Cognitive-Behavioral Therapy, Psychotherapy and Psychosocial Interventions in the Medically Ill
Authors: Richard Balon
Journal: Psychotherapy and Psychosomatics (2009)

Patients with medical diseases and somatizing behaviors, as well as psychological symptoms accompanying various chronic medical illnesses, are notoriously difficult to treat. These patients frequently hold negative views of both pharmacotherapy and psychotherapy. The concept of treating their mostly unexplained symptoms with medication may be associated with various preconceived negative ideas, such as introducing a 'foreign' substance to the body, or simply lack of acceptance of using psychotropic medication for 'clearly somatic' symptoms/illnesses. In addition, the risks of side effects and drug-drug interactions are frequently increased in this population. Psychotherapy may not be accepted well among these patients, either. As Schweickhardt et al. [1] reminded us recently, patients with somatizing behavior 'by definition have no psychological attribution to the symptoms', and thus treatment acceptance and motivation for psychotherapy is low. Another factor complicating the use of psychotherapy and its outcome in this population is alexithymia. Various studies demonstrated the possible negative effects of alexithymia on therapy outcome [e.g. [2, 3]], though some studies did not [4].Nevertheless, the vague character of the symptomatology of these disorders, the associated distress, and the aforementioned possible increased sensitivity/incidence of side effects and drug interactions of psychotropic medications make various therapies a clinically preferable option in the treatment of medical illnesses that are considered to be psychosomatic, somatization and associated symptoms of chronic medical illnesses. Psychotherapies, rather than a strictly pharmacotherapeutic approach, may be more attuned to carefully assessing the complex host of factors affecting individual vulnerability (e.g. life events, allostatic load, psychological well-being) and psychosocial correlates of medical illness discussed by Fava and Sonino [5]. The relationship between some so-called psychosomatic disorders and psychosocial factors could be bi-directional. A recent review and meta-analysis [6] exhibited a positive association between psychosocial factors and future atopic disorders, as well as between atopic disorders and future poor mental health. The authors of this analysis also noted that psychosocial factors had both etiological and prognostic effects on atopic disorders, and suggested that psychological interventions should be used in addition to conventional physical and pharmacological interventions in these disorders [6]. There also seems to be increasing evidence for efficacy and usefulness of at least 1 therapy – cognitive-behavioral therapy (CBT) – in somatoform disorders and medically unexplained symptoms. The review by Sumathipala [7] concluded that CBT is efficacious for either symptom syndromes or for the broader category of medically unexplained symptoms, and also for reducing psychological distress and disability. CBT seems to be effective in reduction of a wide range of physical symptoms, associated mood disturbance, as well as improving overall and physical functioning. Sumathipala [7] actually reviewed the evidence for the efficacy of 2 other interventions – antidepressants and other nonspecific intervention. The evidence for the efficacy of CBT was the strongest, though no study compared pharmacological and psychological treatments. In a similar review of randomized controlled trials, Kroenke [8] concluded that CBT is the best established treatment of a variety of somatoform disorders.Several recent studies examined the role of mostly behavioral or cognitive-behavioral approaches to the treatment of so-called psychosomatic disorders or psychological symptoms of physical illness. Goebel et al. [9] investigated whether the effects of desloratidine, a nonsedating histamine 1 receptor antagonist, can be behaviorally conditioned in patients with allergic house dust mite rhinitis. The authors used a behavioral conditioning procedure. They demonstrated that, in their small sample, behaviorally conditioned effects were not only able to relieve subjective rhinitis symptoms and allergic skin reactions, but also to induce changes in effector immune functions, e.g. basophil activation. As the authors suggest, behavioral conditioning might be utilized as a supplement to immunomodulatory drug regimes to decrease the dose of medication. Lolak et al. [10] found that progressive muscle relaxation added to standard pulmonary rehabilitation significantly reduced anxiety and depression in patients with chronic breathing disorders. These results suggest that adding a behavioral technique to the management of physical illness, such as chronic obstructive pulmonary disease, may reduce the need for adding medications for psychological symptoms, such as depression and anxiety. In an interesting study from China, Wang et al. [11] found that psychological intervention – here defined as psychotherapy that included encouragement, verbal suggestion, relaxation training (RT), distraction with verbal communication about interests of the patients, therapeutically touching the faces of the patients, guided imagery and intra-arterial placebo – significantly reduced pain scores during hepatic arterial chemoembolization therapy of hepatic malignancies. Furthermore, van Kessel et al. [12] studied the efficacy of CBT and RT in multiple-sclerosis-related fatigue. Both CBT and RT were clinically effective, but the effects of CBT were greater than those of RT. Interestingly, even 6 months after treatment, patients in