Seven articles about ISTDP and Medically Unexplained Symptoms

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This review article discusses 7 research articles written by Dr. Allan Abbass, MD, FRCPC about how Intensive Short Term Dynamic Psychotherapy (ISTDP) can be used to treat PPD (also known as TMS). While Dr. Abbass uses the term somatization rather than PPD, his concept of somatization is very similar to the concept of PPD, in that someone knowledgeable about PPD can read his articles about somatization and immediately recognize PPD. While the TMS/PPD and ISTDP approaches have slightly different emphases, the ISTDP approach to somatization will immediately be recognized by someone knowledgeable about PPD as a highly effective method for treating PPD. It is argued in this article that the two communities can learn a great amount from each other about the topic of somatization. Despite this common ground, at this point there is very little awareness in the two communities of their common interests and common approaches. The purpose of this article is to introduce Dr. Abbass' research to the TMS/PPD community as a very valuable resource (both from a clinical and an activism standpoint), and to stimulate interest among the TMS/PPD community in the work of the ISTDP community. It is written with the hope and expectation the the two communities can be great allies for each other in reforming the way that medically unexplained symptoms are treated internationally. Because this article summarizes Dr. Abbasses work and because the precise relationship between the way that the term "somatization" is used in the ISTDP community and the way that TMS and PPD are used within the TMS and PPD communities, we will use the term somatization in this article to refer to what we would otherwise call PPD.

Despite great progress in many areas, the medical community has failed to adequately treat chronic pain and other deemed medically unexplained symptoms (MUS). The growing epidemic of doctors visits by patients with MUS has become a costly burden on the medical system. For instance the cost of treating chronic pain in the United States has reached an estimated $100 billion annually. Most of these MUS are the result of somatization, defined as "the process by which psychological needs are expressed in physical symptoms (Stedman's Medical Dictionary, 26 ed.).

Dr. Allan Abbass, MD, FRCPC, has researched somatization and the effectiveness of Intensive Short-Term Dynamic Therapy (ISTDP) in treating MUS. Abbass has found that the ISTDP approach is highly effective in treating patients with somatization and should be used by hospital emergency departments to cut costs and limit unnecessary return visits. In a series of 7 articles, Dr. Abbass discusses a number of issues, including the need for Practitioner Training, both for physicians and psychotherapists, focusing on diagnosis, referrals, and treating somatization.

Common Themes in the articles

Currently there are a variety of ways to treat patients with somatization. Routinely doctors search for and sometimes attempt to treat physical causes for their patients' somatization. However, since these conditions are caused by somatization, the underlying cause is not a structural problem per se, but rather an emotional one. According to Abbass anxiety and defense mechanisms are formed by feelings that are either frightening, conflicting, or unacceptable. Many times this occurs in children who have been abandoned, traumatized, or neglected by loved ones. This results in a mixture of emotions combining love with rage followed by guilt about this rage. The same thing can happen to adults when certain events create emotional pain. Abbass says, "In essence, the rage or anger is turned inward into somatic symptoms both to protect the other person from the rage and to serve as a form of self punishment for having the rage to begin with." Page 3 of Source 5: Chronic Headaches . This is very similar to the ideas promoted by Dr. John Sarno in all of his books.

Abbass suggests that there are four physical patterns that can be exhibited when emotions are blocked. These patterns can be observed by the therapist and treated accordingly. The first is Striated Muscle Tension which is evident from hand clenching, arm tension, and sighing respirations. These can produce symptoms such as panic attacks, chest pains, headaches, fibromyalgia and other musculoskeletal complaints. Another possible pattern is Smooth Muscle Tension, seen by acute or chronic spasms of the smooth muscle. Common afflictions include GI symptoms, migraines, hypertension, urinary frequency, and upper airway constriction such as asthma. A third pattern is Cognitive-Perceptual Disruption. This is observed by a patient who has anxiety that affects their cognitive and perceptual fields. Examples include vision problems, confusion, memory loss, dizziness, and fatigue. The last pattern of somatization is Motor Conversion which is simply when a patient's voluntary muscles loose some if not all of their tone. The resulting physical symptoms include falling, aphonia, and weakness. For more information about the four patterns see page 216 of Source 6: Somatization or page 2 of Source 5: Chronic Headaches.

By understanding these four patterns Abbass argues that effective diagnosis and treatment are possible and that should begin when a patient first enters the doctor's office. Abbass makes several suggestions on how to diagnosis a patient, the first is to understand that a patient with a MUS is seeking a physical diagnosis and treatment. Most patients are not aware of somatization (or PPD) therefore it is the responsibility of the practitioner to look beyond the physical symptoms and focus on the patient's emotions.

