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Symptom Management in Older Primary Care Patients: Feasibility of an Experimental, Written Self-Disclosure Protocol
Abstract
Distress-driven symptoms are prevalent among older primary care patients and account for a large percentage of office visits and increased medical costs. An experimental written self-disclosure protocol has been shown to reduce symptoms and use of health care services in healthy adults. Written self-disclosure as a method for reducing symptoms has not been evaluated in the primary care setting.
To evaluate the feasibility of adapting an experimental written self-disclosure protocol for the primary care setting.
Randomized, single-blind feasibility study.
University-based geriatric and internal medicine primary care clinics.
45 patients 66 years of age or older without a psychiatric diagnosis.
Three 20-minute writing sessions focusing on distressing experiences (in the intervention group) or health behaviors (in the control group).
The feasibility outcomes were patient recruitment, protocol logistics, and patient and provider satisfaction. The clinical outcomes were somatic and distress symptoms, health care utilization, and associated costs.
One third of patients screened were recruited; 96% of patients recruited completed the protocol. Clinic contact time was an average of 55 minutes per patient. Patients and providers reported high levels of satisfaction with the protocol. Reductions in symptoms were minimal for both groups. Use of outpatient services and associated costs decreased in both groups, but the reduction was twice as great in the treatment group as in the control group.
Findings support the feasibility of implementing the protocol as a primary care intervention.
... Less doctor visits in the months following an exercise of written self-disclosures for three days was one study result (Pennebaker & Graybeal). This result was replicated in a study of elderly patients who reduced their primary care office visits (Klapow, Schmidt, Taylor, Roller, Li, Calhoun, Wallander, & Pennebaker, 2001). Physical health benefits or fewer doctor visits were noted in samples of patients with medical ailments such as asthma, arthritis, diabetes, and migraine headaches (Frattaroli, 2006). ...
... There could be five possible explanations for this hesitancy: participant age, participant computer experiences, participant level of distress, lack of interaction with the researchers, or an environmental influence such as the staff buy-in for the study. Although there was no formal survey of potential participants in this study to determine if age was an influencing factor, younger participants have been reported as more forthcoming with symptoms while using computers (Wright, Aquilino, according to researchers who noted older individuals self-reported more symptoms and had lower recovery scores (Corrigan et al., 1999;Klapow, Schmidt, & Taylor et al., 2001), thus possibly explaining the lack of differences in self-ratings over time (duration) by some of the older patients in this study. ...
... From this sequence, the research assistant delivered the appropriate writing instructions to each participant. The writing instructions were delivered orally to minimize the possibility of misunderstanding, similar to previous expressive writing studies with older adults (21,22). A written copy of the instructions was also provided, so the participant could read the instructions before beginning their writing task. ...
... The healing score was a summation of the number of time points (Days 0, 7, 11, 14, 17, and 21) the wound was healed. Scores ranged from 0 (not healed on Day 21) to 5 (healed on Days 7,11,14,17,and 21). For example, a participant with a healed wound on Day 7 received a score of 5, whereas a participant with a healed wound on Day 17 received a score of 2. Higher scores indicated faster healing. ...
Objective
To investigate whether expressive writing could speed wound reepithelialization in healthy, older adults.Methods
In this randomized controlled trial, 49 healthy older adults aged 64 to 97 years were assigned to write for 20 minutes a day either about upsetting life events (Expressive Writing) or about daily activities (Time Management) for 3 consecutive days. Two weeks postwriting, 4-mm punch biopsy wounds were created on the inner, upper arm. Wounds were photographed routinely for 21 days to monitor wound reepithelialization. Perceived stress, depressive symptoms, health-related behaviors, number of doctor visits, and lipopolysaccharide-stimulated proinflammatory cytokine production were also measured throughout the study.ResultsParticipants in the Expressive Writing group had a greater proportion of fully reepithelialized wounds at Day 11 postbiopsy compared with the Time Management group, with 76.2% versus 42.1% healed, χ(2)(1, n = 40) = 4.83, p = .028. Ordinal logistic regression showed more sleep in the week before wounding also predicted faster healing wounds. There were no significant group differences in changes to perceived stress, depressive symptoms, health-related behaviors, lipopolysaccharide-induced proinflammatory cytokine production, or number of doctor visits over the study period.Conclusions
This study extends previous research by showing that expressive writing can improve wound healing in older adults and women. Future research is needed to better understand the underlying cognitive, psychosocial, and biological mechanisms contributing to improved wound healing from these simple, yet effective, writing exercises.Trial RegistrationAustralian New Zealand Clinical Trials Registry (trial number 343095).
... Available descriptions of present adaptations are concise and rather general, however. Reproduction of results requires precision regarding the adaptation of the standard protocol and its rationale, as well as evidence that the adapted protocol actually brings about the cognitiveemotional change intended to promote its effectiveness [29]. ...
... The adapted protocol with standardized differential instructions per session was safe, viable, and yielded satisfactory adherence and compliance. This is in accordance with findings from previous studies conducted in the home environment [7,10,13,22,29,67] and is important because manual-based home interventions can promote accessibility and applicability, reduce professional involvement, and thus decrease the costs of health care [18,19]. Adherence to the disclosure and control protocol was equal in the present study, indicating that differences between conditions can be attributed to the specific content of the intervention. ...
Emotional engagement, cognitive restructuring, and positive future directedness are considered core elements to induce change in emotional disclosure interventions. Our aim was to examine the induction of these elements and the feasibility of an emotional disclosure intervention adapted for home application.
The intervention emphasized expression of negative and positive emotions (session 1-4), search for meaning (session 3), and a positive future-oriented ending (session 4). A randomized clinical trial in patients with rheumatoid arthritis compared the adapted intervention (n=40) with a time management control condition (n=28). Feasibility was evaluated regarding adherence, compliance with instructions, perceived viability, and clinical safety. Induction of core elements was evaluated by analysis of change in immediate affective responses and by computerized text analysis of word use.
Feasibility criteria were successfully met. The disclosure condition produced higher immediate negative affect and use of emotion, insight, and optimism words compared to control, and induced the elements of change within sessions as intended.
The adapted intervention is feasible for home application and induces change in variables that indicate emotional engagement, cognitive restructuring, and positive future directedness.
Empirical support of health benefits of this emotional disclosure intervention will extend its applicability in patient self-care.
... A sample of different studies points to some of the difficulties of achieving consistency and reliability of research outcomes regarding writing's effects. For example, Schoutrop et al. (2002) examine the impact of writing on the processing of stressful events, Klapow et al. (2001) show a reduced use of outpatient services and Gidron et al. (2002) show a reduced number of clinic visits. In the Schoutrop study, closer analysis of the impact of writing on effects of the trauma was not followed up. ...
Creative writing practices in medical settings and for therapeutic purposes
... Expressive writing is based on the assumption that writing one's feelings gradually eases negative feelings or emotional trauma. These types of intervention have not exclusively been developed in the field of gerontology but as a more general approach to be used in many different types of target populations, for instance, people with traumatic experiences (Smyth & Helm, 2003) or chronic conditions (Broderick, Stone, Smyth, & Kaell, 2004;McGuire, Greenberg, & Gevirtz, 2005;Smith et al., 2015;Smyth, Stone, Hurewitz, & Kaell, 1999), including many nonclinical populations, for instance, student populations (Gortner, Rude, & Pennebaker, 2006;Park, Ramirez, & Beilock, 2014;Yang, Tang, Duan, & Zhang, 2015), and more recently to older adults (Klapow et al., 2001;Koschwanez et al., 2013). ...
Objectives: The aim of the current study was to analyze whether biographical writing interventions have an impact on depression and QoL compared to daily diary writing. We also wanted to investigate differential effects between structured and unstructured interventions.
Method: In two Northern regions of Germany, 119 older adults aged 64–90 were randomly assigned to three different types of narrative writing interventions: written structured and unstructured biographical disclosure as well as daily diary writing. Depression (PHQ-9), QoL (SF-12, EUROHIS) and trauma-related symptoms (PCL-C) were obtained pre- and post-interventions as well as at three-month follow-up.
Results: Follow-up measures were obtained from 85 participants (29% loss to follow-up; mean age = 73.88; 68.2% female). Results of repeated measurement analysis demonstrated a significant effect on depression with the daily diary writing group showing lower depressive symptoms than structured biographical writing. We did not find a significant impact on QoL. Post-hoc analyses showed that posttraumatic symptoms lead to increases in depressive symptoms.
Conclusion: In a non-clinical sample of community-dwelling older adults, biographical writing interventions were not favorable to daily diary writing concerning the outcomes of the study. This might be related to the association of traumtic reminiscences of former children of World War II and outcome measures.
... Existing studies of the effects of expressive writing on mental health and physical outcomes for older adults have produced equivocal findings. In one study on the effects of expressive writing on physical and emotional well-being in older adults (Klapow et al. 2001), 45 patients aged 66 years or older who attended a university-based geriatric primary care clinic in Alabama were randomized to an intervention or control condition. Patients assigned to the treatment condition were asked to write about thoughts and feelings associated with the most distressing event of their lives. ...
... Existing studies of the effects of expressive writing on mental health and physical outcomes for older adults have produced equivocal findings. In one study on the effects of expressive writing on physical and emotional well-being in older adults (Klapow et al. 2001), 45 patients aged 66 years or older who attended a university-based geriatric primary care clinic in Alabama were randomized to an intervention or control condition. Patients assigned to the treatment condition were asked to write about thoughts and feelings associated with the most distressing event of their lives. ...
... Many models of HBPC are emphasizing the importance of palliative approaches for people with complex chronic illnesses. Evidence in non-homebound elders suggests that for older primary care patients, interventions such as in-home palliative care programs and "symptom treatment" protocols can lead to significant symptom improvement, higher satisfaction with services, and reductions in health care utilization (23,48,(53)(54)(55)(56). Further study should specifically assess if effective symptom management has a similar impact in the homebound. ...
Context:
Homebound adults experience significant symptom burden.
Objectives:
To examine demographic and clinical characteristics associated with high symptom burden in the homebound, and to examine associations between symptom burden and time to hospitalization, nursing home placement, and death.
Methods:
Three hundred eighteen patients newly enrolled in the Mount Sinai Visiting Doctors Program, an urban home-based primary care program, were studied. Patient sociodemographic characteristics, symptom burden (measured via the Edmonton Symptom Assessment Scale, ESAS), and incidents of hospitalization, nursing home placement, and death were collected via medical chart review. Multivariate Cox proportional hazards models were used to analyze the effect of high symptom burden on time to first hospitalization, nursing home placement, and death.
