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Direct Diagnosis and Management of Emotional Factors in Chronic Headache Patients
Abstract
Somatization, anxiety, depression and personality disorders are common features of many patients with chronic headaches. Intensive short-term dynamic psychotherapy (ISTDP) is a brief therapy method developed specifically to treat patients with this cluster of somatic problems, symptoms and maladaptive behaviours through focusing on how the patient handles emotional experiences. It also contains a direct method of assessing the somatic discharge pathways of both emotions and anxiety, thus allowing direct observation of somatization in the case of many chronic headache sufferers. In this review, we summarize the extant literature on emotional factors in headache, review the evidence for short-term dynamic therapies in somatic problems and describe the assessment and treatment method of ISTDP we use routinely with chronic headache sufferers.
... One of the modalities available in the clinic is Intensive Short-Term Dynamic Psychotherapy (ISTDP). This is a contemporary brief psychodynamic approach with an emerging evidence-base demonstrating long-term amelioration of symptoms alongside significant savings in healthcare costs for patients with mental health difficulties and/or somatic disorders (Abbass et al., 2012;Abbass et al., 2015;Town & Driessen, 2013;Abbass et al., 2008). ...
... This becomes associated with anxiety leading to a pattern of emotional activation that becomes automatically and immediately accompanied by physical anxiety and defensive processes aimed at keeping the affect at bay. In this context it is the unregulated literal physical impact on the body of the dysregulated anxiety and affective states that are thought to lead to the somatic symptomology (Abbass et al., 2008). ISTDP was originally developed by Davanloo, strongly advocated for by Malan, and theoretical located within the tradition of short-term psychodynamic therapies (Davanloo, 1990;Malan, 1979). ...
... The core components of ISTDP as an intervention for functional disorders are outlined in the work of Abbass (2015) and Neborsky and ten Have-de-Labije (2012). These components can include: ■ Conducting an emotion-focused interview to ascertain the relationship between affect and physical symptoms (Abbass et al., 2008); ■ Using a graded approach to build the patient's capacity to experience emotion in their body whilst facilitating their physical anxiety to be channeled into healthy somatic pathways; ■ Supporting the patient to overcome habitual defences against emotional closeness; and ■ Processing associated memories relating to past experiences that instigated and supported the original learned patterns of affect subjugation. ...
This outcome study evaluated the quality of life and emotional wellbeing of patients referred with functional neurological symptoms (FNS) to an NHS Community Neuropsychology Service and treated with a course of Intensive Short-Term Dynamic Psychotherapy (ISTDP). Measures of quality of life and emotional wellbeing demonstrated significant improvement amongst the eleven patients treated. These outcomes support the view that ISTDP may be a helpful psychological treatment option for patients with FNS.
... Another RCT concerning immune factors in a student population, reported statistically significant changes in the levels of blood associated immune cell counts in the ISTDP group relative to a verbal disclosure control group (Ghorbani, Dadsetan, Ejei, & Motiyan, 2000). In addition, four naturalistic studies reported that ISTDP was effective in reducing somatic symptoms with psychogenic movement disorder (Hinson, Weinstein, Bernard, Leurgans, & Goetz, 2006) chronic back pain (Hawkins, 2003), recurrent headaches (Abbass, Lovas, & Purdy, 2008), and medically unexplained symptoms in frequent attendees at emergency departments (Abbass et al., 2009). ...
... Cost-effectiveness. Eight published studies provided cost-effectiveness data (Abbass, 2002a(Abbass, , 2003(Abbass, , 2006Abbass et al., 2010;Abbass, Lovas, et al., 2008;Abbass, Sheldon, et al., 2008;Cornelissen, Smeets, Willemsen, Busschbach, & Verheul, in prep.;Cornelissen & Verheul, 2002). ...
... Study characteristics and outcome data included in meta-analysis (Abbass, Town, and Driessen, 2012) admissions and mental health appointments. Five studies reported reduced medication usage of 35% to 81.5% (Abbass, 2002a(Abbass, , 2006Abbass, Lovas, et al., 2008;Abbass, Sheldon, et al., 2008). Significant reductions in medication usage were found in ISTDP treated groups versus waiting-list controls (Abbass, Sheldon, et al., 2008) and a treatment as usual group (Abbass, 2002b). ...
Based on over forty years of videotaped case-based research, Habib Davanloo of McGill University, Canada, discovered some of the core ingredients that can enable direct and rapid access to the unconscious in resistant3 patients, patients with func-tional disorders, and patients with fragile character structure. We will describe here some of the main research findings that culminated in his description of a central therapeutic process involved in the intensive short-term dynamic psychotherapy (ISTDP) model. We will also describe the evolution of the technique over the past thirty years and summarize the empirical base for Davanloo’s ISTDP.
... Współcześni autorzy o orientacji psychodynamicznej, podkreślając znaczenie doświadczeń urazowych -zwłaszcza tych doznanych ze strony najbliższych we wczesnym dzieciństwie -w powstawaniu i rozwoju objawów psychosomatycznych, traktują cierpienie fizyczne jako formę obrony przed bólem psychicznym. "poświęcenie własnego ciała" [3] bywa tu rozumiane z jednej strony -jako próba ochrony ważnych obiektów przed własną wściekłością z powodu doznanych krzywd, z drugiej -jako forma ukarania siebie za odczuwaną wobec nich wrogość [4]. Kiedy własne uczucia (jako zbyt bolesne, zakazane, trudne czy głupie, związane z poczuciem winy i/lub wstydu) uznawane są za niemożliwe do zaakceptowania, budzą konflikt i lęk. ...
... relacjach z pierwszymi opiekunami, powtarzanych w bieżących relacjach z innymi ludźmi oraz w relacji z terapeutą. interwencje terapeutyczne bazujące na związkach między "wierzchołkami" każdego z tych trójkątów, a także między trójkątami, umożliwiają integrację emocjonalnych i poznawczych aspektów doświadczenia [13] oraz pomagają pacjentowi zrozumieć psychiczną rzeczywistość i osiągnąć złagodzenie symptomów w stosunkowo krótkim okresie; efekty tej pracy utrzymują się jeszcze przez długi czas [4]. ...
... Davanloo, bazując na prowadzonej przez lata wnikliwej analizie nagrań wideo z terapii kilkuset pacjentów, opisał specyficzne sposoby doznawania i ekspresji podstawowych uczuć, które uzewnętrzniają się w ten sam sposób u wszystkich ludzi, bez względu na wiek, płeć, pochodzenie etniczne czy kulturę [15]. te neurofizjologiczne ścieżki charakterystyczne dla poszczególnych emocji tworzą pewne wzorce, do których można odnieść doznania nieświadomego swych uczuć somatyzującego pacjenta [14,16,4]. ...
The purpose of this article is to present intensive shortterm dynamic psychotherapy (ISTDP) as a type of therapy considered particularly useful when treating patients with somatization. After a short presentation of the psychodynamic understanding of the phenomenon of somatization and the basic principles of ISTDP, the main diagnostic and therapeutic strategies and methods used when working with such patients are discussed. The patients are people who - similarly to patients suffering from depression - demonstrate high levels of unconscious anxiety and very high levels of resistance in transference at the same time, which require a specific way of conduct. During the first stage of psychotherapy, a restructuring of ego defense mechanisms is done using the so called graded format (which constitutes in continuous monitoring of the patient's anxiety level and alternating pressure on the patient's experiencing of emotions and the so called cognitive analysis of what is happening during the session). Only in the second phase of psychotherapy, other ISTDP techniques are used (such as challenge and headon collision) as a part of the central dynamic sequence, leading to the unblocking and processing of the feeling causing the anxiety, the repression of which contributed to the development of the symptoms.
... Another RCT concerning immune factors in a student population, reported statistically significant changes in the levels of blood associated immune cell counts in the ISTDP group relative to a verbal disclosure control group (Ghorbani, Dadsetan, Ejei, & Motiyan, 2000). In addition, four naturalistic studies reported that ISTDP was effective in reducing somatic symptoms with psychogenic movement disorder (Hinson, Weinstein, Bernard, Leurgans, & Goetz, 2006) chronic back pain (Hawkins, 2003), recurrent headaches (Abbass, Lovas, & Purdy, 2008), and medically unexplained symptoms in frequent attendees at emergency departments (Abbass et al., 2009). ...
... Cost-effectiveness. Eight published studies provided cost-effectiveness data (Abbass, 2002a(Abbass, , 2003(Abbass, , 2006Abbass et al., 2010;Abbass, Lovas, et al., 2008;Abbass, Sheldon, et al., 2008;Cornelissen, Smeets, Willemsen, Busschbach, & Verheul, in prep.;Cornelissen & Verheul, 2002). ...
... Study characteristics and outcome data included in meta-analysis (Abbass, Town, and Driessen, 2012) admissions and mental health appointments. Five studies reported reduced medication usage of 35% to 81.5% (Abbass, 2002a(Abbass, , 2006Abbass, Lovas, et al., 2008;Abbass, Sheldon, et al., 2008). Significant reductions in medication usage were found in ISTDP treated groups versus waiting-list controls (Abbass, Sheldon, et al., 2008) and a treatment as usual group (Abbass, 2002b). ...
Based on over forty years of videotaped case-based research, Habib Davanloo of McGill University, Canada, discovered some of the core ingredients that can enable direct and rapid access to the unconscious in resistant3 patients, patients with functional disorders, and patients with fragile character structure. We will describe here some of the main research findings that culminated in his description of a central therapeutic process involved in the intensive short-term dynamic psychotherapy (ISTDP) model. We will also describe the evolution of the technique over the past thirty years and summarize the empirical base for Davanloo's ISTDP. © 2013 Italian Area Group of the Society for Psychotherapy Research.
... The relationship between DP and psychological and physical distress is yet to be fully understood, with a similar attachment-based approach postulating its effect on physical pain through the hyper-activation of the Hypothalamic -pituitary-adrenal (HPA) axis, such as elevated levels of cortisol in response to trauma (Ó Curraoin & Egan, 2016). Abbass et al. (2008) study replicated this by showing how differences in emotion regulation strategies predicted somatization in patients with chronic headaches, with the authors suggesting cognitive reappraisal interventions for patients with chronic pain (Abbass et al., 2008). ...
... The relationship between DP and psychological and physical distress is yet to be fully understood, with a similar attachment-based approach postulating its effect on physical pain through the hyper-activation of the Hypothalamic -pituitary-adrenal (HPA) axis, such as elevated levels of cortisol in response to trauma (Ó Curraoin & Egan, 2016). Abbass et al. (2008) study replicated this by showing how differences in emotion regulation strategies predicted somatization in patients with chronic headaches, with the authors suggesting cognitive reappraisal interventions for patients with chronic pain (Abbass et al., 2008). ...
Our ability to regulate our emotions plays a key protective role against psychological distress and somatic symptoms, with most of the literature focusing on the role of cognitive reappraisal in interventions such as cognitive behavioral therapy (CBT). This study seeks to examine the relationship between emotion dysregulation and psychological and physical distress in university students through the role of depersonalization (DP) and insecure attachment. This study will try to explain the deployment of DP as a defense mechanism to insecure attachment fears and overwhelming stress, developing a maladaptive emotion responding strategy, which affects wellbeing later in life. A cross-sectional design was used on a sample (N = 313) of university students over the age of 18 which consisted of an online survey of 7 questionnaires. Hierarchical multiple regression and mediation analysis were conducted on the results. The results showed that emotion dysregulation and DP predicted each variable of psychological distress and somatic symptoms. Both insecure attachment styles were found to predict psychological distress and somatization, mediated through higher levels of DP, whereby DP may be deployed as a defense mechanism to insecure attachment fears and overwhelming stress, which affects our wellbeing. Clinical implications of these findings highlight the importance of screening for DP in young adults and university students.
... Specifically, headache patients have difficulty regulating anger [18]. Many headache patients turn their anger inward toward themselves, leading to the somatization of their emotions [19][20][21]. Furthermore, emotional awareness deficits with problems identifying and feeling emotions are strongly related to recurrent headaches [20]. ...
... Many headache patients turn their anger inward toward themselves, leading to the somatization of their emotions [19][20][21]. Furthermore, emotional awareness deficits with problems identifying and feeling emotions are strongly related to recurrent headaches [20]. ...
