group therapy for somatization disorders in primary care: maintenance of treatment

goals of short cognitive-behavioural treatment one and a half year follow up

Objective: The objective of this study was to evaluate the maintenance of treatment
goals of a short cognitive behavioural group treatment programme for the
management of somatization disorders in primary care.
Method: In a previous controlled 6-month follow-up study, patients with
somatization disorders (n 32) improved with respect to illness and somatic
preoccupation, hypochondriasis, and medication usage. In the present report the
same group of patients were also investigated one-and-a-half year after initial
treatment. Results: The long-term follow-up manifested maintained improvement
with respect to hypochondriasis. There was additional reduction of anxiety and
psychosocial preoccupation, whereas somatization and depression anxiety scores
improved progressively.
Conclusion: A short cognitive-behavioural group treatment of psychosomatic
patients can be useful in primary care and may manifest maintained or progressive
beneficial outcome

Introduction
The large group of patients with somatization disorders in primary care represents
one of the most complex problems facing the health care system (1). Somatization
disorders are very common, with a prevalence of about 15% in an urban population
(2). In general practice the incidence has been estimated to be in the range 4060%
(3, 4). Somatizing patients are high-level consumers of medical services (5, 6), and
the economic impact is considerable (7). The physicians encounter with the
somatizing patient usually arouses the negative feelings of helplessness and
frustration. Research on the management of somatization has been neglected in
modern medicine (1, 8, 9). Thus, a dilemma facing the attending physician has been
the lack of effective treatment (10). Since the 1960s, however, group therapies
generally involving brief cognitive-behavioural treatment have reported promising
results with respect to the reduction of physical complaints, anxiety and use of
medication (9, 1116). Nevertheless, most studies have been pilot studies or poorly
designed often lacking control groups. Follow-up has generally been short, in the
range of 2 or 3 months. The outcome of a randomized controlled, short cognitivebehavioural group treatment for somatizing patients in primary care, as reported by
this author, has previously been published in this journal (17). Designed as a pre-,
post-, and 6-month follow-up study there were moderate but significant
improvements with respect to perception of illness and somatic preoccupation,
hypochondriasis, and medication usage. However, the study raised the question as
to whether the beneficial effects could be long-lasting. In the literature there are
only a few reports on long-term outcome. Significantly, only five of 30 studies
published from the late 1970s to the mid 1980s involving behavioural techniques

such as biofeedback and relaxation training, and for chronic headache syndromes, had
follow-up periods exceeding 1 year (18). A recent MEDLINE search on cognitive therapy
+ somatization disorder yielded just four studies reporting follow-up for 1 or 2 years.
Aims of the study To make a long-term outcome investigation as to whether the beneficial
treatment effects at 6 months would be maintained at a 18-month follow-up within the
original treated group of somatizing patients.
Material and methods

In the following, only concise accounts will be presented. Details of the definitions of
somatization disorders, the inclusion and exclusion criteria, pretreatment drop-out,
patient characteristics, study design, the cognitive-behavioural treatment programme
and assessment measures have already been described in the original report (17).
Definition of somatization disorders

In short, somatization as defined by Kellner (19) as_functional somatic symptoms (FSS)_,

also including the concept of hypochondriasis, was adopted for the present study.
However, within the definition of FSS, various subgroups of somatization disorders must
be defined. For this purpose, the third edition of the International Classification of Health
Problems in Primary Care (ICHPPC- 2-Defined; 20) was used for the selection of inclusion
and exclusion criteria. The ICHPPC- 2-Defined is an adoption of the ICD-9 intended for
the use in general practice (ICD-10 and later versions of ICHPPC-2-Defined were not
available at the time when the original study was made). In the ICHPPC-2-Defined,
criteria for specific functional disorders are listed. For example, the diagnosis of irritable
colon syndrome (code 558, comparable with ICD-9 code 564B) has to fulfil the following
inclusion criteria: _(a) continuous or intermittent abdominal pain and variable pattern
for over 3 months, and (b) one of the following: (i) increased gas, (ii) tender and
palpable colon, or (iii) mucus without blood in stool. Intestinal disease which is either
proven or presumed to be of infective origin, psychogenic diarrhoea, constipation,
regional enteritis and vascular insufficiency of the gut have to be excluded_. In the
original report patients were diagnosed with myalgia (18 of 33), tension headache (18 of
33), palpitation (18 of 33), chest pain (10 of 33), irritable bowel syndrome (10 of 33),
dizziness (10 of 33), dyspepsia (five of 33) and asthenia (four of 33) according to the
ICHPPC-2-Defined. Nearly half (14 of 33) of the patients were polysymptomatic
(reporting 4 symptoms).
Inclusion and exclusion criteria