Results:
Of the study sample, 43% had severe symptom burden (i.e., ESAS score ≥6 on at least one symptom). Patients with severe symptom burden were younger (82.0 vs. 85.5 years, P<0.01), had more comorbid conditions (3.2 vs. 2.5 Charlson score, P<0.01), higher prevalence of depression (43.4% vs. 12.0%, P<0.01), lower prevalence of dementia (34.3% vs. 60.6%, P<0.01), and utilized fewer hours of home health services (86.2 vs. 110.4 hrs/wk, P<0.01). Severe symptom burden was associated with a shorter time to first hospitalization (hazard ratio=1.51, 95% confidence interval 1.06-2.15) in adjusted models, but had no association with time to nursing home placement or death.
Conclusion:
The homebound with severe symptom burden represent a unique patient cohort who are at increased risk of hospitalization. Tailored symptom management via home-based primary and palliative care programs may prevent unnecessary health care utilization in this population.
... We chose a domestic setting because this is how this intervention would be used in clinical practice. Previous community-based studies of disclosure of emotionally important events have tended to be less effective (30)(31)(32)(33). This difference has been attributed to poorer adherence to EW instructions and the inability to ensure instruction fidelity (29). ...
Asthma is a chronic condition affecting 300 million people worldwide. Management involves adherence to pharmacological treatments such as corticosteroids and β-agonists, but residual symptoms persist. As asthma symptoms are exacerbated by stress, one possible adjunct to pharmacological treatment is expressive writing (EW). EW involves the disclosure of traumatic experiences which is thought to facilitate cognitive and emotional processing, helping to reduce physiological stress associated with inhibiting emotions. A previous trial reported short-term improvements in lung function. This study aimed to assess whether EW can improve lung function, quality of life, symptoms, and medication use in patients with asthma.
Adults (18-45 years) diagnosed as having asthma requiring regular inhaled corticosteroids were recruited from 28 general practices in South East England (n = 146). In this double-blind randomized controlled trial, participants were allocated either EW or nonemotional writing instructions and asked to write for 20 minutes for 3 consecutive days. Lung function (forced expired volume in 1 second [FEV1]% predicted), quality of life (Mark's Asthma Quality of Life Questionnaire), asthma symptoms (Wasserfallen Symptom Score Questionnaire), and medication use (inhaled corticosteroids and β-agonist) were recorded at baseline, 1, 3, 6, and 12 months.
Hierarchical linear modeling indicated no significant main effects between time and condition on any outcomes. Post hoc analyses revealed that EW improved lung function by 14% for 12 months for participants with less than 80% FEV1% predicted at baseline (β = 0.93, p = .002) whereas no improvement was observed in the control condition (β = 0.10, p = .667).
EW seems to be beneficial for patients with moderate asthma (<80% FEV1% predicted). Future studies of EW require stratification of patients by asthma severity.
ISRCTN82986307.
... In contrast to Leppert et al. [28] recent studies show that older individuals do not display more psychological disorders or psychosocial stressors. In contrast to clinical intuition, the prevalence rate of psychological disorders is even lower than in younger individuals [58,59]. One possible explanation might be the decoupling of the use of emotional suppression and psychological distress with age. ...
Background
Recalled parental rearing behavior is one of the factors influencing the strength of resilience. However, it is unclear whether resilience is a relatively stable personality trait or has a relational character whose protective strength changes over the course of life. Therefore, the association between recalled parental rearing and resilience as well as symptoms of anxiety and depression was investigated in respect to age and gender.
Methods
N = 4,782 healthy subjects aged 14-92 (M = 48.1 years) were selected by the random-route sampling method. In this sample, an ultra-short form of the Recalled Parental Rearing Behavior Questionnaire, the German short version of the resilience scale, and two screening instruments for depression and anxiety (PHQ-2, GAD-2) were filled out. Structural equation modelling was used to analyze the data estimated with the maximum likelihood method approach.
Results
The data revealed that rejection and punishment were clearly associated with lower resilience. Moreover, resilience had a strong connection to the symptoms of anxiety and depression. Resilience had the same quality of association in both men and women with respect to anxiety and depression. Furthermore, the effect of resilience did not vary across several age groups even though challenges may differ over a lifetime.
Conclusion
Recalled parental rearing behavior such as rejection and punishment as well as control and overprotection exert a significant association on the strength of resilience. Resilience has an effect independent of gender and does not affect people of different age groups differently.
... Another three studies involved specially trained health care workers seeing patients in the primary care setting (Kennedy 2001; Smith 2006) or specialist advice to GPs during the trial (Pols 2008). Other reasons for exclusion were: specified GP treatment which did not involve reattribution or reframing of physical symptoms (Alamo 2002; Jellema 2005; van Bokhoven; van der Horst 1997) or included participants who did not fulfil criteria for MUS (Bakker 2007; Klapow 2001). Finally two studies were excluded because they did not include a trial arm with usual treatment (Aiarzaguena 2007; Sumathipala 2008). ...
Patients with medically unexplained or functional somatic symptoms are common in primary care. Previous reviews have reported benefit from specialised interventions such as cognitive behavioural therapy and consultation letters, but there is a need for treatment models which can be applied within the primary care setting. Primary care studies of enhanced care, which includes techniques of reattribution or cognitive behavioural therapy, or both, have shown changes in healthcare professionals' attitudes and behaviour. However, studies of patient outcome have shown variable results and the value of enhanced care on patient outcome remains unclear.
We aimed to assess the clinical effectiveness of enhanced care interventions for adults with functional somatic symptoms in primary care. The intervention should be delivered by professionals providing first contact care and be compared to treatment as usual. The review focused on patient outcomes only.
We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR-Studies and CCDANCTR-References) (all years to August 2012), together with Ovid searches (to September 2012) on MEDLINE (1950 - ), EMBASE (1980 - ) and PsycINFO (1806 - ). Earlier searches of the Database of Abstracts of Reviews of Effectiveness (DARE), CINAHL, PSYNDEX, SIGLE, and LILACS were conducted in April 2010, and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2009. No language restrictions were applied. Electronic searches were supplemented by handsearches of relevant conference proceedings (2004 to 2012), reference lists (2011) and contact with authors of included studies and experts in the field (2011).
We limited our literature search to randomised controlled trials (RCTs), primary care, and adults with functional somatic symptoms. Subsequently we selected studies including all of the following: 1) a trial arm with treatment as usual; 2) an intervention using a structured treatment model which draws on explanations for symptoms in broad bio-psycho-social terms or encourages patients to develop additional strategies for dealing with their physical symptoms, or both; 3) delivery of the intervention by primary care professionals providing first contact care; and 4) assessment of patient outcome.
Two authors independently screened identified study abstracts. Disagreements about trial selections were resolved by a third review author. Data from selected publications were independently extracted and risk of bias assessed by two of three authors, avoiding investigators reviewing their own studies. We contacted authors from included studies to obtain missing information. We used continuous outcomes converted to standardised mean differences (SMDs) and based analyses on changes from baseline to follow-up, adjusted for clustering.
We included seven studies from the literature search, but only six provided sufficient data for analyses. Included studies were European, cluster RCTs with adult participants seeing their usual doctor (in total 233 general practitioners and 1787 participants). Methodological quality was only moderate as studies had no blinding of healthcare professionals and several studies had a risk of recruitment and attrition bias. Studies were heterogeneous with regard to selection of patient populations and intensity of interventions. Outcomes relating to physical or general health (physical symptoms, quality of life) showed substantial heterogeneity between studies (I(2) > 70%) and post hoc analysis suggested that benefit was confined to more intensive interventions; thus we did not calculate a pooled effect. Outcomes relating to mental health showed less heterogeneity and we conducted meta-analyses, which found non-significant overall effect sizes with SMDs for changes at 6 to 24 months follow-up: mental health (3 studies) SMD -0.04 (95% CI -0.18 to 0.10), illness worry (3 studies) SMD 0.09 (95% CI -0.04 to 0.22), depression (4 studies) SMD 0.07 (95% CI -0.05 to 0.20) and anxiety (2 studies) SMD -0.07 (95% CI -0.38 to 0.25). Effects on sick leave could not be estimated. Three studies of patient satisfaction with care all showed positive but non-significant effects, and measures were too heterogeneous to allow meta-analysis. Results on healthcare utilisation were inconclusive. We analysed study discontinuation and found that both short term and long term discontinuation occurred more often in patients allocated to the intervention group, RR of 1.25 (95% CI 1.08 to 1.46) at 12 to 24 months.
Current evidence does not answer the question whether enhanced care delivered by front line primary care professionals has an effect or not on the outcome of patients with functional somatic symptoms. Enhanced care may have an effect when delivered per protocol to well-defined groups of patients with functional disorders, but this needs further investigation. Attention should be paid to difficulties including limited consultation time, lack of skills, the need for a degree of diagnostic openness, and patient resistance towards psychosomatic attributions. There is some indication from this and other reviews that more intensive interventions are more successful in changing patient outcomes.
... Außerdem steht die klinische Relevanz der Effekte heute deutlich stärker im Zentrum der Aufmerksamkeit, während sich das Paradigma ursprünglich aus einem sozialpsychologischen Hintergrund entwickelt hatte [Pennebaker, 2004;Sloan und Marx, 2004b;Smyth et al., 1999]. Neueren Befunden zufolge geht ES unter anderem einher mit verbesserter Lungenfunktion bei Asthmatikern und verbesserter Gelenksymptomatik bei Rheumatikern [Smyth et al., 1999], weniger Krankenhaustagen bei Patienten mit zystischer Fibrose [Taylor et al., 2003], reduzierten Pflegebedürfnissen und -kosten bei geriatrischen Patienten [Klapow et al., 2001], weniger Arztbesuchen und Symptomen bei Patientinnen mit Brustkrebs [Stanton et al., 2002], weniger Arztbesuchen bei Hochsicherheitsgefangenen [Richards et al., 2000], verbesserter Schlafqualität bei Patienten mit metastasiertem Nierenkarzinom [de Moor et al., 2002], weniger depressiven Symptomen bei leicht depressiven Patienten [Murray et al., 1989;Donnelly und Murray, 1991] und weniger posttraumatischen Belastungssymptomen bei Traumaopfern [Schoutrop et al., 2002]. Wenige Studien fanden keine bzw. ...
Expressive Writing as a Coping-Tool. A State of the Art Review This article provides a state of the art review on the research on Expressive Writing (EW). In the paradigm originally developed by Pennebaker, participants write about a traumatic experience or a neutral topic on 3-4 days for 15-20 minutes. A large number of studies has now documented the positive effects of EW on physical and mental health. It has been shown that in the months after the study, participants who write about a traumatic experience go to the doctor less often, show improved immune function, report fewer symptoms, are less depressed and anxious and have generally a higher well-being as compared to the control group. Three major models have been proposed to explain the effects of EW. The initial studies assumed that a disclosure induced physiological disinhibition was responsible for its effects. Current research focuses on linguistic and cognitive processes according to which EW fosters the development of a coherent narrative about the events that then can be stored more efficiently and be forgotten more easily. According to the most recent model, EW facilitates social processes that enable individuals to approach others more actively and become better integrated into their social network. Other approaches focus on habituation processes as potential mediators. The different models can be integrated in an emotion regulation model. Finally, potentials of the paradigm in the real world are discussed and show how EW can be used for personal, educational and therapeutic purposes.