This study was a randomized controlled design and examined the feasibility and effectiveness of mindful hypnotherapy on psychological inflexibility, pain acceptance, headache disability, and headache intensity in patients with chronic migraine headaches. The sample consisted of 38 females with chronic migraine who were randomly assigned to mindful hypnotherapy and medical treatment as usual groups. Psychological inflexibility pain scale (PIPS), chronic pain acceptance questionnaire-revised (CPAQ-R), headache disability inventory (HDI), diary scale for headache, and short-form McGill pain questionnaire 2 (SF-MPQ-2) were administered at baseline and post-treatment in both groups. The psychological inflexibility mean (SD) score was 81.00 (12.15) at baseline, which significantly decreased to 53.28 (17.06) after the intervention (p < 0.001). Additionally, the mean (SD) score of the pain acceptance was 46.44 (11.16), which significantly increased to 73.61 (15.65) in post-intervention (p < 0.001). Furthermore, the mean (SD) score of headache disability was 73.55 (19.48), which significantly decreased to 23.33 (19.88) in post-intervention (p < 0.001). Finally, headache intensity was 7.33 (0.98) and 5.78 (1.83), which significantly decreased to 2.77 (2.04), and 1.38 (1.48) after the intervention based on the Diary Scale for Headache and McGill Pain Questionnaire (SF-MPQ-2), respectively (p < 0.001). In conclusion, the results show that mindful hypnotherapy is a feasible and effective treatment for chronic migraine.
... ISTDP uses dynamic assessment to identify patients where maladaptive emotional processing may be linked to their symptoms [57]. It proposes that in these cases bodily symptoms emerge from the patient's habitual avoidance of their unconscious emotional experience and the accompanying pathophysiological anxiety states in the patient's brain and nervous system [36,42,58]. ...
... Sig symptom reduction Chronic Headache [42] Case Series 29 Sig symptom and healthcare cost reduction Pseudoseizures [34] Case Series 28 Sig symptom and cost reduction Chronic Pain [28] (MBT) RCT 63 ISTDP > Mindfulness Based Stress Reduction and TAU Chronic Pain [43] RCT 81 ISTDP in person > ISTDP by Skype Chronic Pain [44] RCT 100 ISTDP by Skype > TAU Irritable Bowel Syndrome [45] RCT 102 ISTDP > Medical TAU MUS in Emergency [46] Controlled 77 Sig symptom reduction and emergency visit reduction pre vs post and vs control Mixed MUS and other [47] Controlled 890 Sig symptom reduction Atopic Dermatitis [48] RCT 32 ISTDP > control in anxious Cases Bruxism [49] RCT 41 ISTDP > control Functional Neurological [35] Case Series 11 Improvement on multiple domains Mixed MUS in Family Practice [50] Case Series 37 Sig symptom improvement Inflammatory Bowel Disease * [51] Case Series 7 Improvement on IBD symptoms Fibromyalgia [52] Case Series 67 Sig symptom reduction Chronic Pain [53] RCT 341 Sig symptom effects ISTDP = CBT Chronic Pain [54]*** Case Series 228 Symptom reduction and healthcare cost reduction Chronic Pain in Veterans ** [29] RCT 64 ISTDP + EAET > CBT Chronic Pain*** [55] RCT 230 EAET > or equal to CBT Irritable Bowel Syndrome *** [56] RCT 106 EAET > Structured Relaxation MUS = Medically Unexplained Symptoms, TAU = Treatment as Usual, RCT = Randomized Controlled Trial. *Though not a somatic symptom disorders, emotional stress is a factor generating symptoms and relapses. ...
The purpose of this article was to raise awareness of an under-recognized but well-supported treatment for Functional Neurological Disorders (FND) termed Intensive Short-term Dynamic Psychotherapy (ISTDP). There has been significant interest in the role of psychological mechanisms in FND onset and maintenance with specific evidence for maladaptive emotional processing. We outline how this supports the theoretical basis for ISTDP as an option in FND treatment and undertake a literature review of the current evidence base. We describe the application of ISTDP to FND illustrated through direct therapy transcripts. We conclude with reflections on the strengths and limitations of ISTDP as well as recommendations regarding future research.
... This particular therapeutic approach has demonstrated its effectiveness in the treatment of MUP, 15 medically unexplained symptoms with repeated emergency visits, 16 pelvic pain or urethral syndrome, 17 chronic back pain, 18 and recurrent headaches. 19 Unfortunately, many patients lack access to inperson ISTDP and the barriers to treatment include lack of appropriate psychotherapeutic centres, concentration of appropriately trained psychotherapists in urban centres, high cost of psychotherapy, social stigma and personal unease with seeking psychotherapy. ...
... 40 Emotional factors, including reduced alexithymia, building awareness of unconscious processes and emotional experiencing, are possible treatment factors rendering these therapies effective. 25 There is a large body of research supporting the conclusion that Internet-based Cognitive-Behavioural Therapy (ICBT) is effective for various conditions such as depression, 19 anxiety disorders, 41 and various healthrelated conditions. 20 Also, there are no indications of differential efficacy compared to face-to-face CBT, with a recent meta-analysis showing guided self-help (a majority of studies being ICBT) to be as effective as face-to-face treatments for mild to moderate depression and anxiety disorders. ...
Introduction:
This study examined the effectiveness of telemedicine in providing psychotherapy to patients with medically unexplained pain (MUP) who may not have access to in-person treatment. The impact of Internet-delivered intensive short-term dynamic psychotherapy (ID-ISTDP) was investigated for MUP via video teleconferencing (Skype™).
Methods:
A randomized, controlled trial of ISTDP, an evidence-based intervention for MUP, was conducted to compare delivery modalities on variations in MUP symptoms. Eighty-one participants with MUP were randomized to either ID-ISTDP (n = 39) or in-person ISTDP (n = 42). Outcome variables included the Numeric Pain Rating Scale, Depression Anxiety Stress Scale-21, Emotion Regulation Questionnaire, Mindful Attention Awareness Scale and the Quality of Life Inventory. In addition, exploratory analyses were used to examine acceptability, satisfaction and compliance in both conditions. Participants were assessed prior to intervention, immediately following the intervention, and 12 months after.
Results:
In the intention-to-treat analysis, in-person ISTDP participants had significantly lower pain intensity than ID-ISTDP participants, both immediately following the intervention (d = 0.97) and at the 12-month follow-up (d = 0.82). Moreover, there were significant decreases in depression, anxiety and stress as well as a greater increase in emotion regulation functioning, mindfulness and quality of life observed in the in-person ISTDP group at the end of the intervention and 12 months after the treatment when compared to the ID-ISTDP group. Participants rated both treatment conditions as equally credible and satisfying.
Conclusion:
ISTDP seems most effective when delivered in person in treating MUP patients with highly comorbid conditions with benefits maintained over 12 months.
... Somatization was attributed to unconscious emotions that produce unconscious anxiety and various defenses against this anxiety. Patterns of somatization, based on 40 years of videotape-based research by Davanloo (5) , were categorized in 4 main pathways: striated muscle tension, smooth muscle tension, cognitive perceptual disruption and conversion (4,6) . Descriptions of these and common examples seen in the ED are presented in Table 1. ...
... One of the methods of STPP, Davanloo's ISTDP has demonstrated effectiveness in several conditions that predispose to excess ED usage. These include panic disorder (10) , functional movement disorders (12) , pelvic pain/urethral syndrome (13) , chronic back pain (14) and recurrent headaches (6) . In a naturalistic study, treated patients experienced a marked drop in both physician visits and hospital use which persisted in 1 and 3-year follow-ups (15,16) . ...
... In the last few years, we are struggling to obtain accurate data on BB by defining (using number of signs and symptoms), if individuals present with mild (3-5), moderate (6-10), severe (11)(12)(13)(14)(15) and extreme (16-25) BB signs and symptoms, respectively. ...
... It may be that patients with more severe CMDs+BB and headaches have somatization tendencies, difficulties regulating anger, and tend to turn anger towards themselves. Headaches predominate in CMDs and BB individuals, they usually indicate somatization 14 and it is known that somatization individuals usually present frequent and intense headaches when subjected to anxiety and stressful situations. Internalization of anger is observed in some psychosomatic disorders including irritable bowel syndrome, hypertension and depression. ...
Objective. To evaluate means in anger-in and aggressive dream content in craniomandibular disorder/bruxers. Method. Two questionnaires to evaluate anger-in and aggressive content in nightmares, clinical examination, and criteria for craniomandibular disorders/bruxism were used in 70 subjects with craniomandibular disorders/bruxism (66 females, mean age 31.3); in 28 bruxers without craniomandibular disorders (19 females, mean age 32.3); and in 39 controls without such disorders (26 females, mean age 30.6). Results. Anger-inward was not different between craniomandibular disorder/bruxism (130.7) and non craniomandibular disorder/bruxism (105.6); but it was different when compared with control group (70.1): craniomandibular disorder/bruxism versus control group (p<0.001); non craniomandibular disorder/bruxism and control group (p<0.01). Frequencies of aggressive dream content in nightmares were about: craniomandibular disorder/bruxism: 71.4%; non craniomandibular disorder/bruxism: 67.9% and control group: 46.2% (p=0.02). Means in aggressive dream events were not different among the groups. Conclusions. Anger-in was higher in those with craniomandibular disorders/bruxism. Aggressive events in bad dreams and nightmares decreased from the more psychologically disturbed subgroup to the less psychological disturbed one. © 2015, Universidade Federal de Sao Paulo. All rights reserved.
... Many studies have demonstrated the efficacy of psychotherapeutic techniques for physical conditions (Abbass et al., 2008;Laird et al., 2016;Lumley et al., 2017). Behavioral treatments often include components of psychoeducation, relaxation training, cognitive restructuring, problem-solving, pain/symptom acceptance, exposure with reduced avoidance or safety behaviors, and valuesbased action (Riehl & Taft, 2021). ...
... 4 A subsequent meta-analysis of 37 trials of within-treatment effects found large reductions in somatic symptoms from pretreatment to posttreatment and beyond 6month follow-up. 3 One type of psychodynamic therapy is intensive short-term dynamic psychotherapy, which specifically targets the activation of inhibited or unconscious emotions related to intrapsychic conflicts and explicitly links them to bodily changes. 1 Several uncontrolled trials of this therapy have found large reductions in pain and substantial improvements in other outcomes, such as healthcare utilization, 2,56 and several RCTs have also demonstrated substantial reductions in centralized ("medically unexplained") CP. 23,24 Emotional awareness and expression therapy (EAET), which was derived from short-term psychodynamic as well as emotion-focused and exposure therapies, was developed specifically for patients with centralized CP. This therapy posits that pain can be reduced by integrating pain neuroscience education with awareness and expression of avoided, adaptive emotions. ...
... • Pain receptors, both mental and physical, are structurally linked (central sensitization), Thus, rehabilitation for chronic pain necessitates neuroplastic remodelling. [12]. To get the best results from treatment, all of the factors that influence pain must be addressed. ...
When a person has difficulty understanding, learning new things, focusing, or making decisions that influence their daily life, they are said to have cognitive impairment. Chronic low back pain (CLBP) can cause physical and psychological impairment and is associated with severe comorbidities such as anxiety and depression or poor sleep quality. The association of low back pain with physical impairment, the world's highest debilitating condition, is also described by the mediation impact of fear, catastrophic and psychological distress. When evaluating clinical assessments, it's important to include unhelpful pain cognitions. The current narrative research looked at a developing but still limited field of study into CLBP's potential cognitive effects, with the objective of establishing which areas of functioning show evidence of a significant relationship between CLBP and cognitive performance.
... When multiple measures were used for the same outcome, we examined the effect of substituting one for the other. A few of the studies have small overlap of patients for certain outcome measures (Abbass et al., 2008;Flibotte, 2012;Lilliengren, 2020;Russell et al., 2017), so we assessed the effect of omitting each study in turn. Finally, we tested for publication bias for our primary outcome (somatic symptoms) using funnel plot asymmetry (where low p values suggest publication bias). ...
Objective
A recent meta-analysis of 17 randomized, controlled trials (RCTs) showed that Short-term Psychodynamic Psychotherapy (STPP) for functional somatic disorders (FSD) reduced somatic symptoms compared to wait list, minimal treatment, and treatment-as-usual controls. A clinically important yet unanswered question is how much improvement patients experience within STPP treatment.
Methods
Following a systematic search, we identified STPP trials presenting data at baseline and post-treatment/follow-up. Meta-analyses determined the magnitude of changes in somatic symptoms and other outcomes from before to after STPP, and analyses examined effect sizes as a function of study, therapy, and patient variables.
Results
We identified 37 trials (22 pre-post studies and 15 RCTs) totaling 2094 patients treated an average of 13.34 sessions for a range of FSD. Across all studies, somatic symptoms improved significantly from pre-treatment to short-term follow-up with a large effect size (SMD = −1.07), which was maintained at long-term follow-up (SMD = −0.90). After excluding two outlier studies, effects at short- and medium-term follow-up remained significant but were somewhat reduced in magnitude (e.g., short-term SMD = −0.73). Secondary outcomes including anxiety, depression, disability, and interpersonal problems had medium to large effects. Effects were larger for studies of STPP that were longer than 12 sessions or used an emotion-focused type of STPP, and for chronic pain or gastrointestinal conditions than for functional neurological disorders.
