Section 3 Psychopathology

*Psychosomatic Medicine*

2016;**30**(8):772-779

2016;**19**(5):488-495

Care):785-794

Medicine. 2017

(England). 2016

2017;**54**(1):17-26

[58] Samsel C et al. Integrated behavioral health care in pediatric subspecialty clinics. Child and

Supportive Care. 2017:1-9

Adolescent Psychiatric Clinics of North America. 2017;**26**(Pediatric Integrated

[59] Naoki Y et al. Association between family satisfaction and caregiver burden in cancer patients receiving outreach palliative care at home. Palliative &

[60] Hatano Y et al. Physician behavior toward death pronouncement in

palliative care units. Journal of Palliative

[61] Götze H et al. Anxiety, depression and quality of life in family caregivers of palliative cancer patients during home care and after the patient's death. European Journal of Cancer Care

[62] Yamaguchi T et al. Effects of endof-life discussions on the mental health of bereaved family members and quality of patient death and care. Journal of Pain and Symptom Management.

[63] Martínez BB, Custodio RP.

Relationship between mental health and spiritual wellbeing among hemodialysis patients: A correlation study. São Paulo Medical Journal. 2014;**132**(1):23-27

[56] Tong E et al. The meaning of self-reported death anxiety in advanced cancer. Palliative Medicine.

[57] Okamoto Y et al. Do symptoms among home palliative care patients with advanced cancer decide the place of death? Focusing on the presence or absence of symptoms during home care. Journal of Palliative Medicine.

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**95**

**1. Introduction**

**Chapter 5**

**Abstract**

Assessing the Effectiveness

of Brief and Low Intensity

Review of the Literature

*Orla McDevitt-Petrovic and Karen Kirby*

**Keywords:** LICBT, MUS, HA, depression, anxiety

**1.1 Definitions, diagnostic criteria and comorbidities**

Psychological Interventions for

Medically Unexplained Symptoms

and Health Anxiety: A Systematic

This chapter presents a systematic review of the literature to assess the effectiveness of *brief* psychological interventions for medically unexplained symptoms (MUS)/somatic symptom disorder, non-cardiac chest pain, and illness anxiety disorder or health anxiety (HA). Google Scholar, PubMed, and Web of Science were searched as data sources. Reference lists were subsequently examined for other relevant articles. Studies were assessed according to specified inclusion criteria and extracted according to PRISMA guidelines. A total of 23 studies were included in the final synthesis. Significant effects for intervention groups relative to control groups were reported in 19 studies, whilst 4 studies did not determine any significant benefits of interventions compared with controls. All of the brief interventions (CBT, psychosocial, psychophysiological, psychosomatic, relaxation and group therapy), with the exception of metaphor therapy, showed significant effects relative to controls in at least one study. The evidence suggests that brief psychological interventions, more specifically time limited CBT based interventions may be effective in treating HA and MUS with psychological distress. Findings are comparable with other reviews. Future research may facilitate the piloting of an intervention, and there remains a need to provide more robust evidence of cost effectiveness.

There has been considerable dispute around the classification and terminologies used in relation to medically unexplained symptoms (MUS) and associated syndromes [1, 2]. MUS is a general term for syndromes without a known pathological cause. The use of the term itself is also often problematic given the negative connotations. Indeed, many patients prefer the use of alternative terms, for example 'persistent physical

#### **Chapter 5**

## Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically Unexplained Symptoms and Health Anxiety: A Systematic Review of the Literature

*Orla McDevitt-Petrovic and Karen Kirby*

### **Abstract**

This chapter presents a systematic review of the literature to assess the effectiveness of *brief* psychological interventions for medically unexplained symptoms (MUS)/somatic symptom disorder, non-cardiac chest pain, and illness anxiety disorder or health anxiety (HA). Google Scholar, PubMed, and Web of Science were searched as data sources. Reference lists were subsequently examined for other relevant articles. Studies were assessed according to specified inclusion criteria and extracted according to PRISMA guidelines. A total of 23 studies were included in the final synthesis. Significant effects for intervention groups relative to control groups were reported in 19 studies, whilst 4 studies did not determine any significant benefits of interventions compared with controls. All of the brief interventions (CBT, psychosocial, psychophysiological, psychosomatic, relaxation and group therapy), with the exception of metaphor therapy, showed significant effects relative to controls in at least one study. The evidence suggests that brief psychological interventions, more specifically time limited CBT based interventions may be effective in treating HA and MUS with psychological distress. Findings are comparable with other reviews. Future research may facilitate the piloting of an intervention, and there remains a need to provide more robust evidence of cost effectiveness.

**Keywords:** LICBT, MUS, HA, depression, anxiety

#### **1. Introduction**

#### **1.1 Definitions, diagnostic criteria and comorbidities**

There has been considerable dispute around the classification and terminologies used in relation to medically unexplained symptoms (MUS) and associated syndromes [1, 2]. MUS is a general term for syndromes without a known pathological cause. The use of the term itself is also often problematic given the negative connotations. Indeed, many patients prefer the use of alternative terms, for example 'persistent physical

symptoms' [3]. The current review assesses the effectiveness of brief interventions for MUS, illness anxiety disorder, somatic symptom disorder, health anxiety (HA) and non-cardiac chest pain (NCCP). Although there may be a degree of overlap within these, it is important to outline what distinguishing features there may be.

Some of the most pronounced revisions within the latest version of the DSM-V relate to MUS [4]. A new category ('Somatic Symptom and Related Disorders') has been created, wherein MUS fits. The category includes diagnoses of Somatic Symptom Disorder (SSD) which replaces the term MUS, and Illness Anxiety Disorder (IAD) which replaces HA. The term hypochondriasis is no longer referred to. The key difference between MUS and SSD is that SSD accounts for cases where symptoms may have an underlying pathology, but there remains an exaggerated response. However, given that SSD also includes cases where there is an absence of pathological cause (i.e. MUS), the term has been included in the current review in addition to a specific SSD and NCCP. The terms IAD and HA are both used to refer to the preoccupation with having a serious illness; somatic symptoms may not be present, or may present in mild form. MUS and IAD may therefore present in isolation or comorbidly; this is determined by the presence (or not) of physical symptoms without pathological cause, and the subsequent response to these.

Up to one third of individuals with physical heath presentations have MUS [5]. The prevalence of MUS within the general population, and more particularly within medical settings, is high [6, 7]. MUS and HA are both associated with increased costs accrued through frequent and inappropriate use of healthcare services, absenteeism and long-term unemployment [8, 9]. It has been estimated that annual healthcare service costs resulting from psychosomatic symptoms are approximately £3 billion in the UK [10].

#### **1.2 The role of depression and anxiety**

Pain is one of the most commonly presented MUS [11]. Physical symptoms are highly prevalent in depression and may result in chronic pain and impede treatment effectiveness. Depression and pain are influenced by the same neurochemical processes, therefore both must be treated simultaneously in order to achieve improvements. Previous research has demonstrated that improvements in depressive symptoms was correlated with the improvement of some physical symptoms [12]. The prevalence of depression and anxiety among MUS patients has been estimated at 70% [11]. The division between services for physical health problems and mental health disorders reinforces the notion of body and mind as entirely separate entities, consequently adding to the psychological distress associated with MUS [13]. In relation to NCCP specifically, higher levels of anxiety have been detected among individuals with NCCP compared with health individuals [14]. Given that MUS and pain have high levels of psychiatric comorbidity, it has been suggested that a multidisciplinary intervention strategy may be appropriate [15].

#### **1.3 Psychological interventions: MUS/SSD**

Qualitative research has reported that individuals with MUS have a tendency to reject psychological constructs of their problems [16], resulting in an unwillingness to engage in psychological treatments [8, 17, 18]. However other studies have suggested that a significant percentage of these patients would consent to undergo psychological or psychiatric interventions [19]. Evidence suggests that cognitive behaviour therapy (CBT) is beneficial in the treatment of MUS [20, 21]. A systematic review and meta-analysis of non-pharmacological interventions for somatoform disorders and MUS in adults determined that psychological therapies irrespective of modality

**97**

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically…*

were more beneficial overall than standard care or waiting lists in relation to reducing symptoms severity [22]. Fourteen from twenty one studies included in the review and subsequent analysis focused on CBT based interventions. CBT was determined to be more effective in reducing the severity of MUS, but there was insufficient evidence to support the efficacy of other modalities. Furthermore, although there is a robust evidence base demonstrating the effectiveness of high intensity CBT for somatoform related disorders, there are limited reviews investigating the effectiveness of low

A critical review of 31 controlled clinical trials including 1600 patients where CBT was employed as an intervention for somatization and symptoms syndromes, found that CBT contributed to the improvement of physical symptoms in 71% of studies, functional status in 47% and psychological distress in 38% [23] Furthermore, group therapy and brief treatments of 5 sessions were also found to be effective, with benefits maintained for up to one year. The review concluded that CBT is an effective intervention for this patient population, and that benefits were achievable even if psychological distress was not entirely alleviated. Similarly, although the focus was not on brief or low intensity treatments, a randomised clinical trial comparing an intensive psychodynamic therapy and CBT for patients with medically unexplained pain indicated that both groups achieved reductions in psychological distress, catastrophic thinking and depression; and interventions were deemed to be equally effective at a three month follow up [24]. The CBT group however, demonstrated an improvement in self-efficacy that was not observed in

In relation to low intensity (brief) interventions, patients attending an IAPT pilot site specifically tailored for long term conditions (LTC)/MUS referrals were offered either a low intensity CBT (guided self-help delivered by a Psychological Wellbeing Practitioner) based intervention, or a mindfulness-based stress reduction treatment (brief, low intensity interventions). Subsequent thematic analysis of qualitative interviews indicated that patients typically reported a positive treatment experience, and felt better able to manage symptoms, even if this was not necessarily reflected by psychometric scores on the Patient Health Questionnaire-9 (PHQ9), Generalised Anxiety Disorder-7 (GAD7), and the WSAS. Although these interventions have been determined as appropriate for these patient groups, it has been suggested in terms of evaluation, that routine outcome measures may not entirely capture the true benefits of interventions [25]. It is also important to consider the clinical implications of these initial findings, namely that there were a higher number of LTC referrals compared with MUS. This may be partly explained by previous reports that GPs feel inadequate and discouraged when dealing with MUS cases [26]. Furthermore, as previously highlighted, research has indicated that MUS patients believe there is disparity between their physical symptoms and a psychological intervention [27]. The difference in referral rates between LTC and MUS patients suggest a need for separate dedicated services for each of these

Current reviews of clinical care have highlighted a failure to appropriately manage NCCP despite the substantial prevalence rates [29]. Studies to date have pointed to the efficacy of CBT [30, 31]. The efficacy of CBT as an intervention for NCCP has been evaluated in a number of randomised controlled trials [32]. A comparison of CBT and standard clinical advice among NCCP patients found major reductions in both the frequency and severity of symptoms in the CBT group, and only modest

*DOI: http://dx.doi.org/10.5772/intechopen.93912*

intensity or brief psychological interventions.

the other group.

patient groups [28].

**1.4 Psychological interventions: NCCP**

improvements within the control group [13].

#### *Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically… DOI: http://dx.doi.org/10.5772/intechopen.93912*

were more beneficial overall than standard care or waiting lists in relation to reducing symptoms severity [22]. Fourteen from twenty one studies included in the review and subsequent analysis focused on CBT based interventions. CBT was determined to be more effective in reducing the severity of MUS, but there was insufficient evidence to support the efficacy of other modalities. Furthermore, although there is a robust evidence base demonstrating the effectiveness of high intensity CBT for somatoform related disorders, there are limited reviews investigating the effectiveness of low intensity or brief psychological interventions.

A critical review of 31 controlled clinical trials including 1600 patients where CBT was employed as an intervention for somatization and symptoms syndromes, found that CBT contributed to the improvement of physical symptoms in 71% of studies, functional status in 47% and psychological distress in 38% [23] Furthermore, group therapy and brief treatments of 5 sessions were also found to be effective, with benefits maintained for up to one year. The review concluded that CBT is an effective intervention for this patient population, and that benefits were achievable even if psychological distress was not entirely alleviated. Similarly, although the focus was not on brief or low intensity treatments, a randomised clinical trial comparing an intensive psychodynamic therapy and CBT for patients with medically unexplained pain indicated that both groups achieved reductions in psychological distress, catastrophic thinking and depression; and interventions were deemed to be equally effective at a three month follow up [24]. The CBT group however, demonstrated an improvement in self-efficacy that was not observed in the other group.

In relation to low intensity (brief) interventions, patients attending an IAPT pilot site specifically tailored for long term conditions (LTC)/MUS referrals were offered either a low intensity CBT (guided self-help delivered by a Psychological Wellbeing Practitioner) based intervention, or a mindfulness-based stress reduction treatment (brief, low intensity interventions). Subsequent thematic analysis of qualitative interviews indicated that patients typically reported a positive treatment experience, and felt better able to manage symptoms, even if this was not necessarily reflected by psychometric scores on the Patient Health Questionnaire-9 (PHQ9), Generalised Anxiety Disorder-7 (GAD7), and the WSAS. Although these interventions have been determined as appropriate for these patient groups, it has been suggested in terms of evaluation, that routine outcome measures may not entirely capture the true benefits of interventions [25]. It is also important to consider the clinical implications of these initial findings, namely that there were a higher number of LTC referrals compared with MUS. This may be partly explained by previous reports that GPs feel inadequate and discouraged when dealing with MUS cases [26]. Furthermore, as previously highlighted, research has indicated that MUS patients believe there is disparity between their physical symptoms and a psychological intervention [27]. The difference in referral rates between LTC and MUS patients suggest a need for separate dedicated services for each of these patient groups [28].

#### **1.4 Psychological interventions: NCCP**

Current reviews of clinical care have highlighted a failure to appropriately manage NCCP despite the substantial prevalence rates [29]. Studies to date have pointed to the efficacy of CBT [30, 31]. The efficacy of CBT as an intervention for NCCP has been evaluated in a number of randomised controlled trials [32]. A comparison of CBT and standard clinical advice among NCCP patients found major reductions in both the frequency and severity of symptoms in the CBT group, and only modest improvements within the control group [13].

*Psychosomatic Medicine*

£3 billion in the UK [10].

**1.2 The role of depression and anxiety**

symptoms' [3]. The current review assesses the effectiveness of brief interventions for MUS, illness anxiety disorder, somatic symptom disorder, health anxiety (HA) and non-cardiac chest pain (NCCP). Although there may be a degree of overlap within

Some of the most pronounced revisions within the latest version of the DSM-V relate to MUS [4]. A new category ('Somatic Symptom and Related Disorders') has been created, wherein MUS fits. The category includes diagnoses of Somatic Symptom Disorder (SSD) which replaces the term MUS, and Illness Anxiety Disorder (IAD) which replaces HA. The term hypochondriasis is no longer referred to. The key difference between MUS and SSD is that SSD accounts for cases where symptoms may have an underlying pathology, but there remains an exaggerated response. However, given that SSD also includes cases where there is an absence of pathological cause (i.e. MUS), the term has been included in the current review in addition to a specific SSD and NCCP. The terms IAD and HA are both used to refer to the preoccupation with having a serious illness; somatic symptoms may not be present, or may present in mild form. MUS and IAD may therefore present in isolation or comorbidly; this is determined by the presence (or not) of physical symptoms without pathological cause, and the subsequent response to these.

Up to one third of individuals with physical heath presentations have MUS [5]. The prevalence of MUS within the general population, and more particularly within medical settings, is high [6, 7]. MUS and HA are both associated with increased costs accrued through frequent and inappropriate use of healthcare services, absenteeism and long-term unemployment [8, 9]. It has been estimated that annual healthcare service costs resulting from psychosomatic symptoms are approximately

Pain is one of the most commonly presented MUS [11]. Physical symptoms are highly prevalent in depression and may result in chronic pain and impede treatment effectiveness. Depression and pain are influenced by the same neurochemical processes, therefore both must be treated simultaneously in order to achieve improvements. Previous research has demonstrated that improvements in depressive symptoms was correlated with the improvement of some physical symptoms [12]. The prevalence of depression and anxiety among MUS patients has been estimated at 70% [11]. The division between services for physical health problems and mental health disorders reinforces the notion of body and mind as entirely separate entities, consequently adding to the psychological distress associated with MUS [13]. In relation to NCCP specifically, higher levels of anxiety have been detected among individuals with NCCP compared with health individuals [14]. Given that MUS and pain have high levels of psychiatric comorbidity, it has been suggested that a

Qualitative research has reported that individuals with MUS have a tendency to reject psychological constructs of their problems [16], resulting in an unwillingness to engage in psychological treatments [8, 17, 18]. However other studies have suggested that a significant percentage of these patients would consent to undergo psychological

or psychiatric interventions [19]. Evidence suggests that cognitive behaviour therapy (CBT) is beneficial in the treatment of MUS [20, 21]. A systematic review and meta-analysis of non-pharmacological interventions for somatoform disorders and MUS in adults determined that psychological therapies irrespective of modality

multidisciplinary intervention strategy may be appropriate [15].

**1.3 Psychological interventions: MUS/SSD**

these, it is important to outline what distinguishing features there may be.

**96**

Similarly, an RCT with UCP patients and found that those who had completed a course of CBT had a significantly higher treatment response when compared with placebo and medication groups [30]. A LICBT intervention, more specifically 'coping skills' resulted in significant improvement relating to the catastrophizing of pain symptoms and anxiety when compared to a placebo group [33].

Recent research has also emphasised the success of brief cognitive behavioural therapy, with a three session CBT intervention determined as effective for UCP patients in terms of illness perception [34]. A recent study concluded that a brief cognitive behavioural intervention significantly reduced levels of anxiety and depression in patients with NCCP, with a diagnosis of panic and/or a depressive disorder based on Hospital anxiety and depression scale (HADS) scores [35]. Based on these findings, it was recommended that individuals presenting with NCCP should be assessed for psychopathology, and a cognitive behavioural intervention offered in cases where psychological difficulties are detected. Cognitive behavioural interventions as brief as even a single session initiated within two weeks of an emergency attendance for the primary complaint of chest pain, have also been found to be effective for panic disorder [36]. Furthermore, it has been recommended that increased efforts should be employed to implement these interventions in the emergency department/primary care setting, considering the high prevalence of panic disorder there.

#### **1.5 Psychological interventions: HA/IAD**

A recent systemic review and meta-analysis evaluating CBT for health anxiety found a large effect size for CBT compared with several control conditions including standard care, waiting lists, medications and other psychological therapies [37]. In Van Gils et al. [38], another systematic review and met-analysis suggested self-help was associated with significant reduction in symptom severity and improvement in quality of life measures among individuals with MUS [38]. Low intensity interventions which are brief and facilitate flexible delivery have been determined as effective for identified health anxiety within medical settings [39].

#### **1.6 Aims of the current review**

A recent study determined that 58.7% of all chest pain presentations to an ED across a three year period resulted in a diagnosis of NCCP [40]. However, care pathways and guidance on the most appropriate interventions for this patient population are very unclear. To date a consolidated and systematic review has not been carried out. In light of these findings, and given the lack of reviews focused on *brief or low intensity* treatments, the purpose of the current review was to assess the effectiveness of brief interventions which may be suitable for these particular and similar patient populations. Given that there is a high prevalence of MUS within primary care with possible associated anxiety, this review sought to examine evidence for brief interventions which may in principle, improve ease of access to appropriate treatment within a stepped care approach, and be implemented at a reduced cost compared with higher intensity or longer term treatments in secondary care. To ensure a more robust assessment, conditions which may exist comorbidly with NCCP were included. Therefore the current review specifically aimed to assess the effectiveness of brief interventions for MUS, illness anxiety disorder,

**99**

**Table 1.** *Search strategy.*

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically…*

Studies were assessed for eligibility for inclusion as per the following criteria: (1) written in the English language; (2) published in a journal; (3) included a quantitative evaluation of a brief intervention, with brief defined as ten or fewer individual of group based treatment sessions; (4) interventions were aimed at reducing the frequency and/or impact of MUS, HA, SSD, illness anxiety disorder, or NCCP; (5) participants were over 18 years of age; (6) outcome measures indicated the degree of MUS, and/or psychological wellbeing pre and post intervention; and (7) ran-

Three databases, specifically Google Scholar, PubMed, and Web of Science were searched for full-text articles which were published in peer reviewed journals. Combinations of the following keywords were used: brief\* and intervention\*, treatment\*, therapy\*. The key search terms were (1) medically unexplained symptoms (2) health anxiety, (3) somatic symptom disorder, (4) illness anxiety disorder and (5) non-cardiac chest pain. **Table 1** indicates the complete search strategy employed in Google Scholar advanced searches, which was subsequently modified for the remaining searches. The reference lists of the articles selected from database

Studies were selected by (1) screening the titles; (2) screening the abstracts and methodologies; (3) reviewing the complete paper if the title, abstract and methodologies did not present conclusive evidence that the inclusion criteria were achieved. Studies which did not meet inclusion criteria were subsequently disregarded. Data were extracted according to PRISMA guidelines, onto an Excel workbook which was

SSD, HA and NCCP, accounting also for the recent changes in terminologies

*DOI: http://dx.doi.org/10.5772/intechopen.93912*

and diagnostic criteria within the DSM-V.

domised controlled trial, with control group(s).

**2. Method**

**2.1 Eligibility criteria**

**2.2 Search strategy**

searches were also examined.

**Searches**

a. brief intervention\* b. brief treatment\* c. or brief therapy\*

**2.3 Study selection and data extraction**

d. and exact phrase medically unexplained symptoms

e. or somatic symptom disorder (exact) f. or illness anxiety disorder (exact)

g. or health anxiety (exact) h. or non-cardiac chest pain (exact) *Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically… DOI: http://dx.doi.org/10.5772/intechopen.93912*

SSD, HA and NCCP, accounting also for the recent changes in terminologies and diagnostic criteria within the DSM-V.

#### **2. Method**

*Psychosomatic Medicine*

group [33].

panic disorder there.

settings [39].

**1.6 Aims of the current review**

**1.5 Psychological interventions: HA/IAD**

Similarly, an RCT with UCP patients and found that those who had completed a course of CBT had a significantly higher treatment response when compared with placebo and medication groups [30]. A LICBT intervention, more specifically 'coping skills' resulted in significant improvement relating to the catastrophizing of pain symptoms and anxiety when compared to a placebo

Recent research has also emphasised the success of brief cognitive behavioural therapy, with a three session CBT intervention determined as effective for UCP patients in terms of illness perception [34]. A recent study concluded that a brief cognitive behavioural intervention significantly reduced levels of anxiety and depression in patients with NCCP, with a diagnosis of panic and/or a depressive disorder based on Hospital anxiety and depression scale (HADS) scores [35]. Based on these findings, it was recommended that individuals presenting with NCCP should be assessed for psychopathology, and a cognitive behavioural intervention offered in cases where psychological difficulties are detected. Cognitive behavioural interventions as brief as even a single session initiated within two weeks of an emergency attendance for the primary complaint of chest pain, have also been found to be effective for panic disorder [36]. Furthermore, it has been recommended that increased efforts should be employed to implement these interventions in the emergency department/primary care setting, considering the high prevalence of

A recent systemic review and meta-analysis evaluating CBT for health anxiety

A recent study determined that 58.7% of all chest pain presentations to an ED across a three year period resulted in a diagnosis of NCCP [40]. However, care pathways and guidance on the most appropriate interventions for this patient population are very unclear. To date a consolidated and systematic review has not been carried out. In light of these findings, and given the lack of reviews focused on *brief or low intensity* treatments, the purpose of the current review was to assess the effectiveness of brief interventions which may be suitable for these particular and similar patient populations. Given that there is a high prevalence of MUS within primary care with possible associated anxiety, this review sought to examine evidence for brief interventions which may in principle, improve ease of access to appropriate treatment within a stepped care approach, and be implemented at a reduced cost compared with higher intensity or longer term treatments in secondary care. To ensure a more robust assessment, conditions which may exist comorbidly with NCCP were included. Therefore the current review specifically aimed to assess the effectiveness of brief interventions for MUS, illness anxiety disorder,

found a large effect size for CBT compared with several control conditions including standard care, waiting lists, medications and other psychological therapies [37]. In Van Gils et al. [38], another systematic review and met-analysis suggested self-help was associated with significant reduction in symptom severity and improvement in quality of life measures among individuals with MUS [38]. Low intensity interventions which are brief and facilitate flexible delivery have been determined as effective for identified health anxiety within medical

**98**

#### **2.1 Eligibility criteria**

Studies were assessed for eligibility for inclusion as per the following criteria: (1) written in the English language; (2) published in a journal; (3) included a quantitative evaluation of a brief intervention, with brief defined as ten or fewer individual of group based treatment sessions; (4) interventions were aimed at reducing the frequency and/or impact of MUS, HA, SSD, illness anxiety disorder, or NCCP; (5) participants were over 18 years of age; (6) outcome measures indicated the degree of MUS, and/or psychological wellbeing pre and post intervention; and (7) randomised controlled trial, with control group(s).

#### **2.2 Search strategy**

Three databases, specifically Google Scholar, PubMed, and Web of Science were searched for full-text articles which were published in peer reviewed journals. Combinations of the following keywords were used: brief\* and intervention\*, treatment\*, therapy\*. The key search terms were (1) medically unexplained symptoms (2) health anxiety, (3) somatic symptom disorder, (4) illness anxiety disorder and (5) non-cardiac chest pain. **Table 1** indicates the complete search strategy employed in Google Scholar advanced searches, which was subsequently modified for the remaining searches. The reference lists of the articles selected from database searches were also examined.

#### **2.3 Study selection and data extraction**

Studies were selected by (1) screening the titles; (2) screening the abstracts and methodologies; (3) reviewing the complete paper if the title, abstract and methodologies did not present conclusive evidence that the inclusion criteria were achieved. Studies which did not meet inclusion criteria were subsequently disregarded. Data were extracted according to PRISMA guidelines, onto an Excel workbook which was


used throughout the searches and the review. This was used specifically to record information about study and participant characteristics, details of interventions, outcome measures and analyses.

#### **2.4 Risk of bias**

The Cochrane Collaboration Risk of Bias Tool was used in order to assess the risk of bias in the studies selected for the review. This involved screening for bias risk in relation to sequence generation, allocation concealment, blinding of participants and assessors, incomplete data, selective reporting and any other relevant bias. Both authors independently reviewed the selected studies and subsequently agreed on the level of risk of bias as either low, unclear or high.

#### **3. Results**

#### **3.1 Study selection**

The literature search and search of references from fully screened articles yielded a total of 1674 studies. After removal of duplicates the total was 885. **Figure 1** indicates the process of exclusion and final selection.

#### **3.2 Study characteristics**

#### *3.2.1 Location*

A summary of the selected studies is presented in **Table 2**. Studies originated in the USA (n = 6), Spain (n = 2), Germany (n = 2), Netherlands (n = 3), UK (n = 4), Iran (n = 2), Norway (n = 1), Sweden (n = 1) and Canada (n = 2). In seven of the studies, the purpose was to evaluate the effect of interventions on medically unexplained symptoms. The remaining studies investigated intervention effects on somatisation (n = 3), health anxiety (n = 2), hypochondriasis (n = 2) and non-cardiac chest pain [10]. All studies considered effectiveness in terms of physical symptoms and psychological wellbeing.

#### **3.3 Participants**

All of the included studies involved both male and female participants, and ages ranged from 16 to 81. The total number of participants varied in each of the studies. Eleven of the studies included less than 60 participants, 4 studies included between 61 and 100 participants, 3 studies included between 101 and 150 participants, 4 studies included between 151 and 200 participants and one study involved 444 participants.

#### *3.3.1 Sample size*

All studies employed selective sampling methods (purposive), whereby potential participants were initially identified by health professionals prior to subsequent additional eligibility screening using diagnostic interview and psychometric questionnaires. Five studies concurrently used opportunistic sampling methods (through public advertising) prior to the additional screening. Six studies provided some details of power calculations made in order to determine optimum sample sizes. The remaining studies did not describe how sample size was calculated.

**101**

*3.3.4 Duration*

**Figure 1.**

months to four years.

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically…*

All of the included studies used random allocation to intervention or control groups. However, one of these studies [41] did not allocate participants in a conventional way, given that they were not actually randomly assigned to conditions, but rather the decision was taken by the authors (for ethical reasons) that the order of

All of the interventions had a psychological basis. Cognitive behavioural therapy formed the theoretical basis of the interventions in 17 of the studies. Two studies described the intervention as psychosocial and communicative. One study described the intervention as psychophysiological, and one study used a brief psychosomatic intervention. Two studies used relaxation and metaphor therapies. Interventions were delivered as individual sessions in the majority of studies (n = 20), and interventions were delivered in a group basis in the remaining studies (see **Table 2**).

The studies selected for the current review varied in their duration from six

the three condition cohorts should be randomly predetermined.

*DOI: http://dx.doi.org/10.5772/intechopen.93912*

*3.3.2 Unit of allocation and risk of bias*

*Prisma flow diagram of search results and selected studies.*

*3.3.3 Theoretical basis of the interventions*

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically… DOI: http://dx.doi.org/10.5772/intechopen.93912*

#### **Figure 1.**

*Psychosomatic Medicine*

**2.4 Risk of bias**

**3. Results**

*3.2.1 Location*

**3.1 Study selection**

**3.2 Study characteristics**

and psychological wellbeing.

**3.3 Participants**

participants.

*3.3.1 Sample size*

outcome measures and analyses.

the level of risk of bias as either low, unclear or high.

**Figure 1** indicates the process of exclusion and final selection.

used throughout the searches and the review. This was used specifically to record information about study and participant characteristics, details of interventions,

The Cochrane Collaboration Risk of Bias Tool was used in order to assess the risk of bias in the studies selected for the review. This involved screening for bias risk in relation to sequence generation, allocation concealment, blinding of participants and assessors, incomplete data, selective reporting and any other relevant bias. Both authors independently reviewed the selected studies and subsequently agreed on

The literature search and search of references from fully screened articles yielded a total of 1674 studies. After removal of duplicates the total was 885.

A summary of the selected studies is presented in **Table 2**. Studies originated in the USA (n = 6), Spain (n = 2), Germany (n = 2), Netherlands (n = 3), UK (n = 4), Iran (n = 2), Norway (n = 1), Sweden (n = 1) and Canada (n = 2). In seven of the studies, the purpose was to evaluate the effect of interventions on medically unexplained symptoms. The remaining studies investigated intervention effects on somatisation (n = 3), health anxiety (n = 2), hypochondriasis (n = 2) and non-cardiac chest pain [10]. All studies considered effectiveness in terms of physical symptoms

All of the included studies involved both male and female participants, and ages ranged from 16 to 81. The total number of participants varied in each of the studies. Eleven of the studies included less than 60 participants, 4 studies included between 61 and 100 participants, 3 studies included between 101 and 150 participants, 4 studies included between 151 and 200 participants and one study involved 444

All studies employed selective sampling methods (purposive), whereby potential participants were initially identified by health professionals prior to subsequent additional eligibility screening using diagnostic interview and psychometric questionnaires. Five studies concurrently used opportunistic sampling methods (through public advertising) prior to the additional screening. Six studies provided some details of power calculations made in order to determine optimum sample sizes. The remaining studies did not describe how sample size was calculated.

**100**

*Prisma flow diagram of search results and selected studies.*

#### *3.3.2 Unit of allocation and risk of bias*

All of the included studies used random allocation to intervention or control groups. However, one of these studies [41] did not allocate participants in a conventional way, given that they were not actually randomly assigned to conditions, but rather the decision was taken by the authors (for ethical reasons) that the order of the three condition cohorts should be randomly predetermined.

#### *3.3.3 Theoretical basis of the interventions*

All of the interventions had a psychological basis. Cognitive behavioural therapy formed the theoretical basis of the interventions in 17 of the studies. Two studies described the intervention as psychosocial and communicative. One study described the intervention as psychophysiological, and one study used a brief psychosomatic intervention. Two studies used relaxation and metaphor therapies. Interventions were delivered as individual sessions in the majority of studies (n = 20), and interventions were delivered in a group basis in the remaining studies (see **Table 2**).

#### *3.3.4 Duration*

The studies selected for the current review varied in their duration from six months to four years.


**103**

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically…*

**session**

**SSP***: Somatoform Symptoms Scale;* **BSI-GSI***: Global Severity Index;* **BDI***: Beck Depression Inventory;* **KKG-I:** *'Internal Control' Multidimensional Self-Report Questionnaire;* **WI***: Whitely Index;* **PSC-51***: Physical Symptoms Checklist;* **HADS***: Hospital Anxiety And Depression Scale;* **NHL***: Nijmegen Hyperventilation List;***4DSQ***: Four-Dimensional Symptom Questionnaire (Distress, Anxiety, Depression, Somatization);* **MAF***: Measure of General Functioning;* **EQ-5***D: Health Related Quality Of Life;* **STAI***: State Trait Anxiety Inventory;* **SCL-90***: Symptom Checklist;* **BSQ***: Bodily Sensations Questionnaire;* **HRQOL***: Health Related Quality of Life;* **BPI***: Brief Pain Inventory;* **JIBT***: Jones Irrational Belief Test;* **PHQ-9***: Patient Health Questionnaire (Depression);* **CAQ***: Cardiac Anxiety Questionnaire;* **FQ:** *Fear Questionnaire;* **MINI***: Mini International Neuropsychiatric Interview;*  **ASI***: Anxiety Sensitivity Index;* **HCQ***: Hypochondrial Cognitions Questionnaire;* **SSI***: Somatic Symptoms Inventory;* **FSQ***: Functional Status Questionnaire;* **SIS***: Severity of Illness Scale;* **PDS***: Pain Discomfort Scale;*  **DASS***: Depression, Anxiety, Stress Scale;* **PAS***: Panic, Agoraphobia Scale;* **ADIS-IV***: Anxiety Disorder Interview Schedule;* **SSS***: Severity of Somatic Symptom Scale;* **GHQ***: General Health Questionnaire;* **SUI***: Summary Utility Index;* **ACQ***: Agoraphobic Cognitions Questionnaire;* **IAS***: Illness Attitude Scale;* **SDIH***: Structured Diagnostic Interview, Hypochondriasis;* **FSS***: Fear Survey Schedule;* **DAS***: Dysfunctional Attitude Scale;* **QOL***: Quality of Life Questionnaire;* **DHBQ***: Dysfunctional Health Beliefs Questionnaire;* **NEO-PI***: Personality Inventory;* **SIP***: Sickness* 

**Duration of treatment**

90 minutes 6 sessions IAS, SDIH, BDI,

2 hours 6 sessions HADS, NHL, SIP,

**Measures**

NHP

FSS, DAS, QOL, DHBQ, NEO-PI

The vast majority of the selected studies (n = 21), employed a 'treatment as usual' control condition. The remaining 2 studies [42, 43] employed 'waiting list'

The cognitive behavioural model considers predisposing, precipitating and perpetuating factors [44]. Psychological distress may be triggered and maintained in individuals with physical health symptoms via a cycle of inaccurate perceptions, avoidance behaviours and subsequent intensification of symptoms. Four of the selected studies included brief CBT based interventions targeting MUS/SSD. One of these, assessed the effectiveness of a 10 session treatment (averaging 50 minutes duration), which had been modified to target somatization problems. More specifically it applied relaxation training, emotional awareness, cognitive restructuring (CR) and communication [45]. Another study facilitated a single session (3–4 hours) which focused primarily on developing psychophysiological explanations of symptoms, relaxation, cognitions and healthcare use [46]. The third of these studies based their brief CBT intervention on the Consequences model within which the focus is on the consequences as opposed to the causes of physical symptoms; applied techniques aim to alter the consequences of symptoms [47, 48]. Participants were offered a maximum of 5, 45 minute sessions. The final study

*DOI: http://dx.doi.org/10.5772/intechopen.93912*

[42] Short-term group based educational CBT

[43] Short-term group

treatment

*Impact Profile;* **NHP***: Nottingham Health Profile.*

**Study Type of intervention Duration of** 

psychological (CBT based)

*3.3.5 Control conditions*

*Key characteristics of selected studies.*

**Table 2.**

control conditions.

*3.4.1 MUS/SSD*

*3.4.1.1 Brief CBT*

**3.4 Interventions: Description and impact**

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically… DOI: http://dx.doi.org/10.5772/intechopen.93912*


**SSP***: Somatoform Symptoms Scale;* **BSI-GSI***: Global Severity Index;* **BDI***: Beck Depression Inventory;* **KKG-I:** *'Internal Control' Multidimensional Self-Report Questionnaire;* **WI***: Whitely Index;* **PSC-51***: Physical Symptoms Checklist;* **HADS***: Hospital Anxiety And Depression Scale;* **NHL***: Nijmegen Hyperventilation List;***4DSQ***: Four-Dimensional Symptom Questionnaire (Distress, Anxiety, Depression, Somatization);* **MAF***: Measure of General Functioning;* **EQ-5***D: Health Related Quality Of Life;* **STAI***: State Trait Anxiety Inventory;* **SCL-90***: Symptom Checklist;* **BSQ***: Bodily Sensations Questionnaire;* **HRQOL***: Health Related Quality of Life;* **BPI***: Brief Pain Inventory;* **JIBT***: Jones Irrational Belief Test;* **PHQ-9***: Patient Health Questionnaire (Depression);* **CAQ***: Cardiac Anxiety Questionnaire;* **FQ:** *Fear Questionnaire;* **MINI***: Mini International Neuropsychiatric Interview;*  **ASI***: Anxiety Sensitivity Index;* **HCQ***: Hypochondrial Cognitions Questionnaire;* **SSI***: Somatic Symptoms Inventory;* **FSQ***: Functional Status Questionnaire;* **SIS***: Severity of Illness Scale;* **PDS***: Pain Discomfort Scale;*  **DASS***: Depression, Anxiety, Stress Scale;* **PAS***: Panic, Agoraphobia Scale;* **ADIS-IV***: Anxiety Disorder Interview Schedule;* **SSS***: Severity of Somatic Symptom Scale;* **GHQ***: General Health Questionnaire;* **SUI***: Summary Utility Index;* **ACQ***: Agoraphobic Cognitions Questionnaire;* **IAS***: Illness Attitude Scale;* **SDIH***: Structured Diagnostic Interview, Hypochondriasis;* **FSS***: Fear Survey Schedule;* **DAS***: Dysfunctional Attitude Scale;* **QOL***: Quality of Life Questionnaire;* **DHBQ***: Dysfunctional Health Beliefs Questionnaire;* **NEO-PI***: Personality Inventory;* **SIP***: Sickness Impact Profile;* **NHP***: Nottingham Health Profile.*

#### **Table 2.**

*Psychosomatic Medicine*

[50] Psychosocial and

[52] Time limited

[53] Brief multimodal

[55] Time-limited mindfulness cognitive therapy

[59] Brief psychoeducation based on CBT

[62] Relaxation training or metaphor therapy

[61] Guided internet therapy (CBT based)

[58] Brief CBT or

[36] Brief panic management (PM) or brief CBT

pharmacological treatment

communication intervention

psychophysiological intervention

psychodynamic therapy

**Study Type of intervention Duration of** 

**session**

[46] Single session CBT 3–4 hours One session BSI-SOM, SOMS-7

[39] Time limited CBT Not specified 5–10 sessions HADS, SFQ-36,

[45] Time limited CBT-type 45–60 minutes Maximum of 10

[47] Time limited CBT 45 minutes Maximum of 5

[41] Short-term CBT 60–90 minutes Maximum of 3

[35] Brief CBT 45 minutes Maximum of 6

[57] Time limited CBT 90 minutes Maximum of 6

[63] Metaphor therapy 2 hours Maximum of 4

[49] Time limited CBT Not specified Maximum of 10

[51] Brief psychosocial 20 minutes Maximum of 6

[60] Brief 1 hour 1 session Chest Pain

2 hours (PM) 1 hour (CBT)

[54] Short-term group therapy 2 hours 8 sessions SF-36

**Duration of treatment**

sessions

sessions

sessions

sessions

sessions

sessions

session and 2 brief follow-up phone calls

sessions

sessions

sessions

sessions

sessions

sessions

sessions

sessions

sessions

1 session (PM) 7 sessions (CBT)

1 hour Maximum of 7

30 minutes Maximum of six

Not specified Maximum of 10

45 minutes Maximum of 9

2 hours Maximum of 8

1 hour 1 face to face

2 hours Maximum of 4

Not specified Maximum of 4

**Measures**

NAS

KKG-I

EQ-5D

CGI-S, CGI-I, VAS, MOS-10, HAM-D, HAM-A

MOS, SF-36, CIDI, PRIME-MD, SLE,

BSI-GSI, WI, BDI,

PSC-51, HADS, MOS SF-36

CGI-S, HAM-A, HAM-D

VAS, NHL, 4DSQ, SF-36 MAF

DSM-IV (structured clinical interview), SHAI, WI, BAI, BDI

BDI, STAI, SF-36, WI, SCL-90

BSQ, SF-36, BDI, HRQOL

CAQ, BSQ, PHQ-9

CGI, HADS, MINI, STAI, FQ

Interview, ASI, CAQ, SF-36, BSI

PDS, DASS,

WI, HAI, HCQ, SSI, FSQ, SCL-90, SIS

ADIS-IV, ACQ, ASI, PAS, BDI, CAQ

CGI-SD, SF-36, SSS

ADIS-IV, BSQ, PAS, ASI, CAQ, ACQ

HADS, SF-36, GHQ,-12, SOMS

BPI, JIBT

**102**

*Key characteristics of selected studies.*

#### *3.3.5 Control conditions*

The vast majority of the selected studies (n = 21), employed a 'treatment as usual' control condition. The remaining 2 studies [42, 43] employed 'waiting list' control conditions.

#### **3.4 Interventions: Description and impact**

#### *3.4.1 MUS/SSD*

#### *3.4.1.1 Brief CBT*

The cognitive behavioural model considers predisposing, precipitating and perpetuating factors [44]. Psychological distress may be triggered and maintained in individuals with physical health symptoms via a cycle of inaccurate perceptions, avoidance behaviours and subsequent intensification of symptoms. Four of the selected studies included brief CBT based interventions targeting MUS/SSD. One of these, assessed the effectiveness of a 10 session treatment (averaging 50 minutes duration), which had been modified to target somatization problems. More specifically it applied relaxation training, emotional awareness, cognitive restructuring (CR) and communication [45]. Another study facilitated a single session (3–4 hours) which focused primarily on developing psychophysiological explanations of symptoms, relaxation, cognitions and healthcare use [46]. The third of these studies based their brief CBT intervention on the Consequences model within which the focus is on the consequences as opposed to the causes of physical symptoms; applied techniques aim to alter the consequences of symptoms [47, 48]. Participants were offered a maximum of 5, 45 minute sessions. The final study

assessing brief CBT for MUS, offered a 10 session manualized intervention adapted for somatization disorder aimed at coping with stress and physical discomfort [49].

Of the five studies which implemented brief CBT interventions targeting MUS/SSD, significant effects were observed in three whereby the intervention was deemed to be effective relative to control groups. No significant effects were observed in one study. One study reported medium effect sizes, and found that the intervention group had a higher percentage of patients with 'very much' or 'much' improved physical symptoms as reported by blinded evaluators (60% vs. 25.8% odds ratio = 4.1; 95% CI, 1.9–8.8; p < .001). There was a significant improvement in the intervention vs. the control group (p < 0.5) for depressive symptoms. Effects however were no longer noticeable at six month follow-up [45]. Small to medium effect sizes were observed in another study and a stronger effect size was detected for the intervention group in relation to reduction of doctors' visits (ŋ<sup>2</sup> = 0.031), and the reduction of somatization severity (ŋ2 = 0.048). Although significant improvements in all other measures were observed for both groups, all participants were still highly impaired with the degree of somatization, health anxiety and depression all above clinical thresholds at a six month follow-up. [46]. One study observed large effect sizes and found that somatization symptoms were significantly improved in the intervention group relative to the control group (p < 0.01), with the intervention also associated with improved self-reported functioning [49] The remaining study determined that the intervention was not more effective than care as usual, although approximately 30% of participants in both groups demonstrated improvements on the clinically relevant outcomes [47].

#### *3.4.1.2 Brief psychosocial interventions*

Two of the included studies used psychosocial and communication interventions targeting MUS/SSD. One study trained GPs to explain symptoms in a physical tangible way as result of hormone imbalance, to subsequently attribute this imbalance to irrational thinking, and to explore psychosocial issues indirectly. Participants were offered six sessions of 30 minutes [50].

Similarly, the second study trained GPs to gather a thorough psychosocial history, evaluate subjective understanding, demonstrate empathy, explain the relationship between symptoms and emotional distress, use symptom diaries, identify stressors and develop new behaviours; six 20 minute sessions were offered [51].

The first study, observed small to medium effect sizes and large effects sizes for bodily pain, social and emotional functioning, and mental health [50]. More specifically, quality of life dimensions in the intervention group were significantly improved relative to the control group in relation to several SF-36 subscales, namely bodily pain (p < 0.03), mental health (p < 0.063), physical functioning (p < 0.01), vitality (p < 0.039), social functioning (p < 0.033), and utility index (p < 0.039). The second study [51] found significant improvements were observed for the intervention group relative to the control group in relation to a reduction of physical symptoms (p = 0.07), reduction of depression (p = 0.211) and reduction of anxiety (p = 0.388). Effect sizes however were modest and were not maintained at six month follow up.

#### *3.4.1.3 Brief psychophysiological interventions*

One of the selected studies used a brief psychophysiological intervention targeting MUS/SSD. This was a ten session manualized treatment designed specifically for MUS; it was described as a treatment to assist with stress and physical discomfort, and specific components were emphasised depending on individual symptoms profiles [52].

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One study used a brief multimodal psychosomatic therapy targeting MUS. The treatment is based on the biopsychosocial model and involved relaxation, mindfulness, CBT techniques and activation therapy; up to 9 sessions of 45 minutes dura-

At 12 months post intervention, improvement in perceived symptom severity was observed [adjusted mean difference −2.0, 95% confidence interval (CI) −3.6 to −0.3], in somatization (adjusted mean difference −4.4, 95% CI −7.5 to −1.4) and in symptoms of hyperventilation (adjusted mean difference −5.7, 95% CI −10.5 to −0.8). Although the small sample size was deemed to be efficient, the authors concluded that a larger trial would be helpful and feasible. This pilot trail was not

One study, implemented a short-term group therapy for MUS/SSD (8 sessions of 2 hour durations), within which the aims were to develop peer support, share coping strategies and improve perceptions and expressions of emotions [54]. In relation to a brief group therapy, the intervention group demonstrated significant improvements compared with the control group on both physical health (p < 0.05), and mental health (p < 0.01) at post-treatment and at 12 month follow-

Four of the included studies implemented brief CBT interventions targeting HA/IAD. The first offered 5–10 sessions of brief CBT which had been adapted for HA [39]. Similarly, another of the studies, employed a 6 session individualised intervention which was designed specifically to target and restructure hypochondrial thoughts [9]. One study implemented a time-limited group mindfulnessbased CBT intervention, which was described a skills training programme adapted for HA [55–56]. A group based intervention was also employed in another study. This took the form of an educational course aimed at improving

coping skills for HA, focused specifically on selective attention, muscle

tension, breathing, environmental factors, stress, mood and explaining somatic

Four of the included studies implemented brief BCT interventions targeting HA/IAD and all reported significant effects for intervention groups relative to control groups. More specifically, one determined small effect sizes, and found that at 12 month follow-up point, the intervention group demonstrated an improvement in health anxiety symptoms which was 2.98 points greater than the control group and these symptomatic improvements were maintained at 2 years follow up. However, there were no significant differences between groups in relation to social functioning or health related quality of life [39]. At a 12-month follow-up, another study found significantly lower levels of hypochondriacal symptoms, beliefs, and attitudes (*P* < .001) and health-related anxiety (*P* = .009). in the intervention group. Furthermore significantly less impairment of social role functioning (*P* = .05) and intermediate activities of daily living (*P* < .001) were also observed. Effect sizes were reported as small to medium and hypochondriacal somatic symptoms were not improved significantly by treatment. The third of these studies determined

*DOI: http://dx.doi.org/10.5772/intechopen.93912*

powered to indicate treatment effect size.

up. Treatment effect sizes were not indicated.

tion were offered [53].

*3.4.1.5 Brief group therapy*

*3.4.2 HA/IAD*

*3.4.2.1 Brief CBT*

symptoms [42].

*3.4.1.4 Brief multimodal psychosomatic therapy*

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically… DOI: http://dx.doi.org/10.5772/intechopen.93912*

#### *3.4.1.4 Brief multimodal psychosomatic therapy*

One study used a brief multimodal psychosomatic therapy targeting MUS. The treatment is based on the biopsychosocial model and involved relaxation, mindfulness, CBT techniques and activation therapy; up to 9 sessions of 45 minutes duration were offered [53].

At 12 months post intervention, improvement in perceived symptom severity was observed [adjusted mean difference −2.0, 95% confidence interval (CI) −3.6 to −0.3], in somatization (adjusted mean difference −4.4, 95% CI −7.5 to −1.4) and in symptoms of hyperventilation (adjusted mean difference −5.7, 95% CI −10.5 to −0.8). Although the small sample size was deemed to be efficient, the authors concluded that a larger trial would be helpful and feasible. This pilot trail was not powered to indicate treatment effect size.

#### *3.4.1.5 Brief group therapy*

One study, implemented a short-term group therapy for MUS/SSD (8 sessions of 2 hour durations), within which the aims were to develop peer support, share coping strategies and improve perceptions and expressions of emotions [54].

In relation to a brief group therapy, the intervention group demonstrated significant improvements compared with the control group on both physical health (p < 0.05), and mental health (p < 0.01) at post-treatment and at 12 month followup. Treatment effect sizes were not indicated.