... However, the magnitude of the decrease was twice as large in the self-disclosure group. 45 Not all self-disclosure protocols have been beneficial. Compelling the patient to discuss emotional problems is generally unproductive. ...
The term "somatoform disorders" refers to several distinct disorders, each characterized by strict diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. These conditions include somatization disorder, conversion disorder, pain disorder with psychological factors, hypochondriasis, body dysmorphic disorder, somatoform disorder not otherwise specified, and undifferentiated somatoform disorder. Two other conditions, factitious disorders and malingering, differ from the somatoform disorders in that the patient Consciously produces the symptoms of the disorder. A logical, stepwise, conservative, and evidence-based approach to diagnosis is recommended in the evaluation of patients with suspected somatization symptoms. Because of the lack of evidence supporting medications to treat somatoform disorder, nondrug therapies are the primary treatments. Psychotherapeutic treatment options include relational therapy, cognitive-behavioral therapy, and psychodynamic psychotherapy. This article contains a discussion of etiology, diagnosis, and treatment approaches, and of the rationale for treating patients with somatoform disorders in the primary care setting.
... The written disclosure paradigm used in this study was previously adapted for older adults (Klapow et al., 2001). Participants were asked to ''write about your deepest thoughts and feelings about the most distressing experience in your life. ...
Unlabelled:
BACKGROUND/STUDY CONTEXT: Vascular and myocardial activation can each increase blood pressure responses to stressors, but vascular responses are uniquely associated with negative affect, pernicious coping processes, and cardiovascular risk. These hemodynamic correlates of coping in response to acute stressors have not been well characterized in older adults.
Methods:
Adults 65 to 97 years of age (N = 74) either engaged in written disclosure about a distressing event (acute stressor) or wrote objectively about a neutral topic (control). Blood pressure, impedance cardiography, and affect measures were assessed at baseline and in response to writing. Moderating effects of age on affect, blood pressure, and vascular and myocardial responses to the acute stressor were tested using multiple linear regression models.
Results:
Follow-up tests of Age × Writing Group interactions indicated that the expected effects of written disclosure on systolic and diastolic blood pressure responses were diminished with increasing age. Regardless of age, compared with neutral writing, written disclosure increased negative affect and vascular responses, but not myocardial responses.
Conclusion:
Blood pressure responses to an acute, emotionally evocative stressor were indistinguishable from blood pressure responses to a control condition among the eldest older adults in our sample. In contrast, characterizing the hemodynamic mechanisms of blood pressure responses revealed notable vascular effects of the acute, emotional stressor across a wide age range. Such characterization may be particularly useful for clarifying the psychophysiological pathways to older adults' cardiovascular health.
... L'effet bénéfique de l'expression émotionnelle écrite sur la santé des rédacteurs L'intérêt pour le diagnostic et la prise en charge des problèmes médicaux apparaît très tôt dans les travaux de Pennebaker et Skelton (1978) (Pennebaker, 1982). Un nombre important de recherches mettent en évidence un effet positif de l'utilisation des sessions d'écriture sur la santé physique des rédacteurs (Beckwith et al., 2005 ;Booth et Davison, 2003 ;Broderick et al., 2005 ;Creswell et al., 2007 ;Gidron et al., 2002 ;Klapow et al., 2001 ;Mann, 2001 ;Norman et al., 2004 ;Petrie et al., 2004 ;Rosenberg et al., 2002 ;Solano et al., 2003 ;Stanton et Danojj-Burg, 2002 ;Taylor et al., 2003. Pour un bilan plus détaillé, voir le Tableau 1 présenté dans l'Annexe 1 qui est disponible dans la publication en ligne de cet article). ...
This review is organized in three sections in order to evaluate if expressive writing (namely, to report emotions and deep thoughts concerning positive or negative personal experiences) has a beneficial impact on the physical and psychological well-being of writers. Part 1 reviews studies that showed a beneficial influence of expressive writing. Part 2 is devoted to the examination of the theories for explaining the processes of emotional and cognitive regulation at work during writing disclosure (Disinhibition theory, Cognitive-processing theory, Self-regulation theory, Exposure theory). Findings of several meta-analyses designed to probe the power and validity of results and models are presented. The necessity of a better understanding of the processes by which expressive writing can transform emotional state and intrusive thoughts among writers is examined within the framework of concepts of cognitive psychology involved in writing productions. It is now crucial to use the knowledge of the cognitive approach of written productions for identifying the cognitive-emotional operations that are involved in disclosures and their dependency upon attentional resources of working memory.
... The first was a randomised single-blinded feasibility study of 45 patients aged >65 years without a psychiatric diagnosis in a university-based geriatric/internal medicine primary care clinic in the US. 17 It explored whether writing could reduce somatic and distress symptoms in older patients and found that three 20-minute writing sessions reduced the use of outpatient services and associated costs to half that of the control group, but with minimal reduction in symptoms. Another study of 41 frequent attendees in Israel found that writing led to lower symptom levels and fewer clinic visits among the writing group. ...
> ‘I hear and I forget, I see and I remember, I write and I understand.’ Chinese Proverb
Disclosure in the form of the spoken word has long been considered beneficial and widely used in counselling and other therapies. Self-inhibition of negative emotions is thought to lead to continuous autonomic arousal and poorer health.1 Writing therapy, otherwise described in the literature as ‘expressive (emotional) disclosure’, ‘expressive writing’, or ’written disclosure therapy’ may have the potential to heal mentally and physically. In early experiments, participants wrote about their most traumatic thoughts and feelings related to a stressful event for up to 20 minutes over three or four writing sessions. To isolate any non-specific beneficial effect from participating in studies, control groups wrote about superficial non-emotive topics. The experimental group observed better physical health, improved immune system functioning, and fewer days off due to illness. This formed the basis of subsequent studies into writing therapy.
How writing potentially brings about health benefits is unknown and the underlying mechanism is likely to be complex and multifactorial. One theory is that of emotional catharsis whereby the mere act of disclosure, essentially ‘getting it off your chest’ is a powerful therapeutic agent in itself.2 Writing may facilitate cognitive processing of traumatic memories, resulting in more adaptive, integrated representations about the writer themselves, their world, and others.3 It is also possible that development of a coherent narrative over time results in ongoing processing and finding meaning in the traumatic experience.4
Writing therapy could potentially be a cheap and easily accessible option that would require minimal input from healthcare professionals. We wondered whether it could be an effective alternative form of therapy in general practice, since access to psychological therapies in primary care can often be slow or limited, much to the frustration of …
... Our research team adapted Pennebaker's laboratory-based protocol to be a suitable health care intervention (cf., Klapow et al., 2001 ). Important modifications include clinic recruitment versus advertisement-based recruitment into a laboratory, introduction of the intervention in the clinic versus the laboratory, and two home-writing sessions prompted by a telephone call rather than an intervention completely implemented in the laboratory. At the conclusion of the ro ...
We conducted a randomized clinical trial of a 3-session written self-disclosure intervention for patients with cystic fibrosis (CF). Patients (n = 39) who were at least 15 years of age and diagnosed with CF participated in the intervention. Participants in the intervention arm were asked to write in the health care setting about an important emotionally distressing issue of personal significance for a 20-min period of time and two additional 20-min writing episodes at the patient's home, which were prompted by telephone calls. Patients in the control condition received standard care alone. Findings revealed that the intervention resulted in a reduction of the number of days patients spent in the hospital over a 3-month period. The intervention did not have an impact on physiological (Forced Expiratory Volume and Body Mass Index or subjective markers of health status. These findings extend those of Pennebaker's (cf., J. Smyth, 1998) demonstrating an effect of the written-self-disclosure intervention on health care utilization. These preliminary findings are promising and justify further investigation of the modified intervention in other chronic illness populations.
... 19 Written disclosure is associated with improved health, psychological well-being, physiological functioning, and general functioning. [16][17][18][20][21][22] Whether expressive writing can reduce psychological distress in cancer patients requires further study, 23 as most of this research with cancer patients has not found changes in distress. [23][24][25][26] In fact, expressive writing initially causes short-term increases in distress, 15,18,27 which benefits some. ...
Adjusting to cancer requires effective cognitive and emotional processing. Written and verbal disclosure facilitate processing and have been studied independently in cancer survivors. Combined written and verbal expression may be more effective than either alone, particularly for patients with difficult to discuss or embarrassing side effects. Thus, the authors developed and tested the efficacy of a 12-session combined written and verbal expression group program for psychologically distressed colorectal cancer (CRC) patients.
Forty post-treatment patients with CRC (stages I-III) identified as psychologically distressed using the Brief Symptom Inventory (BSI) were randomized to an intervention group (Healthy Expressions; n = 25) or standard care (control group; n = 15). Assessments were completed at baseline, Month 2, and Month 4 (postintervention). Primary outcomes were psychological functioning and quality of life (QOL).
Most participants were women (63%), white (63%), and non-Hispanic (75%). The Healthy Expressions group demonstrated significantly greater changes in distress compared with the control group at Month 2 on the BSI Global Severity Index (GSI) and the Centers for Epidemiologic Studies Depression scale (CES-D) scores (P < .05 for each); differences in the European Organization for Research and Treatment of Cancer (EORTC) global QOL scores approached significance (P = .063). The BSI GSI and Positive Symptom Total, CES-D, and EORTC emotional functioning subscale scores were all significant at Month 4 (P < .05 for each).
The Healthy Expressions program improved psychological functioning in CRC patients who reported experiencing distress. Findings demonstrate the program's feasibility and provide strong support for conducting a larger randomized trial.
... Future research should examine the possibility that individuals with lower levels of literacy than college students may benefit from instruction on creating a narrative when engaging in expressive writing. Although expressive writing studies exist in which participants had lower levels of education than college students, the authors of these studies did not explicitly examine narrative formation (Klapow et al., 2001;Reynolds, Brewin, & Saxton, 2000;Richards, Beal, Seagal, & Pennebaker, 2000). Gidron et al. (2002) modified the expressive writing protocol for frequent outpatient community clinic attenders in Israel with an average of 13 years of education. ...
We examined whether instructing participants to write in a narrative fashion about stressful life events would produce superior physical and psychological health benefits relative to standard expressive writing instructions that do not specify the essay's structure. Undergraduates (N=101) were randomly assigned to engage in two, 20-minute narrative writing, standard expressive writing, or control writing tasks. Follow-up data were obtained one month later. The essays of the narrative writing group evidenced higher levels of narrative structure than did those of the expressive writing group. Greater narrative structure was associated with mental health gains, and self-rated emotionality of the essays was associated with lesser perceived stress at follow-up. In addition, the narrative and expressive writing groups reported lower levels of perceived stress and depressive symptoms relative to controls but did not differ from each other with regard to these outcomes. Health care utilization at follow-up did not vary by group assignment. Findings suggest that both emotional expression and narrative structure may be key factors underlying expressive writing's mental health benefits. Results also suggest that, among college students, instruction in narrative formation does not increase the positive effects of expressive writing relative to standard expressive writing instructions.
