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4 Treatment for Chronic Multisymptom Illness
Pages 37-92

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From page 37...
... reviewed were found in the systematic search detailed in Chapter 3 for treatments of multiple physical symptoms associated with CMI. A narrative synthesis of the evidence is presented here by type of treatment: pharmacologic treatments and other biologic interventions, psychotherapies, mind–body approaches (including biofeedback, cognitive rehabilitation therapy, and complementary and alternative therapies)
From page 38...
... , doxycycline (Donta et al., 2004) , and cognitive behavioral therapy (CBT)
From page 39...
... , and it did not demonstrate efficacy. The other eight studies enrolled people in the general population, most of them female, who had somatoform disorder variously described as multisomatoform disorder, undifferentiated somatoform disorder, and somatization disorder.
From page 40...
... (2007) was particularly relevant in that the studies reviewed focused on adults who had medically unexplained symptoms and excluded symptom syndromes such as chronic fatigue syndrome (CFS)
From page 41...
... g High N/A Direct Imprecise Low Doxycycline   RCT: 1 (491) h Low N/A Direct Precise Highi NOTES: RCT = randomized controlled trial; RoB = risk of bias.
From page 42...
... . Han et al., 2008a RCT Venlafaxine vs 61% female, mean age mirtazapine.
From page 43...
... In primary outcome, physical health functioning (SF-36) , treatment and placebo groups' average scores were 30.2 and 30.1 (physical)
From page 44...
... . Kroenke et al., 2006 RCT Venlafaxine ER vs 80% female, mean age placebo.
From page 45...
... After treatment, both treatment and placebo groups had significant (p < 0.0001) decrease in somatic symptoms (PHQ-15 change of –8.3 and –6.6 respectively)
From page 46...
... 64% female, mean age Started at 50 mg/day, 46 years Somatoform disorders increased by 50–200 (ICD-10 codes F45.0, mg/day on day 4. N opipramol = 104 F45.1, F45.3)
From page 47...
... , and one study each investigating multicomponent nurse-care management, aerobic exercise, writing disclosure, paradoxic intention, and explanatory therapy. CBT is most effective for variety of somatoform disorders and outcomes.
From page 48...
... RoB Consistency Directness Precision Evidence REAC-BS   RCT: 1 (888) a Low N/A Indirect Precise Insufficient NOTES: RCT = randomized controlled trial; REAC-BS = radioelectric asymmetric conveyer brain stimulation; RoB = risk of bias.
From page 49...
... . Most of the studies targeted somatoform conditions, including mainly somatization disorder, abridged somatization, and high levels of unexplained physical symptoms.
From page 50...
... (2007) examined medically unexplained symptoms.
From page 51...
... (2007) examined patients who had medically unexplained symptoms (N = 140)
From page 52...
... However, the study lacked description of methods -- including selection and randomization of participants, the intervention, and the control condition -- and therefore carries a high risk of bias. The three brief uncontrolled trials (Abbass et al., 2009a; Aiarzaguena et al., 2002; Reuber et al., 2007)
From page 53...
... Two other systematic reviews looked at multiple treatments for somatoform disorders and medically unexplained symptoms (Kroenke, 2007; Sumathipala, 2007)
From page 54...
... examined EMDR for combat-related medically unexplained physical symptom; it used a single-subject case design and showed the benefit of 5 sessions of EMDR maintained through 6-month follow-up. The Russell (2008)
From page 55...
... e High Psychodynamic, group   Pre–post: 1 (40) f High N/A Indirect Imprecise Insufficient NOTES: CBT = cognitive behavioral therapy; RCT = randomized controlled trial; RoB = risk of bias.
From page 56...
... Biofeedback, the TABLE 4-6  Psychotherapies Study Type Intervention Population Cognitive Behavioral Therapies Allen et al., 2006 RCT CBT + PCI vs PCI 89% female, mean age alone; 10 sessions over 46.6 years, 82% white, Somatoform disorder 3 months. 55% employed Piscataway, New N screened = 142 Jersey N treatment = 43 N control = 41
From page 57...
... (2011) recruited persons who were seeking medical care for unexplained physical symptoms.
From page 58...
... . N treatment = 31 N control = 34 Bleichhardt et al., RCT CBT group therapy vs 73% female, mean age 2004 PMR group therapy vs 44 years waiting-list controls.
From page 59...
... After 1-year follow-up, there was significant improvement in somatic symptoms. continued
From page 60...
... 2–3 independent sessions per week for 12 weeks. Escobar et al., 2007 RCT CBT vs control, 88% female, mean age 10 sessions; each 40 years, and 66% MUS 45–60 minutes long Hispanic.
From page 61...
