Cognitive-Behavioral Intervention Reduces Somatization Symptoms

August 3, 2007 — A therapeutic approach similar to cognitive-behavioral therapy (CBT) significantly relieves symptoms of patients with multiple medically unexplained physical symptoms, according to a paper in the July/August issue of the Annals of Family Medicine.
The authors note that even after appropriate physical evaluations and laboratory testing have ruled out any physical cause, many patients continue to experience symptoms and seek care from primary health care providers.
Previously, a trial group led by Dr. Lesley A. Allen developed a time-limited cognitive behavior therapy (CBT)-type intervention for treatment of somatization disorder in a mental health clinic. In 2006, they reported that the treatment succeeded in reducing symptoms, improving function, and decreasing health care costs.
In the current study, funded by the National Institute of Mental Health, Dr. Alejandro Interian and associates extended those finding by applying a similar CBT-type approach to an ethnically diverse sample of primary care patients with less severe somatic symptoms.
"CBT is usually used to treat mood disorders," Dr. Interian told Reuters Health. "In our approach, the intervention is briefer (10 sessions) and the anchor of the discussion is patients' physical symptoms — their thoughts and feelings about their symptoms — and strategies for coping with them."
The researchers explain in their paper that the intervention focuses on the reduction of physical distress and preoccupation with symptoms through relaxation training, cognitive restructuring and similar approaches.
"More specific details on this intervention can be found in a recently published book containing a manual and step-by-step guidelines for the conduct of each session," they add. The book is referenced as Woolfolk R, Allen L. Treating Somatization; A Cognitive-Behavioral Approach. Guildford Press.
Dr. Interian and associates tested the CBT-type intervention among patients treated at two urban primary care clinics in New Brunswick, New Jersey, run by the Robert Wood Johnson Medical School. The study took place between 2001 and 2005.
Inclusion criteria were stricter than those for Dr. Allen's original study, Dr. Interian noted.
Women were required to have at least six unexplained symptoms, and men had to have at least four. Most complaints were related to pain, such as headache, back pain and abdominal pain; others were feeling faint, excessive flatulence, and lump in the throat. Most subjects had high levels of depression and anxiety.
The study cohort of 172 adults was randomized, 87 to the CBT therapy and 85 to usual care. The 10 CBT sessions lasted 50 minutes each, and took place over 10 to 20 weeks.
When evaluated immediately after completion of the study, subjects in the intervention group were significantly less likely to report physical symptoms and depressive symptoms. "Substantial relief of medically unexplained physical symptoms was observed in about 60% of the patients who completed the intervention, and persisted for months afterward," the authors report.
Clinical global impressions (CGI) rated by blinded evaluators showed that more of the intervention group were rated as "much improved" or "very much improved" at the end of treatment compared with controls (odds ratio = 4.1, p < 0.001). Assessments for depression also found that more in the intervention groups were "much/very much improved" (OR = 3.5, p < 0.004).
Thus, "the effects of the intervention were not only statistically significant but also clinically meaningful," the authors say.
The degree of improvement gradually diminished over time. At the 6-month evaluation, the only variable that remained statistically significantly improved in the intervention group was the severity rating of somatic symptoms.
This is a difficult group to take care of, Dr. Interian commented, because "symptoms are perceived as exaggerated or faked, and they don't go away... A major component of our approach is validating the patients' experience, and concentrating on how they deal with it."
He concluded: "When added to results of the Allen group, our findings now support this new intervention as a way of working with these folks."
His research team has received another grant from the NIMH, he said, and has started several smaller studies, "designed to be seed studies, for finding additional innovative ways" to treat patients with medically unexplained symptoms.
Ann Fam Med. 2007;5:328-335.