... Interestingly, when we surveyed the emotional disclosure literature, we found that few studies evaluated the credibility of control groups. In the four that did (61)(62)(63)(64), three reported that the control condition was equally meaningful or valuable compared with the emotional disclosure condition (including one that used time management (64)). Anecdotally, we can report that it was common for participants in the time management condition to note spontaneously that they felt it was a helpful exercise to examine their use of time. ...
Written expression of traumatic experiences, an intervention found to have health benefits in rheumatoid arthritis, asthma, and breast cancer, was tested in a randomized, controlled trial with female fibromyalgia patients. It was hypothesized that relative to controls, patients engaging in the writing intervention would experience improved status on psychological well-being and physical health variables.
Patients (N = 92) were randomized into a trauma writing group, a control writing group, or usual care control group. The two writing groups wrote in the laboratory for 20 minutes on 3 days at 1-week intervals. Psychological well-being, pain, and fatigue were the primary outcome variables. Assessments were made at pretreatment, posttreatment, 4-month follow-up, and 10-month follow-up.
The trauma writing group experienced significant reductions in pain (effect size [ES] = 0.49) and fatigue (ES = 0.62) and better psychological well-being (ES = 0.47) at the 4-month follow-up relative to the control groups. Benefits were not maintained at the 10-month follow-up.
Fibromyalgia patients experienced short-term benefits in psychological and health variables through emotional expression of personal traumatic experiences.
... Overall, 93 experimental writing studies were located, 42 of which evaluated an HCU outcome. Of these 42 studies, 12 were excluded: 8 because of insufficient information available to calculate an effect size (Donnelly, 1990;Kirk, 1999;Klapow et al., 2001;Levey-Thors, 2000;Murray, Lamnin, & Carver, 1989;Pennebaker & Beall, 1986;Sheffield, Duncan, Thomson, & Johal, 2002;Swanbon, 2000, 2) because of nonrandom assignment to experimental conditions (Hughes, 1994;Solano, Donati, Pecci, Persichetti, & Colaci, 2003), and 2 because oral emotional expression was mixed with written expression (Gidron et al., 2002;Gidron, Peri, Connolly, & Shalev, 1996). Efforts were made to contact the authors of the eight studies to obtain basic statistics needed to calculate effect sizes. ...
This meta-analysis examined whether writing about stressful experiences affects health care utilization (HCU) compared with writing on neutral topics or no-writing control groups. Randomized controlled trials of 30 independent samples representing 2,294 participants were located that contained sufficient information to calculate effect sizes. After omitting one study as an outlier, the effects were combined within 3 homogeneous groups: healthy samples (13 studies), samples with preexisting medical conditions (6 studies), and samples prescreened for psychological criteria (10 studies). Combined effect sizes, Hedges's g (95% confidence interval), with random effects estimation were 0.16 (0.02, 0.31), 0.21 (-0.02, 0.43), and 0.06 (-0.12, 0.24), respectively. Writing about stressful experiences reduces HCU in healthy samples but not in samples defined by medical diagnoses or exposure to stress or other psychological factors. The significance of these effects for individuals' health is unknown.
... Other studies report more modest or limited benefits of disclosure, including studies of patients with renal cell carcinoma (24), prostate cancer (25), chronic pelvic pain (26) and rheumatoid arthritis (27). Other disclosure studies have reported no benefits among people with rheumatoid arthritis (28), breast cancer (29), asthma (30), HIV (31), or people who were bereaved (32,33), in primary care (34,35) or treatment for smoking (36). A recent meta-analysis of disclosure studies in clinical populations (37) reported a substantially smaller effect (d = . ...
The presence and severity of the chronic pain syndrome fibromyalgia (FM) is associated with unresolved stress and emotional regulation difficulties. Written emotional disclosure is intended to reduce stress and may improve health of people with FM.
This study tests the effects of at-home, written emotional disclosure about stressful experiences on the health of people with FM and uses multiple follow-ups to track the time course of effects of disclosure.
Adults with FM (intention-to-treat, n=83; completers, n=72) were randomized to write for 4 days at home about either stressful experiences (disclosure group) or neutral time management (control group). Group differences in immediate mood effects and changes in health from baseline to 1-month and 3-month follow-ups were examined.
Written disclosure led to an immediate increase in negative mood, which did not attenuate across the 4 writing days. Repeated-measures analyses from baseline to each follow-up point were conducted on both intention-to-treat and completer samples, which showed similar outcomes. At 1 month, disclosure led to few health benefits, but control writing led to less negative affect and more perceived support than did disclosure. At 3-month follow-up, these negative affect and social support effects disappeared, and written disclosure led to a greater reduction in global impact, poor sleep, health care utilization, and (marginally) physical disability than did control writing. Interpretation of these apparent benefits needs to be made cautiously, however, because the disclosure group had somewhat poorer health than controls at baseline and the control group showed some minor worsening over time.
Written emotional disclosure can be conducted at home, and there is tentative evidence that disclosure benefits the health of people with FM. The benefits, however, may be delayed for several months after writing and may be of limited clinical significance.
Hypnosis and biofeedback techniques are evidence-based psychophysiological therapies that can be applied with a wide variety of medical and mental health disorders. Research shows efficacy for anxiety, depression, post-traumatic stress disorder (PTDS), chronic pain, hypertension, fibromyalgia, and a host of other disorders. Hypnosis and biofeedback can also augment the effectiveness of psychotherapy. The author utilizes the case narrative of a 36-year-old woman, presenting with postpartum depression and dissociative features, to illustrate the integration of biofeedback training, physiological monitoring, self-hypnosis, hypnotic age regression, and affective journaling into dynamic psychotherapy. The hypnotic techniques and the affective journaling assisted in the retrieval of critical traumatic events during the patient’s adolescence, and a combination of breath training, self-hypnosis, and biofeedback aided the patient in self-calming.
Caregiver stress is a growing problem with an aging population; many spouses are cast in the caregiver role for extended periods. Pre-existing anxiety disorders commonly recur in the face of caregiver stress. This chapter narrates the case of a 71-year-old retired professional woman, serving as caregiver for a husband with dementia. The stress of the caregiver role served to trigger a recurrence of a previously treated anxiety disorder. The case narrative illustrates the value of breath training and heart rate variability biofeedback for the anxiety disorder, as well as an effort to instill sustainable self-regulation skills and lifestyle changes for greater resilience in this long-term situation.
Although people often feel relieved after having shared emotions related to a trauma, there are no clear data showing that trauma-related emotions really are transformed by such act of sharing. Empirical research concerning the effects of verbally sharing emotions, led to contra-intuitive results that are difficult to interpret. This is the case both in experimental social psychology as in clinical research on the prevention of post-traumatic stress disorder. A critical appraisal of these results points out a few vacuums that deserve more attention from research. Questions about the relation between experiential avoidance and sharing of emotions and principally about what a person learns when reporting his or her emotions should be examined more carefully
Caregiver stress is a growing problem with an aging population, and many spouses are cast in the caregiver role for extended periods. Preexisting anxiety disorders commonly recur in the face of caregiver stress. This article narrates the case of a 71-year-old retired professional woman serving as caregiver for a husband with dementia. The stress of the caregiver role served to trigger a recurrence of a previously treated anxiety disorder. The case narrative illustrates the value of mindfulness, breath training, and heart rate variability biofeedback for the anxiety disorder, as well as an effort to instill sustainable self-regulation skills and lifestyle changes for greater resilience in this long-term situation. Some of the lifestyle-oriented interventions are summarized only briefly in this article.
In 1986 Pennebaker and Beall published their renowned study on the long-term beneficial health effects of disclosing traumatic events in 4 brief sequential writing sessions. Their results have been confirmed in various studies, but conflicting results have also been reported. The intent of our study was to replicate the experiments from Pennebaker and Beall (1986), Pennebaker et al. (1988), and Greenberg and Stone (1992) using a German student sample. Additionally, essay variables that point to the emotional processing of events (e.g., depth of self-exploration, number of negative/positive emotions, intensity of emotional expression) were examined as potential mechanisms of action. Trait measures of personality which could moderate the personal consequences of disclosure (alexithymia, self-concealment, worrying, social support) were also assessed. In a second study the experimental condition (disclosure) was varied by implementing "coping" vs. "helping" instructions as variations of the original condition. Under the coping condition participants were asked to elaborate on what they used to do, continue to do, or could do in the future to better cope with the event. Under the helping condition participants were asked to imagine themselves in the role of a adviser and elaborate on what they would recommend to persons also dealing with the trauma in order to better cope with the event. The expected beneficial effects of disclosure on long-term health (e.g., physician visits, physical symptoms, affectivity) could not be corroborated in either the first or the second study. None of the examined essay variables of emotional processing and only a single personality variable was able to explain significant variance in the health-related outcome variables influence. Nevertheless, substantial reductions in posttraumatic stress symptoms (e.g., intrusions, avoidance, arousal), were found in both experiments. These improvements were significantly related to essay variables of emotional expression and self-exploration and were particularly pronounced under the activation of a prosocial motivation (helping condition). Repeated, albeit brief, expressive writing about personally upsetting or traumatic events resulted in an immediate increase in negative mood but did not lead to long-term positive health consequences in a German student sample. It did, however, promote better processing of stressful or traumatic events, as evidenced by reductions in posttraumatic stress symptoms. The instruction to formulate recommendations for persons dealing with the same trauma seems more helpful than standard disclosure or focusing on one's own past, present, and future coping endeavours. Overall, expressive writing seems to be a successful method of improving trauma processing. Determining the appropriate setting (e.g., self-help vs. therapeutic context) for disclore can be seen as an objective of future research.
Expressive writing is a psychosocial intervention that promotes written emotional disclosure of stressful or traumatic events in a structured and confidential manner. Written emotional disclosure is used as an intervention to foster emotional expression without regard to social stigma, and encourages individuals to approach and express their emotions through writing in an experimental setting. The effects of this emotional disclosure are usually compared to writing about emotionally neutral writing topics. The use of writing as a form of therapy appears to have evolved from psychotherapeutic traditions that espoused emotional expression. Expressive writing thus provides a means of expressing and processing emotions that can help avoid the barriers and/or negative consequences that might accompany interpersonal disclosure. Structured expressive writing (as opposed to unstructured) focuses on a specific topic of writing, such as stressful or traumatic life experiences. The majority of experimental studies utilize this form of structured writing within the controlled setting of the laboratory. In the prototypical writing study, disclosure is induced in the laboratory by randomly assigning participants to either an expressive writing group or an emotionally neutral writing condition. Participants in both groups are usually assured of confidentiality and encouraged to write without regard to spelling, style, or grammar. The time and attention are matched between conditions in an attempt to equalize all factors except for the experimental manipulation. Therefore, the sole difference between the experimental and the control groups are the writing instructions.
