Astrid Larisch

Short-term psychotherapeutic interventions for somatizing patients in the general hospital : A randomized controlled study

Background: Treatment acceptance and motivation for psychotherapy of somatizing patients in the general hospital is low. Methods: Patients (n = 91) fulfilling the criteria for somatization were randomized into an intervention group (n = 49) and a control group (n = 42). The patients in the intervention group attended 5 psychotherapeutic sessions based on the modified reattribution model. The patients in the control group received psychoeducational reading material. The primary outcomes were motivation for psychotherapy and contacting a psychotherapist after discharge. The secondary outcomes consisted of changes regarding somatoform symptoms, emotional distress and quality of life. Results: Patients from the intervention group were significantly more motivated for psychotherapy (p = 0.001) than patients from the control group. At the 3-month follow-up, 42% of the patients from the intervention group had contacted a psychotherapist, compared to 20% of the patients from the control group (p = 0.045). At the 6-month follow-up, however, the ratio of patients having contacted a psychotherapist had changed to 44 and 29%, respectively, and was no longer significant. The intensity of somatoform symptoms and the anxiety symptoms decreased and mental functioning improved significantly over time for patients from both groups. Conclusions: Short-term psychotherapeutic interventions for somatizing patients in general hospitals have a moderately better effect on motivation for psychotherapy and contacting a psychotherapist than psychoeducational reading material alone. Future studies should attempt to prove the effectiveness of short-term psychoeducational interventions for somatizing patients in the general hospital.

Psychological and behavioral variables associated with the somatic symptom severity of general hospital outpatients in China

OBJECTIVE In high-income countries, the number and severity of somatic symptoms - irrespective of etiology--are associated with adverse psychobehavioral and functional characteristics. This study aimed to assess these key features among Chinese general hospital outpatients with high levels of somatic symptoms. METHODS This multicenter, cross-sectional study evaluated four outpatient departments of internal medicine and Traditional Chinese Medicine in Beijing and Kunming and enrolled a total of 281 consecutive patients. The patients answered questionnaires concerning somatic symptom severity [Patient Health Questionnaire (PHQ-15)], illness perception (Brief Illness Perception Questionnaire), illness behavior (Scale for the Assessment of Illness Behavior), emotional distress (Hospital Anxiety and Depression Scale) and health-related quality of life (12-Item Short Form Health Survey). Subsamples reporting high scores of somatic symptom severity (PHQ-15 ≥10, SOM+) versus low scores (PHQ-15 <10, SOM-) were compared. RESULTS Twenty-eight percent (79/281) of all outpatients showed high somatic symptom severity. The strongest correlations between high somatic symptom severity and psychobehavioral variables were found for high emotional distress, female gender, living alone, low physical quality of life and high dysfunctional illness behavior. The proportion of the explained variance was 36.1%. CONCLUSION In Chinese outpatients, high somatic symptom severity is frequent and associated with psychobehavioral characteristics. With the PHQ-15 cutoff of 10, SOM+ patients could be differentiated from SOM- patients using these characteristics.

Differentiation of somatizing patients in primary care : Why the effects of treatment are always moderate

The heterogeneity of somatizing patients influences outcomes, especially in unselected samples in primary care. A cluster analysis was performed as secondary analysis on an existing data set of 127 somatizing patients included in a randomized controlled clinical trial. Anxiety and depression (HADS), number and intensity of physical symptoms (SOMS), physical and emotional functioning (short form of the SF-36 Health Survey), health beliefs (KKU-G), and psychological distress (General Health Questionnaire) were used for clustering. Outcome, treatment satisfaction, and diagnosis were calculated and compared for the clusters. We differentiated three groups from this analysis: one with elevated emotional and physical stress, one in which emotional stress dominated, and one with low emotional and physical stress. The three groups did not differ in diagnoses of somatoform disorders. The high-stress groups improved over time, whereas the depression and emotional-functioning scores in the low-stress group deteriorated. All patients were satisfied with the treatment provided. Deterioration in the scores of the low-stress group may be a result of a clinically valuable change process, in that patients who were initially in denial were able to open up and admit their problems. The increased satisfaction with treatment supports this interpretation. This so-called response shift must be taken into account in the planning of studies.

