Psychotherapy in Psychosomatic Disorders A

Survey of

Controlled Studies

Robert Kellner, MD, PhD,

MRCPsych

Published controlled studies of various psychotherapeutic in psychosomatic disorders with adequate designs have formed the basis for the following conclusions: Psychotherapeutic techniques are effective in some patients with psychosomatic disorders. Some psychosomatic disorders, for example, bronchial asthma, peptic ulcer, and migraine headaches are perhaps more amenable to psychotherapy than others, for example, hypertension and ulcerative colitis. There is evidence to suggest that there are differences between the effectiveness of various psychotherapeutic techniques; a few patients differ perhaps from the rest in that they are helped most by the technique that is less effective for the major-

techniques

ity.

published reports of diverse psycho¬ therapeutic methods that have been used apparently successfully in the treatment of various psychoso¬

There matic

are

many

disorders, but

most of these are uncontrolled. The of the present report were to summarize studies purposes of various psychotherapeutic techniques in psychosomatic disorders that were either controlled or in which some form of comparison was made with the results of other treatments, and to discuss the implication of the findings. Throughout this report, the term psychosomatic dis¬ order is used to include organic disease in which emotions appear to act as precipitating or aggravating factors, and psychophysiologic reactions in which the patient is dis¬ tressed by somatic symptoms in the absence of physical disease. This report does not deal with behavior modi¬ fication in the treatment of obesity and enuresis and stud¬ ies of biofeedback. These studies appear to be outside the scope of the present report; they require separate surveys

and have been recently surveyed by others.14 (Throughout this report the terms significance and significantly are Accepted

for

publication Feb 26,

1975.

From the Department of Psychiatry, University of New Mexico School of

Medicine, Albuquerque. Reprint requests to the Department of Psychiatry, University of New Mexico School of Medicine, 930 Stanford Dr NE, Albuquerque, NM 87131 (Dr. Kellner).

used statistically and indicate that the results were at below the conventional 5% level of probability.)

or

Peptic Ulcer

study of the treatment of an organic illness psychological method was published more than two

A controlled

by

a

decades before controlled trials became common in other branches of therapeutics. Chappell and his colleagues" " published their classic study of psychotherapy in patients with peptic ulcers in 1936. The findings merit wider recog¬ nition and probably more frequent application in the treatment of peptic ulcers than is the custom at present.

Sixty-seven patients who had characteristic ulcer pains and at one reliable diagnosis of peptic ulcer participated in the ex¬ periment. The patients were recruited for the study by a news¬ paper advertisement. Forty-seven patients were in the experi¬ mental group (of these 15 dropped out early in the treatment and were apparently not followed up) and 20 in the control group. The least

authors did not describe how these two groups were selected, but the selection was somewhat biased against the experimental group in that the patients in this group had a worse prognosis: the mean duration of symptoms was longer (12 years vs 8 years), the average age was slightly higher, and more patients had had previ¬ ous surgical treatment. All patients had failed to benefit from pre¬ vious treatments. The experimental group had group lectures seven days a week for six weeks. The groups consisted of five to ten patients at one time. The treatment consisted largely of explanatory therapy (in that the relationship of emotions to gastric physiology was ex¬ plained), of suggestion and of directive therapy (which consisted largely of instructions on how to change habitual patterns of thinking). The usual interactions between the members of the group and between patients and therapist did not occur. During the experiment all patients were treated with antacids and an ulcer diet. When the patients were advised to return to a normal diet about halfway through the experiments, all except two could do so in the experimental group without recurrences of symptoms. In the control group, all but two had recurrences of symptoms as severe as that of the original condition; within two months, the remaining two patients also had recurrences that were as severe as the original symptoms. On an eight-month fol-

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low-up, 30 out of 32 patients in the experimental group were in ex¬ cellent health. On a three-year follow-up of the experimental group, ten patients remained entirely free of symptoms and five had only minor recurrences; their symptoms did not appear any worse than that of the population at large. Eleven patients had re¬ currences but regarded themselves as healthy, and confident of their ability to take care of any symptoms. Two patients had re¬ currences that were as severe as their previous illness. Three pa¬ tients could not be located.

The authors did not describe the study design in detail. The groups were apparently not chosen at random but it appears that on important variables the groups were fairly closely matched, with the control group having an apparently better prognosis at the beginning of the study. Since the assessors may have been aware which treatment the patients had, this may have biased their reporting. In spite of these flaws in the design of the study, the results suggest that the psychotherapeutic technique used con¬ tributed to the favorable outcome. The study shows strik¬ ing differences between the two groups and the patients who had been resistant to all previous treatment showed remarkable improvement at the end of psychotherapy and on

follow-up.