The pain anxiety and emotional disclosure literatures are much more recent than those of blood-injection-injury (BII) and dental phobia and concomitantly less developed. A well-designed set of small-sample replication studies suggests that in chronic pain rehabilitation programs, based on instrumental learning principles, targeting pain anxiety directly with in vivo exposure to pain-related fear stimuli extinguishes pain anxiety and facilitate increasing functional capacity. In the migraine headache literature, a case has been made for prolonged exposure to headache triggers to facilitate desensitization of trigger-sensitization hypothesized to develop through long-term avoidance. Viewing the emotional disclosure protocol as an exposure technique rather than as a means to reduce the stress of inhibition and bring about insight has implications for modifying the protocol in a way that may potentially enhance its efficacy.
Background:
Medically unexplained physical symptoms (MUPS) are physical symptoms for which no adequate medical explanation can be found after proper examination. The presence of MUPS is the key feature of conditions known as 'somatoform disorders'. Various psychological and physical therapies have been developed to treat somatoform disorders and MUPS. Although there are several reviews on non-pharmacological interventions for somatoform disorders and MUPS, a complete overview of the whole spectrum is missing.
Objectives:
To assess the effects of non-pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform disorders unspecified, somatoform autonomic dysfunction, pain disorder, and alternative somatoform diagnoses proposed in the literature) and MUPS in adults, in comparison with treatment as usual, waiting list controls, attention placebo, psychological placebo, enhanced or structured care, and other psychological or physical therapies.
Search methods:
We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to November 2013. This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library, EMBASE, MEDLINE, and PsycINFO. We ran an additional search on the Cochrane Central Register of Controlled Trials and a cited reference search on the Web of Science. We also searched grey literature, conference proceedings, international trial registers, and relevant systematic reviews.
Selection criteria:
We included RCTs and cluster randomised controlled trials which involved adults primarily diagnosed with a somatoform disorder or an alternative diagnostic concept of MUPS, who were assigned to a non-pharmacological intervention compared with usual care, waiting list controls, attention or psychological placebo, enhanced care, or another psychological or physical therapy intervention, alone or in combination.
Data collection and analysis:
Four review authors, working in pairs, conducted data extraction and assessment of risk of bias. We resolved disagreements through discussion or consultation with another review author. We pooled data from studies addressing the same comparison using standardised mean differences (SMD) or risk ratios (RR) and a random-effects model. Primary outcomes were severity of somatic symptoms and acceptability of treatment.
Main results:
We included 21 studies with 2658 randomised participants. All studies assessed the effectiveness of some form of psychological therapy. We found no studies that included physical therapy.Fourteen studies evaluated forms of cognitive behavioural therapy (CBT); the remainder evaluated behaviour therapies, third-wave CBT (mindfulness), psychodynamic therapies, and integrative therapy. Fifteen included studies compared the studied psychological therapy with usual care or a waiting list. Five studies compared the intervention to enhanced or structured care. Only one study compared cognitive behavioural therapy with behaviour therapy.Across the 21 studies, the mean number of sessions ranged from one to 13, over a period of one day to nine months. Duration of follow-up varied between two weeks and 24 months. Participants were recruited from various healthcare settings and the open population. Duration of symptoms, reported by nine studies, was at least several years, suggesting most participants had chronic symptoms at baseline.Due to the nature of the intervention, lack of blinding of participants, therapists, and outcome assessors resulted in a high risk of bias on these items for most studies. Eleven studies (52% of studies) reported a loss to follow-up of more than 20%. For other items, most studies were at low risk of bias. Adverse events were seldom reported.For all studies comparing some form of psychological therapy with usual care or a waiting list that could be included in the meta-analysis, the psychological therapy resulted in less severe symptoms at end of treatment (SMD -0.34; 95% confidence interval (CI) -0.53 to -0.16; 10 studies, 1081 analysed participants). This effect was considered small to medium; heterogeneity was moderate and overall quality of the evidence was low. Compared with usual care, psychological therapies resulted in a 7% higher proportion of drop-outs during treatment (RR acceptability 0.93; 95% CI 0.88 to 0.99; 14 studies, 1644 participants; moderate-quality evidence). Removing one outlier study reduced the difference to 5%. Results for the subgroup of studies comparing CBT with usual care were similar to those in the whole group.Five studies (624 analysed participants) assessed symptom severity comparing some psychological therapy with enhanced care, and found no clear evidence of a difference at end of treatment (pooled SMD -0.19; 95% CI -0.43 to 0.04; considerable heterogeneity; low-quality evidence). Five studies (679 participants) showed that psychological therapies were somewhat less acceptable in terms of drop-outs than enhanced care (RR 0.93; 95% CI 0.87 to 1.00; moderate-quality evidence).
Authors' conclusions:
When all psychological therapies included this review were combined they were superior to usual care or waiting list in terms of reduction of symptom severity, but effect sizes were small. As a single treatment, only CBT has been adequately studied to allow tentative conclusions for practice to be drawn. Compared with usual care or waiting list conditions, CBT reduced somatic symptoms, with a small effect and substantial differences in effects between CBT studies. The effects were durable within and after one year of follow-up. Compared with enhanced or structured care, psychological therapies generally were not more effective for most of the outcomes. Compared with enhanced care, CBT was not more effective. The overall quality of evidence contributing to this review was rated low to moderate.The intervention groups reported no major harms. However, as most studies did not describe adverse events as an explicit outcome measure, this result has to be interpreted with caution.An important issue was that all studies in this review included participants who were willing to receive psychological treatment. In daily practice, there is also a substantial proportion of participants not willing to accept psychological treatments for somatoform disorders or MUPS. It is unclear how large this group is and how this influences the relevance of CBT in clinical practice.The number of studies investigating various treatment modalities (other than CBT) needs to be increased; this is especially relevant for studies concerning physical therapies. Future studies should include participants from a variety of age groups; they should also make efforts to blind outcome assessors and to conduct follow-up assessments until at least one year after the end of treatment.
What happens when medical science invites the humanities into its world? How do we, can we, measure and evaluate the qualitative
process and product of oral history to quantitative researchers? Can we incorporate a quantitative tool into the oral history
process to persuasively argue that some patient populations would benefit from the inclusion of a patient-centered, oral narrative
intervention? This is the story of one effort to test the effectiveness of oral history interviewing in a clinical setting
by its inclusion in a treatment program for veterans with prostate cancer. Prostate cancer is the most prevalent cancer in
males, but currently there are no definitive treatment guidelines. This lack of medical consensus on treatment causes significant
psychological distress for many patients, and, increasingly, medical professionals are interested in finding alternative ways
to address their patients’ concerns. This paper concludes that exploring the efficacy of an oral history intervention is a
worthy endeavor, particularly when there is no clear path toward healing. If it is determined that an oral history intervention
benefits veterans with prostate cancer, might it not also help other patient populations with chronic or terminal illness?
We review the history of therapeutic writing, focusing on the role of narrative competence and the use of writing therapy for stress, trauma and coping with chronic illness. After providing a historical overview of the evidence for writing's positive effects on health and the hypothesised mechanisms underlying this effect, we ask whether narrative competence can explain and improve writing's benefit. Narrative competence is defined across two dimensions: (1) Emplotment, or the ability to construct and comprehend goal-oriented connections among temporally situated events; and (2) Meaning, or the ability to understand and communicate contextual interpretations of ambiguous story structures. We suggest that the ability to construct well-organised and meaningful narratives is an important skill for successfully coping with life stressors and trauma, enabling individuals to create coherent stories from fractured memories and to facilitate cognitive processing of traumatic events. Given the positive effect of narrative competence on psycho-physical health, there is a need to broaden medical use of narrative competence therapies beyond the current interventions aimed at fostering empathy among healthcare providers, to include therapies for the patients themselves. Toward this end, we briefly explore one clinical model currently offered by Dr Allan Peterkin and colleagues at Mount Sinai Hospital providing group Narrative Competence Psychotherapy (NCP) for individuals living with HIV.
Writing about traumatic, stressful or emotional events has been found to result in improvements in both physical and psychological health, in non-clinical and clinical populations. In the expressive writing paradigm, participants are asked to write about such events for 15-20 minutes on 3-5 occasions. Those who do so generally have significantly better physical and psychological outcomes compared with those who write about neutral topics. Here we present an overview of the expressive writing paradigm, outline populations for which it has been found to be beneficial and discuss possible mechanisms underlying the observed health benefits. In addition, we suggest how expressive writing can be used as a therapeutic tool for survivors of trauma and in psychiatric settings.
The use of writing in a therapeutic manner can be traced back to psychotherapeutic traditions that encourage the expression of emotions (see Smyth & Helm, 2003). The majority of psychotherapeutic paradigms, regardless of theoretical orientation, consist of some form of interpersonal disclosure that includes identifying, labeling, and disclosing emotional experiences (Smyth & Helm, 2003). Although individuals may have a desire to disclose their thoughts and emotions about a distressing experience, social constraints may limit such interpersonal disclosure (Lepore, Silver, Wortman, & Wayment, 1996). Some individuals may refrain from discussing negative events due to the social stigma thought to be associated with the experience. Other peoplemay lack a social support system and/or receive insensitive or inappropriate support (Wortman & Silver, 1989). In contrast, written emotional expression offers the opportunity to express one's thoughts and feelings without regard to social constraints or barriers that might accompany interpersonal disclosure and reduces the likelihood of negative interpersonal responses.
Somatoform disorders are common conditions, but the current diagnostic criteria are considered to be unreliable, based largely on medically unexplained symptoms. DSM-5 is considering other possible characteristics of somatizers including high utilization, dissatisfaction with care, and poor response to reassurance. The PubMed database was searched combining terms such as "somatoform disorder" with "reassurance," "satisfaction," and "utilization." Evidence was found to support transient but poor sustained response to reassurance, and for over-utilization, particularly in outpatient visits, though this was not specific. Future research should attempt to validate criteria prospectively.
L'écriture expressive consiste à évoquer un événement agréable, désagréable et même traumatisant en faisant état des émotions associées à cet événement. Réitérée trois à quatre fois de suite, pendant des sessions de quinze à vingt minutes, cette confession émotionnelle s'avère efficace pour entraîner une régulation émotionnelle importante de la personne qui écrit. Cette thèse a été l'occasion de faire une revue de questions sur les différentes conditions d'application de cette écriture, ses effets sur la santé psychologique et physique des rédacteurs ainsi que sur les modèles qui expliquent fonctionnellement comment opère cette pratique écrite. Ce bilan rend compte aussi des études critiques qui en contestent l'efficacité. Les recherches réalisées dans cette thèse ont montré que, selon leurs prédispositions émotionnelles (anxiété, appréhension à écrire et à communiquer, procrastination, perfectionnisme et alexithymie), les rédacteurs évoquent différemment un événement positif ou négatif. Ils n'exploitent pas les mêmes quantités de lexique émotionnel de valence positive et négative, ni les mêmes émotions. Pour analyser le contenu de leurs écrits, un logiciel de comptage automatique du lexique émotionnel a été élaboré (EMOTAIX-Tropes). Cet outil permet d'identifier près de 5000 termes dénotant ou connotant diverses catégories d'émotions, d'humeurs, d'affects. Les recherches ont aussi permis de montrer qu'après une unique session d'écriture expressive, les rédacteurs changent de niveau d'anxiété-état. Selon la nature positive ou négative de l'expérience, leur anxiété croît ou décroît. Ce phénomène est plus saillant chez les rédacteurs qui présentent une appréhension à écrire.
