Stress Illness and CBT

Stress Illness (also known as Psychophysiologic Disorder or PPD) is one of the most common causes of Medically Unexplained Symptoms (MUS).  These are symptoms for which no link to a diseased organ or structure can be found after diagnostic testing.  Javier Escobar, MD and colleagues (1) at the Robert Wood Johnson medical school in New Jersey, USA, decided to try a treatment called Cognitive Behavioral Therapy for these patients.

Patients were referred from two urban clinics, one serving primarily a white, middle-class population and the other underserved, ethnically diverse, low-income patients.  To qualify, men had to have at least four unexplained symptoms and women needed at least six.  172 patients were randomly divided into two groups.  The control group received a mental health consultation with a letter sent to their primary physician.  It is known that this is better for symptom relief than usual care.  The second group received the same care as the control group plus ten sessions of 50 minutes of cognitive behavioral therapy (CBT).  This included “relaxation techniques, activity regulation, facilitation of emotional awareness, cognitive restructuring and interpersonal communication.” (2)  The authors do not mention specifically if a history of childhood stress was investigated or how much attention was paid to this critical issue in therapy.

At the conclusion of the CBT, all patients were evaluated for symptom relief by clinicians who did not know which treatment the patient received.  In the CBT group, 60% reported they were “much” or “very much” improved, compared to 25% in the consult/letter-only group.  This benefit faded a bit six months after the CBT with the proportions being 50% vs 31%.  This is an excellent outcome for patients with few good options in the current health care system.

A significant limitation to interpreting the results is that the patients in the CBT group had many more visits with a health care professional than the consult/letter-only group.  The extra contact can be quite helpful for stress-related illness.  Nevertheless, this research supports further effort to develop collaboration between medical and mental health professionals in the care of patients with MUS.

1. Escobar JI et al.  Effectiveness of a time-limited cognitive behavior therapy-type intervention among primary care patients with medically unexplained symptoms.  Ann Fam Med 5: 328-335. Jul/Aug 2007.

2. Wolfolk R, Allen L.  Treating Somatization: A Cognitive-Behavioral Approach.  New York, NY: Guilford Press; 2007.

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