The inclusion criteria were: (i) age range 3060 years, (ii) the presence of a
somatization disorder in accordance with the definition of FSS, and (iii) one or more
symptoms fulfilling the criteria of specific functional disorders as outlined in the ICHPPC2-Defined. The exclusion criteria were as follows: (i) clinical evidence or history of major
mental disorder such as psychotic disorders, mood disorders (major depressive, manic,
bipolar) or anxiety disorders (panic attack, phobias, general anxiety disorder), (ii)
current psychological or psychiatric treatment, (iii) acute or transient functional
symptoms, (iv) clinical evidence or history of drug abuse, (v) presence of a chronic pain
syndrome, and (vi) inability to speak Swedish sufficiently and fluently.
Patient characteristics

In the randomized study (17) the treatment group initially comprised 33 patients (mean
age 43.8 years, range 2560); there were five men and 28 women. The mean duration
of illness was 9.2 years (range 140), and the mean age at onset was 34.2 years (range
659). Of the initial 33 patients two dropped out during follow-up, leaving 31 as subjects
of the investigation. Study design The original report, based on a 6-month follow-up, was
a randomized control study with a 2 3 repeated-measures design (17). There were six
treatment groups consisting of three groups of six patients and three groups of five
patients (i.e. 33 patients in total). The group assignment procedures have been
described in detail in the original report. For a long-term follow-up study of patients
diagnosed with somatization illnesses it is difficult to achieve a controlled design

because of the dropout of waiting-list controls (17, 21, 22), and ethical restrictions (21).
Thus, in the present study the patients in the treatment group served as their own
controls. The Ethics Committee of the Medical Faculty of Lund University approved the
study.
Treatment programme and group sessions

In short, the cognitive-behavioural programme as a whole focused on reducing dread (of

somatic disease) by including the following items: (i) a thorough physical examination,
(ii) education about psychological and physiological stress symptoms to enable
cognitive restructuring, and (iii) relaxation training. Thus, the objective of the
programme was to reduce fear in order to improve the patients ability to cope with
stress, anxiety and functional symptoms (2325). The treatment programme consisted
of eight weekly 3-h evening sessions during 2 months. At each session, an introductory
lesson (Table 1) was followed by a general discussion, ending with relaxation training
using audiotaped instructions. Handouts summarizing the education provided were
distributed to patients at the end of each session as well as written educational material
to be read at home and discussed at the following session. In addition, at least one daily
relaxation training session was to be completed at home using the taped instructions.
The tape recordings consisted of four parts: muscular relaxation; muscular relaxation
training with guided imagery; muscular relaxation training with guided imagery,
focusing on support of self-reliance at the present time; and muscular relaxation training
with guided imagery, but focusing on support of self-reliance in the future. However, the
main focus of most training group sessions was muscular relaxation. Patients were
encouraged to proceed to the other parts only when muscle relaxation had been
satisfactorily achieved. After completion of the treatment session, there was a final 3month follow-up session. A representative two-thirds of the patients considered the
relaxation training programme to be a _great help_ and overall patient attendance was
above 90% (17).
Assessment methods

