University Medical Center Hamburg-Eppendorf Department of Psychosomatic Medicine and Psychotherapy Psychotherapy of somatoform disorders

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1 University Medical Center Hamburg-Eppendorf Department of Psychosomatic Medicine and Psychotherapy Psychotherapy of somatoform disorders Dr. Meike Shedden Mora Fagseminar Somatoforme Lidelser, Oslo, October 9th 2017

2 University Medical Center Hamburg-Eppendorf Department of Psychosomatic Medicine and Psychotherapy Schön Clinic Hamburg Eilbek 2

3 Starting point Somatoform disorders are prevalent 12-month prevalence approx. 3.5% in general population, approx. 20% in primary care are disabling and distressing for the patients Loss of function High health care use, high costs are under-recognized and under-diagnosed How can somatoform disorders be effectively managed and treated? 3

4 Case study: Ms. Leonard, age 49 Current symptomatology: For about 12 months she has been suffering from a variety of symptoms, predominantly palpitations, chest pain, and low back pain. Diagnostic testing (cardiology, orthopedics, neurology) no pathological abnormalities She feels sick and has a lack of energy. She reports sleeping problems, depressed mood and feeling less confident about herself. She worries a lot about her symptoms and fears it could be something serious. She consults doctors about 2-3 times per month. She finds it hard to concentrate on her daily duties. Psychosocial background: Married, one daughter (8 years old) Husband has had depressions, many conflicts about education of daughter and daily hassles Profession: master degree in social pedagogy, currently working in a residential building cooperative, where she was forced to change her department and replaced by a younger colleague. She feels little support. Since 4 weeks she has been on sick leave. Tentative diagnosis: Undifferentiated somatization disorder (ICD-10 F45.1) Mild depressive episode (ICD-10 F32.0) 4

5 Agenda Psychotherapy of somatoform disorders Status quo health care Clinical guidelines and treatment approaches Psychotherapy Innovations and perspectives 5

6 Status quo health care Sectorized treatment High utilization and costs of somatic health care 1 Few referrals to mental health care (aprox. 27% within 12 months) 2 1 Grupp et al., J Psychosom Res 2017; 2 Mack et al., Int J Meth Psych Res

7 Status quo health care Duration of untreated illness (DUI) Interval between the first onset of the somatoform disorder and the first psychotherapeutic or psychiatric treatment Analysis of 139 patients with somatoform disorder Mean DUI: 25,2 years Depends on education: 10 years (n=88): 29,3 years >10 years (n=47): 15,5 years After 10 years: approx. 70% of the patients untreated! Herzog, Shedden-Mora, Jordan & Löwe, in revision 7

8 Status quo health care Challenges in managing patients with somatoform disorders 9

9 Status quo health care Challenges in managing patients with somatoform disorders Patient Hope to find the cause for symptoms frustration Normal test results do not reassure Doctor shopping Both Doctor Feelings of frustration and helplessness Patient: demanding, Doctor: useless Excessive diagnostic testing Only communicating negative findings ( It s not cancer ) Not considering psychosocial factors Risk of iatrogenic harm 10

10 Interim conclusion Status quo health care Long duration of untreated illness (up to 25 years!) Managing patients with somatoform disorders can be challenging for both doctor and patient 11

11 Agenda Psychotherapy of somatoform disorders Status quo health care Clinical guidelines and treatment approaches Psychotherapy Innovations and perspectives 12

12 Clinical guidelines Haussteiner-Wiehle et al., 2013 Martin et al Danish College of General Practitioners, 2013 Olde Hartmann et al., 2013 Trimbos Instituut 2010 Chitnis et al.,

13 Clinical guidelines Guideline recommendation: Stepped, collaborative, coordinated care Stepped care: According to severity and chronicity Collaborative: PCPs, somatic specialists, mental health specialists Coordinated: Coordinated by primary care physician (PCP) PCP as gatekeeper Haussteiner-Wiehle et al., 2013; Martin et al. 2013; Danish College of General Practitioners, 2013; Olde Hartmann et al.,

14 Clinical guidelines Stepped care approach Severe Specialist clinic Multidisciplinary treatment Moderate Coordination by primary care Additional psychotherapy Consider pharmacological treatment Ms. Leonard Mild Management in primary care, Follow-up Psycho-education, biopsychosocial approach Self-management, supportive treatment 16

