groups. Both groups had similar levels of health-care use but patients with NCCP saw more types of health-care worker (mean 1.7) than those with CCP (mean 1.4, P < 0.05).

CONCLUSION

Patients with NCCP are as disabled and distressed as patients with CCP however current services fail to meet their needs. We suggest that a biopsychosocial approach should be explored.

Intrusions in trauma and psychosis: information processing and phenomenology

BACKGROUND

Intrusions are common symptoms of both post-traumatic stress disorder (PTSD) and schizophrenia. It has been suggested that an information processing style characterized by weak trait contextual integration renders psychotic individuals vulnerable to intrusive experiences. This 'contextual integration hypothesis' was tested in individuals reporting anomalous experiences in the absence of a need for care.

METHOD

Twenty-six low schizotypes and 23 individuals reporting anomalous experiences were shown a traumatic film with and without a concurrent visuospatial task (VST). Participants rated post-traumatic intrusions for frequency and form, and completed self-report measures of information processing style. It was predicted that, because of their weaker trait contextual integration, the anomalous experiences (AE) group would (1) exhibit more intrusions following exposure to the trauma film, (2) display intrusions characterized by more PTSD qualities and (3) show a greater reduction of intrusions with the concurrent VST.

RESULTS

As predicted, the AE group reported a lower level of trait contextual integration and more intrusions than the low schizotypes, both immediately after watching the film and during the following 7 days. Their post-traumatic intrusive memories were more PTSD-like (more intrusive, vivid and associated with emotion). The VST had no effect on the number of intrusions in either group.

CONCLUSIONS

These findings provide some support for the proposal that weak trait contextual integration underlies the development of intrusions within both PTSD and psychosis.

Acidification and urine calcium: is it a preanalytical necessity?

Background

It has been suggested that for the accurate measurement of calcium in urine, samples must be collected into bottles containing acid. Acidification poses risks to both patients and laboratory staff. Here we reappraise whether acidification is a preanalytical necessity.

Methods

Twenty-four-hour urine samples were collected from 133 patients into bottles without acid or preservatives. In a subset of 29 patients, 10 mL aliquots were prepared to test the effect on urine calcium of 0.1, 1.0 and 5.0 mol/L hydrochloric acid (HCl). Calcium was then measured immediately after acidification, after 12 h and seven days storage at 4°C. In a separate study, urine calcium concentrations in paired control (non-acidified) and acidified (with 5 mol/L HCl) samples were compared in 133 patients. When available, we recorded the time from start of urine collection to time of analysis. Calcium was measured using the cresolphthalein complexone colorimetric endpoint assay on the Roche Modular system.

Results

There was no significant difference in the calcium concentration in the 29 cases studied between the varying acid concentrations tested compared with non-acidified urine ( P = 0.987). Overall, in 133 patients there was no difference between control and acidified samples ( P = 0.888). We found no correlation between basal urine pH and urine calcium at all time points studied.

Conclusions

Our results suggest that the acidification of urine samples is not a preanalytical necessity for the measurement of urine calcium.