Conclusions
STPP results in moderate to large improvements in multiple outcome domains that are sustained in long-term follow-up. STPP is an effective treatment option for FSD and should be included in treatment guidelines.
... Such experiences suggest that cortical and subcortical circuits not only are responsible for emotion regulation but also play a significant role in pain regulation [24,25]. Various research studies have shown that somatization of emotions in a wide range of patients with recurrent headache is a common feature of their problems [26]. ...
Background: Tension and migraine headaches are the most prevalent types of headaches. Some emotional and psychological factors are associated with these headaches.
Objectives: To elucidate the nature of individual differences in emotion regulation and repetitive negative thinking among patients with tension headaches and migraine and compare it with normal subjects.
Materials & Methods: In this cross-sectional, comparative study, the participants consisted of patients with tension headaches and migraine referring to the two neurology clinics in Isfahan City, Iran from 2019 to 2020. A diverse sample of patients (n =240) completed the difficulties in emotional regulation scale and perseverative thinking questionnaire. The Chi-square tests, Fisher’s exact test, GLM (generalized linear model), Tukey post hoc test, and LSD (least significant difference) test were used to analyze the obtained data in SPSS V. 21.
Results: The results indicated that patients with a high level of repetitive negative thinking reported increased difficulties in emotional regulation and impulse control, limited access to emotion regulation strategies, and lack of emotional clarity (P
... Overall, our metasynthesis illustrates how the expectations of others could shape patterns of emotional perception and communication. Targeting emotional avoidance has shown to be an effective and cost-reducing intervention in short-term psychodynamic treatments (Abbass 2015;Abbass, Lovas, & Purdy, 2008). From the patient perspective, directly targeting emotions in therapy of FSS has also been described as a main facilitating factor (Town et al., 2019). ...
Patients with Functional Somatic Syndromes (FSS) often display troubled relationships with health care providers, psychotherapists, and significant others. Research shows that patients' history of trauma, attachment disturbances, and mentalization deficits may result in the emergence of maladaptive interpersonal patterns, which may later contribute to the onset and maintenance of FSS, "doctor-hopping," and dropout in psychotherapy. As the nature and therapeutic consequences of such maladaptive interpersonal patterns in FSS cannot be understood sufficiently by quantitative methods alone, there is a need for in-depth qualitative research. To address this issue, we conducted a metasynthesis of 23 published case studies of patients with FSS from various psychotherapeutic orientations. Results show that patients with FSS from our sample perceived others as unreliable, i.e., unavailable, overcontrolling, and overprotective. To adapt to such unreliable others, patients attempted to please and to control them. Patients also suppressed their emotional awareness and expression. Although alexithymia could also play a role, the primary reason for emotional avoidance seemed to be interpersonal in nature, i.e., patients were avoiding negative emotions in order to please and control the unreliable others. The onset and worsening of FSS were associated with both interpersonal and physical triggers. Showing signs of physical or emotional distress lead to more rejection, overcontrol, and overprotection from unreliable others, which could create a "vicious circle." Our results suggest that offering a more interpersonal perspective on emotion regulation difficulties would be beneficial for patients with FSS, counselors, psychotherapists, and other health care professionals.
... As previously noted, numerous studies examining the impact of short-term psychodynamic psychotherapy (STPP) for chronic physical pain and somatic symptom disorders have proven to be effective in the immediate-, short-, and long-term when compared to CBT, usual medical care, and/or supportive models (Turk et al., 2008). Abbass and colleagues (2006) have performed rigorous Cochrane Reviewlevel analyses of such studies, finding a total of 24 published studies of individual and group STPPs for a range of these conditions, 9 of which were specifically the most common chronic physical pain conditions including chronic headache, rheumatoid arthritis, chronic back pain, and chronic pelvic pain (Abbass, Lovas, & Purdy, 2008;Baldoni, Baldaro, & Trombini, 1995;Barnat, 1981;Bassett & Pilowsky, 1995;Bassler, Krauthauser, & Hoffmann, 1994;Hawkins, 2003;Monsen & Monsen, 2000;Poulsen, 1991;Ventegodt et al., 2007). An additional 6 studies were identified for mixed somatoform/somatic symptom syndromes and other conditions (including Crohn's disease), which are often characterized by chronic physical pain (Abbass, 2008). ...
Chronic physical pain is prevalent condition and has gained considerable attention in the wake of the opioid crisis and epidemic. As a medical phenomenon, it has highlighted significant gaps in healthcare training, finances, clinical service, and administration. The psychodynamic determinants of pain symptoms or the need for analgesia are rarely considered in the medical management of this problem. The specific objective of this article is to offer a general psychodynamic understanding of chronic physical pain. As a psychodynamically oriented, medically informed psychiatrist practicing in a multidisciplinary pain management program, I propose a clinical construct of psychologically rich "parallel pains" to chronic physical pain, and that these pains inform important interpersonal issues dubbed "dynamic dilemmas." Chronic physical pain is defined, clinical examples are provided, and general implications are considered.
... ISTDP has been tested in patients with pain disorders in a growing number of trials, demonstrating equivalence to CBT (84) and superiority to mindfulness-based stress reduction (85) for centralized pain conditions, and outperforming medical care for pelvic pain (86). Uncontrolled studies suggest the effectiveness of ISTDP for headaches (87). A meta-analysis of trials of short-term psychodynamic psychotherapy for somatic disorders, many of which included pain as a primary symptom, revealed medium to large effects, and the strongest effects occurred for those therapies that emphasized emotional experiencing (49). ...
Objective:
Chronic pain is a significant health problem that is increasing in prevalence, and advances in treatment are needed.
Methods:
We briefly review the leading evidence-based psychological therapies for chronic pain-cognitive-behavioral and acceptance / mindfulness-based therapies-and examine several limitations and missing perspectives of these approaches. We review six lesser-known interventions that address these limitations, and we describe our integrative model for psychological assessment and treatment of centralized pain. We present a typical patient and describe how we apply this approach, along with challenges to its implementation and possible solutions to these challenges.
Results:
Greater pain treatment efficacy may be possible if clinicians: a) distinguish patients with primarily centralized (i.e., somatoform or nociplastic) pain from those with primarily peripheral (nociceptive, inflammatory, or neuropathic) pain; b) acknowledge the capacity of the brain not only to modulate pain but also generate as well as attenuate or eliminate centralized pain; c) consider the powerful role that adverse life experiences and psychological conflicts play in centralized pain; and d) integrate emotional processing and interpersonal changes into treatment. Our integrative treatment involves delivering a progression of interventions, as needed, to achieve pain reduction: tailored pain neuroscience education, cognitive and mindfulness skills to decrease the pain danger alarm mechanism, behavioral engagement in avoided painful and other feared activities, emotional awareness and expression to reverse emotional avoidance and overcome trauma or psychological conflict, and adaptive communication to decrease interpersonal stress.
Conclusions:
This integrative assessment and treatment model has the potential to substantially reduce and sometimes eliminate centralized pain by changing the cognitive, behavioral, emotional, and interpersonal processes that trigger and maintain centralized pain.
... It is known thatpatients with chronic pain experience anger. Undiminished anger, on the other hand may create a hypervigilant state of arousal and magnifyies the pain [16]. Central sensitization is the response by reducing the inhibition of the inflammatory or injured somatosensory nervous system and increasing the excitability of nociceptive nerve fibers. ...
Opinion The lifetime prevalence of non-specific chronic low back pain (LBP) is estimated at 60-70% in industrialized countries which is a common health problem worldwide. Approximately 5-15% of LBP cases can be attributed to a specific cause (i.e. osteoporotic fracture, neoplasm or infection) while for the remaining 85-95% the specific cause of LBP is unclear [1,2]. LBP is the leading cause of activity limitation and work absence throughout much of the world, imposing a high economic burden on individuals, families, communities, industry, and governments [3,4]. It is know that 80% of patients with acute LBP are recovering within 6 weeks, while 7-10% of the patients with LBP become chronic (longer than 7-12 weeks) which has a very poor prognosis with recovery leading to work absence and economic loss [5]. Chronic LBP is a neurophysiological disorder affected by multiple factors (such as individual characteristics, working conditions like heavy physical work, bad working postures, lifestyle factors and psychological factors) which may lead to fear of pain causing activity limitations and decrease in participation. Due to prolonged period of pain caused by LBP patients may gradually decrease their occupational work-related activities and other physical activities [6].
... en aktivering av angst i glatt muskulatur gjør at pasienten kan fremstå svaert rolig (fravaer av tverrstripet aktivering), samtidig som han eller hun begynner å føle seg fysisk dårlig (typisk kvalm/ uvel). pasienter med en kronisk dårlig regulert angst rapporterer ofte funksjonelle lidelser/symptomer (Abbass, 2005;Abbass, kisely & kroenke, 2009), for eksempel visse former for migrene (Abbass, lovas & purdy, 2008) og astma, samt mage-og tarmproblemer (irritabel tarm-syndrom, ulcerøs kolitt). som gruppe er disse pasientene ikke i stand til å skille mellom den kroppslige opplevelsen av følelsen og sin angst, og de har en høy forekomst av kronisk somatisering og kroniske former for depresjon, samt typisk store relasjonelle vansker og selvbildeproblematikk (davanloo 1990 a, c). ...
Affective Change – Intensive Short-term Dynamic Psychotherapy (ISTDP) Intensive short-term dynamic psychotherapy (ISTDP) is characterized by the therapist’s sustained effort to help patients get optimal access to feelings through the pressure for feelings, deactivation of defenses and regulation of anxiety. ISTDP is (a) intensive, in the sense that the therapist aims to help the patients to feel their feelings as deeply as possible, (b) psychodynamic, in the sense that the therapist is actively working with transference feelings and the function of the unconscious, and (c) short-term, in the sense that the therapist works to keep a maximum level of pressure, adapted to the patient’s capacity, with the aim of producing the shortest possible treatment with the greatest possible effect. the authors present the theoretical basis for ISTDP, a brief overview of research on the method, and an introduction to how the therapist works with helping patients access their feelings in ISTDP.
... Researches carried out for the effectiveness of intensive short-term dynamic psychotherapy on mood and anxiety disorders have indicated that this kind of therapy has decreased symptoms, interpersonal confusion, and social-occupational activation. [14] Several studies reported the effect of intensive short-term psychodynamic psychotherapy on somatic disorders, [15] functional somatic syndrome, [16] chronic pains, [17] psychotherapeutic perspectives in urethral syndrome, [18] back pain, [19] chronic headache, [20] depressive disorder, [21][22][23][24][25][26] anxiety, [27] and for reducing marriage incompatibility, [28] marital satisfaction, [29] and couples' compatibility. [30] The present study carried out to test intensive short-term psychodynamic impact on affection control of anxious women based on destructive effect of anxiety and affection control on mental health, quality of relationship, and effective married life of couples and also the positive effect of intensive short-term dynamic psychotherapy on psychological, cognitive, and communicational factors of different people (according to literature review). ...
AIM: The present study was carried out with the aim of assigning the effectiveness of intensive short-term dynamic psychotherapy on affection control of anxious women who referred to Consultation Centers in Esfahan.
METHODS: The research method was quasi-experimental and with pretest–posttest using control group. Statistical population of this study included anxious women who had referred to Aban, Aeein, and Milad-e Noor Consultation Centers in Esfahan in 2016. Among them, 30 persons were selected through convenience sampling and were divided randomly in two control and experimental groups (each included 15 persons). The experimental group attended 15 dynamic psychotherapy sessions that each session lasted 60 min. None of the members of control group attend dynamic psychotherapy sessions. The instruments of the study included Zung's Self-rating Anxiety and Williams's Affection Control Scale. The data collected from scales were analyzed by covariance analysis and using the SPSS-23 software.
FINDINGS: The results showed that intensive short-term dynamic psychotherapy increased the score of affection control in anxious women (P < 0.05).
CONCLUSION: Considering the results and findings, we conclude that intervention of intensive short-term dynamic psychotherapy improves and controls affections in women.
... The striated muscles remain relaxed. Chronic smooth muscle anxiety is associated with hypertension, irritable bowel syndrome and migraine [45,46]. Anxiety may also manifest as cognitive perceptual disruption (CPD) which is experienced as tunnel vision, blurred vision, or ringing or buzzing in the ears, and feelings of depersonalization [40]. ...
