Significant Improvement of Somatic Symptom Disorder With Brief Psychoeducational Intervention by PMHNP in Primary Care

Abstract

Objective:

Patients with somatic symptom disorders (SSD) are prevalent in primary care, urgent care, and emergency rooms and present with reduced quality of life, increased disability, and suicidality . Criteria for SSD include (1) somatic symptoms that cause distress and disrupt life; (2) concurrent physical illness with thoughts and feelings that are disproportionate to the seriousness of the illness; and (3) distress which is persistent and causes suffering. The frequency of SSD in the general population is 5% to 7%; however, in primary care, it is 5% to 35% . Because patients present with anxiety, depression, and/or pain, providers are flummoxed when diagnostic findings do not match symptom intensity. The purpose of this project was to provide an intervention for patients with SSD and measure its effectiveness on their somatic symptoms.

Method:

This study provided a single-session, 30-minute psychoeducational intervention for patients to explain brain pathways for pain and the body’s response to stress, including scientific benefits of exercise and healthy diet. Patients were asked questions using the motivational interviewing technique OARS (open-ended question, affirmation, reflection, summary) and were encouraged to talk about their concerns. The study used a pre- and post-intervention visual analogue scale and a self-reported Patient Health Questionnaire–15 both before and 3 weeks post-intervention.

Results:

Measurements showed significant symptom improvement immediately after the intervention with sustained improvement 3 weeks post-intervention.

Conclusions:

This intervention demonstrates an effective treatment for this insidious illness, which plagues up to 35% of patients in primary care.

Keywords

psychoeducation chronic illness in primary care motivational interviewing neurological pathways visual analogue scale

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References

Agorastos

Pervanidou

Chrousos

G. P.

Baker

D. G.

(2019). Developmental trajectories of early life stress and trauma: A Narrative review on neurobiological aspects beyond stress system dysregulation. Frontiers in Psychiatry, 10, 118. https://doi.org/10.3389/fpsyt.2019.00118

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Baliki

Apkarian

A.V.

(2015). Nociception, pain, negative moods, and behavior selection. Neuron, 87(3), 474-491. https://doi.org/10.1016/j.neuron.2015.06.005

Barsky

A. J.

Ahern

D. K.

Bauer

M. R.

Nolido

Orav

E. J.

(2013). A randomized trial of treatments for high-utilizing somatizing patients. Journal of General Internal Medicine, 28(11), 1396-1404. https://doi.org/10.1007%2Fs11606-013-2392-6

Corrigan

P. W.

Druss

B. G.

Perlick

D. A.

(2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest, 15(2), 37-70. https://doi.org/10.1177/1529100614531398

Dang

B. N.

Westbrook

R. A.

Njue

S. M.

Giordano

T. P.

(2017). Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study. BMC Medical Education, 17(1), 32. https://doi.org/10.1186/s12909-017-0868-5

DeMaster

Bick

Johnson

Montroy

J. J.

Landry

Duncan

A. F.

(2019). Nurturing the preterm infant brain: leveraging neuroplasticity to improve neurobehavioral outcomes. Pediatric Research, 85(2), 166. https://doi.org/10.1038/s41390-018-0203-9

Fava

G. A.

Cosci

Sonino

(2017). Current psychosomatic practice. Psychotherapy and Psychosomatics, 86(1), 13-30. https://doi.org/10.1159/000448856

Goldberg

D. P.

Reed

G. M.

Robles

Bobes

Iglesias

Fortes

Jair Mari

de J.

Lam

T-P.

Minhas

Razzaque

Garcia

J. Á.

Rosendal

Dowell

C A.

Gask

Mbatia

J. K.

Saxena

(2016). Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO’s revised classification of mental disorders in primary care settings. Journal of Psychosomatic Research, 91, 48-54. https://doi.org/10.1016/j.jpsychores.2016.10.002

10.

Guendelman

Medeiros

Rampes

(2017). Mindfulness and emotion regulation: Insights from neurobiological, psychological, and clinical studies. Frontiers in Psychology, 8, Article number 220. https://doi.org/10.3389/fpsyg.2017.00220

11.

Henke

R. M.

Chou

A. F.

Chanin

J. C.

Zides

A. B.

Scholle

S. H.

(2008). Physician attitude toward depression care interventions: implications for implementation of quality improvement initiatives. Implementation Science, 3(1), Article number 40. https://doi.org/10.1186/1748-5908-3-40

12.

