A. E. M. Speckens

Cognitive behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial.

Abstract Objective: To examine the additional effect of cognitive behavioural therapy for patients with medically unexplained physical symptoms in comparison with optimised medical care. Design: Randomised controlled trial with follow up assessments six and 12 months after the baseline evaluation. Setting: General medical outpatient clinic in a university hospital. Subjects: An intervention group of 39 patients and a control group of 40 patients. Interventions: The intervention group received between six and 16 sessions of cognitive behavioural therapy. Therapeutic techniques used included identification and modification of dysfunctional automatic thoughts and behavioural experiments aimed at breaking the vicious cycles of the symptoms and their consequences. The control group received optimised medical care. Main outcome measures: The degree of change, frequency and intensity of the presenting symptoms, psychological distress, functional impairment, hypochondriacal beliefs and attitudes, and (at 12 months of follow up) number of visits to the general practitioner. Results: At six months of follow up the intervention group reported a higher recovery rate (odds ratio 0.40; 95% confidence interval 0.16 to 1.00), a lower mean intensity of the physical symptoms (difference −1.2; −2.0 to −0.3), and less impairment of sleep (odds ratio 0.38; 0.15 to 0.94) than the controls. After adjustment for coincidental baseline differences the intervention and control groups also differed with regard to frequency of the symptoms (0.32; 0.13 to 0.77), limitations in social (0.35; 0.14 to 0.85) and leisure (0.36; 0.14 to 0.93) activities, and illness behaviour (difference −2.5; −4.6 to −0.5). At 12 months of follow up the differences between the groups were largely maintained. Conclusion: Cognitive behavioural therapy seems to be a feasible and effective treatment in general medical patients with unexplained physical symptoms.

A validation study of the Whitely Index, the Illness Attitude Scales, and the Somatosensory Amplification Scale in general medical and general practice patients

The aim of this study was to assess the reliability and validity of the Whitely Index (WI), the Illness Attitude Scales (IAS), and the Somatosensory Amplification Scale (SAS). The study population consisted of 130 general medical outpatients, 113 general practice patients, and 204 subjects from the general population. The factorial structure of the IAS appeared to consist of two subscales, namely Health Anxiety and Illness Behaviour. The internal consistency and stability of the three questionnaires were satisfactory, and their scores were highly intercorrelated. Scores on the WI and Health Anxiety subscale of the IAS declined significantly from general medical outpatients, through general practice patients to subjects from the general population. This might imply that medical care utilisation is related to hypochondriasis. A prospective study is needed to determine whether health anxiety contributes to the decision to seek medical care or the consultation of a general practitioner or consultant gives rise to worry about possible illness.

Unexplained physical symptoms: outcome, utilization of medical care and associated factors

The aim of the study was to investigate the recovery and frequency of physician contact in patients with unexplained physical symptoms and to identify factors associated with persistent disorder. Of 100 consecutive patients who presented with medically unexplained symptoms to a general medical out-patient clinic, 81 participated in a follow-up study. The mean follow-up time was 15.2 months (S.D. 4.0). At follow-up, many of the patients with unexplained physical symptoms reported that they had recovered (30%) or improved (46%) with regard to their presenting symptoms. Female sex and a high number of symptoms predicted a bad outcome in terms of recovery. Persistence of symptoms was not related to the duration of the symptoms, type of presenting complaint or the presence of psychiatric disorder. Forty per cent of patients with unexplained symptoms did not visit their general practitioner on their own initiative in the year following the initial visit to the clinic. Medical care utilization appeared to be associated with female sex, age, number and duration of symptoms, fatigue and psychiatric disorder, especially somatoform disorders. However, the association of a high frequency of physician contact with female sex and psychiatric disorder was not sustained after controlling for possible confounding factors.

The diagnostic and prognostic significance of the Whitely Index, the Illness Attitude Scales and the Somatosensory Amplification Scale

The aim of this study was to assess the ability of the Whitely Index, Illness Attitude Scales and Somatosensory Amplification Scale to differentiate in patients with medically unexplained physical symptoms between hypochondriacal and non-hypochondriacal patients and to examine whether the scores on these questionnaires are predictive of long-term outcome in terms of recovery of presenting symptoms and number of visits to the general practitioner. The study population consisted of 183 consecutive patients, who presented with medically unexplained physical symptoms to a general medical out-patient clinic. The Health Anxiety subscale of the Illness Attitude Scales and the Whitely Index were best in discriminating between hypochondriacal and non-hypochondriacal patients. The sensitivity and specificity of the Health Anxiety subscale of the Illness Attitude Scales were 79% and 84%, and of the Whitely Index 87% and 72%. The Whitely Index was negatively associated with recovery rate at 1 year follow-up. The Illness Behaviour subscale of the Illness Attitude Scales appeared to be predictive of the number of visits to the general practitioner. These findings might have clinical implications in helping to distinguish in patients with medically unexplained symptoms those for whom there is a high chance of persistence of the symptoms and/or of high medical care utilization.

The Reassurance Questionnaire (RQ): psychometric properties of a self-report questionnaire to assess reassurability

BACKGROUNDnThe aim of this study was to develop a questionnaire that assessed the extent to which patients usually feel reassured by their attending physician.nnnMETHODSnThe study population consisted of 204 subjects from the general population, 113 general practice patients, 130 general medical out-patients and 183 general medical patients with unexplained physical symptoms participating in an intervention study on the effect of cognitive behavioural therapy.nnnRESULTSnFactor analysis yielded a one-factor solution. The internal consistency was moderate to high and the test-retest reliability was high. The convergent validity of the Reassurance Questionnaire (RQ) was satisfactory to good, but the scores on the RQ did not appear to differentiate between the general population, general practice patients and general medical out-patients. In medical out-patients with unexplained physical symptoms, the RQ discriminated well between hypochondriacal and non-hypochondriacal patients. Scores on the RQ tended to be associated with a bad outcome in terms of recovery of presenting symptoms at 1 year follow-up. There was no association between scores on the RQ and frequency of physician contact. In patients with unexplained physical symptoms treated with cognitive behavioural therapy, scores on the RQ decreased over a period of 6 months and 1 year.nnnCONCLUSIONSnThe RQ was demonstrated to have psychometrically sound properties and appeared to be a useful instrument to assess reassurability in medical patients.

Cognitive Behavioural Therapy for Unexplained Physical Symptoms: Process and Prognostic Factors

The aims of this study were to examine the construct validity of a cognitive behavioural treatment model for medically unexplained physical symptoms and to examine potential predictors of treatment outcome. In concordance with the treatment model we used, the extent of hypochondriacal cognitions and psychological distress at baseline appeared to be associated. Change in hypochondriacal cognitions was related to change in psychological distress. The extent of hypochondriacal cognitions after treatment was predictive of the level of psychological distress at one year follow-up. The only baseline variable that predicted a negative treatment outcome was illness behaviour.