Most people experience performance anxiety (PA) at some time in a range of diverse endeavours. However,
for those in careers related to the performing arts (music, theatre and dance), public speaking, or sport, it can be a career-limiting or career-ending experience. Little attention has been paid to performance anxiety, empirically, diagnostically, or therapeutically. This paper contributes to the theory proposed by Kenny that the underlying psychopathology of severe performance anxiety is an attachment rupture in early life that is unresponsive to cognitive behavioural therapies. Accordingly, a short-term psychodynamic psychotherapy (STPP) whose therapeutic focus is the resolution of attachment ruptures was undertaken with a young female musician who was in danger of failing her final year at a prestigious music school because she could no longer perform without breaking down. This paper describes the application of the triangle of conflict and the triangle of time/person in the resolution of the attachment ruptures of the three key attachment figures in the life of this young musician. This paper represents only the second detailed case report on the treatment of debilitating music performance anxiety using STPP. Given the successful outcome of both cases, further investigation of this therapeutic approach for severe performance anxiety is warranted.
... Motor conversion is a mechanism whereby voluntary muscle is shut off under the mechanism of repression. Each of these patterns can be detected in clinical interviews allowing direct detection of processes of somatization (Abbass, Lovas, & Purdy, 2008). ...
Intensive short-term dynamic psychotherapy (ISTDP) was developed out of the need for relatively short psychodynamic psychotherapeutic treatment approaches to complex and resistant patient populations so common in public health systems. Based on extensive study of video recordings, Habib Davanloo discovered, and other researchers have validated, some important clinical ingredients that align the therapist with healthy aspects of the patient striving for resolution of chronic neurotic disorders and fragile character structure. In the case of character neurotic highly resistant patients, these approaches including "pressure," "clarification," "challenge to defenses," and "head on collision" can be used in a tailored and properly timed way to help the chronically suffering patient to overcome his or her own resistance and access core drivers of these pathologies. In this article the meta-psychological basis of ISTDP is reviewed and illustrated with an extended case vignette.
... Results of the current study are consistent with other studies that have found efficacy of ISTDP for somatization disorders such as medically unexplained symptoms, 5,14,[27][28][29] including two meta-analyses. 30,31 Unresolved unconscious emotional issues have long been considered an important causal factor in a range of physical illnesses and somatic symptom disorders. ...
Objective: Research has shown that Intensive Short-Term Dynamic Psychotherapy (ISTDP) can effectively decrease pain intensity and improve quality of life in patients with Medically Unexplained Pain (MUP). Understanding that not all patients with MUP have access to in-person ISTDP, this study aims to investigate the efficacy of an Internet-Delivered ISTDP (ID-ISTDP) for individuals with MUP using Skype™ in comparison with Treatment as Usual (TAU). Method: In this randomized controlled trial, 100 patients were randomly allocated into ID-ISTDP (n = 50) and TAU (n = 50) groups. Treatment intervention consisted of sixteen weekly, hour-long therapy sessions. The primary outcome was perceived pain assessed using the Numeric Pain Rating Scale (NPRS). The secondary outcome included Depression Anxiety Stress Scale-21 (DASS-21), Emotion Regulation Questionnaire (ERQ), Mindful Attention Awareness Scale (MAAS) and Quality of Life Inventory (QOLI). Blind assessments were conducted at the baseline, post-treatment and at a six-month follow-up. 2 Results: In the intention-to-treat analysis, pain symptoms in the intervention group were significantly reduced (p < 0.001), while a reduction was not observed in the TAU group (p = 0.651). Moreover, there were significant decreases in depression, anxiety and stress, as well as a greater increase in emotion regulation functioning, mindfulness and quality of life observed in the intervention group six-month after the treatment compared to the TAU condition. Conclusion: The results of this pilot trial demonstrates that sixteen weeks of ISTDP delivered by Skype™ can significantly improve pain intensity and clinical symptoms of MUP.
... Results of the current study are consistent with other studies that have found efficacy of ISTDP for somatization disorders such as medically unexplained symptoms, 5,14,[27][28][29] including two meta-analyses. 30,31 Unresolved unconscious emotional issues have long been considered an important causal factor in a range of physical illnesses and somatic symptom disorders. ...
Background:
Research has shown that Intensive Short-Term Dynamic Psychotherapy (ISTDP) can effectively decrease pain intensity and improve quality of life in patients with medically unexplained pain.
Objective:
Understanding that not all patients with medically unexplained pain have access to in-person ISTDP, this study aims to investigate the efficacy of an Internet-delivered ISTDP for individuals with medically unexplained pain using Skype in comparison with treatment as usual.
Method:
In this randomized controlled trial, 100 patients were randomly allocated into Internet-delivered ISTDP (n = 50) and treatment-as- usual (n = 50) groups. Treatment intervention consisted of 16 weekly, hour-long therapy sessions. The primary outcome was perceived pain assessed using the Numeric Pain Rating Scale. The secondary outcome included Depression Anxiety Stress Scale-21, Emotion Regulation Questionnaire, Mindful Attention Awareness Scale, and Quality-of-Life Inventory. Blind assessments were conducted at the baseline, posttreatment, and at a 6-month follow-up.
Results:
In the intention-to-treat analysis, pain symptoms in the intervention group were significantly reduced (p < 0.001), whereas a reduction was not observed in the treatment as usual group (p = 0.651). Moreover, there were significant decreases in depression, anxiety, and stress, as well as a greater increase in emotion regulation functioning, mindfulness, and quality of life observed in the intervention group 6 months after the treatment compared with the treatment as usual condition.
Conclusion:
The results of this pilot trial demonstrate that 16 weeks of ISTDP delivered by Skype can significantly improve pain intensity and clinical symptoms of medically unexplained pain.
... The resultant chemical hypersensitivity and inflammatory response create a multitude of physical symptoms in addition to magnifying the pain. 35 • Pain pathways, mental and physical, are structurally imbedded (central sensitization), and it takes neuroplastic reorganization to recover from chronic pain. 36 To successfully treat chronic pain, interventions that stimulate neuroplasticity to rewire the brain and also to calm down the nervous system are warranted. ...
Study Design Narrative review of the literature.
Objectives Determine if the term cognitive behavioral therapy (CBT) is useful in clinical care and research. What literature supports these variables being relevant to the experience of chronic pain? What effects of CBT in treating these factors have been documented? What methods and platforms are available to administer CBT?
Methods Chronic low back pain (CLBP) is a complex neurologic disorder with many components. CBT refers to a broad family of therapies that address both maladaptive thoughts and behaviors. There are several ways to deliver it. CLBP was broken into five categories that affect the perception of pain, and the literature was reviewed to see the effects of CBT on these variables.
Results The term cognitive behavioral therapy has little use in future research because it covers such a wide range of therapies. CBT should always be defined by the problem it is intended to solve. The format and method of delivery should be defined because they have implications for outcomes. They are readily available even at the primary care level. The effectiveness of CBT is unquestioned regarding its effectiveness in treating each of the variables that affect CLBP. It is unclear why it is not more widely implemented.
Conclusions CBT represents a family of therapies that are effective for a wide range of problems, many of which coexist with and influence CLBP. Each of the variables can be improved with focused CBT. Early, widespread adoption of CBT in treating and preventing CLBP is recommended. Future research and clinical care should focus on strategies to operationalize these well-documented treatments utilizing a public health approach.
... All treated cases received an individual integrated form of psychotherapy emphasizing emotional mobilization and handling of defenses against emotional experiencing called Intensive Short-Term Dynamic Psychotherapy (ISTDP) (Davanloo, 2000). The method begins with a single interview therapeutic trial with a specialized evaluative procedure to help determine the relative contribution of emotional factors to somatic and psychiatric presentations (Abbass et al, 2008b). ...
To evaluate whether a mixed population of patients treated with Intensive Short-term Dynamic Psychotherapy (ISTDP) would exhibit reduced healthcare costs in long-term follow-up.
A quasi-experimental design was employed in which data on pre- and post-treatment healthcare cost were compared for all ISTDP cases treated in a tertiary care service over a nine year period. Observed cost changes were compared with those of a control group of patients referred but never treated. Physician and hospital costs were compared to treatment cost estimates and normal population cost figures.
1082 patients were included; 890 treated cases for a broad range of somatic and psychiatric disorders and 192 controls. The treatment averaged 7.3 sessions and measures of symptoms and interpersonal problems significantly improved. The average cost reduction per treated case was $12,628 over 3 follow-up years: this compared favorably with the estimated treatment cost of $708 per patient. Significant differences were seen between groups for follow-up hospital costs.
ISTDP in this setting appears to facilitate reductions in healthcare costs, supporting the notion that brief dynamic psychotherapy provided in a tertiary setting can be beneficial to health care systems overall. CLINICALTRIALS.
NCT01924715.
Copyright © 2015. Published by Elsevier Ltd.
Objective:
In this narrative review, we summarize relevant literature pertaining to psychosocial risk factors for headache and migraine progression, current behavioral and psychological treatments, and consider promising treatments.
Background:
Headache and migraine are common and associated with significant burden and disability. Current treatments targeting psychosocial risk factors show modest outcomes and do not directly address the impact of early life adversity, including the development of maladaptive emotional processing. An intervention that could address these factors and include components of current evidence-based interventions may lead to improved outcomes.
Methods:
We searched PubMed and Google Scholar for articles through December 2022. Search terms included headache, migraine, psychological interventions, behavioral interventions, cognitive-behavioral therapy, mindfulness, psychiatric comorbidities, adverse childhood experiences, trauma, and emotional processing.
Results:
Trauma and childhood adversity show a correlation with headache and migraine progression. Developmental adversity and trauma interfere with adaptive emotional processing, which may worsen headache and migraine symptoms, while adaptive ways of experiencing emotions are shown to improve symptoms. Current behavioral and psychological interventions, such as cognitive-behavioral and mindfulness therapies, are effective treatments for headache, but they produce small to medium effect sizes and do not directly address the impact of trauma and emotional conflicts-common factors that contribute to chronicity and disability, especially among certain subpopulations of headache patients such as those with migraine. Thus, there exists a gap in current treatment.
Conclusion:
There is a gap in headache and migraine treatment for those patients who have a history of trauma, childhood adversity, and maladaptive emotional processing. We suggest that an integrated psychological treatment that includes components of current evidence-based interventions and addresses gaps by focusing on processing trauma-related emotions may improve chronic and debilitating symptoms.
Aim and Background: Rheumatoid arthritis is the most common inflammatory rheumatic disease. In most communities, its prevalence is approximately 3%. Anxiety has been reported as one of the most common displeasing psychological experiences in rheumatoid arthritis patients. The aim of this study was to evaluate the effectiveness of intensive short-term dynamic psychotherapy (ISTDP) on reducing anxiety in rheumatoid patients.
Methods and Materials: This study was a quasi-experimental study with pre-test and post-test design along with a control group. The statistical population of the study included patients with rheumatoid arthritis who had visited rheumatology clinics in Kerman during the research. We purposefully selected 40 males and females patients with rheumatoid arthritis as a statistical sample. Then the members of the sample group were randomly divided into two 20-memebr parts as experimental and control groups. For the experimental group, 15 one-and-a-half-hour sessions of intensive short-term dynamic psychotherapy was performed once a week and individually. Research data was analyzed using analysis of covariance and SPSS 19 software.
Findings: After reviewing the pre-test scores between the experimental and control groups, the results of the study indicated that intensive short-term dynamic psychotherapy is effective in reducing anxiety scores in rheumatoid patients (p
Whilst the vast majority of headaches are minor ailments, some patients develop chronic symptoms that have psychiatric dimensions. These symptoms can be immensely challenging to manage and can have a serious impact on the patient's quality of life. The relationship between headache and psychiatric disease is often rationalized as cause and effect; however, the interplay between the two is complex. Management of each of the co-morbid disorders affects the other one in positive and/or negative ways. The Neuropsychiatry of Headache details the current concepts of various headache conditions and the psychiatric syndromes; topics covered include migraine, mood disorders, medication overuse and personality disorders. Headache specialists, neurologists, psychiatrists, neuropsychiatrists and neuropsychologists will find this an invaluable resource for understanding and co-managing these conditions.
