Effectiveness of a Time-Limited Cognitive Behavior Therapy–Type Intervention Among Primary Care Patients With Medically Unexplained Symptoms

Javier I. Escobar; Michael A. Gara; Angelica M. Diaz-Martinez; Alejandro Interian; Melissa Warman; Lesley A. Allen; Robert L. Woolfolk; Eric Jahn; Denise Rodgers

doi:10.1370/afm.702

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What were the perameters of your treatment for these patients?
Carolyn L. Leier

Published on: 21 August 2008
Treating medically-unexplained symptoms: is it still a shot in the dark?
Oye Gureje

Published on: 18 August 2007
Response to Lucassen et al.
Javier I Escobar

Published on: 16 August 2007
Some remarks about a high-quality trial
Peter L Lucassen

Published on: 02 August 2007

Published on: (21 August 2008)

What were the perameters of your treatment for these patients?
Carolyn L. Leier, Calgary, Alberta, Canada
If, in your work with these patients, it must be noted that any work regarding medications,stress management, self-hypnosis, imaging, bio- feedback, etc. would certainly have produced results during the time of the sessions. It is obvious, that left on their own with excruciating pain, they would be unable to continue these management methods on a regular basis and, therefore, would revert back to a more painful existe...
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If, in your work with these patients, it must be noted that any work regarding medications,stress management, self-hypnosis, imaging, bio- feedback, etc. would certainly have produced results during the time of the sessions. It is obvious, that left on their own with excruciating pain, they would be unable to continue these management methods on a regular basis and, therefore, would revert back to a more painful existence.
Your response would be appreciated.
C. Leier, Calgary, Alberta, Canada
Competing interests: None declared
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Competing Interests: None declared.
Published on: (18 August 2007)

Treating medically-unexplained symptoms: is it still a shot in the dark?
Oye Gureje, Ibadan, Nigeria
Unexplained medical symptoms are a source of distress to patients who experience them and a source of frustration to clinicians who have to deal with them. The cumulative effect of high prevalence, chronicity and associated distress is a high level of medical service utilization and costs. Several attempts have been made to devise an effective intervention for patients with these conditions (1, 2), but the outcome has been...
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Unexplained medical symptoms are a source of distress to patients who experience them and a source of frustration to clinicians who have to deal with them. The cumulative effect of high prevalence, chronicity and associated distress is a high level of medical service utilization and costs. Several attempts have been made to devise an effective intervention for patients with these conditions (1, 2), but the outcome has been very modest. The paper by Escobar and colleagues is therefore very timely. Based on a methodologically sound study, it deserves wide attention. The authors have used a previously described intervention package in an underserved, ethnically diverse primary care group. Compared with the original use of the package, the aim was to test the effectiveness of the intervention among patients with moderate levels of somatization. It can be said that if any intervention for somatization is to be adjudged successful, it has to do well among primary care patients. Primary care is where the majority of somatizing patients are seen; it is where the presentation constitutes a clog in the delivery of effective assessment and treatment of patients; and it is where clinicians have the most need for help in choosing the right approach to managing the problem.
The improvements achieved are modest. Even though there were significant positive effects of intervention shortly on completion of treatment, these effects were not sustained so that, by 6 months, much of the gains had disappeared. The PHQ-15 ratings continued to be significantly better for the intervention than the control group at 6 months. However, it is to be noted that the PHQ-15 rated all physical complaints. On the other hand, the visual analogue scores, reflecting patients’ own assessment of the severity of their symptoms, and this time focusing only on medically unexplained symptoms, did not indicate any gain for the intervention group at 6 months. That is, even for the suggestion that physical symptoms continued to be less at 6 months among the intervention group (as suggested by the PHQ-15), the VAS provides a reason to be cautious.
As noted by Escobar and colleagues, the largely unimpressive results at 6 months might reflect the attrition of the groups and the consequent attenuation of statistical power. Nevertheless, set against the background of previous efforts, the conclusion is that we are yet to find the right package of intervention that will benefit a majority of patients with medically unexplained symptoms presenting in primary care settings. Unfortunately, this is likely to remain so for as long as we have a poor understanding of the nosological status and profile of the construct that we call medically unexplained symptoms. The construct is at the moment a very heterogeneous group of conditions with poorly defined boundaries (3). The authors note very broadly divergent clinical response in their sample, probably a reflection of the heterogeneous group they were dealing with. There is also the added problem that, perhaps somatization is itself a manifestation of patient-doctor interaction (4) and that any effective management of the problem will have to have that interaction as its focus.
References
1. Goldberg D, Gask L, O’Dowd T. The treatment of somatization: teaching the skills of reattribution. J. Psychosom. Res. 1989; 33: 689 – 695. 2. Morris R, Gask L, Ronalds C. et al. Clinical and patient satisfaction outcome of a new treatment for somatized mental disorder taught to general practitioners. Br. J. Gen. Pract. 1999; 49: 263 – 267. 3. Gureje O. Somatoform disorders: deconstructing a diagnosis. In: Somatoform Disorders. Eds. Maj M, Akiskal HS, Mezzich JE, Okasha AM. Chichester: John Wiley &Sons. 4. Gureje O. What can we learn from a cross-national study of somatic distress? J. Psychosom. Res. 2004; 56: 409 – 412.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (16 August 2007)

