ABSTRACT
BACKGROUND
Somatization and hypochondriacal health anxiety are common sources of distress, impairment, and costly medical utilization in primary care practice. A range of interventions is needed to improve the care of these patients.
OBJECTIVE
To determine the effectiveness of two cognitive behavioral interventions for high-utilizing, somatizing patients, using the resources found in a routine care setting.
DESIGN
Patients were randomly assigned to a two-step cognitive behavioral treatment program accompanied by a training seminar for their primary care physicians, or to relaxation training. Providers routinely working in these patients’ primary care practices delivered the cognitive behavior therapy and relaxation training. A follow-up assessment was completed immediately prior to treatment and 6 and 12 months later.
SUBJECTS
Eighty-nine medical outpatients with elevated levels of somatization, hypochondriacal health anxiety, and medical care utilization.
MEASUREMENTS
Somatization and hypochondriasis, overall psychiatric distress, and role impairment were assessed with well-validated, self-report questionnaires. Outpatient visits and medical care costs before and after the intervention were obtained from the encounter claims database.
RESULTS
At 6 month and 12 month follow-up, both intervention groups showed significant improvements in somatization (p < 0.01), hypochondriacal symptoms (p < 0.01), overall psychiatric distress (p < 0.01), and role impairment (p < 0.01). Outcomes did not differ significantly between the two groups. When both groups were combined, ambulatory visits declined from 10.3 to 8.8 (p = 0.036), and mean ambulatory costs decreased from $3,574 to $2,991 (p = 0.028) in the year preceding versus the year following the interventions. Psychiatric visits and costs were unchanged.
CONCLUSIONS
Two similar cognitive behavioral interventions, delivered with the resources available in routine primary care, improved somatization, hypochondriacal symptoms, overall psychiatric distress, and role function. They also reduced the ambulatory visits and costs of these high utilizing outpatients.
Similar content being viewed by others
REFERENCES
Escobar JI, Golding JM, Hough RL, Karno M, Burnham MA, Wells KB. Somatization in the community: relationship to disability and use of services. Am J Pub Health. 1987;77:837–840.
Smith GR. The course of somatization and its effects on utilization of health care resources. Psychosomatics. 1994;35:263–267.
Kroenke K, Spitzer RL, Williams JBW, et al. Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med. 1994;3:774–779.
Kroenke K, Spitzer RL, deGruy FV. Multisomatoform disorder. An alternative to undiffferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiat. 1997;54:352–358.
Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiat. 2005;62:903–910.
Lin EH, Katon W, Von Korff M, et al. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Int Med. 1991;6:241–246.
Barsky AJ, Wyshak G, Latham KS, Klerman GL. Hypochondriacal patients, their physicians, and their medical care. J Gen Int Med. 1991;6:413–419.
Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient in primary care: prevalence, psychopathology, and impairment. J Gen Int Med. 1996;11:1–8.
Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159:1069–1075.
Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. 2007;69:881–888.
Sumathipala A. What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies. Psychosom Med. 2007;69:889–900.
Allen LA, Escobar JI, Lehrer PM, Gara MA, Woolfolk RL. Psychosocial treatments for multiple unexplained physical symptoms: a review of the literature. Psychosom Med. 2002;64:939–950.
Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom. 2000;69:205–215.
Raine R, Haines AP, Sensky T, Hutchings A, Larkin KT, Black N. Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care? Br Med J. 2002;325:1082.
Hedman E, Ljotsson B, Andersson E, Ruck C, Andersson G, Lindefors N. Effectiveness and cost offset analysis of group CBT for hypochondriasis delivered in a psychiatric setting: an open trial. Cogn Behav Ther. 2010;39:239–250.
Clark DM, Salkovskis PM, Hackmann A, et al. Two psychological treatments for hypochondriasis. Br J Psychiat. 1998;173:218–225.
Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis; A randomized controlled trial. JAMA. 2004;291:1464–1470.
Sumathipala A, Hewege S, Hanwella R, Mann AH. Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: a feasibility study in Sri Lanka. Psychol Med. 2000;30:747–757.
Allen LA, Woolfolk RL, Escobar JI, Gara MA, Hamer RM. Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial. Arch Intern Med. 2006;166:1512–1518.
Hellman CJC, Budd M, Borysenko J, McClelland DC, Benson H. A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behav Med. 1990;16:165–173.
Fava GA, Grandi S, Rafanelli C, Fabbri S, Cazzaro M. Explanatory therapy in hypochondriasis. J Clin Psychiatry. 2000;61:317–322.
Greeven A, van Balkom AJ, Visser S, et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. Am J Psychiatry. 2007;164:91–99.
Sorensen P, Birket-Smith M, Wattar U, Buemann I, Salkovskis P. A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis. Psychol Med. 2011;41:431–441.
Rost K, Kashner TM, Smith GR Jr. Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs. Gen Hosp Psychiat. 1994;16:381–387.
Kashner TM, Rost K, Smith GR, Lewis S. An analysis of panel data; the impact of a psychiatric consultation letter on the expenditures and outcomes of care for patients with somatization disorder. Med Care. 1992;30:811–821.
Smith GR, Rost K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiat. 1995;52:238–243.
Dickinson WP, Dickinson LM, deGruy FV, Main DS, Candib LM, Rost K. A randomized clinical trial of a care recommendation letter intervention for somatization in primary care. Ann Fam Med. 2003;1:228–235.
