CBT Shows Effectiveness in Treating Somatization Disorder

Not long ago, New Jersey psychology researchers designed a cognitive-behavioral therapy (CBT) course to help primary care patients who have many unexplained physical symptoms and fit criteria for somatization disorder.

Along with Javier Escobar, M.D., chair of the Department of Psychiatry at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, the researchers then tested the course in a controlled study of 84 subjects diagnosed with somatization disorder. As they reported in the July 24, 2006, Archives of Internal Medicine, they obtained encouraging results. Fifteen months after the start of the study, medically unexplained physical symptoms were significantly less severe in those treated with CBT.

After that, the researchers and Escobar tested the effectiveness of the course in a larger, more ethnically diverse population. Once again, they obtained encouraging results, which they reported in the July/August Annals of Family Medicine.

The most recent study included 172 patients attending two university-affiliated primary care clinics in New Brunswick, N.J. Each patient had repeatedly sought care for at least four medically unexplained symptoms, which physicians or nurses at the clinics thought were a source of distress or which they suspected of having a psychiatric origin—notably headache, back pain, abdominal pain, chest pain, joint pain, feeling faint, excessive flatulence, and a lump in the throat. About two-thirds of the patients were Hispanic, about one-fifth were Caucasian, and the rest were African American, Asian, or of other racial or ethnic backgrounds.

Half the subjects received CBT, and half received usual clinical care from their primary care physician. The CBT consisted of 10 standardized sessions expressly designed for patients with somatization problems. It used relaxation techniques, activity regulation, facilitation of emotional awareness, cognitive restructuring, and interpersonal communication to reduce subjects' physical distress and preoccupation with their symptoms.

From the start of the study until six months later, the researchers used various yardsticks to evaluate each of the subjects for psychiatric and physical symptoms. They then compared the outcomes for the CBT and control groups at the end of treatment (around three months) and then again at six months.

A significantly greater number of CBT subjects than control subjects experienced a decrease in their physical symptoms by the end of treatment. In fact, CBT led to substantial symptom relief in 60 percent of subjects who completed treatment. Also, the symptom relief continued during the subsequent three-month follow-up period, although it gradually diminished.

“I do not think any single component [of the CBT program was] more helpful than any other,” Escobar said in an interview with Psychiatric News. “In fact, in our experience, the full package works better than isolated relaxation, cognitive restructuring, or psychoeducation pieces.”

Exactly how the CBT course countered physical symptoms in these subjects is not clear. However, it did not seem to be by reducing subjects' depression, because when the researchers assessed changes in subjects' depression scores from the start of treatment to the end of treatment, the CBT group still had a significant lessening of physical symptoms compared with the control group.

If primary care physicians were willing to train clinicians to deliver the CBT course, it could be implemented in many primary care settings, the researchers believe. “We have a collaboration with the Miguel Servet Hospital and University of Zaragoza in Spain, where the intervention is being implemented in primary care,” Escobar said. “We are hoping that other sites in the United States and other countries will also join in.”

“Effectiveness of a Time-Limited Cognitive Behavior Therapy–Type Intervention Among Primary Care Patients With Medical Unexplained Symptoms” is posted at<www.annfammed.org/cgi/reprint/5/4/328>. The CBT course that the researchers designed is described in detail in the book, Treating Somatization: A Cognitive Behavioral Approach, by Robert Woolfolk, Ph.D., and Lesley Allen, Ph.D., who helped design the course; it is published by Guilford Press. ▪