An Interdisciplinary Multimodal Integrative Healthcare Program For Somatic Symptom Disorder With Predominant Spinal Pain   March 27th, 2023

Somatic symptom disorders (SSD) are characterized by an excessive focus on somatic symptoms that causes significant emotional distress and a disruption of daily life. In addition, individuals suffering from a SSD often have excessive thoughts, feelings and/or behaviors related to these somatic symptoms and associated health concerns [1]. A recent study evaluated the effectiveness of an interdisciplinary multimodal integrative healthcare program, designed for individuals suffering from SSD whose somatic symptoms predominantly involved persistent spinal pain.

Commonly used therapies for SSD include: cognitive behavioral therapy[2, 3], mindfulness-based cognitive therapy [4] and psychotherapy [5]. Relapse and recurrence rates for common mental disorders following treatment are however substantial. Previous studies reported relapse rates of approximaletly 30% [6, 7] and recurrence rates ranging from 40-60% [8, 9]. Moreover, accumulating evidence suggest that a large proportion of patients with SSD are in reality too multicolored to treat with mono-interventions. There is often substantial heterogeneity with regard to symptom presentation, response to treatment and prognosis and considerable overlap with other mental disorders (e.g. anxiety and mood disorders, PTSD, etc.) [10]. This emphasizes the need for the development of interventions with more sustainable results. Interdisciplinary multimodal interventions could provide a suitable alternative. Within these interventions, at least two different therapeutic interventions with different mechanisms of action (i.e. multimodality) are delivered by a team of different healthcare professionals with a common treatment philosophy and shared therapeutic aims and treatment goals (i.e. interdisciplinary) [11, 12].

To date, only few studies support the use of interdisciplinary multimodal interventions for patients suffering from SSD [13-16]. In order to contribute to the existing evidence, our research group evaluated the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program for patients suffering from SSD with predominant spinal pain. The primary variable was health-related quality of life (HRQoL) measured with the Research and Development-36 (RAND-36) and secondary variables were symptoms of psychopathology measured with the Brief Symptom Inventory (BSI). Participants filled in the questionnaires at four time points: at the start of the 20-week intervention (i.e. T0), halfway through the 20-week intervention (i.e. T1), at the end of the 20-week intervention (i.e. T2) and at the end of the 12-month relapse prevention program (i.e. T3). The healthcare program is provided at a specialized secondary mental healthcare center (i.e. het Rughuis) and is characterized by an interdisciplinary, multimodal and integrative approach for patients with a SSD and persistent spinal pain. The healthcare program is best described as a multimodal cognitive behavioral therapy. It combines the use of different therapeutic methods, based on the problems, needs and unique circumstances of each individual client. The program is led by an interdisciplinary team consisting of psychologists, physical therapists and a coordinating practitioner (i.e. psychiatrist, clinical/health care psychologist). It is divided into two parts: 1) a main 20-week outpatient healthcare programand 2) a subsequent 12-month ‘Relapse Prevention Program’ with a main focus on sustainability of treatment results through the encouragement of self-management and patient autonomy). Other important elements within the healthcare program are: 1) a modular approach [17], where evidence-based elements can be delivered flexible and tailored towards the individual, based on specific underlying biopsychosocial risk, protective- and/or maintaining factors of the mental health problem; 2) intensive, time-bound intervention program; 3) an emphasis on the biopsychosocial model; 4) ‘shared decision making’ with collaborative goal-setting; 5) a ‘recovery-oriented’ approach, in which patients are encouraged to cope autonomously with changing physical, emotional and social challenges [18]; 6) a focus on relapse prevention, through the incorporation of a 12-month relapse prevention program and 7) ‘blended care’, characterized by a combination of online and offline therapy, with the support of an e-health environment.

Results showed significant improvements following the 20-week main intervention for both HRQoL (RAND-36) and symptoms of psychopathology (BSI), which were both maintained until the end of the 12-month relapse prevention program. Moreover, there were significant improvements following the 12-month relapse prevention program for two subscales: physical role restrictions due to physical problems (RAND-36) and interpersonal sensitivity (BSI). In conclusion, the results of the study suggest that the interdisciplinary multimodal integrative healthcare program contributes to the recovery of patients diagnosed with a SSD and predominant spinal pain. In addition, the results suggest that it is effective to individualize treatment components, based on specific underlying biopsychosocial predisposing, perpetuating and maintaining factors of the healthcare problems.