15 Green, yellow and red flags - examples Characteristics of mild course (protective factors) Active coping (e.g., physical exercise, positive attitude, motivation for psychotherapy), healthy lifestyle Social support Good working conditions Characteristics of severe course (risk factors) Several persistent complaints, from several organ systems High disability in daily life, low psychosocial functioning Work incapacity > 4 weeks Doctor-patient-relationship perceived as difficult Mental comorbidity, e.g., depressive symptoms, anxiety Alarm signals for very severe courses Suicidal ideation Severe mental comorbidity Haussteiner-Wiehle

16 Green, yellow and red flags - examples Characteristics of mild course (protective factors) Active coping (e.g., physical exercise, positive attitude, motivation for psychotherapy), healthy lifestyle Social support Good working conditions Characteristics of severe course (risk factors) Several persistant complaints, from several organ systems High disability in daily life, low psychosocial functioning Work incapacity > 4 weeks Doctor-patient-relationship perceived as difficult Mental comorbidity, e.g., depressive symptoms, anxiety Ms. Leonard Alarm signals for very severe courses Suicidal ideation Severe mental comorbidity Haussteiner-Wiehle

17 Clinical guidelines Guideline recommendations for primary care The doctor-patient relationship and communication is highly important Take the symptoms seriously Validate the patient s distress Try to understand the patient s biopsychosocial background Be transparent about the expected (normal) results of a diagnostic test Avoid unnecessary diagnostic testing Explaining the symptoms is crucial Develop a targeted and tangible biopsychosocial explanation that makes sense to the patient Establish a stepped, collaborative, coordinated care approach Develop realistic and achievable treatment goals Be the gatekeeper Haussteiner-Wiehle 2013; Olde Hartmann et al., BGGP

18 Interim conclusion Clinical guidelines and treatment approaches Guidelines recommend a stepped, collaborative, coordinated care approach The PCP plays a central role 20

19 Agenda Psychotherapy of somatoform disorders Status quo health care Clinical guidelines and treatment approaches Psychotherapy Innovations and perspectives 21

20 PSYCHOTHERAPY FOR SOMATOFORM DISORDERS 22

21 Treatment goals Goals of treatment for somatoform disorders Status quo Aim Leisure time Friends Friends Sport Work Family Bodily symptoms Leisure time Bodily symptoms Work Family 23

22 Treatment goals Goals of treatment for somatoform disorders Improve psychosocial functioning in daily life, reduce disability Improve quality of life Avoid chronic course and self-harm (e.g., through excessive avoidance behavior) Foster understanding, develop a biopsychosocial illness model Foster active coping and self-efficacy No goal: to find the one true cause of the symptoms Not realistic: being free of symptoms Collaborative goal setting Specific, stepped goals Goals Ms. Leonard: Get rid of the complaints Get back to work Improve mood Improve relationship 24

23 Treatment goals Goals Ms. Leonard: Get rid of the complaints Get back to work Improve mood Improve relationship Less disability through complaints Get back to work Improved mood, Improved relationship Set up regular appointments with PCP (avoid acute consultations) Set up appointment with boss to resolve conflict at work Set up regular exercise plan with 20 min walking 3 times a week. Understand factors contributing to symptom development, find an illness model Establish talking culture and positive activities with partner Danish College of General Practitioners,

24 Treatment goals Central treatment goals in different functional disorders Functional syndrome Central goals and topics Irritable bowel syndrome Reduce nutritional and social avoidance behavior Chronic fatigue syndrome Graded increase in physical activity and fitness Fibromyalgia Reduce pain-increasing endurance/avoidance behavior Increase healthy activity levels Non cardiac chest pain Reduce checking behavior Reduce excessive health care use Reduce catastrophizing cognitions Kleinstäuber et al.,

25 Psychotherapy for somatoform disorders Psychotherapy elements Goal setting Acceptancebased strategies Cognitive therapy Psychotherapy for somatoform disorders Behavioral activation and exposure Development of illness model Stressmanagement and relaxation 27

26 Psychotherapy for somatoform disorders Development of an illness model Enrichment of patients illness model by bio-psycho-social Aspects Strain on my back, sitting too much Getting old Bodily complaints Conflicts at work: feeling not needed Worrying might increase tension Illness? (not yet discovered) Too little physical activity Conflict with partner Ms. Leonard Somatic explanations Psychosocial explanations 28