Orgel7 treated with psychoanalysis 15 psychoneurotic patients who also had chronic peptic ulcers. Five patients discontinued treatment and ten patients completed it. The duration and sever¬ ity of the illnesses were similar for the patients in these two groups. The follow-up period ranged from 10 to 22 years. All five patients who terminated treatment continued to have symptoms and four of these had complications, either hemorrhage or perfo¬ ration. None of the ten patients who completed psychoanalysis had recurrences of symptoms. The control group in this study was inadequate. Pa¬ tients who seek treatment and terminate prematurely are likely to differ from those who persevere, and, therefore, do not constitute a valid control group. Moreover, the au¬ thor was apparently the only assessor of outcome and this may have biased the results further. However, the re¬ sponse to treatment of the patients who persevered ap¬ pears to have been extremely good and was in striking contrast to those who discontinued. The findings suggest that the patients who completed treatment had benefited from psychoanalysis. Ulcerative Colitis

Grace et al,8 in a retrospective study, compared the out¬ of ulcerative colitis patients (group 1) who had psy¬ chotherapy in addition to routine medical treatment and a matched group of patients (group 2) who had only routine treatment. The groups were matched on a number of vari¬ ables such as age, weight loss, roentgenographic and proctoscopic findings, and duration of illness. There were 34 patients in each group, 24 women and ten men. Another control group (group 3) comprised of all the remaining pa¬ tients with ulcerative colitis were treated at the same hos¬ come

pital. The treatment in the psychotherapy group was aimed largely at stress in the life of the patients." The follow-up pe¬ riod lasted for two years or longer. Since patients in group 3 are not comparable to those in the other two groups, only the results with groups 1 and 2 are summa-

"alleviating

rized here: There was a greater number of operations, complica¬ tions, and deaths in group 2 than there were in group 1. The time spent in the hospital was considerably shorter for group 1 and somewhat more patients showed substantial improvements on

roentgenographic findings.

The authors do not state how the patients were chosen for psychotherapy. Since this was a retrospective study, the patients who had psychotherapy were either selected or self-selected for psychotherapy and thus may have dif¬ fered from the control group on important psychological variables, such as motivation and perseverance. The au¬ thors carried out the evaluation of both groups and were aware which patient had which treatment because they had treated the patients themselves, and this could have biased their assessment. O'Connor and his colleagues9 reported another retro¬

spective study.

Fifty-seven patients who had either psychotherapy or psycho¬ analysis were matched with another 57 patients on four variables: the severity of illness in the first year of the disease, sex of pa¬ tient, age at onset, and the use of steroids. None of the patients had been ill for less than five years. The emphasis on evaluating outcome was on recorded data at the time of observation. These were as follows: (1) proctoscopic findings; (2) description of symptoms, such as diarrhea and amount of blood in stools; (3) rating of personal effectiveness, such as being able to work, being able to enjoy leisure time, and effi¬ ciency at work; and (4) the number of patients requiring surgery. Other changes, such as the number of admissions to the hospital, were also recorded. Thirty-eight patients were treated in psychoanalytically ori¬ ented psychotherapy on the average of two visits per week for one to two years. Thirteen patients were seen in short-term therapy, none of whom had more than 20 sessions. Six patients were treated by psychoanalysis. Originally, there were 102 patients who had been treated by psychotherapy. Forty-five were eliminated from this study be¬ cause they did not have a minimum five-year follow-up or did not have recorded proctoscopic or symptomatic ratings. Most of the ratings by physicians of the symptomatic course and the proctoscopic findings were carried out before this study was undertaken. In the remaining cases, in a large proportion, the physicians were unaware which patients had psychotherapy. The matching of patients with controls was carried out at the end of the follow-up (A. Karush, written communication, 1964). Most patients in the psychotherapy group had been diagnosed as suffering from various psychiatric disorders, whereas in the control group there was "less evidence of psychological distur¬ bance." On follow-up, lasting to 25 years, there were nine deaths in each group; 15 patients required colectomy or subtotal colectomy in the psychotherapy group and 18 in the control group. In the control group, the rate of surgery was higher in the early years but the rates in the psychotherapy group began to increase later dur¬ ing the follow-up. Comparison of ratings of proctoscopy reports showed a gain by the psychotherapy group over the control group and, similarly, there was a gain in the symptomatic course of the psychotherapy group on follow-up; there was no improvement in the control group. The type of psychotherapy, the orientation of the therapist, and the number of sessions was found to be unrelated to the physio¬ logical improvement; the number of sessions appeared to be re¬ lated to the degree of psychological improvement. When the results were analyzed according to the psychiatric diagnosis, it was found that there was a conspicuous symptomatic

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improvement in the patients who were not diagnosed as schizo¬ phrenic and had psychotherapy. Patients diagnosed as suffering from schizophrenia had a worse outcome.

study shows a substantial improvement in the symptomatic course and in changes on proctoscopic find¬ ings in the group treated with psychotherapy. However, the number of deaths and operations was the same in both groups. The better outcome in the psychotherapy group is surprising because these patients, in addition to suffering from ulcerative colitis, had conspicuous psychiatric abnor¬ malities and were probably less resilient. This study shares some of the features of the previous study of psychotherapy for patients with ulcerative colitis. The study was retrospective, the patients had been se¬ lected or self-selected for psychotherapy, and a large pro¬ portion of patients who had psychotherapy could not be This

followed up. No definite conclusions can be drawn about the effects of the treatments, but it appeared that psycho¬ therapy had favorably influenced the course of ulcerative colitis in those patients who did not suffer from schizo¬

phrenia.