If you want to read the study in more detail, please follow the following link:

Jaap Wijnen

PhD researcher Spine, Head and Pain Research Unit, Ghent University, Belgium and researcher at Intergrin, Geleen, the Netherlands.

2023Pain in Motion

References and further reading:

[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders.

[2] Allen, L. A., & Woolfolk, R. L. (2010). Cognitive behavioral therapy for somatoform disorders. Psychiatric Clinics33(3), 579-593.

[3] Jones, B., & de C Williams, A. C. (2019). CBT to reduce healthcare use for medically unexplained symptoms: systematic review and meta-analysis. British Journal of General Practice69(681), e262-e269.

[4] Menon, V., Rajan, T. M., Kuppili, P. P., & Sarkar, S. (2017). Cognitive behavior therapy for medically unexplained symptoms: a systematic review and meta-analysis of published controlled trials. Indian journal of psychological medicine39(4), 399-406.

[5] Abbass, A., Town, J., Holmes, H., Luyten, P., Cooper, A., Russell, L., ... & Kisely, S. (2020). Short-term psychodynamic psychotherapy for functional somatic disorders: A meta-analysis of randomized controlled trials. Psychotherapy and Psychosomatics89(6), 363-370.

[6] Lorimer, B., Kellett, S., Nye, A., & Delgadillo, J. (2021). Predictors of relapse and recurrence following cognitive behavioural therapy for anxiety-related disorders: a systematic review. Cognitive Behaviour Therapy50(1), 1-18.

[7] Wojnarowski, C., Firth, N., Finegan, M., & Delgadillo, J. (2019). Predictors of depression relapse and recurrence after cognitive behavioural therapy: a systematic review and meta-analysis. Behavioural and cognitive psychotherapy47(5), 514-529.

[8] Bockting, C. L., Hollon, S. D., Jarrett, R. B., Kuyken, W., & Dobson, K. (2015). A lifetime approach to major depressive disorder: the contributions of psychological interventions in preventing relapse and recurrence. Clinical psychology review41, 16-26.

[9] Eaton, W. W., Shao, H., Nestadt, G., Lee, B. H., Bienvenu, O. J., & Zandi, P. (2008). Population-based study of first onset and chronicity in major depressive disorder. Archives of general psychiatry65(5), 513-520.

[10] Caspi, A., Houts, R. M., Belsky, D. W., Goldman-Mellor, S. J., Harrington, H., Israel, S., ... & Moffitt, T. E. (2014). The p factor: one general psychopathology factor in the structure of psychiatric disorders?. Clinical psychological science2(2), 119-137.

[11] Gatchel, R. J., McGeary, D. D., McGeary, C. A., & Lippe, B. (2014). Interdisciplinary chronic pain management: past, present, and future. American psychologist69(2), 119.

[12] Dragioti, E., Evangelou, E., Larsson, B., & Gerdle, B. (2018). Effectiveness of multidisciplinary programmes for clinical pain conditions: An umbrella review.

[13] Houtveen, J. H., van Broeckhuysen-Kloth, S., Lintmeijer, L. L., Bühring, M. E., & Geenen, R. (2015). Intensive multidisciplinary treatment of severe somatoform disorder: a prospective evaluation. The Journal of nervous and mental disease203(2), 141-148.

[14] Pieh, C., Neumeier, S., Loew, T., Altmeppen, J., Angerer, M., Busch, V., & Lahmann, C. (2014). Effectiveness of a multimodal treatment program for somatoform pain disorder. Pain Practice14(3), E146-E151.

[15] De Vroege, L., Emons, W. H., Sijtsma, K., & Van der Feltz-Cornelis, C. M. (2018). Alexithymia has no clinically relevant association with outcome of multimodal treatment tailored to needs of patients suffering from somatic symptom and related disorders. A clinical prospective study. Frontiers in psychiatry9, 292.

[16] de Greck, M., Bölter, A. F., Lehmann, L., Ulrich, C., Stockum, E., Enzi, B., ... & Northoff, G. (2013). Changes in brain activity of somatoform disorder patients during emotional empathy after multimodal psychodynamic psychotherapy. Frontiers in human neuroscience7, 410.

[17] Dalgleish, T., Black, M., Johnston, D., & Bevan, A. (2020). Transdiagnostic approaches to mental health problems: Current status and future directions. Journal of consulting and clinical psychology88(3), 179.

[18] Davidson, L., O'Connell, M. J., Tondora, J., Lawless, M., & Evans, A. C. (2005). Recovery in serious mental illness: a new wine or just a new bottle?. Professional psychology: research and practice36(5), 480.