#### *3.4.2 HA/IAD*

*Psychosomatic Medicine*

assessing brief CBT for MUS, offered a 10 session manualized intervention adapted for somatization disorder aimed at coping with stress and physical discomfort [49]. Of the five studies which implemented brief CBT interventions targeting MUS/SSD, significant effects were observed in three whereby the intervention was deemed to be effective relative to control groups. No significant effects were observed in one study. One study reported medium effect sizes, and found that the intervention group had a higher percentage of patients with 'very much' or 'much' improved physical symptoms as reported by blinded evaluators (60% vs. 25.8% odds ratio = 4.1; 95% CI, 1.9–8.8; p < .001). There was a significant improvement in the intervention vs. the control group (p < 0.5) for depressive symptoms. Effects however were no longer noticeable at six month follow-up [45]. Small to medium effect sizes were observed in another study and a stronger effect size was detected

for the intervention group in relation to reduction of doctors' visits (ŋ2

strated improvements on the clinically relevant outcomes [47].

Participants were offered six sessions of 30 minutes [50].

and develop new behaviours; six 20 minute sessions were offered [51].

improvements in all other measures were observed for both groups, all participants were still highly impaired with the degree of somatization, health anxiety and depression all above clinical thresholds at a six month follow-up. [46]. One study observed large effect sizes and found that somatization symptoms were significantly improved in the intervention group relative to the control group (p < 0.01), with the intervention also associated with improved self-reported functioning [49] The remaining study determined that the intervention was not more effective than care as usual, although approximately 30% of participants in both groups demon-

Two of the included studies used psychosocial and communication interventions targeting MUS/SSD. One study trained GPs to explain symptoms in a physical tangible way as result of hormone imbalance, to subsequently attribute this imbalance to irrational thinking, and to explore psychosocial issues indirectly.

Similarly, the second study trained GPs to gather a thorough psychosocial history, evaluate subjective understanding, demonstrate empathy, explain the relationship between symptoms and emotional distress, use symptom diaries, identify stressors

The first study, observed small to medium effect sizes and large effects sizes for bodily pain, social and emotional functioning, and mental health [50]. More specifically, quality of life dimensions in the intervention group were significantly improved relative to the control group in relation to several SF-36 subscales, namely bodily pain (p < 0.03), mental health (p < 0.063), physical functioning (p < 0.01), vitality (p < 0.039), social functioning (p < 0.033), and utility index (p < 0.039). The second study [51] found significant improvements were observed for the intervention group relative to the control group in relation to a reduction of physical symptoms (p = 0.07), reduction of depression (p = 0.211) and reduction of anxiety (p = 0.388). Effect sizes however were modest and were not maintained

One of the selected studies used a brief psychophysiological intervention targeting MUS/SSD. This was a ten session manualized treatment designed specifically for MUS; it was described as a treatment to assist with stress and physical discomfort, and specific components were emphasised depending on individual symptoms profiles [52].

and the reduction of somatization severity (ŋ2

*3.4.1.2 Brief psychosocial interventions*

= 0.031),

= 0.048). Although significant

**104**

at six month follow up.

*3.4.1.3 Brief psychophysiological interventions*

#### *3.4.2.1 Brief CBT*

Four of the included studies implemented brief CBT interventions targeting HA/IAD. The first offered 5–10 sessions of brief CBT which had been adapted for HA [39]. Similarly, another of the studies, employed a 6 session individualised intervention which was designed specifically to target and restructure hypochondrial thoughts [9]. One study implemented a time-limited group mindfulnessbased CBT intervention, which was described a skills training programme adapted for HA [55–56]. A group based intervention was also employed in another study. This took the form of an educational course aimed at improving coping skills for HA, focused specifically on selective attention, muscle tension, breathing, environmental factors, stress, mood and explaining somatic symptoms [42].

Four of the included studies implemented brief BCT interventions targeting HA/IAD and all reported significant effects for intervention groups relative to control groups. More specifically, one determined small effect sizes, and found that at 12 month follow-up point, the intervention group demonstrated an improvement in health anxiety symptoms which was 2.98 points greater than the control group and these symptomatic improvements were maintained at 2 years follow up. However, there were no significant differences between groups in relation to social functioning or health related quality of life [39]. At a 12-month follow-up, another study found significantly lower levels of hypochondriacal symptoms, beliefs, and attitudes (*P* < .001) and health-related anxiety (*P* = .009). in the intervention group. Furthermore significantly less impairment of social role functioning (*P* = .05) and intermediate activities of daily living (*P* < .001) were also observed. Effect sizes were reported as small to medium and hypochondriacal somatic symptoms were not improved significantly by treatment. The third of these studies determined

medium effect sizes; their intervention group demonstrated significantly lower health anxiety than the control group both immediately following treatment (d = 0.48), and at a 12 month follow-up (d = 0.48) [55]. In the final study significant improvement was observed in the intervention group relative to the control group on all measures including physical symptoms (p = 0.03), dysfunctional health beliefs (p = 0.02), vulnerability (p = 0.03) and lack of control (p = 0.06); effect sizes were not reported [42].

#### *3.4.3 NCCP*

#### *3.4.3.1 Brief CBT*

Seven of the selected studies involved brief CBT based interventions targeting NCCP. One of these implemented a 7 session treatment which incorporated psychoeducation on chest pain, panic disorder (PD), exposure and CR [58]. Two interventions were evaluated in another study [36], namely a single session panic management intervention and a 7 session CBT treatment for NCCP and PD [36]. Another also trialled a single individualised information session with psychoeducational materials [59] One study used a single session of brief CBT (60 minute duration) which included psychoeducation, breathing exercises and CR [62]. Psychoeducation was again a component of the intervention offered in another of the studies, which also included CR, and strategies to influence avoidance behaviours over 6 sessions of 45 minutes [35]. One study offered a 3 session programme (60–90 minutes) which focuses on the CBT model of panic and exposure therapy [41]. Guided brief CBT was delivered online in another study and involved 4 sessions of psychoeducation, physical activity advice and relaxation [61].

Of the seven selected studies which implemented brief CBT based interventions targeting NCCP, five reported significant effects for interventions relative to control groups and two observed no significance. Large treatment effect sizes were observed in one study; both intervention groups demonstrated significant improvements relative to the control group in relation to the severity of panic disorder (p = 0.12), frequency of panic (p = 0.48), and depressive symptoms (p = 0.27) [58]. Similarly large effect sizes were also observed in another study; both interventions also achieved significant reductions in the severity of panic disorder relative to the control group (ŋ<sup>2</sup> = 0.07), although no superiority was demonstrated by one intervention as compared with the other [36]. Medium effect sizes with significant improvements for the intervention versus control in relation to frequency and fear of chest pain, and anxiety sensitivity, but not in relation to severity of chest pain, quality of life and psychological distress were determined on one study [60]. In another study, significant improvements were observed for intervention versus control group in relation to reduction of disease severity, anxiety and depression symptoms but effect sizes were not determined [35]. A brief CBT intervention was effective compared to care as usual and reported medium to large effect sizes. Significant differences were observed for fear of bodily sensations, avoidance of physical activities and depression. However, the sample size was small and no power analysis was carried out [41]. Another study concluded that although improvements were demonstrated by both intervention and control groups in relation to cardiac anxiety, fear of bodily sensations and depression, no significant differences were observed between the groups [61]. Similarly, the remaining study found that although both groups achieved slight improvements on the main outcomes,

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specifically chest pain, mood and limitation of activities, no significant effects

Two studies evaluated relaxation and metaphor therapies targeting NCCP [62, 63]. Both treatments consisted of 4 2 hour sessions. The relaxation therapy was group based involving learning and practising relaxation and breathing techniques. Metaphor therapy involved challenging and connecting metaphoric stories of hopelessness, with the ultimate goal of challenging unhelpful beliefs. The first of these reported small to medium effect sizes, and determined significant differences between the relaxation group and both control groups for hopelessness (DM = 9.79, p < 0.05), pain severity (DM = 1.96, p < 0.05), and emotional irresponsibility (DM = 4.80, p < 0.05). No significant effects were observed in relation to the metaphor therapy intervention group [62]. The subsequent study assessed the effectiveness of metaphor therapy only, and again determined no

One study implemented a short-term (8 session of 2 hours) group therapy for NCCP within which the focus was on sharing experiences and coping strategies, education on chest pain, relaxation and breathing exercise, physical exercise, CR and graded exposure [43]. Significant improvements were observed in the intervention group relative to the control group in relation to chest pain episodes (p < 0.01) and anxiety and depression (p < 0.05), with benefits maintained at a six month

Therapists trained specifically in the relevant interventions were used in eleven of the studies. Primary care physicians (GPSs) delivered interventions in four of the studies, and four of the studies used clinical psychologists to deliver treatments

Several combinations of primary and secondary outcome measures including questionnaires and diagnostic interviews were used in the selected studies at pre, post and follow-up points. The measures assessed medically unexplained symptoms, mental health, health related quality life and general functioning. The most frequently used outcome measure was the MOS SF-36 (medical outcomes study 36 item short-form health survey), which was used in ten of the selected studies. A full list of the outcome measures used in each of the included studies is presented in

The majority of the studies (n = 17) included in the review adapted longitudinal designs and evaluated outcomes at pre and post intervention points and at one or more follow-up points. Six of the included studies evaluated outcomes at pre and

significant treatment effects relative to the control group [63].

follow-up. Treatment effect sizes were not indicated.

Cardiac nurses delivered interventions in two studies.

**Table 2**. Intervention effects are presented in **Table 3**.

post intervention points only and did not use a longitudinal design.

*DOI: http://dx.doi.org/10.5772/intechopen.93912*

*3.4.3.2 Relaxation and metaphor therapy*

*3.4.3.3 Short-term group therapy*

**3.5 Delivery of the intervention**

**3.7 Pre, post and follow-up data**

**3.6 Outcome measures**

were observed [59].

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically… DOI: http://dx.doi.org/10.5772/intechopen.93912*

specifically chest pain, mood and limitation of activities, no significant effects were observed [59].

#### *3.4.3.2 Relaxation and metaphor therapy*

*Psychosomatic Medicine*

sizes were not reported [42].

*3.4.3 NCCP*

*3.4.3.1 Brief CBT*

relaxation [61].

disorder relative to the control group (ŋ<sup>2</sup>

medium effect sizes; their intervention group demonstrated significantly lower health anxiety than the control group both immediately following treatment

(d = 0.48), and at a 12 month follow-up (d = 0.48) [55]. In the final study significant improvement was observed in the intervention group relative to the control group on all measures including physical symptoms (p = 0.03), dysfunctional health beliefs (p = 0.02), vulnerability (p = 0.03) and lack of control (p = 0.06); effect

Seven of the selected studies involved brief CBT based interventions targeting NCCP. One of these implemented a 7 session treatment which incorporated psychoeducation on chest pain, panic disorder (PD), exposure and CR [58]. Two interventions were evaluated in another study [36], namely a single session panic management intervention and a 7 session CBT treatment for NCCP and PD [36]. Another also trialled a single individualised information session with psychoeducational materials [59] One study used a single session of brief CBT (60 minute duration) which included psychoeducation, breathing exercises and CR [62]. Psychoeducation was again a component of the intervention offered in another of the studies, which also included CR, and strategies to influence avoidance behaviours over 6 sessions of 45 minutes [35]. One study offered a 3 session programme (60–90 minutes) which focuses on the CBT model of panic and exposure therapy [41]. Guided brief CBT was delivered online in another study and involved 4 sessions of psychoeducation, physical activity advice and

Of the seven selected studies which implemented brief CBT based interventions

= 0.07), although no superiority was

targeting NCCP, five reported significant effects for interventions relative to control groups and two observed no significance. Large treatment effect sizes were observed in one study; both intervention groups demonstrated significant improvements relative to the control group in relation to the severity of panic disorder (p = 0.12), frequency of panic (p = 0.48), and depressive symptoms (p = 0.27) [58]. Similarly large effect sizes were also observed in another study; both interventions also achieved significant reductions in the severity of panic

demonstrated by one intervention as compared with the other [36]. Medium effect sizes with significant improvements for the intervention versus control in relation to frequency and fear of chest pain, and anxiety sensitivity, but not in relation to severity of chest pain, quality of life and psychological distress were determined on one study [60]. In another study, significant improvements were observed for intervention versus control group in relation to reduction of disease severity, anxiety and depression symptoms but effect sizes were not determined [35]. A brief CBT intervention was effective compared to care as usual and reported medium to large effect sizes. Significant differences were observed for fear of bodily sensations, avoidance of physical activities and depression. However, the sample size was small and no power analysis was carried out [41]. Another study concluded that although improvements were demonstrated by both intervention and control groups in relation to cardiac anxiety, fear of bodily sensations and depression, no significant differences were observed between the groups [61]. Similarly, the remaining study found that although both groups achieved slight improvements on the main outcomes,

**106**

Two studies evaluated relaxation and metaphor therapies targeting NCCP [62, 63]. Both treatments consisted of 4 2 hour sessions. The relaxation therapy was group based involving learning and practising relaxation and breathing techniques. Metaphor therapy involved challenging and connecting metaphoric stories of hopelessness, with the ultimate goal of challenging unhelpful beliefs.

The first of these reported small to medium effect sizes, and determined significant differences between the relaxation group and both control groups for hopelessness (DM = 9.79, p < 0.05), pain severity (DM = 1.96, p < 0.05), and emotional irresponsibility (DM = 4.80, p < 0.05). No significant effects were observed in relation to the metaphor therapy intervention group [62]. The subsequent study assessed the effectiveness of metaphor therapy only, and again determined no significant treatment effects relative to the control group [63].

#### *3.4.3.3 Short-term group therapy*

One study implemented a short-term (8 session of 2 hours) group therapy for NCCP within which the focus was on sharing experiences and coping strategies, education on chest pain, relaxation and breathing exercise, physical exercise, CR and graded exposure [43]. Significant improvements were observed in the intervention group relative to the control group in relation to chest pain episodes (p < 0.01) and anxiety and depression (p < 0.05), with benefits maintained at a six month follow-up. Treatment effect sizes were not indicated.

#### **3.5 Delivery of the intervention**

Therapists trained specifically in the relevant interventions were used in eleven of the studies. Primary care physicians (GPSs) delivered interventions in four of the studies, and four of the studies used clinical psychologists to deliver treatments Cardiac nurses delivered interventions in two studies.

#### **3.6 Outcome measures**

Several combinations of primary and secondary outcome measures including questionnaires and diagnostic interviews were used in the selected studies at pre, post and follow-up points. The measures assessed medically unexplained symptoms, mental health, health related quality life and general functioning. The most frequently used outcome measure was the MOS SF-36 (medical outcomes study 36 item short-form health survey), which was used in ten of the selected studies. A full list of the outcome measures used in each of the included studies is presented in **Table 2**. Intervention effects are presented in **Table 3**.

#### **3.7 Pre, post and follow-up data**

The majority of the studies (n = 17) included in the review adapted longitudinal designs and evaluated outcomes at pre and post intervention points and at one or more follow-up points. Six of the included studies evaluated outcomes at pre and post intervention points only and did not use a longitudinal design.


**109**

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically…*

Although both groups achieved slight improvements on the main outcomes, specifically chest pain, mood and limitation of activities, no significant effects were

The intervention was effective compared to care as usual; significant differences were observed for fear of bodily sensations, avoidance of physical activities and

There were significant differences observed between the relaxation group and both control groups for hopelessness (DM = 9.79, p < 0.05), pain severity (DM = 1.96, p < 0.05), and emotional irresponsibility

Although improvements were demonstrated by both groups in relation to cardiac anxiety, fear of bodily sensations and depression, no significant differences were observed between the groups. No significance

Significant improvements were observed for intervention versus control group in relation to reduction of disease severity, anxiety and depression symptoms. Effect sizes: unknown (trial not powered to

Significant improvements were observed for intervention versus control in relation to frequency and fear of chest pain, and anxiety sensitivity, but not in relation to severity of chest pain, quality of life and

Significant differences were observed for the intervention group versus control group in relation to hypochondrial symptoms, beliefs and attitudes, health anxiety, and social functioning. Effect sizes: small to

There were no significance differences demonstrated by the intervention group compared with control group on any of the outcome variables (depression, anxiety, stress and pain discomfort). No significance observed: intervention not effective as compared with control

Both intervention groups demonstrated significant improvement relative to the control group in relation to the severity of panic disorder (p = 0.12), frequency of panic (p = 0.48), and depressive symptoms (p = 0.27).

Somatization symptoms were significantly improved in the intervention group relative to control group

indicate treatment effect sizes.

psychological distress. Effect sizes: medium

medium

group Effect sizes: NA

Effect sizes large.

(p < 0.01). Effect sizes large.

depression. Effect sizes medium to large

observed. Effect sizes: NA

(DM = 4.80, p < 0.05). Effect sizes small to medium.

observed. Effect sizes: N/A

*DOI: http://dx.doi.org/10.5772/intechopen.93912*

[59] Brief psychoeducational and

[41] Short-term CBT for non-cardiac

therapists.

[63] Relaxation training versus

psychologists.

[61] Guided internet therapy (CBT

[35] Brief CBT for non-cardiac chest

[60] Brief CBT for non-cardiac chest

[57] CBT for hypochondriasis delivered by trained therapists

cardiac chest pain delivered by

treatment for non-cardiac chest pain with associated panic disorder delivered by psychologists.

[63] Metaphor therapy for non-

psychologists

[58] Brief CBT or pharmacological

[49] Time limited CBT for somatization

disorder

pain

**Study Intervention Outcomes**

cognitive behavioural intervention for non-cardiac chest pain, delivered by cardiac nurses

chest pain delivered by trained

metaphor therapy for non-cardiac chest pain delivered by clinical

based) for non-cardiac chest pain delivered by cardiac nurses

pain with associated depression and panic disorder delivered by clinical psychologists


*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically… DOI: http://dx.doi.org/10.5772/intechopen.93912*

*Psychosomatic Medicine*

**Study Intervention Outcomes**

The intervention group had a higher percentage of patients with 'very much' or 'much' improved physical symptoms as reported by blinded evaluators (60% vs. 25.8% odds ratio = 4.1; 95% CI, 1.9–8.8; p < 0.001). There was a significant improvement in the intervention vs. the control group (p < 0.5) for depressive symptoms. Effects were no

longer noticeable at six month follow-up. Effect sizes

Improvements in all dimensions of the SF-36 were demonstrated by patients in both groups. The intervention group demonstrated significantly more improvement in bodily pain, mental health, physical functioning, social functioning and vitality (p < 0.039). Effect sizes: small to medium (large effect sizes for bodily pain, social and emotional functioning and

There was a stronger effect size in the intervention group in relation to reduction of doctors' visits

= 0.031), and the reduction of somatization

The intervention was not more effective than care as usual; approximately 30% of participants in both groups demonstrated improvements on the clinically relevant outcomes. No significance observed: intervention not effective as compared with control

There was a significantly greater improvement in the frequency and severity of physical symptoms in the interventions group (p < 0.05). Effect sizes also indicated a greater improvement in the interventions group for depression symptoms

Significant differences between groups were observed at 12 month follow up; the intervention group demonstrated greater improvement in perceived symptom severity, somatization and hyperventilation. Effect sizes: unknown (trial not powered to indicate

The intervention group demonstrated significantly lower health anxiety than the control group both immediately following treatment (d = 0.48), and at a 12 month follow-up (d = 0.48). Effect sizes:

At a 12 month follow-up point, the intervention group demonstrated an improvement in health anxiety symptoms which was 2.98 points greater than the control group. Significance observed: intervention effective as compared with control group. Effect sizes

 = 0.048). Although significant improvements in all other measures were observed for both groups, all participants were still highly impaired with the degree of somatization, health anxiety and depression all above clinical thresholds at a six month follow-up. Effect sizes: small

medium.

mental health).

severity (ŋ2

to medium

(d = 0.81)

medium

small

group. Effect sizes: N/A.

treatment effect sizes)

(ŋ2

[45] Time limited CBT type therapy delivered in primary care for patients with medically unexplained physical symptoms

[50] A psychosocial and communication intervention delivered by GPs for patients with medically unexplained symptoms.

[46] A one session CBT intervention for

[47] Cognitive behavioural treatment

[52] Psychophysiological treatment

[53] Brief multimodal psychodynamic

[55] Time-limited mindfulness-based

[39] CBT for health anxiety delivered by trained health professionals

practitioners.

and clinicians.

medically unexplained symptoms delivered by clinical psychologist

delivered by family physician for medically unexplained symptoms

(described to participants as an intervention to assist in coping with physical comfort and distress) delivered by psychologists

therapy for medically unexplained symptoms delivered by trained

cognitive therapy for health anxiety delivered by trained practitioners

**108**


#### **Table 3.**

*Summary of results for included studies.*

#### **4. Discussion**

#### **4.1 Summary of evidence**

This is the first systematic review which examined evidence for brief or time-limited interventions for both MUS/SSD, HA/IAD and NCCP specifically. Significant effects for the intervention groups relative to control groups were reported in 19 studies, and 4 studies did not determine any significant benefits of interventions compared with control groups. Significant effects relative to controls were determined for all of the brief interventions in at least one study (CBT, psychosocial, psychophysiological, psychosomatic, relaxation and group therapy), with the exception of metaphor therapy for which no significant effects were reported. [63]. Of those studies reporting significance, large treatment effects were reported in 3 [39, 49, 58], medium effect sizes were reported by 3 [45, 55, 60], medium to large effects were reported in 2 [34, 52], four studies observed small to medium effect sizes [46, 50, 57, 62], and small effect sizes were determined in 2 [39, 51]. Five studies did not indicate effect sizes (see **Table 3**). All of the studies within which the largest effect sizes were reported, involved brief CBT for either MUS or NCCP [36, 49, 58].

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There are several possible explanations for the lack of effect on medically unexplained symptoms and psychological wellbeing in the trials within which no significance was observed. The findings specifically, that time limited CBT delivered by GPs for MUS did not result in significantly better outcomes than care as usual, are consistent with other research which has outlined the limited feasibility and effectiveness of CBT for MUS delivered by primary care doctors [47, 64, 65]. Although it was found that brief online CBT guided by cardiac nurses was feasible for NCCP given that it decreased cardiac anxiety, frequency of chest pain and depression symptoms, no significant differences were observed relative to the control group [61]. These findings were comparable with another study where no significant treatment effects were determined after a brief single session CBT intervention for NCCP again delivered by cardiac nurses [59]. Authors of both studies have highlighted the limitations of small sample sizes and recruitment difficulties, possibly due to the fact that patients found it difficult to reject a physical explanation for the cause of chest pain. As outlined earlier, previous research has suggested that individuals with MUS have a tendency to reject psychological constructs of their problems resulting in an

Regarding the use of metaphor therapy for NCCP after which no significant benefits were observed in terms of discomfort, anxiety or depression, the authors suggested that the nature of the intervention itself may not be suitable given that it is dependent on an individual's ability to visualise [62, 63]. However, some evidence exists to support the use of this intervention, and it was a component of a group psychological intervention for NCCP included in the current review within which

Some included studies reported significant treatment effects compared with controls after brief CBT for MUS/SSD [45, 46, 49]. As previously highlighted, findings in one indicated a more marked reduction in the amount of doctor's visits and in the severity of somatization in the CBT group compared with the standard care group [46]. Although actual treatment effects were smaller for this single session intervention when compared with more intensive CBT approaches, brief interventions still facilitate the treatment of a greater number of MUS patients. It has been suggested that brief intervention could improve the general management of MUS at the primary care level and subsequently aid access to more specialist interventions if clinically required. Furthermore, the importance of early intervention should be highlighted given that the condition becomes much less manageable and complex over time [9]. It has been suggested that a brief treatment such as a single session CBT/LICBT intervention could be an appropriate and effective first point of treatment within a stepped care approach in order to

Differences in the outcomes observed in the selected studies, may be a result of variations in the components and theoretical frameworks of the interventions, the duration of the interventions, sampling issues, the selection strategies employed to recruit participants, the outcome measures used to determine MUS and psychological wellbeing, the experience levels of persons delivering the interventions, and

The psychological framework of the interventions evaluated in the selected studies included CBT, psychosocial, psychosomatic, relaxation, metaphor, and general group therapy. Significant effects at the post-intervention stage (at least), were reported by all included studies except 3 studies which implemented brief CBT, and

unwillingness to engage in psychological treatments [8, 16–18].

significant treatment effects were observed [43].

improve management of MUS [46, 66].

how data was collected and analysed.

2 studies which implemented brief metaphor therapy.

**4.2 Variations in outcomes**

*DOI: http://dx.doi.org/10.5772/intechopen.93912*

#### *Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically… DOI: http://dx.doi.org/10.5772/intechopen.93912*

There are several possible explanations for the lack of effect on medically unexplained symptoms and psychological wellbeing in the trials within which no significance was observed. The findings specifically, that time limited CBT delivered by GPs for MUS did not result in significantly better outcomes than care as usual, are consistent with other research which has outlined the limited feasibility and effectiveness of CBT for MUS delivered by primary care doctors [47, 64, 65].

Although it was found that brief online CBT guided by cardiac nurses was feasible for NCCP given that it decreased cardiac anxiety, frequency of chest pain and depression symptoms, no significant differences were observed relative to the control group [61]. These findings were comparable with another study where no significant treatment effects were determined after a brief single session CBT intervention for NCCP again delivered by cardiac nurses [59]. Authors of both studies have highlighted the limitations of small sample sizes and recruitment difficulties, possibly due to the fact that patients found it difficult to reject a physical explanation for the cause of chest pain. As outlined earlier, previous research has suggested that individuals with MUS have a tendency to reject psychological constructs of their problems resulting in an unwillingness to engage in psychological treatments [8, 16–18].

Regarding the use of metaphor therapy for NCCP after which no significant benefits were observed in terms of discomfort, anxiety or depression, the authors suggested that the nature of the intervention itself may not be suitable given that it is dependent on an individual's ability to visualise [62, 63]. However, some evidence exists to support the use of this intervention, and it was a component of a group psychological intervention for NCCP included in the current review within which significant treatment effects were observed [43].

Some included studies reported significant treatment effects compared with controls after brief CBT for MUS/SSD [45, 46, 49]. As previously highlighted, findings in one indicated a more marked reduction in the amount of doctor's visits and in the severity of somatization in the CBT group compared with the standard care group [46]. Although actual treatment effects were smaller for this single session intervention when compared with more intensive CBT approaches, brief interventions still facilitate the treatment of a greater number of MUS patients. It has been suggested that brief intervention could improve the general management of MUS at the primary care level and subsequently aid access to more specialist interventions if clinically required. Furthermore, the importance of early intervention should be highlighted given that the condition becomes much less manageable and complex over time [9]. It has been suggested that a brief treatment such as a single session CBT/LICBT intervention could be an appropriate and effective first point of treatment within a stepped care approach in order to improve management of MUS [46, 66].

#### **4.2 Variations in outcomes**

Differences in the outcomes observed in the selected studies, may be a result of variations in the components and theoretical frameworks of the interventions, the duration of the interventions, sampling issues, the selection strategies employed to recruit participants, the outcome measures used to determine MUS and psychological wellbeing, the experience levels of persons delivering the interventions, and how data was collected and analysed.

The psychological framework of the interventions evaluated in the selected studies included CBT, psychosocial, psychosomatic, relaxation, metaphor, and general group therapy. Significant effects at the post-intervention stage (at least), were reported by all included studies except 3 studies which implemented brief CBT, and 2 studies which implemented brief metaphor therapy.

*Psychosomatic Medicine*

**Study Intervention Outcomes**

Significant improvements were observed for the intervention group relative to the control group in relation to a reduction of physical symptoms (p = 0.07), reduction of depression (p = 0.211) and reduction of anxiety (p = 0.388). Effects were not maintained at six month follow up. Effects not maintained at 6 month

Both interventions demonstrated significant reductions in the severity of panic disorder relative to the control

 = 0.07) although no superiority was demonstrated by one intervention as compared with

The intervention group demonstrated significant improvements relative to the control group on both physical health (p < 0.05), and mental health (p < 0.01) at post-treatment and at 12 month follow-up. Effect sizes: Unknown (trial not powered to indicate

Significant improvements were observed in the intervention group relative to the control group on all measures including physical symptoms (p = 0.03), dysfunctional health beliefs (p = 0.02), vulnerability (p = 0.03) and lack of control (p = 0.06). Effect sizes unknown (trial not powered to indicate treatment

Significant improvements observed in the intervention group relative to the control group in relation to chest pain episodes (p < 0.01) and anxiety and depression (p < 0.05), with benefits maintained at a six month follow-up. Effect sizes: Unknown (trial not powered to

the other. Effect sizes large (time)

treatment effect sizes

indicate treatment effect sizes.

effect sizes

follow-up. Effect sizes small

group (ŋ2

somatising patients delivered by

(panic management and CBT) for panic disorder with non-cardiac chest pain delivered by trained

somatization disorder delivered by

[51] Psychosocial intervention for

general practitioners

[36] Brief psychological interventions

therapists.

[54] Short-term group therapy for

trained therapists

[42] Short-term group therapy (CBT based) for hypochondriasis delivered by trained therapists

[43] Time limited group psychological

treatment for non-cardiac chest pain delivered by trained therapists

**110**

**4. Discussion**

**Table 3.**

**4.1 Summary of evidence**

*Summary of results for included studies.*

This is the first systematic review which examined evidence for brief or time-limited interventions for both MUS/SSD, HA/IAD and NCCP specifically. Significant effects for the intervention groups relative to control groups were reported in 19 studies, and 4 studies did not determine any significant benefits of interventions compared with control groups. Significant effects relative to controls were determined for all of the brief interventions in at least one study (CBT, psychosocial, psychophysiological, psychosomatic, relaxation and group therapy), with the exception of metaphor therapy for which no significant effects were reported. [63]. Of those studies reporting significance, large treatment effects were reported in 3 [39, 49, 58], medium effect sizes were reported by 3 [45, 55, 60], medium to large effects were reported in 2 [34, 52], four studies observed small to medium effect sizes [46, 50, 57, 62], and small effect sizes were determined in 2 [39, 51]. Five studies did not indicate effect sizes (see **Table 3**). All of the studies within which the largest effect sizes were reported, involved brief CBT for either MUS or NCCP [36, 49, 58].

However, 13 studies did determine significant effects for brief CBT, as did both studies which used psychosocial treatments. Furthermore each of the single studies evaluating either psychosomatic, relaxation or general group therapy also reported significance. It is not possible therefore to concretely conclude if one of these brief interventions might offer superior benefits to the other, given the more limited available outcomes from trials assessing interventions other than those which are CBT based. Rather, it may concluded that some evidence exists to support the use of all of the interventions for medically unexplained symptoms and associated psychological distress, with the exception of metaphor therapy. More specifically there is substantial evidence within the current review supporting the use of brief/ time-limited CBT, and existing but more limited evidence supporting the use of the remaining included interventions.

Several studies highlighted issues with sampling and sampling size, which might have influenced outcomes. Despite screening 6409 potential participants, only 65 were included in the trial for one study [47]. Some were excluded due to a natural reduction of symptoms or due to the presence of severe and comorbid conditions. Chronic issues with somatization are likely to follow a path of highs and lows in relation to the severity of and response to symptoms, much like depression and anxiety disorders, however, a majority of eligible participants declined the intervention as they had 'accepted' symptoms were part of their life.

As indicated earlier, there was a large variation in sample size in the selected studies. Eleven of the studies included 60 or fewer participants, and one study included 444 participants. Given that the power of the study may be affected by a sample which is either too large or small, it is reasonable to suppose that at least some of the included studies may have been under-powered to clearly indicate between-group differences of statistical significance [67, 68].

The selection of an appropriate outcome measure is an important consideration which can impact the value of results from clinical studies. Selection of measures has tended to concentrate more on the psychometric properties, but less on the actual suitability of the instruments for their intended purpose. It has been suggested that in addition to an evaluation of basic psychometric properties, researchers should consider that different instruments may capture different aspects of complex phenomena and may therefore not be equally valid for everyone. Furthermore, a good fit between the measure and what the researcher expects to change post treatment is required to facilitate a valid interpretation of the outcomes. As indicated earlier, a considerably large variety of primary and secondary outcome measures were included in the selected studies, and it may be the case that not all of those were the optimum instruments [69].

The interventions evaluated in the selected studies were delivered by either therapists who had been trained specifically in the relevant interventions, GPs, clinical psychologists, or cardiac nurses. Both studies using cardiac nurses reported no significant intervention effects, and 2 of the 4 studies within which interventions were delivered by GPs also reported no significant intervention effects. A systematic review and meta-analysis of randomised controlled trials of psychological treatments found psychological interventions were more beneficial when delivered by psychotherapists compared with GPs, and more specifically that psychotherapists had a greater effect on physical symptoms than GPs [70]. An earlier systematic review considered the prevalence of medically unexplained physical symptoms, the extent of comorbidity with psychiatric disorders, the importance of psychological processes and the effectiveness of interventions. It was reported that there was significant overlap between symptoms and syndromes, and that patients with MUS should therefore be considered as having complex adaptive systems within which cognitive, physiological and

**113**

*Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically…*

environmental factors interact. CBT and antidepressants are effective, however these benefits are heightened when patients feel empowered by their own doctors to address their problems [71]. The importance of the GP role was consequently highlighted i.e. to validate the patient experience, provide positive and empowering explanations of symptoms and to offer evidence based interventions including CBT. Further research has suggested that GP-patient interactions did impact consultation and communication patterns but did not subsequently impact

It is also important to acknowledge that while the current review focused on time-limited intervention, the duration of the course of treatments evaluated in the included studies ranged from a single session to ten sessions, with sessions also varying in length in addition to varying times between sessions, and the point at which follow up data was collected. The potential impact of this on outcomes cannot be disregarded. In order to reach more robust conclusions regarding the confounding factors which impact clinical outcome in MUS, larger sample sizes and longer follow –ups should be employed, given the effects of clustering and generally

There are other methodological issues to consider including that there a were variety of methodologies employed in relation to data analysis. Not all of the included studies reported specifically how data was cleaned or how missing data was handled, and there is a possibility this may account for variability between outcomes. Furthermore, some studies employed power analysis and reported effect sizes, and some did not. It is therefore recommended that any future trial addresses this methodological weakness in order to improve and determine the

All of the included studies employed random allocation to intervention or control group, although many lacked precise details regarding how this was achieved,

The main strength of this systematic review is the focus on brief interventions which are feasible to offer as part of a stepped care approach. A limitation is that the included studies were screened by only one author (except for risk of bias examina-

The evidence suggests that brief psychological interventions, more specifically

time limited BCT based interventions may have small to large effects in reducing the severity of MUS and associated psychological distress. These findings are comparable with other reviews which have assessed the efficacy of higher intensity and/or longer term interventions. Given that there is a broad range of symptom severity and willingness to engage in psychological treatments among MUS patients in primary care, it is reasonable to suggest that a stepped care approach may be suitable thereby facilitating a more specialist intervention in chronic cases [73–75]. However, there remains a need to provide more robust evidence of cost effectiveness is relation to mild and moderate cases for which briefer interventions such as

tion), increasing the possibility that a study might have been missed.

and the risk of bias remained unclear in several studies.

those evaluated here, tend to be recommended.

*DOI: http://dx.doi.org/10.5772/intechopen.93912*

patient outcomes [72].

modest effects observed.

most effective treatment.

**4.4 Strengths and limitations**

**4.3 Risk of bias**

**5. Conclusion**

#### *Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically… DOI: http://dx.doi.org/10.5772/intechopen.93912*

environmental factors interact. CBT and antidepressants are effective, however these benefits are heightened when patients feel empowered by their own doctors to address their problems [71]. The importance of the GP role was consequently highlighted i.e. to validate the patient experience, provide positive and empowering explanations of symptoms and to offer evidence based interventions including CBT. Further research has suggested that GP-patient interactions did impact consultation and communication patterns but did not subsequently impact patient outcomes [72].

It is also important to acknowledge that while the current review focused on time-limited intervention, the duration of the course of treatments evaluated in the included studies ranged from a single session to ten sessions, with sessions also varying in length in addition to varying times between sessions, and the point at which follow up data was collected. The potential impact of this on outcomes cannot be disregarded. In order to reach more robust conclusions regarding the confounding factors which impact clinical outcome in MUS, larger sample sizes and longer follow –ups should be employed, given the effects of clustering and generally modest effects observed.

There are other methodological issues to consider including that there a were variety of methodologies employed in relation to data analysis. Not all of the included studies reported specifically how data was cleaned or how missing data was handled, and there is a possibility this may account for variability between outcomes. Furthermore, some studies employed power analysis and reported effect sizes, and some did not. It is therefore recommended that any future trial addresses this methodological weakness in order to improve and determine the most effective treatment.

#### **4.3 Risk of bias**

*Psychosomatic Medicine*

remaining included interventions.

tion as they had 'accepted' symptoms were part of their life.

between-group differences of statistical significance [67, 68].

not all of those were the optimum instruments [69].

However, 13 studies did determine significant effects for brief CBT, as did both studies which used psychosocial treatments. Furthermore each of the single studies evaluating either psychosomatic, relaxation or general group therapy also reported significance. It is not possible therefore to concretely conclude if one of these brief interventions might offer superior benefits to the other, given the more limited available outcomes from trials assessing interventions other than those which are CBT based. Rather, it may concluded that some evidence exists to support the use of all of the interventions for medically unexplained symptoms and associated psychological distress, with the exception of metaphor therapy. More specifically there is substantial evidence within the current review supporting the use of brief/ time-limited CBT, and existing but more limited evidence supporting the use of the

Several studies highlighted issues with sampling and sampling size, which might have influenced outcomes. Despite screening 6409 potential participants, only 65 were included in the trial for one study [47]. Some were excluded due to a natural reduction of symptoms or due to the presence of severe and comorbid conditions. Chronic issues with somatization are likely to follow a path of highs and lows in relation to the severity of and response to symptoms, much like depression and anxiety disorders, however, a majority of eligible participants declined the interven-

As indicated earlier, there was a large variation in sample size in the selected studies. Eleven of the studies included 60 or fewer participants, and one study included 444 participants. Given that the power of the study may be affected by a sample which is either too large or small, it is reasonable to suppose that at least some of the included studies may have been under-powered to clearly indicate

The selection of an appropriate outcome measure is an important consideration which can impact the value of results from clinical studies. Selection of measures has tended to concentrate more on the psychometric properties, but less on the actual suitability of the instruments for their intended purpose. It has been suggested that in addition to an evaluation of basic psychometric properties, researchers should consider that different instruments may capture different aspects of complex phenomena and may therefore not be equally valid for everyone. Furthermore, a good fit between the measure and what the researcher expects to change post treatment is required to facilitate a valid interpretation of the outcomes. As indicated earlier, a considerably large variety of primary and secondary outcome measures were included in the selected studies, and it may be the case that

The interventions evaluated in the selected studies were delivered by either therapists who had been trained specifically in the relevant interventions, GPs, clinical psychologists, or cardiac nurses. Both studies using cardiac nurses reported no significant intervention effects, and 2 of the 4 studies within which interventions were delivered by GPs also reported no significant intervention effects. A systematic review and meta-analysis of randomised controlled trials of psychological treatments found psychological interventions were more beneficial when delivered by psychotherapists compared with GPs, and more specifically that psychotherapists had a greater effect on physical symptoms than GPs [70]. An earlier systematic review considered the prevalence of medically unexplained physical symptoms, the extent of comorbidity with psychiatric disorders, the importance of psychological processes and the effectiveness of interventions. It was reported that there was significant overlap between symptoms and syndromes, and that patients with MUS should therefore be considered as having complex adaptive systems within which cognitive, physiological and

**112**

All of the included studies employed random allocation to intervention or control group, although many lacked precise details regarding how this was achieved, and the risk of bias remained unclear in several studies.

#### **4.4 Strengths and limitations**

The main strength of this systematic review is the focus on brief interventions which are feasible to offer as part of a stepped care approach. A limitation is that the included studies were screened by only one author (except for risk of bias examination), increasing the possibility that a study might have been missed.

#### **5. Conclusion**

The evidence suggests that brief psychological interventions, more specifically time limited BCT based interventions may have small to large effects in reducing the severity of MUS and associated psychological distress. These findings are comparable with other reviews which have assessed the efficacy of higher intensity and/or longer term interventions. Given that there is a broad range of symptom severity and willingness to engage in psychological treatments among MUS patients in primary care, it is reasonable to suggest that a stepped care approach may be suitable thereby facilitating a more specialist intervention in chronic cases [73–75]. However, there remains a need to provide more robust evidence of cost effectiveness is relation to mild and moderate cases for which briefer interventions such as those evaluated here, tend to be recommended.

*Psychosomatic Medicine*

#### **Author details**

Orla McDevitt-Petrovic\* and Karen Kirby School of Psychology, Ulster University, United Kingdom

\*Address all correspondence to: om.mcdevitt-petrovic@ulster.ac.uk

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**115**

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[9] Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Archives of general psychiatry. 2005

[10] Department of Health. No health without mental health: a crossgovernment mental health outcomes strategy for people of all ages (2011) Retrieved from https://www.gov.uk/ government/publications/no-healthwithout-mental-health-a-crossgovernment-outcomes-strategy

[11] Department of Health. No health without mental health: a crossgovernment mental health outcomes strategy for people of all ages (2008) Retrieved from https://www.gov.uk/ government/publications/no-healthwithout-mental-health-a-crossgovernment-outcomes-strategy

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**Author details**

Orla McDevitt-Petrovic\* and Karen Kirby

provided the original work is properly cited.

School of Psychology, Ulster University, United Kingdom

\*Address all correspondence to: om.mcdevitt-petrovic@ulster.ac.uk

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

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Wearden A, Dowrick C, Peters S. Factors influencing engagement of patients in a novel intervention for CFS/ME: a qualitative study. Primary health care research & development. 2011

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[24] Chavooshi B, Mohammadkhani P, Dolatshahee B. Telemedicine vs. in-person delivery of intensive shortterm dynamic psychotherapy for patients with medically unexplained pain: A 12-month randomized,

controlled trial. Journal of telemedicine and telecare. 2017 Jan;23(1):133-41.

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org/10.1192%2Fpb.38.5.252

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journal of clinical practice. 2015

Sep;69(9):922-7.

disciplinary, biopsychosocial treatment for non-cardiac chest pain. International

2000;69(4):205-15.

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[19] Speckens AE, Van Hemert AM, Bolk JH, Rooijmans HG, Hengeveld MW.

Unexplained physical symptoms: outcome, utilization of medical care and associated factors. Psychological medicine. 1996 Jul;26(4):745-52.

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org/10.1016/j.cpr.2007.10.004

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Vadeboncoeur A, Chauny JM, Poitras J, Dupuis G, Fleet R, Foldes-Busque G, Lavoie KL. Comparing two brief psychological interventions to usual care in panic disorder patients presenting to the emergency department with chest pain. Behavioural and cognitive psychotherapy. 2012 Mar 1;40(2):129.

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a randomized controlled trial.

[53] Wortman MS, Lucassen PL, van Ravesteijn HJ, Bor H, Assendelft PJ, Lucas C, Olde Hartman TC. Brief multimodal

Psychosomatics. 2011 May 1;52(3):218-29.

psychosomatic therapy in patients with medically unexplained symptoms: feasibility and treatment effects. Family practice. 2016 Aug 1;33(4):346-53.

[54] Kashner TM, Rost K, Cohen B, Anderson M, Smith Jr GR. Enhancing the health of somatization disorder patients: Effectiveness of short-term group therapy. Psychosomatics. 1995

[55] McManus F, Surawy C, Muse K, Vazquez-Montes M, Williams JM. A randomized clinical trial of

mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis). Journal of

Sep 1;36(5):462-70.

1;57(6):507-14.

24;166(14):1512-8.

[43] Potts SG, Lewin R, Fox KA, Johnstone EC. Group psychological treatment for chest pain with normal coronary arteries. Qjm. 1999 Feb

[44] Beck, A. T. Cognitive Therapy and the Emotional Disorders. New York: Penguin. 1976. https://www. penguin.co.uk/books/151/15136/ cognitive-therapy-and-the-emotional-

disorders/9780140156898.html

[46] Martin A, Rauh E, Fichter M, Rief W. A one-session treatment for patients suffering from medically unexplained symptoms in primary care: a randomized clinical trial. Psychosomatics. 2007 Jul

[47] Arnold, I. A., De Waal, M. W., Eekhof, J. A., Assendelft, W. J., Spinhoven, P., & Van Hemert, A. M. Medically unexplained physical symptoms in primary care: a controlled study on the effectiveness of cognitivebehavioral treatment by the family physician. Psychosomatics. 2009 50(5), 515-524. doi: 10.1176/appi.psy.50.5.515.

[48] Speckens AE, van Hemert AM, Bolk JH, Hawton KE, Rooijmans HG. The acceptability of psychological treatment in patients with medically unexplained physical symptoms. Journal of psychosomatic research. 1995

[45] Escobar JI, Gara MA, Diaz-Martinez AM, Interian A, Warman M, Allen LA, Woolfolk RL, Jahn E, Rodgers D. Effectiveness of a time-limited cognitive behavior therapy–type intervention among primary care patients with medically unexplained symptoms. The Annals of Family Medicine. 2007 Jul 1;5(4):328-35.

1;48(4):294-303.

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Oct 1;39(7):855-63.

[56] McManus F, Muse K, Surawy C. Mindfulness-based Cognitive Therapy (MBCT) For Severe Health Anxiety. Healthcare, Counselling and Psychotherapy Journal. 2011:19-23.

[57] Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. Jama. 2004 Mar 24;291(12):1464-70.

[58] Pelland MÈ, Marchand A, Lessard MJ, Belleville G, Chauny JM, Vadeboncoeur A, Poitras J, Foldes-Busque G, Bacon SL, Lavoie KL. Efficacy of 2 interventions for panic disorder in patients presenting to the ED with chest pain. The American journal of emergency medicine. 2011 Nov 1;29(9):1051-61.

[59] Sanders D, Bass C, Mayou RA, Goodwin S, Bryant BM, Tyndel S. Non-cardiac chest pain: why was a brief intervention apparently ineffective?. Psychological medicine. 1997 Sep;27(5): 1033-40.

[60] Esler, J. L., Barlow, D. H., Woolard, R. H., Nicholson, R. A., Nash, J. M., & Erogul, M. H. A brief cognitivebehavioral intervention for patients with noncardiac chest pain. Behavior Therapy,. 2003 34(2), 129-148. https:// doi.org/10.1016/S0005-7894(03)80009-6

[61] Mourad G, Strömberg A, Jonsbu E, Gustafsson M, Johansson P, Jaarsma T. Guided Internet-delivered cognitive behavioural therapy in patients with non-cardiac chest pain–a pilot randomized controlled study. Trials. 2016 Dec 1;17(1):352.

[62] Bahremand M, Moradi G, Saeidi M, Mohammadi S, Komasi S. Reducing irrational beliefs and pain severity in patients suffering from non-cardiac chest pain (NCCP): a comparison of relaxation training and metaphor

therapy. The Korean Journal of Pain. 2015 Apr;28(2):88.

[63] Bahremand M, Saeidi M, Komasi S. How effective is the use of metaphor therapy on reducing psychological symptoms and pain discomfort in patients with non-cardiac chest pain: a randomized, controlled trial. Journal of Cardio-Thoracic Medicine. 2016;4(2):444-9.

[64] Smith RC, Lyles JS, Gardiner JC, et al: Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial. J Gen Intern Med 2006; 21:671-677

[65] Huibers MJ, Beurskens AJ, Bleijenberg G, et al: The effective-ness of psychosocial interventions delivered by general practitioners. Cochrane Database Syst Rev 2003(2):CD003494

[66] Rief W, Nanke A, Emmerich J, Bender A, Zech T. Causal illness attributions in somatoform disorders: associations with comorbidity and illness behavior. Journal of psychosomatic research. 2004 Oct 1;57(4):367-71.

[67] Machin D, Campbell MJ, Tan SB, Tan SH. Sample sizes for clinical, laboratory and epidemiology studies. John Wiley & Sons; 2018 Aug 20.

[68] Button KS, Ioannidis JP, Mokrysz C, Nosek BA, Flint J, Robinson ES, Munafò MR. Power failure: why small sample size undermines the reliability of neuroscience. Nature reviews neuroscience. 2013 May;14(5):365-76.

[69] Coster WJ. Making the best match: selecting outcome measures for clinical trials and outcome studies. American Journal of Occupational Therapy. 2013 Mar 1;67(2):162-70.

[70] Gerger H, Hlavica M, Gaab J, Munder T, Barth J. Does it matter who provides psychological interventions for medically unexplained symptoms? A meta-analysis. Psychotherapy and Psychosomatics. 2015;84(4):217-26.

[71] Burton C. Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS). British Journal of General Practice. 2003 Mar 1;53(488):231-9.

[72] Morriss R, Dowrick C, Salmon P, Peters S, Dunn G, Rogers A, Lewis B, Charles-Jones H, Hogg J, Clifford R, Rigby C. Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. The British Journal of Psychiatry. 2007 Dec;191(6):536-42.

[73] Looper KJ, Kirmayer LJ. Behavioral medicine approaches to somatoform disorders. Journal of consulting and clinical psychology. 2002 Jun;70(3):810.

[74] Smith, R. C., Lein, C., Collins, C., Lyles, J. S., Given, B., Dwamena, F. C., ... & Given, C. W. Treating patients with medically unexplained symptoms in primary care. *J*ournal of General Internal Medicine, 18 2003. (6), 478-489. https://doi. org/10.1046/j.1525-1497.2003.20815.x

[75] Williams GC, Halvari H, Niemiec CP, Sørebø Ø, Olafsen AH, Westbye C. Managerial support for basic psychological needs, somatic symptom burden and work-related correlates: A self-determination theory perspective. Work & Stress. 2014 Oct 2;28(4):404-19.