Assessments were made at pretreatment, posttreatment, and at 6 and 18 months

follow-up. The following assessment instruments were used: The Social Problem
Questionnaire (SPQ; aggregate score range 063) describing the severity of current
psychosocial preoccupation (26, 27); The Illness Behaviour Questionnaire (IBQ;
aggregate score range 052) for the assessment of somatization (28) including the
subscale Whiteley Index (WI; 29) for the identification of hypochondriasis (aggregate
score range 013); The Hospital Anxiety and Depression Scale (HAD; 30) measuring
anxiety and depression index (aggregate score range 042) and anxiety (A) and
depression (D) separately in their subscales (aggregate score range 021 for both); The
Sleep Disturbance Index (SDI; 31, 32) for the assessment of sleep quality (aggregate
score range 030); and, finally, Medication usage measured by the construction of a
_drug usage questionnaire_ (17) for medication taken within the previous month
(aggregate score range 024). Changes in the use of medical resources and health care
costs were not assessed.
Statistical analysis

For this investigation three non-parametric statistical methods were used, namely the
Friedman two-way analysis of variance (ANOVA), the Wilcoxon matched pairs signed
ranks test and the Spearmans rank correlation coefficient analysis. The latter was
included in order to test changes during the time of follow-up with respect to the
differing variables (tendency analysis). All statistical calculations were performed on a
Personal Computer using SPSS. Two-tailed tests of significance were calculated, P-values
<0.05 being considered significant.

Results
Analysis of variance The results of the ANOVA showed significant differences between the

four assessments for all variables except depression (Table 2). The separate sum score
of SPQ, IBQ, WI, HAD, the anxiety subscale of HAD, SDI and medication usage decreased
over time compared with pretreatment. However, there was a gradual increase in the
scoring of quality of sleep (SDI) and medication usage after treatment.
Wilcoxon test

The Wilcoxon matched pairs signed ranks test manifested significant change for several
variables between pretreatment, post-treatment, and at the 6- and 18-month follow-ups
(Fig. 1). The SPQ manifested a slow reduction in score over time. However, compared
with pretreatment SPQ, it did not decrease until after the 18-month assessment (P <
0.001). The IBQ manifested a continuous reduction in score (P < 0.05 at post-treatment;
P < 0.01 at 6 months; and P < 0.001 at 18 months) and compared with pretreatment.
However, there was no significant change after 6 months. The WI declined significantly
during follow-up (P < 0.01 at post-treatment; P < 0.001 at 6 months, and P < 0.01 at 18
months) and compared with pretreatment. The reduction was most prominent from
pretreatment to 6 months. There was no further improvement after that. The HAD did
not manifest any change until the 6-month assessment (P < 0.05). There was a further
improvement at 18 months (P < 0.01) compared with pretreatment. The subscale for
depression did not decrease in score until the 18-month follow-up (P < 0.05), whereas
the anxiety score reduced earlier (P < 0.01 at both the 6- and 18-month follow-up). The
SDI manifested an initial reduction in scoring (P < 0.05 at post-treatment) but not
thereafter. The change in medication usage was similar (P < 0.05 at post-treatment and
at 6 months). Spearman's rank correlation coefficient analysis This statistical tendency
analysis indicated reductions in scoring over time from pretreatment to the final 18month assessment. Significant correlations include the SPQ (Spearman correlation )
0.26; P < 0.003), IBQ ()0.19; P < 0.035), WI ()0.20; P < 0.029) and anxiety score ()0.20;
P < 0.030). The significant correlations may be designated as _fairly strong_ with
respect to the number of patients and the results of the other tests of significance made
in this study.
Discussion

The original controlled study manifested moderate improvements compared with the
control group of patients. Somatization and medication usage were reduced at posttreatment (P < 0.05 for both) and at 6-month follow-up (P < 0.01 and P < 0.05,
respectively). There was also an improvement in hypochondriasis (P < 0.05). The
present second long-term follow-up study of the original group of treated patients
manifested maintained improvement with respect to hypochondriasis, there was an
additional reduction of anxiety, and psychosocial preoccupation, somatization, and
depression-anxiety scores improved progressively. It may be assumed that, had more
patients been included, there might have been additional improvement because of
more statistical power. However, there are several problematic issues inherent in
somatization treatment studies (21). The definition of somatization in primary care is
one such issue, and others are the patients aversion to participation in _psychological_
treatment for physical symptoms, the high patient drop-out of waiting-list controls (21,
22) and problematic randomization, all of which have been discussed in the original
report (17). Thus, some caution is justified in the interpretation of the results.
This reservation applies also to the present longterm investigation as it was not possible
to use a controlled study design and for reasons already addressed in the methods
section. The control group had been on the waiting-list for 8 months and the ethics
committee had approved of a study design that required treatment of the controls after
that time. Unfortunately, there was no long-term follow-up of the later treated control
subjects. Moreover, in preparation of the original investigation, 70 patients fulfilled the
criteria for inclusion, however, 20 (29%) decided not to participate. Thus, the results