27 Psychotherapy for somatoform disorders Biofeedback Continuous feedback of physiologic processes e.g., muscle activity, breathing, skin temperature, skin conductance Aims: To demonstrate of mind-body interrelations To improve self-control of bodily processes To improve relaxation skills To improve coping skills and feelings of control Shedden-Mora et al., Clin J Pain

28 Biofeedback: psychophysiological relations Stress-Relaxation-Test Relaxation I Stress phase Relaxation II 30

29 Psychotherapy for somatoform disorders Stress-management and relaxation I get stressed when Ich put myself under pressure by When I m stressed I react Stressors Individual aggravating factors Stressreaction Problemfocused coping Emotional and cognitive coping Regenerative coping Kaluza,

30 Psychotherapy for somatoform disorders Relaxation techniques Progressive muscle relaxation (Jacobson) Autogenic training (Schulz) Biofeedback Hypnosis Imagination techniques Breathing exercise Mindfulness and meditation Body exercises I guess it s a question of breathing 32

31 Psychotherapy for somatoform disorders Exposure-based techniques Fear-Avoidance model: a vicious circle Bodily complaints Catastrophizing: Appraisal as threat reappraisal improvement exposure Deconditioning, disability Fear of pain and movement Avoidance behaviour 33

32 Psychotherapy for somatoform disorders Exposure-based techniques Interoceptive exposure (Symptom provocation and response prevention) In-vivo exposure 34

33 Psychotherapy for somatoform disorders Cognitive techniques Aim: Identifying and restructuring dysfunctional, catastrophizing and symptom-aggravating thoughts and beliefs Interventions: Understanding relation between cognitions and bodily reactions Identifying dysfunctional thoughts (through situation analyses etc.) Cognitive restructuring towards more functional, coping-oriented appraisal 35

34 Psychotherapy for somatoform disorders Acceptance-based strategies: Acceptance und Commitment Therapy (ACT) Developing an mindful, non-judging attitude towards your experiences Accepting difficult experiences and emotions means allowing the emotion to be present, because fighting against it would just make it stronger concentrating on the things I can change - my own behaviour and accepting the other things I can use my energy for other things instead of fighting Commitment to values Hayes 2005; van Ravesteijn et al., Psychotherapy Psychosomatics

35 Psychotherapy for somatoform disorders Current evidence Enhanced primary care (psychoeducation, reattribution, CBT elements) Mixed evidence for effects on mental health, illness worry, depression, anxiety, and HCU 1 Consultation letters of psychiatrists in primary care Limited evidence for improved physical functioning, lower medical costs 2 Psychotherapy Good evidence of moderate effectiveness on symptom severity: d = ,4,5 Long-term positive effects Physical therapy No evidence 4 1 Rosendahl et al, Cochr Rev 2013; 2 Hoedeman, Cochr Rev 2010; 3 Kleinstäuber et al., Clin Psychol Rev 2011; 4 Van Dessel et al., Cochr Rev 2014; 5 Koelen, BJP

36 Psychotherapy for somatoform disorders Psychotherapy - evidence Kleinstäuber et al., Clin Psychol Rev 2011; Van Dessel et al., Cochr Rev 2014; 5 Koelen, BJP

37 Interim conclusion Psychotherapy Psychotherapy has long-term positive effects on symptom severity Psychotherapy is the best treatment option we have, but it could be better! 39

38 Agenda Psychotherapy of somatoform disorders Status quo health care Clinical guidelines and treatment approaches Psychotherapy Innovations and perspectives 40

39 Innovations Innovative treatment approaches Interoceptive exposure (Craske et al., Beh Res Ther 2011) CBT enhanced with emotion regulation training (Kleinstäuber et al., Cont Clin Trials 2016) E-Health interventions (Hedman et al., Br J Psych 2017) Early intervention 41

40 Innovations Exposure-based cognitive behavioural therapy for somatic symptom disorder and illness anxiety disorder d = Hedman et al., Br J Psych

41 Innovations and perspectives Guideline recommendation: Stepped, collaborative, coordinated care Not yet established and evaluated in routine care! 43

42 Network for somatoform and functional disorders: Sofu-Net Structure of Sofu-Net 35 Psychotherapists 41 PCPs in 20 Primary Care Practices Hamburg 7 Clinics Screening max. 4 Weeks Further diagnostic procedures max. 8 Weeks Accompanying treatment Shedden-Mora, Groß, Lau, Gumz, Wegscheider & Löwe. J Psychosom Res