There are five possible mindsets a patient can have as they enter a doctor's office. Some patients arrive ready to focus on emotional factors. These patients tend to have observable anxiety evident through hand clenching and sighing. They may even simply say they want to discuss emotional factors. Another mindset is what Abbass calls “Consciously Defending,” and tend to have reservations about talking with a therapist. However, Abbass notes that they rarely outright reject interacting with a therapist. The third mindset patients have is “Unconsciously Defending” which is common in patients that intellectualize their emotions and use an unconscious defense mechanism. Some patients come to the office in a confused state in which the patient has no idea why they are at a therapist's office. Abbass suggests that this usually results from a poor explanation by the referring doctor. The last mindset is a combination of two or more of the others. It is job of the therapist to understand the mindset the patient has and adjust the treatment accordingly. For more information about the five mindsets see pages 45-46 of Source 3: Implementing in the Emergency Department.

The patient-centered interview consists of five steps that help the therapist recognize the repressed emotions and then explain the condition to the patient. According to Abbass the first action a therapist should take is to simply observe the patient and notice any signs of defensiveness, unconscious anxiety, or somatic distress. The next step is to ask questions regarding the patient's emotions. Abbass gives three sample questions:

• Can you describe a situation when the symptoms get worse?
• What feelings do you have when you talk about that?
• How do you experience the feeling of anger in your body when it is there?

After initially investigating the patients emotions the therapist should then separate feelings from anxiety and defenses. This includes asking the patient what they felt inside. The fourth step is to observe the patients physical responses to investigating their emotions. What does the patient do when they begin to discuss their emotions? Do their symptoms worsen or lessen? The last step is to discuss with the patient the interview and give feedback on your thoughts behind the somatization. This can include developing a treatment plan or giving the patient a referral for further treatment. Key to this process is forming a supportive patient-doctor relationship. For more information about the patient interview see pages 46-48 of Source 3: Implementing in the Emergency Department and pages 218-220 of Source 6: Somatization.

Medically Unexplained Symptoms in a Hospital Emergency Department

An important aspect to remember about patients with somatization is that they rarely start out in a therapist office. These patients often understand their symptoms to be structural in origin therefore they routinely go to either a primary care physician or a hospital emergency room for diagnosis and treatment. Emergency departments especially are not highly effective at treating medically unexplained symptoms. For instance It has been found that 98% of chronic chest pain patients are misdiagnosed by Emergency Departments and discharged with "chest pain not yet diagnosed." This results in multiple return visits and an increase in medical costs for both the patients and the hospital.

In light of these facts Abbass investigated the ISTDP approach in an emergency room environment. Three research studies were conducted that tested various aspects of the approach in treating somatization. These three studies are all closely related and build off one another. The articles examine 1) the affect ISTDP has on reducing the rates of return visits in patients with medically unexplained symptoms, 2) the financial savings of the ISTDP approach over standard treatment, and 3) an overview on the implementation of an ISTDP program in an emergency room setting.

After reviewing the results it is clear that ISTDP therapy is an effective tool for hospital departments. For instance, in one study of 50 patients with MUS who were treated with ISTDP therapy, 40 patients (80%) had either a reduction or elimination of symptoms. Furthermore the study found that by using ISTDP, patients on average visited the emergency room 3.2 times less, a 69% reduction [1]. Such a reduction would obviously result in a decrease of medical costs, which was proven true through another one of Abbass's studies. He found that after an average of 3.8 ISTDP therapy sessions there was a 69% drop in ED visits in patients with MUS, dropping from 4.6 emergency room visits a year to 1.4. This drop resulted in an average of $910 in savings on medical expenses, showing the significant financial savings this therapy has over standardized medicine in treating somatization [2].

With savings such as these the next question is how can a hospital repeat these same results. Not every hospital is going to have a highly developed ISTDP therapeutic program, so creating an outline on how to establish and implement such a program is key to effectively treating somatization on a widespread scale. With this in mind Abbass created an implementation protocol and studied the effectiveness of such a program in raising the rates of referrals in patients with MUS. A key step in this process was forming close relationships between physicians and therapists that increased the possibility of referrals. Next physicians were trained on how to recognize somatization in patients and taught to look for common signs, such as clinched fists, or repressed emotions. Important to the success of the program is to ensure that patients who are referred to a therapist are seen relatively soon. To ensure this, Abbass created a group of rapid response therapists who made themselves available to see any referral patient within two weeks. In order for a referral program to work patients need to be seen in a short time period. The longer a patient has to wait for their referral appointment the less likely the patient is of going to it. The rapid response team that Abbass established sought to ensure that patients made their appointments and doctors continued to refer their patients to therapists. Overall this implementation program saw a drastic rise in the number of referrals which rose to 50 referrals in a 5 month period [3].

In researching these three areas Abbass found that ISTDP therapy is not only highly effective in reducing return emergency department visits, it can also significantly reduce cost for both the patient and hospital. This is particularly important when considering the ease to which Abbass was able to implement his therapeutic program in an emergency department.