Smith RC, Lyles JS, Gardiner JC, et al. Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial. J Gen Intern Med. 2006;21:671–677.
Rief W, Martin A, Rauh E, Zech T, Bender A. Evaluation of general practitioners’ training: how to manage patients with unexplained physical symptoms. Psychosomatics. 2006;47:304–311.
Sharpe M, Carson A. “Unexplained” somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Ann Intern Med. 2001;134:926–930.
Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med. 1989;86:262–266.
Speckens AEM, van Hemert AM, Bolk JH, Rooijmans HGM, Hengeveld MW. Unexplained physical symptoms: outcome, utilization of medical care and associated factors. Psychol Med. 1996;26:745–752.
Jackson JL, Kroenke K. Prevalence, impact, and prognosis of multisomatoform disorder in primary care: a 5-year follow-up study. Psychosom Med. 2008;70:430–434.
Speckens AEM, van Hemert A, Bolk JH, Hawton KE, Rooijmans HGM. The acceptability of psychological treatment in patients with medically unexplained physical symptoms. J Psychosom Res. 1995;7:855–863.
Benjamin S, Bridges K. The special needs of chronic somatizers. In: Benjamin S, House A, Jenkins P, eds. Liaison psychiatry: defining needs and planning services. London: Gaskell Press, Royal Collage of Psychiatrists; 1994:16–23.
Bass CM. Assessment and management of patients with functional somatic symptoms. In: Bass CM, ed. Somatization: physical symptoms and psychological illness. Oxford: Blackwell; 1990:40–72.
Barsky AJ, Fama JM, Bailey ED, Ahern DK. A prospective 4–5 year study of DSM-III-R hypochondriasis. Arch Gen Psychiat. 1998;55:737–744.
Barsky AJ, Wyshak G, Klerman GL. Transient hypochondriasis. Arch Gen Psychiat. 1990;47:746–752.
Johnson C, Shenoy RS, Langer S. Relaxation therapy for somatoform disorders. Hosp Commun Psychiat. 1981;32:423–424.
Jacobsen E. Progressive relaxation: a physiological and clinical investigation of muscular states and their significance in psychology and medical practice. Chicago: University of Chicago Press; 1974.
Weinstein MC, Berwick DM, Goldman PA, Murphy JM, Barsky AJ. A comparison of three psychiatric screening tests using receiver operating characteristic (ROC) analysis. Med Care. 1989;27:593–607.
Barsky AJ, Wyshak G, Klerman GL. Hypochondriasis: an evaluation of the DSM-III criteria in medical outpatients. Arch Gen Psychiat. 1986;43:493–500.
Barsky AJ, Wyshak G, Klerman GL. Medical and psychiatric determinants of outpatient medical utilization. Med Care. 1986;24:548–560.
Barsky AJ, Cleary PD, Spitzer RL, Williams JBW, Wyshak G, Klerman GL. A structured diagnostic interview for hypochondriasis: a proposed criterion standard. J Nerv Ment Dis. 1992;180:20–27.
Pilowsky I. A general classification of abnormal illness behaviours. Br J Med Psychol. 1978;51:131–137.
Pilowsky I. Dimensions of hypochondriasis. Br J Psychiat. 1967;113:89–93.
Salkovskis PM, Rimes KA, Warwick HMC, Clark DM. The health anxiety inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med. 2002;32:843–853.
Deacon B, Abramowitz JS. Is hypochondriasis related to obsessive-compulsive disorder, panic disorder, or both? An empirical evaluation. J Cog Psychother. 2008;22:115–127.
Jette AM, Davies AR, Cleary PD, et al. The functional status questionnaire: reliability and validity when used in primary care. J Gen Int Med. 1986;1:143–149.
Cleary PD, Jette AJ. Reliability and validity of the functional status questionnaire. Qual Life Res. 2001;9:747–753.
Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci. 1974;19:1–15.
Derogatis LR. SCL-90. Administration, scoring and procedures manual. Clinical psychometric research. Baltimore: John Hopkins University School of Medicine; 1977.
Lipman RS, Covi L, Shapiro AK. The Hopkins Symptom Checklist (HSCL): factors derived from the HSCL-90. Psychopharm Bull. 1977;13:43–45.
Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res. 2004;57:35–43.
Benson H. The relaxation response: therapeutic effect. Science. 1997;278:1694–1695.
Esch T, Fricchione GL, Stefano GB. The therapeutic use of the relaxation response in stress-related diseases. Med Sci Monit. 2003;9:RA23–RA34.
Barsky AJ, Cleary PD, Sarnie MK, Klerman GL. The course of transient hypochondriasis. Am J Psychiat. 1993;150:484–488.
Acknowledgements
The authors wish to acknowledge the critical assistance of Jessica Ferriero, Zvi Shapiro, Jennifer Sy, and Alexis Lawrence at the Brigham and Women’s Hospital, and Robert Schneider and Noelle Lawler at the Harvard Vanguard Medical Associates.
This work was supported by research grant RO1 MH 071688 from the National Institute of Mental Health.
This work has not been presented previously.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Additional information
ClinicalTrials.gov identifier: NCT00368212
Rights and permissions
About this article
Cite this article
Barsky, A.J., Ahern, D.K., Bauer, M.R. et al. A Randomized Trial of Treatments for High-Utilizing Somatizing Patients. J GEN INTERN MED 28, 1396–1404 (2013). https://doi.org/10.1007/s11606-013-2392-6
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-013-2392-6