Muscular Pain

Draspa's study10 differs from the others in that the pa¬ tients suffered from muscular pains for which no organic cause was found, whereas in the other controlled studies the patients had confirmed organic pathological disorder. A total of 224 patients participated; the experimental group was treated by a combination of psychotherapeutic techniques and physiotherapy, whereas a matched control group was treated with physiotherapy alone. The psychotherapeutic techniques consisted of supportive therapy, which consisted of reassuring the patients of the innocuous nature of the pain, of insight psychotherapy, and of passive and active relaxation of the affected muscle. The assessment of the degree of recovery was made by the same physicians who diagnosed the patient's condition initially. There was a significant difference in the number of patients who recovered during the study: 66 in the experimental group and 36 in the control group. The duration of the symptoms was signifi¬ cantly shorter in the experimental group and the number of at¬ tendances in the experimental group was significantly fewer than in the control group. It is not stated whether or not the assessors knew which treat¬ ment the patients had. The kinds of assessment and the uniform¬ ity of the results suggest that physiotherapy and the psycho¬ therapeutic techniques used accelerated improvement and led to a greater proportion of recoveries than physiotherapy alone.

Hypertension Titchener and others11 investigated changes in arterial hypertension in patients undergoing group psychother¬ apy. The

patients participated in a drug trial of reserpine, rauwolfia serpentina, and placebo. The first nine patients were given, in ad¬ dition to their drug treatment, group psychotherapy. Two of these patients attended more than three sessions but less than 12 ses¬ sions. Five patients attended between 12 and 26 sessions. Two pa¬ tients dropped out. The next seven consecutive patients comprised the control group. No mention is made of which patients received a drug and which the placebo. Comparison of the changes in blood pressure showed that the patients who attended group therapy had a significant increase of systolic pressure. When the total number of patients were consid-

ered

(including

those who

dropped out), there

was

also

a

signifi¬

cant increase in diastolic pressure. The authors concluded that transference and countertransference phenomena in group psy¬

chotherapy might have counteracted the beneficial effects of hypotensive drugs.

knowledge, this is the only controlled study of psychotherapy with hypertensive patients. The findings cannot be regarded as conclusive because of the small number of patients in each group, the nonrandom selection of patients for the study, and the participation in a placebo-controlled drug trial that may have con¬ To my

group

founded other treatment effects.

Bronchial Asthma Five studies have been reported on the treatment of asthma by various psychotherapeutic methods. Smith and Burns'2 carried out a controlled study of hypnosis in children suffering from asthma. The children's mean age was 11 years, and most of them had suffered from asthma for many years. All the children in the study were regarded by the authors as adequate hypnotic subjects. There were 25 children in the treated group. A sequential analysis was used. Each child was hypnotized on four occasions; a simple interview with a psychia¬ trist was used as the treatment in a control group. The children's progress was assessed by measurement of vital capacity and forced expiratory volume at the beginning of treat¬ ment, before and after each hypnotic session, and at the end of the treatment. In addition, the parents recorded attacks of wheez¬ ing, the number of bronchodialator tablets taken, and the number of times inhalers were used. The control group was abandoned because of a complete failure of any changes having been observed. When the results of the ex¬ perimental group were analyzed, there also showed that no objec¬ tive changes of any kind had occurred. Subjective improvement was claimed by "a number" of the children.

In this study, the children apparently derived no benefit from hypnotic suggestion. It is not possible to evaluate the significance of the reported subjective improvements because the control group was abandoned. There is no evi¬ dence at present that hypnosis is of value in the treatment of asthma in children. However, the children in this study had long-standing illnesses and had only a few sessions of

hypnosis.

Sciare and Crocket13 and Groen and Pelser14 examined the effects of group psychotherapy in asthmatic patients. In Sciare and Crocket's study,13 25 female patients were treated with pharmacotherapy and group psychotherapy. Nine had fewer than five sessions of group psychotherapy and the remaining pa¬ tients had a median of 16 sessions. There were several control groups comprised of patients who had pharmacotherapy only. The evaluation of outcome was carried out by the physician who pre¬ scribed the medications; the physician was aware to which treat¬ ment group the patients belonged. At the end of the study, there were no statistically significant differences between the severity and frequency of asthma in the various groups. There appeared to have been changes in the psy¬ chotherapy group in that "the patients could be differentiated from other chronic asthmatics by their robust and constructive at¬ titude towards their life situation and their asthma."