Although written emotional disclosure has potential as a stress management intervention for people with health problems, the main (group) effects of disclosure in medical populations are limited. This study sought to identify individual difference moderators of the effects of written disclosure among women with chronic pelvic pain.
In a prospective, randomized trial, 48 women with chronic pelvic pain completed 3 individual difference measures and then wrote for 3 days about stressful consequences of their pain (disclosure) or positive events (control). Health status was assessed at baseline and 2 months after writing.
Main effect group comparisons indicated that disclosure writing resulted in significantly lower evaluative pain intensity ratings than control writing at follow-up, but there were no main effects on other outcome variables (sensory or affective pain, disability, affect). Three baseline individual difference measures, however, significantly moderated group effects. Compared with control writing, disclosure led to less disability among women with higher baseline ambivalence over emotional expression or higher catastrophizing, and to increased positive affect among women with higher baseline negative affect. Ambivalence, but not catastrophizing, was independent of negative affect in its moderation effect.
Although the main effects of writing about the stress of pelvic pain are limited, women with higher baseline ambivalence about emotional expression or negative affect appear to respond more positively to this intervention.
A diagnosis of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a life-changing event, where persons must deal with a life-threatening, debilitating disease and its associated stigma and isolation. Studies over the past decade have shown that writing and talking about stressful and traumatic experiences, such as a life-threatening illness, causes emotions surrounding the trauma to change and to become cognitively reorganized. The result is a reduction in inhibition and change in basic cognitive and linguistic processes, which have contributed to meaningful behavioural, psychological, and physical health benefits across a variety of populations.
To describe the construction of the Integrated Model of Health Promotion for persons with HIV/AIDS, and present initial empirical support of the model from a feasibility pilot study of women with HIV/AIDS.
The Integrated Model of Health Promotion is described and relevant literature in the field is reviewed. The model is implemented in a feasibility pilot study utilizing the emotional writing disclosure intervention.
Participants in the experimental condition demonstrated a promising pattern of cognitive reorganization, a reduced perception of stigma, and an improvement in mental health scores compared with the control condition.
Implications of these findings are discussed within the framework of the Integrated Model of Health Promotion. The model explores health and behavioural benefits associated with emotional writing in individuals with HIV/AIDS. The limited sample size of this pilot study precludes testing for significance. Further studies are required prior to the development of practice guidelines.
To test the effect of psychological intervention on multiple medically unexplained physical symptoms, psychological symptoms, and health care utilization in addition to medical care as usual. To identify patient-related predictors of change in symptoms and care utilization.
In a randomized controlled trial, subjects were assigned to one of two conditions: psychological intervention by a qualified therapist plus care as usual by a general practitioner (GP) or care as usual only. Participants (N=98) were administered a standardized interview and several outcome measures at intake and after 6 months and 12 months after intake. GPs rated medically unexplained and explained symptoms and consultations over a period of 1 1/2 years.
ANOVAs for repeated measures showed that self-reported and GP-registered unexplained physical symptoms decreased from pretest to posttest to follow-up. Psychological symptoms and consultations decreased from pretest to posttest. GP-registered explained symptoms did not decrease. However, intervention and control groups did not differ in symptom reduction. Path analysis revealed two paths to a decrease in self-reported unexplained physical symptoms: from more negative affectivity via more psychological attribution and more pretreatment anxiety, and from more somatic attribution via more psychological attribution and more pretreatment anxiety.
Intervention and control groups did not differ in symptom reduction. Reduction of self-reported medically unexplained symptoms was well predicted by patient-related symptom perception variables, whereas the prediction of change in registered symptoms and consultations requires a different model.
Forty-three women newly diagnosed with breast cancer participated in this study, which examined the role of expressive journal writing characteristics on mood over the course of a 12-week support group. Writing was analyzed using the linguistic inquiry and word count program. Writing characteristics that were examined included: average word count, number of journal entries, positive and negative emotion words, the ratio of positive to negative words, and the use of cognitive mechanism words (i.e. insight and causal words). Regression analyses revealed that increased levels of anxiety and depression, post-intervention, were predicted by the prevalence of negative emotion in writing. Unique variance in mood (anxiety and depression) was accounted for by expression of negative emotion (7 and 6%, respectively). These relationships were significant (p<0.05) and remained significant even after accounting for pre-intervention levels of distress, and for the quantity and frequency of writing. These findings suggest the need for additional research into the naturalistic application of journaling so that appropriate recommendations for writing (e.g. focus, timing, amount) can be offered to patients who might choose to utilize this approach for coping with the stresses of cancer diagnosis and treatment.
To describe the patterns of physical symptoms in older adults and to examine the validity of symptoms in predicting hospitalization and mortality.
Adults aged 60 years and older (N=3498) who completed screening for self-reported symptoms at routine primary care visits. Self-reported symptoms were collected using an abbreviated PRIME-MD screening instrument. Clinical characteristics, hospitalization, and mortality in the year following screening were measured using data taken from a comprehensive electronic medical record.
The mean patient age was 69 years, 69% were women, and 56% were African-American. A majority (51%) of respondents characterized their health as fair or poor. The most commonly reported symptoms were musculoskeletal pain (65%), fatigue (55%), back pain (45%), shortness of breath (41%), and difficulty sleeping (38%). A summary score of physical symptoms (range 0-12) was a significant independent predictor of future hospitalization and death even when controlling for clinical characteristics, chronic medical conditions, self-rated health, and affective symptoms. Disease-specific symptoms were more common among patients diagnosed with the specific condition but there was also a substantial background prevalence of these symptoms.
Physical symptoms are highly prevalent in older primary care patients and predict hospitalization and mortality at one year. Future work is needed to determine how to target symptoms as a potential mechanism to reduce health care use and mortality.
Emotional disclosure has been widely publicized as having beneficial effects on physical and psychological health. A full systematic review was undertaken, with standard health technology appraisal methods, with the aim to assess the effects of emotional disclosure on healthy participants and those with pre-existing morbidity, particularly on longer-term physical health, performance, and psychological outcomes.
Randomized controlled trials of emotional disclosure were obtained from database searches (Medline (1966-2003), Embase (1980-2003), Cochrane Library (2002, issue 4), Web of Science (1981-2003), Cinahl (1982-2003), and Theses (March 2003), Internet sites (including Professor J.W. Pennebaker's home pages), and personal contacts. Quality was assessed qualitatively and by Jadad score. Meta-analysis was conducted, using Revman 4.1 software, where more than two trials reported the same outcome.
Sixty-one trials were found meeting the inclusion criteria. Most had less than 100 participants and the median Jadad score was 0. A wide variety of physical, physiological, immunological, performance, and psychological outcomes were measured, but fewer were reported. There was no clear improvement for emotional disclosure compared with controls in objectively measured physical health and most other outcomes assessed.
The opinion that this intervention is beneficial needs to be reassessed in light of the totality of evidence available.
Disclosing information, thoughts, and feelings about personal and meaningful topics (experimental disclosure) is purported to have various health and psychological consequences (e.g., J. W. Pennebaker, 1993). Although the results of 2 small meta-analyses (P. G. Frisina, J. C. Borod, & S. J. Lepore, 2004; J. M. Smyth, 1998) suggest that experimental disclosure has a positive and significant effect, both used a fixed effects approach, limiting generalizability. Also, a plethora of studies on experimental disclosure have been completed that were not included in the previous analyses. One hundred forty-six randomized studies of experimental disclosure were collected and included in the present meta-analysis. Results of random effects analyses indicate that experimental disclosure is effective, with a positive and significant average r-effect size of .075. In addition, a number of moderators were identified.
This study had three aims: 1) to investigate whether cardiovascular responses to laboratory stress and levels of emotional distress were attenuated following written emotional disclosure; 2) to test, in addition to the potential main effects, whether levels of alexithymia moderated the impact of writing; and 3) to examine whether alexithymics who successfully disclosed emotion in their essays would experience positive effects following writing.
Eighty-seven participants wrote about their most stressful life experience or about a non-stressful experience, for 15 minutes, over 3 consecutive days. Two weeks later, blood pressure (BP) responses to laboratory stress and levels of emotional distress were assessed. Emotional characteristics of the disclosure essays were analysed with the Linguistic Inquiry and Word Count programme and alexithymia was assessed at baseline using the Toronto Alexithymia Scale-20.
Analyses found no evidence in support of the main effects of disclosure on cardiovascular responses to stress or on emotional distress. However, alexithymia was found to moderate the impact of writing such that non-alexithymic participants in the experimental condition reported significantly lower emotional distress 2 weeks later. In addition, alexithymic participants who disclosed a greater number of negative when compared with positive emotion words exhibited reduced systolic and diastolic responses to stress. Conversely, non-alexithymic participants who disclosed more positive and less negative emotion words displayed attenuated BP reactivity to stress.
The results of this exploratory study are important as they highlighted, in the absence of main effects, the importance of examining potential moderators of the emotional writing process. These findings may have implications for the development of cardiovascular health interventions.
Narrative medicine is based upon physicians' awareness of patients' narration of their suffering, their hopes, and how illness has affected them. It offers a model for improving health outcomes. To determine whether incorporating a narrative approach in patients with cancer decreases pain intensity and improves their global sense of well-being, we performed a randomized, single-blind controlled trial in adult patients with cancer and average pain intensity levels of at least 5/10. Two hundred thirty-four patients were randomized into three groups: (1) narrative (n=79), in which patients wrote a story about how cancer affected their lives for at least 20 minutes once a week for three weeks; (2) questionnaire (n=77), in which patients filled out the McGill Pain Questionnaire; and (3) control (n=78), in which patients came weekly to medical visits during which they received usual customary care. Patients rated their pain on a 0-10 scale and their well-being on a seven-point Likert scale weekly for eight weeks. Two raters independently evaluated the emotional content of the narratives. Pain intensity and sense of well-being were similar in all groups before and after treatment. Subgroup analyses showed that patients whose narratives had high emotional disclosure had significantly less pain and reported higher well-being scores than patients whose narratives were less emotional. Further study is needed to demonstrate whether the implementation of narrative medicine is associated with health benefits in this and other contexts.
