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Service Evaluation of Cognitive Analytic Therapy for Patients with Complex Medically Unexplained Symptoms Referred to a Liaison Psychiatry Department

Alison Jenaway, Carol Gregory, Damaris Koch and Kate Bristow

Cite as: Jenaway, A., Gregory, C., Koch, D., & Bristow, K. (2018). Service Evaluation of Cognitive Analytic Therapy for Patients with Complex Medically Unexplained Symptoms Referred to a Liaison Psychiatry Department. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 2(1), 140–147. https://www.internationalcat.org/_files/ugd/ff32b4_5cab82bc91674a40a3bbf8bff5efa53c.pdf

 

Int. Journal of CAT & RMH Vol. 2, 2018 / ISSN2059-9919

Abstract

This paper describes the introduction of cognitive analytic therapy within a liaison psychiatry service in a general hospital. This therapy modality was offered as an alternative to cognitive behaviour therapy for patients referred with complex medically unexplained symptoms (MUS). A brief introduction to using cognitive analytic therapy in this group of patients is included.

 

The paper gives information about a sample of patients with complex MUS (n=28) who were treated by trained cognitive analytic therapists. Rates of drop-out, experience of previous therapy and the duration of MUS are detailed.

 

The outcome measure of the CORE34 was collected before and after completion of therapy. This measure showed a clinically meaningful reduction towards the normal range, from an average of 1.87 per item to an average of 1.09 per item.

 

The findings suggest that cognitive analytic therapy is an acceptable and effective therapy for treating psychological symptoms in patients with complex MUS.

Introduction

Medically unexplained symptoms (MUS) refers to persistent bodily complaints for which adequate examination does not reveal sufficient explanatory, structural, or other specified, pathology (Guidance JCPMH, 2016). They are a common reason for referral to liaison psychiatry services and form a significant percentage of patients seen in the General Hospital. Studies of hospital outpatients suggest that between 49% and 60% of patients still have no organic explanation for their symptoms despite investigations (Nimnuan et al, 2001). The overall cost to the NHS of treating these patients is estimated to be around £3 billion per year (No Health Without Mental Health, 2011). Symptoms may vary from short term, stress-related symptoms, which are likely to improve with education and reassurance, through to those with moderate difficulties who are still able to function in work and social roles, and to those with severe and complex difficulties. While there is some evidence that brief interventions in primary care (Edwards et al, 2010) and Cognitive Behaviour Therapy (Nezu et al, 2001) can be helpful to those with mild or moderate symptoms, there is little evidence of efficacy for therapy approaches in the more severe end of the spectrum or those who report little benefit from Cognitive Behaviour Therapy.

 

A recent commissioning guidance issued jointly by the Royal College of Psychiatrists and the Royal College of General Practitioners suggests a multidisciplinary approach for these patients, which should include General Practice, medicine, nursing, psychology/psychotherapy, psychiatry, occupational therapy and physiotherapy, with an emphasis on education and training of all staff (Guidance JCPMH, 2016).

 

In the absence of such a comprehensive team approach, we have been offering Cognitive Analytic Therapy as an outpatient treatment for those with complex MUS. Reasons for referral for CAT, rather than CBT, are that the patient has already had CBT, that they express a preference for CAT when both therapies are explained, or where there is a history of early neglect or abuse and the patient is able to acknowledge a possible link between this and their symptoms. Sometimes the first few sessions are carried out while the patient is still in hospital, with a view to engaging the patient before discharge. We report on the outcomes of a group of patients treated in this way.

Description of sample

Patients were referred to the therapy team of the liaison psychiatry department in Cambridge University Hospital by liaison psychiatrists assessing both inpatients and outpatients. We describe a series of consecutive patients treated by qualified therapists in the department with CAT. Additional patients with less complex presentations were treated by trainees, often junior psychiatrists who needed to take on a psychotherapy case as part of their training, or trainee clinical psychologists. However these have not been included as they were considered less complex at assessment, we are less confident about the quality of the therapy provided and data collection was poor. Over three years, 32 of those patients who were referred for CAT were seen by qualified CAT therapists, of which 28 were formally engaged in therapy. Of these 28 cases, 4 dropped out later in the therapy. The overall drop- out rate from CAT in our department has been reported previously as 27% (Channer and Jenaway, 2015). In that sample of patients, the drop- out rate was higher in patients seen by trainees than in those seen by qualified therapists, and higher in those travelling from outside the Cambridge area. This high rate probably reflects the practical difficulties of travelling to the clinic for those with MUS, as well as ambivalence, which we frequently see, about accepting a psychological therapy for what is experienced as physical problems. It is likely that more experienced therapists are more able to maintain the therapeutic relationship through the early sessions when the patient is still not sure that therapy will be helpful.

