P. Spinhoven

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.

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.

Reciprocal effects of stable and temporary components of neuroticism and affective disorders: results of a longitudinal cohort study.

BACKGROUNDnCross-sectional studies show that neuroticism is strongly associated with affective disorders. We investigated whether neuroticism and affective disorders mutually reinforce each other over time, setting off a potential downward spiral.nnnMETHODnA total of 2981 adults aged 18-65 years, consisting of healthy controls, persons with a prior history of affective disorders and persons with a current affective disorder were assessed at baseline (T1) and 2 (T2) and 4 years (T3) later. At each wave, affective disorders according to DSM-IV criteria were assessed with the Composite Interview Diagnostic Instrument (CIDI) version 2.1 and neuroticism with the Neuroticism-Extraversion-Openness Five Factor Inventory (NEO-FFI).nnnRESULTSnUsing structural equation models the association of distress disorders (i.e. dysthymia, depressive disorder, generalized anxiety disorder) and fear disorders (i.e. social anxiety disorder, panic disorder, agoraphobia without panic) with neuroticism could be attributed to three components: (a) a strong correlation of the stable components of distress and fear disorders with the stable trait component of neuroticism; (b) a modest contemporaneous association of change in distress and fear disorders with change in neuroticism; (c) a small to modest delayed effect of change in distress and fear disorders on change in neuroticism. Moreover, neuroticism scores in participants newly affected at T2 but remitted at T3 did not differ from their pre-morbid scores at T1.nnnCONCLUSIONSnOur results do not support a positive feedback cycle of changes in psychopathology and changes in neuroticism. In the context of a relative stability of neuroticism and affective disorders, only modest contemporaneous and small to modest delayed effects of psychopathology on neuroticism were observed.

Response to an unsolicited intervention offer to persons aged ≥ 75 years after screening positive for depressive symptoms: a qualitative study.

BACKGROUNDnScreening can increase detection of clinically relevant depressive symptoms, but screen-positive persons are not necessarily willing to accept a subsequent unsolicited treatment offer. Our objective was to explore limiting and motivating factors in accepting an offer to join a coping with depression course, and perceived needs among persons aged ≥75 years who screened positive for depressive symptoms in general practice.nnnMETHODSnIn a randomized controlled trial, in which 101 persons who had screened positive for depressive symptoms were offered a coping with depression course, a sample of 23 persons were interviewed, of whom five (22%) accepted the treatment offer. Interview transcripts were coded independently by two researchers.nnnRESULTSnAll five individuals who accepted a place on the course felt depressed and/or lonely and had positive expectations about the course. The main reasons for declining to join the course were: not feeling depressed, or having negative thoughts about the course effect, concerns about group participation, or about being too old to change and learn new things. Although perceived needs to relieve depressive symptoms largely matched the elements of the course, most of those who had been screened were not (yet) prepared to accept an intervention offer. Many expressed the need to discuss this treatment decision with their general practitioner.nnnCONCLUSIONSnAlthough the unsolicited treatment offer closely matched the perceived needs of people screening positive for depressive symptoms, only those who combined feelings of being depressed or lonely with positive expectations about the offered course accepted it. Treatment should perhaps be more individually tailored to the patients motivational stage towards change, a process in which general practitioners can play an important role.