A research synthesis was conducted to examine the relationship between a written emotional expression task and subsequent health. This writing task was found to lead to significantly improved health outcomes in healthy participants. Health was enhanced in 4 outcome types—reported physical health, psychological well-being, physiological functioning, and general functioning—but health behaviors were not influenced. Writing also increased immediate (pre- to postwriting) distress, which was unrelated to health outcomes. The relation between written emotional expression and health was moderated by a number of variables, including the use of college students as participants, gender, duration of the manipulation, publication status of the study, and specific writing content instructions.
In a first experiment, subjects verbalizing the stream of consciousness for a 5-min period were asked to try not to think of a white bear, but to ring a bell in case they did. As indicated both by mentions and by bell rings, they were unable to suppress the thought as instructed. On being asked after this suppression task to think about the white bear for a 5-min period, these subjects showed significantly more tokens of thought about the bear than did subjects who were asked to think about a white bear from the outset. These observations suggest that attempted thought suppression has paradoxical effects as a self-control strategy, perhaps even producing the very obsession or preoccupation that it is directed against. A second experiment replicated these findings and showed that subjects given a specific thought to use as a distracter during suppression were less likely to exhibit later preoccupation with the thought to be suppressed.
We tested the assumption that the act of inhibiting ongoing behavior requires physiological work. In a guilty knowledge test (GKT) paradigm, subjects were induced to attempt to deceive the experimenter on two separate occasions while electrodermal activity was measured. For 20 of the 30 subjects, overt behaviors (changes in eye movement and facial expression) were recorded during the second GKT. Results indicated that the incidence of behaviors decreased during their deceptive responses. This behavioral inhibition coincided with increases in skin conductance level. In addition to suggesting nonverbal correlates of deception, the results indicate that long-term behavioral inhibition may be a factor in psychosomatic disease.
Background:
While physical symptoms are the leading reason for outpatient visits, a substantial proportion of physical complaints and "minor" illnesses remain poorly understood. The purpose of our study was to determine the prevalence, patient-attributed cause, and psychiatric comorbidity of symptoms in a general population.Methods:
We analyzed data on 13 538 individuals interviewed in the Epidemiologic Catchment Area Program, a multicommunity mental health survey that used the Diagnostic Interview Schedule to determine the prevalence of psychiatric disorders. The Diagnostic Interview Schedule inquires about 38 physical symptoms and includes a probing scheme to classify symptom severity and potential cause. We focused on 26 symptoms most germane to primary care.Results:
Of the 26 symptoms, 24 had been problems for more than 10% of persons at some point in their life, with the most common nonmenstrual symptoms being joint pains (36.7%), back pain (31.5%), headaches (24.9%), chest pain (24.6%), arm or leg pain (24.3%), abdominal pain (23.6%), fatigue (23.6%), and dizziness (23.2%). Most symptoms (84%) were at some point considered major in that they interfered with routine activities or had led individuals to take medications or visit a physician. Nearly one third of symptoms were either psychiatric or unexplained, and most symptoms were associated with at least a twofold increased lifetime risk of a common psychiatric disorder.Conclusion:
Symptoms in the community are prevalent as well as bothersome. Often lacking an apparent physical explanation, such symptoms are associated with an increased likelihood of psychiatric disorders.(Arch Intern Med. 1993;153:2474-2480)
Context
The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed
as a screening instrument but its administration time has limited its clinical
usefulness.Objective
To determine if the self-administered PRIME-MD Patient Health Questionnaire
(PHQ) has validity and utility for diagnosing mental disorders in primary
care comparable to the original clinician-administered PRIME-MD.Design
Criterion standard study undertaken between May 1997 and November 1998.Setting
Eight primary care clinics in the United States.Participants
Of a total of 3000 adult patients (selected by site-specific methods
to avoid sampling bias) assessed by 62 primary care physicians (21 general
internal medicine, 41 family practice), 585 patients had an interview with
a mental health professional within 48 hours of completing the PHQ.Main Outcome Measures
Patient Health Questionnaire diagnoses compared with independent diagnoses
made by mental health professionals; functional status measures; disability
days; health care use; and treatment/referral decisions.Results
A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585
had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those
of independent mental health professionals (for the diagnosis of any 1 or
more PHQ disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%;
specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses
had more functional impairment, disability days, and health care use than
did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the
PHQ was far less than to administer the original PRIME-MD (<3 minutes for
85% vs 16% of the cases). Although 80% of the physicians reported that routine
use of the PHQ would be useful, new management actions were initiated or planned
for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously
recognized.Conclusion
Our study suggests that the PHQ has diagnostic validity comparable to
the original clinician-administered PRIME-MD, and is more efficient to use.
Figures in this Article
Mental disorders in primary care are common, disabling, costly, and
treatable.1- 5
However, they are frequently unrecognized and therefore not treated.2- 6
Although there have been many screening instruments developed,7- 8
PRIME-MD (Primary Care Evaluation of Mental Disorders)5
was the first instrument designed for use in primary care that actually diagnoses
specific disorders using diagnostic criteria from the Diagnostic
and Statistical Manual of Mental Disorders, Revised Third Edition9(DSM-III-R) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition10(DSM-IV).
PRIME-MD is a 2-stage system in which the patient first completes a
26-item self-administered questionnaire that screens for 5 of the most common
groups of disorders in primary care: depressive, anxiety, alcohol, somatoform,
and eating disorders. In the original study,5
the average amount of time spent by the physician to administer the clinician
evaluation guide to patients who scored positively on the patient questionnaire
was 8.4 minutes. However, this is still a considerable amount of time in the
primary care setting, where most visits are 15 minutes or less.11
Therefore, although PRIME-MD has been widely used in clinical research,12- 28
its use in clinical settings has apparently been limited. This article describes
the development, validation, and utility of a fully self-administered version
of the original PRIME-MD, called the PRIME-MD Patient Health Questionnaire
(henceforth referred to as the PHQ).
DESCRIPTION OF PRIME-MD PHQ
ABSTRACT
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DESCRIPTION OF PRIME-MD PHQ
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STUDY PURPOSE
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METHODS
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RESULTS
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COMMENT
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REFERENCES
The 2 components of the original PRIME-MD, the patient questionnaire
and the clinician evaluation guide, were combined into a single, 3-page questionnaire
that can be entirely self-administered by the patient (it can also be read
to the patient, if necessary). The clinician scans the completed questionnaire,
verifies positive responses, and applies diagnostic algorithms that are abbreviated
at the bottom of each page. In this study, the data from the questionnaire
were entered into a computer program that applied the diagnostic algorithms
(written in SPSS 8.0 for Windows [SPSS Inc, Chicago, Ill]). The computer program
does not include the diagnosis of somatoform disorder, because this diagnosis
requires a clinical judgment regarding the adequacy of a biological explanation
for physical symptoms that the patient has noted.
A fourth page has been added to the PHQ that includes questions about
menstruation, pregnancy and childbirth, and recent psychosocial stressors.
This report covers only data from the diagnostic portion (first 3 pages) of
the PHQ. Users of the PHQ have the choice of using the entire 4-page instrument,
just the 3-page diagnostic portion, a 2-page version (Brief PHQ) that covers
mood and panic disorders and the nondiagnostic information described above,
or only the first page of the 2-page version (covering only mood and panic
disorders) (Figure 1).
Figure 1. First Page of Primary Care Evaluation
of Mental Disorders Brief Patient Health QuestionnaireGrahic Jump Location+View Large |
Save Figure |
Download Slide (.ppt)
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View in Article ContextCopyright held by Pfizer Inc, but may be photocopied ad libitum.
For office coding, see the end of the article.
The original PRIME-MD assessed 18 current mental disorders. By grouping
several specific mood, anxiety, and somatoform categories into larger rubrics,
the PHQ greatly simplifies the differential diagnosis by assessing only 8
disorders. Like the original PRIME-MD, these disorders are divided into threshold
disorders (corresponding to specific DSM-IV diagnoses,
such as major depressive disorder, panic disorder, other anxiety disorder,
and bulimia nervosa) and subthreshold disorders (in which the criteria for
disorders encompass fewer symptoms than are required for any specific DSM-IV diagnoses: other depressive disorder, probable alcohol
abuse or dependence, and somatoform and binge eating disorders).
One important modification was made in the response categories for depressive
and somatoform symptoms that, in the original PRIME-MD, were dichotomous (yes/no).
In the PHQ, response categories are expanded. Patients indicate for each of
the 9 depressive symptoms whether, during the previous 2 weeks, the symptom
has bothered them "not at all," "several days," "more than half the days,"
or "nearly every day." This change allows the PHQ to be not only a diagnostic
instrument but also to yield a measure of depression severity that can be
of aid in initial treatment decisions as well as in monitoring outcomes over
time. Patients indicate for each of the 13 physical symptoms whether, during
the previous month, they have been "not bothered," "bothered a little," or
"bothered a lot" by the symptom. Because physical symptoms are so common in
primary care, the original PRIME-MD dichotomous-response categories often
led patients to endorse physical symptoms that were not clinically significant.
An item was added to the end of the diagnostic portion of the PHQ asking
the patient if he or she had checked off any problems on the questionnaire:
"How difficult have these problems made it for you to do your work, take care
of things at home, or get along with other people?" As with the original PRIME-MD,
before making a final diagnosis, the clinician is expected to rule out physical
causes of depression, anxiety and physical symptoms, and, in the case of depression,
normal bereavement and history of a manic episode.
STUDY PURPOSE
ABSTRACT
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DESCRIPTION OF PRIME-MD PHQ
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STUDY PURPOSE
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METHODS
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RESULTS
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COMMENT
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REFERENCES
Our major purpose was to test the validity and utility of the PHQ in
a multisite sample of family practice and general internal medicine patients
by answering the following questions:
Are diagnoses made by the PHQ as accurate as diagnoses
made by the original PRIME-MD, using independent diagnoses made by mental
health professionals (MHPs) as the criterion standard?Are the frequencies of mental disorders found by
the PHQ comparable to those obtained in other primary care studies?Is the construct validity of the PHQ comparable
to the original PRIME-MD in terms of functional impairment and health care
use?Is the PHQ as effective as the original PRIME-MD
in increasing the recognition of mental disorders in primary care patients?How valuable do primary care physicians find the
diagnostic information in the PHQ?How comfortable are patients in answering the questions
on the PHQ, and how often do they believe that their answers will be helpful
to their physicians in understanding and treating their problems?
Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters.
To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress.
A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits.
Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months.
Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.
Consumer Reports (1995, November) published an article which concluded that patients benefited very substantially from psychotherapy, that long-term treatment did considerably better than short-term treatment, and that psychotherapy alone did not differ in effectiveness from medication plus psychotherapy. Furthermore, no specific modality of psychotherapy did better than any other for any disorder; psychologists, psychiatrists, and social workers did not differ in their effectiveness as treaters; and all did better than marriage counselors and long-term family doctoring. Patients whose length of therapy or choice of therapist was limited by insurance or managed care did worse. The methodological virtues and drawbacks of this large-scale survey are examined and contrasted with the more traditional efficacy study, in which patients are randomized into a manualized, fixed duration treatment or into control groups. I conclude that the Consumer Reports survey complements the efficacy method, and that the best features of these two methods can be combined into a more ideal method that will best provide empirical validation of psychotherapy.