Aim and Background: Rheumatoid arthritis is the most common inflammatory rheumatic disease. In most communities, its prevalence is approximately 3%. Anxiety has been reported as one of the most common displeasing psychological experiences in rheumatoid arthritis patients. The aim of this study was to evaluate the effectiveness of intensive short-term dynamic psychotherapy (ISTDP) on reducing anxiety in rheumatoid patients. Methods and Materials: This study was a quasi-experimental study with pre-test and post-test design along with a control group. The statistical population of the study included patients with rheumatoid arthritis who had visited rheumatology clinics in Kerman during the research. We purposefully selected 40 males and females patients with rheumatoid arthritis as a statistical sample. Then the members of the sample group were randomly divided into two 20-memebr parts as experimental and control groups. For the experimental group, 15 one-and-a-half-hour sessions of intensive short-term dynamic psychotherapy was performed once a week and individually. Research data was analyzed using analysis of covariance and SPSS 19 software. Findings: After reviewing the pre-test scores between the experimental and control groups, the results of the study indicated that intensive short-term dynamic psychotherapy is effective in reducing anxiety scores in rheumatoid patients (p<0.05). Conclusions: The use of psychodynamic concepts and techniques in understanding anxiety disorders, seems to be very important. Intensive short-term dynamic psychotherapy considerably helps to reduce anxiety as well as clinical symptoms in rheumatoid patients by affecting the discharge path of anxiety and careful control and moment-by-moment monitoring of anxiety, emotions, and defenses.
The phrase “psychodynamic therapy” refers to the family of treatment approaches based on the early work of Sigmund Freud. It is one of the major forms of contemporary psychotherapy practice and has undergone a great deal of theoretical and technical modification over the past 120 years. Its main techniques have been catalogued and many forms of psychodynamic therapy have been manualized. There is mounting evidence not only in favor of its efficacy, but also in terms of theory-based mechanisms of change and the research generativity of its concepts (e.g., attachment theory).
The phrase “psychodynamic therapy” refers to the family of treatment approaches based on the early work of Sigmund Freud. It is one of the major forms of contemporary psychotherapy practice and has undergone a great deal of theoretical and technical modification over the past 120 years. Its main techniques have been cataloged and many forms of psychodynamic therapy have been manualized. There is mounting evidence not only in favor of its efficacy, but also in terms of theory-based mechanisms of change and the research generativity of its concepts (e.g., attachment theory).
This book maps out the relationship between the discovery of heartfulness and the psychology of inner peace. It presents a rigorous psychological analysis of the underlying components of the psychology of inner peace and the role of innerness in addressing the nature of peace. Alternative theories are introduced that discuss the conceptualization of peace, and their merits are outlined in comparison to more mainstream psychological theories. The author highlights the inadequacies of mind-oriented theories on peace and demonstrates the concept of heartfulness to show how genuine peace can be achieved.
Objective. To evaluate means in anger-in and aggressive dream content in craniomandibular disorder/bruxers. Method. Two questionnaires to evaluate anger-in and aggressive content in nightmares, clinical examination, and criteria for craniomandibular disorders/ bruxism were used in 70 subjects with craniomandibular disorders/ bruxism (66 females, mean age 31.3); in 28 bruxers without craniomandibular disorders (19 females, mean age 32.3); and in 39 controls without such disorders (26 females, mean age 30.6). Results. Anger-inward was not different between craniomandibular disorder/bruxism (130.7) and non craniomandibular disorder/bruxism (105.6); but it was different when compared with control group (70.1): craniomandibular disorder/bruxism versus control group (p<0.001); non craniomandibular disorder/bruxism and control group (p<0.01). Frequencies of aggressive dream content in nightmares were about: craniomandibular disorder/bruxism: 71.4%; non craniomandibular disorder/bruxism: 67.9% and control group: 46.2% (p=0.02). Means in aggressive dream events were not different among the groups. Conclusions. Anger-in was higher in those with craniomandibular disorders/bruxism. Aggressive events in bad dreams and nightmares decreased from the more psychologically disturbed subgroup to the less psychological disturbed one.
In diesem Kapitel wird zunächst eine Übersicht über verschiedene Wirksamkeitsnachweise für die Intensive Psychodynamische Kurzzeittherapie nach Davanloo (IS-TDP) gegeben. Im Anschluss werden die aktuellen Forschungsaktivitäten der Deutschen Gesellschaft für IS-TDP beschrieben.
The purpose of this chapter is to look at the decision-making process, outcomes, and complications of revision lumber decompressions versus primary decompressions. Decision-making and the choice of procedure is possibly the most critical factor in determining a successful outcome. The chapter will address the issues in relationship to both soft disc ruptures and spinal stenosis. The focus is pathology recurring at the same level and side and contralateral ruptures at the same level will not be considered.
Music performance anxiety (MPA) can end the musical aspirations of even the most talented and dedicated musician. Mastering MPA can be almost as challenging as the most difficult concerto or operatic role. Yet there are currently very few evidence-based treatments for this potentially debilitating conditions. In this book, Dianna Kenny synthesizes 15 years of research in MPA. First, she explores underlying factors that contribute to MPA, then presents ways of assessing and treating MPA using a highly individualized approach based on the musician's presentation. A must for musicians, clinicians, teachers and music psychologists.
Psychodynamische Psychotherapie bietet ein sehr breites therapeutisches Spektrum mit verschiedenen Anwendungen. Wesentlich dabei ist die Konzentration des therapeutischen Prozesses durch eine Begrenzung der Behandlungsziele. Ein bewältigungsorientierter Zugang bei einer somatischen und ein kausal-lösungsorientiertes Vorgehen bei einer überwiegend psychischen Verursachung werden vorgestellt. Zu unterscheiden sind die subjektive (innere) Realität, also die Wahrnehmung der Beschwerden und die Bedeutungen, die der Kranke seinen Beschwerden zuschreibt, und die objektive (äußere) Realität, also die ärztlichen Befunde vor dem Hintergrund aller medizinischen Maßnahmen.
This books presents current theory and assessment of music performance anxiety, the role of anxious attachment in the etiology of severe music performance anxiety and a series of case studies that present the process of therapy for severely performance anxious musicians.
Background: Kenny has proposed that severe music performance anxiety that is unresponsive to usual treatments such as cognitive-behaviour therapy may be one manifestation of unresolved attachment ruptures in early life. Intensive Short-Term Dynamic Psychotherapy specifically targets early relationship trauma. Accordingly, a trial of Intensive Short-Term Dynamic Psychotherapy with severely anxious musicians was implemented to assess whether resolution of attachment ruptures resulted in clinically significant relief from music performance anxiety.
Volunteer musicians participating in a nationally funded study were screened for MPA severity. Those meeting the critical cut-off score on the Kenny Music Performance Anxiety Inventory were offered a trial of Intensive Short-Term Dynamic Psychotherapy. In this paper, we present the theoretical foundations and rationale for the treatment approach, followed by sections of a verbatim transcript and process analysis of the assessment phase of treatment that comprised a three-hour trial therapy session.
Case presentation: The ‘case’ was a professional orchestral musician (male, aged 55) who had suffered severe music performance anxiety over the course of his entire career, which spanned more than 30 years at the time he presented for treatment following his failure to secure a position at audition. The participant was able to access the pain, rage and grief associated with unresolved attachment ruptures with both parents that demonstrated the likely nexus between early attachment trauma and severe music performance anxiety.
Conclusions: Intensive Short-Term Dynamic Psychotherapy is a potentially cost-effective treatment for severe music performance anxiety. Further research using designs with higher levels of evidence are required before clinical recommendations can be made for the use of this therapy with this population.
Chronic nonmalignant pain affects millions worldwide and has been resistant to effective medical treatment. Current medical practice views chronic pain primarily as a structural disorder and is "blind" to the powerful role that the mind plays in the production and perpetuation of painful syndromes. This chapter posits the view that many individuals with chronic pain suffer from a psychophysiologic disorder (PPD) and that by not taking the mind into account when diagnosing and treating these disorders, the traditional medical approach to chronic pain is essentially "mindless." The first and most important step in an effective approach to psychophysiologic disorders is to become "mindful." A mindful approach understands the interaction between the mind and the body and makes correlations between stressful life events and the onset and/or exacerbation of symptoms of PPD. This chapter summarizes a comprehensive mind-body approach to chronic pain. Such a comprehensive treatment approach has been shown to be effective in preliminary data. There is now hope that a significant proportion of the symptoms of chronic pain and other psychophysiologic disorders can be alleviated.
Background
Intensive short-term dynamic psychotherapy (ISTDP), as developed by Habib Davanloo, is an intensive emotion-focused psychodynamic therapy with an explicit focus on handling resistance in treatment. A core assumption in ISTDP is that psychotherapeutic effects are dependent on in-session emotional processing in the form of an increase in complex transference feelings that occur when treatment resistance is challenged. Recent research indicates that an unlocking of the unconscious, a powerful emotional breakthrough achieved by a rise in complex transference feelings, can potentially enhance the effectiveness of ISTDP. While ISTDP has a growing evidence base, most of the research conducted has used small samples and has tested therapy delivered by expert therapists. The aims of this study were to evaluate the overall effectiveness of ISTDP when delivered in a tertiary psychotherapy service and to investigate whether unlocking the unconscious during therapy promotes enhanced treatment effectiveness.
Methods
A total of 412 patients were included in the analysis. The average length of treatment was 10.2 sessions (SD 13.3). Multilevel growth curve modeling was used to evaluate treatment effectiveness and the association between unlocking the unconscious and outcome. A number of control predictors including type of treatment resistance were selected and included in the analysis. Outcome was measured with the brief symptom inventory (BSI) and the inventory of interpersonal problems (IIP). Approximately half of the patients in the study were treated by therapists in training and the rest by more experienced therapists.
Results
Growth curve analyses using the full intention to treat sample revealed significant within-group effects of ISTDP on both the BSI and the IIP. Effect sizes were large (> 0.80). Unlocking the unconscious during therapy was associated with a significant improvement in treatment outcome. The relationship was further moderated by the type of treatment resistance.
Conclusion
This study adds to the empirical base of Davanloo’s ISTDP with confirmed treatment effectiveness in a large-scale patient sample when ISTDP was delivered by therapists with a wide range of experience. Furthermore, emotional mobilization in the form of unlocking the unconscious was confirmed as a process factor enhancing the effectiveness of ISTDP.
Psychodynamische Psychotherapie ist aus psychoanalytischer Sicht bei chronischen Schmerzen die Methode der Wahl, da dieses Therapiekonzept durch seine vielfältigen Anwendungsmöglichkeiten ein sehr breites therapeutisches Spektrum mit verschiedenen Anwendungen bietet. Wesentlich dabei ist die Konzentration des therapeutischen Prozesses durch eine Begrenzung der Behandlungsziele. Bei der Anwendung wird ein bewältigungsorientierter Zugang bei einem tatsächlich vorliegenden somatischen Befund, etwa bei einer Krebserkrankung, von einem kausal-lösungsorientierten Vorgehen bei einer überwiegend psychischen Verursachung unterschieden. Die Vorgehensweisen werden anhand klinischer Beispiele erläutert. Bei der Behandlung von Patienten mit chronischem Schmerz sind die subjektive (innere) Realität, also die Wahrnehmung der Beschwerden und die Bedeutungen, die der Kranke seinen Beschwerden zuschreibt, und objektive (äußere) Realität, also die ärztlichen Befunde vor dem Hintergrund aller medizinischen Maßnahmen, deutlich zu unterscheiden, sie klaffen oft weit auseinander.
Objective: This is a study to evaluate the personality types based on Myers-Briggs Type Indicator (MBTI) in patients with chronic vascular or tension-type headache. Methods: This was a cross-sectional study conducted on 210 patients with tension-type and vascular headache in the Mashhad city, northeast of Iran. Patients were selected through convenience nonprobability method from December 2010 to January 2012. They were asked to fill demographic questionnaire and MBTI. Data were analyzed with SPSS using Mann-Whitney U, Chi-square and Fisher exact test. Results: The mean age of participants was 33.7 ± 8.2. Patients with vascular headache were mostly female, had higher levels of education, experienced more attacks per month and had shorter duration of headache until seeking treatment compared to the patients with tension-type headache. There was a significant difference in the distribution of personality types and frequency of each personality dimension between two groups. Patients with vascular headaches were significantly more introverted, sensing, thinking and judgmental, as compared to extraversion, intuitional, feeling, and perceiving among the tension-type headaches. Conclusion: Since there was a significant difference in the personality type of the different headache patients, further neuropsychological studies may throw light on the etiology of these chronic headaches.
Headache, which affects a large part of the community and causes loss of workforce, is gaining importance in terms of
the burden which it brings on the society, by its function of restricting individuals social activities as well as increasing
the health expenditure likewise drug consumption. Migraine and tension headaches are primary headaches which any
organic causes can not be determined for them. For the treatment of headaches of this type besides the use of medicine,
exercises with bio-feedbacks and acupuncture; in recent years cognitive behavioral treatments (CBT) appears to be
effective. It’s shown that the negative mode of thinking on individuals which have recurrent headaches, stimulates the
headache, increase its severity and complicates the management of it. CBT provides for the person a self-help opportunity
even the therapy is terminated, besides behavioral methods such as relaxation exercises, by developing strategies of selfmonitoring,
education, abilities of pain management and coping with the maladaptive beliefs and houghts. The purpose
of this text is, providing information about the use of the cognitive behavioral therapies on primary headaches and basic
principles of treatment.