Hollander

J. E

Carr

B. G.

(2020). Virtually perfect? Telemedicine for Covid-19. New England Journal of Medicine, 382, 1679-1681. https://doi.org/10.1056/NEJMp2003539

13.

Karatinos

(2014). The role of the autonomic nervous system in psychiatry.

14.

Kleinstäuber

Rief

(2017). Somatic symptom disorders. In Hofmann

S. G.

(Ed.), Clinical Psychology: A Global Perspective (pp. 261-282). Wiley-Blackwell.

15.

Klerman

G. L.

Budman

Berwick

Weissman

M. M.

Damico-White

Demby

Feldstein

(1987). Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. Medical Care, 25(11), 1078-1088. https://doi.org/10.1097/00005650-198711000-00006

16.

Koball

A. M.

Rasmussen

Olson-Dorff

Klevan

Ramirez

Domoff

S. E.

(2019). The relationship between adverse childhood experiences, healthcare utilization, cost of care and medical comorbidities. Child Abuse & Neglect, 90, 120-126. https://doi.org/10.1016/j.chiabu.2019.01.021

17.

Kocalevent

R. D.

Hinz

Brähler

(2013). Standardization of a screening instrument (PHQ-15) for somatization syndromes in the general population. BMC Psychiatry, 13, Article number 91. https://doi.org/10.1186/1471-244X-13-91

18.

Koelen

J. A.

Houtveen

J. H.

Abbass

Luyten

Eurelings-Bontekoe

E. H.

Van Broeckhuysen-Kloth

S. A.

Bühring

M. E. F.

Geenen

(2014). Effectiveness of psychotherapy for severe somatoform disorder: Meta-analysis. British Journal of Psychiatry, 204(1), 12-19. https://doi.org/10.1192/bjp.bp.112.121830

19.

Kohlmann

Gierk

Hümmelgen

Blankenberg

Löwe

(2013). Somatic symptoms in patients with coronary heart disease: prevalence, risk factors, and quality of life. JAMA Internal Medicine, 173(15), 1469-1471. https://doi.org/10.1001/jamainternmed.2013.6835

20.

Kontos

Beach

S. R.

Smith

F. F.

Greenberg

D. B.

(2017). Psychosomatic conditions: Somatic symptom. In Stern

T. A.

Freudenreich

Smith

F. A.

Fricchione

G. L.

Rosenbaum

J. F.

(Eds.), Massachusetts General Hospital handbook of general hospital psychiatry (e-book; pp. 161-177). Elsevier Health Sciences.

21.

Kroenke

Spitzer

R. L.

Williams

J. B.

Löwe

(2010). The patient health questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. General Hospital Psychiatry, 32(4), 345-359. https://doi.org/10.1016/j.genhosppsych.2010.03.006

22.

Kurlansik

S. L.

Maffei

M. S.

(2016). Somatic symptom disorder. American Family Physician, 93(1), 49-54. https://doi.org/10.1016/j.amjms.2016.07.013

23.

Leonhart

de Vroege

Zhang

Liu

Dong

Schaefert

Nolte

Fischer

Fritzsche

van der Feltz-Cornelis

C. M.

(2018). Comparison of the factor structure of the patient health questionnaire for somatic symptoms (PHQ-15) in Germany, the Netherlands, and China. A transcultural Structural Equation Modeling (SEM) Study. Frontiers in Psychiatry, 9, 240. https://doi.org/10.3389/fpsyt.2018.00240

24.

Levinson

Lesser

C. S.

Epstein

R. M.

(2010). Developing physician communication skills for patient-centered care. Health Affairs, 29(7), 1310-1318. https://doi.org/10.1377/hlthaff.2009.0450

25.

Linehan

M. M.

(2018). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

26.

Meier

(2015). Incorporating progress monitoring and outcomes measures into counseling and psychotherapy: A primer. Oxford University Press.

27.

Meyer

R. G.

Weaver

C. M.

(2006). The clinician’s handbook: Integrated diagnostics, assessment, and intervention in adult and adolescent psychopathology. Waveland Press.

28.

Miller

G. E.

Chen

Zhou

(2007). If it goes up must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychological Bulletin, 133(1), 25-45. https://doi.org/10.1037/0033-2909.133.1.25

29.

Mosadeghrad

A. M.

(2014). Factors influencing healthcare service quality. International Journal of Health Policy and Management, 3(2), 77-89. https://doi.org/10.15171/ijhpm.2014.65

30.