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rehabilitation

**1. Introduction**

**Chapter 6**

**Abstract**

Psychosomatic Inpatient

Depression in Germany

*Olivia Patsalos and Hubertus Himmerich*

ing people's functional level as well as their quality of life.

Rehabilitation for People with

*Ralf F. Tauber, Carola Nisch, Mutahira M. Qureshi,* 

In Germany, inpatient therapy for depression mainly takes place in either health insurance-financed psychiatric hospitals, or in pension insurance-financed, psychotherapy-focused, psychosomatic rehabilitation hospitals. In psychiatric hospitals, the diagnosis is made according to the International Classification of Diseases (ICD), and therapeutic attempts are made to achieve remission, whereas in rehabilitation hospitals, the International Classification of Functioning, Disability and Health (ICF) plays an essential diagnostic role. Accordingly, the main German pension insurance, Deutsche Rentenversicherung, has developed a rehabilitation therapy standard for depressive disorders. In this chapter, we focus on the psychotherapeutic inpatient rehabilitation for patients with depression based on an example of a specialized psychotherapeutic hospital. This example illustrates how psychotherapeutic inpatient rehabilitation can be tailored to the individual's needs and may include any of the following therapeutic modalities: Cognitive Behavior Therapy (CBT), Schema Therapy, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), pharmacotherapy, group therapy for comorbid conditions, skills training, psychoeducation, occupational therapy (OT), movement therapy, physiotherapy, music therapy, social work, family work, and self-help groups. People with depression may benefit from this service model of psychosomatic inpatient rehabilitation beyond symptom remission, as it focuses on increas-

**Keywords:** inpatient therapy, psychosomatic therapy, psychotherapy, depression,

Mental and substance use disorders are the leading cause of years lived with disability (YLD) worldwide, whereby depressive disorders account for 42.5% of YLDs caused by mental and substance use disorders [1]. The health report of the German technicians' health insurance in 2016 [2] found that the number of work absences due to a mental disorder has almost doubled from the year 2000, reaching its highest value in 2015 at 245 sick leave days per 100 insurance years. Patients with depressive illnesses represented the group with most sick days [2]. Cumulative data

#### **Chapter 6**

*Psychosomatic Medicine*

1;53(488):231-9.

provides psychological interventions for medically unexplained symptoms? A meta-analysis. Psychotherapy and Psychosomatics. 2015;84(4):217-26.

[71] Burton C. Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS). British Journal of General Practice. 2003 Mar

[72] Morriss R, Dowrick C, Salmon P, Peters S, Dunn G, Rogers A, Lewis B, Charles-Jones H, Hogg J, Clifford R, Rigby C. Cluster randomised controlled

reattribution for medically unexplained symptoms. The British Journal of Psychiatry. 2007 Dec;191(6):536-42.

[73] Looper KJ, Kirmayer LJ. Behavioral medicine approaches to somatoform disorders. Journal of consulting and clinical psychology. 2002 Jun;70(3):810.

[74] Smith, R. C., Lein, C., Collins, C., Lyles, J. S., Given, B., Dwamena, F. C., ... & Given, C. W. Treating patients with medically unexplained symptoms in primary care. *J*ournal of General Internal Medicine, 18 2003. (6), 478-489. https://doi. org/10.1046/j.1525-1497.2003.20815.x

[75] Williams GC, Halvari H, Niemiec CP, Sørebø Ø, Olafsen AH, Westbye C. Managerial support for basic psychological needs, somatic symptom burden and work-related correlates: A self-determination theory perspective. Work & Stress. 2014 Oct 2;28(4):404-19.

trial of training practices in

**120**

## Psychosomatic Inpatient Rehabilitation for People with Depression in Germany

*Ralf F. Tauber, Carola Nisch, Mutahira M. Qureshi, Olivia Patsalos and Hubertus Himmerich*

#### **Abstract**

In Germany, inpatient therapy for depression mainly takes place in either health insurance-financed psychiatric hospitals, or in pension insurance-financed, psychotherapy-focused, psychosomatic rehabilitation hospitals. In psychiatric hospitals, the diagnosis is made according to the International Classification of Diseases (ICD), and therapeutic attempts are made to achieve remission, whereas in rehabilitation hospitals, the International Classification of Functioning, Disability and Health (ICF) plays an essential diagnostic role. Accordingly, the main German pension insurance, Deutsche Rentenversicherung, has developed a rehabilitation therapy standard for depressive disorders. In this chapter, we focus on the psychotherapeutic inpatient rehabilitation for patients with depression based on an example of a specialized psychotherapeutic hospital. This example illustrates how psychotherapeutic inpatient rehabilitation can be tailored to the individual's needs and may include any of the following therapeutic modalities: Cognitive Behavior Therapy (CBT), Schema Therapy, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), pharmacotherapy, group therapy for comorbid conditions, skills training, psychoeducation, occupational therapy (OT), movement therapy, physiotherapy, music therapy, social work, family work, and self-help groups. People with depression may benefit from this service model of psychosomatic inpatient rehabilitation beyond symptom remission, as it focuses on increasing people's functional level as well as their quality of life.

**Keywords:** inpatient therapy, psychosomatic therapy, psychotherapy, depression, rehabilitation

#### **1. Introduction**

Mental and substance use disorders are the leading cause of years lived with disability (YLD) worldwide, whereby depressive disorders account for 42.5% of YLDs caused by mental and substance use disorders [1]. The health report of the German technicians' health insurance in 2016 [2] found that the number of work absences due to a mental disorder has almost doubled from the year 2000, reaching its highest value in 2015 at 245 sick leave days per 100 insurance years. Patients with depressive illnesses represented the group with most sick days [2]. Cumulative data

for all public and private health insurance companies in Germany are not available, but comparable reports of individual insurances show similar results.

Compared to other diseases whose number of hospital admissions has remained relatively constant over the past few years (e.g., diseases of the circulatory system, the musculoskeletal system, and cancer), the incidence of mental illnesses in the inpatient care system has steadily increased since 1990. While the number of admissions due to somatic diseases has tended to decrease, psychiatric diagnoses have risen from 175 to 350 days per 1000 insured years since 1990. Among these psychiatric diagnoses, substance misuse disorders as well as depressive disorders are by far the most frequent ones [3]. The Federal Health Care Report (Gesundheitsberichterstattung des Bundes) estimates an increase in the direct cost of mental illness from €219 million in 2002 to about €254 million in 2008 [4]. Beyond the financial cost, mental illnesses, and specifically depression, are accompanied by severe suffering, considerable impairment of work performance, and reduced quality of life (QoL) [5].

#### **2. The significance of mental disorders for German pension insurances**

In contrast to other health systems such as the public National Health Service (NHS) in the United Kingdom, which is funded by the state, health care in Germany is mainly funded by either public or private health insurances, as well as by pension insurance, taxes, and out-of-pocket co-payments. Public and private health insurances as well as pension insurances are financed by contributions from both the employer and the employee; a percentage of the employee's gross income is transferred to the individual's health and pension scheme. Whereas health care in general is funded by public or private health care insurances, rehabilitation and work reintegration is funded by pension insurances, which also cover the costs of treatment in rehabilitation hospitals.

As a result, mental illnesses are placing an increasingly heavy burden on pension insurance schemes such as the German Statutory Pension Insurance (Deutschen Rentenversicherung; DRV). While only 6.6% of all occupational disabilityrelated illnesses were of a mental nature in 1982, their incidence rose to 42% by 2012. Among women, almost half (48.5%) of sickness leave was due to a mental disorder [6]. In addition, the average age of retirement in patients with mental illness is lower as compared to other diagnostic groups (48.1 vs. 50.4 years) [6]. Consequently, fewer social insurance contributions are generated by patients and their employers (since they are no longer working), and the duration of pension payments increases (since patients retire earlier).

The amount of DRV reimbursement for medical rehabilitation of mental disorders in 2012 was €716 million as reported in their 2016 position paper of the DRV on the Significance of Mental Illnesses in Rehabilitation and Disability Reduction [7]. Against this background, the DRV has a pressing need to reduce the incapacity to work that results from depressive or other psychological disorders.

#### **3. A disease model for the rehabilitative treatment of depressed patients**

Acute and long-term treatments of mental illnesses are either directed at the assumed causes of a certain disorder or the presenting symptoms. They are primarily centered on the clinical picture as a manifestation of the disease or

**123**

treatment [11].

*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany*

injury and are aimed at treatment response or remission. In the case of disorders with a tendency toward chronicity, prevention of episode aggravation or precipitation of another episode is crucial. The conceptual framework of acute and long-term psychiatric disorders is frequently based on a medical disease model that corresponds to the classification according to the International Classification of Diseases (ICD) of the World Health Organization (WHO) [8]. For example, in Germany a patient with a severe third episode of depressive symptoms is seen by a psychiatrist in their practice, referred and admitted to a psychiatric hospital, diagnosed with recurrent major depressive disorder (ICD-10 code: F33.2) [8], and treated by the multidisciplinary team on the psychiatric ward according to the German national guidelines for the treatment of unipolar depression [9], which advise psychopharmacological treatment with an antidepressant that will continue after discharge. The costs of admission are incurred by the private or public

In contrast, medical rehabilitation as practiced in rehabilitation hospitals in Germany is based on the biopsychosocial model of functioning, disability and health. This model has also been introduced by the WHO [10] in their International Classification of Functioning, Disability and Health (ICF) framework. While ICD-10 gives users an etiological or symptom-based framework for the classification, that is, the diagnosis of a disease, disorder, or health condition, the ICF classifies functioning and disability as associated with health conditions. The ICD-10 and

In the biopsychosocial model of functioning, disability and health, impairments take place on three levels: (1) body structures and functions, (2) activity, and (3) participation. Health is seen as embedded in the context of "functioning." A person

• Their physical functions including that of the mind and body are of accepted

• They can perform all levels of activities that are expected of a person without a

• They are able to develop their participation in all areas of life that are important to them, in the manner and extent that is expected of a person without impairment of body structures, functions, or activities (i.e., a level of partici-

This model conceptualizes health and disease as a result of the interlocking of physiological, psychological, and social processes (see **Figure 1**). The type and extent of functional health of a person are therefore also dependent on the circumstances or the background of the person's life. These contextual factors consist of personal factors (e.g., age, sex, and lifestyle) and environmental factors (e.g., family, residential situation, and work situation). These factors can either exert a favorable influence (positive context factors) or have a detrimental influence (negative context factors or barriers) on the overall prognosis, recovery, and reintegration into work and society. **Figure 2** gives an example of how this model can be applied in the case of a patient with a depressive episode. By considering these context factors, it is ensured that in addition to any medical diagnoses, personal and/or social conditions, the patients' experience is part of the rehabilitative

ICF are therefore seen as complementary to one another [10, 11].

is therefore "functionally healthy" when:

*DOI: http://dx.doi.org/10.5772/intechopen.91923*

health insurance.

standards,

health problem, and

pation in all spheres of life).

#### *Psychosomatic Inpatient Rehabilitation for People with Depression in Germany DOI: http://dx.doi.org/10.5772/intechopen.91923*

injury and are aimed at treatment response or remission. In the case of disorders with a tendency toward chronicity, prevention of episode aggravation or precipitation of another episode is crucial. The conceptual framework of acute and long-term psychiatric disorders is frequently based on a medical disease model that corresponds to the classification according to the International Classification of Diseases (ICD) of the World Health Organization (WHO) [8]. For example, in Germany a patient with a severe third episode of depressive symptoms is seen by a psychiatrist in their practice, referred and admitted to a psychiatric hospital, diagnosed with recurrent major depressive disorder (ICD-10 code: F33.2) [8], and treated by the multidisciplinary team on the psychiatric ward according to the German national guidelines for the treatment of unipolar depression [9], which advise psychopharmacological treatment with an antidepressant that will continue after discharge. The costs of admission are incurred by the private or public health insurance.

In contrast, medical rehabilitation as practiced in rehabilitation hospitals in Germany is based on the biopsychosocial model of functioning, disability and health. This model has also been introduced by the WHO [10] in their International Classification of Functioning, Disability and Health (ICF) framework. While ICD-10 gives users an etiological or symptom-based framework for the classification, that is, the diagnosis of a disease, disorder, or health condition, the ICF classifies functioning and disability as associated with health conditions. The ICD-10 and ICF are therefore seen as complementary to one another [10, 11].

In the biopsychosocial model of functioning, disability and health, impairments take place on three levels: (1) body structures and functions, (2) activity, and (3) participation. Health is seen as embedded in the context of "functioning." A person is therefore "functionally healthy" when:


This model conceptualizes health and disease as a result of the interlocking of physiological, psychological, and social processes (see **Figure 1**). The type and extent of functional health of a person are therefore also dependent on the circumstances or the background of the person's life. These contextual factors consist of personal factors (e.g., age, sex, and lifestyle) and environmental factors (e.g., family, residential situation, and work situation). These factors can either exert a favorable influence (positive context factors) or have a detrimental influence (negative context factors or barriers) on the overall prognosis, recovery, and reintegration into work and society. **Figure 2** gives an example of how this model can be applied in the case of a patient with a depressive episode. By considering these context factors, it is ensured that in addition to any medical diagnoses, personal and/or social conditions, the patients' experience is part of the rehabilitative treatment [11].

*Psychosomatic Medicine*

reduced quality of life (QoL) [5].

treatment in rehabilitation hospitals.

payments increases (since patients retire earlier).

for all public and private health insurance companies in Germany are not available,

**2. The significance of mental disorders for German pension insurances**

(NHS) in the United Kingdom, which is funded by the state, health care in Germany is mainly funded by either public or private health insurances, as well as by pension insurance, taxes, and out-of-pocket co-payments. Public and private health insurances as well as pension insurances are financed by contributions from both the employer and the employee; a percentage of the employee's gross income is transferred to the individual's health and pension scheme. Whereas health care in general is funded by public or private health care insurances, rehabilitation and work reintegration is funded by pension insurances, which also cover the costs of

In contrast to other health systems such as the public National Health Service

As a result, mental illnesses are placing an increasingly heavy burden on pension insurance schemes such as the German Statutory Pension Insurance (Deutschen Rentenversicherung; DRV). While only 6.6% of all occupational disabilityrelated illnesses were of a mental nature in 1982, their incidence rose to 42% by 2012. Among women, almost half (48.5%) of sickness leave was due to a mental disorder [6]. In addition, the average age of retirement in patients with mental illness is lower as compared to other diagnostic groups (48.1 vs. 50.4 years) [6]. Consequently, fewer social insurance contributions are generated by patients and their employers (since they are no longer working), and the duration of pension

The amount of DRV reimbursement for medical rehabilitation of mental disorders in 2012 was €716 million as reported in their 2016 position paper of the DRV on the Significance of Mental Illnesses in Rehabilitation and Disability Reduction [7]. Against this background, the DRV has a pressing need to reduce the incapacity

**3. A disease model for the rehabilitative treatment of depressed patients**

Acute and long-term treatments of mental illnesses are either directed at the assumed causes of a certain disorder or the presenting symptoms. They are primarily centered on the clinical picture as a manifestation of the disease or

to work that results from depressive or other psychological disorders.

Compared to other diseases whose number of hospital admissions has remained relatively constant over the past few years (e.g., diseases of the circulatory system, the musculoskeletal system, and cancer), the incidence of mental illnesses in the inpatient care system has steadily increased since 1990. While the number of admissions due to somatic diseases has tended to decrease, psychiatric diagnoses have risen from 175 to 350 days per 1000 insured years since 1990. Among these psychiatric diagnoses, substance misuse disorders as well as depressive disorders are by far the most frequent ones [3]. The Federal Health Care Report (Gesundheitsberichterstattung des Bundes) estimates an increase in the direct cost of mental illness from €219 million in 2002 to about €254 million in 2008 [4]. Beyond the financial cost, mental illnesses, and specifically depression, are accompanied by severe suffering, considerable impairment of work performance, and

but comparable reports of individual insurances show similar results.

**122**

**Figure 1.** *ICF model with definitions of the terms used.*

**125**

*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany*

**Figure 2.**

*Example of applying the ICF model to a sample patient with depression.*

*DOI: http://dx.doi.org/10.5772/intechopen.91923*

#### *Psychosomatic Inpatient Rehabilitation for People with Depression in Germany DOI: http://dx.doi.org/10.5772/intechopen.91923*

**Figure 2.**

*Example of applying the ICF model to a sample patient with depression.*

**Figure 1.**

*ICF model with definitions of the terms used.*

*Psychosomatic Medicine*

**124**

#### **4. The goal of rehabilitative treatment of depressed patients**

Against the background of the biopsychosocial model of functional health, the rehabilitation goals of each of three levels of functioning are specified taking into account their respective context factors (**Figure 3** exemplifies these goals for the patient described in **Figure 2**). The aim is to remove or reduce the impending or already manifest impairments of participation or prevent their exacerbation and worsening. The patient is ultimately to be enabled or re-enabled by the rehabilitation to spend their life in a way that is normal within their personal life context.

Participation in their professional life may be of specific interest, even if their job has not been the trigger of a depressive episode. For example, a depressive episode following the death of a close relative may require psychosomatic rehabilitation, because it may impact on the capacity to work and subsequent disability. Therefore, it is in the interest of the cost-bearers such as the pension insurance to prevent such depressive disorders at an early stage.

In psychosomatic rehabilitation for depression, the acute psychiatric treatment is usually not yet completed by the time of discharge from hospital. In some cases, the rehabilitation hospitals are the first treatment providers and thus must provide acute care including psychoeducation, psychopharmacological and psychological therapy. Thus, good psychosomatic rehabilitation encompasses elements of acute psychiatric treatment in addition to the core rehabilitation goals of enhancing the individual's resources, removing barriers, and improving the overall performance to compensate for remaining restrictions and disabilities.

#### **5. The therapeutic standard for rehabilitation in depressive disorders**

In recent years, several national and international clinical guidelines have been developed, which provide an optimal, up-to-date therapy or action algorithm as a guidance for the practicing physician. In Germany, the national guidelines for the treatment of unipolar depression [9] constitute the central systematic summary of the current scientific status on the acute treatment and care for people with depression. In addition to this guideline, the DRV has developed a therapeutic standard for rehabilitation (RTS) of depressive disorder [12]. In this standard, the so-called "evidence-based therapy modules" (ETMs) derived from rehabilitation research are defined. The RTS clarifies the specific therapies that constitute an ETM, as well as their duration and frequency. In turn, the therapies provided by the psychosomatic rehabilitation hospital are listed, described, and coded in the German Classification of Therapeutic Procedures [13].

The documentation of applied therapies according to the KTL system is regularly communicated to the funders, for example, a pension insurance, for each patient individually. This can then be used to determine annually to what extent the RTS was implemented by the hospital. We will depict the practicalities of rehabilitative treatment of depressive illnesses in psychosomatic hospitals by using our own hospital, the Psychosomatic Department of the Sachsenklinik Bad Lausick, as an example. This will illustrate not only the application of the aforementioned guidelines, but also the freedom that exists within this framework to implement hospital-specific cognitive-behavioral approaches or novel concepts such as schema therapy [14] or Cognitive Behavioral Analysis System of Psychotherapy (CBASP) [15].

**127**

*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany*

**Figure 3.**

*Rehabilitation goals and therapeutic measures according to the ICF model for a patient with depression.*

*DOI: http://dx.doi.org/10.5772/intechopen.91923*

**Figure 3.**

*Rehabilitation goals and therapeutic measures according to the ICF model for a patient with depression.*

*Psychosomatic Medicine*

context.

disabilities.

of Therapeutic Procedures [13].

**4. The goal of rehabilitative treatment of depressed patients**

prevent such depressive disorders at an early stage.

Against the background of the biopsychosocial model of functional health, the rehabilitation goals of each of three levels of functioning are specified taking into account their respective context factors (**Figure 3** exemplifies these goals for the patient described in **Figure 2**). The aim is to remove or reduce the impending or already manifest impairments of participation or prevent their exacerbation and worsening. The patient is ultimately to be enabled or re-enabled by the rehabilitation to spend their life in a way that is normal within their personal life

Participation in their professional life may be of specific interest, even if their job has not been the trigger of a depressive episode. For example, a depressive episode following the death of a close relative may require psychosomatic rehabilitation, because it may impact on the capacity to work and subsequent disability. Therefore, it is in the interest of the cost-bearers such as the pension insurance to

In psychosomatic rehabilitation for depression, the acute psychiatric treatment is usually not yet completed by the time of discharge from hospital. In some cases, the rehabilitation hospitals are the first treatment providers and thus must provide acute care including psychoeducation, psychopharmacological and psychological therapy. Thus, good psychosomatic rehabilitation encompasses elements of acute psychiatric treatment in addition to the core rehabilitation goals of enhancing the individual's resources, removing barriers, and improving the overall performance to compensate for remaining restrictions and

**5. The therapeutic standard for rehabilitation in depressive disorders**

In recent years, several national and international clinical guidelines have been developed, which provide an optimal, up-to-date therapy or action algorithm as a guidance for the practicing physician. In Germany, the national guidelines for the treatment of unipolar depression [9] constitute the central systematic summary of the current scientific status on the acute treatment and care for people with depression. In addition to this guideline, the DRV has developed a therapeutic standard for rehabilitation (RTS) of depressive disorder [12]. In this standard, the so-called "evidence-based therapy modules" (ETMs) derived from rehabilitation research are defined. The RTS clarifies the specific therapies that constitute an ETM, as well as their duration and frequency. In turn, the therapies provided by the psychosomatic rehabilitation hospital are listed, described, and coded in the German Classification

The documentation of applied therapies according to the KTL system is regularly communicated to the funders, for example, a pension insurance, for each patient individually. This can then be used to determine annually to what extent the RTS was implemented by the hospital. We will depict the practicalities of rehabilitative treatment of depressive illnesses in psychosomatic hospitals by using our own hospital, the Psychosomatic Department of the Sachsenklinik Bad Lausick, as an example. This will illustrate not only the application of the aforementioned guidelines, but also the freedom that exists within this framework to implement hospital-specific cognitive-behavioral approaches or novel concepts such as schema therapy [14] or Cognitive Behavioral Analysis System of Psychotherapy

**126**

(CBASP) [15].

#### **6. Example of psychosomatic inpatient treatment for depression**

*Psychotherapeutic and medical treatment:* In the Psychosomatic Department of the Sachsenklinik Bad Lausick, a treatment concept is applied that places special emphasis on the high quality and density of specific psychotherapeutic interventions. The clinic currently comprises of 100 beds, which are allocated to six wards with multidisciplinary teams (MDT). Each MDT is divided into two thematically specialized sub-teams. Psychological and medical staff are permanently assigned to these sub-teams. **Table 1** depicts the structure of the Psychosomatic Department of the Sachsenklinik Bad Lausic in more detail. In each sub-team, approximately eight to nine patients are assigned and treated by their reference therapists within this family-like group. This allows frequent patient-centered contacts with the reference therapists. There are, in principle, three disorder-specific group therapies (90 min each) as well as at least one individual interview. Thus, the patients are guaranteed a total of at least 20 psychotherapeutic contacts with their reference therapist within a 5-week stay. Nine of the sub-teams of this department are specialized in treating depressive patients. However, there are conceptual differences between the subteams (see below).

For patients with psychiatric comorbidities, disorder-specific group therapies are offered, which are applied across all the teams and can thus be attended by those patients referred to by their sub-teams. According to cognitive-behavioral treatment principles, manualized group therapies are facilitated for people with anxiety disorders, pain disorders, obesity, binge eating disorder, obsessive-compulsive disorder, and tinnitus. In addition to these symptom-oriented skills, training is also offered according to the Dialectic Behavioral Therapy (DBT) created by Linehan [16]. These groups take place once or twice a week and each has a duration of 90–120 min per week.

In addition to the groups for the treatment of existing mental illnesses, further non-disorder-specific group therapy is offered. In these groups, patients are trained in general life skills (which are relevant at the ICF level of activities) geared toward coping with difficulties and not necessarily related to a specific psychiatric disorder. Examples include stress management, enjoyment training, social competences training, and imagination groups. In addition, there is a metacognitive training (MCT) group based on metacognitive therapy techniques, in which patients learn a new way of dealing with rumination or worrying thoughts.

Within this context, two separate groups are offered, which have a special working reference within the framework of medical-occupational rehabilitation (medizinisch-berufliche rehabilitation). One group, the so-called professional competence group, is designed to recognize, solve, and avoid workplace conflicts and interpersonal problems, such as bullying. The other group is known as the work-related motivation group. In this group, special focus is given to building up the systematic motivation necessary to take a proactive position and to (re-)enter professional life. Above all, the therapeutic community with other affected people can also be used as a resource to reduce the often-present despair or the sometimesexaggerated concerns of returning to the workplace. The disorder-specific groups each have a timeframe of about 60–120 min per week.

In addition to goal-oriented therapeutic interventions for the reduction of unhelpful behavior and symptoms, resource-oriented approaches are also used to tap into previously unused potential and abilities of the patient. These wellprepared, high-quality, therapeutically guided cognitive-behavioral group therapies are not simply about psychoeducation or group participant interaction. Instead, in these groups, the therapeutic process between the individual participants and the therapist can be advanced and expanded, especially after appropriate preparation

**129**

*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany*

**Table 1.** *Structure of the Psychosomatic Department of the Sachsenklinik Bad Lausick, Germany.*

*DOI: http://dx.doi.org/10.5772/intechopen.91923*


**Table 1.** *Structure of the Psychosomatic Department of the Sachsenklinik Bad Lausick, Germany.*

*Psychosomatic Medicine*

teams (see below).

90–120 min per week.

**6. Example of psychosomatic inpatient treatment for depression**

*Psychotherapeutic and medical treatment:* In the Psychosomatic Department of the Sachsenklinik Bad Lausick, a treatment concept is applied that places special emphasis on the high quality and density of specific psychotherapeutic interventions. The clinic currently comprises of 100 beds, which are allocated to six wards with multidisciplinary teams (MDT). Each MDT is divided into two thematically specialized sub-teams. Psychological and medical staff are permanently assigned to these sub-teams. **Table 1** depicts the structure of the Psychosomatic Department of the Sachsenklinik Bad Lausic in more detail. In each sub-team, approximately eight to nine patients are assigned and treated by their reference therapists within this family-like group. This allows frequent patient-centered contacts with the reference therapists. There are, in principle, three disorder-specific group therapies (90 min each) as well as at least one individual interview. Thus, the patients are guaranteed a total of at least 20 psychotherapeutic contacts with their reference therapist within a 5-week stay. Nine of the sub-teams of this department are specialized in treating depressive patients. However, there are conceptual differences between the sub-

For patients with psychiatric comorbidities, disorder-specific group therapies are offered, which are applied across all the teams and can thus be attended by those patients referred to by their sub-teams. According to cognitive-behavioral treatment principles, manualized group therapies are facilitated for people with anxiety disorders, pain disorders, obesity, binge eating disorder, obsessive-compulsive disorder, and tinnitus. In addition to these symptom-oriented skills, training is also offered according to the Dialectic Behavioral Therapy (DBT) created by Linehan [16]. These groups take place once or twice a week and each has a duration of

In addition to the groups for the treatment of existing mental illnesses, further non-disorder-specific group therapy is offered. In these groups, patients are trained in general life skills (which are relevant at the ICF level of activities) geared toward coping with difficulties and not necessarily related to a specific psychiatric disorder. Examples include stress management, enjoyment training, social competences training, and imagination groups. In addition, there is a metacognitive training (MCT) group based on metacognitive therapy techniques, in which patients learn a

Within this context, two separate groups are offered, which have a special working reference within the framework of medical-occupational rehabilitation (medizinisch-berufliche rehabilitation). One group, the so-called professional competence group, is designed to recognize, solve, and avoid workplace conflicts and interpersonal problems, such as bullying. The other group is known as the work-related motivation group. In this group, special focus is given to building up the systematic motivation necessary to take a proactive position and to (re-)enter professional life. Above all, the therapeutic community with other affected people can also be used as a resource to reduce the often-present despair or the sometimesexaggerated concerns of returning to the workplace. The disorder-specific groups

In addition to goal-oriented therapeutic interventions for the reduction of unhelpful behavior and symptoms, resource-oriented approaches are also used to tap into previously unused potential and abilities of the patient. These wellprepared, high-quality, therapeutically guided cognitive-behavioral group therapies are not simply about psychoeducation or group participant interaction. Instead, in these groups, the therapeutic process between the individual participants and the therapist can be advanced and expanded, especially after appropriate preparation

new way of dealing with rumination or worrying thoughts.

each have a timeframe of about 60–120 min per week.

**128**

during individual therapy. Furthermore, these therapies provide opportunities to exchange experiences, to learn from other patients as well as the group leader, and test new behaviors in a protected environment, guided by the group therapist. Group psychotherapy is particularly well suited for the treatment of disorders that manifest predominantly in a group context [17, 18]. The experience gained in the group, the acquired knowledge, and the acquired abilities can be further strengthened in individual therapy. Overall, patients receive an average of 40–50 psychotherapy hours during their stay.

Although the main emphasis is on psychotherapy, drug treatment is also an important part of the overall treatment. As the name would suggest, in the biopsycho-social approach, drug therapy is seen as an equally important treatment modality. Based on the latest evidence available, a combination of psychotherapy and antidepressant medication seems to be of most benefit for patients with depressive disorders [19], specifically with regard to QoL.

Another treatment modality available to medical professionals is light therapy. This treatment has been successfully used in seasonal depression and is scientifically recognized as an effective biological treatment methodology. Given its successful application in SAD, light therapy can also be utilized for other types of depression, where indications that this type of chronobiologic therapy could be beneficial are present [20].

Ultimately, the use of biofeedback is a treatment approach worthy of consideration. Patients could greatly benefit from being trained in this domain as disorder symptoms could potentially be reduced via feedback of otherwise unconsciously running processes controlled by the autonomic nervous system [21].

*Complementary therapies:* Occupational therapy (OT) includes classic OT, project-oriented OT, and expression-centered OT, within which patients learn different creative techniques. Thusly, patient resources and capabilities are rediscovered or reactivated. Participation in OT is thought to help in building up positive activities and lead to further insights that may be important for psychotherapy such as realizing one's own perfectionism.

In addition to this, specific measures of the medical-occupational rehabilitation are assessed using standardized tests. These could include workplace and concentration training, stress tests in the artisan or office work area, as well as targeted work-related skills tests. Examples of these are the "Diagnostic Instrument to Assess Work Skills" (IDA—Instrumentarium zur Diagnostik von Arbeitsfähigkeiten) and the "Psychological Traits Profiles for the Integration of Disabled People to Work" (MELBA—Psychologische Merkmalsprofile zur Eingliederung Behinderter in Arbeit). For patients with office jobs, workplace training is also offered for ergonomic sitting and working.

Art therapy, a predominantly non-linguistic therapeutic method, is a suitable open and direct emotional approach, which can be very beneficial to patients who have very limited contact with their emotions. In the Psychosomatic Department, art therapy is based on the concept of schema therapy.

Physiotherapy and sports therapy offer a wide range of therapeutic measures ranging from active sports therapy, to specific individual physiotherapy, to interaction-centered groups and, to medical training. The medical-occupational rehabilitation model also utilizes body-oriented workplace training along with problem-specific function-related physiotherapeutic tests and assessments. Furthermore, passive and relieving therapy measures, such as relaxation baths and massages, are also used where necessary, especially at the beginning of the therapeutic process.

The main relaxation technique, which is taught and practiced in our department is Progressive Muscle Relaxation (PMR) as described by Jacobson [22].

**131**

*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany*

Alternatively, the Autogenic Training according to Schultz [23] is used. In addition, as a further relaxation measure, mindfulness and body-centered procedures such as yoga, TaiChi, QiGong, and specific exercises focusing on body perception are

Dietary and nutritional therapy is an integral part of the therapeutic concept in patients with comorbid problematic eating behaviors. A dietary consultation is offered to all patients who have experienced nutritional or weight-related problems

Social therapy, which is usually facilitated by a social worker, consists of counseling on various issues relating to social law and participation in working life. This may include getting in contact with external institutions such as integration services, employment or pension agencies, as well as other appropriate services. In addition, social services also provide support with contacting the employer to plan a stepwise return to work, or to adjust the work plan or job description so that reintegration into the workplace can be as smooth as possible. Additionally, within this framework of the medical-occupational rehabilitation approach, social services can organize and support external stress tests in either a simulated or the actual

*Special consideration of clinical subtypes of depression:* Depressive disorders can show a variety of symptom clusters. Thus, it makes sense to have sub-teams that can offer more tailored approaches for each of the following specific symptom clusters:

• Chronic forms of affective disorders like dysthymia, chronic depression, and

• Depressive forms with predominant exhaustion and, in some cases, workplacerelated conflict situations, which are often also referred to as "burnout

• Depressive disorders after loss and death, which may be similar to the symp-

• Depressive forms complicated by specific personality traits, the so-called

• Chronic or ever-flaring depressive pictures that can be described as posttraumatic embitterment [24], where there is a strong correlation between the individual's biography and certain traumatic experiences or failed adaptive

In the context of psychosomatic medicine, therapies can be individually tailored with the intention of improving their effectiveness and generating a better subjective understanding among patients. The assumptions and techniques of classic cognitive behavioral therapy (especially the development of activities and cognitive restructuring) form the basis of these therapies, since CBT has shown the most efficacy in these disorders, and its high efficiency and long-term effects are empiri-

Through the systematic development of positive activities, which, in addition to leisure activities and enjoyment, can also include duties, work or other tasks, the patients are brought back into a more proactive position, thereby reducing "learned helplessness" as described by Alloy and Seligman [27]. For many patients, positive activities must be discovered or rediscovered and systematically practiced. As part of further treatment, the focus is on emotional perception and cognitive acceptance

tom pattern of stress-related disorders or grief disorder.

*DOI: http://dx.doi.org/10.5772/intechopen.91923*

such as obesity or binge eating disorder.

working environment of the patient.

maladaptive schemata [14].

double depression.

syndrome."

performance.

cally well documented [25, 26].

offered.

*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany DOI: http://dx.doi.org/10.5772/intechopen.91923*

Alternatively, the Autogenic Training according to Schultz [23] is used. In addition, as a further relaxation measure, mindfulness and body-centered procedures such as yoga, TaiChi, QiGong, and specific exercises focusing on body perception are offered.

Dietary and nutritional therapy is an integral part of the therapeutic concept in patients with comorbid problematic eating behaviors. A dietary consultation is offered to all patients who have experienced nutritional or weight-related problems such as obesity or binge eating disorder.

Social therapy, which is usually facilitated by a social worker, consists of counseling on various issues relating to social law and participation in working life. This may include getting in contact with external institutions such as integration services, employment or pension agencies, as well as other appropriate services. In addition, social services also provide support with contacting the employer to plan a stepwise return to work, or to adjust the work plan or job description so that reintegration into the workplace can be as smooth as possible. Additionally, within this framework of the medical-occupational rehabilitation approach, social services can organize and support external stress tests in either a simulated or the actual working environment of the patient.

*Special consideration of clinical subtypes of depression:* Depressive disorders can show a variety of symptom clusters. Thus, it makes sense to have sub-teams that can offer more tailored approaches for each of the following specific symptom clusters:


In the context of psychosomatic medicine, therapies can be individually tailored with the intention of improving their effectiveness and generating a better subjective understanding among patients. The assumptions and techniques of classic cognitive behavioral therapy (especially the development of activities and cognitive restructuring) form the basis of these therapies, since CBT has shown the most efficacy in these disorders, and its high efficiency and long-term effects are empirically well documented [25, 26].

Through the systematic development of positive activities, which, in addition to leisure activities and enjoyment, can also include duties, work or other tasks, the patients are brought back into a more proactive position, thereby reducing "learned helplessness" as described by Alloy and Seligman [27]. For many patients, positive activities must be discovered or rediscovered and systematically practiced. As part of further treatment, the focus is on emotional perception and cognitive acceptance

*Psychosomatic Medicine*

therapy hours during their stay.

beneficial are present [20].

as realizing one's own perfectionism.

nomic sitting and working.

art therapy is based on the concept of schema therapy.

sive disorders [19], specifically with regard to QoL.

during individual therapy. Furthermore, these therapies provide opportunities to exchange experiences, to learn from other patients as well as the group leader, and test new behaviors in a protected environment, guided by the group therapist. Group psychotherapy is particularly well suited for the treatment of disorders that manifest predominantly in a group context [17, 18]. The experience gained in the group, the acquired knowledge, and the acquired abilities can be further strengthened in individual therapy. Overall, patients receive an average of 40–50 psycho-

Although the main emphasis is on psychotherapy, drug treatment is also an important part of the overall treatment. As the name would suggest, in the biopsycho-social approach, drug therapy is seen as an equally important treatment modality. Based on the latest evidence available, a combination of psychotherapy and antidepressant medication seems to be of most benefit for patients with depres-

Another treatment modality available to medical professionals is light therapy.

Ultimately, the use of biofeedback is a treatment approach worthy of consideration. Patients could greatly benefit from being trained in this domain as disorder symptoms could potentially be reduced via feedback of otherwise unconsciously

In addition to this, specific measures of the medical-occupational rehabilitation are assessed using standardized tests. These could include workplace and concentration training, stress tests in the artisan or office work area, as well as targeted work-related skills tests. Examples of these are the "Diagnostic Instrument to Assess Work Skills" (IDA—Instrumentarium zur Diagnostik von Arbeitsfähigkeiten) and the "Psychological Traits Profiles for the Integration of Disabled People to Work" (MELBA—Psychologische Merkmalsprofile zur Eingliederung Behinderter in Arbeit). For patients with office jobs, workplace training is also offered for ergo-

Art therapy, a predominantly non-linguistic therapeutic method, is a suitable open and direct emotional approach, which can be very beneficial to patients who have very limited contact with their emotions. In the Psychosomatic Department,

Physiotherapy and sports therapy offer a wide range of therapeutic measures

The main relaxation technique, which is taught and practiced in our department is Progressive Muscle Relaxation (PMR) as described by Jacobson [22].

ranging from active sports therapy, to specific individual physiotherapy, to interaction-centered groups and, to medical training. The medical-occupational rehabilitation model also utilizes body-oriented workplace training along with problem-specific function-related physiotherapeutic tests and assessments. Furthermore, passive and relieving therapy measures, such as relaxation baths and massages, are also used where necessary, especially at the beginning of the thera-

*Complementary therapies:* Occupational therapy (OT) includes classic OT, project-oriented OT, and expression-centered OT, within which patients learn different creative techniques. Thusly, patient resources and capabilities are rediscovered or reactivated. Participation in OT is thought to help in building up positive activities and lead to further insights that may be important for psychotherapy such

This treatment has been successfully used in seasonal depression and is scientifically recognized as an effective biological treatment methodology. Given its successful application in SAD, light therapy can also be utilized for other types of depression, where indications that this type of chronobiologic therapy could be

running processes controlled by the autonomic nervous system [21].

**130**

peutic process.

of the positive activities, which can be promoted by additional use of "mindfulness" and mindfulness techniques (according to Linehan [16]). Furthermore, a so-called "euthymic therapy," also referred to as genus training, is deemed to be very useful in this context [28].

In cognitive therapy, patients are guided toward dealing with negative cognitions in a systematic manner. The depressed and exaggerated negative character of the thoughts is examined against reality, and an attempt into modifying these thoughts into more helpful ones is made [29–31]. In addition, according to Wells, metacognitive therapy can also be used to improve mood and cognitive processes [32]. This is deemed to be particularly helpful in patients with constant negative thoughts and rumination. In the following paragraphs, we will explain the therapeutic focus relevant to each sub-team.

*Focus on "Burnout" type:* Burnout had originally been characterized by a pronounced physical, mental, and emotional exhaustion due to occupational stress and repeated frustration in caring professions. Over the years, the concept has expanded to include depressive syndromes, which are closely related to occupational or private stress [33]. Important therapeutic aims for these patients (treated by a specialist sub-team) could be to rediscover the positive aspects that originally gave meaning and pleasure to their work, to learn how to deal with frustrations, to clarify responsibilities at work, to identify stress-aggravating thoughts, to identify resources available to them, and to formulate achievable goals.

*Focus on loss, grief, and adjustment processes:* Patients whose depressive symptoms are related to a loss are allocated to a specific sub-team. This includes patients who are bereaved, those who have experienced separation or divorce, loss of home or property as well as those who are suffering from a physical illness. For all these situations, the common thread is the necessity for fundamental reorientation. Typical dysfunctional assumptions must be addressed (e.g., "If I stop mourning, it means that it (the loss) did not mean anything to me." or "The more you have loved a person, the longer you mourn"). Thus, patients need guidance to develop new and more realistic beliefs that enable them to view their life in a positive light. The specialized sub-team endeavors to achieve this by applying wisdom therapy [34] and Worden's Tasks of Mourning [35]. It also considers the role of avoidance or excessive work engagement as being a potentially unhealthy and harmful coping strategy (according to Rosner et al. [36]).

*Focus on personality traits:* Recurrent depressive disorders are frequently accompanied by unhelpful personality traits or personality disorders, which contribute significantly to the maintenance of the depressive disorder and therapy resistance [37]. These disturbances are treated in the Department of Psychosomatic Medicine using schema therapy developed by Jeffrey Young.

Using the Young Schema Questionnaire (YSQ ) [38], the maladaptive cognitive and emotional schemata of the patient are identified, and personality-related problems are communicated to the patient in a transparent and friendly way that motivates the patient to cooperate [39]. Changes are achieved by imaginative, emotion- or relationship-oriented, or cognitive behavioral therapy [40]. In the Psychosomatic Department, weekly group exercises take place in the context of imagination exercises, in which the patient's injurious and traumatizing experiences of childhood are re-scripted by the introduction of a protective and helping person (in part the therapist, ideally the patient in the "healthy adult mode" themselves).

In addition, during weekly individual and group therapy sessions, specific exercises are employed. Any changes in the experience of the exercise and any accompanying behavior change are discussed, and appropriate responses are practiced. In this way, common, everyday scenarios are evaluated on memo cards and healthy adult behavior patterns are worked out and practiced.

**133**

*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany*

*Focus on chronic depression:* Chronic forms of depression like persistent depressive disorder (formerly known as dysthymia), major depressive disorder (MDD), and double depression are a challenge to clinicians as these patients often do not respond to common psychotherapeutic or pharmacological treatment [41]. However, for patients with these presentations, a specialized psychotherapy treatment that shows satisfactory response rates is available. The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) developed by McCullough and Negt et al. [15, 42] postulate that chronically depressed patients remain at the stage of preoperational thinking (according to Piaget) due to their specific learning history that took place during their cognitive-emotional development. Thought is therefore characterized by a global, pre-linguistic style, a strongly egocentric view, and the inability to feel authentic interpersonal empathy [43]. Moreover, their ability to regulate their mood is severely restricted; they experience constant depressive mood independent of external factors or influence, which they perceive as completely unchangeable. In the context of CBASP, these patients are guided to develop their thinking style from preoperational thinking to formal operational thinking, and to establish more appropriate responses to external influences, including the therapist. Hence, CBASP is a method used to teach patients how to gradually reach the formal operational stage of cognitive thinking and to break the psychic barrier

In addition to individual therapy, there are two further core elements of CBASP: situational analysis (according to McCullough) as well as a social competence training specifically tailored to the CBASP model. In situational analysis, real-life occurrences on the ward are thought about and analyzed. This is an essential technique of CBASP that teaches patients to recognize their own impact on the course and quality of their life. The social competence training serves to make patients aware of the influence of their behavior on others by means of exercises in the group context, and to jointly work out the desirable behavior in role-play situations with the aid of

Taken together, we have outlined how the increasing incidence and prevalence of mental disorders, and specifically depressive disorders in Germany, has led to an

Consequently, pension insurance companies, such as the German Statutory Pension Insurance, are supporting therapy and rehabilitation in psychotherapyfocused psychosomatic rehabilitation hospitals. We have further explained that in these rehabilitation hospitals, the ICF and rehabilitation therapy standards play an essential diagnostic and therapeutic role. To explain how medical-occupational rehabilitation works in practice, we have used the Psychosomatic Department of the Sachsenklinik Bad Lausick as an example to illustrate how patients are treated with medical-psychological and complementary therapies by taking their specific depressive subtype into account. This article raises further questions about how the care and rehabilitation of patients with depression should be financed and commissioned, how diagnostic approaches can meet the needs of the patients, whether we can distinguish clinical subtypes of depression with certainty, and how much

In principle, there are four main ways to fund treatment for mental health problems. Patients can pay privately for their treatment, a public or private health insurance covers the cost of treatment, a pension insurance, or pension fund sponsor the treatment, or costs are covered by the state. To fund treatment for

escalating burden on public and private health, and pension insurance.

evidence we have for the specific therapies currently available.

*DOI: http://dx.doi.org/10.5772/intechopen.91923*

between themselves and their environment.

video feedback.

**7. Conclusion**

#### *Psychosomatic Inpatient Rehabilitation for People with Depression in Germany DOI: http://dx.doi.org/10.5772/intechopen.91923*

*Focus on chronic depression:* Chronic forms of depression like persistent depressive disorder (formerly known as dysthymia), major depressive disorder (MDD), and double depression are a challenge to clinicians as these patients often do not respond to common psychotherapeutic or pharmacological treatment [41]. However, for patients with these presentations, a specialized psychotherapy treatment that shows satisfactory response rates is available. The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) developed by McCullough and Negt et al. [15, 42] postulate that chronically depressed patients remain at the stage of preoperational thinking (according to Piaget) due to their specific learning history that took place during their cognitive-emotional development. Thought is therefore characterized by a global, pre-linguistic style, a strongly egocentric view, and the inability to feel authentic interpersonal empathy [43]. Moreover, their ability to regulate their mood is severely restricted; they experience constant depressive mood independent of external factors or influence, which they perceive as completely unchangeable. In the context of CBASP, these patients are guided to develop their thinking style from preoperational thinking to formal operational thinking, and to establish more appropriate responses to external influences, including the therapist. Hence, CBASP is a method used to teach patients how to gradually reach the formal operational stage of cognitive thinking and to break the psychic barrier between themselves and their environment.

In addition to individual therapy, there are two further core elements of CBASP: situational analysis (according to McCullough) as well as a social competence training specifically tailored to the CBASP model. In situational analysis, real-life occurrences on the ward are thought about and analyzed. This is an essential technique of CBASP that teaches patients to recognize their own impact on the course and quality of their life. The social competence training serves to make patients aware of the influence of their behavior on others by means of exercises in the group context, and to jointly work out the desirable behavior in role-play situations with the aid of video feedback.

#### **7. Conclusion**

*Psychosomatic Medicine*

this context [28].

peutic focus relevant to each sub-team.

strategy (according to Rosner et al. [36]).

using schema therapy developed by Jeffrey Young.

adult behavior patterns are worked out and practiced.

of the positive activities, which can be promoted by additional use of "mindfulness" and mindfulness techniques (according to Linehan [16]). Furthermore, a so-called "euthymic therapy," also referred to as genus training, is deemed to be very useful in

In cognitive therapy, patients are guided toward dealing with negative cognitions in a systematic manner. The depressed and exaggerated negative character of the thoughts is examined against reality, and an attempt into modifying these thoughts into more helpful ones is made [29–31]. In addition, according to Wells, metacognitive therapy can also be used to improve mood and cognitive processes [32]. This is deemed to be particularly helpful in patients with constant negative thoughts and rumination. In the following paragraphs, we will explain the thera-

*Focus on "Burnout" type:* Burnout had originally been characterized by a pronounced physical, mental, and emotional exhaustion due to occupational stress and repeated frustration in caring professions. Over the years, the concept has expanded to include depressive syndromes, which are closely related to occupational or private stress [33]. Important therapeutic aims for these patients (treated by a specialist sub-team) could be to rediscover the positive aspects that originally gave meaning and pleasure to their work, to learn how to deal with frustrations, to clarify responsibilities at work, to identify stress-aggravating thoughts, to identify

*Focus on loss, grief, and adjustment processes:* Patients whose depressive symptoms are related to a loss are allocated to a specific sub-team. This includes patients who are bereaved, those who have experienced separation or divorce, loss of home or property as well as those who are suffering from a physical illness. For all these situations, the common thread is the necessity for fundamental reorientation. Typical dysfunctional assumptions must be addressed (e.g., "If I stop mourning, it means that it (the loss) did not mean anything to me." or "The more you have loved a person, the longer you mourn"). Thus, patients need guidance to develop new and more realistic beliefs that enable them to view their life in a positive light. The specialized sub-team endeavors to achieve this by applying wisdom therapy [34] and Worden's Tasks of Mourning [35]. It also considers the role of avoidance or excessive work engagement as being a potentially unhealthy and harmful coping

*Focus on personality traits:* Recurrent depressive disorders are frequently accompanied by unhelpful personality traits or personality disorders, which contribute significantly to the maintenance of the depressive disorder and therapy resistance [37]. These disturbances are treated in the Department of Psychosomatic Medicine

Using the Young Schema Questionnaire (YSQ ) [38], the maladaptive cognitive and emotional schemata of the patient are identified, and personality-related problems are communicated to the patient in a transparent and friendly way that motivates the patient to cooperate [39]. Changes are achieved by imaginative, emotion- or relationship-oriented, or cognitive behavioral therapy [40]. In the Psychosomatic Department, weekly group exercises take place in the context of imagination exercises, in which the patient's injurious and traumatizing experiences of childhood are re-scripted by the introduction of a protective and helping person (in part the therapist, ideally the patient in the "healthy adult mode" themselves). In addition, during weekly individual and group therapy sessions, specific exercises are employed. Any changes in the experience of the exercise and any accompanying behavior change are discussed, and appropriate responses are practiced. In this way, common, everyday scenarios are evaluated on memo cards and healthy

resources available to them, and to formulate achievable goals.