Headache is the most frequent pathology in neurology. Migraine is very frequent in the population and it is a disease of young people, with repercussion in their social life and in their job and with important expenses. In cluster headache the pain is very severe and disabling. The patients have difficulties in having a normal life and are often absent in their jobs – some of them even lose their employment – and very frequently use symptomatic and very expensive treatments. All of the above mentioned causes severe anxiety, mood disorders and disabilities to these patients.
CME Educational Objectives
1. Review the outcome evidence of prior meta-analytic reviews of intensive short-term dynamic psychotherapy (ISTDP).
2. Provide an additional meta-analysis of ISTDP for the treatment of personality and somatic disorders.
3. Suggest areas for future study in the use of psychodynamic psychotherapy for personality and somatic disorders.
The literature reviewing studies of psychodynamic psychotherapy clearly demonstrates evidence for the efficacy of both short-term and long-term models. 1–3 Meta-analytic reviews synthesizing effects across different psychodynamic psychotherapy formats have been conducted for common mental disorders, 1 depression, 4,5 depression in the setting of personality disorder, 6 personality disorders, 7 and somatic disorders. 8 Psychodynamic psychotherapy demonstrates superiority to control condition, 1,9 and no significant difference to other formal psychotherapies, including cognitive behavioral therapies. 4,5,7,9,10 Building upon a recently published systematic review and meta-analysis, 11 the aim of this article is to further examine the evidence for a contemporary psychodynamic psychotherapy treatment protocol, 12,13 intensive short-term dynamic psychotherapy (ISTDP), in the treatment of personality and somatic disorders.
FOREWORD
In this book Dianna Kenny sets out to discover what remains of Freud in contemporary psychoanalytic practice. To do this, she engages us in an intensive dialogue with four eminent practitioners. While no four people can be said to be representative of an entire community of practitioners they are each distinctive and different with respect to their theoretical framework and the cultural milieu within which they operate. After the interviews, she lets them loose on a therapy transcript, which acts as a kind of Rorschach inkblot onto which they project their fantasies about the patient and the therapist.
Before we meet the four clinicians, Professor Kenny sets the scene with an unusually lucid exposition of the core ideas of Freud and post-Freudian psychoanalysis. This is an heroic task to accomplish in two chapters but she achieves it with remarkable fluency. Inevitably some detail is missing but the core ideas are so clearly enunciated that these chapters alone will prove to be invaluable to any person seeking to navigate this complex and jargon-infested territory.
The four interviews that follow are themselves outstanding exemplars of psychoanalytic enquiry. I cannot put it more clearly than Robert Stolorow, who said at the end of the interview ‘Your questions were very thoughtful and incisive.’ It is clear that Professor Kenny had a plan that she brought to each interview. Her plan was informed by a close reading of the published work of each clinician and curiosity about how their ideas and approaches related to other strands of psychoanalytic thinking. However, she never allowed the plan to get in the way of the conversation and many of the questions were stimulated by the thoughts of the person she was interviewing. Indeed, there were times when the questions were as interesting and informative as the responses.
This is a scholarly work, with all the key ideas assiduously footnoted or referenced. The reader will have no difficulty further exploring any of the many thought- provoking fragments that the conversations weave together. However, it is much more than scholarly. There is an intimacy to the interviews, which enables each clinician to tell a very personal story. We are constantly reminded that an intellectual journey is shaped by life experience and not just by reading and ideas. For clinicians this is in part vicarious life experience through constant engagement with patients. However, through these interviews we also learn about formative personal life experiences such as the death of a spouse, working in an overburdened health system, or the search for a father.
When it comes to the transcripts, each of the therapists adopts the position of the ‘master clinician’ or therapy supervisor. Here we encounter something of the superego of each clinician. They are not always in agreement as to what the therapist might do better but they share what might best be described as a clear vision for how the work should proceed. Stolorow put it most graphically when he said in response to one of the therapist’s interventions, “The therapist is still pursuing a cognitive behavioural approach, which is not, at this point, helpful to the patient”. Each of the clinicians felt strongly about both therapist and patient and were emphatic in their advice-giving to the therapist which was motivated by an unwillingness to provide tacit endorsement of interventions that they considered less than ideal from their perspective.
However, after the thoughtful and sometimes humble communication in the four interviews, the assumption of the role of expert came as something of a shock. There is a lot we can learn about therapeutic technique from the responses to the transcript. It also reminds us how strongly identified clinicians are with the patient and how little patience they can have with therapists, who struggle with their patients down difficult byways.
A truly unique feature of this book is the textual and thematic analysis of the four interviews that aims to identify the similarities and “real” differences in the conceptualization of the key concepts in psychoanalytic process. This was enriched by the application of textual and conceptual analyses of the psychotherapists’ commentaries on the transcript of the analytic session, followed by the identification of commonalities in the overall case formulation. In these three processes, Professor Kenny demonstrated that underneath the somewhat unique vocabularies and concepts of these four branches of psychoanalytic practice were common core concepts that inform therapist behaviour in the session.
I hope you enjoy this book as much as I have. It did not set out to provide you with a complete or fully integrated picture of contemporary psychoanalytic thinking; it does, however, provide you with an excellent overview. Furthermore, it will give you more than a glimpse into the world of the practicing clinician. It may also help you understand something Allan Abbas did not when he said ‘I don’t know what might be happening in psychoanalytic treatments that take so long… I can’t see the added value --- the health dollar is so stretched.’ Psychoanalysis may not be the most cost effective treatment but the conversations with Spielman, Holmes and Stolorow do take us to where we might find some of the added value.
Robert King, PhD, FAPS
Professor and Coordinator of Clinical Psychology Training
School of Psychology and Counselling
Queensland University of Technology
A substantial literature on the "hypertensive personality" links essential hypertension (EH) with the suppression of negative emotions, implying that suppression may elevate blood pressure. Yet affective inhibition might also impair communication with health care providers and exacerbate EH by limiting therapeutic collaboration. We studied 542 patient-physician interviews from a national sample to see if patients with EH (n = 203) were less likely to exhibit negative emotions than normotensive patients (n = 339) as rated by their physicians and independent observers. EH patients did not differ from others on self-rated emotional or physical health. However, physicians were less accurate in characterizing the emotional states of EH patients than those of normotensive patients, and they rated EH patients as exhibiting fewer signs of distress during the visit. Independent observers also judged the EH patients as less distressed than normotensives, thereby validating the physicians' appraisals. Content analysis disclosed that physicians paid less attention to psychosocial concerns and concentrated on biomedical matters to a greater degree with hypertensive patients than with their normotensive patients. EH patients, particularly those experiencing emotional distress, appear to have patterns of self-presentation that could present an obstacle to effective communication with their physicians, and this difficulty may be amplified by physicians' disinclination to probe for emotional difficulty.
5 Emotion-linked disorders are common and costly, but diagnosable and treatable. These disorders can lead to excessive medical service use, poor outcomes and disability. When physicians have emotion-linked disorders, medical error can occur. With the advent of new diagnostic techniques and brief psychotherapies, medical educators are now able to teach residents how to better understand, diagnose and manage the emotional components of medical care.
Urethral syndrome (urinary symptoms and pain without organic lesions) is a frequent female pathology but its aetiology is obscure and its treatment undetermined. A number of studies have highlighted emotional disturbances in these patients. To assess the efficacy of psychotherapy in the treatment of this syndrome, the authors studied 36 patients diagnosed with urethral syndrome. Of these, 13 were randomly selected for short-term dynamic psychotherapy. The remaining 23 patients were treated with traditional urological therapies and used as the control group. After the medical diagnosis and during follow-up at 6 months and 4 years, one psychological questionnaire (SQ) was administered together with a specially prepared clinical questionnaire. The urinary symptomatology and pain disappeared completely in over 70 per cent of the patients who had completed the psychotherapy. For the remaining patients, at the termination of the treatment the symptomatology had improved to the point that it was no longer a problem. These results proved stable in time and were associated with a general improvement in psychic status, particularly for the depression, anxiety and hostility levels. In the controls, on the other hand, no significant improvement was noted in the parameters examined.
Objective.—The role of psychological factors related to headache has long been a focus of investigation. The aim of this study was to evaluate depression, automatic thoughts, alexithymia, and assertiveness in persons with tension-type headache and to compare the results with those from healthy controls.
Methods.—One hundred five subjects with tension-type headache (according to the criteria of the International Headache Society classification) and 70 controls were studied. The Beck Depression Inventory, Automatic Thoughts Scale, Toronto Alexithymia Scale, and Rathus Assertiveness Schedule were administered to both groups. Sociodemographic variables and headache features were evaluated via a semistructured scale.
Results.—Compared with healthy controls, the subjects with headache had significantly higher scores on measures of depression, automatic thoughts, and alexithymia and lower scores on assertiveness. Subjects with chronic tension-type headache had higher depression and automatic thoughts scores than those with episodic tension-type headache.
Conclusions.—These findings suggested that persons with tension-type headache have high depression scores and also may have difficulty with expression of their emotions. Headache frequency appears to influence the likelihood of coexisting depression.
Short-term dynamic psychotherapy is a group of well-researched brief treatments with over 50 published controlled trials testing its effectiveness against a range of treatment and nontreatment controls. Studied samples are often high users of medical services, hospital services, mental health services and disability insurance. If short-term dynamic psychotherapy is effective, it should translate into demonstrable reductions in medical and social system costs. This review examines whether or not short-term dynamic psychotherapy is a cost-effective treatment.
Insurance companies, legislators, and funding agencies have become increasingly concerned with efficacy and accountability in regard to psychotherapy, and psychodynamic therapy is a primary target of concern because it is widely practiced in outpatient settings. This paper is a meta-analytic review of recent well-controlled studies of the efficacy of brief dynamic therapy.
The meta-analysis included both published studies, located through an extensive computerized search of psychiatry and psychology journals, and studies reported at conferences. Eleven studies met the inclusion criteria: use of a specific form of short-term dynamic psychotherapy as represented in a treatment manual or manual-like guide; comparison of brief dynamic therapy and a waiting list control condition, nonpsychiatric treatment, alternative psychotherapy, pharmacotherapy, or other form of dynamic therapy; provision of the information necessary for calculation of effect sizes; at least 12 therapy sessions; and therapists who were trained and experienced in brief dynamic therapy. The outcome measures compared were target symptoms, psychiatric symptoms generally, and social functioning.
Brief dynamic therapy demonstrated large effects relative to waiting list conditions but only slight superiority to nonpsychiatric treatments. Its effects were about equal to those of other psychotherapies and medication.
These data confirm previous indications that various psychotherapies do not differ in effectiveness, although this finding should not be generalized to all patient populations, outcome measures, and treatment types. Also, the highly controlled conditions of these studies limit conclusions about actual practice. Future studies should address various treatment lengths, follow-up assessments, and specific treatments, patient groups, and outcome measures.
The efficacy of short-term psychotherapy has become an area of increasing interest. The primary objective of this study was to assess the results of two forms of short-term psychotherapy in patients with personality disorders.
Eighty-one patients with personality disorders were randomly assigned to brief adaptive psychotherapy, short-term dynamic psychotherapy, or a waiting list for therapy. Outcome at termination of therapy for the treatment groups and at the end of the waiting period for the waiting list group was evaluated by means of ratings of target complaints and scores on the SCL-90 and the Social Adjustment Scale. In addition, for 38 of the treated patients, target complaints were reevaluated an average of 1.5 years after treatment ended.
Patients in the two therapy conditions improved significantly on all measures in comparison with the patients on the waiting list. There was no significant difference between the results in the two therapy conditions. The waiting list period averaged approximately 15 weeks; treatment averaged 40 weeks. At follow-up, after an average of 1.5 years, target complaint ratings were not significantly different from those at the termination of therapy.
These data indicate that brief adaptive psychotherapy and short-term dynamic psychotherapy are effective for patients with certain types of personality disorder and that the two therapy approaches do not differ in overall outcome.
Primary chronic daily headache can be subdivided into transformed migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. We proposed and tested criteria in 150 consecutive outpatients with chronic daily headache. Based on preliminary analysis, we revised the criteria for transformed migraine. Using the International Headache Society criteria, 43% of the patients could not be classified; using our old criteria, 25% could not be classified; however, using our new criteria, we were able to classify 100%. Seventy-eight percent had transformed migraine, 15.3% had chronic tension-type headache, and 6.7% had other headache disorders.