Sense of coherence contributes to physical and mental health in general hospital patients in China

The sense of coherence (SOC) may explain why some people become ill under stress whereas others remain healthy. SOC is strongly related to perceived health, particularly mental health. Little is known about the physical and mental health statuses associated with SOC among general hospital outpatients in China. This multicentre cross-sectional study analysed 491 outpatients from four large Chinese general hospitals located in Beijing, Shanghai, Chengdu and Kunming. Patients completed questionnaires examining their SOC (SOC-9), somatic symptom severity (PHQ-15), depression (PHQ-9), generalised anxiety disorder (GAD), health anxiety (WI-7), quality of life (QoL; SF-12) and socio-demographic and clinical characteristics. SOC was negatively correlated with daily-life impairment, symptom duration, somatic symptom severity, depression, GAD and health anxiety, but was positively correlated with age as well as physical and mental QoL. Using a multiple linear regression model, the three strongest correlates of SOC were mental QoL, depression and age. These three variables explained 52% of the variance. SOC may be an important contributor to both mental and physical health in Chinese general hospital outpatients, which is consistent with the results obtained for primary care patients in Western countries. Longitudinal studies are needed to investigate how SOC predicts physical and mental health statuses over time and how these statuses respond to treatment for low SOC.

Quality of doctor—patient relationship in patients with high somatic symptom severity in China

BACKGROUND High somatic symptom severity (SSS) is associated with reduced health-related function and may affect doctor-patient interactions. This study aimed to explore the quality of the doctor-patient relationship (DPR) and its association with SSS in Chinese general hospitals outpatients. PATIENTS AND METHODS This multicenter cross-sectional study assessed the quality of DPR from both the doctors and patients perspective in general outpatients (n=484) from 10 departments of Psychosomatic Medicine (PM), Traditional Chinese Medicine (TCM), and Biomedicine (BM). SSS was assessed with the PHQ-15. The quality of the DPR was measured with the CARE, PDRQ-9, and DDPRQ-10 questionnaires. In addition, several standard instruments were used to assess psychosocial variables such as depression, anxiety, sense of coherence and quality of life. RESULTS From the doctors perspective, patients with high SSS were rated as significantly more difficult than patients with low SSS. No differences were noted from the perspective of the patients. Patients from the TCM department rated the quality of their DPR significantly higher than those in BM and PM and were rated from doctors perspective as less difficult than those in BM and PM. Multiple regression analysis revealed satisfaction of treatment, time of treatment and psychosocial variables, such as age, health related anxiety, depression, mental quality of life and sense of coherence as predictors for DPR. CONCLUSION PM and BM departments should learn from TCM departments to be empathic, to manage patients with high SSS and to establish long-term relationships with their patients.

Treating patients with functional somatic symptoms. A treatment guide for use in general practice.

Patients who experience body symptoms in response to psychosocial stress are a challenge for the general practitioner (GP). This paper is a contribution to the improved treatment of these patients. It presents a specific psychosocial treatment model provided by the GP including the following steps: (a) taking a thorough symptom history, conducting a psychosocial anamnesis and exploring the patients own perception of the illness, (b) developing alternative perceptions of the illness by understanding the psycho-physiological relationship; and (c) reducing the impact of psychosocial stress. The application of these specific techniques requires a trustful, helping alliance between the doctor and the patient and cooperation with mental health services.

Psychische Belastung und Psychosomatischer Behandlungswunsch von Patienten mit Pulmonaler Hypertonie

BACKGROUND The study investigated the level of mental distress in patients with pulmonary hypertension (PH) and assessed the use of and the wish for psychosomatic treatment. METHODS A total sample of n=187 outpatients participated in the cross-sectional survey. The short form of the Patient Health Questionnaire (PHQ-D), the EuroQol (EQ-5D) and a questionnaire assessing the wish for psychosomatic treatment were applied. RESULTS 50.6% of the patients exhibited depressive symptoms of varying degrees, 19.2% showed symptoms of major depression. 14.8% of the pa-tients reported panic attacks, and 7.1% demonstrated symptoms of a panic syndrome. Quality of life was low (EQ-5D VAS M=60). Experience with outpatient or inpatient psychotherapy was reported by 23.4% and 8.6% of the patients, respectively. 56.5% reported a wish for psychosomatic treatment. CONCLUSIONS PH-Patients are more likely to suffer from mild or subthreshold depressive syndromes, but are very interested in psychosomatic treatment. The implementation of psychosomatic interventions into clinical practice would be desirable.