**132**

Taken together, we have outlined how the increasing incidence and prevalence of mental disorders, and specifically depressive disorders in Germany, has led to an escalating burden on public and private health, and pension insurance.

Consequently, pension insurance companies, such as the German Statutory Pension Insurance, are supporting therapy and rehabilitation in psychotherapyfocused psychosomatic rehabilitation hospitals. We have further explained that in these rehabilitation hospitals, the ICF and rehabilitation therapy standards play an essential diagnostic and therapeutic role. To explain how medical-occupational rehabilitation works in practice, we have used the Psychosomatic Department of the Sachsenklinik Bad Lausick as an example to illustrate how patients are treated with medical-psychological and complementary therapies by taking their specific depressive subtype into account. This article raises further questions about how the care and rehabilitation of patients with depression should be financed and commissioned, how diagnostic approaches can meet the needs of the patients, whether we can distinguish clinical subtypes of depression with certainty, and how much evidence we have for the specific therapies currently available.

In principle, there are four main ways to fund treatment for mental health problems. Patients can pay privately for their treatment, a public or private health insurance covers the cost of treatment, a pension insurance, or pension fund sponsor the treatment, or costs are covered by the state. To fund treatment for

mental health issues such as depression privately can be difficult or impossible, if people are not wealthy, because low income and indebtedness may have already been a contributing factor for the development of depression [44], and depression might lead to further debts due to medical bill problems [45]. Additionally, one has to consider that treatment time for depression might be unforeseeably long, especially in the case of a recurring or chronic depressive disorder. Public or private health insurances will provide the funding, if they cover mental health. However, they are only obligated to cover treatment costs where the patient has a formal diagnosis according to the ICD-10 [8] or the DSM-5 [46] and where the treatment is proposed according to national guidelines, such as the German national guidelines for the treatment of depression (S3-Leitlinie/Nationale VersorgungsLeitlinie Unipolare Depression) [9]. Consequently, rehabilitation in which the main aim is increasing people's functional level as well as their quality of life, is usually not covered by health insurance. In Germany, this is paid for by pension insurance, if approved. Having different insurance providers dealing with different aspects of the same disorder can be quite challenging. For clinicians, it is sometimes tricky to decide whether the patient needs acute hospital treatment or medical-occupational rehabilitation, since treatment approaches often overlap. At first glance, it might seem more practical and efficient for the state to fund treatment, as is the case in the UK. However, at a closer look one can discern that even in the case of the UK, one has to apply for funding to different funding streams within the NHS (e.g., NHS England, Clinical Commissioning Groups, etc.). Hence, there does not seem to be a funding system to cover mental health costs in place that is generally agreed upon. Nevertheless, from the insurer's, the patients', and certainly the employers' perspective, a pension insurance-funded rehabilitation makes particularly good sense for those with depression who need and want support in order to resume working activities.

Accurately diagnosing mental disorders has always been a challenge, hence the constant revision of diagnostic entities and criteria; the 5th edition of the DSM and the soon to be 11th edition of ICD are a case in point. However, these diagnostic classifications base diagnoses mainly on acute symptoms, and less so on the level of functioning and QoL. As such, the WHO's ICF [10] complements the ICD, providing a more holistic diagnosis. Thus, the emphasis on ICF by pension insurance-financed psychosomatic hospitals for medical-occupational rehabilitation indicates their commitment to a comprehensive assessment of depressed patients.

A perhaps more controversial point worthy of discussion is the decision-making process by which patients are allocated to certain sub-teams in the Psychosomatic Department of the Sachsenklinik Bad Lausick, the case presented. The procedure suggests that certain subtypes of depression are assumed: the burnout, the loss and grief, the complicated personality, and the chronic subtype. However, there is currently no scientific evidence that supports the existence of these subtypes. In fact, diagnostic and genetic research has recently come up with two main subtypes of depression, an anxious subtype that is characterized by decreased appetite and body weight, and insomnia and suicidal ideation, and a metabolic subtype showing increased appetite and weight, low energy, hypersomnia, leaden paralysis, and a poor metabolic profile [47–49]. Despite the research evidence for these subtypes, they seem to be irrelevant for the purposes of treatment, since there are no subtype-specific treatment algorithms available. Another approach would be to define subtypes according to treatment response. This approach has been used in psychiatry since the development of tricyclic antidepressants, and subtypes were suggested according to whether patients responded or not respond to tricyclic antidepressant treatment [50]. This strategy seems natural from a practical point of

**135**

*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany*

view, and this line of thinking is the basis of how patients are assigned to specialized sub-teams who offer a specific psychotherapeutic focus. The question whether wisdom therapy [34] and the Worden's Tasks of Mourning model [35] are the best approach for people suffering from bereavement and loss, whether schema therapy according to Jeffrey Young [39] is most effective to treat patients with personality difficulties, whether CBASP is most efficient in patients with chronic depression, and—last but not least—whether inpatient rehabilitation is necessary and superior to outpatient rehabilitation and treatment, however, is beyond the scope of this

In summary, this article provides a review of the literature on rehabilitation for depression in psychosomatic hospitals in Germany. It highlights the importance of thinking beyond the clinical diagnosis by taking the level of functioning and QoL into account during assessment and therapeutic goal setting. It also explains the practicalities of medical-occupational inpatient rehabilitation for depression by reference to the Psychosomatic Department of the Sachsenklinik Bad Lausick. Questions which remain unanswered are how to fund rehabilitation for depressed patients in the best way possible, how to define subtypes of depression in order to provide an individually tailored therapy for people with depression, and what

Based on the example of how psychosomatic inpatient rehabilitation for people with depression is delivered at the Sachsenklinik Bad Lausick, this article reflected on the following principal ideas about psychosomatic and psychiatric diagnoses,

• Disease models can be based on the etiology, the pathophysiology, symptoms or symptom clusters, diagnoses, the level of functioning, activities and participation, and QoL. Thus, in practice, a holistic diagnostic approach should not only make use of a disease classification but should also comprise an assess-

• Therapies should be individually tailored; this can be achieved taking patient characteristics, personal and environmental factors, the diagnostic subtype, the profile of symptoms and impairments, the availability of therapies, and individual preferences of the patients and their therapists into account.

• Psychosomatic medicine aspires to holistic treatment approaches that consider a variety of therapeutic modalities such as psychoeducation, psychotherapy, pharmacotherapy and other biological therapies, OT, art and music therapy, skills training, movement therapy and physiotherapy, social work, family

• Potential sources of funding for psychosomatic treatment include public institutions, private assets, and public or private health or pension insurances.

Hubertus Himmerich has received salary support from the National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) at South London and Maudsley NHS Foundation Trust (SLaM) and King's College London. Olivia Patsalos is funded by OBELIX (Obesity, Lifestyle and Learning from Extreme Phenotypes), a research framework within the Biomedical Research Centre (BRC) of the South London and Maudsley NHS Foundation Trust (SLaM) and the IoPPN.

*DOI: http://dx.doi.org/10.5772/intechopen.91923*

therapies and in what settings they are most effective.

individually tailored care as well as care provision and funding.

ment of functioning, disability, and overall health.

work, and self-help.

**Funding statement**

article.

#### *Psychosomatic Inpatient Rehabilitation for People with Depression in Germany DOI: http://dx.doi.org/10.5772/intechopen.91923*

view, and this line of thinking is the basis of how patients are assigned to specialized sub-teams who offer a specific psychotherapeutic focus. The question whether wisdom therapy [34] and the Worden's Tasks of Mourning model [35] are the best approach for people suffering from bereavement and loss, whether schema therapy according to Jeffrey Young [39] is most effective to treat patients with personality difficulties, whether CBASP is most efficient in patients with chronic depression, and—last but not least—whether inpatient rehabilitation is necessary and superior to outpatient rehabilitation and treatment, however, is beyond the scope of this article.

In summary, this article provides a review of the literature on rehabilitation for depression in psychosomatic hospitals in Germany. It highlights the importance of thinking beyond the clinical diagnosis by taking the level of functioning and QoL into account during assessment and therapeutic goal setting. It also explains the practicalities of medical-occupational inpatient rehabilitation for depression by reference to the Psychosomatic Department of the Sachsenklinik Bad Lausick. Questions which remain unanswered are how to fund rehabilitation for depressed patients in the best way possible, how to define subtypes of depression in order to provide an individually tailored therapy for people with depression, and what therapies and in what settings they are most effective.

Based on the example of how psychosomatic inpatient rehabilitation for people with depression is delivered at the Sachsenklinik Bad Lausick, this article reflected on the following principal ideas about psychosomatic and psychiatric diagnoses, individually tailored care as well as care provision and funding.


#### **Funding statement**

Hubertus Himmerich has received salary support from the National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) at South London and Maudsley NHS Foundation Trust (SLaM) and King's College London. Olivia Patsalos is funded by OBELIX (Obesity, Lifestyle and Learning from Extreme Phenotypes), a research framework within the Biomedical Research Centre (BRC) of the South London and Maudsley NHS Foundation Trust (SLaM) and the IoPPN.

*Psychosomatic Medicine*

working activities.

patients.

mental health issues such as depression privately can be difficult or impossible, if people are not wealthy, because low income and indebtedness may have already been a contributing factor for the development of depression [44], and depression might lead to further debts due to medical bill problems [45]. Additionally, one has to consider that treatment time for depression might be unforeseeably long, especially in the case of a recurring or chronic depressive disorder. Public or private health insurances will provide the funding, if they cover mental health. However, they are only obligated to cover treatment costs where the patient has a formal diagnosis according to the ICD-10 [8] or the DSM-5 [46] and where the treatment is proposed according to national guidelines, such as the German national guidelines for the treatment of depression (S3-Leitlinie/Nationale VersorgungsLeitlinie Unipolare Depression) [9]. Consequently, rehabilitation in which the main aim is increasing people's functional level as well as their quality of life, is usually not covered by health insurance. In Germany, this is paid for by pension insurance, if approved. Having different insurance providers dealing with different aspects of the same disorder can be quite challenging. For clinicians, it is sometimes tricky to decide whether the patient needs acute hospital treatment or medical-occupational rehabilitation, since treatment approaches often overlap. At first glance, it might seem more practical and efficient for the state to fund treatment, as is the case in the UK. However, at a closer look one can discern that even in the case of the UK, one has to apply for funding to different funding streams within the NHS (e.g., NHS England, Clinical Commissioning Groups, etc.). Hence, there does not seem to be a funding system to cover mental health costs in place that is generally agreed upon. Nevertheless, from the insurer's, the patients', and certainly the employers' perspective, a pension insurance-funded rehabilitation makes particularly good sense for those with depression who need and want support in order to resume

Accurately diagnosing mental disorders has always been a challenge, hence the constant revision of diagnostic entities and criteria; the 5th edition of the DSM and the soon to be 11th edition of ICD are a case in point. However, these diagnostic classifications base diagnoses mainly on acute symptoms, and less so on the level of functioning and QoL. As such, the WHO's ICF [10] complements the ICD, providing a more holistic diagnosis. Thus, the emphasis on ICF by pension insurance-financed psychosomatic hospitals for medical-occupational rehabilitation indicates their commitment to a comprehensive assessment of depressed

A perhaps more controversial point worthy of discussion is the decision-making process by which patients are allocated to certain sub-teams in the Psychosomatic Department of the Sachsenklinik Bad Lausick, the case presented. The procedure suggests that certain subtypes of depression are assumed: the burnout, the loss and grief, the complicated personality, and the chronic subtype. However, there is currently no scientific evidence that supports the existence of these subtypes. In fact, diagnostic and genetic research has recently come up with two main subtypes of depression, an anxious subtype that is characterized by decreased appetite and body weight, and insomnia and suicidal ideation, and a metabolic subtype showing increased appetite and weight, low energy, hypersomnia, leaden paralysis, and a poor metabolic profile [47–49]. Despite the research evidence for these subtypes, they seem to be irrelevant for the purposes of treatment, since there are no subtype-specific treatment algorithms available. Another approach would be to define subtypes according to treatment response. This approach has been used in psychiatry since the development of tricyclic antidepressants, and subtypes were suggested according to whether patients responded or not respond to tricyclic antidepressant treatment [50]. This strategy seems natural from a practical point of

**134**

*Psychosomatic Medicine*

### **Declaration of interest**

The authors declare no conflict of interest.

#### **Author details**

Ralf F. Tauber1 , Carola Nisch1 , Mutahira M. Qureshi2 , Olivia Patsalos2 and Hubertus Himmerich2,3\*

1 Fachabteilung für Psychosomatik, Sachsenklinik, Bad Lausick, Germany

2 Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK

3 South London and Maudsley NHS Foundation Trust, London, UK

\*Address all correspondence to: hubertus.himmerich@kcl.ac.uk

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**137**

*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany*

BD594F6D21E986C221DFBD3928D4F8. delivery1-9-replication. [Accessed: 13

[8] World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva PP, Geneva: World Health Organization. Available from: https:// apps.who.int/iris/handle/10665/37958

[Accessed: 13 February 2020]

Nationale VersorgungsLeitlinie Unipolare Depression-Langfassung. Available from: https://www.awmf.org/ uploads/tx\_szleitlinien/nvl-005l\_S3\_ Unipolare\_Depression\_2017-05.pdf. [Accessed: 13 February 2020]

[10] Towards a Common Language for Functioning, Disability and The International Classification of Functioning, Disability and Health. Available from: https://www.who.int/ classifications/icf/icfbeginnersguide. pdf [Accessed: 13 February 2020]

[11] Nisch C, Tauber RF, Himmerich H.

[12] Deutsche Rentenversicherung Bund. Reha-Therapiestandards Depressive

[13] KTL Klassifikation therapeutischer Leistungen in der medizinischen

Rentenversicherung. Available from: www.deutsche-rentenversicherung.de

[14] Kellogg SH, Young JE. Schema therapy for borderline personality disorder. Journal of Clinical Psychology.

Stationäre Psychotherapie der Depression: Kliniken, Leitlinien, Methoden und Herausforderungen. Die

Psychiatrie. 2017;**14**:143-150

Störungen. Berlin; 2016

Rehabilitation Deutsche

2006;**62**:445-458

[Accessed: 13 February 2020]

[9] DGPPN, Bäk, KBV, et al. S3-Leitlinie/

February 2020]

*DOI: http://dx.doi.org/10.5772/intechopen.91923*

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[2] Krankenkasse T. Gesundheitsreport

Betrieblichen Gesundheitsmanagement der TK. Retrieved from: www.tk.de [Accessed: 13 February 2020]

[3] Augurzky B, Wübker A, Pilny A, et al. Barmer GEK Report Krankenhaus 2016. Schriftenreihe zur Gesundheitsanalyse Band 40. Available from: http://dnb.ddb.

2016-Veröffentlichungen zum

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[6] DRV. Statistiken und Berichte-Statistiken und Berichte. Available from: https://www.deutscherentenversicherung.de/DRV/DE/ Experten/Zahlen-und-Fakten/ Statistiken-und-Berichte/statistiken\_ und\_berichte.html?https=1&nn=254258

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*Psychosomatic Inpatient Rehabilitation for People with Depression in Germany DOI: http://dx.doi.org/10.5772/intechopen.91923*

#### **References**

*Psychosomatic Medicine*

**Declaration of interest**

The authors declare no conflict of interest.

**136**

**Author details**

Ralf F. Tauber1

and Hubertus Himmerich2,3\*

, Carola Nisch1

Neuroscience, King's College London, London, UK

provided the original work is properly cited.

, Mutahira M. Qureshi2

2 Department of Psychological Medicine, Institute of Psychiatry, Psychology and

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 Fachabteilung für Psychosomatik, Sachsenklinik, Bad Lausick, Germany

3 South London and Maudsley NHS Foundation Trust, London, UK

\*Address all correspondence to: hubertus.himmerich@kcl.ac.uk

, Olivia Patsalos2

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[35] Worden JW. Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner. 4th ed. New York: Springer Publishing Company; 2009

[36] Rosner R, Pfoh G, Kotoučová M. Treatment of complicated grief. European Journal of Psychotraumatology. 2011;**2**:7995

[37] Young M. Treatment-resistant depression: The importance of identifying and treating co-occurring personality disorders. The Psychiatric Clinics of North America. 2018;**41**:249-261

[38] Young JE, Brown G. Young schema questionnaire. In: Young JE, editor. Cognitive therapy for personality disorders: A schema-focused approach. Sarasota: Professional Resource Press; 1994

[39] Young JE, Klosko JS, Weishaar ME. Schema Therapy: A practitioner's Guide. New York: Guilford Press; 2003

[40] Rafaeli E, Bernstein D, Young J. Schema therapy: Distinctive features. Available from: https:// www.taylorfrancis.com/books/ 9780203841709 [Accessed: 13 February 2020]

[41] Schüle C. Chronische Depression - Epidemiologische Daten und therapeutische Möglichkeiten. Fortschritte der Neurologie Psychiatrie. 2014;**82**:155-173

[42] Negt P, Brakemeier EL, Michalak J, et al. The treatment of chronic depression with cognitive behavioral

analysis system of psychotherapy: A systematic review and meta-analysis of randomized-controlled clinical trials. Brain and Behavior. 2016;**6**:e00486

[43] Piaget J. The Origins of Intelligence in Children. 2nd ed. New York: International Universities Press; 1952

[44] Turunen E, Hiilamo H. Health effects of indebtedness: A systematic review. BMC Public Health. 2014;**14**:489

[45] Tu HT. Rising health costs, medical debt and chronic conditions. Issue Brief (Center for Studying Health System Change). 2004;**88**:1-5

[46] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington: APA Publishing; 2013

[47] Lamers F, De Jonge P, Nolen WA, et al. Identifying depressive subtypes in a large cohort study: Results from the Netherlands study of depression and anxiety (NESDA). Journal of Clinical Psychiatry. 2010;**71**:1582-1589

[48] Milaneschi Y, Lamers F, Peyrot WJ, et al. Polygenic dissection of major depression clinical heterogeneity. Molecular Psychiatry. 2016;**21**:516-522

[49] Penninx BWJH, Milaneschi Y, Lamers F, et al. Understanding the somatic consequences of depression: Biological mechanisms and the role of depression symptom profile. BMC Medicine. 2013;**11**:129

[50] Kupfer DJ, Pickar D, Himmelhoch JM, et al. Are there two types of unipolar depression? Archives of General Psychiatry. 1975;**32**:866-871

**141**

**Chapter 7**

**Abstract**

**1. Introduction**

addictive eating?

Emotional Eating and Obesity

*Ignacio Jáuregui-Lobera and Marian Montes-Martínez*

The first time that terms such as food addiction and addictive eating were mentioned was in 1956, in an article by T.G. Randolph. Recently, from a psychosomatic point of view, some authors have linked obesity and food addiction. Along with the concept of food addiction (derived from the similarities between the consumption of certain foods and "substance addictions"), a couple of questions seem to arise: What if it's not just the particular food (the substance) that we are addicted to? Could it be that we are addicted to something else that makes us eat it? Thus, the concept of eating addiction has its own set of particulars. It brings the attention back to the individual and not the external substance (the food or ingredient). The focus on confronting the obesity problem should be moved away from the food itself (the addictive substance) to the person's act of eating (the addictive behavior). Undoubtedly, there are many links between emotions and overweight/obesity. This chapter aims to review the current state of this field of study which is the emotional basis of obesity (at least a particular case of obesity and weight-related disorders).

**Keywords:** food addiction, eating addiction, emotional eating, stress, negative

Some time ago, in a wonderful article by Adriaanse et al. [1], a question was suggested, "Emotional eating: Eating when emotional or emotional about eating?" Due the increasing number of people who are overweight and the increase in the worldwide prevalence of obesity over the past decades [2], some etiological factors have been proposed. Summarizing, both environmental and personal factors seem to be involved. With respect to the first, a "toxic food environment" was mentioned by Wadden et al. [3], and other authors have thought that tempting palatable foods available everywhere might be a relevant factor to explain the epidemic figures of overweight [4]. Along with food, personal factors must be considered. How does a person respond individually to food? Are there different possible responses depending on specific foods? Are there individuals prone to develop food addiction or

The first time that terms such as food addiction and addictive eating were mentioned was in 1956, in an article by T.G. Randolph [2]. Recently, from a psychosomatic point of view, some authors have linked obesity and food addiction [5, 6]. Along with the concept of "food addiction" (derived from the similarities between the consumption of certain foods and "substance addictions"), a couple of questions seem to arise: What if it is not just the particular food (the substance) that we are addicted to? Could it be that we are addicted to something else that makes us eat it? Thus, the concept of eating addiction has its own set of peculiarities. It brings the

emotions, posttraumatic stress disorder, overweight, obesity

#### **Chapter 7**

## Emotional Eating and Obesity

*Ignacio Jáuregui-Lobera and Marian Montes-Martínez*

#### **Abstract**

The first time that terms such as food addiction and addictive eating were mentioned was in 1956, in an article by T.G. Randolph. Recently, from a psychosomatic point of view, some authors have linked obesity and food addiction. Along with the concept of food addiction (derived from the similarities between the consumption of certain foods and "substance addictions"), a couple of questions seem to arise: What if it's not just the particular food (the substance) that we are addicted to? Could it be that we are addicted to something else that makes us eat it? Thus, the concept of eating addiction has its own set of particulars. It brings the attention back to the individual and not the external substance (the food or ingredient). The focus on confronting the obesity problem should be moved away from the food itself (the addictive substance) to the person's act of eating (the addictive behavior). Undoubtedly, there are many links between emotions and overweight/obesity. This chapter aims to review the current state of this field of study which is the emotional basis of obesity (at least a particular case of obesity and weight-related disorders).

**Keywords:** food addiction, eating addiction, emotional eating, stress, negative emotions, posttraumatic stress disorder, overweight, obesity

#### **1. Introduction**

Some time ago, in a wonderful article by Adriaanse et al. [1], a question was suggested, "Emotional eating: Eating when emotional or emotional about eating?" Due the increasing number of people who are overweight and the increase in the worldwide prevalence of obesity over the past decades [2], some etiological factors have been proposed. Summarizing, both environmental and personal factors seem to be involved. With respect to the first, a "toxic food environment" was mentioned by Wadden et al. [3], and other authors have thought that tempting palatable foods available everywhere might be a relevant factor to explain the epidemic figures of overweight [4]. Along with food, personal factors must be considered. How does a person respond individually to food? Are there different possible responses depending on specific foods? Are there individuals prone to develop food addiction or addictive eating?

The first time that terms such as food addiction and addictive eating were mentioned was in 1956, in an article by T.G. Randolph [2]. Recently, from a psychosomatic point of view, some authors have linked obesity and food addiction [5, 6]. Along with the concept of "food addiction" (derived from the similarities between the consumption of certain foods and "substance addictions"), a couple of questions seem to arise: What if it is not just the particular food (the substance) that we are addicted to? Could it be that we are addicted to something else that makes us eat it? Thus, the concept of eating addiction has its own set of peculiarities. It brings the attention back to the individual and not the external substance (the food or ingredient). The focus on confronting the obesity problem should be moved away from the food itself (the addictive substance) to the person's act of eating (the addictive behavior). Undoubtedly, there are many links between emotions and overweight/ obesity.

It is well known that calorie-restricted diets are clearly ineffective for patients with overweight beyond the short term. In the long term, the most amount of weight lost is usually regained, with some patients even ending up weighing more than before the diet [7–9]. It is usual to think about emotional eating just linked to the abandon of restricted diets. Nevertheless, emotional eating may also occur, independently or regardless of dieting. Several authors have referred to emotional eating as an outcome of poor interoceptive awareness, a confusion of internal states of hunger and satiety and physiological symptoms associated with emotions, alexithymia, or poor emotion regulation strategies [9, 10]. Emotional eating has also been associated with a reversed stress response of the hypothalamic pituitary adrenal (HPA) axis (a blunted instead of the typical elevated cortisol response to stress) [11, 12].

#### **2. When does emotional eating appear?**

The prevalence of emotional eating in childhood is usually very low. In this regard, what tends to occur when food intake is linked to negative emotions/stress in children? The usual, natural response is that they tend to lose appetite. Then, in the transition from childhood to adulthood, emotional eating emerges in the form of overeating. Puberty (with its hormonal changes) would be the base for this phenomenon in adolescence [9]. As we referred, a common explanation for the increase in obesity over recent decades is the environment and, in particular, the availability of highly varied, palatable, and fattening foods—which have been considered to be addictive [13–16]. The point is that many individuals manage to resist these temptations and maintain a healthy weight, but others (e.g., overweight and obese individuals) have been shown to have preference for energy-dense foods compared to healthy-weight people [17–19]. In sum, not all children would become emotional eaters during adolescence.

Some research has shown that when food is eaten to satisfy one's feelings instead of satisfying hunger, it might result in emotional eating, which increases the risk of obesity. The study of emotional eating is complex because it is influenced by several risk factors, and some of these factors have been studied from a psychological point of view, such as self-regulation, effects of stress on eating behavior, parenting and emotional eating, and parental bonding and coping.

Considering self-regulation, emotional eating, as a learned response, is suggested to be associated with depressive feelings and inadequate parenting in adolescence [20], and it seems that self-regulation plays an important role in this respect. Galloway et al. [21] investigated the association between feeding practices used in childhood, eating behaviors, and weight status in early adulthood, and they found a significant positive correlation between practices based on controlling child feeding, emotional eating, and body mass index among children. Moreover, controlling child feeding practices are linked with poorer self-regulation of food intake [22]. On the one hand, the probability of eating in the absence of hunger is increased by restrictive feeding practices [23]. On the other hand, children's natural ability to self-regulate would be interfered by eating under pressure [24].

Although research shows that children tend to have poorer self-regulation because of immaturity of the brain [25], proper parenting such as being a positive role model [26] is a crucial factor to consider a successful self-regulation.

**143**

food seeking and consumption [50–55].

*Emotional Eating and Obesity*

*DOI: http://dx.doi.org/10.5772/intechopen.91734*

The effects of stress on eating behavior might be summarized, highlighting that the response to stressful circumstances is usually loss of appetite. Therefore, emotional eating would be an atypical response to this factor [27]. Besides, it can influence preference for sweet and fatty foods, among other unhealthy foods [11]. Studies have found that stressful circumstances such as examinations or times of high workloads are associated with greater energy and fat intake [28], so that emotion regulation through eating is experienced in a student population during stress under real life conditions with distraction as a possible mediating mechanism [29]. Other fields of study are the parenting styles and their influence on eating. In this regard, studies have found that authoritative parenting style is associated with higher levels of emotional eating in children and adolescents [30] as well as less maternal support, more maternal psychological control, and less maternal behavioral control [31], which is, on the other hand, associated with alexithymia [32]. Emotional awareness among obese children has been associated with other parenting styles such as overprotection and, in turn, emotional awareness with emotional eating [33]. In addition, the ability to cope with challenging situations, which determines children's well-being and success in college, seems to be positively associated with parental bonding [34]. Besides, the use of problem solving, active distraction, social-support seeking, and less

passive resignation of failure has been linked with maternal bonding [35].

If we focus on specific foods, the person's act of eating, and emotions linked to eating, it seems that two aspects of self-regulatory failure that are particularly pertinent in both substance use and overeating are impulsivity and reward sensitivity [36–38]. With respect to impulsivity (a multifaceted construct, it can be defined broadly as "the tendency to think and act without sufficient forethought, which often results in behavior that is discordant with one's long-term goals") [39], it has been implicated in overeating and obesity [40–43]. Regarding reward sensitivity, a heightened general sensitivity to reward has also been linked to overeating [44–46]. Nevertheless, the causal direction between reward sensitivity and overeating remains uncertain. On the one hand, increasing reward sensitivity may lead to overeating by increasing motivation toward pleasurable activities, such as consuming energy-dense foods that elicit dopamine and opioid activation. On the other hand, decreased reward sensitivity may cause individuals to seek out rewarding activities as a form of "self-medication" in order to boost dopamine functioning (i.e., addictive behavior would be the result of a "reward deficiency syndrome") [47, 48].

It seems that we face two possibilities: (a) an increased reward sensitivity might lead to overeating (which will produce an activation of dopamine and opioids) via increased motivation to obtain gratification; and (b) a decreased reward sensitivity might push individuals to seek "something" capable to stimulate dopamine functioning. Burger and Stice have proposed several theories about the way these two causal directions would combine to explain obesity [49]. Thus, high sensitivity to reward might initially cause individuals to over-consume palatable foods. Nevertheless, this sensitivity would be modified over time as the brain's reward system adapts and shows divergent changes in food motivation ("wanting") versus hedonic pleasure ("liking"). The point is that with repeated exposures to palatable foods, the hedonic pleasure derived from the ingestion would decrease due to neural habituation, while the anticipation of reward would increase. As a result, the individual is experiencing less pleasure from the food ("liking"), but simultaneously he/she experiences an increased desire ("wanting") for the food, driving further

**3. Food addiction, eating addiction, and emotional eating**

#### *Emotional Eating and Obesity DOI: http://dx.doi.org/10.5772/intechopen.91734*

*Psychosomatic Medicine*

obesity.

attention back to the individual and not the external substance (the food or ingredient). The focus on confronting the obesity problem should be moved away from the food itself (the addictive substance) to the person's act of eating (the addictive behavior). Undoubtedly, there are many links between emotions and overweight/

It is well known that calorie-restricted diets are clearly ineffective for patients with overweight beyond the short term. In the long term, the most amount of weight lost is usually regained, with some patients even ending up weighing more than before the diet [7–9]. It is usual to think about emotional eating just linked to the abandon of restricted diets. Nevertheless, emotional eating may also occur, independently or regardless of dieting. Several authors have referred to emotional eating as an outcome of poor interoceptive awareness, a confusion of internal states of hunger and satiety and physiological symptoms associated with emotions, alexithymia, or poor emotion regulation strategies [9, 10]. Emotional eating has also been associated with a reversed stress response of the hypothalamic pituitary adrenal (HPA) axis (a blunted instead

The prevalence of emotional eating in childhood is usually very low. In this regard, what tends to occur when food intake is linked to negative emotions/stress in children? The usual, natural response is that they tend to lose appetite. Then, in the transition from childhood to adulthood, emotional eating emerges in the form of overeating. Puberty (with its hormonal changes) would be the base for this phenomenon in adolescence [9]. As we referred, a common explanation for the increase in obesity over recent decades is the environment and, in particular, the availability of highly varied, palatable, and fattening foods—which have been considered to be addictive [13–16]. The point is that many individuals manage to resist these temptations and maintain a healthy weight, but others (e.g., overweight and obese individuals) have been shown to have preference for energy-dense foods compared to healthy-weight people [17–19]. In sum, not all children would become emotional

Some research has shown that when food is eaten to satisfy one's feelings instead of satisfying hunger, it might result in emotional eating, which increases the risk of obesity. The study of emotional eating is complex because it is influenced by several risk factors, and some of these factors have been studied from a psychological point of view, such as self-regulation, effects of stress on eating behavior, parenting and

Considering self-regulation, emotional eating, as a learned response, is suggested to be associated with depressive feelings and inadequate parenting in adolescence [20], and it seems that self-regulation plays an important role in this respect. Galloway et al. [21] investigated the association between feeding practices used in childhood, eating behaviors, and weight status in early adulthood, and they found a significant positive correlation between practices based on controlling child feeding, emotional eating, and body mass index among children. Moreover, controlling child feeding practices are linked with poorer self-regulation of food intake [22]. On the one hand, the probability of eating in the absence of hunger is increased by restrictive feeding practices [23]. On the other hand, children's natural ability to

Although research shows that children tend to have poorer self-regulation because of immaturity of the brain [25], proper parenting such as being a positive

role model [26] is a crucial factor to consider a successful self-regulation.

of the typical elevated cortisol response to stress) [11, 12].

**2. When does emotional eating appear?**

emotional eating, and parental bonding and coping.

self-regulate would be interfered by eating under pressure [24].

eaters during adolescence.

**142**

The effects of stress on eating behavior might be summarized, highlighting that the response to stressful circumstances is usually loss of appetite. Therefore, emotional eating would be an atypical response to this factor [27]. Besides, it can influence preference for sweet and fatty foods, among other unhealthy foods [11]. Studies have found that stressful circumstances such as examinations or times of high workloads are associated with greater energy and fat intake [28], so that emotion regulation through eating is experienced in a student population during stress under real life conditions with distraction as a possible mediating mechanism [29].

Other fields of study are the parenting styles and their influence on eating. In this regard, studies have found that authoritative parenting style is associated with higher levels of emotional eating in children and adolescents [30] as well as less maternal support, more maternal psychological control, and less maternal behavioral control [31], which is, on the other hand, associated with alexithymia [32]. Emotional awareness among obese children has been associated with other parenting styles such as overprotection and, in turn, emotional awareness with emotional eating [33]. In addition, the ability to cope with challenging situations, which determines children's well-being and success in college, seems to be positively associated with parental bonding [34]. Besides, the use of problem solving, active distraction, social-support seeking, and less passive resignation of failure has been linked with maternal bonding [35].

#### **3. Food addiction, eating addiction, and emotional eating**

If we focus on specific foods, the person's act of eating, and emotions linked to eating, it seems that two aspects of self-regulatory failure that are particularly pertinent in both substance use and overeating are impulsivity and reward sensitivity [36–38]. With respect to impulsivity (a multifaceted construct, it can be defined broadly as "the tendency to think and act without sufficient forethought, which often results in behavior that is discordant with one's long-term goals") [39], it has been implicated in overeating and obesity [40–43]. Regarding reward sensitivity, a heightened general sensitivity to reward has also been linked to overeating [44–46]. Nevertheless, the causal direction between reward sensitivity and overeating remains uncertain. On the one hand, increasing reward sensitivity may lead to overeating by increasing motivation toward pleasurable activities, such as consuming energy-dense foods that elicit dopamine and opioid activation. On the other hand, decreased reward sensitivity may cause individuals to seek out rewarding activities as a form of "self-medication" in order to boost dopamine functioning (i.e., addictive behavior would be the result of a "reward deficiency syndrome") [47, 48].

It seems that we face two possibilities: (a) an increased reward sensitivity might lead to overeating (which will produce an activation of dopamine and opioids) via increased motivation to obtain gratification; and (b) a decreased reward sensitivity might push individuals to seek "something" capable to stimulate dopamine functioning. Burger and Stice have proposed several theories about the way these two causal directions would combine to explain obesity [49]. Thus, high sensitivity to reward might initially cause individuals to over-consume palatable foods. Nevertheless, this sensitivity would be modified over time as the brain's reward system adapts and shows divergent changes in food motivation ("wanting") versus hedonic pleasure ("liking"). The point is that with repeated exposures to palatable foods, the hedonic pleasure derived from the ingestion would decrease due to neural habituation, while the anticipation of reward would increase. As a result, the individual is experiencing less pleasure from the food ("liking"), but simultaneously he/she experiences an increased desire ("wanting") for the food, driving further food seeking and consumption [50–55].

Impulsivity, reward sensitivity, and the experience of intense craving (the intense desire to consume a specific food) [56, 57] would be the three facets of food addiction in the field of overeating, overweight, and obesity. Chocolate, carbohydrates, and salty snack are the most commonly craved foods [58–62]. Studies on cue-reactivity research have repeatedly shown similarities between drug and food craving. In both cases craving is more likely to occur in the presence of substancerelated stimuli. Thus, substance cues or food cues tend to increase the craving [63].

#### **4. Between personal risk factors and overweight/obesity: emotional eating as mediator?**

One might emphasize dispositional factors (biological or psychological), which would lead to overweight or obesity, or focus the attention on food properties (to some extent "addictive") or the mere fact of eating (eating behavior, eating addiction). Alternatively, the mediation of emotions might be considered (emotional eating).

The tendency to eat in response to negative emotions or stress is an atypical stress response, as the typical stress response consists of not eating because the physiological stress reactions mimic the internal sensations associated with feeding-induced satiety [27] (see for empirical support [64]). Emotional eating, as "disinhibitor," requires prior inhibition (i.e., restraint) by definition. However, it has not yet been resolved whether restraint eating is a cause of the consequence of emotional eating [65, 66], and this may also differ in various subgroups [67]. Nevertheless, as it was mentioned above, emotional eating may also occur, independently of food restrictions. We noted that emotional eating tends to co-occur with external eating (i.e., overeating in response to food-related cues such as the sight and smell of attractive food) [68]. In addition, Slochower [69] reported that negative emotions and food cues were shown to operate conjointly to elicit overeating in female students with obesity—the participants only overate in the high anxiety-high food salience condition, but not when the anxiety and/or the food salience was low.

With respect to "negative emotions," feeling depressed is normally associated with loss of appetite and subsequent weight loss. There exists, however, a subtype of depression that is characterized by the atypical features of increased appetite and subsequent weight gain [70]. Emotional eating has been considered a marker of this depression subtype [71] because it shares with this subtype the atypical feature of increased appetite in response to distress such as feelings of depression (for support, see [72]). In various cross-sectional studies, emotional eating was indeed found to act as a mediator between depression and obesity [73–76].

Generally speaking, life adverse experiences are defined as all kinds of traumatic experiences occurring in childhood, adolescence, and adulthood, which include emotional abuse, physical abuse, sexual abuse, sexual harassment, rape, bullying by peers, witnessing domestic violence, and serious accidents that threatened the lives of subjects. As an example of traumatic experiences, abuse-related PTSD symptoms are associated with hyperactivation of HPA axis and with subsequent increases in peripheral cortisol, which in turn have been linked to accumulation of fat in adipose tissues and, consequently, an increase in abdominal obesity [77, 78]. In line with these findings, the hyperactivation of HPA axis with an exaggerated cortisol response to stress has been observed in obese patients [79] and was also put in relation with stress-induced eating [80], with night eating syndrome (NES) [81] and with waist adiposity in binge eating disorder (BED) patients [82].

Stress, depression, life adverse experiences, abuse-related PTSD, etc. might be potential risk factors for obesity via emotional eating. Some studies have focused their interest on the relationship between trauma, dissociation, and binge eating

**145**

*Emotional Eating and Obesity*

*DOI: http://dx.doi.org/10.5772/intechopen.91734*

associated with emotional eating [93].

of obesity in adulthood [90].

and adolescents [98, 99].

"comfort" foods [102–104].

ronment [96, 105, 106].

eating, and binge eating [82, 107, 108].

mediate between the trauma and eating disorder link.

mediating role in the abuse and binge eating link [86, 87].

disorder. Generally, it is concluded that dissociation may play an important mediating role between the presence of early trauma and the development of eating disorders (e.g., [83]). In this regard, it has been hypothesized that when negative emotional states are activated, a shift toward lower levels of cognition and selfawareness is initiated, which involves cognitive processes similar to dissociation. This mechanism tends to remove the inhibitions, thereby facilitating the start of binge eating or overeating, both in clinical (e.g., [84]) and in nonclinical subjects [85]. Several studies seem to support the hypothesis that dissociation may have a

Along with dissociation, other authors have proposed some specific psychologi-

cal variables that function as mediators in the relationship between childhood abuse, obesity, and bingeing, such as depression [88], trait anger [89], and perceived stress [90]. With respect to depression, Moyer et al. [88] even suggested that depression may be the only significant variable in the link between childhood abuse and adult obesity. Depression has been consistently associated with obesity and central obesity [91]. Once again, a possible way to interpret the link between childhood abuse, depression, and obesity is emotional eating. Regarding trait anger, (a) it seems to be related to the increase of visceral adipose tissue [92]; and (b) it is

Considering adverse experiences, the following ideas seem to be relevant:

• Subjects with adverse childhood experiences have a higher risk of developing maladaptive coping strategies, including stress-induced emotional eating [94].

• Perceived stress may explain the link between child abuse and the development

• Activation of the stress response can lead to emotional dysregulation that has been associated with increased appetite, a preference for foods high in sugar and fat [11, 95–97], fat visceral accumulation, and obesity in adults [97–99]

• Some authors have reported that overweight subjects tend to gain weight when stressed [11] and that obese individuals increase their food intake after having

• Laboratory studies have demonstrated that acute physical or emotional distress was followed by high cortisol reactivity, which induces increased intake of

• Stress-related adaptation involves the concept of allostasis, which is the ability to achieve the physiological balance through the change of the internal envi-

• Conditions of repeated or incontrollable chronic stress are followed by higher cortisol response and tend to activate a state of allostatic load, resulting in neural and emotional dysregulation, which contribute to maladaptive behaviors such as repeated consumption of high caloric food [96], lack of control over

Overall these abovementioned results suggest that psychophysiological responses to stress may influence subsequently eating behavior and hence may also

experienced negative emotions and perceived stress [100, 101].

#### *Emotional Eating and Obesity DOI: http://dx.doi.org/10.5772/intechopen.91734*

*Psychosomatic Medicine*

**eating as mediator?**

Impulsivity, reward sensitivity, and the experience of intense craving (the intense desire to consume a specific food) [56, 57] would be the three facets of food addiction in the field of overeating, overweight, and obesity. Chocolate, carbohydrates, and salty snack are the most commonly craved foods [58–62]. Studies on cue-reactivity research have repeatedly shown similarities between drug and food craving. In both cases craving is more likely to occur in the presence of substancerelated stimuli. Thus, substance cues or food cues tend to increase the craving [63].

**4. Between personal risk factors and overweight/obesity: emotional** 

found to act as a mediator between depression and obesity [73–76].

and with waist adiposity in binge eating disorder (BED) patients [82].

Generally speaking, life adverse experiences are defined as all kinds of traumatic experiences occurring in childhood, adolescence, and adulthood, which include emotional abuse, physical abuse, sexual abuse, sexual harassment, rape, bullying by peers, witnessing domestic violence, and serious accidents that threatened the lives of subjects. As an example of traumatic experiences, abuse-related PTSD symptoms are associated with hyperactivation of HPA axis and with subsequent increases in peripheral cortisol, which in turn have been linked to accumulation of fat in adipose tissues and, consequently, an increase in abdominal obesity [77, 78]. In line with these findings, the hyperactivation of HPA axis with an exaggerated cortisol response to stress has been observed in obese patients [79] and was also put in relation with stress-induced eating [80], with night eating syndrome (NES) [81]

Stress, depression, life adverse experiences, abuse-related PTSD, etc. might be potential risk factors for obesity via emotional eating. Some studies have focused their interest on the relationship between trauma, dissociation, and binge eating

One might emphasize dispositional factors (biological or psychological), which would lead to overweight or obesity, or focus the attention on food properties (to some extent "addictive") or the mere fact of eating (eating behavior, eating addiction). Alternatively, the mediation of emotions might be considered (emotional eating). The tendency to eat in response to negative emotions or stress is an atypical stress response, as the typical stress response consists of not eating because the physiological stress reactions mimic the internal sensations associated with feeding-induced satiety [27] (see for empirical support [64]). Emotional eating, as "disinhibitor," requires prior inhibition (i.e., restraint) by definition. However, it has not yet been resolved whether restraint eating is a cause of the consequence of emotional eating [65, 66], and this may also differ in various subgroups [67]. Nevertheless, as it was mentioned above, emotional eating may also occur, independently of food restrictions. We noted that emotional eating tends to co-occur with external eating (i.e., overeating in response to food-related cues such as the sight and smell of attractive food) [68]. In addition, Slochower [69] reported that negative emotions and food cues were shown to operate conjointly to elicit overeating in female students with obesity—the participants only overate in the high anxiety-high food salience condition, but not when the anxiety and/or the food salience was low. With respect to "negative emotions," feeling depressed is normally associated with loss of appetite and subsequent weight loss. There exists, however, a subtype of depression that is characterized by the atypical features of increased appetite and subsequent weight gain [70]. Emotional eating has been considered a marker of this depression subtype [71] because it shares with this subtype the atypical feature of increased appetite in response to distress such as feelings of depression (for support, see [72]). In various cross-sectional studies, emotional eating was indeed

**144**

disorder. Generally, it is concluded that dissociation may play an important mediating role between the presence of early trauma and the development of eating disorders (e.g., [83]). In this regard, it has been hypothesized that when negative emotional states are activated, a shift toward lower levels of cognition and selfawareness is initiated, which involves cognitive processes similar to dissociation. This mechanism tends to remove the inhibitions, thereby facilitating the start of binge eating or overeating, both in clinical (e.g., [84]) and in nonclinical subjects [85]. Several studies seem to support the hypothesis that dissociation may have a mediating role in the abuse and binge eating link [86, 87].

Along with dissociation, other authors have proposed some specific psychological variables that function as mediators in the relationship between childhood abuse, obesity, and bingeing, such as depression [88], trait anger [89], and perceived stress [90]. With respect to depression, Moyer et al. [88] even suggested that depression may be the only significant variable in the link between childhood abuse and adult obesity. Depression has been consistently associated with obesity and central obesity [91]. Once again, a possible way to interpret the link between childhood abuse, depression, and obesity is emotional eating. Regarding trait anger, (a) it seems to be related to the increase of visceral adipose tissue [92]; and (b) it is associated with emotional eating [93].

Considering adverse experiences, the following ideas seem to be relevant:


Overall these abovementioned results suggest that psychophysiological responses to stress may influence subsequently eating behavior and hence may also mediate between the trauma and eating disorder link.

#### **5. Posttraumatic stress disorder (PTSD): a psychosomatic paradigm of emotional eating?**

It is well known that PTSD is usually associated with significantly higher rates of substance use disorders, other comorbid psychiatric disorders, and a variety of self-destructive and impulsive behaviors, including suicide [109–111]. It has been suggested that the ingestion, and especially over-ingestion, of fatty or sugary energy sources may be just another strategy that traumatized individuals use to numb themselves from their unpleasant feeling states and memories [112]. Thus, certain foods might act just like other substances that alter brain chemistry and, hence, consciousness. As we mentioned above, Randolph first described the phenomenon of food addiction and linked it with addictive drinking in 1956 [2]. Since then, the notion that certain foods can act like other addicting substances in the brain (despite having other peripheral metabolic effects that substances of abuse do not necessarily have) has been accepted. In fact, food intake and drug use both cause dopamine release in parts of the brain that mediate pleasure and emotion. The degree of subjective reward or experience of pleasure is clearly linked with the amount of dopamine release. Comparing similarities between action of certain foods and other substances of abuse, it must be noted that (a) food can stimulate the opiate system and there are similarities in use and withdrawal patterns of sugar and of classic drugs of abuse; (b) similar patterns of brain activation occur in response to food and drug cues; and (c) people may gain weight when they stop smoking or drinking.

It has been proposed that certain foods can be addicting to certain people, especially traumatized people. Part of the people exposed to alcohol, nicotine, drugs of abuse, etc. are prone to be attracted for these substances/behaviors, and finally they are at high risk to develop addictions. The point is how can we determine if someone will go on to develop an addiction to food or to any substance or behavior? From a genetic perspective, it has been proven that people with reduced dopamine type 2 receptor availability have a predisposition toward obesity and substance dependence. Other risk factors are environmental. In this regard, a history of psycho-trauma would be an example and leads to the self-medication hypothesis of PTSD. This way, victims of interpersonal violence may select highly palatable foods containing high concentrations of sugar, fat, salt, or caffeine, sometimes to the point of addiction, in an attempt to dampen arousal and facilitate numbing and avoidance specific symptoms to PTSD [112].

Hirth et al. [113] observed an association between PTSD symptoms and drinking more than one serving of soda per day as well as consumption of fast food more often. The participants of this study may have eaten more fast food to reduce

**147**

*Emotional Eating and Obesity*

**6. Conclusions**

responses to food.

and overeating.

associated with greater energy and fat intake.

interfere with their attitudes toward the act of eating.

*DOI: http://dx.doi.org/10.5772/intechopen.91734*

trauma-induced PTSD symptoms, using that food as self-medication. Both fast food consumption and sugary soda consumption are usually associated with weight gain. PTSD symptoms may initiate a process of overindulging in unhealthy food and beverages in an attempt to compensate for the way trauma-induced memories make trauma victims feel. Through this process overeating behavior would lead to overweight/obesity. The problem would get worse when patients with PTSD symptoms try to reduce the effects of bingeing with unhealthy dieting behaviors and possibly develop eating pathology, consistent with the model of Stice and Shaw [114]. The results reported by Hirth et al. are consistent with theories that unhealthy dieting behaviors, such as vomiting and laxative abuse, are linked to PTSD [115, 116]. In sum, PTSD symptoms are associated with specific food and drink choices, and PTSD symptoms are also associated with unhealthy eating behaviors, which would be the gate to develop overweight/obesity and eating disorders. **Figure 1** tries to

summarize the model which links negative emotions with weight gain.