The authors report preliminary results of Brief Supportive Psychotherapy (BSP) in the Beth Israel Brief Psychotherapy Program for a sample with primarily Cluster C Axis II disorders. This study compares 24 patients treated with BSP with 25 patients treated with Short-Term Dynamic Psychotherapy (STDP). STDP was chosen because its confrontational methods contrast dramatically to BSP, which emphasizes building self-esteem, reducing anxiety, and enhancing coping mechanisms. Videotaped therapies were based on manualized 40-session protocols. Similar degrees of improvement were seen in BSP and STDP at termination and at 6-month follow-up. A study of therapeutic alliance in BSP showed stable and high levels of alliance in good-outcome cases and more variability in poor-outcome cases. These preliminary findings are consistent with other studies and suggest supportive psychotherapy may be effective for many patients, leading to significant and lasting change.
To assess the cost and clinical effectiveness of psychiatrist-provided Intensive Short-term Dynamic Psychotherapy (ISTDP) of patients referred to a private office.
ISTDP was provided to 89 patients referred to a private psychiatric office in Vancouver, Canada. Pretherapy self-report scores, (BDI, BAI, BSI, IIP [see full names in text]) medication costs, disability costs and healthcare costs were compared with posttherapy values and normative values.
Patients' mean self-report scores went from the abnormal to normal range after an average of 14.9 hours of therapy. Returns to work, reduced healthcare utilization, and medication stopping accounted for a cost reduction of over Cdn$400,000 at one year after therapy.
ISTDP appears to be an effective and cost-effective form of intervention when provided by a psychiatrist in a private office. Randomized controlled studies are warranted to further examine the cost benefits and efficacy of ISTDP.
Community studies have shown that stressful life events, psychological distress, and depressive and anxiety disorders are associated with 1) a range of medical symptoms without identified pathology, 2) increased health care utilization, and 3) increased costs. In both primary care and medical specialty samples, patients who have syndromes with ill-defined pathologic mechanisms (such as the irritable bowel syndrome and fibromyalgia) have been shown to have significantly higher rates of anxiety and depressive disorders than do patients with comparable, well-defined medical diseases and similar symptoms. Other studies show that after adjustment for severity of medical illness, patients with depression or anxiety and comorbid medical disease have significantly more medical symptoms without identified pathology than do patients with a similar medical disease alone. Both childhood maltreatment and psychological trauma in adulthood have been associated with increased vulnerability to psychiatric illness and more medical symptoms. The substantial functional impairment, distress, and costs associated with medical symptoms without identified pathology suggest that research studies promoting a better understanding of the biopsychosocial cause of these symptoms may yield pragmatic, cost-effective approaches to treatment in medical settings.
The objective is to study the effectiveness of Intensive Short-Term Dynamic Psychotherapy (ISTDP) trial therapies. In a tertiary psychotherapy service, Brief Symptom Inventory (BSI), Inventory of Interpersonal Problems (IIP) medication use, and need for further treatment were evaluated before versus 1-month post trial therapy in a sequential series of 30 clients. Trial therapies were interviews with active focus on emotions and how they are experienced. The interviews resulted in statistically significant improvements on all BSI subscales and one of the IIP subscales. One-third of clients required no further treatment, seven stopped medications, and two returned to work following trial therapy. The ISTDP trial therapy appeared tobe clinicallyeffectiveandcosteffective. Future researchdirections arediscussed. (Brief Treatment and Crisis Intervention 8:164-170 (2008))
This is the second part of a two-part article, the first part of which appears in this issue of the journal. The article considers the basic problems of Short-term Dynamic Psychotherapy, namely (1) how to develop techniques that maximize success, and (2) how to recognize suitable patients. In addition, there is a deep theoretical problem: why is it that purely interpretative therapy, even when intense dynamic interaction occurs, only a relatively small proportion of patients experience resolution of their neurosis? Davanloo has developed a technique which leads to solutions to all these problems. The technique is illustrated by an initial evaluation, begun in Part I and completed in the present Part. The article ends with a discussion of the practical and theoretical consequences of this work. Copyright © 1986 John Wiley & Sons, Ltd.
In this article, the author has examined the relationships between the “central dynamic sequence” discovered by Davanloo and the activation of specific neuronal systems in the brain. The participation of defined brain areas is postulated in the clinical expression of “superego pathology”. A hypothesis regarding the involvement of subcortical structures in the central neurotic mechanism is proposed. According to this view, human neurosis results from a functional disorder of the brain which can be corrected by the specific interventions of the “system for short-term dynamic psychotherapy” discovered by Davanloo. Copyright © 1992 John Wiley & Sons, Ltd.
SYNOPSIS
Research regarding psychological factors in head pain have generally focused upon personality traits and psychopathology. The role of illness beliefs offers another method of elucidating perceptions, attitudes and convictions towards a somatic complaint. One hundred patients, evaluated for head pain at a neurology clinic, were administered the Illness Behavior Questionnaire (IBQ) to delineate illness beliefs; the Illness Effects Questionnaire (IEQ) to quantify the disruptive aspects of head pain; and the Toronto Alexithymia Scale (TAS) to assess the subjects propensity to somatize as well as the ability to identify and report emotions. The data found no difference between subjects diagnosed with migraine syndrome and those with tension head pain in the IBQ dimensions, the TAS or in reported levels of anxiety or depression. However, chronicity of symptoms was associated with increased irritability. The clinical implications of the findings suggest that patients with head pain are psychologically distressed but often possess alexithymic characteristics that make insightful associations difficult.
The present article begins by describing the two basic questions in Short-Term Dynamic Psychotherpy, namely what are the techniques that maximize success, and how may suitable patients be recognized? A consideration of work at the Tavistock Clinic leads to the conclusion that purely interpretative techniques, whether of short- or long-term therapy, are inadequate. In the author's view, Davanloo has developed a technique that largely overcomes these limitations. This is illustrated by an initial interview of great length and complexity, which therefore needs to be divided into two parts. The second part follows. At the end of the second part the practical and theoretical consequences of Davanloo's work will be considered.
SYNOPSIS
A battery of standardized psychometric tests was administered to a group of 47 episodic tension-type headache sufferers and 47 headache-free controls. Compared to controls, headache subjects showed higher levels of anxiety, depression, and anger/hostility. The groups did not differ significantly on a measure of anger expressed toward persons or objects, but headache subjects showed significantly greater levels of suppressed anger. The results provide objective data that are in general agreement with predictions derived from psychosomatic theories about the interrelationships among anxiety, depression, and anger/hostility.
Individuals with tension-type headache report significant anger, depression, anxiety, and stressors. However, it is not clear to what extent these variables are interrelated. The objective of the present study was to explore the role of anger in headaches, and to examine its relationship to anxiety, depression, and daily life stressors. Participants were 65 young adult women who suffered from recurrent headaches. The sample was obtained in a large-scale screening of young adult women using the Headache Symptoms List to identify those with recurrent headache. Those individuals reporting headaches completed a battery of assessment measures that included the State-Trait Anger Expression Inventory, the Mood and Anxiety Symptoms Questionnaire, and the Hassles Scale. Results revealed a significant relationship between anger suppression and depression (r = 0.40, P<.01), as well as anger expression and anxiety (r = 0.41, P<.01) for those with headache. The use of the Mood and Anxiety Symptoms Questionnaire allowed for the separate analysis of general distress symptoms and symptoms more specific to anxiety and depression. Results indicated that those with headache experience more general, nonspecific distress rather than symptoms indicative of anxiety and depression (P<.01). In addition, the mixed headache group scored high on both general (mean, 28.96) and specific measures of depression (mean, 65.76) and on anger suppression (mean, 20.12), suggesting that they might experience more psychological distress than those with tension-type headache. The present results indicate the need to distinguish the unique dimensions of anxiety and depression that should be assessed in the population with recurrent headache.
Twenty-six studies of the effectiveness of short-term dynamic therapy (STDT) were subjected to two meta-analyses. Effect sizes (ES) obtained by each method were similar. STDT attained average ESs of 71 and 34, relative to waitlist and minimal treatment groups, respectively. When studies using psychosomatic patients were excluded, STDT achieved an ES of 85, relative to waitlist groups. We found no evidence that STDT is superior or inferior to other forms of psychotherapy at posttreatment, although it evidenced a slight superiority at long-term followup assessment. There was, in addition, evidence that studies employing manuals or therapists trained in STDT produced larger ESs than those that did not.
Typescript. Thesis (Ph. D.)--New York University, School of Education, 2003. Includes bibliographical references (leaves 152-172).
Assessment of the physiological effects of physical and emotional stress has been hampered by a lack of suitable laboratory techniques. Since hypnosis can be used safely to induce specific emotional states of considerable intensity, we studied the effect on distal colonic motility of three hypnotically induced emotions (excitement, anger, and happiness) in 18 patients aged 20-48 years with irritable bowel syndrome. Colonic motility index was reduced by hypnosis on its own (mean change 19.1; 95% CI 0.8, 37.3; p less than 0.05) and this change was accompanied by decreases in both pulse (12; 8, 15) and respiration (6; 4, 8) rates (p less than 0.001 for both). Anger and excitement increased the colonic motility index (50.8; 29.4, 72.2; and 30.4; 8.9, 51.9, respectively; p less than 0.01 for both), pulse rate (26; 22, 30; and 28; 24, 32; p less than 0.001 for both), and respiration rate (14; 12, 16; and 12; 10, 14; p less than 0.001 for both). Happiness further reduced colonic motility although not significantly from that observed during hypnosis alone. Changes in motility were mainly due to alterations in rate than in amplitude of contractions. Our results indicate that hypnosis may help in the investigation of the effects of emotion on physiological functions; this approach could be useful outside the gastrointestinal system. Our observation that hypnosis strikingly reduces fasting colonic motility may partly explain the beneficial effects of this form of therapy in functional bowel disorders.
A substantial literature on the "hypertensive personality" links essential hypertension (EH) with the suppression of negative emotions, implying that suppression may elevate blood pressure. Yet affective inhibition might also impair communication with health care providers and exacerbate EH by limiting therapeutic collaboration. We studied 542 patient-physician interviews from a national sample to see if patients with EH (n = 203) were less likely to exhibit negative emotions than normotensive patients (n = 339) as rated by their physicians and independent observers. EH patients did not differ from others on self-rated emotional or physical health. However, physicians were less accurate in characterizing the emotional states of EH patients than those of normotensive patients, and they rated EH patients as exhibiting fewer signs of distress during the visit. Independent observers also judged the EH patients as less distressed than normotensives, thereby validating the physicians' appraisals. Content analysis disclosed that physicians paid less attention to psychosocial concerns and concentrated on biomedical matters to a greater degree with hypertensive patients than with their normotensive patients. EH patients, particularly those experiencing emotional distress, appear to have patterns of self-presentation that could present an obstacle to effective communication with their physicians, and this difficulty may be amplified by physicians' disinclination to probe for emotional difficulty.
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 ($7,778) and back pain ($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.
The present investigation was designed to study the effect of anger on colon motor and myoelectric activity in irritable bowel syndrome. Patients with irritable bowel syndrome were compared with normal controls during resting and two anger stressors: criticism of performance on an intelligence test and during a delay of assistance for a diagnostic procedure. At rest patients with irritable bowel syndrome had higher motor and spike potential activity than normal subjects; however, the difference was only significant for spike activity. Anger significantly increased colon motor and spike potential activity in the groups compared with the resting state. Patients with irritable bowel syndrome produced significantly higher motor and spike potential activity when angered. They also reported themselves to be more hostile and appeared angrier than normal controls after the study. However, they did not report themselves to be more anxious or depressed, suggesting that the observed changes in colonic function of both groups were due to anger. Patients with irritable bowel syndrome scored significantly higher than controls on the Minnesota Multiphasic Personality Inventory scales of hypochondriasis, hysteria, and depression, but these personality factors did not significantly influence their anger level before the study. The results are discussed in terms of the role of learning in the colon and the abnormal reinforcement of bowel behavior in patients with irritable bowel syndrome.
SYNOPSIS
The purpose of this controlled study was to compare anger experience, anger-relevant psychophysiological parameters, and expressive anger behavior of migraine patients, with those of pain patients and of healthy controls. Based on the probability of solving anagram tasks, we defined an anger-provoking condition and a control condition. Data from 72 female subjects were used for analysis. Migraine patients showed a deficit in open anger behavior; their diastolic blood pressure decreased and their pulse pressure (SBP-DBP) was higher compared to the two control groups. They did not differ with respect to their self-reported anger experience.