Neto

(2015). Educational motivation meets Maslow: Self-actualisation as a contextual driver. Journal of Student Engagement: Education Matters, 5(1), 18-27. http://ro.uow.edu.au/jseem/vol5/iss1/4

31.

Norcross

J. C.

Pfund

R. A.

Prochaska

J. O.

(2013). Psychotherapy in 2022: A Delphi poll on its future. Professional Psychology: Research and Practice, 44(5), 363-370. https://doi.org/10.1037/a0034633

32.

North

C. S.

(2015). The classification of hysteria and related disorders: historical and phenomenological considerations. Behavioral Sciences, 5(4), 496-517. https://doi.org/10.3390/bs5040496

33.

Payne

Brooks

S. D. M.

(2017). Moving on: The Body-Mind Approach TM for medically unexplained symptoms. Journal of Public Mental Health, 16(2), 1-9. https://doi.org/10.1108/JPMH-10-2016-0052

34.

Pincus

Holt

Vogel

Underwood

Savage

Walsh

D. A.

Taylor

S. J. C.

(2013). Cognitive and affective reassurance and patient outcomes in primary care: A systematic review. Pain, 154(11), 2407-2416. https://doi.org/10.1016/j.pain.2013.07.019

35.

Rosic

Kalra

Samaan

(2016). Somatic symptom disorder, a new DSM-5 diagnosis of an old clinical challenge. BMJ Case Reports, 2016, bcr2015212553. https://doi.org/10.1136/bcr-2015-212553

36.

Roter

D. L.

Frankel

R. M.

Hall

J. A.

Sluyter

(2006). The expression of emotion through nonverbal behavior in medical visits. Journal of General Internal Medicine, 21(S1), S28-S34. https://doi.org/10.1111/j.1525-1497.2006.00306.x

37.

Sapolsky

R. M.

Romero

L. M.

Munck

A. U.

(2000). How do glucocorticoids influence stress responses: Integrating permissive, suppressive, stimulatory, and preparative actions. Endocrine Review, 21(1), 55-89. https://doi.org/10.1210/edrv.21.1.0389

38.

Shorter

(2015). The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders. Dialogues in Clinical Neuroscience, 17(1), 59-67.

39.

Silberman

D. M.

Acosta

G. B.

Zubilete

M. A. Z.

(2016). Long-term effects of early life stress exposure: Role of epigenetic mechanisms. Pharmacological Research, 109, 64-73. https://doi.org/10.1016/j.phrs.2015.12.033

40.

Silverman

Kurtz

Draper

(2016). Skills for communicating with patients. CRC Press.

41.

Silverman

W. H.

(2013). The future of psychotherapy: One editor’s perspective. Psychotherapy, 50(4), 484-489. https://doi.org/10.1037/a0030573

42.

Somashekar

Jainer

Wuntakal

(2013). Psychopharmacotherapy of somatic symptoms disorders. International Review of Psychiatry, 25(1), 107-115. https://doi.org/10.3109/09540261.2012

43.

Thomason

T. C.

(2010). The trend towards evidence-based practice and the future of psychotherapy. American Journal of Psychotherapy, 64(1), 29-38. https://doi.org/10.1176/appi.psychotherapy.2010.64.1.29

44.

Thorn

B. E.

(2017). Cognitive therapy for chronic pain: a step-by-step guide. Guilford Press.

45.

Victor

T. L.

Van Dyk

K. M.

(2017). The role of early life trauma in somatization: Implications for the clinical practice of neuropsychology. In Boone

K. B.

(Ed.), Neuropsychological evaluation of somatoform and other functional somatic conditions: Assessment primer (pp. 43-112). Routledge.

46.

Weisz

J. R.

Kuppens

M. Y.

Eckshtain

Ugueto

A. M.

Vaughn-Coaxum

Jensen-Doss

Hawley

Krumholx

Lauren

Chu

Weersing

Fordwood (2017). What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice. American Psychologist, 72(2), 79-117. https://doi.org/10.1037/a0040360

47.

Zänkert

Bellingrath

Wüst

Kudielka

B. M.

(2018). HPA axis responses to psychological challenge linking stress and disease: What do we know on sources of intra- and interindividual variability? Psychoneuroendocrinology, 105(July), 86-97. https://doi.org/10.1016/j.psyneuen.2018.10.027

48.

Zamani-Alavijeh

Araban

Harandy

T. F.

Bastami

Almasian

(2019). Sources of health care providers’ self-efficacy to deliver health education: a qualitative study. BMC Medical Education, 19(1), 16. https://doi.org/10.1186/s12909-018-1448-z