both CBT and RT groups reported fatigue levels equivalent to those of the healthy comparison group.Some seem to believe that CBT could also work 'per proxy'. It has been suggested that parents should be the main agents of change in treatment of childhood obesity [e.g. [13]]. Thus, Munsch et al. [14] conducted an interesting study in childhood obesity. Obese children (age 8–12 years) and their families were randomly assigned to a 16-session CBT for the mothers only (children in this group attended progressive muscle relaxation training of equal frequency and duration to the disorder-specific CBT in the other group) or CBT for both parents and children. Both treatments reduced children's overweight percentage significantly and equally at 6-month follow-up. Both treatments also similarly reduced behavioral problems, anxiety and depression. Unfortunately, the design of this study did not allow them to determine whether CBT in parents only ('per proxy') works better than CBT in both parents and children – the use of progressive muscle relaxation confounded the results.A recent review article [15] also suggested that there is good evidence that hypnotherapy benefits many patients with irritable bowel syndrome, a condition where medication use could be especially difficult. In addition to its psychological effects, hypnotherapy may modulate gastrointestinal physiology and even influence immune function. Nevertheless, Whorwell [15] felt that hypnotherapy should be a part of an integrated approach to the treatment of irritable bowel syndrome and not used as a 'stand alone' treatment. Similarly, Fried and Hussain [16] reviewed the evidence of the efficacy of nonpharmacological interventions in psychocutaneous disorders, defined in 3 broad categories: (1) skin conditions associated with a primary psychiatric diagnosis; (2) dual psychiatric-dermatological diagnosis such lichen simplex chronicus or dermatitis artefacta; (3) skin conditions known to be elicited or worsened by emotional factors such as rosacea, acne, psoriasis, alopecia areata. Fried and Hussain [15] felt, based on their review of the literature, that interventions such as hypnosis, support groups, biofeedback, meditation, guided imagery and progressive muscle relaxation, various forms of psychotherapy (interpersonal, CBT), massage and physician support and reassurance could be of substantial help in various psychocutaneous disorders.The evidence for the usefulness of various forms of psychotherapy (especially CBT) and other psychosocial interventions in medical diseases, somatoform or so-called psychosomatic disorders and psychological symptoms accompanying physical illnesses keeps growing. The next steps in research should probably involve attempts to develop either manuals of various therapies (mostly CBT) for particular disorders, or at least identification of more specific guidance and possible limiting factors. Another venue of research in this area should focus on a possible positive effect of psychotherapeutic techniques on the reduction of sympathetic arousal in individuals with these disorders, as suggested by Conrad et al. [17]. These authors also suggested that techniques such as autogenic relaxation or a modified form of expressive writing might prove to be economical therapy options leading to reduction of sympathetic arousal, even in patients with ocular disease such as central serous chorioretinopathy [17].Some of the factors limiting the efficacy of psychosocial interventions in medical diseases (so-called psychosomatic disorders) and/or psychological factors accompanying physical illness (such as alexithymia [2, 3, 17]) or limiting participation in psychosocial interventions (such as low level distress, lower socioeconomic class and adaptive coping [18]) have been identified. Some of the interventions – e.g. the short-term psychotherapeutic intervention for somatizing patients in general hospitals prior to referral for outpatient psychosocial intervention suggested by Schweickhardt et al. [1] – could probably be used uniformly.As North et al. [19] suggested in the case of irritable bowel syndrome, no single mode of treatment is likely to be universally effective or help resolve all symptoms. Combinations with medications, or even behavioral conditioning for some medication effects, may be useful. Nevertheless, psychotherapy and other psychosocial interventions seem to become a more obvious choice in the management of so-called psychosomatic disorders and/or psychological symptoms of medical illness, either alone or as an augmentation of other treatments. At the present time, the most useful and best evaluated form among various psychotherapy/psychosocial interventions for these conditions is CBT.Fava et al. [e.g., [20]] have been proposing a sequential treatment approach to mood and anxiety disorders. Maybe a similar sequential paradigm – the short-term preparatory psychotherapeutic intervention proposed by Schweickhardt et al. [1] and/or motivational interviewing, followed by psychotherapy (CBT), behavioral conditioning for medication and finally medication itself – could be tested for treatment of some medical diseases, so-called psychosomatic disorders and/or psychological symptoms of medical illness. Interestingly, motivational interviewing has been used, in addition to the management of alcohol and other substance abuses, in the management of eating and weight disorders either alone [21] or in combination with CBT [22], chronic heart failure [23] and in health coaching [24].Several studies mentioned in this article were supported by various national and other foundations; however, none of the cited studies, to my knowledge, was supported by the pharmaceutical industry.