Sources:

[1] Abbass, Allan; et al "Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre–post intervention study" CJEM 2009; 11(5):1-6

[2] Abbass, Allan; et al. "Cost Savings of Treatment of Medically Unexplained Symptoms Using Intensive Short-term Dynamic Psychotherapy (ISTDP) by a Hospital Emergency Department." Journal of the Academy of Medical Psychology. 2010, 34-43.

[3] Abbass, Allan, et al. "Implementing an Emotion-Focused Consultation Service to Examine Medically Unexplained Symptoms in the Emergency Department." Journal of the Academy of Medical Psychology. 2010, 44-51.

Other Articles

Through his research Abbass found that the ISTDP therapeutic approach is highly effective at treating patients with MUS. Due to the effectiveness of this approach Abbass set out to raise awareness for ISTDP and increase its usage in treating patients with somatization. The approach used to achieve this goal included 1) providing an overview of previous studies, 2) presenting new symptoms ISTDP can treat, 3) requesting for the establishment of a formal training curriculum for residents, as well as 4) developing an ISTDP training guide for practitioners.

The first step in raising awareness for any approach involves showing how effective it actually is at treating patients. Abbass reviewed the effectiveness of ISTDP related clinical trials in treating a wide range of somatic disorders including chronic back, joint, chest, abdominal, and headache pain, along with fatigue, dizziness, palpitations. IBS, fibromyalgia, chronic fatigue syndrome, temporomandibular disorder and interstitial cystitis were also included. 23 studies were reviewed including both RCTs and Pre/Post evaluations that had a combined total of 1,870 participants. An overwhelming majority of the studies found that ISTDP did or could have a significant impact on treating medically unexplained symptoms. Writing about this evidence raises the awareness people have of the ISTDP approach in that it brings multiple studies to show just how effective the approach is. In writing about these studies Abbass effectively raised awareness for the ISTDP approach as a valid and effective form of treatment of medically unexplained symptoms [4].

With the growing knowledge of the ISTDP approach and its effectiveness in treating patients with a somatization, there has been a growing number of studies focusing on the application of the approach. In order to better promote ISTDP, Abbass conducted research on the use of it in patients with chronic headaches. Abbass argues that headaches can either be brought on or exacerbated by repressed emotions or feelings. The article in question explains specific ISTDP techniques and protocols and how they are used in treating headaches. The main objective of this article is to lead to further evidence based research proving the effectiveness of the ISTDP approach on treating headaches. By connecting headaches and ISTDP Abbass raises awareness of another symptom that the approach can adequately treat [5].

It is clear that the number of patients with a somatization far out weighs the number of practitioners who can identify and treat somatization. Abbass suggested creating a 30 hour program that combines video-based training with didatic teaching and case based small groups. Establishing a training program will greatly increase the number of practitioners using this approach. First it will provide practitioners who are interested in somatization an avenue to learn more and receive the much needed training to responsibly treat patients. Furthermore it will create an institutionalization of the approach which will gain it respect as a valid treatment approach for medically unexplained symptoms [6].

In addition to a formal training program, Abbass and coauthors also published an article to education Family Practitioners about how to diagnose somatization through emotion focused interviewing. The article provides an overview of how repressed emotions can lead to physical symptoms. This is followed by an explanation of each type of emotion blocking pattern. Furthermore Abbass gives a step by step account of the interview process and explains how to evaluate the patient's response. With this overview a practitioner would have the basic understanding of the approach that was proven to be effective in treating somatization. While this article will not give a practitioner expert knowledge, nor enough training to implement the approach in their own practice, it does increase interest in the approach and the ease in which one can utilize it in their own practice [7].

There is still much that needs to be done for somatization to be fully understood and adequately treated. However articles and research written by Abbass raises awareness of the approach and provides any reader with a clear understanding of the effectiveness and techniques involved in the treatment approach.

Sources:

[4]Abbass, Allan; et al. "Short-Term Psychodynamic Psychotherapy for Somatic Disorders: Systematic Review and Meta-Analysis of Clinical Trials" Psychotherapy and Psychosomatics. 2009; 78:265–274

[5]Abbass, Allan; et al. "Direct diagnosis and management of emotional factors in chronic headache patients" Cephalalgia" 2008 Dec, 28(12), 1305-14

[6] Abbass, Allan. "The Case for Specialty Specific Core Curriculum on Emotions and Health" Royal College Outlook. 2005; 1(4): 5-7

[7] Abbass, Allan. "Somatization: Diagnosing it sooner through emotion-focused interviewing." Journal of Family Practice. 2005; 54(3): 215-224

Allan Abbass has researched extensively about the effectiveness of the ISTDP approach, which has led to a significant increase in the incorporation of the approach in therapy practices. He has written on all aspects of the approach ranging from treatment techniques, treatment effectiveness, and program implementation. By promoting the ISTDP approach Abbass has helped numerous people overcome debilitating chronic symptoms and regain their lives back by focusing on the underlying emotional causes.

Additional Information

Additional information and links can be found in our main page on ISTDP.

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