 

Of the 24 patients who completed therapy, 3 had incomplete data. Therefore, only 21 individuals (of whom only 2 were male) completed pre- and post-therapy CORE34 questionnaires, following an average of 17 sessions of CAT (SD=2.42). The CORE34 is a self-report questionnaire with 34 questions, designed for use as an outcome measure in any psychotherapy. Each question has a maximum score of 4, indicating high severity. Patients were referred from various departments in the General

 

Hospital, with the majority suffering from functional neurological symptoms or chronic, unexplained pain. As can be seen in Table 1, most patients had experienced symptoms for more than 2 years. Table 2 shows rates of previous psychological therapy, with just over half the sample of patients having had previous psychological or psychiatric treatment.

Results

Overall, CORE34 scores fell from an average of 1.87 per item (SD=0.77) to 1.09 per item (SD=0.60). Jacobson and Truax’s (1991) methodology was applied to the data, to identify the extent to which this difference represented an effective move towards more normative data (clinically meaningful index), and the confidence with which such a change could be attributed to factors external to measurement error or chance (reliable change index). As shown in Figure 1, the observed decrease in CORE34 scores represented a clinically meaningful change; post-therapy scores fell below the clinical cut-off mark (females=1.29; males=1.19; CORE manual). However, with a reliable change index calculated at 1.06 (using reliability co-efficients reported in Evans et al, 2002), this difference falls short of a statistically reliable change. The number of patients is small, but the change in average CORE34 scores in those who have had previous psychological therapy (1.79 at start to 1.21 at end, n=12) was similar to those with no previous experience of therapy (1.79 at start to 1.21 at end, n=9).

Figure 1. Change in CORE scores following CAT therapy

Discussion

We describe a service where it has been possible to introduce CAT as an alternative therapy model so that patients, and clinicians, have increased choice. This is particularly useful since many of the patients referred to us with complex medically unexplained symptoms report little benefit from previous cognitive behaviour therapy. Cognitive Analytic Therapy appears to be acceptable to patients with complex MUS and shows promise as an effective outpatient therapy in terms of reducing psychological symptoms as measured by the CORE34. One problem with self-report questionnaires, such as the CORE34, is that some patients with MUS show low scores initially. These patients have been described in the Health Psychology literature as ‘Repressors’ as they fail to report negative affect and appear to be out of touch with their feelings (Myers, 2000). These same patients sometimes report an increase in distress as therapy proceeds, as they get back in touch with warded-off feelings. This phenomenon may have reduced the average before and after differences in our sample.

 

Two of the patients reported here appeared to fit this description, both were female with severe physical symptoms and disability, but surprisingly low initial CORE34 scores (both scoring below 0.5 per item at the start). Neither had previous experience of psychological therapy, and both scored higher at the end of therapy, despite reporting it as helpful. Further research is indicated, using a larger sample and a randomised controlled design, with more objective measures of functioning included. Our intention is to start collecting outcome data using the Brief Illness Perception Questionnaire (a scale which provides a picture of the patients’ cognitive and emotional representation of their illness) (Broadbent et al., 2006) as well as the CORE34.

 

In summary, we feel that CAT is a useful addition to Cognitive Behaviour Therapy in a service designed for complex patients with MUS. It offers both patients and the treating team a choice and may be more effective for those patients with significant history of early childhood neglect and abuse, and where problems in relationships are part of the clinical picture. Because the CAT model also provides a structure for understanding problematic relationship patterns, it is often helpful in assisting family and staff members in coping with the complex interactions which can occur with these patients. 

References

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Channer K. & Jenaway A. (2015) Audit of factors predicting Drop Out from Cognitive Analytic Therapy. Reformulation, winter, 33-35.

Edwards T.M. Stern A. Clarke D.D. Ivbijaro G. & Kasney L.M. (2010) The Treatment of patients with medically unexplained symptoms in primary care: A review of the literature. Mental Health in Family Medicine, Dec 7(4): 209-221.

Evans C. Connell J. Barkham M. Margison F. McGrath G. Mellor-Clark J. & Audin K. (2002). Towards a standardised brief outcome measure: Psychometric properties and utility of the CORE-OM. British Journal of Psychiatry, 180(1), 51-60. doi:10.1192/ bjp.180.1.51

Guidance for Commissioners of services for people with Medically Unexplained Symptoms (MUS), Joint Commissioning Panel for Mental Health, (2016), Co-chaired by Simon Heyland and Carolyn Chew-Graham.

Jenaway A. (2011). Using Cognitive Analytic Therapy for Medically Unexplained Symptoms; some theory and initial outcomes. Reformulation, winter, 53-55.

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Myers L.B. (2000). Identifying Repressors: A methodological issue for health psychology. Journal of Psychology and Health, 15 (2), 205-215. Doi.org/10.1080/08870440008400301

Nezu A. Nezu C.M. & Lombardo E.R. (2001). Cognitive Behaviour Therapy for MUS: A critical review of the treatment literature. Behaviour Therapy, 32(3): 537 – 583. doi.org/10.1016/s0005-7894(01)80035-6

No Health Without Mental Health (2011). A cross-government mental health outcomes strategy for people of all ages Department of Health.

Nimnuan C. Hotopf M. & Wessley S. (2001). Medically Unexplained Symptoms: An epidemiological study in seven specialities. Journal of Psychosomatic Research, Jul; 51(1): 361-367. PMID 114487044

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