... . Mean scores in treatment and control groups, respectively, from baseline to 6-month follow-up -- physical functioning: 63.28–73.22 vs 61.41–69.41; somatic complaints: 14.17– 9.11 vs 13.98–10.91, at 6 months p = 0.03; depression: 18.25–12.88 vs 17.41–14.29; anxiety: 20.46–14.85 vs 20.99–17.58; medically unexplained symptoms: 42.34–23.72 vs 39.62–25.25.
From page 62...
... months. N treatment = 64 symptoms N control = 63 Scotland Sumathipala et al., RCT CBT vs structured 78% female, mean age 2000 care, 6 30-min 35 years sessions over Medically unexplained 3 months.
From page 63...
... , p = 0.7. After treatment, there was significant time × group interaction over all outcomes (number and severity of somatic symptoms, SOMS-7; depression and anxiety, HADS; and healthbased quality of life, SF-12 for physical and mental health)
From page 64...
... controlled therapy vs usual care. Somatoform disorders N group therapy = 20 8 1.5-hour weekly N control = 20 Germany sessions, up to 10 participants per group.
From page 65...
... Number needed to treat to improve scored by 1 SD in at least one outcome measure = 2.0; to improve 2 or more outcome measures = 3.9; and to see improvement in all 3 outcome measures = 7.0. continued
From page 66...
... Number of sessions 5–22. Allen et al., 2002 Systematic Psychosocial N = 34 studies review treatments Multiple unexplained physical symptoms
From page 67...
... No significant associations with treatment outcome were found for different diagnoses, treatment types, treatment formats, or control conditions. Only 2 of 34 studies looked at unexplained physical symptoms.
From page 68...
... N RCT = 29 review 24 studies used fixed N nonrandomized Somatization, number of sessions controlled trials = 2 somatoform disorders, with median of 8 persistent symptoms, sessions (range, 2–16)
From page 69...
... . CBT is most effective for variety of somatoform disorders and outcomes.
From page 70...
... age 43 years N screened = 181 results screened N included = 16 studies (102 patients) NOTE: BDI = Beck Depression Inventory; BSI = Brief Symptom Inventory; CBT = cognitive behavioral therapy; CFS = chronic fatigue syndrome; CGI = Clinical Global Impressions Scale; CI = confidence interval; CORE-OM = Clinical Outcomes in Routine Evaluation Outcome Measure; ­ EPENAS = Detection-Explanation-Plan-Exploration-Normalization-Action-Follow-Up; D ­ DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; ED = emergency department; EMC = enhanced medical care; EMDR = eye movement desensitization and reprocessing; EQ-5D = EuroQol health status questionnaire; ES = effect size; FLZM = Questions on Life Satisfaction; GHQ-30 = 30-Item General Health Questionnaire; ­ GSH = guided self-help; HADS = Hospital Anxiety and Depression Scale; HAM-A = Hamilton ­ A ­ nxiety Rating Scale; ­ AM-D = Hamilton Depression Rating Scale; IAS = Illness Attitude H ­ Scale; IBQ = Illness Behaviors Questionnaire; IBS = irritable bowel syndrome; MFI = Multi­ ­
From page 71...
... dimensional Fatigue Inventory; MUPS = medically unexplained physical symptoms; MUS = medically unexplained symptoms; OR = odds ratio; PC = primary care; PCI = psychiatric consultation inter­ ention; PHQ-15 = ­ atient Health Questionnaire 15-Item Somatic Symptom v P Severity Scale; PIT = psycho­ ynamic interpersonal therapy; PMR = progressive muscle relax d ation; PSC-51 = ­ hysical Symptoms Checklist; RCT = randomized controlled trial; SCL-90-R = P Symptom Checklist-90-Revised; SDI = Sleep Disturbance Inventory; SF-12 = Medical Outcomes Study 12-Item Short Form Health Survey; SF-36 = Medical Outcomes Study 36-Item Short Form Health Survey; SOMS-7 = Screening for Somatoform Symptoms-7; SPQ = Social Problems Questionnaire; V/SF-36 = Medical Outcomes Study 36-Item Short Form Health Survey for Veterans; VAS = Visual Analogue Scale; WI = Whitely Index.
From page 72...
... rather than somatic symptoms. After treatment, c patients who received biofeedback had statistically significant improvement for catastrophizing of somatic complaints compared with patients who received group relaxation.
From page 73...
... RoB Consistency Directness Precision Evidence RCT: 2 (88) a High Inconsistent Indirect Imprecise Insufficient Clinical trial: 1 (90)
From page 74...
... 5 30-min sessions a week for first 4 weeks followed by 3 30-min sessions a week for 8 weeks. NOTE: BDI-II = Beck Depression Inventory Second Edition; CABAH = Cognitions About Body and Health Questionnaire; CGI = Clinical Global Impression Scale; MUPS = medically unexplained physical symptoms; SF-36 = Medical Outcomes Study 36-Item Short Form Health Survey; TMAS = Taylor Manifest Anxiety Scale.