Kosten-Nutzen-Aspekte psychosozialer Interventionen bei somatisierenden Patienten in der Hausarztpraxis

Zusammenfassung. Theoretischer Hintergrund: Somatisierende Patienten fuhren durch das hohe Inanspruchnahmeverhalten medizinischer Leistungen zu inadaquaten Kosten im Gesundheitssystem. Fragestellung: Fuhren psychosoziale Interventionen des Hausarztes bei somatisierenden Patienten zu einer Reduktion der Gesundheitskosten? Methode: 42 Hausarzte und 127 Patienten nahmen an einer randomisierten kontrollierten Studie zur Verbesserung der Behandlung von somatisierenden Patienten teil. In dieser Kosten-Nutzen-Analyse wurden Arztbesuche, Arbeitsunfahigkeitstage, stationare Aufenthalte, Medikamente sowie das Training berucksichtigt. Ergebnisse: In der Interventionsgruppe (IG) wurde gegenuber der Kontrollgruppe (KG) eine zusatzliche Ersparnis der direkten Kosten von 38,2% (262 eeee) pro Patient und Quartal erzielt. Die starkste Kostenreduktion fand sich im stationaren Bereich: IG 63,2% vs. KG 15,2%. Unter Berucksichtigung der indirekten Kosten reduzierte sich die zusatzliche Ersparnis der IG auf 11,9% (49,5 eeee). ...

Treating post-traumatic stress disorder by resource activation in Cambodia.