Response to Lucassen et al.
Javier I Escobar, New Brunswick, NJ, USA
We appreciate the thoughtful comments submitted by Dr. Lucassen and collaborators related to our recently published paper in the Annals.
We share their concern about the feasibility of this treatment in busy primary care settings. While the research protocol worked well in our case, implementation of this in practice would be a different story.
They make a good case documenting that non-specific effect...
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We appreciate the thoughtful comments submitted by Dr. Lucassen and collaborators related to our recently published paper in the Annals.
We share their concern about the feasibility of this treatment in busy primary care settings. While the research protocol worked well in our case, implementation of this in practice would be a different story.
They make a good case documenting that non-specific effects go beyond reassurance, and we appreciate the additional insights they provide in this regard.
They also appear to endorse our staged approach with the caveat that the patient-doctor communication be considered in this context, a suggestion we will seriously consider in our future work.
Finally, we would like to hear more about the authors research agenda on MUS that we hope will be soon emerging in future publications from the group.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (2 August 2007)

Some remarks about a high-quality trial
Peter L Lucassen, Nijmegen, the Netherlands
Other Contributors:
First of all we would like to compliment the authors of this publication with their high-quality randomized controlled trial in primary care on a difficult subject. It must have been a great effort to complete this trial in patients with medically unexplained symptoms (MUS) in primary care in a (partly) underserved, ethnically diverse, low-income urban population.
However, we have some critical comments as well...
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First of all we would like to compliment the authors of this publication with their high-quality randomized controlled trial in primary care on a difficult subject. It must have been a great effort to complete this trial in patients with medically unexplained symptoms (MUS) in primary care in a (partly) underserved, ethnically diverse, low-income urban population.
However, we have some critical comments as well. First of all, we have some doubts about the feasibility of ten 50-minute treatment sessions of CBT in patients with MUS in primary care settings, as patients might be reluctant to undergo a time and money consuming mental health therapy while they present physical symptoms and there has been no attempt to reattribute the symptoms first. Reattribution can be a first step when treating patients with MUS effectively and we found no reference to this intervention1,2 in the article. We would be interested in the number of patients refusing participation when offered a psychological teratment ‘out of the blue’. In addition, as the researchers wrote, less than one half of the referred patients was actually enrolled in the study. Consequently, we have serious doubts on the external validity of the study. Second, the authors state that they cannot rule out nonspecific effects of increased visits and physician attention as explanation for the better outcomes in the intervention group. However, they think that nonspecific effects are not likely to play a major role in treatment success. They motivate this with the research by Rief et al. that indicates that reassurance does not provide much benefit to patients with unexplained symptoms. However, nonspecific effects include more than just reassuring patients and we think that these non-specific effects might be more important than the authors describe. In the contextual model, nonspecific factors are supposed to comprise three factors: the therapeutic bond between therapist and patient, the expectancy of the patient to have a positive outcome, and the shared goals of the therapist and the patiënt.3 Moreover, Ahn and Wampold demonstrated in their systematic review that ‘there is no evidence that the specific ingredients of psychological treatments are responsible for the beneficial outcomes of counseling and psychotherapy’.4 Third, we believe that even with proper training, the intervention does not have the desired results when this training is directed at activities solely during consultations. There is a huge gap between what physicians think about patients with MUS and what patients expect from their physician, often resulting in stressful consultations. We strongly believe that training directed at incorrect assumptions of physicians about patients with MUS is at least as important as any treatment of these patients. Fourth, we agree with the authors that a staged approach will be effective in patients with MUS. However, we would like to add something at their proposal of activities. We think that prior to the application of brief educational videos, there is room for much improvement in the patient- doctor communication. According to Epstein et al. family physicians explore patients’ feelings, cognitions and expectations far less in patients with MUS compared to patients with medically explained symptoms.5 Moreover, family physicians offer patients with MUS too many medical interventions, do not respond adequately to psychosocial utterances and do not show much empathy.6
In short, one piece of the intriguing puzzle of treating MUS patients has been added by this excellent trial. However, there are many pieces that still have to be found. Within this frame, we hope to provide you soon with the results of our symposium ‘MUS in family medicine: the state of the art’ and workshop ‘MUS in family medicine: where should we go?’ at the recent Wonca (World Organisation of National Colleges and Academies of Family Medicine) conference in Singapore. In this symposium and workshop we built a research agenda on MUS, using a nominal group technique in an audience of more than 30 nationalities from all over the world.
References
1.Blankenstein AH, van der Horst HE, Schilte AF et al. Development and feasibility of a modified reattribution model for somatising patients applied by their own general practitioners. Pat Educ Couns 2002;47:229-35
2.Kaaya S, Goldberg D, Gask L. Management of somatic presentations of psychiatric illness in general medical settings: evaluation of a new training course for general practitioners. Med Educ 1992;26:138-44
3.Hyland ME. A tale of two therapies: psychotherapy and complementary and alternative medicine (CAM) and the human effect. Clin Med 2005;5:361-7
4.Ahn H, Wampold BE. Where oh where are the specific ingredients? A meta-analysis of component studies in counseling and psychotherapy. J Couns Psychother 2001;48:252-7
5.Epstein R, Shields G, Meldrum SC, Fiscella K, Carroll J, Carney PA et al. Physicians’ responses to patients’ medically unexplained symptoms. Psychosom Med 2006;68:269-76.
6.Ring A, Dowrick CF, Humphris GM, Davies, Salmon P. The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms. Soc Sci Med 2005;61:1505-15.
Tim olde Hartman MD, FP Lieke Franke MD Peter Lucassen, MD, FP, PhD Evelyn van Weel-Baumgarten, MD, FP, PhD
Competing interests: None declared
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Competing Interests: None declared.