Nonpharmacological treatments with little patient cost or risk are useful supplements to pharmacotherapy in the treatment of patients with chronic illness. Research has demonstrated that writing about emotionally traumatic experiences has a surprisingly beneficial effect on symptom reports, well-being, and health care use in healthy individuals.
To determine if writing about stressful life experiences affects disease status in patients with asthma or rheumatoid arthritis using standardized quantitative outcome measures.
Randomized controlled trial conducted between October 1996 and December 1997.
Outpatient community residents drawn from private and institutional practice.
Volunteer sample of 112 patients with asthma (n = 61) or rheumatoid arthritis (n = 51) received the intervention; 107 completed the study, 58 in the asthma group and 49 in the rheumatoid arthritis group.
Patients were assigned to write either about the most stressful event of their lives (n = 71; 39 asthma, 32 rheumatoid arthritis) or about emotionally neutral topics (n = 41; 22 asthma, 19 rheumatoid arthritis) (the control intervention).
Asthma patients were evaluated with spirometry and rheumatoid arthritis patients were clinically examined by a rheumatologist. Assessments were conducted at baseline and at 2 weeks and 2 months and 4 months after writing and were done blind to experimental condition.
Of evaluable patients 4 months after treatment, asthma patients in the experimental group showed improvements in lung function (the mean percentage of predicted forced expiratory volume in 1 second [FEV1] improved from 63.9% at baseline to 76.3% at the 4-month follow-up; P<.001), whereas control group patients showed no change. Rheumatoid arthritis patients in the experimental group showed improvements in overall disease activity (a mean reduction in disease severity from 1.65 to 1.19 [28%] on a scale of 0 [asymptomatic] to 4 [very severe] at the 4-month follow-up; P=.001), whereas control group patients did not change. Combining all completing patients, 33 (47.1%) of 70 experimental patients had clinically relevant improvement, whereas 9 (24.3%) of 37 control patients had improvement (P=.001).
Patients with mild to moderately severe asthma or rheumatoid arthritis who wrote about stressful life experiences had clinically relevant changes in health status at 4 months compared with those in the control group. These gains were beyond those attributable to the standard medical care that all participants were receiving. It remains unknown whether these health improvements will persist beyond 4 months or whether this exercise will prove effective with other diseases.
To examine how the type and number of physical symptoms reported by primary care patients are related to psychiatric disorders and functional impairment. Outpatient mental health survey. Four primary care clinics. One thousand adult clinic patients, of whom 631 were selected randomly or consecutively and 369 by convenience. Psychiatric disorders as determined by the Primary Care Evaluation of Mental Disorders procedure; the presence or absence of 15 common physical symptoms and whether symptoms were somatoform (ie, lacked an adequate physical explanation); and functional status as determined by the Medical Outcomes Study Short-form General Health Survey. Each of the 15 common symptoms was frequently somatoform (range, 16% to 33%). The presence of any physical symptom increased the likelihood of a diagnosis of a mood or anxiety disorder by at least twofold to three-fold, and somatoform symptoms had a particularly strong association with psychiatric disorders. The likelihood of a psychiatric disorder increased dramatically with increasing numbers of physical symptoms. The prevalence of a mood disorder in patients with 0 to 1, 2 to 3, 4 to 5, 6 to 8, and 9 or more symptoms was 2%, 12%, 23%, 44%, and 60%, respectively, and the prevalence of an anxiety disorder was 1%, 7%, 13%, 30%, and 48%, respectively. Finally, each physical symptom was associated with significant functional impairment; indeed, the number of physical symptoms was a powerful correlate of functional status. The number of physical symptoms is highly predictive for psychiatric disorders and functional impairment. Multiple or unexplained symptoms may signify a potentially treatable mood or anxiety disorder.
Background: Specific concerns and expectations may be a key reason that people with common physical complaints seek health care for their symptoms. Objectives: To determine the frequency of symptomrelated patient concerns and expectations, physician perceptions and actions, and the relationship of these factors to patient satisfaction and symptom outcome. Methods: This was a prospective cohort study of 328 adult outpatients presenting for evaluation of a physical complaint. The setting was a general medicine clinic in a teaching hospital. Measures included previsit patient questionnaire to identify symptom-related concerns and expectations; a postvisit physician questionnaire to determine physician perceptions and actions; and a 2-week follow-up patient questionnaire to assess symptom outcome and satisfaction with care. Results: Pain of some type accounted for 55% of com mon symptoms, upper respiratory tract illnesses for 22%, and other physical complaints for 23%. Two thirds of patients were worried their symptom might represent a serious illness, 62% reported impairment in their usual activities, and 78%, 46%, and 41% hoped the physician would prescribe a medication, order a test, or provide a referral. Physicians often perceived symptoms as less serious or disabling and frequently did not order anticipated tests or referrals. While symptoms improved 78% of the time at 2-week follow-up, only 56% of patients were fully satisfied. Residual concerns and expectations were the strongest correlates of patient satisfaction. Conclusions: Improved recognition of symptom-related concerns and expectations might improve satisfaction with care in patients presenting with common physical complaints. Arch Intern Med. 1997;157:1482-1488
Results from a Consumer Reports (CR) survey indicated that psychotherapy has proven to be quite effective and that longer-term therapy has been more effective than shorter-term therapy. Critiques of the methodology of this study have included the claim that (a) the self-selected sample was biased in favor of people who felt that they had benefited from psychotherapy, (b) the use of retrospective accounts led to a further positive bias, and (c) the validity of the outcome assessment was questionable. Supplemental data from other sources, including prospective data from a large sample of psychotherapy patients, are presented to augment the interpretation of the results of the CR study and to illustrate how some critiques of research results can be evaluated systematically. © 2001 John Wiley & Sons, Inc. J Clin Psychol 57: 865–874, 2001.
Many symptoms in outpatient practice are poorly understood. To determine the incidence, diagnostic findings, and outcome of 14 common symptoms, we reviewed the records of 1,000 patients followed by house staff in an internal medicine clinic over a three-year period. The following data were abstracted for each symptom: patient characteristics, symptom duration, evaluation, suspected etiology of the symptom, treatment prescribed, and outcome of the symptom. Cost estimates for diagnostic evaluation were calculated by means of the schedule of prevailing rates for Texas employed by the Civilian Health and Medical Program of the Uniformed Services for physician reimbursement.
A total of 567 new complaints of chest pain, fatigue, dizziness, headache, edema, back pain, dyspnea, insomnia, abdominal pain, numbness, impotence, weight loss, cough, and constipation were noted, with 38 percent of the patients reporting at least one symptom. Although diagnostic testing was performed in more than two thirds of the cases, an organic etiology was demonstrated in only 16 percent. The cost of discovering an organic diagnosis was high, particularly for certain symptoms, such as headache (7,263). Treatment was provided for only 55 percent of the symptoms and was often ineffective. Where outcome was documented, 164 (53 percent) of 307 symptoms improved. Three favorable prognostic factors were an organic etiology (p = 0.006), a symptom duration of less than four months (p = 0.009), and a history of two or fewer symptoms (p = 0.001).
The classification, evaluation, and management of common symptoms need to be refined. Diagnostic strategies emphasizing organic causes may be inadequate.
This prospective study was conducted to determine the influence of primary care patients' health perceptions on their utilization of health care services. Patients' health perceptions were measured using the RAND Corporation's General Health Perceptions Questionnaire. Physicians provided scores of how they thought the patients perceived their health and of actual physical and emotional health. Utilization data (number of office visits, number of telephone calls to the physician, and ambulatory charges) were evaluated for a 12-month period after completion of the questionnaire. Of 208 patients, 62 (30%) patients with health perceptions scores less than 50 had greater degrees of anxiety (P less than .001), depression (P less than .001), health-related worry (P less than .001), and felt less able to resist illness (P less than .001) than patients with higher health perception scores. Analysis of covariance was used to control for differences in physical health among groups of patients with varying health perceptions. These analyses revealed that patients with low health perceptions made more office visits (P = .002), more telephone calls to the physician (P = .01), and had more office charges (P = .05) than patients with higher scores. Physicians accurately predicted the patients' health perceptions in 49% of the cases. In 37%, they thought patients would score their health perceptions higher than they did; in 14% they thought patients would score their health perceptions lower. Health perceptions are an important factor contributing to the use of health care by primary care patients, regardless of the patient's actual physical health. Persons with low health perceptions account for approximately 5% of office visits, a clinically important fraction, especially when compared to the 9% of office visits for hypertension, the most common disease treated in the medical office.
This paper presents the results of two studies that compared methods for measuring patient satisfaction with specific medical encounters. One form used six-point response scales ranging from "very satisfied" to "very dissatisfied" (S6 scale); the other used five-point scales ranging from "excellent" to "poor" (E5 scale). Forms were assigned randomly to outpatients in fee-for-service (N = 136) and prepaid systems of care (N = 363) and were compared in terms of response variability, reliability, and validity. In both studies, the E5 scales showed greater response variability and better predicted whether patients intended to return to the same doctor in the future, recommend the doctor to a friend, and comply with the medical regimen. Reliability was satisfactory and did not differ between methods. Results are discussed in terms of their implications for constructing visit-specific satisfaction rating scales.
When individuals are asked to write or talk about personally upsetting experiences, significant improvements in physical health are found. Analyses of subjects' writing about traumas indicate that those whose health improves most tend to use a higher proportion of negative emotion words than positive emotion words. Independent of verbal emotion expression, the increasing use of insight, causal, and associated cognitive words over several days of writing is linked to health improvement. That is, the construction of a coherent story together with the expression of negative emotions work together in therapeutic writing. Evidence of these processes are also seen in specific links between word production and immediate autonomic nervous system activity. Implications for therapy and for considering the mind and body as fluid, dynamic systems are discussed.
Writing about important personal experiences in an emotional way for as little as 15 minutes over the course of three days brings about improvements in mental and physical health. This finding has been replicated across age, gender, culture, social class, and personality type. Using a text-analysis computer program, it was discovered that those who benefit maximally from writing tend to use a high number of positive-emotion words, a moderate amount of negative-emotion words, and increase their use of cognitive words over the days of writing. These findings suggest that the formation of a narrative is critical and is an indicator of good mental and physical health. Ongoing studies suggest that writing serves the function of organizing complex emotional experiences. Implications for these findings for psychotherapy are briefly discussed.
Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome
- R L Marple
- K Kroenke
- C R Lucey
- J Wilder
- C A Lucas
Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and
expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome. Arch Intern Med. 1997;157:
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Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial
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- A A Stone
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- L R Barker
- K A Cole
- R P Roca
Smyth JM, Stone AA, Hurewitz A, Kaell A. Effects of writing about stressful
experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial. JAMA. 1999;281:1304-9. [PMID: 0010208146]
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