There is a need for effective, low‐threshold psychotherapeutic treatments in post‐conflict settings1. However, systematic outcome research on site is still extremely rare. To address this problem we integrated rigorous research procedures into a humanitarian program, the so called Mekong Project, and conducted a randomized controlled trial for the treatment of post‐traumatic stress disorder (PTSD) in Cambodia. In short, the Mekong Project aims at establishing independent psychotherapeutic services in several Southeast Asian countries via the systematic training of local health professionals and offering free of charge psychological help to traumatized civilians. Cambodia is one of the least developed countries in Asia, facing many challenges (e.g., poor standards of health and education, rural exodus, and political instability). Mental health morbidity in Cambodia is high. It has been found that 53.4% of the Cambodian population suffer from a mental disorder, with anxiety and PTSD being the most frequent (40.0% and 28.4% respectively)2. Thus, although some stability has returned to the country during the past decades, there are urgent mental health care needs, including the need for individualized psychiatric services. Our aim was to test the efficacy of a non‐confrontational psychotherapeutic treatment for PTSD. The therapy includes two main treatment principles described in treatment manuals: resource‐oriented trauma therapy and resource installation with eye movement desensitization and reprocessing (EMDR) (short: ROTATE). ROTATE aims at strengthening resilience and coping capacities by activating positive personal resources, and largely draws on psychodynamic principles of the therapeutic relationship. It includes a variety of imaginative resource‐activating methods3, 4 as well as resource development and installation, an EMDR technique aiming at systematically developing and anchoring resources using alternating bilateral stimulation5. ROTATE has several advantages: a) it can be safely applied even to complex trauma conditions, with no major side effects being observed so far; b) instead of solely focusing on PTSD symptoms, it also considers the mental comorbidities typically found in these clients, notably depression and anxiety; c) it is especially suitable for clients from non‐Western countries, as traditional healing resources like mindfulness strategies can be integrated in an overall framework of resource activation; d) its basic elements can easily be taught, even to paraprofessionals. Our trial was carried out in cooperation with the Royal University of Phnom Penh and was located in Phnom Penh City and the nearby Kandal Province. Help‐seeking outpatients screening positively for PTSD (PTSD Check List ≥ 446) were eligible for inclusion. We allowed for comorbid mental health disorders except for psychosis, organic brain disorder, cognitive impairment, dementia, acute suicidality, and acute need for treatment. Overall, 800 patients were screened for eligibility, of whom 86 (mean age 27 years, 61% female) fulfilled the selection criteria and were randomly assigned to either 5 weekly sessions of ROTATE (N=53) or a 5‐week waiting list control group (N=33). Symptoms were measured before and after the intervention (or waiting period). Assessments were performed via personal interview by an investigator blind to treatment allocation. All patients in the control group were offered treatment after the end of the waiting period. The primary outcome was PTSD symptom change on the Indochinese version of the Harvard Trauma Questionnaire (HTQ)7. The PTSD scale of the HTQ includes 16 items reflecting the DSM‐IV criteria for PTSD. Secondary outcomes included depression, anxiety and social functioning. All applied instruments have been validated for the Cambodian population7. The therapy was provided by six Cambodian psychologists who had completed a 3‐year course in trauma therapy as part of the Mekong Project. Based on previous findings of psychological therapies for PTSD8, we expected ROTATE to be superior to waiting list with a between group effect size of at least d=0.65 on the primary outcome. To detect this difference with a power of 0.80 at α=0.05, 2‐sided test, 2 × 40 patients were required. Unfortunately, the concept of randomization, especially being randomized to a waiting list, was very difficult for some clients. As a consequence, randomization failed in 38 patients, leading to an unbalanced allocation ratio (1.6:1), with an overrepresentation of patients randomized to treatment. The trial stopped when the necessary sample size to achieve a power of 0.80 was reached. Data were analyzed by general linear regression models, controlling for baseline symptom severity. The drop‐out rate during the intervention was very low (N=2, one in each group), thus only completer data were analyzed (N=84). Most frequent types of trauma were traffic accidents (24%), domestic violence (23%) and sexual abuse (16%). Patients receiving ROTATE showed significant reductions in PTSD symptoms compared to the waiting list (baseline adjusted means post‐treatment: 1.39, 95% CI: 1.23‐1.54 for ROTATE, and 2.86, 95% CI: 2.66‐3.06 for waiting list, p<0.00001). The between‐group effect size was large (d=2.59). The within‐group effect size was also large for ROTATE (d=4.43), while it was moderate in the control group (d=0.52). No harms were reported. We conclude that a treatment focusing on stabilization rather than confrontation, by establishing a secure patient‐therapist relationship, applying stabilization techniques, and putting an emphasis on a patients own resources, significantly reduced symptoms of PTSD in comparison to a waiting list. The strengths of our study are the following: a) it was conducted on site by local psychologists, which meant that communication between therapists and patients was natural and no interpreters were needed; b) therapists and patients had similar cultural backgrounds, so that culture specific interpretations of symptoms could be taken into account, a factor that has been identified as vital in the therapeutic work with Cambodian patients9; c) local psychologists were trained in ROTATE, which is expected to facilitate patient access to a psychological treatment in a country struggling with insufficient mental health care. Conducting a randomized controlled trial in a developing country is challenging. Nevertheless, we were able to show that the implementation of such a trial was possible and that this specific form of trauma therapy was well accepted by therapists and patients. Our results are preliminary but promising. Further research is required to corroborate the findings. Christiane Steinert1, Peter J. Bumke2, Rosa L. Hollekamp1, Astrid Larisch1, Falk Leichsenring1, Helga Matthes3, Sek Sisokhom4, Ute Sodemann2, Markus Stingl1, Ret Thearom4, Hana Vojtova5, Wolfgang Woller6, Johannes Kruse1,7 1Clinic for Psychosomatic Medicine and Psychotherapy, University of Giessen, Giessen, Germany; 2Trauma Aid Germany, Berlin, Germany; 3Psychotraumatology Institute Europe, Duisburg, Germany; 4Department of Psychology, Royal University of Phnom Penh, Phnom Penh, Cambodia; 5Slovak Institute for Psychotraumatology and EMDR, Trencin, Slovakia, and Center for Neuropsychiatric Research of Traumatic Stress, Charles University, Prague, Czech Republic; 6Hospital for Psychosomatic Medicine and Psychotherapy, Rhein‐Klinik, Bad Honnef, Germany; 7Clinic for Psychosomatic Medicine and Psychotherapy, University of Marburg, Marburg, Germany