In accordance with our review, we found that in spite of the fact that there are many risk factors involved in the increase in prevalence of obesity all around the world over the past few years, from those related to environmental and personal factors, particularly emotional eating plays a crucial and complex role in it. In the meantime, emotional eating is as well influenced by several risk factors: from social and physical environment to genetics, psychology, and food preferences. In addition, concepts such as food addiction and addictive eating were profoundly analyzed in order to explain the person's behavior toward food, and we concluded that there are many links between emotions and overweight/obesity. From our exploration we concluded that the epidemic of overweight and obesity is not only a matter of palatable and addictive foods available everywhere but also the individual

Undoubtedly, we explored that emotional eating emerges in response to negative emotions, but it was also important to examine how self-regulation, effects of stress, parenting, and parental bonding and coping would have an effect on the act of eating and subsequently on emotional eating and its correlation with the body mass index. Although it is well known that the typical response of stress on eating behavior is usually loss of appetite, we found that stressful circumstances are

Considering the field of study focused on overeating, it was seen that impulsivity, reward sensitivity, and the experience of intense craving result from self-regulation failures regarding both substance use and overeating. Nevertheless, some more research is needed in order to prove the causal direction between reward sensitivity

Another important factor to consider in order to self-regulate successfully among children is the proper parenting styles, which would influence positively on eating behavior. Authoritative parenting style, less maternal support, the lack of parental bond, and overprotection would disrupt the well-being of children and the ability to cope with challenging situations. Subsequently, these factors would

On the other hand, regarding negative emotions and feeling depressed, it is known that they are associated with loss of appetite and, as a result, weight loss. However, research showed that emotional eating would act as a mediator for a specific subtype of depression and it would have just the opposite effect on eating behavior, increasing weight as a result. In this regard, life adverse experiences,

#### **Figure 1.**

*Negative emotions, emotional eating, and weight gain.*

#### *Emotional Eating and Obesity DOI: http://dx.doi.org/10.5772/intechopen.91734*

trauma-induced PTSD symptoms, using that food as self-medication. Both fast food consumption and sugary soda consumption are usually associated with weight gain. PTSD symptoms may initiate a process of overindulging in unhealthy food and beverages in an attempt to compensate for the way trauma-induced memories make trauma victims feel. Through this process overeating behavior would lead to overweight/obesity. The problem would get worse when patients with PTSD symptoms try to reduce the effects of bingeing with unhealthy dieting behaviors and possibly develop eating pathology, consistent with the model of Stice and Shaw [114]. The results reported by Hirth et al. are consistent with theories that unhealthy dieting behaviors, such as vomiting and laxative abuse, are linked to PTSD [115, 116]. In sum, PTSD symptoms are associated with specific food and drink choices, and PTSD symptoms are also associated with unhealthy eating behaviors, which would be the gate to develop overweight/obesity and eating disorders. **Figure 1** tries to summarize the model which links negative emotions with weight gain.

#### **6. Conclusions**

*Psychosomatic Medicine*

**emotional eating?**

avoidance specific symptoms to PTSD [112].

*Negative emotions, emotional eating, and weight gain.*

**5. Posttraumatic stress disorder (PTSD): a psychosomatic paradigm of** 

It is well known that PTSD is usually associated with significantly higher rates of substance use disorders, other comorbid psychiatric disorders, and a variety of self-destructive and impulsive behaviors, including suicide [109–111]. It has been suggested that the ingestion, and especially over-ingestion, of fatty or sugary energy sources may be just another strategy that traumatized individuals use to numb themselves from their unpleasant feeling states and memories [112]. Thus, certain foods might act just like other substances that alter brain chemistry and, hence, consciousness. As we mentioned above, Randolph first described the phenomenon of food addiction and linked it with addictive drinking in 1956 [2]. Since then, the notion that certain foods can act like other addicting substances in the brain (despite having other peripheral metabolic effects that substances of abuse do not necessarily have) has been accepted. In fact, food intake and drug use both cause dopamine release in parts of the brain that mediate pleasure and emotion. The degree of subjective reward or experience of pleasure is clearly linked with the amount of dopamine release. Comparing similarities between action of certain foods and other substances of abuse, it must be noted that (a) food can stimulate the opiate system and there are similarities in use and withdrawal patterns of sugar and of classic drugs of abuse; (b) similar patterns of brain activation occur in response to food and drug cues; and (c) people may gain weight when they stop smoking or drinking. It has been proposed that certain foods can be addicting to certain people, especially traumatized people. Part of the people exposed to alcohol, nicotine, drugs of abuse, etc. are prone to be attracted for these substances/behaviors, and finally they are at high risk to develop addictions. The point is how can we determine if someone will go on to develop an addiction to food or to any substance or behavior? From a genetic perspective, it has been proven that people with reduced dopamine type 2 receptor availability have a predisposition toward obesity and substance dependence. Other risk factors are environmental. In this regard, a history of psycho-trauma would be an example and leads to the self-medication hypothesis of PTSD. This way, victims of interpersonal violence may select highly palatable foods containing high concentrations of sugar, fat, salt, or caffeine, sometimes to the point of addiction, in an attempt to dampen arousal and facilitate numbing and

Hirth et al. [113] observed an association between PTSD symptoms and drinking more than one serving of soda per day as well as consumption of fast food more often. The participants of this study may have eaten more fast food to reduce

**146**

**Figure 1.**

In accordance with our review, we found that in spite of the fact that there are many risk factors involved in the increase in prevalence of obesity all around the world over the past few years, from those related to environmental and personal factors, particularly emotional eating plays a crucial and complex role in it. In the meantime, emotional eating is as well influenced by several risk factors: from social and physical environment to genetics, psychology, and food preferences. In addition, concepts such as food addiction and addictive eating were profoundly analyzed in order to explain the person's behavior toward food, and we concluded that there are many links between emotions and overweight/obesity. From our exploration we concluded that the epidemic of overweight and obesity is not only a matter of palatable and addictive foods available everywhere but also the individual responses to food.

Undoubtedly, we explored that emotional eating emerges in response to negative emotions, but it was also important to examine how self-regulation, effects of stress, parenting, and parental bonding and coping would have an effect on the act of eating and subsequently on emotional eating and its correlation with the body mass index. Although it is well known that the typical response of stress on eating behavior is usually loss of appetite, we found that stressful circumstances are associated with greater energy and fat intake.

Considering the field of study focused on overeating, it was seen that impulsivity, reward sensitivity, and the experience of intense craving result from self-regulation failures regarding both substance use and overeating. Nevertheless, some more research is needed in order to prove the causal direction between reward sensitivity and overeating.

Another important factor to consider in order to self-regulate successfully among children is the proper parenting styles, which would influence positively on eating behavior. Authoritative parenting style, less maternal support, the lack of parental bond, and overprotection would disrupt the well-being of children and the ability to cope with challenging situations. Subsequently, these factors would interfere with their attitudes toward the act of eating.

On the other hand, regarding negative emotions and feeling depressed, it is known that they are associated with loss of appetite and, as a result, weight loss. However, research showed that emotional eating would act as a mediator for a specific subtype of depression and it would have just the opposite effect on eating behavior, increasing weight as a result. In this regard, life adverse experiences,

childhood trauma, and abuse-related PTSD, among other traumatic and stressful situations, were associated with dissociation, which plays an important role in the development of eating disorders, emotional eating, and obesity. In the field of over-ingestion of specific kinds of foods, such as sugary and fatty sources, these foods were proposed to be addicting to traumatized people. The genetic hypothesis proved the link between reduced dopamine type 2 receptor availability and the predisposition toward obesity and substance dependence. On the other hand, the PTSD hypothesis showed the over-ingestion of palatable foods in traumatized people derives from an attempt to lessen arousal and to avoid specific symptoms derived from PTSD, that is, emotional eating as self-medication.

In conclusion, in order to face the obesity problem, the addictive behavior should be the focus of research and treatment and not the addictive substance as traditionally has been considered.

### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Ignacio Jáuregui-Lobera\* and Marian Montes-Martínez Behavioral Sciences Institute, Seville, Spain

\*Address all correspondence to: ijl@tcasevilla.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**149**

2018;**18**:35

*Emotional Eating and Obesity*

**References**

*DOI: http://dx.doi.org/10.5772/intechopen.91734*

[10] Bruch H. Eating Disorders. New York: Basic Books; 1973

[11] Dallman MF. Stress-induced obesity and the emotional nervous system. Trends in Endocrinology and

Metabolism. 2010;**21**:159-165

[12] Van Strien T, Roelofs K, de Weerth C. Cortisol reactivity and distress-induced emotional eating. Psychoneuroendocrinology.

[13] Cummins S, Macintyre S. Food environments and obesity— Neighbourhood or nation?

International Journal of Epidemiology.

[14] Jeffery RW, Utter J. The changing environment and population obesity in the United States. Obesity Research.

[15] Levitsky DA. The non-regulation of food intake in humans: Hope for reversing the epidemic of obesity. Physiology & Behavior.

2013;**38**:677-684

2006;**35**:100-104

2003;**11**:12S-22S

2005;**86**:623-632

2015;**10**:e0117959

1993;**57**:772S-778S

1985;**35**:617-622

[19] Drewnowski A, Kurth C, Holden-Wiltse J, Saari J. Food

[16] Schulte EM, Avena NM,

Gearhardt AN. Which foods may be addictive? The roles of processing, fat content, and glycemic load. PLoS One.

[17] Blundell JE, Burley VJ, Cotton JR, Lawton CL. Dietary fat and the control of energy intake: Evaluating the effects of fat on meal size and postmeal satiety. American Journal of Clinical Nutrition.

[18] Drewnowski A, Brunzell J, Sande K, Iverius P, Greenwood M. Sweet tooth reconsidered: Taste responsiveness in human obesity. Physiology & Behavior.

[1] Adriaanse MA, de Ridder DTD, Evers C. Emotional eating: Eating when emotional or emotional about eating? Psychology & Health. 2011;**26**(1):23-39

[2] Randolph TG. The descriptive features of food addiction; addictive eating and drinking. Quarterly Journal of Studies on Alcohol. 1956;**17**:198-224

[3] Wadden TA, Brownell KD, Foster GD. Obesity: Responding to the global epidemic. Journal of Consulting and Clinical Psychology.

[4] Van den Bos R, de Ridder DTD. Evolved to satisfy our immediate needs: Self-control and the rewarding

properties of food. Appetite.

[5] Avena NM, Bocarsly ME,

Hoebel BG. Animal models of sugar and fat binge-ing: Relationship to food addiction and increased body weight. Methods in Molecular Biology.

[6] Pedram P, Wadden D, Amini P, Gulliver W, Randell E, Cahill F, et al. Food addiction: Its prevalence and significant association with obesity in the general population. PLoS One.

[7] Langeveld M, De Vries H. The long-term effect of energy restricted diets for treating obesity. Obesity.

[8] Mann T, Tomiyama J, Wesling E, Lew A, Samuels B, Chatman J. Medicare's search for effective obesity treatments. Diets are not the answer. American Psychologist. 2007;**62**:220-233

[9] Van Strien T. Causes of emotional eating and matched treatment of obesity. Current Diabetes Reports.

2002;**70**:510-525

2006;**47**:24-29

2012;**829**:351-365

2013;**8**:e74832

2015;**23**:1529-1538

### **References**

*Psychosomatic Medicine*

traditionally has been considered.

The authors declare no conflict of interest.

Ignacio Jáuregui-Lobera\* and Marian Montes-Martínez

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: ijl@tcasevilla.com

Behavioral Sciences Institute, Seville, Spain

provided the original work is properly cited.

**Conflict of interest**

childhood trauma, and abuse-related PTSD, among other traumatic and stressful situations, were associated with dissociation, which plays an important role in the development of eating disorders, emotional eating, and obesity. In the field of over-ingestion of specific kinds of foods, such as sugary and fatty sources, these foods were proposed to be addicting to traumatized people. The genetic hypothesis proved the link between reduced dopamine type 2 receptor availability and the predisposition toward obesity and substance dependence. On the other hand, the PTSD hypothesis showed the over-ingestion of palatable foods in traumatized people derives from an attempt to lessen arousal and to avoid specific symptoms

In conclusion, in order to face the obesity problem, the addictive behavior should be the focus of research and treatment and not the addictive substance as

derived from PTSD, that is, emotional eating as self-medication.

**148**

**Author details**

[1] Adriaanse MA, de Ridder DTD, Evers C. Emotional eating: Eating when emotional or emotional about eating? Psychology & Health. 2011;**26**(1):23-39

[2] Randolph TG. The descriptive features of food addiction; addictive eating and drinking. Quarterly Journal of Studies on Alcohol. 1956;**17**:198-224

[3] Wadden TA, Brownell KD, Foster GD. Obesity: Responding to the global epidemic. Journal of Consulting and Clinical Psychology. 2002;**70**:510-525

[4] Van den Bos R, de Ridder DTD. Evolved to satisfy our immediate needs: Self-control and the rewarding properties of food. Appetite. 2006;**47**:24-29

[5] Avena NM, Bocarsly ME, Hoebel BG. Animal models of sugar and fat binge-ing: Relationship to food addiction and increased body weight. Methods in Molecular Biology. 2012;**829**:351-365

[6] Pedram P, Wadden D, Amini P, Gulliver W, Randell E, Cahill F, et al. Food addiction: Its prevalence and significant association with obesity in the general population. PLoS One. 2013;**8**:e74832

[7] Langeveld M, De Vries H. The long-term effect of energy restricted diets for treating obesity. Obesity. 2015;**23**:1529-1538

[8] Mann T, Tomiyama J, Wesling E, Lew A, Samuels B, Chatman J. Medicare's search for effective obesity treatments. Diets are not the answer. American Psychologist. 2007;**62**:220-233

[9] Van Strien T. Causes of emotional eating and matched treatment of obesity. Current Diabetes Reports. 2018;**18**:35

[10] Bruch H. Eating Disorders. New York: Basic Books; 1973

[11] Dallman MF. Stress-induced obesity and the emotional nervous system. Trends in Endocrinology and Metabolism. 2010;**21**:159-165

[12] Van Strien T, Roelofs K, de Weerth C. Cortisol reactivity and distress-induced emotional eating. Psychoneuroendocrinology. 2013;**38**:677-684

[13] Cummins S, Macintyre S. Food environments and obesity— Neighbourhood or nation? International Journal of Epidemiology. 2006;**35**:100-104

[14] Jeffery RW, Utter J. The changing environment and population obesity in the United States. Obesity Research. 2003;**11**:12S-22S

[15] Levitsky DA. The non-regulation of food intake in humans: Hope for reversing the epidemic of obesity. Physiology & Behavior. 2005;**86**:623-632

[16] Schulte EM, Avena NM, Gearhardt AN. Which foods may be addictive? The roles of processing, fat content, and glycemic load. PLoS One. 2015;**10**:e0117959

[17] Blundell JE, Burley VJ, Cotton JR, Lawton CL. Dietary fat and the control of energy intake: Evaluating the effects of fat on meal size and postmeal satiety. American Journal of Clinical Nutrition. 1993;**57**:772S-778S

[18] Drewnowski A, Brunzell J, Sande K, Iverius P, Greenwood M. Sweet tooth reconsidered: Taste responsiveness in human obesity. Physiology & Behavior. 1985;**35**:617-622

[19] Drewnowski A, Kurth C, Holden-Wiltse J, Saari J. Food preferences in human obesity: Carbohydrates versus fats. Appetite. 1992;**18**:207-221

[20] Snoek HM, van Strien T, Janssens JM, Engels RC. Emotional, external, restrained eating and overweight in Dutch adolescents. Scandinavian Journal of Psychology. 2007;**48**(1):23-32

[21] Galloway AT, Farrow CV, Martz DM. Retrospective reports of child feeding practices, current eating behaviors, and BMI in college students. Obesity. 2010;**18**(7):1330-1335

[22] Constanza PR, Woody EZ. Domainspecific parenting styles and their impact on the child's development of particular deviance: The example of obesity and proneness. Journal of Social and Clinical Psychology. 1985;**3**:425

[23] Birch LL, Fisher JO, Davison KK. Learning to overeat: Maternal use of restrictive feeding practices promotes girls' eating in the absence of hunger. American Journal of Clinical Nutrition. 2003;**78**:215-220

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[26] Ho AY. Risk factors of emotional eating in undergraduates [Dissertation]. Cleveland, Ohio: Case Western Reserve University; 2014

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Neuroscience & Biobehavioral Reviews.

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#### *Emotional Eating and Obesity DOI: http://dx.doi.org/10.5772/intechopen.91734*

*Psychosomatic Medicine*

1992;**18**:207-221

2007;**48**(1):23-32

preferences in human obesity: Carbohydrates versus fats. Appetite. [28] McCann BS, Warnick GR, Knopp RH. Changes in plasma lipids and dietary intake accompanying shifts in perceived workload and stress. Psychosomatic Medicine.

[29] Macht M, Haupt C, Ellgring H. The perceived function of eating is changed during examination stress: A field study. Eating Behaviors. 2005;**6**(2):109-111

[30] Topham GL, Hubbs-Tait L, Rutledge JM, Page MC, Kennedy TS, Shriver LH, et al. Parenting styles, parental response to child emotion, and family emotional responsiveness are related to child emotional eating.

Appetite. 2011;**56**(2):261-264

[32] De Panfilis C, Rabbaglio P,

disturbance, parental bonding and alexithymia in patients with eating disorders. Psychopathology.

[33] Rommel D, Nandrino JL, Ducro C, Andrieux S, Delecourt F, Antoine P. Impact of emotional awareness and parental bonding on emotional eating in obese women. Appetite.

2007;**49**(1):223-230

2003;**36**(5):239-246

2012;**59**(1):21-26

2001;**50**(2):67-72

2005;**44**(Pt3):371-395

[31] Snoek HM, Engels RC, Janssens JM, van Strien T. Parental behaviour and adolescents' emotional eating. Appetite.

Rossi C, Zita G, Maggini C. Body image

[34] Adlaf EM, Gliksman L, Demers A, Newton-Taylor B. The prevalence of elevated psychological distress among Canadian undergraduates: Findings from the 1998 Canadian campus survey. Journal of American College Health.

[35] Matheson K, Kelly O, Cole B, Tannenbaum B, Dodd C, Anisman H. Parental bonding and depressive affect: The mediating role of coping resources. The British Journal of Social Psychology.

1990;**51**(1):97-108

[20] Snoek HM, van Strien T, Janssens JM, Engels RC. Emotional, external, restrained eating and overweight in Dutch adolescents. Scandinavian Journal of Psychology.

[21] Galloway AT, Farrow CV, Martz DM. Retrospective reports of child feeding practices, current eating behaviors, and BMI in college students.

Obesity. 2010;**18**(7):1330-1335

[23] Birch LL, Fisher JO,

Davison KK. Learning to overeat: Maternal use of restrictive feeding practices promotes girls' eating in the absence of hunger. American Journal of Clinical Nutrition. 2003;**78**:215-220

[24] Johnson SL, Birch LL. Parents' and children's adiposity and eating style. Pediatrics. 1994;**94**(5):653-661

Robertson ER, Sokol-Hessner P, Ray RD, et al. The development of emotion regulation: An fMRI study of cognitive reappraisal in children, adolescents and young adults. Social and Cognition Affective Neuroscience. 2012;**7**(1):11-22

[26] Ho AY. Risk factors of emotional eating in undergraduates [Dissertation]. Cleveland, Ohio: Case Western Reserve

[25] McRae K, Gross JJ, Weber J,

[22] Constanza PR, Woody EZ. Domainspecific parenting styles and their impact on the child's development of particular deviance: The example of obesity and proneness. Journal of Social and Clinical Psychology. 1985;**3**:425

**150**

University; 2014

2002;**7**:254-275

[27] Gold PW, Chrousos GP. Organization of the stress system and its dysregulation in melancholic and atypical depression: High vs low CRH/NE states. Molecular Psychiatry. [36] Dawe S, Loxton NJ. The role of impulsivity in the development of substance use and eating disorders. Neuroscience & Biobehavioral Reviews. 2004;**28**:343-351

[37] Gullo M, Dawe S. Impulsivity and adolescent substance use: Rashly dismissed as "all-bad"? Neuroscience & Biobehavioral Reviews. 2008;**32**:1507-1518

[38] Schulte EM, Grilo CM, Gearhardt AN. Shared and unique mechanisms underlying binge eating disorder and addictive disorders. Clinical Psychology Review. 2016;**44**:125-139

[39] Adams RC, Sedgmond J, Maizey L, Chambers CD, Lawrence NS. Food addiction: Implications for the diagnosis and treatment of overeating. Nutrients. 2019;**11**(9):E2086

[40] Emery RL, Levine MD. Questionnaire and behavioral task measures of impulsivity are differentially associated with body mass index: A comprehensive metaanalysis. Psychological Bulletin. 2017;**143**:868-902

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[54] Berridge KC, Ho CY, Richard JM, Di Feliceantonio AG. The tempted brain eats: Pleasure and desire circuits in obesity and eating disorders. Brain Research. 2010;**1350**:43-64

[55] Hetherington M, Pirie L, Nabb S. Stimulus satiation: Effects of repeated exposure to foods on pleasantness and intake. Appetite. 2002;**38**:19-28

[56] Kekic M, McClelland J, Campbell I, Nestler S, Rubia K, David AS, et al. The effects of prefrontal cortex transcranial direct current stimulation (tDCS) on food craving and temporal discounting in women with frequent food cravings. Appetite. 2014;**78**:55-62

[57] Weingarten HP, Elston D. The phenomenology of food cravings. Appetite. 1990;**15**:231-246

[58] Cocores JA, Gold MS. The salted food addiction hypothesis may explain overeating and the obesity epidemic. Medical Hypotheses. 2009;**73**:892-899

[59] Corsica JA, Spring BJ. Carbohydrate craving: A double-blind, placebocontrolled test of the self-medication hypothesis. Eating Behaviors. 2008;**9**:447-454

[60] Hill AJ, Heaton-Brown L. The experience of food craving: A prospective investigation in healthy women. Journal of Psychosomatic Research. 1994;**38**:801-814

[61] Massey A, Hill AJ. Dieting and food craving. A descriptive, quasi-prospective study. Appetite. 2012;**58**:781-785

[62] Rozin P, Levine E, Stoess C. Chocolate craving and liking. Appetite. 1991;**17**:199-212

[63] Jáuregui-Lobera I, Bolaños-Ríos P, Valero E, Ruiz-Prieto I. Induction of food craving experience; the role of mental imagery, dietary restraint, mood and coping strategies. Nutrición Hospitalaria. 2012;**27**(6):1928-1935

[64] Van Strien T, Ouwens MA, Engel C, de Weerth C. Hunger, inhibitory control and distress-induced emotional eating. Appetite. 2014;**79**:124-133

[65] Polivy J, Herman CP. Dieting and bingeing. A causal analysis. American Psychologist. 1985;**40**(2):193-201

[66] Van Strien T, Herman CP, Verheijden MW. Eating style, overeating and overweight in a representative Dutch sample: Does external eating play a role? Appetite. 2009;**52**:380-387

[67] Van Strien T, Engels RCME, Van Leeuwe J, Snoek HM. The Stice model of overeating: Tests in clinical and non-clinical samples. Appetite. 2005;**4**:205-213

[68] Van Strien T. Nederlandse Vragenlijst voor eetgedrag (NVE). Handleiding. [Dutch Eating Behaviour Questionnaire. Manual]. Amsterdam: Hogrefe; 2015

[69] Slochower JA. Excessive Eating. The Role of Emotions and the Environment. New York: Human Sciences Press, Inc.; 1983

[70] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5. (DSM-5). Washington, DC: American Psychiatric Publication; 2013

[71] Van Strien T, van der Zwaluw CS, Engels RCME. Emotional eating in adolescents: A gene (SLC6A4/5-HTT) depressive feelings interaction analysis. Journal of Psychiatric Research. 2010;**44**(15):1035-1042

**153**

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Research. 2018;**97**:38-46

2014;**37**(4):577-586

2014;**47**(3):281-286

2010;**54**(3):473-479

2000;**41**(1):97-116

2006;**1083**:111-128

*DOI: http://dx.doi.org/10.5772/intechopen.91734*

[80] Vicennati V, Pasqui F, Cavazza C, Pagotto U, Pasquali R. Stress-related development of obesity and cortisol in women. Obesity. 2009;**17**(9):1678-1683

[81] Birketvedt GS, Florholmen J,

Dingers D, Bilker W, et al. Behavioral and neuroendocrine characteristics of the night-eating syndrome. The Journal of the American Medical Association.

Sundsfjord J, Osterud B,

[82] Gluck ME, Geliebter A,

Lorence M. Cortisol stress response is positively correlated with central obesity in obese women with binge eating disorder (BED) before and after cognitive-behavioral treatment. Annals of New York Academy of Sciences.

[83] Treuer T, Koperdak M, Rozsa S, Furedi J. The impact of physical and sexual abuse on body image in eating disorders. European Eating Disorders

[84] Engelberg MJ, Steiger H, Gauvin L, Wonderlich SA. Binge antecedents in bulimic syndromes: An examination of dissociation and negative affect. International Journal of Eating Disorders. 2007;**40**:531-536

Sousa L. What triggers abnormal eating in bulimic and non-bulimic women? The role of dissociative experiences, negative affect, and psychopathology. Psychology of Women Quarterly.

[86] Rodriguez-Srednicki O. Childhood sexual abuse, dissociation and adult self-destructive behavior. Journal of Child Sexual Abuse. 2001;**10**(3):75-90

[87] La Mela C, Maglietta M, Castellini G, Amoroso L, Lucarelli S. Dissociation in eating disorders: Relationship between dissociative experiences and binge-eating episodes. Comprehensive

Psychiatry. 2010;**51**(4):393-400

[85] Lyubomirsky S, Casper RC,

2001;**25**:223-232

1999;282:657-663

2004;**1032**:202-207

Review. 2005;**13**:106-111

Penninx WJH. Eating styles in major depressive disorder: Results from a large-scale study. Journal of Psychiatric

[73] Clum GA, Rice JC, Broussard M, Johnson CC, Webber LS. Associations between depressive symptoms, self-efficacy, eating styles, exercise and body mass index in women. Journal of Behavioral Medicine.

[74] Goldschmidt AB, Crosby RD, Engel SG, Crow SJ, Cao L, Peterson CB, et al. Affect and eating behavior in obese adults with and without elevated depression symptoms. International

Journal of Eating Disorders.

[75] Konttinen H, Männistö S, Sarlio-Lähteenkorva S,

[76] Van Strien T, Winkens LHH,

Appetite. 2016;**105**:500-508

Silventoinen K, Haukkala A. Emotional eating, depressive symptoms and self-reported food consumption. A population-based study. Appetite.

Broman Toft M, Pedersen S, Brouwer IA, et al. The mediation effect of emotional eating between depression and body mass index in Denmark and Spain.

[77] Glaser D. Child abuse and neglect and the brain—A review. Journal of Child Psychology and Psychiatry.

[78] Pasquali R, Vicennati V, Cacciari M, Pagotto U. The hypothalamic-pituitaryadrenal axis activity in obesity and the metabolic syndrome. Annals of New York Academy of Sciences.

[79] Marin P, Darin N, Amemiya T, Andersson B, Jern S, Bjorntorp P. Cortisol secretion in relation to body fat distribution in obese premenopausal women. Metabolism. 1992;**41**:882-886

[72] Paans NPG, Bot M, Van Strien T, Brouwer IA, Visser M,

#### *Emotional Eating and Obesity DOI: http://dx.doi.org/10.5772/intechopen.91734*

*Psychosomatic Medicine*

Behavior. 2009;**97**:537-550

Research. 2010;**1350**:43-64

2002;**38**:19-28

Appetite. 2014;**78**:55-62

Appetite. 1990;**15**:231-246

2008;**9**:447-454

2012;**58**:781-785

[57] Weingarten HP, Elston D. The phenomenology of food cravings.

[58] Cocores JA, Gold MS. The salted food addiction hypothesis may explain overeating and the obesity epidemic. Medical Hypotheses. 2009;**73**:892-899

[59] Corsica JA, Spring BJ. Carbohydrate craving: A double-blind, placebocontrolled test of the self-medication hypothesis. Eating Behaviors.

[60] Hill AJ, Heaton-Brown L. The experience of food craving: A prospective investigation in healthy women. Journal of Psychosomatic

Research. 1994;**38**:801-814

[61] Massey A, Hill AJ. Dieting and food craving. A descriptive, quasi-prospective study. Appetite.

[62] Rozin P, Levine E, Stoess C. Chocolate craving and liking. Appetite. 1991;**17**:199-212

[55] Hetherington M, Pirie L, Nabb S. Stimulus satiation: Effects of repeated exposure to foods on pleasantness and intake. Appetite.

[53] Berridge KC. 'Liking' and 'wanting' food rewards: Brain substrates and roles in eating disorders. Physiology &

[63] Jáuregui-Lobera I, Bolaños-Ríos P, Valero E, Ruiz-Prieto I. Induction of food craving experience; the role of mental imagery, dietary restraint, mood and coping strategies. Nutrición Hospitalaria. 2012;**27**(6):1928-1935

[64] Van Strien T, Ouwens MA, Engel C, de Weerth C. Hunger, inhibitory control and distress-induced emotional eating.

[65] Polivy J, Herman CP. Dieting and bingeing. A causal analysis. American Psychologist. 1985;**40**(2):193-201

Verheijden MW. Eating style, overeating and overweight in a representative Dutch sample: Does external eating play a role? Appetite. 2009;**52**:380-387

Appetite. 2014;**79**:124-133

[66] Van Strien T, Herman CP,

[67] Van Strien T, Engels RCME, Van Leeuwe J, Snoek HM. The Stice model of overeating: Tests in clinical and non-clinical samples. Appetite.

[68] Van Strien T. Nederlandse Vragenlijst voor eetgedrag (NVE). Handleiding. [Dutch Eating Behaviour Questionnaire. Manual]. Amsterdam:

[69] Slochower JA. Excessive Eating. The Role of Emotions and the Environment. New York: Human Sciences Press, Inc.;

[70] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5. (DSM-5). Washington, DC: American Psychiatric

[71] Van Strien T, van der Zwaluw CS, Engels RCME. Emotional eating in adolescents: A gene (SLC6A4/5-HTT) depressive feelings interaction analysis.

Journal of Psychiatric Research.

2010;**44**(15):1035-1042

[72] Paans NPG, Bot M, Van Strien T, Brouwer IA, Visser M,

2005;**4**:205-213

Hogrefe; 2015

Publication; 2013

1983

[54] Berridge KC, Ho CY, Richard JM, Di Feliceantonio AG. The tempted brain eats: Pleasure and desire circuits in obesity and eating disorders. Brain

[56] Kekic M, McClelland J, Campbell I, Nestler S, Rubia K, David AS, et al. The effects of prefrontal cortex transcranial direct current stimulation (tDCS) on food craving and temporal discounting in women with frequent food cravings.

**152**

Penninx WJH. Eating styles in major depressive disorder: Results from a large-scale study. Journal of Psychiatric Research. 2018;**97**:38-46

[73] Clum GA, Rice JC, Broussard M, Johnson CC, Webber LS. Associations between depressive symptoms, self-efficacy, eating styles, exercise and body mass index in women. Journal of Behavioral Medicine. 2014;**37**(4):577-586

[74] Goldschmidt AB, Crosby RD, Engel SG, Crow SJ, Cao L, Peterson CB, et al. Affect and eating behavior in obese adults with and without elevated depression symptoms. International Journal of Eating Disorders. 2014;**47**(3):281-286

[75] Konttinen H, Männistö S, Sarlio-Lähteenkorva S, Silventoinen K, Haukkala A. Emotional eating, depressive symptoms and self-reported food consumption. A population-based study. Appetite. 2010;**54**(3):473-479

[76] Van Strien T, Winkens LHH, Broman Toft M, Pedersen S, Brouwer IA, et al. The mediation effect of emotional eating between depression and body mass index in Denmark and Spain. Appetite. 2016;**105**:500-508

[77] Glaser D. Child abuse and neglect and the brain—A review. Journal of Child Psychology and Psychiatry. 2000;**41**(1):97-116

[78] Pasquali R, Vicennati V, Cacciari M, Pagotto U. The hypothalamic-pituitaryadrenal axis activity in obesity and the metabolic syndrome. Annals of New York Academy of Sciences. 2006;**1083**:111-128

[79] Marin P, Darin N, Amemiya T, Andersson B, Jern S, Bjorntorp P. Cortisol secretion in relation to body fat distribution in obese premenopausal women. Metabolism. 1992;**41**:882-886

[80] Vicennati V, Pasqui F, Cavazza C, Pagotto U, Pasquali R. Stress-related development of obesity and cortisol in women. Obesity. 2009;**17**(9):1678-1683

[81] Birketvedt GS, Florholmen J, Sundsfjord J, Osterud B, Dingers D, Bilker W, et al. Behavioral and neuroendocrine characteristics of the night-eating syndrome. The Journal of the American Medical Association. 1999;282:657-663

[82] Gluck ME, Geliebter A, Lorence M. Cortisol stress response is positively correlated with central obesity in obese women with binge eating disorder (BED) before and after cognitive-behavioral treatment. Annals of New York Academy of Sciences. 2004;**1032**:202-207

[83] Treuer T, Koperdak M, Rozsa S, Furedi J. The impact of physical and sexual abuse on body image in eating disorders. European Eating Disorders Review. 2005;**13**:106-111

[84] Engelberg MJ, Steiger H, Gauvin L, Wonderlich SA. Binge antecedents in bulimic syndromes: An examination of dissociation and negative affect. International Journal of Eating Disorders. 2007;**40**:531-536

[85] Lyubomirsky S, Casper RC, Sousa L. What triggers abnormal eating in bulimic and non-bulimic women? The role of dissociative experiences, negative affect, and psychopathology. Psychology of Women Quarterly. 2001;**25**:223-232

[86] Rodriguez-Srednicki O. Childhood sexual abuse, dissociation and adult self-destructive behavior. Journal of Child Sexual Abuse. 2001;**10**(3):75-90

[87] La Mela C, Maglietta M, Castellini G, Amoroso L, Lucarelli S. Dissociation in eating disorders: Relationship between dissociative experiences and binge-eating episodes. Comprehensive Psychiatry. 2010;**51**(4):393-400

[88] Moyer D, Di Pietro L, Berkowitz R, Sunkard AJ. Childhood sexual abuse and precursors of binge eating in an adolescent female population. International Journal of Eating Disorders. 1997;**21**(1):23-30

[89] Midei AJ, Matthews KA, Bromberger J. Childhood abuse is associated with adiposity in mid-life women/possible pathways through trait anger and reproductive hormones. Psychosomatic Medicine. 2010;**72**(2):215-223

[90] Alvarez J, Pavao J, Baumrind N, Kimerling N. The relationship between child abuse and adult obesity among California women. American Journal of Preventive Medicine. 2007;**33**(1):28-33

[91] Katz JR, Taylor NF, Goodrick S, Perry L, Yudkin JS, Coppack SW. Central obesity, depression and the hypothalamo-pituitary-adrenal axis in men and postmenopausal women. International Journal of Obesity and Related Metabolic Disorders: Journal of the International Association for the Study of Obesity. 2000;**24**(2):246-251

[92] Räikkönen K, Matthews KA, Kuller LH. Anthropometric and psychosocial determinants of visceral obesity in healthy postmenopausal women. International Journal of Obesity and Related Metabolic Disorders: Journal of the International Association for the Study of Obesity. 1999;**23**(8):775-782

[93] Appelhans BM, Whited MC, Schneider KL, Oleski J, Pagoto SL. Response style and vulnerability to anger-induced eating in obese adults. Eating Behaviors. 2011;**12**(1):9-14

[94] Evers C, Stok FM, de Ridder DT. Feeding your feelings: Emotion regulation strategies and emotional eating. Personality and Social Psychology Bulletin. 2010;**36**:792-804 [95] Adam TC, Epel ES. Stress, eating and the reward system. Physiology & Behavior. 2007;**91**(4):449-458

[96] McEwen BS. Physiology and neurobiology of stress and adaptation: Central role of the brain. Physiological Reviews. 2007;**87**(3):873-904

[97] Torres SJ, Nowson CA. Relationship between stress, eating behavior, and obesity. Nutrition. 2007;**23**(11):887-894

[98] Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. Journal of the American Medical Association. 2007;**298**(14):1685-1687

[99] De Vriendt T, Clays E, Maes L, De Bourdeaudhuij I, Vicente-Rodriguez G, Moreno LA, et al. European adolescents' level of perceived stress and its relationship with body adiposity—The HELENA study. The European Journal of Public Health. 2012;**22**(4):519-524

[100] Barrington WE, Beresford SA, McGregor BA, White E. Perceived stress and eating behaviors by sex, obesity status, and stress vulnerability: Findings from the vitamins and lifestyle (vital) study. Journal of the Academy of Nutrition and Dietetics. 2014;**114**(11):1791-1799

[101] Telch CF, Agras WS. Do emotional states influence binge eating in the obese? International Journal of Eating Disorders. 1996;**20**(3):271-279

[102] Epel E, Lapidus R, McEwen B, Brownell K. Stress may add bite to appetite in women: A laboratory study of stress-induced cortisol and eating behavior. Psychoneuroendocrinology. 2001;**26**(1):37-49

[103] Garg N, Wansink B, Inman JJ. The influence of incidental affect on consumers' food intake. Journal of Marketing. 2007;**71**(1):194-206

**155**

*Emotional Eating and Obesity*

2007;**32**(2):125-132

2013;**73**(9):827-835

2004;**66**:876-881

[104] Newman E, O'Connor DB, Conner M. Daily hassles and eating behaviour: The role of cortisol reactivity status. Psychoneuroendocrinology.

*DOI: http://dx.doi.org/10.5772/intechopen.91734*

addiction as self-medication. Journal of

[113] Hirth J, Mahbubur R, Berenson AB.

Women's Health. 2011;**20**(8):1-2

The association of posttraumatic stress disorder with fast food and soda consumption and unhealthy weight loss behaviors among young women. Journal

of Women's Health. 2011;**20**:8

2002;**53**:985-993

2007;**15**:285-304

[114] Stice E, Shaw HE. Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. Journal of Psychosomatic Research.

[115] Brewerton TD. Eating disorders, trauma, and comorbidity: Focus on PTSD. Eating Disorders.

[116] Gleaves DH, Ebarenz KP, May MC. Scope and significance of posttraumatic symptomatology among women hospitalized for an eating disorder. International Journal of Eating

Disorders. 1998;**24**:147-156

[105] Seeman TE, Singer BH, Rowe JW, Horwitz RI, McEwen BS. Price of adaptation allostatic load and its health consequences: MacArthur studies of successful aging. Archives of Internal Medicine. 1997;**157**(19):2259-2268

[106] Sinha R, Jastreboff AM. Stress as a common risk factor for obesity and addiction. Biological Psychiatry.

[107] Gluck ME, Geliebter A, Hung J, Yahav E. Cortisol, hunger, and desire to binge eat following a cold stress test in obese women with binge eating disorder. Psychosomatic Medicine.

[108] Groesz LM, McCoy S, Carl J, Saslow L, Stewart J, Adler N, et al. What is eating you? Stress and the drive to eat.

[109] Brewerton TD. Eating disorders, victimization and PTSD: Principles of treatment. In: Brewerton TD, editor. Clinical Handbook of Eating Disorders: An Integrated Approach. New York: Marcel Dekker; 2004. pp. 509-545

[110] Dansky BS, Brewerton TD, Kilpatrick DG. Comorbidity of bulimia nervosa and alcohol use disorders: Results from the National Women's study. International Journal of Eating

Disorders. 2000;**27**:180-190

Journal of Clinical Psychiatry. 2000;**61**(Suppl 7):22-32

[111] Brady K, Killeen TK, Brewerton TD, Sylverini S. Comorbidity of psychiatric disorders and posttraumatic disorder.

[112] Brewerton TD. Posttraumatic stress disorder and disordered eating: Food

Appetite. 2012;**58**(2):717-721

#### *Emotional Eating and Obesity DOI: http://dx.doi.org/10.5772/intechopen.91734*

*Psychosomatic Medicine*

[88] Moyer D, Di Pietro L, Berkowitz R, Sunkard AJ. Childhood sexual abuse and precursors of binge eating in an adolescent female population. International Journal of Eating Disorders. 1997;**21**(1):23-30

[95] Adam TC, Epel ES. Stress, eating and the reward system. Physiology &

[97] Torres SJ, Nowson CA. Relationship between stress, eating behavior, and obesity. Nutrition. 2007;**23**(11):887-894

Behavior. 2007;**91**(4):449-458

Reviews. 2007;**87**(3):873-904

[98] Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. Journal of the American Medical Association.

[99] De Vriendt T, Clays E, Maes L, De Bourdeaudhuij I, Vicente-Rodriguez G, Moreno LA, et al. European adolescents'

relationship with body adiposity—The HELENA study. The European Journal of Public Health. 2012;**22**(4):519-524

[100] Barrington WE, Beresford SA, McGregor BA, White E. Perceived stress and eating behaviors by sex, obesity status, and stress vulnerability: Findings from the vitamins and lifestyle (vital) study. Journal of the Academy of Nutrition and Dietetics.

[101] Telch CF, Agras WS. Do emotional states influence binge eating in the obese? International Journal of Eating

level of perceived stress and its

2007;**298**(14):1685-1687

2014;**114**(11):1791-1799

2001;**26**(1):37-49

Disorders. 1996;**20**(3):271-279

[102] Epel E, Lapidus R, McEwen B, Brownell K. Stress may add bite to appetite in women: A laboratory study of stress-induced cortisol and eating behavior. Psychoneuroendocrinology.

[103] Garg N, Wansink B, Inman JJ. The influence of incidental affect on consumers' food intake. Journal of Marketing. 2007;**71**(1):194-206

[96] McEwen BS. Physiology and neurobiology of stress and adaptation: Central role of the brain. Physiological

[89] Midei AJ, Matthews KA, Bromberger J. Childhood abuse is associated with adiposity in mid-life women/possible pathways through trait anger and reproductive

2010;**72**(2):215-223

hormones. Psychosomatic Medicine.

[90] Alvarez J, Pavao J, Baumrind N, Kimerling N. The relationship between child abuse and adult obesity among California women. American Journal of Preventive Medicine. 2007;**33**(1):28-33

[91] Katz JR, Taylor NF, Goodrick S, Perry L, Yudkin JS, Coppack SW. Central

hypothalamo-pituitary-adrenal axis in men and postmenopausal women. International Journal of Obesity and Related Metabolic Disorders: Journal of the International Association for the Study of Obesity. 2000;**24**(2):246-251

[92] Räikkönen K, Matthews KA, Kuller LH. Anthropometric and psychosocial determinants of visceral obesity in healthy postmenopausal women. International Journal of Obesity and Related Metabolic

Disorders: Journal of the International Association for the Study of Obesity.

[93] Appelhans BM, Whited MC, Schneider KL, Oleski J, Pagoto SL. Response style and vulnerability to anger-induced eating in obese adults. Eating Behaviors. 2011;**12**(1):9-14

[94] Evers C, Stok FM, de Ridder DT. Feeding your feelings: Emotion regulation strategies and emotional eating. Personality and Social

Psychology Bulletin. 2010;**36**:792-804

1999;**23**(8):775-782

obesity, depression and the

**154**

[104] Newman E, O'Connor DB, Conner M. Daily hassles and eating behaviour: The role of cortisol reactivity status. Psychoneuroendocrinology. 2007;**32**(2):125-132

[105] Seeman TE, Singer BH, Rowe JW, Horwitz RI, McEwen BS. Price of adaptation allostatic load and its health consequences: MacArthur studies of successful aging. Archives of Internal Medicine. 1997;**157**(19):2259-2268

[106] Sinha R, Jastreboff AM. Stress as a common risk factor for obesity and addiction. Biological Psychiatry. 2013;**73**(9):827-835

[107] Gluck ME, Geliebter A, Hung J, Yahav E. Cortisol, hunger, and desire to binge eat following a cold stress test in obese women with binge eating disorder. Psychosomatic Medicine. 2004;**66**:876-881

[108] Groesz LM, McCoy S, Carl J, Saslow L, Stewart J, Adler N, et al. What is eating you? Stress and the drive to eat. Appetite. 2012;**58**(2):717-721

[109] Brewerton TD. Eating disorders, victimization and PTSD: Principles of treatment. In: Brewerton TD, editor. Clinical Handbook of Eating Disorders: An Integrated Approach. New York: Marcel Dekker; 2004. pp. 509-545

[110] Dansky BS, Brewerton TD, Kilpatrick DG. Comorbidity of bulimia nervosa and alcohol use disorders: Results from the National Women's study. International Journal of Eating Disorders. 2000;**27**:180-190

[111] Brady K, Killeen TK, Brewerton TD, Sylverini S. Comorbidity of psychiatric disorders and posttraumatic disorder. Journal of Clinical Psychiatry. 2000;**61**(Suppl 7):22-32

[112] Brewerton TD. Posttraumatic stress disorder and disordered eating: Food

addiction as self-medication. Journal of Women's Health. 2011;**20**(8):1-2

[113] Hirth J, Mahbubur R, Berenson AB. The association of posttraumatic stress disorder with fast food and soda consumption and unhealthy weight loss behaviors among young women. Journal of Women's Health. 2011;**20**:8

[114] Stice E, Shaw HE. Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. Journal of Psychosomatic Research. 2002;**53**:985-993

[115] Brewerton TD. Eating disorders, trauma, and comorbidity: Focus on PTSD. Eating Disorders. 2007;**15**:285-304

[116] Gleaves DH, Ebarenz KP, May MC. Scope and significance of posttraumatic symptomatology among women hospitalized for an eating disorder. International Journal of Eating Disorders. 1998;**24**:147-156

**157**

events.

**Chapter 8**

**Abstract**

are also discussed.

**1. Introduction**

factors, treatments, children, adolescents

Post-Traumatic Stress Disorder in

Children and Adolescents: Some

Childhood trauma can have a profound effect on development, with a lifelong impact on physical growth, psychological development, and mental health. This chapter provides a framework for adolescent health professionals to understand the impacts of traumatic stress on children and adolescents. This chapter mainly takes the Wenchuan Earthquake studies in China as an example, and reviews recent research findings on epidemiological characteristics of PTSD and related mental disorders, as well as on possible influencing factors and mechanisms for posttraumatic adaptation in children and adolescents. Important intervention strategies for PTSD in children and adolescents are introduced. Prospects for future research

**Keywords:** PTSD, comorbidity, post-traumatic adaptation, protective and risk

Exposure to potentially traumatic events such as hostilities of school shootings, terrorist attacks, threats of war, destruction of public property, suicide bombings, and natural disasters is highly frequent among young people across the world. Many children appear to be confronted with one or more potentially traumatic events while growing up. As children and adolescents have limited coping strategies and are less capable of effectively protecting themselves, they are more vulnerable to traumatic disaster than adults. It was reported that, in the immediate aftermath of such events, a high percentage of children will experience symptoms of Posttraumatic Stress Disorder (PTSD) with approximately 20–30% going on to develop the full disorder in the first 6 months [1]. However, due to the special stage of their physical and mental development, unique features of pediatric PTSD have less been studied. Fortunately, there is growing recognition of the fact that traumatic events can have severe and lasting impacts on children, and clinicians are becoming increasingly sensitive to the psychological needs of young survivors of traumatic

Depending upon the developmental stage and level of cognitive and emotional maturity, the symptomatology of PTSD in children are expected to be different from that in adults [2]. Prevalence and symptomatology of PTSD also vary greatly

Recent Research Findings

*George Musa and Christina Hoven*

*Yuanyuan Li, Ya Zhou, Xiaoyan Chen, Fang Fan,* 

#### **Chapter 8**

## Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings

*Yuanyuan Li, Ya Zhou, Xiaoyan Chen, Fang Fan, George Musa and Christina Hoven*

#### **Abstract**

Childhood trauma can have a profound effect on development, with a lifelong impact on physical growth, psychological development, and mental health. This chapter provides a framework for adolescent health professionals to understand the impacts of traumatic stress on children and adolescents. This chapter mainly takes the Wenchuan Earthquake studies in China as an example, and reviews recent research findings on epidemiological characteristics of PTSD and related mental disorders, as well as on possible influencing factors and mechanisms for posttraumatic adaptation in children and adolescents. Important intervention strategies for PTSD in children and adolescents are introduced. Prospects for future research are also discussed.

**Keywords:** PTSD, comorbidity, post-traumatic adaptation, protective and risk factors, treatments, children, adolescents

#### **1. Introduction**

Exposure to potentially traumatic events such as hostilities of school shootings, terrorist attacks, threats of war, destruction of public property, suicide bombings, and natural disasters is highly frequent among young people across the world. Many children appear to be confronted with one or more potentially traumatic events while growing up. As children and adolescents have limited coping strategies and are less capable of effectively protecting themselves, they are more vulnerable to traumatic disaster than adults. It was reported that, in the immediate aftermath of such events, a high percentage of children will experience symptoms of Posttraumatic Stress Disorder (PTSD) with approximately 20–30% going on to develop the full disorder in the first 6 months [1]. However, due to the special stage of their physical and mental development, unique features of pediatric PTSD have less been studied. Fortunately, there is growing recognition of the fact that traumatic events can have severe and lasting impacts on children, and clinicians are becoming increasingly sensitive to the psychological needs of young survivors of traumatic events.

Depending upon the developmental stage and level of cognitive and emotional maturity, the symptomatology of PTSD in children are expected to be different from that in adults [2]. Prevalence and symptomatology of PTSD also vary greatly among children and adolescents depending upon the traumatic event itself, the severity and duration of exposure, and the child's demographic variables such as gender, age, and ethnicity. For example, rates of PTSD diagnosis are higher among girls, middle school children, and Hispanics [3–5]. Interpersonal traumas, such as sexual and physical assaults, are more likely to result in PTSD than exposure to natural or technological disasters [2, 6]. In addition, numerous psychological, family, and social factors such as parental mental status and, prolonged life disruption could also affect children and adolescents' post-trauma adaptation and recovery [7, 8]. Currently, PTSD is increasingly viewed as a potentially serious disorder in children and adolescents, because of not only the intense suffering it wreaks on young people, but also its adverse effects on biological, psychological, and social development [9]. Left untreated, PTSD can persist for years, increase the children's risk of developing other disorders, and impair their psychosocial functioning in future life [10].

In this chapter, we will take the Wenchuan Earthquake studies in China as an example to introduce current research results of PTSD and related mental disorders, their influencing factors and mechanisms, and intervention strategies in adolescents. The Wenchuan Earthquake is an 8.0-magnitude earthquake that struck Wenchuan County in China's south-western Sichuan Province on May 12, 2008. This massive disaster left 69,197 people dead, 374,176 injured, 18,222 listed as missing, and at least 4.8 million people were rendered homeless in the earthquake affected areas. Moreover, a number of subsequent earthquakes have ravaged south-western China during the years after the Wenchuan Earthquake. Since this earthquake, researchers in China have conducted a series of studies to examine the impacts of earthquake exposure on mental health development among Chinese children and adolescents. For example, Fan and his colleagues established the Wenchuan Earthquake Adolescents Health Cohort (WEAHC) [11], which is a 6-wave longitudinal study across 10 years in a cohort of 2250 adolescents exposed to this disaster. The WEAHC project examined longitudinal epidemiological characteristics of various disaster-related mental health disorders (i.e., PTSD, depression, anxiety, sleep disturbances, etc.), and collected psychological, familial, and genetic data with the aim of exploring potential etiologies of these disorders. In addition to the WEAHC project, other research teams have also conducted longitudinal investigations of child and adolescent earthquake survivors in China since 2008. All these studies have offered novel insights into the epidemiology, symptomology, related risk and proactive factors, and preventive and intervening measures for PTSD and comorbid disorders in Chinese children and adolescents. In this chapter, we will introduce important findings from the WEAHC study as well as these other studies.