We studied the effect of individual short-term psychotherapy in combination with medical treatment compared with medical treatment only in 103 outpatients with chronic peptic ulcer disease, randomly allocated to two treatment groups. Psychotherapy was given in ten hour-long sessions over three months. According to self-rating and evaluation by independent raters, the patients in both groups had improved to a similar degree after the first three months. At 15 months’ follow-up there were significant differences in favor of the psychotherapy group, which maintained the improvement while the control group deteriorated.
Synopsis
This is an introductory report for the Brief Symptom Inventory (BSI), a brief psychological self-report symptom scale. The BSI was developed from its longer parent instrument, the SCL-90-R, and psychometric evaluation reveals it to be an acceptable short alternative to the complete scale. Both test-retest and internal consistency reliabilities are shown to be very good for the primary symptom dimensions of the BSI, and its correlations with the comparable dimensions of the SCL-90-R are quite high. In terms of validation, high convergence between BSI scales and like dimensions of the MMPI provide good evidence of convergent validity, and factor analytic studies of the internal structure of the scale contribute evidence of construct validity. Several criterion-oriented validity studies have also been completed with this instrument
SYNOPSIS
As seemed necessary, short-term exploratory psycho-therapy was offered to patients seeking treatment for refractory headache. The reasons for their psycho-therapeutic referral included patient request, refractoriness to all medication, emotional traumatization at the time they were seen, or suspected family or marital triggers for headache. An attempt was made to sample the responses of these patients. Patients were asked via a specially devised form to state why they thought they were referred for psychotherapy, what they perceived they derived from the process and how they perceived it from a cost-benefit standpoint. Preliminary findings suggest that patients do see a general rationale to referrals and rate the effort more positively than negatively in cost-benefit terms. Their written interpretation however does not reflect some of the subtle and specific effects of psychotherapeutic intervention.
Research regarding psychological factors in head pain have generally focused upon personality traits and psychopathology. The role of illness beliefs offers another method of elucidating perceptions, attitudes and convictions towards a somatic complaint. One hundred patients, evaluated for head pain at a neurology clinic, were administered the illness Behavior Questionnaire (IBQ) to delineate illness beliefs; the illness Effects Questionnaire (IEQ) to quantify the disruptive aspects of head pain; and the Toronto Alexithymia Scale (TAS) to assess the subjects propensity to somatize as well as the ability to identify and report emotions. The data found no difference between subjects diagnosed with migraine syndrome and those with tension head pain in the IBQ dimensions, the TAS or in reported levels of anxiety or depression. However, chronicity of symptoms was associated with increased irritability. The clinical implications of the findings suggest that patients with head pain are psychologically distressed but often possess alexithymic characteristics that make insightful associations difficult.
Although panic disorder can be effectively alleviated by drug treatment, the relapse rate is high. By adding brief dynamic psychotherapy focused on the psychosocial vulnerability of patients with panic disorder to an established drug treatment regimen, we hypothesized that this would result in a lower relapse rate after pharmacotherapy.
Patients with panic disorder (defined by DSM-III-R) were randomized to treatment with either clomipramine for 9 months (n = 20), or clomipramine for 9 months combined with 15 weekly sessions of brief dynamic psychotherapy (n = 20). Measures of anxiety and depression were collected at intake and at regular intervals. The patients had blind follow-up interviews at 6, 12, and 18 months after beginning treatment.
All patients in both groups became free of panic attacks within 26 weeks of the start of treatment. On termination of pharmacotherapy, the relapse rate was significantly higher in the clomipramine-only group during the follow-up period. There were significantly lower scores for most anxiety measures in the clomipramine plus psychotherapy group at the 9-month follow-up.
The addition of brief dynamic psychotherapy to treatment with clomipramine significantly reduces the relapse rate of panic disorder compared with clomipramine treatment alone.
The impact of static muscle tension on total respiratory resistance (TRR) was examined. Participants (24 healthy, 24 asthmatic) performed biofeedback-assisted sequences of tensing (15 s) and relaxing (20 s) forehead and forearm muscles. Muscle tension levels were 40% or 80% of the maximum individual force. Oscillatory TRR, electromyograms, ventilation, heart period, and respiratory sinus arrhythmia were recorded. Baseline TRR did not change over the session as a whole. Decreases in TRR during forehead tension in both groups were accompanied by increases in end-expiratory volume, which could have mediated TRR changes. During forearm tension, decreases in TRR with minimal ventilation changes were only observed in healthy participants, whereas asthmatic patients revealed marked increases in respiratory volume and flow. These results indicate that static muscle activity and TRR are negatively related. Ventilatory changes can exaggerate or diminish evidence for this relationship.
To study the prevalence of somatoform disorders (SDs) in primary care, a questionnaire including the modified 25-item version of the Symptom Checklist-90 was administered to 191 patients consecutively consulting their family physician. A stratified sample of the patients was interviewed with the Schedules for Clinical Assessment in Neuropsychiatry. The study showed that 22.3% (confidence interval [CI]: 95%: 16.4-28.1) of the patients fulfilled the diagnostic criteria for an International Classification of Diseases--10th Revision (ICD-10) SD, excluding SD, unspecified, and 57.5% (CI: 95%: 50.5-64.5) for DSM-IV SD. But 30.3% met the criteria (CI: 95%: 23.8-36.9) when the DSM-IV Not Otherwise Specified (NOS) diagnostic group is excluded. The most frequent ICD-10 diagnosis was autonomous dysfunction, for which 14.1% of the patients fulfilled the criteria, whereas the prevalence of the other somatoform diagnosis was between 3.0% and 8.1%. The most frequent DSM-IV diagnoses were SD NOS and undifferentiated SD, which 29.93% and 27.3% of the interviewed patients, respectively, received, whereas the prevalence of the other diagnoses was between 1.0% and 8.1%. A high comorbidity between SDs and other mental disorders was found. The general practitioners identified between 50% and 71% of the patients with an ICD-10 SD and between 36% and 48%, according to DSM-IV criteria. Patients with SDs used more nonpsychiatric health care facilities than other patients (P = 0.01).
The phenomenon of somatization, which results in unexplained physical complaints, is ubiquitous in primary care settings although it often goes unrecognized. Medical training emphasizes the identification and treatment of organic problems and may leave physicians unprepared to recognize and address somatoform complaints. As a process, somatization ranges from mild stress-related symptoms to severe debilitation. Patients at the low end of the spectrum often respond to simple reassurance, but patients who are more impaired require interventions specifically designed to avoid unnecessary exposure to dangerous, costly and frustrating diagnostic procedures and treatments.
This study aimed to determine whether brief psychodynamic-interpersonal (PI) psychotherapy is more efficacious than a psychological control for patients with chronic, intractable functional dyspepsia (FD), and whether patients with abnormal gastric function respond differently than those with normal gastric function.
Ninety-five consecutive patients with chronic symptoms of FD who had failed to respond to conventional pharmacologic treatments were approached. Thirty-seven received PI psychotherapy, and 36 the control condition (supportive therapy). Patients completed self-report questionnaires before and after treatment and 12 months later. The patients' gastroenterologists, who were blind to the study groups, conducted independent ratings before and after treatment. Forty-nine patients also underwent a radioisotope gastric emptying study. An intention-to-treat analysis was used with baseline scores as covariates.
At the end of treatment, there were significant advantages for PI psychotherapy compared with controls for the gastroenterologists' (P = 0.002) and patients' total symptom score (P = 0.015). One year after treatment, the symptomatic scores were similar. However, a subanalysis showed that PI therapy was superior to the control condition at 1 year, when patients with severe heartburn were excluded. There was no difference in outcome between patients with normal and abnormal gastric emptying.
PI therapy may have both short- and long-term effects in patients with dyspepsia, but further evaluation is required. Its cost-effectiveness needs to be determined.
To determine if individuals in the general community with chronic headache or migraine differ in terms of anger, depression, and coping strategies and from headache-free individuals in terms of anger and depression.
A community sample comprising 16 chronic tension-type headache (CTH), 28 migraine headache (MH), and 38 headache-free control subjects (CNT) were compared on measures of anger, depression, and use of various coping strategies. Affective and coping measures, recorded during a headache-free period, were regressed on headache activity measured in a daily diary over the following 2 weeks. Relationships between anger, depression, and coping were also examined in each of the headache groups.
The MH subjects were found to use less effective coping strategies than controls and CTH, while the CTH group had higher levels on depression and various anger scales compared to controls and MH. Direct positive relationships were observed between suppressed anger and depression in the MH group, and between trait anger and depression in the CTH group. Anger and coping were predictive of headache activity in the following 2 weeks for both MH and CTH groups, while depression and coping, compared to coping only, were predictive of lifestyle interference from head pain in MH and CTH, respectively.
The results support a relationship between affective and coping factors in headache activity and adjustment.
Community studies have shown that stressful life events, psychological distress, and depressive and anxiety disorders are associated with 1) a range of medical symptoms without identified pathology, 2) increased health care utilization, and 3) increased costs. In both primary care and medical specialty samples, patients who have syndromes with ill-defined pathologic mechanisms (such as the irritable bowel syndrome and fibromyalgia) have been shown to have significantly higher rates of anxiety and depressive disorders than do patients with comparable, well-defined medical diseases and similar symptoms. Other studies show that after adjustment for severity of medical illness, patients with depression or anxiety and comorbid medical disease have significantly more medical symptoms without identified pathology than do patients with a similar medical disease alone. Both childhood maltreatment and psychological trauma in adulthood have been associated with increased vulnerability to psychiatric illness and more medical symptoms. The substantial functional impairment, distress, and costs associated with medical symptoms without identified pathology suggest that research studies promoting a better understanding of the biopsychosocial cause of these symptoms may yield pragmatic, cost-effective approaches to treatment in medical settings.
To examine the resource utilization of patients with high levels of somatization and health-related anxiety.
Consecutive patients on randomly chosen days completed a self-report questionnaire assessing somatization and health-related, hypochondriacal anxiety. Their medical care utilization in the year preceding and following completion of the questionnaire was obtained from an automated patient record. The utilization of patients above and below a predetermined threshold on the questionnaire was then compared.
Eight hundred seventy-six patients attending a primary care clinic in a large, urban, teaching hospital.
Number of ambulatory physician visits (primary care and specialist), outpatient costs (total, physician services, and laboratory procedures), proportion of patients hospitalized, and proportion of patients receiving emergency care.
Patients in the uppermost 14% of the clinic population on somatization and hypochondriacal health anxiety had appreciably and significantly higher utilization in the year preceding and the year following completion of the somatization questionnaire than did the rest of the patients in the clinic. After adjusting for group differences in sociodemographic characteristics and medical comorbidity, significant differences in utilization remained. In the year preceding the assessment of somatization, their adjusted total outpatient costs were $1,312 (95% CI $1154, $1481) versus $954 (95% CI $868, $1057) for the remainder of the patients and the total number of physician visits was 9.21 (95% CI 7.94, 10.40) versus 6.33 (95% CI 5.87, 6.90). In the year following the assessment of somatization, those above the threshold had adjusted total outpatient costs of $1,395 (95% CI $1243, $1586) versus $1,145 (95% CI $1038, $1282), 9.8 total physician visits (95% CI 8.66, 11.07) versus 7.2 (95% CI 6.62, 7.77), and had a 24% (95% CI 19%, 30%) versus 17% (95% CI 14%, 20%) chance of being hospitalized.
Primary care patients who somatize and have high levels of health-related anxiety have considerably higher medical care utilization than nonsomatizers in the year before and after being assessed. This differential persists after adjusting for differences in sociodemographic characteristics and medical morbidity.
The principal goal of this study is to examine the base rates of somatoform symptoms and of hypochondriacal features in the general population.
A representative sample of 2050 persons in Germany was examined by use of screening for somatoform symptoms and the Whiteley Index.
The most frequent somatoform symptoms were back pain, joint pain, pain in extremities, and headache, as well as abdominal symptoms (bloating or intolerance of several foods) and cardiovascular symptoms (palpitation). People reported a mean of two somatization symptoms of DSM-IV somatization disorder (SD) during the prior 2 years. Strong age and medium gender effects were found for most somatoform symptoms, as well as for composite indices. However, the sex ratio suggested in DSM-IV for SD seems to be an overestimation. Hypochondriacal features showed only small sex differences but, again, pronounced age effects. In contrast to low rates for SD, the base rates for somatization and hypochondriacal features were high and represented the health care relevance of subthreshold syndromes.
We present base rates of hypochondriacal and somatization features that may be important facets in the development of classification criteria and in the interpretation of health care expenditure.