might have been biased by the selection of individuals motivated for this type of
intervention. Spontaneous recovery, external and coincidental events, and other
treatments might also have influenced the outcome of the present study. In another
report (33) about half of the patients with somatization disorders improved
spontaneously after 1 year (however, somatization was defined by a health
questionnaire). The mean duration of somatization illness being over 9 years in the
present sample makes it unlikely that overall improvement was to be the result of
spontaneous recovery. Similarly, as a result of the stable illness in this group it is
improbable that beneficial external events exerted major influences. However, one
weakness of this study was that it was not designed to eliminate the interference from
other treatment during follow-up. Despite these reservations, there is still much support
for the beneficial effects of cognitivebehavioural intervention. Previous reports have
similarly demonstrated that positive results from cognitive-behavioural therapy are
maintained or even improve progressively, even in patients with illnesses such as
chronic pain (3437). Thus, in certain individuals a cognitive process may be initiated
which is characterized by continuing reduction of distress, functional symptoms and
dysfunctional coping (17, 38). Previous comparable long-term studies on the effects of
cognitive-behavioural therapy for somatization patients add further support to a model
of _cognitive restructuring_. Speckens et al. (39) reported a high recovery rate at 6month followup with improved physical symptoms and quality of sleep. At 12 months,
the initial improvement was largely maintained. In a report by Kashner et al. (40) a short
group therapy programme resulted in better physical and mental health. There was also
an economic benefit, with 52% net savings in health care charges. McLeod and Budd
(41) similarly reported decreased emotional and physical distress, increases in
functional status, and high levels of satisfaction. Improvement was also reflected in
decreased use of medical resources after a long-standing pattern of high utilization.
Finally, McKay (42) found that patients diagnosed with body dysmorphic disorder (BDD)
were more effective in managing symptoms and had lower anxiety and depression even
at 18- and 24-month follow-up after cognitive-behavioural therapy. The long-term
outcome of the present study should add support to the usefulness of cognitivebehavioural intervention in chronic functional disorders. The reasons for neglecting
treatment of somatization illnesses in the past merit some discussion. The generally low
interest by psychiatrists has recently been given attention by Bass (43), suggesting that
_psychiatrists preoccupation with serious mental illness has given somatization
disorders low priority_. One cause of this might be that somatization patients usually
reject psychiatric treatment and when applied, the results have not been encouraging
(44). There is also a more general criticism. This refers to the misconception that
somatizing patients are only _worried well_, undeserving of health services resources.
This might be because of the persistence of mind-body dualism among the medical
profession and the general public, as stated by Mayou and Sharpe (45). They also
consider the mind-body dualism to be an obstacle for more widespread use of cognitivebehavioural treatment and call for a change in doctors professional training to integrate
a biopsychosocial disease illness model. Nevertheless, there is a growing professional
interest in functional disorders. In fact, somatization has been the focus of several
recent editorials in clinical journals (4547). Much of this new attention has focused on
the beneficial outcome of an increasing number of cognitive-behavioural treatment
reports. The potential benefits in terms of reduction of distress, for both patient and
doctor, and the reduced costs have been assumed to _be enormous_ (48). The present
study illustrates that positive results might be obtained also in a primary care setting
where the problem of functional disorders might be the largest. It is the opinion of this
author that also nurses or physical therapists can be trained to apply a short cognitive

group treatment programme of functional illnesses in primary care similar to the one
used in the present investigation.