Countrygirl
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In this new Lancet article, our favourite duo, Sharpe and Per Fink recommend more intensive CBT for the severely ill.
http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00233-3/fulltext?elsca1=etoc&elsca2=email&elsca3=2215-0366_201507_2_7_&elsca4=Forensic and Legal Medicine|Lancet|Neuropsychiatry|Psychiatry/Addiction Medicine
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http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00233-3/fulltext?elsca1=etoc&elsca2=email&elsca3=2215-0366_201507_2_7_&elsca4=Forensic and Legal Medicine|Lancet|Neuropsychiatry|Psychiatry/Addiction Medicine
The discipline of so-called medically unexplained or functional somatic symptoms is divided into a large number of terminology-defined diagnostic concepts that have been developed on the basis of expert consensus rather than through systematic research in representative samples.1 These diagnoses have been used to define inclusion criteria for clinical trials and establish which trials are selected for meta-analyses. The result is a confusing scientific literature and contradictory systematic reviews. Although a focus on symptom clusters such as gastrointestinal symptoms (irritable bowel syndrome), musculoskeletal pain (fibromyalgia), and fatigue (chronic fatigue syndrome) makes some sense because these clusters are supported by epidemiological research,2division of patients by arbitrarily defined diagnostic constructs that describe the same clinical conditions (namely medical functional somatic syndromes as opposed to psychiatric somatoform disorders) is unhelpful and could be misleading.2,3
An example is the Cochrane review on non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms,figure). The figure shows that although effect sizes were similar across the partly overlapping diagnostic groups (range 0·32–0·51), we noted a considerable difference when we grouped patients according to illness severity. The most severely ill patients gained little from group CBT (effect size 0·29 [95% CI −0·12 to 0·71]; p=0·17), whereas patients with less severe illness had substantial symptom reductions (0·72 [0·33–1·11]; p=0·0003). Although this analysis was not planned in advance and therefore should be treated with caution, its results are in line with the few systematic reviews that have attempted to cover the whole discipline of functional somatic syndromes.6 On the basis of this work, stepped-care models have been proposed in which psychological treatment delivered by specialists is reserved for patients with severe illness, whereas enhanced care alone is recommended in mild and moderate cases.6, 7 Our results suggest that the most severely ill patients might need even more intensive treatment than that delivered in our trial.
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We defined the most severely ill patients as those who reported more than 30 functional somatic symptoms during the past 2 years and who had severe impairment in daily living according to the clinician. Because these patients meet diagnostic criteria for more functional somatic syndromes than do patients with less severe illness,
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