43 Sofu-Net Health Care Network Elements of the complex intervention Early diagnosis Screening (PHQ) in primary care practices Early treatment Network pathways Treatment quality Patient education Specialized consultations Referral to psychotherapy Efficient communication: mailing-list, directory, short report form Network conferences Quality circles Patient information booklet, psychenet-website Psycho-education group Shedden-Mora, Groß, Lau, Gumz, Wegscheider & Löwe. J Psychosom Res

44 Sofu-Net Scientific evaluation Health Care Network Sofu-Net (41 PCPs, 35 psychotherapists, 7 clinics) Pre-post-intervention study Aim: Evaluation of feasibility (Shedden-Mora et al., 2016) Pre assessment: current health care Post assessment: Sofu-Net care Controlled study Aim: Evaluation of effectiveness (Löwe et al., 2017) Sofu-Net Care as usual 6-month Follow Up 46

45 Discussion of psychosocial distrress Sofu-Net: Pre-post-study Discussion of psychosocial distress with PCP often 4 ** ** Low-risk patients 3,5 ** High-risk patients 3 2,5 never 2 1,5 Pre Sofu-Net 63.3% Post Sofu-Net 79.2% ** p <.001 Interaction effect ANOVA (F (1, 3218) = 8.09, p<.01, η²=.003) Shedden-Mora, Groß, Lau, Gumz, Wegscheider & Löwe, J Psychosom Res

46 % prescriptions Sofu-Net: Pre-post-study Prescribed medication ** ** Pre Sofu-Net Post Sofu-Net ,2 21,8 22,0 15,4 3,8 6,5 Antidepressants Benzodiazepines Pain medication ** p <.001 Shedden-Mora, Groß, Lau, Gumz, Wegscheider & Löwe, J Psychosom Res

47 % patients Sofu-Net: Controlled Study Referral to mental health care (psychotherapy or psychiatric consultations) * Sofu-Net (n=119) Care as usual (n=100) , ,9 31,0 48, Mental Health Treatment since start of Sofu-Net Initiated by PCP * p >.05 Mixed logistic regression, IRR = 1.96; 95% CI ( ) Löwe, Piontek, Daubmann, Härter, Wegscheider, König, Shedden-Mora, Psychosomatic Medicine (2017) 51

48 PHQ-15 sum score Results Controlled Study Secundary outcome: somatic symptom burden (PHQ-15) Significant symptom reductions in both groups Sofu-Net (n=119) Care as usual (n=100) Baseline 6-month follow up Linear mixed models Löwe, Piontek, Daubmann, Härter, Wegscheider, König, Shedden-Mora, Psychosomatic Medicine (2017) 53

49 Results Controlled Study Network evaluation 31 PCPs, 28 psychotherapists, 7 inpatient clinics (response 82.5%) Satisfied with network would recommend network interested in further participation 80 86,4 87,9 Changes for patients within Sofu-Net Improved health care Early detection Improved referral to psychotherapy 69,8 72,3 64,1 Do not agree Agree Löwe, Piontek, Daubmann, Härter, Wegscheider, König, Shedden-Mora, Psychosomatic Medicine (2017) 54

50 Sofu-Net: Summary Effectiveness of Sofu-Net intervention Effective at health care system level o Improved communication about psychosocial distress in primary care o More adequate prescription of antidepressants and benzodiazepines o Successful referral into mental health treatment o Positive evaluation of network Not effective at patient level o Clinical symptoms not improved o No reduced health care use 55

51 Perspectives Network structure & stepped Care Optimized (early) psychotherapy & 56

52 Conclusions Management and treatment of somatoform disorders can be challenging for both doctor and patient Guidelines recommend a stepped, collaborative, coordinated care approach Psychotherapy (CBT, psychodynamic therapy, third wave) has long-term positive effects on symptom severity, with small to moderate effect sizes New, innovative treatment approaches are needed 57

53 Universitätsklinikum Hamburg-Eppendorf Institut und Poliklinik für Psychosomatische Medizin und Psychotherapie Thank you! 58

54 Universitätsklinikum Hamburg-Eppendorf Institut und Poliklinik für Psychosomatische Medizin und Psychotherapie Dr. Meike Shedden Mora Senior Researcher Martinistraße 52 D Hamburg Telefon: +49 (0) Telefax: +49 (0)