Specific issues of this chapter are as follows: (1) assessment of post-traumatic stress disorder in children and adolescents; (2) epidemiological characteristics of PTSD among children and adolescents; (3) possible mechanisms for PTSD in children and adolescents; (4) post-traumatic growth; (5) psychological and pharmacological treatments for children and adolescents with PTSD.

#### **2. Assessment of post-traumatic stress disorder in children and adolescents**

There is consensus that core symptoms for the diagnosis of PTSD in children over the age of 7 years are almost similar to those used for adults. However, below this age (particularly below the age of 5 years), there is less agreement on the criteria for diagnosis. Nevertheless, trauma-affected symptoms in younger

**159**

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings*

children are gradually being identified, such as regression to immature behaviors (becoming more anxious and clingy, and having difficulty settling to sleep), aggression (becoming irritable, having temper tantrums, or displaying destructive behavior), repetitive reenactment in play or drawings, and nightmares may occur less frequently [12]. We also need to be able to identify children and adolescents

Children may not report their psychological reactions to the trauma unless they are specifically asked about aspects of trauma [13]. Due to cognitive immaturity, children may not be given the opportunities to talk about the event. Even having the opportunity, limited cognitive and expressive language skills of children may make it difficult to infer their thoughts and feelings smoothly. However, since parents and teachers have often been shown to be poor reporters of symptoms in children [2], directly asking the children about their symptoms is almost always

To date, more evaluation tools have been developed to evaluate the reactions and symptoms of children and adolescents exposed to traumatic events. The evaluation tools can be roughly divided into two categories: subjective instruments and (semi-)

Self-rating or other-rating (usually reported by parents or caregivers) scales are considered as effective tools for screening PTSD in children and adolescents, which can reflect the current stress response of the patient to a certain extent, and are

The Impact of Event Scale-Revised (IES-R) is a self-report measure of current subjective distress in response to a specific traumatic event [14]. Although originally developed for adults, this scale is useful to monitor post-traumatic stress symptoms as well as to track progress with interventions among individuals over the age of

IES-R is a revised version of the Impact of Event Scale [16], which consists of 22-item, with 3 core symptom clusters of PTSD: intrusion (8 items related to intrusive thoughts, nightmares, intrusive feelings, and imagery associated with the traumatic event), avoidance (8 items related to avoidance of feelings, situations, and ideas), and hyperarousal (6 items related to difficulty concentrating, anger and irritability, psychophysiological arousal upon exposure to reminders and hypervigilance). IES-R requests subjects to report on the degree of distress rather than the frequency of the symptoms and takes approximately 10 min to complete and score with no special training required to administer the questionnaire. It also

The Children's Revised Impact of Event Scale (CRIES-13) with good reliability and validity as well as a stable factors structure, is a brief child-friendly measure designed to screen children at risk for PTSD. It has been used to screen a large number of at-risk-children following multiple types of traumatic events [17]. According to the DSM criteria with 17 PTSD symptoms across three symptom clusters, CRIES revealed a three-factor solution corresponding to the intrusion (4 items), avoidance (4 items), and arousal (5 items) subscales. Higher scores reflect children's

convenient for large-scale use in the trauma-exposed population.

showed good reliability, validity, and sensitivity to change.

*2.1.2 The Children's Revised Impact of Event Scale, CRIES-13*

symptomatology as it relates to their functioning in different contexts.

*DOI: http://dx.doi.org/10.5772/intechopen.92284*

required.

7 years [15].

structured interview tools.

**2.1 Subjective instruments**

*2.1.1 Impact of Event Scale-Revised, IES-R*

#### *Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings DOI: http://dx.doi.org/10.5772/intechopen.92284*

children are gradually being identified, such as regression to immature behaviors (becoming more anxious and clingy, and having difficulty settling to sleep), aggression (becoming irritable, having temper tantrums, or displaying destructive behavior), repetitive reenactment in play or drawings, and nightmares may occur less frequently [12]. We also need to be able to identify children and adolescents symptomatology as it relates to their functioning in different contexts.

Children may not report their psychological reactions to the trauma unless they are specifically asked about aspects of trauma [13]. Due to cognitive immaturity, children may not be given the opportunities to talk about the event. Even having the opportunity, limited cognitive and expressive language skills of children may make it difficult to infer their thoughts and feelings smoothly. However, since parents and teachers have often been shown to be poor reporters of symptoms in children [2], directly asking the children about their symptoms is almost always required.

To date, more evaluation tools have been developed to evaluate the reactions and symptoms of children and adolescents exposed to traumatic events. The evaluation tools can be roughly divided into two categories: subjective instruments and (semi-) structured interview tools.

#### **2.1 Subjective instruments**

*Psychosomatic Medicine*

future life [10].

as these other studies.

**adolescents**

among children and adolescents depending upon the traumatic event itself, the severity and duration of exposure, and the child's demographic variables such as gender, age, and ethnicity. For example, rates of PTSD diagnosis are higher among girls, middle school children, and Hispanics [3–5]. Interpersonal traumas, such as sexual and physical assaults, are more likely to result in PTSD than exposure to natural or technological disasters [2, 6]. In addition, numerous psychological, family, and social factors such as parental mental status and, prolonged life disruption could also affect children and adolescents' post-trauma adaptation and recovery [7, 8]. Currently, PTSD is increasingly viewed as a potentially serious disorder in children and adolescents, because of not only the intense suffering it wreaks on young people, but also its adverse effects on biological, psychological, and social development [9]. Left untreated, PTSD can persist for years, increase the children's risk of developing other disorders, and impair their psychosocial functioning in

In this chapter, we will take the Wenchuan Earthquake studies in China as an example to introduce current research results of PTSD and related mental disorders, their influencing factors and mechanisms, and intervention strategies in adolescents. The Wenchuan Earthquake is an 8.0-magnitude earthquake that struck Wenchuan County in China's south-western Sichuan Province on May 12, 2008. This massive disaster left 69,197 people dead, 374,176 injured, 18,222 listed as missing, and at least 4.8 million people were rendered homeless in the earthquake affected areas. Moreover, a number of subsequent earthquakes have ravaged south-western China during the years after the Wenchuan Earthquake. Since this earthquake, researchers in China have conducted a series of studies to examine the impacts of earthquake exposure on mental health development among Chinese children and adolescents. For example, Fan and his colleagues established the Wenchuan Earthquake Adolescents Health Cohort (WEAHC) [11], which is a 6-wave longitudinal study across 10 years in a cohort of 2250 adolescents exposed to this disaster. The WEAHC project examined longitudinal epidemiological characteristics of various disaster-related mental health disorders (i.e., PTSD, depression, anxiety, sleep disturbances, etc.), and collected psychological, familial, and genetic data with the aim of exploring potential etiologies of these disorders. In addition to the WEAHC project, other research teams have also conducted longitudinal investigations of child and adolescent earthquake survivors in China since 2008. All these studies have offered novel insights into the epidemiology, symptomology, related risk and proactive factors, and preventive and intervening measures for PTSD and comorbid disorders in Chinese children and adolescents. In this chapter, we will introduce important findings from the WEAHC study as well

Specific issues of this chapter are as follows: (1) assessment of post-traumatic stress disorder in children and adolescents; (2) epidemiological characteristics of PTSD among children and adolescents; (3) possible mechanisms for PTSD in children and adolescents; (4) post-traumatic growth; (5) psychological and phar-

There is consensus that core symptoms for the diagnosis of PTSD in children

macological treatments for children and adolescents with PTSD.

**2. Assessment of post-traumatic stress disorder in children and** 

over the age of 7 years are almost similar to those used for adults. However, below this age (particularly below the age of 5 years), there is less agreement on the criteria for diagnosis. Nevertheless, trauma-affected symptoms in younger

**158**

Self-rating or other-rating (usually reported by parents or caregivers) scales are considered as effective tools for screening PTSD in children and adolescents, which can reflect the current stress response of the patient to a certain extent, and are convenient for large-scale use in the trauma-exposed population.

#### *2.1.1 Impact of Event Scale-Revised, IES-R*

The Impact of Event Scale-Revised (IES-R) is a self-report measure of current subjective distress in response to a specific traumatic event [14]. Although originally developed for adults, this scale is useful to monitor post-traumatic stress symptoms as well as to track progress with interventions among individuals over the age of 7 years [15].

IES-R is a revised version of the Impact of Event Scale [16], which consists of 22-item, with 3 core symptom clusters of PTSD: intrusion (8 items related to intrusive thoughts, nightmares, intrusive feelings, and imagery associated with the traumatic event), avoidance (8 items related to avoidance of feelings, situations, and ideas), and hyperarousal (6 items related to difficulty concentrating, anger and irritability, psychophysiological arousal upon exposure to reminders and hypervigilance). IES-R requests subjects to report on the degree of distress rather than the frequency of the symptoms and takes approximately 10 min to complete and score with no special training required to administer the questionnaire. It also showed good reliability, validity, and sensitivity to change.

#### *2.1.2 The Children's Revised Impact of Event Scale, CRIES-13*

The Children's Revised Impact of Event Scale (CRIES-13) with good reliability and validity as well as a stable factors structure, is a brief child-friendly measure designed to screen children at risk for PTSD. It has been used to screen a large number of at-risk-children following multiple types of traumatic events [17]. According to the DSM criteria with 17 PTSD symptoms across three symptom clusters, CRIES revealed a three-factor solution corresponding to the intrusion (4 items), avoidance (4 items), and arousal (5 items) subscales. Higher scores reflect children's

higher risk with PTSD. According to Smith et al. [18], the scores were related to the children's level of traumatic exposure, anxiety, and depression, as well as distress reported from mothers and teachers.

#### *2.1.3 Child PTSD Symptom Scale, CPSS*

The Child PTSD Symptom Scale [19] is a self-report measure of PTSD severity among 8–18 years old children, which is in accordance with the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV 4th ed. [20]). It seems well understood by children and is relatively quick for them to administer. The CPSS indexes the frequency of the 17 PTSD symptoms (DSM–IV), with each item rated on a 4-point Likert-type scale (0 = not at all, 1 = once a week or less, 2 = 2–4 times a week, 3 = 5 or more times per week). The impact of symptoms on daily function is also measured with seven dichotomously scored items that include aspects such as schoolwork and relationship with one's family [21].

The CPSS can be used as a continuous measure of symptom severity (ranging from 0 to 51), and a cutoff of 11 or above was found to have sensitivity of 95% and specificity of 96% [21]. Foa et al. [19] also reported that the 17 symptom items could be scored dichotomously to generate a DSM–IV consistent diagnosis of PTSD.

#### *2.1.4 The UCLA PTSD Reaction Index for DSM-IV, revision 1 (UCLA CPTSD-R*Ɪ*)*

In 1985, the UCLA PTSD Reaction Index, a screening questionnaire based on DSM diagnostic criteria to assess post-traumatic stress reactions among children and adolescents was developed by UCLA Trauma Psychiatry Program.

The UCLA PTSD-RI is a self-report instrument showing satisfactory reliability and validity [22–24], which has been used widely around the world for the measurement of childhood PTSD [25]. The 33-item scale contains two parts: (1) a section with 13 questions (scored dichotomously) that aligned with DSM-IV criterion A (the objective and subjective experiences and memories of the traumatic event); (2) a section with 20 questions map directly onto the DSM-IV criterion B (intrusion), criterion C (sense of "numbness" and avoidance), and criterion D (arousal) for PTSD, with each item scored from 0 (never or rarely) to 4 (most or all of the time).

#### **2.2 Structured and semi-structured diagnostic interview schedules**

These interview tools have strict implementation procedures, and must be used by professionals or strictly trained surveyors to objectively evaluate the subject's symptoms. Because these tools provide greater diagnostic reliability, they have become major assets in assessing treatment efficacy, epidemiological patterns of psychopathology, and the continuity and validity of psychiatric syndromes appearing in children and adolescents [26]. The contents of most of these interview schedules are generally symptom-based, but differ in format.

#### *2.2.1 The schedule for affective disorders and schizophrenia for school-age childrenpresent and lifetime version, K-SADS-PL*

K-SADS-PL is a semi-structured diagnostic interview schedule used by a child and adolescent psychiatry specialists to ascertain both lifetime and current status of mental illness in children and adolescents, which is DSM-IV compatible. It is formatted to interview both parents and children. Score sheet margin notations

**161**

25 to 75%.

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings*

are required if the worst current episode symptoms have resolved. This later information is needed to determine whether diagnostic criteria are still met for the disorder. Therefore, symptoms rated in the current episode may not be those that

*2.2.2 Mini international neuropsychiatric interview for children and adolescents,* 

MINI-KID is a structured clinical diagnostic interview designed to assess the presence of psychiatric disorders according to ICD-10 and DSM-IV criteria in children and adolescents aged 6–17 years without mental retardation. It is a brief but valid and reliable diagnostic instrument that can be used in clinical settings in psychiatry [27]. MINI-KID can be easily conducted by a trained surveyor, which allows it easy to be used in large-scale epidemiological investigations. MINI has been translated into over 40 different languages and validity and reliability have

When selecting the appropriate evaluation tool and formulating an evaluation

background, the familiarity of the tools and the objective conditions. The surveyors should first consider the purpose and object of the assessment. For example, a simple and reliable self-report questionnaire is more appropriate to use in large-scale epidemiological surveys, while a more comprehensive and diagnose assessment method seems more suitable for individual assessment. In the selection and planning of assessment tools, the following factors should be considered: the type and severity of trauma, the evaluation of risk and protective factors, the evaluation of children's social functions, the characteristics of children and adolescents' psychological development in different ages, assessments of parents' mental health. In addition, it should be noted that cultural differences may weaken

plan, the surveyors need to consider factors based on their own knowledge

**3. Epidemiological characteristics of PTSD among children and** 

Due to the lack of relatively mature investigative tools and ethical reasons, the epidemiological characteristics of PTSD in children and adolescents are less studied than that in adults, and research has been mostly focused on children or adolescents at an advanced age. Findings from earlier studies indicate that the prevalence of PTSD in children and adolescents is lower than in adults. But with the development of various survey tools and methods, more and more studies show that the prevalence of PTSD in children and adolescents is not lower than that in adults. In 2002, La Greca et al. [28] reviewed the prevalence of PTSD of children exposed to natural or man-made disasters, and found that 5–10% of the children meet the diagnostic criteria for PTSD. In other traumatic contexts, such as fires, sexual assaults and wars, surveys show that the prevalence of PTSD in children ranges from

After the 2008 Wenchuan Earthquake, a large number of studies have been done among child and adolescent earthquake survivors. As stated above, a representative research project is the WEAHC established by Fan et al. [11] in Dujiangyan City, one of the 10 worst affected areas by the Wenchuan Earthquake. A large sample of 2250 adolescents was enrolled in the initial survey conducted at 6 months post-earthquake. Among them, 1573 were followed-up subsequently at 12, 18, 24, and 30 months post-earthquake. Data were collected on adolescents' mental health problems (i.e.,

the child is experiencing at the time of the interview [26].

*DOI: http://dx.doi.org/10.5772/intechopen.92284*

been reported over 7 different languages [27].

*MINI-KID*

their original effects.

**adolescents**

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings DOI: http://dx.doi.org/10.5772/intechopen.92284*

are required if the worst current episode symptoms have resolved. This later information is needed to determine whether diagnostic criteria are still met for the disorder. Therefore, symptoms rated in the current episode may not be those that the child is experiencing at the time of the interview [26].

#### *2.2.2 Mini international neuropsychiatric interview for children and adolescents, MINI-KID*

MINI-KID is a structured clinical diagnostic interview designed to assess the presence of psychiatric disorders according to ICD-10 and DSM-IV criteria in children and adolescents aged 6–17 years without mental retardation. It is a brief but valid and reliable diagnostic instrument that can be used in clinical settings in psychiatry [27]. MINI-KID can be easily conducted by a trained surveyor, which allows it easy to be used in large-scale epidemiological investigations. MINI has been translated into over 40 different languages and validity and reliability have been reported over 7 different languages [27].

When selecting the appropriate evaluation tool and formulating an evaluation plan, the surveyors need to consider factors based on their own knowledge background, the familiarity of the tools and the objective conditions. The surveyors should first consider the purpose and object of the assessment. For example, a simple and reliable self-report questionnaire is more appropriate to use in large-scale epidemiological surveys, while a more comprehensive and diagnose assessment method seems more suitable for individual assessment. In the selection and planning of assessment tools, the following factors should be considered: the type and severity of trauma, the evaluation of risk and protective factors, the evaluation of children's social functions, the characteristics of children and adolescents' psychological development in different ages, assessments of parents' mental health. In addition, it should be noted that cultural differences may weaken their original effects.

#### **3. Epidemiological characteristics of PTSD among children and adolescents**

Due to the lack of relatively mature investigative tools and ethical reasons, the epidemiological characteristics of PTSD in children and adolescents are less studied than that in adults, and research has been mostly focused on children or adolescents at an advanced age. Findings from earlier studies indicate that the prevalence of PTSD in children and adolescents is lower than in adults. But with the development of various survey tools and methods, more and more studies show that the prevalence of PTSD in children and adolescents is not lower than that in adults. In 2002, La Greca et al. [28] reviewed the prevalence of PTSD of children exposed to natural or man-made disasters, and found that 5–10% of the children meet the diagnostic criteria for PTSD. In other traumatic contexts, such as fires, sexual assaults and wars, surveys show that the prevalence of PTSD in children ranges from 25 to 75%.

After the 2008 Wenchuan Earthquake, a large number of studies have been done among child and adolescent earthquake survivors. As stated above, a representative research project is the WEAHC established by Fan et al. [11] in Dujiangyan City, one of the 10 worst affected areas by the Wenchuan Earthquake. A large sample of 2250 adolescents was enrolled in the initial survey conducted at 6 months post-earthquake. Among them, 1573 were followed-up subsequently at 12, 18, 24, and 30 months post-earthquake. Data were collected on adolescents' mental health problems (i.e.,

*Psychosomatic Medicine*

*CPTSD-R*Ɪ*)*

of the time).

reported from mothers and teachers.

*2.1.3 Child PTSD Symptom Scale, CPSS*

higher risk with PTSD. According to Smith et al. [18], the scores were related to the children's level of traumatic exposure, anxiety, and depression, as well as distress

The Child PTSD Symptom Scale [19] is a self-report measure of PTSD severity among 8–18 years old children, which is in accordance with the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV 4th ed. [20]). It seems well understood by children and is relatively quick for them to administer. The CPSS indexes the frequency of the 17 PTSD symptoms (DSM–IV), with each item rated on a 4-point Likert-type scale (0 = not at all, 1 = once a week or less, 2 = 2–4 times a week, 3 = 5 or more times per week). The impact of symptoms on daily function is also measured with seven dichotomously scored items that include aspects such as schoolwork and relationship with one's family [21].

The CPSS can be used as a continuous measure of symptom severity (ranging from 0 to 51), and a cutoff of 11 or above was found to have sensitivity of 95% and specificity of 96% [21]. Foa et al. [19] also reported that the 17 symptom items could be scored dichotomously to generate a DSM–IV consistent diagnosis of PTSD.

In 1985, the UCLA PTSD Reaction Index, a screening questionnaire based on DSM diagnostic criteria to assess post-traumatic stress reactions among children

The UCLA PTSD-RI is a self-report instrument showing satisfactory reliability

These interview tools have strict implementation procedures, and must be used by professionals or strictly trained surveyors to objectively evaluate the subject's symptoms. Because these tools provide greater diagnostic reliability, they have become major assets in assessing treatment efficacy, epidemiological patterns of psychopathology, and the continuity and validity of psychiatric syndromes appearing in children and adolescents [26]. The contents of most of these interview

*2.2.1 The schedule for affective disorders and schizophrenia for school-age children-*

K-SADS-PL is a semi-structured diagnostic interview schedule used by a child and adolescent psychiatry specialists to ascertain both lifetime and current status of mental illness in children and adolescents, which is DSM-IV compatible. It is formatted to interview both parents and children. Score sheet margin notations

*2.1.4 The UCLA PTSD Reaction Index for DSM-IV, revision 1 (UCLA* 

and adolescents was developed by UCLA Trauma Psychiatry Program.

**2.2 Structured and semi-structured diagnostic interview schedules**

schedules are generally symptom-based, but differ in format.

*present and lifetime version, K-SADS-PL*

and validity [22–24], which has been used widely around the world for the measurement of childhood PTSD [25]. The 33-item scale contains two parts: (1) a section with 13 questions (scored dichotomously) that aligned with DSM-IV criterion A (the objective and subjective experiences and memories of the traumatic event); (2) a section with 20 questions map directly onto the DSM-IV criterion B (intrusion), criterion C (sense of "numbness" and avoidance), and criterion D (arousal) for PTSD, with each item scored from 0 (never or rarely) to 4 (most or all

**160**

PTSD, depression, anxiety, and sleep disturbances), earthquake-related stressors (i.e., earthquake exposure and negative life events post-earthquake), psychosocial and familial factors (e.g., trait resilience, coping styles, social support, and parenting styles), and behavioral/social functioning (e.g., prosocial behaviors and academic performance). Five years and a half after the earthquake (October and November 2013), another screening survey on mental health problems were conducted among 3501 adolescents (some were from the original cohort). Based on survey results, 512 adolescents were enrolled for individual clinical interviews and provided their oral mucosal samples for genetic analysis. Data from the WEAHC study provided great opportunity to investigate longitudinal epidemiological characteristics of mental disorders among Chinese adolescent earthquake survivors, as well as to explore the psychosocial and genetic mechanisms underlying these disorders. Aside from the WEAHC, longitudinal investigations of child and adolescent earthquake survivors have also been conducted by other research teams in China after 2008. Yet, many of them were limited by small sample sizes, few survey waves, or short follow-up duration. Regarding epidemiological characteristics of PTSD among child and adolescent earthquake survivors, some major findings from the WEAHC study and other studies are as follows.

First, the WEAHC study showed that prevalence estimates of probable PTSD were 21.0, 23.3, 13.5, and 14.7% at 6, 12, 18, and 24 months after the earthquake [11]. The rates tended to be higher at 12 and 24 months, suggesting an "anniversary reaction" in adolescents' post-earthquake mental adaptation process. This highlights the importance of providing adolescents with more intensive mental health support around the anniversary dates. In addition, the effects of trauma exposure in childhood can continue into adulthood. For example, data from Wenchuan Earthquake samples found that the prevalence of PTSD among the young adults 8.5 years later after they experienced the 2008 Wenchuan Earthquake was still as high as 4.75% [29].

Second, there are individual differences in the long-term change of PTSD symptoms among adolescent earthquake survivors. The WEAHC study observed five different patterns of the PTSD trajectories [30]: resistance (minimal or no symptoms over time, 65.3% of the sample), recovery (initially moderate/severe symptoms followed by a gradual return to pre-trauma functioning, 20.0%), relapsing/remitting (symptoms displaying a cyclical course, 3.3%), delayed dysfunction (initially minimal/no symptoms followed by elevated symptoms, 4.2%), and chronic dysfunction (moderate or severe symptoms over time, 7.2%). Different types of trajectories have their own characteristics, and those who show the latter three patterns are at high risk for PTSD. Post-disaster psychological intervention should focus on prevention, and it is necessary to identify high-risk populations to enhance the pertinence and effectiveness of the intervention.

Third, clinical presentations are exceedingly complex and children with PTSD are at increased risk of having comorbid psychiatric diagnoses. Depression and anxiety disorder have been reported to be common comorbid disorders associated with PTSD [31]. Consistent with previous studies based in western countries, research on the post-traumatic psychological consequences of adolescents after the Wenchuan Earthquake have also proved the prevalence of the comorbidity of PTSD and other mental disorders [32, 33]. One publication from the WEAHC study [34] examined the associations of adolescent survivors' PTSD symptoms, depression, generalized anxiety disorder (GAD), separation anxiety disorder (SAD), panic disorder, social phobia, conduct disorder, and attention deficit hyperactivity disorder (ADHD) at 1 and 1.5 years post-earthquake. Results showed that 91.9 and 94.0% of the adolescents with PTSD symptoms had at least one comorbid

**163**

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings*

psychiatric disorder at 1 and 1.5 years post-earthquake, respectively. 54.3 and 50.4% of those without PTSD symptoms had at least one other psychiatric disorder. Compare to behavior problems, PTSD symptoms were more likely to co-occur with subtypes of anxiety or depression symptoms. Adolescents who were identified as having PTSD comorbid with depression or SAD at half year were more likely to have PTSD symptoms over time. Longitudinal analyses showed that depression, GAD, and SAD symptoms at 1 year post-earthquake predicted higher levels of PTSD symptoms at 1.5 years post-earthquake. In turn, increased PTSD symptoms predicted increases in GAD and panic disorder symptoms. The reason of the high prevalence of PTSD and comorbid depression/anxiety may be due to the shared variance resulting from the overlapping symptoms between PTSD and other mental disorders [35]. These findings suggest that specific multi-modal assessments and treatments targeting both PTSD and its comorbid disorders are warranted.

Forth, different environmental and psychological factors have different impacts on post-traumatic adaptations among adolescents with different characteristics. For example, positive coping styles and social support resources have positive effect on post-traumatic adaptation [36], and adolescents with different characteristics (i.e., different ages) need to be trained with different coping skills to guide them in seeking and take good use of various social support resources. In addition, the predictive effects of environmental factors such as negative life events on the posttraumatic psychopathology of certain groups (such as those with high resilience) diminished over time. The design of post-traumatic mental disorder intervention strategies and mental health education efforts should consider the characteristics of different individuals, focus on individuals at high risk for continuing, relapsing or delayed mental symptoms, and fully consider various environmental/psychological

Finally, the occurrence of post-traumatic mental disorder shows familial

environmental factors have impact on adolescents' post-traumatic mental disorder. HPA axis-related genes and serotonin transporter genes have been evidenced to have a role in various stress-related physical and mental illnesses [37]. The WEAHC study examined the relationship between glucocorticoid receptor gene (NR3C1), one of the key genes involved in the HPA axis regulation, and anxiety disorders in adolescent earthquake survivors. NR3C1 polymorphisms rs6191 GG genotype, rs6196 AA genotype, and rs41423247 GG genotype were found associated with decreased risk of anxiety disorders. There was also a significant interaction between rs41423247 genotypes and maternal warmth in predicting adolescent anxiety disorders; that is, rs41423247 GG genotype was linked with reduced risk of anxiety disorders only when maternal warmth was high. In another case-control study conducted 3 years following the Wenchuan Earthquake, 183 adolescents with the average age of 15 years (64 adolescents diagnosed with PTSD and 119 controls) were investigated. The results showed that serotonin transporter gene polymorphisms (i.e., 5-HTTLPR and 5-HTTVNTR) and earthquake exposure had a significant interaction effects on PTSD of the adolescents. Specifically, when a teenager who carrying an S allele exposed to high level of earthquake exposure, he/she would have a fourfold increased risk in developing PTSD [38]. These findings highlight the importance of considering family and genetic variables in developing interventions. Exposure to traumatic events in early life may influence individuals' gene expression through epigenetic modification, which would have long-term and even lifetime effects on their physical and mental function in the future. Future research on the epigenetic mechanisms underlying the relationship between genetic etiologies, family factors

aggregation, and the interaction between susceptible genes and family

and adolescent PTSD is warranted, to further explore the disease etiology.

*DOI: http://dx.doi.org/10.5772/intechopen.92284*

factors in implementing targeted intervention.

#### *Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings DOI: http://dx.doi.org/10.5772/intechopen.92284*

psychiatric disorder at 1 and 1.5 years post-earthquake, respectively. 54.3 and 50.4% of those without PTSD symptoms had at least one other psychiatric disorder. Compare to behavior problems, PTSD symptoms were more likely to co-occur with subtypes of anxiety or depression symptoms. Adolescents who were identified as having PTSD comorbid with depression or SAD at half year were more likely to have PTSD symptoms over time. Longitudinal analyses showed that depression, GAD, and SAD symptoms at 1 year post-earthquake predicted higher levels of PTSD symptoms at 1.5 years post-earthquake. In turn, increased PTSD symptoms predicted increases in GAD and panic disorder symptoms. The reason of the high prevalence of PTSD and comorbid depression/anxiety may be due to the shared variance resulting from the overlapping symptoms between PTSD and other mental disorders [35]. These findings suggest that specific multi-modal assessments and treatments targeting both PTSD and its comorbid disorders are warranted.

Forth, different environmental and psychological factors have different impacts on post-traumatic adaptations among adolescents with different characteristics. For example, positive coping styles and social support resources have positive effect on post-traumatic adaptation [36], and adolescents with different characteristics (i.e., different ages) need to be trained with different coping skills to guide them in seeking and take good use of various social support resources. In addition, the predictive effects of environmental factors such as negative life events on the posttraumatic psychopathology of certain groups (such as those with high resilience) diminished over time. The design of post-traumatic mental disorder intervention strategies and mental health education efforts should consider the characteristics of different individuals, focus on individuals at high risk for continuing, relapsing or delayed mental symptoms, and fully consider various environmental/psychological factors in implementing targeted intervention.

Finally, the occurrence of post-traumatic mental disorder shows familial aggregation, and the interaction between susceptible genes and family environmental factors have impact on adolescents' post-traumatic mental disorder. HPA axis-related genes and serotonin transporter genes have been evidenced to have a role in various stress-related physical and mental illnesses [37]. The WEAHC study examined the relationship between glucocorticoid receptor gene (NR3C1), one of the key genes involved in the HPA axis regulation, and anxiety disorders in adolescent earthquake survivors. NR3C1 polymorphisms rs6191 GG genotype, rs6196 AA genotype, and rs41423247 GG genotype were found associated with decreased risk of anxiety disorders. There was also a significant interaction between rs41423247 genotypes and maternal warmth in predicting adolescent anxiety disorders; that is, rs41423247 GG genotype was linked with reduced risk of anxiety disorders only when maternal warmth was high. In another case-control study conducted 3 years following the Wenchuan Earthquake, 183 adolescents with the average age of 15 years (64 adolescents diagnosed with PTSD and 119 controls) were investigated. The results showed that serotonin transporter gene polymorphisms (i.e., 5-HTTLPR and 5-HTTVNTR) and earthquake exposure had a significant interaction effects on PTSD of the adolescents. Specifically, when a teenager who carrying an S allele exposed to high level of earthquake exposure, he/she would have a fourfold increased risk in developing PTSD [38]. These findings highlight the importance of considering family and genetic variables in developing interventions. Exposure to traumatic events in early life may influence individuals' gene expression through epigenetic modification, which would have long-term and even lifetime effects on their physical and mental function in the future. Future research on the epigenetic mechanisms underlying the relationship between genetic etiologies, family factors and adolescent PTSD is warranted, to further explore the disease etiology.

*Psychosomatic Medicine*

other studies are as follows.

was still as high as 4.75% [29].

PTSD, depression, anxiety, and sleep disturbances), earthquake-related stressors (i.e., earthquake exposure and negative life events post-earthquake), psychosocial and familial factors (e.g., trait resilience, coping styles, social support, and parenting styles), and behavioral/social functioning (e.g., prosocial behaviors and academic performance). Five years and a half after the earthquake (October and November 2013), another screening survey on mental health problems were conducted among 3501 adolescents (some were from the original cohort). Based on survey results, 512 adolescents were enrolled for individual clinical interviews and provided their oral mucosal samples for genetic analysis. Data from the WEAHC study provided great opportunity to investigate longitudinal epidemiological characteristics of mental disorders among Chinese adolescent earthquake survivors, as well as to explore the psychosocial and genetic mechanisms underlying these disorders. Aside from the WEAHC, longitudinal investigations of child and adolescent earthquake survivors have also been conducted by other research teams in China after 2008. Yet, many of them were limited by small sample sizes, few survey waves, or short follow-up duration. Regarding epidemiological characteristics of PTSD among child and adolescent earthquake survivors, some major findings from the WEAHC study and

First, the WEAHC study showed that prevalence estimates of probable PTSD were 21.0, 23.3, 13.5, and 14.7% at 6, 12, 18, and 24 months after the earthquake [11]. The rates tended to be higher at 12 and 24 months, suggesting an "anniversary

reaction" in adolescents' post-earthquake mental adaptation process. This highlights the importance of providing adolescents with more intensive mental health support around the anniversary dates. In addition, the effects of trauma exposure in childhood can continue into adulthood. For example, data from Wenchuan Earthquake samples found that the prevalence of PTSD among the young adults 8.5 years later after they experienced the 2008 Wenchuan Earthquake

Second, there are individual differences in the long-term change of PTSD symptoms among adolescent earthquake survivors. The WEAHC study observed five different patterns of the PTSD trajectories [30]: resistance (minimal or no symptoms over time, 65.3% of the sample), recovery (initially moderate/severe symptoms followed by a gradual return to pre-trauma functioning, 20.0%), relapsing/remitting (symptoms displaying a cyclical course, 3.3%), delayed dysfunction (initially minimal/no symptoms followed by elevated symptoms, 4.2%), and chronic dysfunction (moderate or severe symptoms over time, 7.2%). Different types of trajectories have their own characteristics, and those who show the latter three patterns are at high risk for PTSD. Post-disaster psychological intervention should focus on prevention, and it is necessary to identify high-risk populations to enhance the pertinence and effectiveness of the intervention.

Third, clinical presentations are exceedingly complex and children with PTSD are at increased risk of having comorbid psychiatric diagnoses. Depression and anxiety disorder have been reported to be common comorbid disorders associated with PTSD [31]. Consistent with previous studies based in western countries, research on the post-traumatic psychological consequences of adolescents after the Wenchuan Earthquake have also proved the prevalence of the comorbidity of PTSD and other mental disorders [32, 33]. One publication from the WEAHC study [34] examined the associations of adolescent survivors' PTSD symptoms, depression, generalized anxiety disorder (GAD), separation anxiety disorder (SAD), panic disorder, social phobia, conduct disorder, and attention deficit hyperactivity disorder (ADHD) at 1 and 1.5 years post-earthquake. Results showed that 91.9 and 94.0% of the adolescents with PTSD symptoms had at least one comorbid

**162**

### **4. Possible mechanisms for PTSD in children and adolescents**

#### **4.1 Biological factors**

#### *4.1.1 Genetic factors*

Studies have shown that the occurrence of PTSD may be associated with genetic susceptibility. Xian et al. [39] assessed 3304 monozygotic and dizygotic male-male twin pair members with PTSD and found that genetic factors have an impact on all PTSD symptoms. On one hand, stress can induce the abnormal expression of cognition and neuroendocrine related genes, which eventually leads to the occurrence of PTSD. For example, abnormal expression of Corticosterone-related genes may cause PTSD. On the other hand, the development of PTSD may be related to gene polymorphism. At present, most candidate genes for PTSD are located in dopamine system and serotonin system. For example, a meta-analysis showed that 5-hydroxytryptaminentransporter (5-HTT) gene polymorphism is closely related to post-stress affective disorder. In addition, glucocorticoid receptor genes, GABA-A receptors, BDNF genes et al. have been reported to be related to PTSD. It is worth noting that the pathogenic genes of neuropsychiatric diseases are pleiotropic, that is, one genotype can be susceptible to several different mental diseases. Pleiotropy is clearly manifested in PTSD. For example, the incidence of anxiety and affective disorders in patients with PTSD is much higher than that in the general population. Finally, PTSD is often comorbid with many mental illnesses, such as depression and suicidal tendencies, which made its clinical features complex and diverse. As a result, the homogeneity of the research sample decreases, which further increases the difficulty of genetic research.

#### *4.1.2 Neuroendocrine changes*

The role of HPA axis dysfunction in the pathogenesis of PTSD in adults has been extensively researched and explained. Previous studies have found that cortisol levels decreased in adult patients with PTSD, which could also predict the patients' PTSD level after 6 months [40]. Low cortisol levels may strengthen the memory of traumatic events and increase individuals' subjective distressing experience. This kind of distressing experience can change individual's psychological functioning, delay their recovery and increase their adverse reactions, which may affect the ability of the victim to cope with traumatic experience, and in turn, lead to the occurrence of PTSD. However, Lipschitz et al. [41] found that the suppression of salivary cortisol following low-dose dexamethasone in adolescent PTSD patients showed no difference from those who experienced traumatic events without PTSD and healthy non-traumatized controls, while PTSD subjects with co-occurring depression showed higher salivary cortisol level before and after this experiment compared to controls.

#### *4.1.3 Neuroimaging findings*

Brain is a human organ that processes emotions and thoughts. Evidence has identified the changes in brain imaging among adults with PTSD. However, due to immature neurodevelopment, it is thought that the brain changes of children and adolescents with PTSD may be different from those in adults. We reviewed the current neuroimaging findings in children and adolescents and summarize the main findings below:

**165**

exposure and PTSD [47].

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings*

to PTSD and cognitive impairment caused by PTSD.

II.Hippocampus and memory, behavioral abnormalities: A series of

between hippocampus and memory among young PTSD subjects. This study found that during a verbal memory task, the activation of the right hippocampus of the children decreased; while children's avoidance and numbing symptoms was related to reduced activation of the left hippocampus [44]. It's worth noting that, most of these studies were cross-sectional design, future longitudinal study studies with neuropsychological measures as well as trauma control subjects are needed to clarify the role of hippocampal functioning in the development

Mass disasters such as natural disasters, large-scale human-induced accidents,

spree shootings, war and terrorism, all have been shown to exert deleterious impacts on children and adolescents. The level of exposure also has consistently been associated with later post-traumatic stress reactions following various types of trauma [45]. These distinctions are likely to result in different effects. For example, many studies conducted after Wenchuan Earthquake all reported that different levels of earthquake exposure level could positively predict adolescents' PTSD at

In addition, the severity of disaster exposure includes objective exposure level (e.g., direct exposure such as death, disappearance and/or injury of family members, house damage, property loss and direct witness of traumatic events) and the severity of subjective fear. Studies examining the impact of trauma exposure on PTSD have found that PTSD is more directly affected by objective exposure, and social support plays a moderating role in the relationship between objective

of PTSD in children and adolescents.

*4.2.1 Trauma type and traumatic exposure level*

different time points post-earthquake [32, 46].

**4.2 Sociopsychological factors**

studies in children and adolescents with PTSD and PTSS have reported inconsistent findings within the hippocampal volumetric and memory as well as behavioral abnormalities. For example, a longitudinal study found that the severity of PTSS and corticosteroid levels can serve as independent predictors of children's hippocampal volume reductions 1 year later [42]. However, De Bellis [43] found that the hippocampal volume of children with PTSD was significantly larger compared to normal controls. In addition, this study also found that hippocampal volume was positively correlated with age at onset of PTSD. Therefore, the researchers hypothesized that the increase in hippocampal volume may be related to behavioral abnormalities such as attention impairment in children with PTSD [43]. Another fMRI study reported the relationship

I.Prefrontal cortex and cognitive impairment: A study conducted by Carrion in 2010 found that in children with PTSD, the decrease in the volume of the left prefrontal cortex was related to their plasma cortisol levels before bed, suggesting that this area may be related to cortisol imbalance in children. In the study of functional magnetic resonance imaging (fMRI), it was found that the key areas of the prefrontal cortex of children with PTSD could not reach the activation level of children of normal age when performing cognitive functions. The above studies suggest that changes in the structure and function of the prefrontal cortex may be related to children's susceptibility

*DOI: http://dx.doi.org/10.5772/intechopen.92284*

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings DOI: http://dx.doi.org/10.5772/intechopen.92284*


#### **4.2 Sociopsychological factors**

#### *4.2.1 Trauma type and traumatic exposure level*

Mass disasters such as natural disasters, large-scale human-induced accidents, spree shootings, war and terrorism, all have been shown to exert deleterious impacts on children and adolescents. The level of exposure also has consistently been associated with later post-traumatic stress reactions following various types of trauma [45]. These distinctions are likely to result in different effects. For example, many studies conducted after Wenchuan Earthquake all reported that different levels of earthquake exposure level could positively predict adolescents' PTSD at different time points post-earthquake [32, 46].

In addition, the severity of disaster exposure includes objective exposure level (e.g., direct exposure such as death, disappearance and/or injury of family members, house damage, property loss and direct witness of traumatic events) and the severity of subjective fear. Studies examining the impact of trauma exposure on PTSD have found that PTSD is more directly affected by objective exposure, and social support plays a moderating role in the relationship between objective exposure and PTSD [47].

*Psychosomatic Medicine*

**4.1 Biological factors**

increases the difficulty of genetic research.

*4.1.2 Neuroendocrine changes*

compared to controls.

*4.1.3 Neuroimaging findings*

*4.1.1 Genetic factors*

**4. Possible mechanisms for PTSD in children and adolescents**

Studies have shown that the occurrence of PTSD may be associated with genetic susceptibility. Xian et al. [39] assessed 3304 monozygotic and dizygotic male-male twin pair members with PTSD and found that genetic factors have an impact on all PTSD symptoms. On one hand, stress can induce the abnormal expression of cognition and neuroendocrine related genes, which eventually leads to the occurrence of PTSD. For example, abnormal expression of Corticosterone-related genes may cause PTSD. On the other hand, the development of PTSD may be related to gene polymorphism. At present, most candidate genes for PTSD are located in dopamine system and serotonin system. For example, a meta-analysis showed that 5-hydroxytryptaminentransporter (5-HTT) gene polymorphism is closely related to post-stress affective disorder. In addition, glucocorticoid receptor genes, GABA-A receptors, BDNF genes et al. have been reported to be related to PTSD. It is worth noting that the pathogenic genes of neuropsychiatric diseases are pleiotropic, that is, one genotype can be susceptible to several different mental diseases. Pleiotropy is clearly manifested in PTSD. For example, the incidence of anxiety and affective disorders in patients with PTSD is much higher than that in the general population. Finally, PTSD is often comorbid with many mental illnesses, such as depression and suicidal tendencies, which made its clinical features complex and diverse. As a result, the homogeneity of the research sample decreases, which further

The role of HPA axis dysfunction in the pathogenesis of PTSD in adults has been

extensively researched and explained. Previous studies have found that cortisol levels decreased in adult patients with PTSD, which could also predict the patients' PTSD level after 6 months [40]. Low cortisol levels may strengthen the memory of traumatic events and increase individuals' subjective distressing experience. This kind of distressing experience can change individual's psychological functioning, delay their recovery and increase their adverse reactions, which may affect the ability of the victim to cope with traumatic experience, and in turn, lead to the occurrence of PTSD. However, Lipschitz et al. [41] found that the suppression of salivary cortisol following low-dose dexamethasone in adolescent PTSD patients showed no difference from those who experienced traumatic events without PTSD and healthy non-traumatized controls, while PTSD subjects with co-occurring depression showed higher salivary cortisol level before and after this experiment

Brain is a human organ that processes emotions and thoughts. Evidence has identified the changes in brain imaging among adults with PTSD. However, due to immature neurodevelopment, it is thought that the brain changes of children and adolescents with PTSD may be different from those in adults. We reviewed the current neuroimaging findings in children and adolescents and summarize the main

**164**

findings below:

#### *4.2.2 Personality characteristics*

Studies have shown that children and adolescents' negative personality characteristics are associated with their PTSD symptoms. For example, it was reported that neuroticism was significantly related to PTSD, and emotionoriented coping partly mediated the effect of neuroticism on PTSD symptoms [48]. Extraversion was reported to have significant indirect effects on both PTSD and post-traumatic growth through social support [49]. Further, An et al. [50] longitudinally investigated the contribution of personality in the development of PTSD and found that neuroticism was an independent and significant predictor of subsequent PTSD. In addition, gratitude was reported to be a protective factor of relieving PTSD symptoms [51].

#### *4.2.3 Cognitive models*

PTSD is thought to be maintained by a range of cognitive and behavioral strategies that the individual uses to control the current threat [52]. At an early stage of a traumatic event, children and adolescents' cognitive reconstruction of the disaster and the reorganization of post-traumatic broken memory all influence the occurrence of PTSD [53]. Their problematic appraisals of the trauma and/or its aftermath are also considered to increase the risk of developing PTSD. Dunmore et al. [54] found that cognitive processing style during assault (mental defeat, mental confusion, detachment); appraisal of assault sequelae (appraisal of symptoms, perceived negative responses of others, permanent change); negative beliefs about self and world; and maladaptive control strategies (avoidance/safety seeking) could significantly predict PTSD in the 9 months follow-up. Thus, misunderstanding of traumatic events can lead to secondary trauma.

#### *4.2.4 Social support*

Social support is a robust protective factor for post-traumatic mental health [55]. Supportive social environment can not only provide individuals with necessary coping resources, but also provide them with a safe environment, reduce their experience of subsequent negative life events, and encourage them to think positively about traumatic events, thereby helping to reduce the negative impact of traumatic events on individuals and promote positive changes after trauma. Much literature on adolescent exposure to Wenchuan Earthquake also suggested the positive protective effect of social support on alleviating PTSD. For example, Zhao et al. [56] found that social support (both subjective support and support availability) improved the quality of life of the earthquake survivors with PTSD symptoms. Moreover, Wu et al. reported that among all the social support resources, the support of parents and teachers is the most important [47].

#### *4.2.5 Age and gender*

There are gender differences in children and adolescent's defense and coping styles, as well as the effects of social support, which have important influence on their post-traumatic reactions. Many studies have found that girls are more likely to have PTSD symptoms than boys following disasters [30, 33, 57]. Generally, female more often use strategies such as repression and fantasy to deal with traumatic events [58]. Second, there are also gender differences in the neuroendocrine

**167**

to PTSD.

**Wenchuan Earthquake**

of PTSD.

*4.2.6 Family factors*

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings*

reaction caused by trauma. Girls have more adverse physical and psychological reactions after trauma, which may further aggravate girls' PTSD symptoms [59]. Children's experience of danger, their perception and understanding of trauma, susceptibility to parental distress, own coping styles and skills, and memory of trauma may vary with ages. Most studies suggest a positive relationship between PTSD and children's age after the earthquake [30]. However, another study reported that at 1 month after the earthquake, the incidence of PTSD in survivors under 15 years of age was significantly higher than that in survivors over 15 years [60]. Age differences are also shown in children's experience of specific post-traumatic symptoms and previous studies results are mixed. For preschool children, they may display more overt aggression and destructiveness as well as behavioral re-enactments of the traumatic event. While, the reactions of children over the age of 8–10 years, are more similar to those manifested by adults [61]. Inconsistent research conclusions may be related to differences in stressors, study criteria, measurement and distance from stressors. For example, a study of earthquake reported that there was an interaction between age and distance from the epicenter, younger children in areas closer to the epicenter showed severer PTSD symptoms while older children in areas far away from the epicenter showed severer PTSD symptoms [62]. The reason may be that in areas far away from the epicenter, older children are more likely to follow media coverage of the earthquake and experience alternative trauma; younger children are more susceptible to direct trauma exposure. All these current explanations are tentative and should be interpreted cautiously, also, future studies are suggested to further illustrate these possible explanations and explain with caution due to the complex nature

Family environmental factors (e.g., poor parent-child relationship and family adversity) are risk factors that accelerate PTSD. In addition, as family members sometimes encounter a disaster simultaneously, children's and parents' postdisaster symptoms can be highly interactive [63, 64]. Parents' response after the trauma event affects children's judgment of the event, and their coping styles are imitated by children. In addition, given mothers are primary caregivers of children, maternal poor psychological states, continued focus on the disaster event, or changes in family support could be a risk factor for children's posttraumatic symptoms. Moreover, some studies also suggest that the incidence of PTSD is substantially related to genetic factors. Xian et al. [39] investigated 3304 monozygotic and dizygotic male–male twin pair subjects to examine whether and to what degree genetic and environmental contributed to PTSD. The results showed that genetic and family environmental factors have influence on all PTSD symptoms, the liability for PTSD being 20.0% due to genetic contribution specific

**5. Post-traumatic growth among children and adolescents exposed to** 

PTSD is a prevalent psychiatric disorder in adolescents after traumatic events. However, researchers found personal growth in the aftermath of traumatic events [65, 66]. Tedeschi and Calhoun [67] used the term post-traumatic growth (PTG) to describe these positive outcomes after struggling with a traumatic experience. Dimensions of PTG encompass recognition and elaboration of personal strengths,

*DOI: http://dx.doi.org/10.5772/intechopen.92284*

#### *Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings DOI: http://dx.doi.org/10.5772/intechopen.92284*

reaction caused by trauma. Girls have more adverse physical and psychological reactions after trauma, which may further aggravate girls' PTSD symptoms [59].

Children's experience of danger, their perception and understanding of trauma, susceptibility to parental distress, own coping styles and skills, and memory of trauma may vary with ages. Most studies suggest a positive relationship between PTSD and children's age after the earthquake [30]. However, another study reported that at 1 month after the earthquake, the incidence of PTSD in survivors under 15 years of age was significantly higher than that in survivors over 15 years [60]. Age differences are also shown in children's experience of specific post-traumatic symptoms and previous studies results are mixed. For preschool children, they may display more overt aggression and destructiveness as well as behavioral re-enactments of the traumatic event. While, the reactions of children over the age of 8–10 years, are more similar to those manifested by adults [61]. Inconsistent research conclusions may be related to differences in stressors, study criteria, measurement and distance from stressors. For example, a study of earthquake reported that there was an interaction between age and distance from the epicenter, younger children in areas closer to the epicenter showed severer PTSD symptoms while older children in areas far away from the epicenter showed severer PTSD symptoms [62]. The reason may be that in areas far away from the epicenter, older children are more likely to follow media coverage of the earthquake and experience alternative trauma; younger children are more susceptible to direct trauma exposure. All these current explanations are tentative and should be interpreted cautiously, also, future studies are suggested to further illustrate these possible explanations and explain with caution due to the complex nature of PTSD.