From page 75...
... total: 21.57, p = 0.0011. Physical functioning (SF-36)
From page 76...
... TABLE 4-10  Cognitive Rehabilitation Therapy Study Type Intervention Size Jakcsy, 2002 Pre–post Computer-assisted Persian Gulf War cognitive retraining veterans, 50% female, Mild memory vs control training, all white, average age problems 6 4-hour sessions over 36 years in treatment 6 weeks. group and 39 years in Black Hills Health control group Care System, VA campus at Fort Meade N eligible = 80 N treatment = 10 N control = 10 mental, and emotional well-being vary widely and include the use of natural products, such as probiotics and herbal or botanic medicines, and mind– body practices, such as acupuncture, deep-breathing techniques, yoga, and Tai Chi (NIH, 2012)
From page 77...
... examined the effects of dance-movement psychotherapy on 17 patients who had medically unexplained symptoms and found statistically significant increases in activity and well-being. The effect sizes were moderate to large (0.31–0.72)
From page 78...
... , the committee rated the strength of evidence as shown in Table 4-11 and concluded that • There is low strength of evidence that acupuncture improves well being in people who have medically unexplained symptoms. • There is insufficient evidence to support conclusions about the effectiveness of movement therapy in people who have medically unexplained symptoms or of Kampo in people who have undif ferentiated somatoform disorder.
From page 79...
... . Two studies conducted research on the effects of exercise on unexplained physical symptoms.
From page 80...
... groups 60% and 76% Unexplained multiple 300 mg of SJW female, respectively; somatic symptoms, extract administered mean age 47.6 years somatization and twice daily for undifferentiated 6 weeks. N screened = 184 somatoform disorders, N treatment = 87 and somatoform N placebo = 88 autonomic dysfunction Germany Nickel et al., 2006 RCT BE vs light About 15% of gymnastics.
From page 81...
... 24.1% of treatment-group patients reported total of 27 adverse events, whereas 18.1% of placebogroup patients reported total of 24 adverse events. At end of treatment, symptom checklist (SCL-90-R)
From page 82...
... for CD N = 120 NOTES: BE = bioenergetic exercise; BMA = body–mind approach; CD = conversion dis­ order; CGI = Clinical Global Impressions Scale; CORE-OM = Counseling Outcome Routine­ E ­ valuation–Outcome Measure; DMP = dance-movement psychotherapy; EQ-5D = EuroQol ­ health status questionnaire; ES = effect size; HAM-A = Hamilton Anxiety Rating Scale; MUPS = medically unexplained physical symptoms; MUS = medically unexplained symptoms; MYMOP = Measure Yourself Medical Outcome Profile; SCL-90-R = Symptom Checklist-90-­ Revised; SJW = St. John's wort (Hypericum)
From page 83...
... , psychic symptoms (SCL-90-R SJW 61.65–29.39 vs placebo 66.37–50.50, p = 0.0001) , somatic symptoms (SCL-90-R somatization subscale SJW 15.57–6.84 vs placebo 15.95–12.50, p = 0.0001)
From page 84...
... Liverpool, United Homework: exercise N screened = 323 Kingdom or stretch for 20 min N aerobic training = 3 times weekly. 114 N stretching training = 114 NOTES: CBT = cognitive behavioral therapy; GP = General Practitioner; HADS = Hospital Anxiety and Depression Scale; MSPQ = Modified Somatic Perception Questionnaire; PUPS = persistent unexplained physical symptoms; RCT = randomized controlled trial; SD = standard ­ deviation; V/SF-36 = Medical Outcomes Study 36-Item Short Form Health Survey for Veterans.
From page 85...
... . 6 months after training, aerobic exercise and stretching resulted in improvement from baseline with fewer symptoms recorded by GP; fewer GP consultations; fewer prescriptions; fewer secondary-care contacts; and fewer new referrals to secondary care (all p < 0.01)
From page 86...
... The method of adverse-event reporting may be important; use of a standardized list of adverse events may cause study participants who are suggestible (such as people who are seeking psychologic health
From page 87...
... 2009. Medically unexplained physical symptoms in primary care: A controlled study on the effectiveness of cognitive-behavioral treatment by the family physician.
From page 88...
... 2003. Cognitive behavioral therapy and aerobic exercise for Gulf War veterans' ill nesses: A randomized controlled trial.
From page 89...
... 2011. Psycho physiologic treatment for patients with medically unexplained symptoms: A randomized controlled trial.
From page 90...
... 2002. A randomized controlled trial of group aerobic exercise in primary care patients with persistent, unexplained physical symptoms.
From page 91...
... 2000. Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: A feasibility study in Sri Lanka.


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