#### *4.2.6 Family factors*

*Psychosomatic Medicine*

*4.2.2 Personality characteristics*

relieving PTSD symptoms [51].

*4.2.3 Cognitive models*

trauma.

*4.2.4 Social support*

important [47].

*4.2.5 Age and gender*

Studies have shown that children and adolescents' negative personality characteristics are associated with their PTSD symptoms. For example, it was reported that neuroticism was significantly related to PTSD, and emotionoriented coping partly mediated the effect of neuroticism on PTSD symptoms [48]. Extraversion was reported to have significant indirect effects on both PTSD and post-traumatic growth through social support [49]. Further, An et al. [50] longitudinally investigated the contribution of personality in the development of PTSD and found that neuroticism was an independent and significant predictor of subsequent PTSD. In addition, gratitude was reported to be a protective factor of

PTSD is thought to be maintained by a range of cognitive and behavioral strategies that the individual uses to control the current threat [52]. At an early stage of a traumatic event, children and adolescents' cognitive reconstruction of the disaster and the reorganization of post-traumatic broken memory all influence the occurrence of PTSD [53]. Their problematic appraisals of the trauma and/or its aftermath are also considered to increase the risk of developing PTSD. Dunmore et al. [54] found that cognitive processing style during assault (mental defeat, mental confusion, detachment); appraisal of assault sequelae (appraisal of symptoms, perceived negative responses of others, permanent change); negative beliefs about self and world; and maladaptive control strategies (avoidance/safety seeking) could significantly predict PTSD in the 9 months follow-up. Thus, misunderstanding of traumatic events can lead to secondary

Social support is a robust protective factor for post-traumatic mental health

There are gender differences in children and adolescent's defense and coping styles, as well as the effects of social support, which have important influence on their post-traumatic reactions. Many studies have found that girls are more likely to have PTSD symptoms than boys following disasters [30, 33, 57]. Generally, female more often use strategies such as repression and fantasy to deal with traumatic events [58]. Second, there are also gender differences in the neuroendocrine

[55]. Supportive social environment can not only provide individuals with necessary coping resources, but also provide them with a safe environment, reduce their experience of subsequent negative life events, and encourage them to think positively about traumatic events, thereby helping to reduce the negative impact of traumatic events on individuals and promote positive changes after trauma. Much literature on adolescent exposure to Wenchuan Earthquake also suggested the positive protective effect of social support on alleviating PTSD. For example, Zhao et al. [56] found that social support (both subjective support and support availability) improved the quality of life of the earthquake survivors with PTSD symptoms. Moreover, Wu et al. reported that among all the social support resources, the support of parents and teachers is the most

**166**

Family environmental factors (e.g., poor parent-child relationship and family adversity) are risk factors that accelerate PTSD. In addition, as family members sometimes encounter a disaster simultaneously, children's and parents' postdisaster symptoms can be highly interactive [63, 64]. Parents' response after the trauma event affects children's judgment of the event, and their coping styles are imitated by children. In addition, given mothers are primary caregivers of children, maternal poor psychological states, continued focus on the disaster event, or changes in family support could be a risk factor for children's posttraumatic symptoms. Moreover, some studies also suggest that the incidence of PTSD is substantially related to genetic factors. Xian et al. [39] investigated 3304 monozygotic and dizygotic male–male twin pair subjects to examine whether and to what degree genetic and environmental contributed to PTSD. The results showed that genetic and family environmental factors have influence on all PTSD symptoms, the liability for PTSD being 20.0% due to genetic contribution specific to PTSD.

#### **5. Post-traumatic growth among children and adolescents exposed to Wenchuan Earthquake**

PTSD is a prevalent psychiatric disorder in adolescents after traumatic events. However, researchers found personal growth in the aftermath of traumatic events [65, 66]. Tedeschi and Calhoun [67] used the term post-traumatic growth (PTG) to describe these positive outcomes after struggling with a traumatic experience. Dimensions of PTG encompass recognition and elaboration of personal strengths, enhanced interpersonal relationships, and positive changes in life priorities [68]. Prior studies revealed that survivors may develop PTG in spite of different types of traumatic events [69, 70]. For example, Jin et al. [71] found that the PTG prevalence among adolescents after the earthquake was even up to 51.1%.

Take the trends of PTG in Chinese adolescent sample as example. One study found that the average PTG was 2.96 (ranging from 0 to 5) among adolescents 1 year after the Wenchuan Earthquake, suggesting the relative high level of PTG among adolescent survivors. Further analysis found that PTG in this time showed significant difference in gender (female was higher than that of male) and, insignificant difference was found in grades. However, a decreased tendency of PTG (average mean = 2.77) after 2.5 years was observed in Wenchuan Earthquake [72].

After 3.5 years of Wenchuan Earthquake, the average of PTG was 2.78, and there were significant differences in gender and grades. Specifically, female had higher PTG than male, and junior students was lower than that of senior students [73]. This research group followed the development of PTG among this adolescent sample, and found the average of PTG was 2.68 after 4.5 years earthquake. Further analysis of the results at 8.5 years after the earthquake were similar to 3.5 years after the earthquake, with average mean was 2.80, a higher female and ethnic minorities level of PTG than that of male and Chinese Han population (the majority ethnic of the Chinese population), and lower levels of PTG among junior students than that among senior students [29].

The relationship between PTSD and PTG has been one of the interested areas among researchers. A review of 77 papers showed that the relationship was ambiguous [74]. The particular reason that accounts for this unclear relationship is that most studies employed cross-sectional rather than longitudinal designs, making it impossible for us to establish a definitive causal relationship. Some study of Wenchuan Earthquake examined the longitudinal relationships between PTSD and PTG among adolescents. A three-wave, cross-lagged study found that PTSD reported at 3.5 and 4.5 years after the earthquake both could predicted PTG 4.5 and 5.5 years after the earthquake, respectively, while PTG did not predict PTSD during the 3 years follow-up. This study suggests that, after exposure to traumatic events, PTSD and PTG can coexist in individuals, and the relieved PTSD symptoms do not indicate the improvement of PTG [75]. This relationship between PTSD and PTG may be because that cognitive pathways to PTSD and PTG is different. For example, deliberate rumination leads to PTG whereas intrusive rumination elicits PTSD in a long time after trauma [76].

From previous mentioned studies, the PTG level of adolescents was highest at 1 year after the earthquake, and although it has declined slightly since then, it has remained at a high level for a long time. That phenomenon could be explained that traumatic events like the earthquake might bring psychological stresses, and it is this stresses that may encourage adolescent survivors to use positive coping ways to overcome the negative outcomes because of traumatic events. During this coping process, having a new interpretation and understanding of traumatic events may help adolescents achieve personal growth. As the negative effects of traumatic events on individuals decreased when time passes, therefore, this decreased situation not only eases the stresses of traumatic events, but also reduces the incentive for individuals to implement PTG. Meanwhile, female may be better than male to develop PTG and senior survivors may be more likely to develop PTG than junior students. Moreover, the racial disparities in PTG level suggest that cultural factors may need to be consider in PTG research. Together, all these suggest that the relationships between gender and PTG is stable over time, the same result was observed when grade differences were considered.

**169**

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings*

Young people with PTSD may suffer from major depression, aggression, and conduct disorder [77, 78]. They may also be more likely to have suicidal ideation and attempts [79]. Left untreated, PTSD can lead to negative effects on sufferers' adulthood, such as college drop-out [80] and lower quality of life [81]. The National Child Traumatic Stress Network (NCTSN) suggests that trauma treatments should not only help children receive timely and appropriate treatments to recover from traumatic events but also build their resilience to cope with future stress more successfully. Hence, the identification of high-risk children and adolescents and providing them with appropriate and timely treatments are essential and

Currently, the number of treatment models for PTSD has proliferated. The first-line treatments encompass trauma-focused CBT (i.e., TF-CBT) [82, 83] and Prolonged Exposure for Adolescents (i.e, PE-A) [84]. Traditionally, components of treatments include: psychoeducation about PTSD, affective modulation and cognitive processing, behavioral activation, relaxation skills, trauma narrative, in vivo mastery of trauma reminders, conjoint parent-child sessions, and future safety and development [85, 86]. Furthermore, cognitive behavioral interventions for trauma in schools (CBITS) [87, 88] and trauma and grief component therapy for adolescents (TGCT) [89] are also welcomed as efficient ways to treat traumatized youths mainly due to available resources of schools. Eye Movement Desensitization and Reprocessing (EMDR), using dual-stimulation exercises to lower emotional arousal of the traumatic triggers [90], is evidenced as a promising method for youths with PTSD [91, 92]. Given the various and effective aspects of intervention, different treatments can be employed as a combination to gain a superior result. For example, TF-CBT combined with supportive therapy and a psychodynamic form (.i.e., play therapy) showed a better result [93]. Though it is true that forms of treatments have made progress, they are subject to some drawbacks such as high drop-out rates [94–96]. It is mainly because the nature of trauma symptoms (especially avoidance) leads participants to be unwilling to address the traumatic event directly and reprocess the details of their suffering [97]. It is therefore

difficult to see the long-term efficacy and benefits of treatments if participants have

as "third-wave" cognitive behavioral treatments, were proposed to solve this high drop-out problem. Mindfulness is characterized by paying attention to one's experience in the present moment in a non-judgmental manner [98]. There are some theoretical reasons to explain the potential mechanisms why mindfulness may reduce PTSD. Mindfulness interventions can help the sufferers to improve the ability to distinguish the past and present, so as to lower the re-experiencing symptoms [99] of post-traumatic stress disorder. In addition, increasing sufferers' capability to tolerate distressing memories, thoughts, and feelings when employing mindfulness interventions may be more likely to reduce avoidance of distressing memories [100]. Furthermore, hyperarousal of PTSD could decrease because of the training in stress reduction and relaxation [101]. Within MBIs, Mindfulnessbased stress reduction (MBSR) and Mindfulness-based cognitive therapy (MBCT) were widely cited in the background of MBIs. Compared with trauma-focused therapies, MBIs showed equally efficacious and significantly lower drop-out rate [102], and were well-accepted for PTSD treatments of youths [103]. Despite the

Unlike traditional CBT interventions, mindfulness-based interventions (MBIs),

**6. Treatments for children and adolescents with post-traumatic** 

*DOI: http://dx.doi.org/10.5772/intechopen.92284*

**stress disorder**

imperative.

poor adherence.

**6.1 Psychological treatments**

#### **6. Treatments for children and adolescents with post-traumatic stress disorder**

#### **6.1 Psychological treatments**

*Psychosomatic Medicine*

among senior students [29].

long time after trauma [76].

grade differences were considered.

enhanced interpersonal relationships, and positive changes in life priorities [68]. Prior studies revealed that survivors may develop PTG in spite of different types of traumatic events [69, 70]. For example, Jin et al. [71] found that the PTG prevalence

Take the trends of PTG in Chinese adolescent sample as example. One study found that the average PTG was 2.96 (ranging from 0 to 5) among adolescents 1 year after the Wenchuan Earthquake, suggesting the relative high level of PTG among adolescent survivors. Further analysis found that PTG in this time showed significant difference in gender (female was higher than that of male) and,

insignificant difference was found in grades. However, a decreased tendency of PTG (average mean = 2.77) after 2.5 years was observed in Wenchuan Earthquake [72]. After 3.5 years of Wenchuan Earthquake, the average of PTG was 2.78, and there were significant differences in gender and grades. Specifically, female had higher PTG than male, and junior students was lower than that of senior students [73]. This research group followed the development of PTG among this adolescent sample, and found the average of PTG was 2.68 after 4.5 years earthquake. Further analysis of the results at 8.5 years after the earthquake were similar to 3.5 years after the earthquake, with average mean was 2.80, a higher female and ethnic minorities level of PTG than that of male and Chinese Han population (the majority ethnic of the Chinese population), and lower levels of PTG among junior students than that

The relationship between PTSD and PTG has been one of the interested areas among researchers. A review of 77 papers showed that the relationship was ambiguous [74]. The particular reason that accounts for this unclear relationship is that most studies employed cross-sectional rather than longitudinal designs, making it impossible for us to establish a definitive causal relationship. Some study of Wenchuan Earthquake examined the longitudinal relationships between PTSD and PTG among adolescents. A three-wave, cross-lagged study found that PTSD reported at 3.5 and 4.5 years after the earthquake both could predicted PTG 4.5 and 5.5 years after the earthquake, respectively, while PTG did not predict PTSD during the 3 years follow-up. This study suggests that, after exposure to traumatic events, PTSD and PTG can coexist in individuals, and the relieved PTSD symptoms do not indicate the improvement of PTG [75]. This relationship between PTSD and PTG may be because that cognitive pathways to PTSD and PTG is different. For example, deliberate rumination leads to PTG whereas intrusive rumination elicits PTSD in a

From previous mentioned studies, the PTG level of adolescents was highest at 1 year after the earthquake, and although it has declined slightly since then, it has remained at a high level for a long time. That phenomenon could be explained that traumatic events like the earthquake might bring psychological stresses, and it is this stresses that may encourage adolescent survivors to use positive coping ways to overcome the negative outcomes because of traumatic events. During this coping process, having a new interpretation and understanding of traumatic events may help adolescents achieve personal growth. As the negative effects of traumatic events on individuals decreased when time passes, therefore, this decreased situation not only eases the stresses of traumatic events, but also reduces the incentive for individuals to implement PTG. Meanwhile, female may be better than male to develop PTG and senior survivors may be more likely to develop PTG than junior students. Moreover, the racial disparities in PTG level suggest that cultural factors may need to be consider in PTG research. Together, all these suggest that the relationships between gender and PTG is stable over time, the same result was observed when

among adolescents after the earthquake was even up to 51.1%.

**168**

Young people with PTSD may suffer from major depression, aggression, and conduct disorder [77, 78]. They may also be more likely to have suicidal ideation and attempts [79]. Left untreated, PTSD can lead to negative effects on sufferers' adulthood, such as college drop-out [80] and lower quality of life [81]. The National Child Traumatic Stress Network (NCTSN) suggests that trauma treatments should not only help children receive timely and appropriate treatments to recover from traumatic events but also build their resilience to cope with future stress more successfully. Hence, the identification of high-risk children and adolescents and providing them with appropriate and timely treatments are essential and imperative.

Currently, the number of treatment models for PTSD has proliferated. The first-line treatments encompass trauma-focused CBT (i.e., TF-CBT) [82, 83] and Prolonged Exposure for Adolescents (i.e, PE-A) [84]. Traditionally, components of treatments include: psychoeducation about PTSD, affective modulation and cognitive processing, behavioral activation, relaxation skills, trauma narrative, in vivo mastery of trauma reminders, conjoint parent-child sessions, and future safety and development [85, 86]. Furthermore, cognitive behavioral interventions for trauma in schools (CBITS) [87, 88] and trauma and grief component therapy for adolescents (TGCT) [89] are also welcomed as efficient ways to treat traumatized youths mainly due to available resources of schools. Eye Movement Desensitization and Reprocessing (EMDR), using dual-stimulation exercises to lower emotional arousal of the traumatic triggers [90], is evidenced as a promising method for youths with PTSD [91, 92]. Given the various and effective aspects of intervention, different treatments can be employed as a combination to gain a superior result. For example, TF-CBT combined with supportive therapy and a psychodynamic form (.i.e., play therapy) showed a better result [93]. Though it is true that forms of treatments have made progress, they are subject to some drawbacks such as high drop-out rates [94–96]. It is mainly because the nature of trauma symptoms (especially avoidance) leads participants to be unwilling to address the traumatic event directly and reprocess the details of their suffering [97]. It is therefore difficult to see the long-term efficacy and benefits of treatments if participants have poor adherence.

Unlike traditional CBT interventions, mindfulness-based interventions (MBIs), as "third-wave" cognitive behavioral treatments, were proposed to solve this high drop-out problem. Mindfulness is characterized by paying attention to one's experience in the present moment in a non-judgmental manner [98]. There are some theoretical reasons to explain the potential mechanisms why mindfulness may reduce PTSD. Mindfulness interventions can help the sufferers to improve the ability to distinguish the past and present, so as to lower the re-experiencing symptoms [99] of post-traumatic stress disorder. In addition, increasing sufferers' capability to tolerate distressing memories, thoughts, and feelings when employing mindfulness interventions may be more likely to reduce avoidance of distressing memories [100]. Furthermore, hyperarousal of PTSD could decrease because of the training in stress reduction and relaxation [101]. Within MBIs, Mindfulnessbased stress reduction (MBSR) and Mindfulness-based cognitive therapy (MBCT) were widely cited in the background of MBIs. Compared with trauma-focused therapies, MBIs showed equally efficacious and significantly lower drop-out rate [102], and were well-accepted for PTSD treatments of youths [103]. Despite the

prior research showed positive effects of MBIs in youth with PTSD, the mean effect size among youths is still lower than adults. Hence, some adaptive programs should be developed to gain satisfying results among youths [104] by shortening the session length, for example, from 90 to 30–45 min. Second, different exercises are suggested to provide specific needs for youths, such as more body scans and drawings. Third, children are more dependent on caregivers; inviting caregivers to treatment sessions should also be concerned.

In addition, art therapy is another promising intervention programmer, which promotes expression and healing. It is acknowledged that traumatic memories are sometimes overwhelming, and difficult to express in words alone [105]. Art therapy as an alternative approach can help sufferers to access the traumatic memory safely [106]. More importantly, young children are often unable to provide coherent descriptions about the traumatic event mainly due to their limited language capacity [107], making it difficult for clinicians to offer suitable interventions in helping these young children. Some previous empirical studies have provided preliminary evidence that art therapy could ameliorate PTSD symptoms in children [108, 109]. For example, Lyshak-Stelzer et al. [110] recruited 29 valid participants (14 took a trauma-focused expressive art therapy protocol (TF-ART); 15 completed a treatment-as-usual (TAU) control condition; the average age was 15.07). Results showed that patients in TF-ART had greater reduction in PTSD symptom severity than youth in the TAU condition. To support future research and practice of employing art therapy for PTSD treatment, Spiegel et al. [105] concluded some characteristics that differ from other approaches of treating PTSD: relaxation, non-verbal expression, containment of traumatic material within an object or image, symbolic expression, externalization of traumatic memories and emotions, and enjoying the pleasure that arose from creation. Again, prior studies reported promising results for art therapy in relieving PTSD among youths; however, future studies need to develop more effective and age-appropriate treatments under art therapy structure.

In conclusion, both traditional approaches like TF-CBT and the "third-wave" treatments like mindfulness-based interventions provide positive preliminary evidence in PTSD treatments among youths. Although the various interventions provide necessary helps in mitigating PTSD, it is still far way to go in developing PTSD treatments among youths. Future studies should expand the sample size, use randomized controlled trials and offer long follow-up assessments after treatments to make more definitive conclusions about the efficacy of PTSD treatments among youths. Also, researchers and practitioners need to continue to contribute to developing adaptive interventions in youths.

#### **6.2 Pharmacological treatments**

To date, experiences with efficacious pharmacological interventions used for children and adolescents with PTSD are relatively lack. A common consensus is that adopting some targeted pharmacological treatments for young patients, especially for hyperarousal symptoms, sleep problems and psychiatric comorbidity, may improve their life quality and social functions [111, 112].

There was evidence supporting the using of pharmacological treatments such as serotonin-selective reuptake inhibitors (SSRIs), divalproex sodium (DVP), atypical antipsychotics and beta-receptor antagonism in reducing PTSD symptoms among children and adolescents. SSRIs have been proved their effects in treating youths with depression and anxiety disorders [113]. Overall, SSRIs are safe and well-tolerated, but it is important to note that they may increase the risk of suicide

**171**

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings*

in children and adolescents in addition to the common anticholine side effects [114, 115]. DVP was reported to be effective for treating core PTSD symptoms in a randomized controlled clinical trial (high dose of DVP conditions: 500–1500 mg/ day compared with dose conditions: <250 mg/day) [116]. Atypical antipsychotics agents (i.e., risperidone, quetiapine, clozapine) and anti-adrenergic agents (i.e., clonidine) are often used in treating children with PTSD, schizophrenia, bipolar disorder, or psychotic symptoms in children. A study provided preliminary evidence that patients presented rapid and sustained improvement across all symptom clusters of acute stress disorders with minimal to no adverse effects after using moderate dosages of risperidone [117]. Other studies reported that beta-receptor antagonism (propranolol) [118, 119] and clonidine had significant effects on alleviating PTSD symptoms in children [120]. Further, pharmacological treatments are highly suggested to combine with TF-CBT or other trauma-centered therapy [121, 122]. Given methodological limitations, e.g., small sample sizes and few well-designed clinical trials, these findings should be interpreted cautiously. Some important points when using pharmacological treatments in children and adolescence with PTSD should be noticed. First, are they and their parents willing to take part in pharmacological interventions. Second, those who comorbid with depression or other serious mental illnesses should be highly concerned. Moreover, specific developmental characteristics should be considered when adopting pharmacological treatments. The response effects of pharmacological treatments may vary with age, weight, gender, mental health as well as absorption, distribution, metabolism, and excretion of medication. Taken together, future studies should ideally take into account these developmental factors when applying

Taking the Wenchuan Earthquake studies in China as an example, this chapter introduces some current research results about the epidemiological characteristics of PTSD and related mental disorders in children and adolescents, as well as their influencing factors and mechanisms. Important intervention strategies for PTSD in children and adolescents have also discussed. There are some issues that need

First, apart from mental health effects of disasters on children and adolescents,

future research should pay more attention to other aspects of their well-being and functioning, such as academic performance and relationship quality. This can provide an important reference for our in-depth understanding of posttraumatic psychological reactions and behavior changes, and also help to develop integrative interventions beneficial for the overall psychological and behavioral improvement of trauma-exposed children and adolescents. Second, considering the possible coexistence of PTSD and PTG, it is necessary to study the relationship between PTSD and PTG within longitudinal data with the aim of clarifying the relationship between these two variables, it is necessary to study the relationship between PTSD and PTG within longitudinal data. As mentioned, previous studies have mainly analyzed the mechanism of PTSD or PTG from a single perspective, ignoring the coexistence characteristics of them, making it difficult to effectively compare the differences between the two mechanisms. Therefore, future research can incorporate PTSD and PTG into a model at the same time, so as to determine the similarities and differences between the two mechanisms. Third, clinical intervention research from the perspective of integrating the remission of PTSD

*DOI: http://dx.doi.org/10.5772/intechopen.92284*

pharmacological approaches.

**7. Summary**

further research.

#### *Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings DOI: http://dx.doi.org/10.5772/intechopen.92284*

in children and adolescents in addition to the common anticholine side effects [114, 115]. DVP was reported to be effective for treating core PTSD symptoms in a randomized controlled clinical trial (high dose of DVP conditions: 500–1500 mg/ day compared with dose conditions: <250 mg/day) [116]. Atypical antipsychotics agents (i.e., risperidone, quetiapine, clozapine) and anti-adrenergic agents (i.e., clonidine) are often used in treating children with PTSD, schizophrenia, bipolar disorder, or psychotic symptoms in children. A study provided preliminary evidence that patients presented rapid and sustained improvement across all symptom clusters of acute stress disorders with minimal to no adverse effects after using moderate dosages of risperidone [117]. Other studies reported that beta-receptor antagonism (propranolol) [118, 119] and clonidine had significant effects on alleviating PTSD symptoms in children [120]. Further, pharmacological treatments are highly suggested to combine with TF-CBT or other trauma-centered therapy [121, 122]. Given methodological limitations, e.g., small sample sizes and few well-designed clinical trials, these findings should be interpreted cautiously.

Some important points when using pharmacological treatments in children and adolescence with PTSD should be noticed. First, are they and their parents willing to take part in pharmacological interventions. Second, those who comorbid with depression or other serious mental illnesses should be highly concerned. Moreover, specific developmental characteristics should be considered when adopting pharmacological treatments. The response effects of pharmacological treatments may vary with age, weight, gender, mental health as well as absorption, distribution, metabolism, and excretion of medication. Taken together, future studies should ideally take into account these developmental factors when applying pharmacological approaches.

#### **7. Summary**

*Psychosomatic Medicine*

treatment sessions should also be concerned.

developing adaptive interventions in youths.

improve their life quality and social functions [111, 112].

**6.2 Pharmacological treatments**

prior research showed positive effects of MBIs in youth with PTSD, the mean effect size among youths is still lower than adults. Hence, some adaptive programs should be developed to gain satisfying results among youths [104] by shortening the session length, for example, from 90 to 30–45 min. Second, different exercises are suggested to provide specific needs for youths, such as more body scans and drawings. Third, children are more dependent on caregivers; inviting caregivers to

In addition, art therapy is another promising intervention programmer, which promotes expression and healing. It is acknowledged that traumatic memories are sometimes overwhelming, and difficult to express in words alone [105]. Art therapy as an alternative approach can help sufferers to access the traumatic memory safely [106]. More importantly, young children are often unable to provide coherent descriptions about the traumatic event mainly due to their limited language capacity [107], making it difficult for clinicians to offer suitable interventions in helping these young children. Some previous empirical studies have provided preliminary evidence that art therapy could ameliorate PTSD symptoms in children [108, 109]. For example, Lyshak-Stelzer et al. [110] recruited 29 valid participants (14 took a trauma-focused expressive art therapy protocol (TF-ART); 15 completed a treatment-as-usual (TAU) control condition; the average age was 15.07). Results showed that patients in TF-ART had greater reduction in PTSD symptom severity than youth in the TAU condition. To support future research and practice of employing art therapy for PTSD treatment, Spiegel et al. [105] concluded some characteristics that differ from other approaches of treating PTSD: relaxation, non-verbal expression, containment of traumatic material within an object or image, symbolic expression, externalization of traumatic memories and emotions, and enjoying the pleasure that arose from creation. Again, prior studies reported promising results for art therapy in relieving PTSD among youths; however, future studies need to develop more

effective and age-appropriate treatments under art therapy structure.

In conclusion, both traditional approaches like TF-CBT and the "third-wave" treatments like mindfulness-based interventions provide positive preliminary evidence in PTSD treatments among youths. Although the various interventions provide necessary helps in mitigating PTSD, it is still far way to go in developing PTSD treatments among youths. Future studies should expand the sample size, use randomized controlled trials and offer long follow-up assessments after treatments to make more definitive conclusions about the efficacy of PTSD treatments among youths. Also, researchers and practitioners need to continue to contribute to

To date, experiences with efficacious pharmacological interventions used for children and adolescents with PTSD are relatively lack. A common consensus is that adopting some targeted pharmacological treatments for young patients, especially for hyperarousal symptoms, sleep problems and psychiatric comorbidity, may

There was evidence supporting the using of pharmacological treatments such as serotonin-selective reuptake inhibitors (SSRIs), divalproex sodium (DVP), atypical antipsychotics and beta-receptor antagonism in reducing PTSD symptoms among children and adolescents. SSRIs have been proved their effects in treating youths with depression and anxiety disorders [113]. Overall, SSRIs are safe and well-tolerated, but it is important to note that they may increase the risk of suicide

**170**

Taking the Wenchuan Earthquake studies in China as an example, this chapter introduces some current research results about the epidemiological characteristics of PTSD and related mental disorders in children and adolescents, as well as their influencing factors and mechanisms. Important intervention strategies for PTSD in children and adolescents have also discussed. There are some issues that need further research.

First, apart from mental health effects of disasters on children and adolescents, future research should pay more attention to other aspects of their well-being and functioning, such as academic performance and relationship quality. This can provide an important reference for our in-depth understanding of posttraumatic psychological reactions and behavior changes, and also help to develop integrative interventions beneficial for the overall psychological and behavioral improvement of trauma-exposed children and adolescents. Second, considering the possible coexistence of PTSD and PTG, it is necessary to study the relationship between PTSD and PTG within longitudinal data with the aim of clarifying the relationship between these two variables, it is necessary to study the relationship between PTSD and PTG within longitudinal data. As mentioned, previous studies have mainly analyzed the mechanism of PTSD or PTG from a single perspective, ignoring the coexistence characteristics of them, making it difficult to effectively compare the differences between the two mechanisms. Therefore, future research can incorporate PTSD and PTG into a model at the same time, so as to determine the similarities and differences between the two mechanisms. Third, clinical intervention research from the perspective of integrating the remission of PTSD

#### *Psychosomatic Medicine*

and promotion of PTG is needed. In the past, traumatic research mainly focused on the remission of individual PTSD, and developed related intervention methods, and also tested its effects through empirical studies. However, overall clinical empirical research on the promotion of PTG in the treatment for PTSD is still very rare. Therefore, research on psychological intervention for PTSD from the integration perspective of PTSD remission and PTG promotion at the same time is an important issue to be explored in the future. Fourth, future research should explore effective genetic, neuroendocrine, and neuroimaging related biomarkers, which may be of utility in developing new treatments and evaluating treatment outcomes.

#### **Author details**

Yuanyuan Li1 , Ya Zhou2 , Xiaoyan Chen1 , Fang Fan1 \*, George Musa3 and Christina Hoven3

1 School of Psychology, Center for Studies of Psychological Application, and Key Laboratory of Mental Health and Cognitive Science of Guangdong Province, South China Normal University, Guangdong, China

2 Department of Psychology, Lund University, Lund, Sweden

3 Department of Child and Adolescent Psychiatry, New York State Psychiatric Institute, Columbia University, New York, USA

\*Address all correspondence to: fangfan@scnu.edu.cn

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**173**

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings*

actor-partner interdependence model. Journal of Affective Disorders.

[9] Kirsch V, Wilhelm FH, Goldbeck L. Psychophysiological characteristics of ptsd in children and adolescents: A review of the literature. Journal of Traumatic Stress. 2011;**24**(3):370-372

[10] Bolton D, O'Ryan D, Udwin O, Boyle S, Yule W. The longterm effects of a disaster experienced in adolescence: II: General psychopathology. Journal of Child Psychology and Psychiatry.

[11] Fan F, Zhou Y, Mo L, Zhang W, Xie J, Liu X, et al. Cohort profile: The Wenchuan Earthquake adolescent health cohort study. International Journal of Epidemiology. 2017;

[12] Tareen A, Garralda ME,

2007;**92**(1):ep1-ep6

Neglect. 1994;**18**:37-50

2003;**41**(12):1489-1496

[16] Horowitz M, Wilner N, Alvarez W. Impact of event scale: A measure of subjective stress. Psychosomatic Medicine.

2010;**56**(3):203

1979;**41**(3):209-218

[14] Creamer M, Bell R, Failla S. Psychometric properties of the impact of event scale—Revised. Behaviour Research and Therapy.

[15] Motlagh H. Impact of event scalerevised. Journal of Physiotherapy.

Hodes M. Post-traumatic stress disorder in childhood. Archives of Disease in Childhood-Education and Practice.

[13] Wolfe DA, Sas L, Wekerle C. Factors associated with the development of post traumatic stress disorder among child victims of sexual abuse. Child Abuse &

2017;**226**:301

2000;**41**(4):513-523

**46**(1):27-28

*DOI: http://dx.doi.org/10.5772/intechopen.92284*

[1] Schnurr PP, Friedman MJ, Bernardy NC. Research on posttraumatic stress disorder: Epidemiology, pathophysiology, and assessment. Journal of Clinical Psychology. 2002;**58**(8):877-889

[2] Kar N. Psychological impact of disasters on children: Review of assessment and interventions. World Journal of Pediatrics. 2009;**5**(1):5-11

Thorpe LE, Thalji L, Murphy J, Wu D, et al. Posttraumatic stress symptoms, PTSD, and risk factors among lower Manhattan residents 2 ~ 3 years after the September 11, 2001 terrorist attacks. Journal of Traumatic Stress.

[3] DiGrande L, Perrin MA,

[4] Galea S, Ahern J, Resnick H,

Kilpatrick D, Bu cuvalas M, Gold J, et al. Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine.

[5] Schlenger WE, Caddell JM, Ebert L, Jordan BK, Rourke KM, Wilson D, et al. Psychological reactions to terrorist attacks. Journal of the American Medical Association.

[6] Shaw JA. Children, adolescents and trauma. Psychiatric Quarterly.

[7] Comer JS, Fan B, Duarte CS, Wu P, Musa GJ, Mandell DJ, et al. Attackrelated life disruption and child psychopathology in New York city public schoolchildren 6-months post-9/11. Journal of Clinical Child & Adolescent Psychology.

[8] Shi X, Zhou Y, Geng F, Li Y, Fan F. Posttraumatic stress disorder symptoms in parents and adolescents after the Wenchuan Earthquake: A longitudinal

2008;**21**(3):264-273

2002;**346**(13):982-987

2002;**288**(5):58I-588I

2000;**71**(3):227-243

2010;**39**(4):460-469

**References**

*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings DOI: http://dx.doi.org/10.5772/intechopen.92284*

#### **References**

*Psychosomatic Medicine*

**172**

**Author details**

and Christina Hoven3

, Ya Zhou2

, Xiaoyan Chen1

2 Department of Psychology, Lund University, Lund, Sweden

South China Normal University, Guangdong, China

Institute, Columbia University, New York, USA

provided the original work is properly cited.

\*Address all correspondence to: fangfan@scnu.edu.cn

1 School of Psychology, Center for Studies of Psychological Application, and Key Laboratory of Mental Health and Cognitive Science of Guangdong Province,

3 Department of Child and Adolescent Psychiatry, New York State Psychiatric

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

, Fang Fan1

and promotion of PTG is needed. In the past, traumatic research mainly focused on the remission of individual PTSD, and developed related intervention methods, and also tested its effects through empirical studies. However, overall clinical empirical research on the promotion of PTG in the treatment for PTSD is still very rare. Therefore, research on psychological intervention for PTSD from the integration perspective of PTSD remission and PTG promotion at the same time is an

important issue to be explored in the future. Fourth, future research should explore effective genetic, neuroendocrine, and neuroimaging related biomarkers, which may be of utility in developing new treatments and evaluating treatment outcomes.

\*, George Musa3

Yuanyuan Li1

[1] Schnurr PP, Friedman MJ, Bernardy NC. Research on posttraumatic stress disorder: Epidemiology, pathophysiology, and assessment. Journal of Clinical Psychology. 2002;**58**(8):877-889

[2] Kar N. Psychological impact of disasters on children: Review of assessment and interventions. World Journal of Pediatrics. 2009;**5**(1):5-11

[3] DiGrande L, Perrin MA, Thorpe LE, Thalji L, Murphy J, Wu D, et al. Posttraumatic stress symptoms, PTSD, and risk factors among lower Manhattan residents 2 ~ 3 years after the September 11, 2001 terrorist attacks. Journal of Traumatic Stress. 2008;**21**(3):264-273

[4] Galea S, Ahern J, Resnick H, Kilpatrick D, Bu cuvalas M, Gold J, et al. Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine. 2002;**346**(13):982-987

[5] Schlenger WE, Caddell JM, Ebert L, Jordan BK, Rourke KM, Wilson D, et al. Psychological reactions to terrorist attacks. Journal of the American Medical Association. 2002;**288**(5):58I-588I

[6] Shaw JA. Children, adolescents and trauma. Psychiatric Quarterly. 2000;**71**(3):227-243

[7] Comer JS, Fan B, Duarte CS, Wu P, Musa GJ, Mandell DJ, et al. Attackrelated life disruption and child psychopathology in New York city public schoolchildren 6-months post-9/11. Journal of Clinical Child & Adolescent Psychology. 2010;**39**(4):460-469

[8] Shi X, Zhou Y, Geng F, Li Y, Fan F. Posttraumatic stress disorder symptoms in parents and adolescents after the Wenchuan Earthquake: A longitudinal

actor-partner interdependence model. Journal of Affective Disorders. 2017;**226**:301

[9] Kirsch V, Wilhelm FH, Goldbeck L. Psychophysiological characteristics of ptsd in children and adolescents: A review of the literature. Journal of Traumatic Stress. 2011;**24**(3):370-372

[10] Bolton D, O'Ryan D, Udwin O, Boyle S, Yule W. The longterm effects of a disaster experienced in adolescence: II: General psychopathology. Journal of Child Psychology and Psychiatry. 2000;**41**(4):513-523

[11] Fan F, Zhou Y, Mo L, Zhang W, Xie J, Liu X, et al. Cohort profile: The Wenchuan Earthquake adolescent health cohort study. International Journal of Epidemiology. 2017; **46**(1):27-28

[12] Tareen A, Garralda ME, Hodes M. Post-traumatic stress disorder in childhood. Archives of Disease in Childhood-Education and Practice. 2007;**92**(1):ep1-ep6

[13] Wolfe DA, Sas L, Wekerle C. Factors associated with the development of post traumatic stress disorder among child victims of sexual abuse. Child Abuse & Neglect. 1994;**18**:37-50

[14] Creamer M, Bell R, Failla S. Psychometric properties of the impact of event scale—Revised. Behaviour Research and Therapy. 2003;**41**(12):1489-1496

[15] Motlagh H. Impact of event scalerevised. Journal of Physiotherapy. 2010;**56**(3):203

[16] Horowitz M, Wilner N, Alvarez W. Impact of event scale: A measure of subjective stress. Psychosomatic Medicine. 1979;**41**(3):209-218

[17] Perrin S, Meiser-Stedman R, Smith P. The Children's Revised Impact of Event Scale (CRIES): Validity as a screening instrument for PTSD. Behavioural and Cognitive Psychotherapy. 2005;**33**(4):487-498

[18] Smith P, Perrin S, Yule W, Rabe-Hesketh S. War exposure and maternal reactions in the psychological adjustment of children from Bosnia-Hercegovina. The Journal of Child Psychology and Psychiatry. 2001;**42**(3):395-404

[19] Foa EB, Johnson KM, Feeny NC, Treadwell KR. The Child PTSD Symptom Scale: A preliminary examination of its psycho-metric properties. Journal of Clinical Child Psychology. 2001;**30**:376-384. DOI: 10.1207/S15374424JCCP3003\_9

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[114] Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials. Journal of the American Medical Association. 2007;**297**(15):1683-1696

[115] Seedat S, Stein DJ, Ziervogel C, Middleton T, Kaminer D, Emsley RA, et al. Comparison of response to a selective serotonin reuptake inhibitor in children, adolescents, and adults with posttraumatic stress disorder. Journal of Child and Adolescent Psychopharmacology. 2002;**12**(1): 37-46

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*Post-Traumatic Stress Disorder in Children and Adolescents: Some Recent Research Findings*

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[119] Famularo R, Kinscherff R, Fenton T. Propranolol treatment for childhood posttraumatic stress disorder, acute type: A pilot study. American Journal of Diseases of Children.

1988;**142**(11):1244-1247

1996;**35**(9):1247-1249

2002;**14**(2):155-163

2010;**71**(7):932

[122] Strawn JR, Keeshin BR, DelBello MP, Geracioti TD Jr, Putnam FW. Psychopharmacologic treatment of posttraumatic stress disorder in children and adolescents: A review. Journal of Clinical Psychiatry.

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[121] March JS. Combining medication and psychosocial treatments: An evidence-based medicine approach. International Review of Psychiatry*.*

of preschool children with thermal burns and acute stress disorder. Journal of Child and Adolescent Psychopharmacology.

2007;**17**(2):223-232

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[116] Steiner H, Saxena KS, Carrion V, Khanzode LA, Silverman M, Chang K. Divalproex sodium for the treatment of PTSD and conduct disordered youth: A pilot randomized controlled clinical trial. Child Psychiatry and Human Development. 2007;**38**(3):183-193

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jts.21881

[102] Frost ND, Laska KM, Wampold BE. The evidence for present-centered therapy as a treatment for posttraumatic stress disorder. Journal of Trauma Stress. 2014;**27**(1):1-8. DOI: 10.1002/

of post-traumatic stress, depression and anxiety among Syrian refugee children. Vulnerable Children and Youth Studies. 2016;**11**(2):89-102. DOI:

10.1080/17450128.2016.1181288

[110] Lyshak-Stelzer F, Singer P, Patricia SJ, Chemtob CM. Art therapy for adolescents with posttraumatic stress disorder symptoms: A pilot study. Art Therapy. 2007;**24**(4):163-169. DOI: 10.1080/07421656.2007.10129474

[111] Cohen JA et al. AACAP work group on quality issues. Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child & Adolescent Psychiatry.

[112] Davis LL, Frazier EC, Williford RB, Newell JM. Long-term pharmacotherapy for post-traumatic stress disorder. CNS

[113] Cohen JA, Mannarino AP, Perel JM, Staron V. A pilot randomized controlled trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms. Journal of the American Academy of Child & Adolescent Psychiatry. 2007;**46**(7):811-819

[114] Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials. Journal of the American Medical Association. 2007;**297**(15):1683-1696

[115] Seedat S, Stein DJ, Ziervogel C, Middleton T, Kaminer D, Emsley RA, et al. Comparison of response to a selective serotonin reuptake inhibitor in children, adolescents, and adults with posttraumatic stress disorder. Journal of Child and Adolescent Psychopharmacology. 2002;**12**(1):

37-46

2010;**49**(4):414-430

Drugs. 2006;**20**(6):465-476

[104] Borquist-Conlon DS, Maynard BR, Brendel KE, Farina ASJ. Mindfulnessbased interventions for youth with anxiety: A systematic review and meta-analysis. Research on Social Work Practice. 2019;**29**(2):195-205. DOI:

[105] Spiegel D, Malchiodi C, Backos A, Collie K. Art therapy for combat-related

[103] Zoogman S, Goldberg SB, Hoyt WT, Miller L. Mindfulness interventions with youth: A metaanalysis. Mindfulness. 2014;**6**(2):290- 302. DOI: 10.1007/s12671-013-0260-4

10.1177/1049731516684961

PTSD: Recommendations for research and practice. Art

Therapy. 2006;**23**(4):157-164. DOI: 10.1080/07421656.2006.10129335

[106] Talwar S. Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP). The Arts in Psychotherapy. 2007;**34**(1):22- 35. DOI: 10.1016/j.aip.2006.09.001

[107] Feldman R, Vengrober A.

Academy of Child & Adolescent Psychiatry. 2011;**50**(7):645-658. DOI:

[108] Berger R, Pat-Horenczyk R, Gelkopf M. School-based intervention for prevention and treatment of elementary-students' terror-related distress in Israel: A quasi-randomized controlled trial. Journal of Trauma Stress. 2007;**20**(4):541-551. DOI:

[109] Ugurlu N, Akca L, Acarturk C. An art therapy intervention for symptoms

10.1016/j.jaac.2011.03.001

10.1002/jts.20225

Posttraumatic stress disorder in infants and young children exposed to warrelated trauma. Journal of the American

**180**

[117] Meighen KG, Hines LA, Lagges AM. Risperidone treatment of preschool children with thermal burns and acute stress disorder. Journal of Child and Adolescent Psychopharmacology. 2007;**17**(2):223-232

[118] Alarcón RD, Glover S, Boyer W, Balon R. Proposing an algorithm for the pharmacological management of posttraumatic stress disorder. Annals of Clinical Psychiatry. 2000;**12**(4):239-246

[119] Famularo R, Kinscherff R, Fenton T. Propranolol treatment for childhood posttraumatic stress disorder, acute type: A pilot study. American Journal of Diseases of Children. 1988;**142**(11):1244-1247

[120] Harmon RJ, Riggs PD. Clonidine for posttraumatic stress disorder in preschool children. Journal of the American Academy of Child & Adolescent Psychiatry. 1996;**35**(9):1247-1249

[121] March JS. Combining medication and psychosocial treatments: An evidence-based medicine approach. International Review of Psychiatry*.* 2002;**14**(2):155-163

[122] Strawn JR, Keeshin BR, DelBello MP, Geracioti TD Jr, Putnam FW. Psychopharmacologic treatment of posttraumatic stress disorder in children and adolescents: A review. Journal of Clinical Psychiatry. 2010;**71**(7):932

**183**

**1. Introduction**

**Chapter 9**

**Abstract**

Use of Falun Gong to Address

Although mental health service providers have focused on the effects of trauma and related interventions for decades, little is known about pervasive and historic trauma, particularly for socially marginalized individuals. Thus, clinical issues associated with sociopolitical oppression have been under-investigated. Coupled with the lack of sufficient cultural competence when working with diverse clients, mainstream clinicians frequently lack adequate case conceptualization skills and culturally sensitive interventions to assist clients from diverse backgrounds. Using traumatic stress as a framework for exploring evidence-based interventions to address long-term, pervasive marginalization and its psychological effects, the authors propose that mindfulness techniques are particularly beneficial to this client population. The authors reviewed culture-centered interventions to address traumatic stress for marginalized client populations, focusing on the mindfulness practice of Falun Gong. Recommendations for practice include the inclusion of traumatic stress theory and techniques in pre-service training, professional development training for practitioners focusing on mindfulness techniques with clients assessed with historical trauma, and Web-based training for clinical faculty to enhance their knowledge about traumatic stress, historical trauma, and associated interventions for clients from marginalized communities. The authors offer recommendations for future research that focuses on studies exploring the usefulness of

Traumatic Stress among

Marginalized Clients

*Margaret Trey and Cirecie West-Olatunji*

Falun Gong in working with clients with traumatic stress.

**Keywords:** Falun Gong, Falun Dafa, meditation, mindfulness, traumatic stress

Scholars have most recently begun to investigate the impact of pervasive micro aggressions and other forms of systemic oppression on individuals from culturally and socially marginalized groups. Researchers have suggested that trauma affected clients report emotional and psychological impairment, such as depression and anxiety [1]. Other investigators have found that problems interpersonal conflicts and substance abuse problems are evident. Educational researchers have also explored traumatic stress and academic achievement and assert that severe persistent stress due to environmental factors, such as racism, can negatively impact children's academic performance [2, 3]. The authors use

#### **Chapter 9**

## Use of Falun Gong to Address Traumatic Stress among Marginalized Clients

*Margaret Trey and Cirecie West-Olatunji*

#### **Abstract**

Although mental health service providers have focused on the effects of trauma and related interventions for decades, little is known about pervasive and historic trauma, particularly for socially marginalized individuals. Thus, clinical issues associated with sociopolitical oppression have been under-investigated. Coupled with the lack of sufficient cultural competence when working with diverse clients, mainstream clinicians frequently lack adequate case conceptualization skills and culturally sensitive interventions to assist clients from diverse backgrounds. Using traumatic stress as a framework for exploring evidence-based interventions to address long-term, pervasive marginalization and its psychological effects, the authors propose that mindfulness techniques are particularly beneficial to this client population. The authors reviewed culture-centered interventions to address traumatic stress for marginalized client populations, focusing on the mindfulness practice of Falun Gong. Recommendations for practice include the inclusion of traumatic stress theory and techniques in pre-service training, professional development training for practitioners focusing on mindfulness techniques with clients assessed with historical trauma, and Web-based training for clinical faculty to enhance their knowledge about traumatic stress, historical trauma, and associated interventions for clients from marginalized communities. The authors offer recommendations for future research that focuses on studies exploring the usefulness of Falun Gong in working with clients with traumatic stress.

**Keywords:** Falun Gong, Falun Dafa, meditation, mindfulness, traumatic stress

#### **1. Introduction**

Scholars have most recently begun to investigate the impact of pervasive micro aggressions and other forms of systemic oppression on individuals from culturally and socially marginalized groups. Researchers have suggested that trauma affected clients report emotional and psychological impairment, such as depression and anxiety [1]. Other investigators have found that problems interpersonal conflicts and substance abuse problems are evident. Educational researchers have also explored traumatic stress and academic achievement and assert that severe persistent stress due to environmental factors, such as racism, can negatively impact children's academic performance [2, 3]. The authors use

traumatic stress theory as a framework for exploring effective interventions to decrease symptomology due to systemic oppression.

The purpose of this paper is to outline the benefits of Falun Gong, an ancient Chinese mind-body and spiritual discipline, as a mindfulness intervention when working with culturally marginalized clients. The authors provide an overview of the clinical issues associated with historical trauma and then present Falun Gong as an alternative solution for ameliorating the effects of social marginalization. The authors suggest that Falun Gong is beneficial in addressing the psychological, physical, academic, and financial needs of these particular types of clients. Recommendations for practice include expanded training on Falun Gong as a clinical intervention and an enhancement of the curriculum in various mental health-training programs to include more emphasis on mindfulness and, more particularly, Falun Gong. Suggestions for future research focus on developing a national study exploring the impact of Falun Gong practices on traumatic stress symptoms for culturally marginalized clients.

#### **2. The effects of historical trauma on marginalized populations**

How individuals cope with trauma is dependent upon their social positioning prior to the onset of traumatic experiences. Some groups of people, such as poor people, the elderly, culturally diverse, and mentally/physically impaired, are disproportionately affected by traumatic events and experiences based upon institutionalized and historical biases in society. Lack of access to institutional resources and lack of power to control those institutions creates a cycle of socio-cultural abuse that threatens the psyche of culturally diverse individuals.

Yet, mental health professionals have been slow to acknowledge clinical issues related to pervasive trauma & chronic stress due to cultural hegemony [4]. For culturally diverse clients, for example, this has meant diagnoses based upon models of normalcy for middle-class Whites. Research has shown that systemic oppression has deleterious physical and mental health effects. Traumatic stress and psychological distress have been shown to be evident in several studies. Some of the outcomes of systemic oppression are noted in physical/psychological health [1–3] and education disparities [2, 5].

#### **2.1 Cultural and clinical competence**

For the most part, traditional perspectives in the behavioral sciences have focused on the client as a poorly functioning individual. An ecological approach considers the possibility of a malfunctioning system and its impact on the client [6]. In analyzing some hypotheses to explain why clinicians have been slow to incorporate systemic interventions into their roles and responsibilities, one study suggests that clinicians may "underestimate the power of resources other than their values, skills, and personalities" ([7], p. 33).

An eco-systemic perspective in examining trauma aids in understanding and conceptualizing the needs of culturally diverse communities. Concentrating on the African American experience, researchers have begun investigating the correlates between historical trauma and oppression [1, 8–10]. Additional work in this area by Seaton [11] revealed that, in particular, due to racism, African Americans experience more stressful events than European Americans. In summarizing the Differential Exposure Hypothesis (DEH), Seaton suggested that racism, bias, and discrimination are detrimental to African Americans because they are disproportionately placed at higher risk for psychological disorders. Eco-systemic

**185**

*Use of Falun Gong to Address Traumatic Stress among Marginalized Clients*

interventions incorporate an understanding of those external influences that

Over the past two decades, mental health practitioners across all disciplines have become increasingly aware of the need for clinicians to involve themselves in the role of advocate for their clients [12–14]. Clinicians need to consider their clients within the context of their families and communities, as well as their social, cultural, and religious systems [15]. Additionally, assessment and treatment models are needed to intervene with clients who have been impacted by systemic oppression. Clinicians can explore relevant themes to address the context of systemic oppression and the related traumatic experiences. Intervening for trauma due to systemic oppression is necessary for recovery. Through their expanded awareness of sociocultural oppression, clinicians can become healers as well as

Chronic stress/pervasive trauma, related to systemic oppression, is transgenerational in nature: this is contextualized by historical and systemic oppression resulting in discriminatory legislation and racism in the U.S. Current effects of systemic oppression and trauma may be additive to the historical trauma experienced by previous generations [3]. Many of the problems reported by individual trauma survivors also are reported by their partners, including individual stress symptoms, isolation, poor relationship quality, and reduced intimacy. The available literature suggests that trauma and trauma symptoms affect not only the individual but also the people with whom traumatized persons have a significant relationship (e.g., spouses, partners, and children). However, this literature on the systemic effects of

Trauma is experienced intergenerationally despite the absence of direct exposure to a traditional traumatic stimulus as evidenced from the study of Jewish Holocaust survivor's children [17]. This study was also extended to the family members of veterans from World War II and the Vietnam War, indigenous peoples, individuals and groups living under repressive regimes, those experiencing domestic violence and crime, and those living with infection and life-threatening diseases. Symptoms may include depression, anxiety, suicidal ideation and behavior, sub-

Effective interventions with culturally diverse clients: (a) build on existing knowledge within the client's worldviews, (b) maintain client empowerment and agency, (c) demonstrate reciprocity in the transformation process, and (d) honor the historical and contextual forms of healing within the client's familial and community networks. Some examples of these types of interventions include the use of story circle and other forms of narrative storytelling. More recently, clinical research has explored the benefits of meditation and mindfulness is assisting trauma-affected clients. Both of these types of interventions can be useful in work-

Story circle is a tool to build equal partnerships that foster better understanding and communication among participants with like interests, thereby creating a stronger sense of community [18]. The story circle is oral and affective in nature. Stories tell individuals about their whole selves. Clients have the opportunity to share their feelings, thoughts and emotions with other people. They free their spirit in a way that is incomprehensible to outsiders. The term outsiders, refers to either observers

*DOI: http://dx.doi.org/10.5772/intechopen.93301*

impact an individual's functioning [6].

advocates for their clients [14].

trauma is predominantly clinical in nature [16].

**2.2 Traumatic stress theory**

stance abuse, and violence.

ing with culturally diverse clients.

**2.3 Story circle**

#### *Use of Falun Gong to Address Traumatic Stress among Marginalized Clients DOI: http://dx.doi.org/10.5772/intechopen.93301*

interventions incorporate an understanding of those external influences that impact an individual's functioning [6].

Over the past two decades, mental health practitioners across all disciplines have become increasingly aware of the need for clinicians to involve themselves in the role of advocate for their clients [12–14]. Clinicians need to consider their clients within the context of their families and communities, as well as their social, cultural, and religious systems [15]. Additionally, assessment and treatment models are needed to intervene with clients who have been impacted by systemic oppression. Clinicians can explore relevant themes to address the context of systemic oppression and the related traumatic experiences. Intervening for trauma due to systemic oppression is necessary for recovery. Through their expanded awareness of sociocultural oppression, clinicians can become healers as well as advocates for their clients [14].

#### **2.2 Traumatic stress theory**

*Psychosomatic Medicine*

alized clients.

disparities [2, 5].

**2.1 Cultural and clinical competence**

and personalities" ([7], p. 33).

traumatic stress theory as a framework for exploring effective interventions to

The purpose of this paper is to outline the benefits of Falun Gong, an ancient Chinese mind-body and spiritual discipline, as a mindfulness intervention when working with culturally marginalized clients. The authors provide an overview of the clinical issues associated with historical trauma and then present Falun Gong as an alternative solution for ameliorating the effects of social marginalization. The authors suggest that Falun Gong is beneficial in addressing the psychological, physical, academic, and financial needs of these particular types of clients. Recommendations for practice include expanded training on Falun Gong as a clinical intervention and an enhancement of the curriculum in various mental health-training programs to include more emphasis on mindfulness and, more particularly, Falun Gong. Suggestions for future research focus on developing a national study exploring the impact of Falun Gong practices on traumatic stress symptoms for culturally margin-

**2. The effects of historical trauma on marginalized populations**

How individuals cope with trauma is dependent upon their social positioning prior to the onset of traumatic experiences. Some groups of people, such as poor people, the elderly, culturally diverse, and mentally/physically impaired, are disproportionately affected by traumatic events and experiences based upon institutionalized and historical biases in society. Lack of access to institutional resources and lack of power to control those institutions creates a cycle of socio-cultural abuse that

Yet, mental health professionals have been slow to acknowledge clinical issues related to pervasive trauma & chronic stress due to cultural hegemony [4]. For culturally diverse clients, for example, this has meant diagnoses based upon models of normalcy for middle-class Whites. Research has shown that systemic oppression has deleterious physical and mental health effects. Traumatic stress and psychological distress have been shown to be evident in several studies. Some of the outcomes of systemic oppression are noted in physical/psychological health [1–3] and education

For the most part, traditional perspectives in the behavioral sciences have focused on the client as a poorly functioning individual. An ecological approach considers the possibility of a malfunctioning system and its impact on the client [6]. In analyzing some hypotheses to explain why clinicians have been slow to incorporate systemic interventions into their roles and responsibilities, one study suggests that clinicians may "underestimate the power of resources other than their values, skills,

An eco-systemic perspective in examining trauma aids in understanding and conceptualizing the needs of culturally diverse communities. Concentrating on the African American experience, researchers have begun investigating the correlates between historical trauma and oppression [1, 8–10]. Additional work in this area by Seaton [11] revealed that, in particular, due to racism, African Americans experience more stressful events than European Americans. In summarizing the Differential Exposure Hypothesis (DEH), Seaton suggested that racism, bias, and discrimination are detrimental to African Americans because they are disproportionately placed at higher risk for psychological disorders. Eco-systemic

decrease symptomology due to systemic oppression.

threatens the psyche of culturally diverse individuals.

**184**

Chronic stress/pervasive trauma, related to systemic oppression, is transgenerational in nature: this is contextualized by historical and systemic oppression resulting in discriminatory legislation and racism in the U.S. Current effects of systemic oppression and trauma may be additive to the historical trauma experienced by previous generations [3]. Many of the problems reported by individual trauma survivors also are reported by their partners, including individual stress symptoms, isolation, poor relationship quality, and reduced intimacy. The available literature suggests that trauma and trauma symptoms affect not only the individual but also the people with whom traumatized persons have a significant relationship (e.g., spouses, partners, and children). However, this literature on the systemic effects of trauma is predominantly clinical in nature [16].

Trauma is experienced intergenerationally despite the absence of direct exposure to a traditional traumatic stimulus as evidenced from the study of Jewish Holocaust survivor's children [17]. This study was also extended to the family members of veterans from World War II and the Vietnam War, indigenous peoples, individuals and groups living under repressive regimes, those experiencing domestic violence and crime, and those living with infection and life-threatening diseases. Symptoms may include depression, anxiety, suicidal ideation and behavior, substance abuse, and violence.

Effective interventions with culturally diverse clients: (a) build on existing knowledge within the client's worldviews, (b) maintain client empowerment and agency, (c) demonstrate reciprocity in the transformation process, and (d) honor the historical and contextual forms of healing within the client's familial and community networks. Some examples of these types of interventions include the use of story circle and other forms of narrative storytelling. More recently, clinical research has explored the benefits of meditation and mindfulness is assisting trauma-affected clients. Both of these types of interventions can be useful in working with culturally diverse clients.

#### **2.3 Story circle**

Story circle is a tool to build equal partnerships that foster better understanding and communication among participants with like interests, thereby creating a stronger sense of community [18]. The story circle is oral and affective in nature. Stories tell individuals about their whole selves. Clients have the opportunity to share their feelings, thoughts and emotions with other people. They free their spirit in a way that is incomprehensible to outsiders. The term outsiders, refers to either observers

of the story circle, or other cultures that may not be familiar with storytelling traditions in their society. The story circle tends to create a comfortable environment that encompasses warmth and trust. The facilitator's job is to make sure each person connects the themes and patterns that the stories have created. All stories should connect in some way or another. It is also appropriate for members of the story circle to challenge one another after the storytelling has taken place. When it is time to process, members should discuss where they felt connected and focus on feelings and thought processes. The facilitator should also let everyone share responsibility for keeping track of time because it can last a while. Also, a follow-up activity should be conducted for the group as well.

#### **2.4 Mindfulness/meditation and emergent practices**

There is plentiful evidence to show that Eastern meditation and mindfulness techniques have beneficial effects on our personal and work life [19–22]. One study showed that participants reported significant reduction in anxiety, depression, and stress levels after a 10-week mindfulness meditation program [20]. Other studies indicated that meditation could alter brain function and even change the physical structure of the human brain, impacting the concept of lifelong neuroplasticity [23–26]. Weaver [22] noted some of these studies showed that even novice or inexperienced meditators can rewire their brains and reap the benefits of meditative practices. These modified Eastern meditative and mindfulness techniques have shown to be beneficial effects.

As more people are seeking peace, inner balance, and wellbeing through meditation and mindfulness practices, there is a mushrooming of interest from those in the helping profession to integrate these ancient practices into their work [27–32]. A survey by the *Psychotherapy Networker* revealed 41.4% of about 2600 therapists reported integrating certain mindfulness techniques into their professional practice [29]. An online survey by *Counseling Today,* a publication of the American Counseling Association (ACA), indicated that 87% of counselors reported adopting an integrated practice with mindfulness approaches into their professional work with clients [28]. Writers, like Meyers [28], regard meditation as a form of mindfulness based technique.

Today, Falun Gong is one of the fastest emergent Chinese spiritual and meditative movement practices that is spreading throughout the world [31–33]. Large scale studies conducted in mainland China showed the tremendous health and wellness effects of Falun Gong [32, 34–36]. Likewise, various studies outside of mainland China and around the world indicated Falun Gong's beneficial effects [33, 37–39]. There were two studies outside of China that stood out. The first was the Australian survey completed by the first author under the auspices of The University of South Australia for partial fulfillment of the Doctor of counseling degree examined the health and wellness effects of Falun Gong from the selfreports of Falun Gong practitioners [38]. It was the first empirical study with a diverse sample outside of mainland China [33, 38]. The second one, completed for the partial fulfillment of the Doctor of Philosophy in Psychology at the University of California, Los Angeles, demonstrated that practicing Falun Gong has a beneficial effect and that long-term practice may lead to hemispheric changes in the brain [40, 41].

Falun Gong has not been a subject for much research. Besides these two studies conducted under the auspices of an Australian and a US university respectively, a team of medical doctors and researchers in the United States had undertaken a pilot study to examine the effects of Falun Gong on gene expression and the role of neutrophils in Falun Gong practitioners [42]. Findings from their pilot study revealed

**187**

*Use of Falun Gong to Address Traumatic Stress among Marginalized Clients*

superior gene expression, enhanced immunity, and longer lifespan of neutrophils in Falun Gong respondents [42]. The researchers' endeavor provided the first evidence to suggest that practicing Falun Gong could influence immunity, metabolic rate, and cell regeneration. Then there were several publications documented many individuals experiencing health and wellness healing effects after they started

Also known as Falun Dafa, Falun Gong is a high-level Chinese self-cultivation practice for overall mind, body, and spiritual improvement [33, 46, 47]. It originated from Northeast China. Over the past two decades since its teacher and founder, Master Li Hongzhi first introduced Falun Gong to the public in 1992, there are numerous terms used to describe Falun Gong [33, 38]. Most non-Falun Gong writers concurred that Falun Gong is a form of qigong [46, 48–51] or a Buddhist qigong system [52]. Other expressions used to describe Falun include traditional Chinese religious practice, or revival of traditional Chinese spiritual practice [49, 53–56], or as a new religious movement [57–60]. Gale and Gorman-Yao [61] described Falun Gong as a cultural movement, while Ackerman [62] referred to the

Despite the myriad of descriptive terms and expressions, there is a mutual understanding that Falun Gong is a form of qigong, a comprehensive spiritual meditation discipline, a quasi-religious practice, or a new Chinese religious movement. Human Rights Watch Senior Advisor Spiegel [51] offered a comprehensive

*"A form of qigong, an ancient Chinese deep-breathing exercise system sometimes combined with meditation that enthusiasts claim promotes physical, mental, and spiritual well-being by enhancing the flow of vital energy through a person's body. It also includes elements of popular Buddhism and Daoism" (Spiegel, 2002, p. 8).*

Among practitioners, Falun Gong, an ancient Chinese spiritual discipline, is better known as Falun Dafa. The Chinese word "Fa" ([63], p. 390) refers to law or principles in the Buddha School teachings but this is not the same as the Buddhism taught by Buddha Shakyamuni or Siddhārtha Gautama. Penny states in his book, *The Religion of Falun Gong,* that the "falun" in the name Falun Gong "has a different meaning from that in Buddhism" ([64], p. 5). He describes Falun Gong as "the practice of the Wheel of the Law" (p. 5), and that Falun Dafa refers to "the Great

In *Zhuan Falun*, the complete teachings of Falun Gong, "Dafa," which is pronounced as "Dah-fah" simply means the "Great Law" or the "Great Way" ([63], p. 2). While Falun Dafa is more befitting and widely used in Falun Gong literature, for the purpose of this article that comprises the White Paper, many writers have consistently alluded to this Chinese spiritual discipline as Falun Gong. This is partly because Falun Gong has remained more popular and widely used across different media, popular search engines, and literature by non-Falun Gong people [33, 38].

Most Falun Gong literature describes the practice as an ancient Chinese spiritual discipline in the Buddha tradition [31, 33, 38, 47, 65, 66]. Falun Gong, pronounced "Fah-loon Gong," is a high-level, mind-body spiritual system with its roots in both

*DOI: http://dx.doi.org/10.5772/intechopen.93301*

practice as a New Age spiritual movement.

Method of the Wheel of the Law" ([64], p. 5).

**3.1 Advanced practice with ancient roots**

definition, describing Falun Gong as a synthesis of qualities:

practicing Falun Gong [43–45].

**3. What is Falun Gong?**

*Use of Falun Gong to Address Traumatic Stress among Marginalized Clients DOI: http://dx.doi.org/10.5772/intechopen.93301*

superior gene expression, enhanced immunity, and longer lifespan of neutrophils in Falun Gong respondents [42]. The researchers' endeavor provided the first evidence to suggest that practicing Falun Gong could influence immunity, metabolic rate, and cell regeneration. Then there were several publications documented many individuals experiencing health and wellness healing effects after they started practicing Falun Gong [43–45].

#### **3. What is Falun Gong?**

*Psychosomatic Medicine*

be conducted for the group as well.

shown to be beneficial effects.

mindfulness based technique.

**2.4 Mindfulness/meditation and emergent practices**

of the story circle, or other cultures that may not be familiar with storytelling traditions in their society. The story circle tends to create a comfortable environment that encompasses warmth and trust. The facilitator's job is to make sure each person connects the themes and patterns that the stories have created. All stories should connect in some way or another. It is also appropriate for members of the story circle to challenge one another after the storytelling has taken place. When it is time to process, members should discuss where they felt connected and focus on feelings and thought processes. The facilitator should also let everyone share responsibility for keeping track of time because it can last a while. Also, a follow-up activity should

There is plentiful evidence to show that Eastern meditation and mindfulness techniques have beneficial effects on our personal and work life [19–22]. One study showed that participants reported significant reduction in anxiety, depression, and stress levels after a 10-week mindfulness meditation program [20]. Other studies indicated that meditation could alter brain function and even change the physical structure of the human brain, impacting the concept of lifelong neuroplasticity [23–26]. Weaver [22] noted some of these studies showed that even novice or inexperienced meditators can rewire their brains and reap the benefits of meditative practices. These modified Eastern meditative and mindfulness techniques have

As more people are seeking peace, inner balance, and wellbeing through meditation and mindfulness practices, there is a mushrooming of interest from those in the helping profession to integrate these ancient practices into their work [27–32]. A survey by the *Psychotherapy Networker* revealed 41.4% of about 2600 therapists reported integrating certain mindfulness techniques into their professional practice [29]. An online survey by *Counseling Today,* a publication of the American Counseling Association (ACA), indicated that 87% of counselors reported adopting an integrated practice with mindfulness approaches into their professional work with clients [28]. Writers, like Meyers [28], regard meditation as a form of

Today, Falun Gong is one of the fastest emergent Chinese spiritual and meditative movement practices that is spreading throughout the world [31–33]. Large scale studies conducted in mainland China showed the tremendous health and wellness effects of Falun Gong [32, 34–36]. Likewise, various studies outside of mainland China and around the world indicated Falun Gong's beneficial effects [33, 37–39]. There were two studies outside of China that stood out. The first was the Australian survey completed by the first author under the auspices of The University of South Australia for partial fulfillment of the Doctor of counseling degree examined the health and wellness effects of Falun Gong from the selfreports of Falun Gong practitioners [38]. It was the first empirical study with a diverse sample outside of mainland China [33, 38]. The second one, completed for the partial fulfillment of the Doctor of Philosophy in Psychology at the University

of California, Los Angeles, demonstrated that practicing Falun Gong has a beneficial effect and that long-term practice may lead to hemispheric changes in

Falun Gong has not been a subject for much research. Besides these two studies conducted under the auspices of an Australian and a US university respectively, a team of medical doctors and researchers in the United States had undertaken a pilot study to examine the effects of Falun Gong on gene expression and the role of neutrophils in Falun Gong practitioners [42]. Findings from their pilot study revealed

**186**

the brain [40, 41].

Also known as Falun Dafa, Falun Gong is a high-level Chinese self-cultivation practice for overall mind, body, and spiritual improvement [33, 46, 47]. It originated from Northeast China. Over the past two decades since its teacher and founder, Master Li Hongzhi first introduced Falun Gong to the public in 1992, there are numerous terms used to describe Falun Gong [33, 38]. Most non-Falun Gong writers concurred that Falun Gong is a form of qigong [46, 48–51] or a Buddhist qigong system [52]. Other expressions used to describe Falun include traditional Chinese religious practice, or revival of traditional Chinese spiritual practice [49, 53–56], or as a new religious movement [57–60]. Gale and Gorman-Yao [61] described Falun Gong as a cultural movement, while Ackerman [62] referred to the practice as a New Age spiritual movement.

Despite the myriad of descriptive terms and expressions, there is a mutual understanding that Falun Gong is a form of qigong, a comprehensive spiritual meditation discipline, a quasi-religious practice, or a new Chinese religious movement. Human Rights Watch Senior Advisor Spiegel [51] offered a comprehensive definition, describing Falun Gong as a synthesis of qualities:

*"A form of qigong, an ancient Chinese deep-breathing exercise system sometimes combined with meditation that enthusiasts claim promotes physical, mental, and spiritual well-being by enhancing the flow of vital energy through a person's body. It also includes elements of popular Buddhism and Daoism" (Spiegel, 2002, p. 8).*

Among practitioners, Falun Gong, an ancient Chinese spiritual discipline, is better known as Falun Dafa. The Chinese word "Fa" ([63], p. 390) refers to law or principles in the Buddha School teachings but this is not the same as the Buddhism taught by Buddha Shakyamuni or Siddhārtha Gautama. Penny states in his book, *The Religion of Falun Gong,* that the "falun" in the name Falun Gong "has a different meaning from that in Buddhism" ([64], p. 5). He describes Falun Gong as "the practice of the Wheel of the Law" (p. 5), and that Falun Dafa refers to "the Great Method of the Wheel of the Law" ([64], p. 5).

In *Zhuan Falun*, the complete teachings of Falun Gong, "Dafa," which is pronounced as "Dah-fah" simply means the "Great Law" or the "Great Way" ([63], p. 2). While Falun Dafa is more befitting and widely used in Falun Gong literature, for the purpose of this article that comprises the White Paper, many writers have consistently alluded to this Chinese spiritual discipline as Falun Gong. This is partly because Falun Gong has remained more popular and widely used across different media, popular search engines, and literature by non-Falun Gong people [33, 38].

#### **3.1 Advanced practice with ancient roots**

Most Falun Gong literature describes the practice as an ancient Chinese spiritual discipline in the Buddha tradition [31, 33, 38, 47, 65, 66]. Falun Gong, pronounced "Fah-loon Gong," is a high-level, mind-body spiritual system with its roots in both

ancient Buddhist and Taoist traditions [63, 67]. The *gong* in Falun Gong and qigong connotes exercise or practice but Falun Gong is not one at the same as practicing qigong. The *gong* in Falun Gong actually pertains to a "high-energy substance that manifests in the form of light, and its particles are fine and its density is high" ([63], p. 5). In Falun Gong, it is the cultivation of this *gong* that facilitates genuine healing, mind-body, and spiritual transformation [63] that many individuals experience. Simply put, Falun Gong, with its moral teachings and fivea meditative exercises, is a popular, tranquil cultivation practice for overall mind-body and spiritual improvement.

At the heart of the practice, Falun Gong teaches three universal principles— Truthfulness, Compassion, Forbearance—or *Zhen, Shan, Ren* in Chinese ([63], pp. 13-17). While some people in the West describe Falun Gong as a "Chinese yoga" ([47], p. 40), Falun Gong exercises are a lot simpler than yoga and do not imitate animal movements, like Indian yoga does. Falun Gong has only four standing exercises and one sitting meditation [67]. First introduced to the public in mainland China in 1992, the founder of the practice explains that Falun Gong is an advanced spiritual cultivation discipline and hence a high level form of qigong [63]. Within 7 years—from 1992 to 1999—Falun Gong rose from anonymity to become one of the fastest growing spiritual practices. On July 20, 1999, Falun Gong was illegally banned in mainland China and followers of the practice received the most horrendous persecution [33]. At the time, about 100 million people in China were practicing Falun Gong, which means that about one out of 13 Chinese people in mainland China was practicing Falun Gong [68], as a result of the practice's healing benefits.

#### **3.2 Cultivating the heart and mind**

A unique characteristic of Falun Gong lies in its focus on heart and mind cultivation and on becoming a morally upright person. Falun Gong is based on the ancient tradition of self-cultivation, transcending ordinary existence toward a higher state of being, and liberating one from the illusions of this material world. Thus, cultivation calls for letting go of desires, being virtuous and uprightness, as well as using special practices techniques to refine both the mind and body [33, 63].

Falun Gong comprises two distinctive aspects—cultivation and practice. Cultivation or self-cultivation is an Eastern concept for mind, body, and spiritual improvement [69] that is a crucial and vital aspect of traditional Chinese culture. Falun Gong underlines *xinxing* cultivation, which is, cultivating the heart and mind [63, 67]. Cultivating the heart denotes improving one's moral character—guided by the principles of truthfulness, compassion, and forbearance [63].

It must be noted that improving one's mind and heart, or moral character, requires a strong main consciousness. In Falun Gong cultivation, it is important that "the mind must be right" ([63], p. 245). According to the teachings of Falun Gong, when one's heart and mind or *xinxing* improves, one's body, mind, and spirit will naturally transform [63] and one will thereby reach optimum health and wellness. So, Falun Gong is more than just a meditation practice; it is a spiritual cultivation discipline for overall body, mind, and spiritual advancement. Of the two—cultivation versus practice—it must be noted that cultivation is far more important than the exercise practice. The latter is merely to strengthen the mechanisms in the body [67].

The practice component of Falun Gong involves a sitting meditation and four standing exercises. Each exercise has specific health-related aims and benefits [67]. Simple, yet beneficial is its health-wellness impact on millions of individuals who turn to Falun Gong for solace. From the integrative counseling perspective, Falun

**189**

*Use of Falun Gong to Address Traumatic Stress among Marginalized Clients*

Gong is a mind-body approach embodying the art of self-care as well as serving as an intervention strategy [37]. Hence, there is potential for its integration into the helping profession [32, 33, 37, 70–74], in particular for addressing traumatic stress

Practicing Falun Gong has numerous benefits. Many individuals can attest to it that Falun Gong can help to ease anxiety, stress, and traumatic stress; enhance energy and vitality; and improves the mind and body [43, 44]. Falun Gong has offered inner joy, peace, and serenity, leading to spiritual growth and enlightenment for many individuals. At the 2018 International Conference on Spirituality and Psychology, the first author, who was invited to speak about the viability of Falun Gong integration, presented three case examples on how Falun Gong was able to help individuals to overcome anxiety, depression, and post-traumatic stress

Case story examples illustrate the healing benefits of Falun Gong and its integration feasibility with counseling in helping clients toward self-healing and realizing their varied purpose in life. The ancient art of storytelling helps to provide insight into the healing effects of Falun Gong, allowing individuals who have benefitted from the practice to express their inner world and to create meaning by describing in their own words how Falun Gong has impacted and transformed their lives. For example, voice actor and author Rich Crankshaw is one such individual who has benefited tremendously from the practice. His healing from traumatic stress arising from child hood abuse was empowering: "After three days, my anxiety was lower, my stress level was lower, my depression was not as dominant, and all of a sudden, I understood that I just didn't need to smoke weed or drink beer anymore" ([75], p. 197) . Falun Gong "has been a major part of my ongoing healing and recovery" ([75], p. 198), stated

Academic research exploring the therapeutic effects of Falun Gong is still lacking. The prevailing body of Falun Gong literature exploring its beneficial effects can be classified into two groups. The first wave of enquiry was in mainland China before the persecution of Falun Gong began on July 20, 1999, while the second movement of scholarly enquiry into the beneficial effects of practicing Falun Gong took place outside of China after 1999. This section revisits some of the studies from both categories. Before 1999, a team of researchers in mainland China completed an extensive survey with a sample size of 12,731 participants from five districts in Beijing [34]. Findings from this massive survey indicated Falun Gong's effectiveness was over 99%, with a 59% cure rate. For physical and mental health, the improve-

After the onset of the persecution in 1999, some practitioners in Canada and the United States conducted the North American survey [39]. Findings from this survey supported and reinforced the results from the large-scale Beijing surveys [34]. In 2000, a single-case study for partial fulfillment of a master's degree in social science in counseling showed the beneficial use of Falun Gong in relieving burnout and posttraumatic stress [37]. Additionally, there are two reports worth citing. The first is an independent study conducted in Taiwan, which found that people who practice Falun Gong are physically and mentally healthier than the general Taiwanese population [76]. Respondents reported that practicing Falun Gong helped to eliminate unhealthy and addictive lifestyle habits, such as gambling, cigarette smoking, alcohol addiction, and chewing betel nuts that is a common habit in Asian countries [76]. Lio et al.'s study also highlighted Falun Gong's medical cost-saving potential, showing a 50% decrease in the use of medical health insurance for Falun Gong

Crankshaw who has an English-Mohawk indigenous ancestry.

ment rate was over 80 and 97%, respectively [34].

*DOI: http://dx.doi.org/10.5772/intechopen.93301*

among marginalized clients.

**3.3 Benefits**

disorder [71, 72].

Gong is a mind-body approach embodying the art of self-care as well as serving as an intervention strategy [37]. Hence, there is potential for its integration into the helping profession [32, 33, 37, 70–74], in particular for addressing traumatic stress among marginalized clients.

#### **3.3 Benefits**

*Psychosomatic Medicine*

improvement.

ing benefits.

**3.2 Cultivating the heart and mind**

ancient Buddhist and Taoist traditions [63, 67]. The *gong* in Falun Gong and qigong connotes exercise or practice but Falun Gong is not one at the same as practicing qigong. The *gong* in Falun Gong actually pertains to a "high-energy substance that manifests in the form of light, and its particles are fine and its density is high" ([63], p. 5). In Falun Gong, it is the cultivation of this *gong* that facilitates genuine healing, mind-body, and spiritual transformation [63] that many individuals experience. Simply put, Falun Gong, with its moral teachings and fivea meditative exercises, is a popular, tranquil cultivation practice for overall mind-body and spiritual

At the heart of the practice, Falun Gong teaches three universal principles— Truthfulness, Compassion, Forbearance—or *Zhen, Shan, Ren* in Chinese ([63], pp. 13-17). While some people in the West describe Falun Gong as a "Chinese yoga" ([47], p. 40), Falun Gong exercises are a lot simpler than yoga and do not imitate animal movements, like Indian yoga does. Falun Gong has only four standing exercises and one sitting meditation [67]. First introduced to the public in mainland China in 1992, the founder of the practice explains that Falun Gong is an advanced spiritual cultivation discipline and hence a high level form of qigong [63]. Within 7 years—from 1992 to 1999—Falun Gong rose from anonymity to become one of the fastest growing spiritual practices. On July 20, 1999, Falun Gong was illegally banned in mainland China and followers of the practice received the most horrendous persecution [33]. At the time, about 100 million people in China were practicing Falun Gong, which means that about one out of 13 Chinese people in mainland China was practicing Falun Gong [68], as a result of the practice's heal-

A unique characteristic of Falun Gong lies in its focus on heart and mind cultivation and on becoming a morally upright person. Falun Gong is based on the ancient tradition of self-cultivation, transcending ordinary existence toward a higher state of being, and liberating one from the illusions of this material world. Thus, cultivation calls for letting go of desires, being virtuous and uprightness, as well as using

special practices techniques to refine both the mind and body [33, 63].

the principles of truthfulness, compassion, and forbearance [63].

Falun Gong comprises two distinctive aspects—cultivation and practice. Cultivation or self-cultivation is an Eastern concept for mind, body, and spiritual improvement [69] that is a crucial and vital aspect of traditional Chinese culture. Falun Gong underlines *xinxing* cultivation, which is, cultivating the heart and mind [63, 67]. Cultivating the heart denotes improving one's moral character—guided by

It must be noted that improving one's mind and heart, or moral character, requires a strong main consciousness. In Falun Gong cultivation, it is important that "the mind must be right" ([63], p. 245). According to the teachings of Falun Gong, when one's heart and mind or *xinxing* improves, one's body, mind, and spirit will naturally transform [63] and one will thereby reach optimum health and wellness. So, Falun Gong is more than just a meditation practice; it is a spiritual cultivation discipline for overall body, mind, and spiritual advancement. Of the two—cultivation versus practice—it must be noted that cultivation is far more important than the exercise practice. The latter is merely to strengthen the mecha-

The practice component of Falun Gong involves a sitting meditation and four standing exercises. Each exercise has specific health-related aims and benefits [67]. Simple, yet beneficial is its health-wellness impact on millions of individuals who turn to Falun Gong for solace. From the integrative counseling perspective, Falun

**188**

nisms in the body [67].

Practicing Falun Gong has numerous benefits. Many individuals can attest to it that Falun Gong can help to ease anxiety, stress, and traumatic stress; enhance energy and vitality; and improves the mind and body [43, 44]. Falun Gong has offered inner joy, peace, and serenity, leading to spiritual growth and enlightenment for many individuals. At the 2018 International Conference on Spirituality and Psychology, the first author, who was invited to speak about the viability of Falun Gong integration, presented three case examples on how Falun Gong was able to help individuals to overcome anxiety, depression, and post-traumatic stress disorder [71, 72].

Case story examples illustrate the healing benefits of Falun Gong and its integration feasibility with counseling in helping clients toward self-healing and realizing their varied purpose in life. The ancient art of storytelling helps to provide insight into the healing effects of Falun Gong, allowing individuals who have benefitted from the practice to express their inner world and to create meaning by describing in their own words how Falun Gong has impacted and transformed their lives. For example, voice actor and author Rich Crankshaw is one such individual who has benefited tremendously from the practice. His healing from traumatic stress arising from child hood abuse was empowering: "After three days, my anxiety was lower, my stress level was lower, my depression was not as dominant, and all of a sudden, I understood that I just didn't need to smoke weed or drink beer anymore" ([75], p. 197) . Falun Gong "has been a major part of my ongoing healing and recovery" ([75], p. 198), stated Crankshaw who has an English-Mohawk indigenous ancestry.

Academic research exploring the therapeutic effects of Falun Gong is still lacking. The prevailing body of Falun Gong literature exploring its beneficial effects can be classified into two groups. The first wave of enquiry was in mainland China before the persecution of Falun Gong began on July 20, 1999, while the second movement of scholarly enquiry into the beneficial effects of practicing Falun Gong took place outside of China after 1999. This section revisits some of the studies from both categories. Before 1999, a team of researchers in mainland China completed an extensive survey with a sample size of 12,731 participants from five districts in Beijing [34]. Findings from this massive survey indicated Falun Gong's effectiveness was over 99%, with a 59% cure rate. For physical and mental health, the improvement rate was over 80 and 97%, respectively [34].

After the onset of the persecution in 1999, some practitioners in Canada and the United States conducted the North American survey [39]. Findings from this survey supported and reinforced the results from the large-scale Beijing surveys [34]. In 2000, a single-case study for partial fulfillment of a master's degree in social science in counseling showed the beneficial use of Falun Gong in relieving burnout and posttraumatic stress [37]. Additionally, there are two reports worth citing. The first is an independent study conducted in Taiwan, which found that people who practice Falun Gong are physically and mentally healthier than the general Taiwanese population [76]. Respondents reported that practicing Falun Gong helped to eliminate unhealthy and addictive lifestyle habits, such as gambling, cigarette smoking, alcohol addiction, and chewing betel nuts that is a common habit in Asian countries [76]. Lio et al.'s study also highlighted Falun Gong's medical cost-saving potential, showing a 50% decrease in the use of medical health insurance for Falun Gong

respondents [76, 77]. In another study, a group of researchers in Russia reported a 73% improvement rate in the respondents' health and wellness [78].

Researchers from Switzerland, Taiwan, UK, and the US did a meta-analysis based on the self-reports from Chinese cancer patients between 2000 and 2015 and found that practicing Falun Gong could significantly improve survival rate for cancer patients [79]. About 97 percent (n = 147, 96.7%) indicated full symptom recovery, with 60 cases confirmed by their doctors [79].

#### **4. Discussion**

Falun Gong can be a useful alternative to existing interventions for traumatic stress because of its ability to alleviate anxiety and bring about innerpeace [33, 73]. Contemporary research that explores traumatic stress as it relates to racial bias suggests that individuals often report unhealthy and addictive lifestyles as a means of coping with the daily microaggressions. Falun Gong could help these clients to become more congruent in their perspectives on mind body connection. Falun Gong is likely to target the psychological and physical issues associated with traumatic stress and provide clients with less cognitive distress leading toward better decision-making and help clear negative thought patterns. Falun Gong can also provide clients with a cost-effective intervention that makes it accessible to clients across the socio-economic spectrum.

Moreover, Falun Gong is an intervention that can be conducted within systems, such as family, work, and organization, in much the same way mindfulness and meditation have been introduced into various workplace [21, 80–83]. The use of Falun Gong within the family system is likely to impact interpersonal conflicts that may result from ongoing stressors within the social environment. Parent-child, sibling, and couple interactions can be improved when family members engage in Falun Gong practices and activities together. In this manner, families can share in countering the effects of institutional racism and Falun Gong can serve as a coping mechanism for reducing the associated stress.

Using the mindful practice of Falun Gong in the workplace, employees can become much more productive when they are able to reduce the stress related to workloads and any differential treatment that some members from within the working environment may experience. This would allow for opportunities to clearly think through forms of advocacy for themselves and for others who may be victims of microaggressions in the workplace. On the organizational level, Falun Gong can support members in finding harmony, improving collaboration efforts, and thinking clearly about strategic goals and initiatives for the organization. Rather than becoming riddled with interpersonal conflicts due to competing demands, issues of power and control among various factions, or challenges caused by lack of member engagement or financial concerns, organizational leaders are able to stay focused on how to work toward a unified goal.

Although Falun Gong, as a mindfulness and meditative practice, is still new to the mental health professions, it is promising as an effective intervention, particularly when working with marginalized clients who experience traumatic stress in a diverse and multiple settings. In fact, various studies have shown that practicing mindfulness and meditation may be beneficial for both the therapists and their clients. For instance, in Germany, a team of researchers found that therapists' personal training in meditation could have favorable impact on clients [84]. The randomized double blind controlled study conducted by Grepmair et al. [84] revealed that it did not matter whether or not the clients themselves practice meditation or know that

**191**

sessions.

*Use of Falun Gong to Address Traumatic Stress among Marginalized Clients*

their therapist practices meditation. Their findings revealed that the outcome was

In another study, Schure et al. [85] emphasized the relevance of preparing counseling students with mindfulness techniques as self-care skills and intervention strategies that students could later incorporate into their professional work. In an earlier study, Gale and Gorman-Yao [61] discussed the health-wellness potential and cultural implications of integrating Falun Gong into nursing for a "culturally appropriate and sensitive nursing care to all clients" (p. 124), a concept that counseling educators and professionals could consider and implement in teaching

Suggestions for improving clinical practice include the inclusion of traumatic stress theory and techniques in pre-service training as well as professional development training for practitioners. Additionally, it is recommended that clinical faculty enhance their knowledge about traumatic stress so that it can be integrated into the various curricula in mental health training programs. Pre-service and practitioner training could focus on integrating Falun Gong in to working with clients assessed with historical trauma. For faculty, web-based training would enhance their knowledge about traumatic stress, historical trauma, and associated interventions for clients from marginalized communities, as well as learning about

The need for proper training in the mindful practice of Falun Gong via counseling programs in tertiary institutions is crucial. It is hoped an integrated approach with Falun Gong will be part of a training program. While other types of mindfulness techniques are widely taught, there are hardly any institutions that currently

The authors offer a recommendation for future research to focus on studies that explore and document the use of Falun Gong to work with clients who have been assessed with traumatic stress. There is a dire need for these studies to provide solid evidence of the positive link between practicing Falun Gong and traumatic stress mainstream and minority communities. For Falun Gong's integration viability, there is thus a need for pioneers in the field to shoulder greater responsibilities, emphasize on-going research, evaluations, and implement proper documentation on the health and wellness effects of Falun Gong, its auxiliary and integrative potential for the health and wellbeing of counseling and health professionals,

The authors wish to thank counseling students from the Xavier University of Louisiana who participated in the mindfulness practice of Falun Gong training sessions. Special thanks to Dr. Cirecie West-Olatunji, Professor and Director of the Center for Traumatic Stress Research Center for organizing the double training

offer the mindful practice of Falun Gong as part of their curriculum.

*DOI: http://dx.doi.org/10.5772/intechopen.93301*

**5. Recommendations for Practice**

still favorable for the clients.

programs.

Falun Gong.

**6. Conclusion**

clients, and the community at large.

**Acknowledgements**

*Use of Falun Gong to Address Traumatic Stress among Marginalized Clients DOI: http://dx.doi.org/10.5772/intechopen.93301*

their therapist practices meditation. Their findings revealed that the outcome was still favorable for the clients.

In another study, Schure et al. [85] emphasized the relevance of preparing counseling students with mindfulness techniques as self-care skills and intervention strategies that students could later incorporate into their professional work. In an earlier study, Gale and Gorman-Yao [61] discussed the health-wellness potential and cultural implications of integrating Falun Gong into nursing for a "culturally appropriate and sensitive nursing care to all clients" (p. 124), a concept that counseling educators and professionals could consider and implement in teaching programs.

#### **5. Recommendations for Practice**

Suggestions for improving clinical practice include the inclusion of traumatic stress theory and techniques in pre-service training as well as professional development training for practitioners. Additionally, it is recommended that clinical faculty enhance their knowledge about traumatic stress so that it can be integrated into the various curricula in mental health training programs. Pre-service and practitioner training could focus on integrating Falun Gong in to working with clients assessed with historical trauma. For faculty, web-based training would enhance their knowledge about traumatic stress, historical trauma, and associated interventions for clients from marginalized communities, as well as learning about Falun Gong.

The need for proper training in the mindful practice of Falun Gong via counseling programs in tertiary institutions is crucial. It is hoped an integrated approach with Falun Gong will be part of a training program. While other types of mindfulness techniques are widely taught, there are hardly any institutions that currently offer the mindful practice of Falun Gong as part of their curriculum.

#### **6. Conclusion**

*Psychosomatic Medicine*

**4. Discussion**

spectrum.

respondents [76, 77]. In another study, a group of researchers in Russia reported a

Researchers from Switzerland, Taiwan, UK, and the US did a meta-analysis based on the self-reports from Chinese cancer patients between 2000 and 2015 and found that practicing Falun Gong could significantly improve survival rate for cancer patients [79]. About 97 percent (n = 147, 96.7%) indicated full symptom

Falun Gong can be a useful alternative to existing interventions for traumatic stress because of its ability to alleviate anxiety and bring about innerpeace [33, 73]. Contemporary research that explores traumatic stress as it relates to racial bias suggests that individuals often report unhealthy and addictive lifestyles as a means of coping with the daily microaggressions. Falun Gong could help these clients to become more congruent in their perspectives on mind body connection. Falun Gong is likely to target the psychological and physical issues associated with traumatic stress and provide clients with less cognitive distress leading toward better decision-making and help clear negative thought patterns. Falun Gong can also provide clients with a cost-effective intervention that makes it accessible to clients across the socio-economic

Moreover, Falun Gong is an intervention that can be conducted within systems, such as family, work, and organization, in much the same way mindfulness and meditation have been introduced into various workplace [21, 80–83]. The use of Falun Gong within the family system is likely to impact interpersonal conflicts that may result from ongoing stressors within the social environment. Parent-child, sibling, and couple interactions can be improved when family members engage in Falun Gong practices and activities together. In this manner, families can share in countering the effects of institutional racism and Falun Gong can serve as a coping

Using the mindful practice of Falun Gong in the workplace, employees can become much more productive when they are able to reduce the stress related to workloads and any differential treatment that some members from within the working environment may experience. This would allow for opportunities to clearly think through forms of advocacy for themselves and for others who may be victims of microaggressions in the workplace. On the organizational level, Falun Gong can support members in finding harmony, improving collaboration efforts, and thinking clearly about strategic goals and initiatives for the organization. Rather than becoming riddled with interpersonal conflicts due to competing demands, issues of power and control among various factions, or challenges caused by lack of member engagement or financial concerns, organizational leaders are able to stay focused on

Although Falun Gong, as a mindfulness and meditative practice, is still new to the mental health professions, it is promising as an effective intervention, particularly when working with marginalized clients who experience traumatic stress in a diverse and multiple settings. In fact, various studies have shown that practicing mindfulness and meditation may be beneficial for both the therapists and their clients. For instance, in Germany, a team of researchers found that therapists' personal training in meditation could have favorable impact on clients [84]. The randomized double blind controlled study conducted by Grepmair et al. [84] revealed that it did not matter whether or not the clients themselves practice meditation or know that

73% improvement rate in the respondents' health and wellness [78].

recovery, with 60 cases confirmed by their doctors [79].

mechanism for reducing the associated stress.

how to work toward a unified goal.

**190**

The authors offer a recommendation for future research to focus on studies that explore and document the use of Falun Gong to work with clients who have been assessed with traumatic stress. There is a dire need for these studies to provide solid evidence of the positive link between practicing Falun Gong and traumatic stress mainstream and minority communities. For Falun Gong's integration viability, there is thus a need for pioneers in the field to shoulder greater responsibilities, emphasize on-going research, evaluations, and implement proper documentation on the health and wellness effects of Falun Gong, its auxiliary and integrative potential for the health and wellbeing of counseling and health professionals, clients, and the community at large.

#### **Acknowledgements**

The authors wish to thank counseling students from the Xavier University of Louisiana who participated in the mindfulness practice of Falun Gong training sessions. Special thanks to Dr. Cirecie West-Olatunji, Professor and Director of the Center for Traumatic Stress Research Center for organizing the double training sessions.

### **Note**


### **Author details**

Margaret Trey1 \* and Cirecie West-Olatunji2

1 Sibubooks; Center for Psychology and Mind Studies (Researcher & Author of two books on the effects of Falun Gong), New York, USA

2 Center for Traumatic Stress Research, Xavier University of Louisiana, New Orleans, United States

\*Address all correspondence to: sibubooks@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**193**

*Use of Falun Gong to Address Traumatic Stress among Marginalized Clients*

in Black college students coping with race-related stress. Journal of Black Psychology. 2004;**30**:208-228

[9] Rich JA, Grey CM. Pathways to recurrent trauma among young Black men: Traumatic stress, substance abuse, and the "code of the street". American Journal of Public Health.

[10] Scott LD Jr. Cultural orientation and coping with perceived discrimination among African American youth. Journal of Black Psychology. 2003;**29**:235-256

[11] Seaton EK. An examination of the factor structure of the index of racerelated stress among a sample of African American adolescents. Journal of Black

[12] Bryant-Davis T, Ocampo C. The trauma of racism: Implications for counseling, research, and education. The Counseling Psychologist.

[13] Constantine MG, Sue DW. Factors contributing to optimal human functioning in people of color in the United States. The Counseling Psychologist. 2006;**34**(2):228-244. DOI: 10.1177/0011000005281318

Psychology. 2003;**29**:292-307

2005;**95**:816-824

2005;**33**:574-578

[14] Griffen B. Promoting

Supervision. 1993;**33**:2-9

jcop.20010

professionalism, collaboration, and advocacy. Counselor Education and

[15] Boydell KM, Volpe T. A qualitative examination of the implementation of a community-academic coalition. Journal of Community Psychology. 2004;**32**:357-374. DOI: 10.1002/

[16] Frazier KN, West-Olatunji C, St Juste S, Goodman R. Transgenerational trauma & CSA: Reconceptualizing cases involving young survivors of child

*DOI: http://dx.doi.org/10.5772/intechopen.93301*

[1] Harrell JP, Hall S, Taliaferro J. Physiological responses to racism and discrimination. American Journal of Public Health. 2003;**93**:243-248. DOI:

10.2105/AJPH.93.2.243

[2] Goodman RD, Miller MD, West-Olatunji CA. Traumatic stress, socioeconomic status, and academic achievement among primary school students. Psychological Trauma Theory Research Practice and Policy. 2012;**4**(3):252. DOI: 10.1037/a0024912

[3] Goodman RD, West-Olatunji CA. Educational hegemony, traumatic stress, and African American and Latino American students. Journal of Multicultural Counseling and Development. 2010;**38**(3):176-186

[4] Ibrahim FA, Roysircar-Sodowsky G,

Ohimshi H. Worldview: Recent developments and needed directions. In: Ponterotto JG, Casas JM, Suzuki LA, Alexander CM, editors. Handbook of multicultural counseling. 2nd ed. Thousand Oaks, CA: Sage Publications;

[5] West-Olatunji C, Sanders T,

practices among low-income parents/guardians of academically successful fifth grade African American children. Multicultural Perspectives. 2010;**12**(3):138-144. DOI:

10.1080/15210960.2010.504475

1997;**32**(127):625-634

[6] Chung WS, Pardeck JT. Treating powerless minorities through an ecosystem approach. Adolescence.

[7] Eriksen K. Counselor advocacy: A qualitative analysis of leaders' perceptions, organizational activities, and advocacy documents. Journal of Mental Health Counseling. 1999;**21**:33-49

[8] Danoff-Burg S, Prelow HM,

Swenson RR. Hope and life satisfaction

Barden S, Behar-Horenstein L. Parenting

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#### **References**

*Psychosomatic Medicine*

**Note**

**192**

**Author details**

Margaret Trey1

New Orleans, United States

\* and Cirecie West-Olatunji2

books on the effects of Falun Gong), New York, USA

\*Address all correspondence to: sibubooks@gmail.com

provided the original work is properly cited.

1 Sibubooks; Center for Psychology and Mind Studies (Researcher & Author of two

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1.This paper and its topic were initially presented at the 2019 International Conference on Spirituality and Psychology in Bangkok, Thailand, by the co-authors. The first author has included more information about Falun Gong from the original White Paper that focuses on integration and the use of Falun Gong

2.For citation purposes in this book chapter, the authors have used the Fair Winds Press publication of *Zhuan Falun*. However, it is recommended that readers refer to the 2014 hardcover edition of *Zhuan Falun* for references: [86].

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**198**

### *Edited by Ignacio Jáuregui Lobera*

Modern psychosomatic medicine is a comprehensive framework for a holistic (biopsychosocial) perspective of illnesses and patient care. It highlights the influence of psychosocial factors on health, the interaction between psychosocial and biological factors in the course and outcome of diseases, and a whole perspective with respect to treatments. This book discusses holistic approaches to both organic and psychopathological diseases. Over three sections, authors address psychosomatic approaches to fibromyalgia, palliative care, anxiety and depression, obesity, and traumatic stress disorders.

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Psychosomatic Medicine

*Edited by Ignacio Jáuregui Lobera*