In this study group, psychotherapy had no effects on the of asthma. The design of the study appears to have been inadequate, mainly that the assessor knew which treatment the patients had received. course

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In Groen and Pelser's study,14 three groups were compared: (1) patients treated by routine medical methods without adrenocorticotropic hormone (ACTH) (N 114); (2) patients treated with routine medical methods and ACTH (N 35); and (3) patients with group therapy and, if necessary, with routine medical methods with or without ACTH (N 33). =

=

=

The base line data for groups 1 and 3 were obtained from charts of asthmatic patients attending the same clinic and data for group 2 from the charts of another clinic. The follow-up was prospective and ranged from 13 months to six years. The three groups were similar in social class, sex, and severity of the disease. The psychotherapy group was on the average five years younger than the other groups. There were also differences in the duration of follow-up among the three groups. A comparison of outcome showed that recovery (meaning ab¬ sence of asthmatic attacks), "index of benefits" (meaning percent¬ age of improved minus percentage of deteriorated), and the num¬ ber of patients who became worse or died significantly favored the psychotherapy group over the other groups. When the groups were matched by age and sex, the "index of benefits" remained significantly higher in the psychotherapy group, but the difference in mortality, which was statistically sig¬ nificant before, although still greater in the control groups, failed to remain significant. Rorschach responses before and after treatment of patients treated with psychotherapy were compared with those of a ran¬ dom sample of patients who had routine treatment. The psycholo¬ gist who assessed the Rorschach protocols did not know which treatment the patient had received. All changes were in the ex¬ pected direction and two of four differences among the groups reached a statistically significant level.15

This study shows substantial differences in outcome between the group treated with psychotherapy and the groups that had only routine treatment. However, the groups were not randomly selected and, although appar¬ ently comparable, they may have differed on important variables. The results suggest that the patients' asthma improved as a result of group psychotherapy but no defi¬ nite conclusions can be drawn from this study. The differ¬ ences in Rorschach responses suggest that group therapy lead to a better psychological adjustment. Maher-Loughnan and colleagues1" carried out a con¬ trolled study of hypnosis in adults suffering from bron¬ chial asthma. New patients who attended a chest clinic with the complaint of asthma were included in this study. Patients who had also other chronic chest disorders, such as bronchiectasis, and other unsuit¬ able patients, for example, those with a history of psychosis, were excluded. Sixty-two patients were divided into a hypnosis group and a control group. The control group was given an inhaler containing a new effective bronchodilator, whereas the hypnosis group had no change in their medication. The patients in the hyp¬ nosis group had ten sessions of direct therapeutic suggestions un¬ der hypnosis. They were also taught autohypnosis and encouraged to practice autohypnosis for half an hour each day. The study lasted for six months. Fifty-five patients completed six months of treatment. In the hypnosis group, there was both a significantly greater reduction in reported wheezing and there was a significantly greater de¬ crease in the use of bronchodilators. Patients who were easy to hypnotize achieved most progress, whereas patients who were dif¬ ficult to hypnotize achieved least. Patients in light trance did least well, whereas patients in medium and deep trance showed similar improvement. Patients who achieved autohypnosis did much bet-

ter than the few patients who

were

not able to learn

autohypnosis.

discussed with those of the larger con¬ The findings trolled study that was carried out by the British Tubercu¬ losis Association17 and that is summarized next: are

patients were accepted for the trial. Two treat¬ compared: (1) hypnosis; and (2) the teaching of breathing exercises combined with bodily relaxation. The patients in group 1 were treated once a month by direct hypnotic suggestion; they were taught autohypnosis and in¬ structed to practice autohypnosis each day. Suggestions were given that the patient would derive the same benefit from auto¬ hypnosis as from hypnosis. The patients in group 2 were taught how to relax physically and were taught special breathing exer¬ cises. An illustrated booklet of instructions was given to the pa¬ tients and they were instructed to carry out the treatment for 15 minutes each day. The study lasted for 12 months. The outcome was assessed as follows: (1) the patients reported the amount and frequency and intensity of wheezing in special diaries; (2) the amount of bronchodilators used; (3) monthly recording of forced expiratory volume and vital capacity were made; and (4) at the end of the year, an independent assessment was made by physicians who were unaware of which treatment the patients had had. Significantly more patients were withdrawn as treatment fail¬ ures from the control group (N 17) than from the hypnosis group (N 7). There was a tendency for improvement in both groups. For ex¬ ample, the wheezing score improved by two thirds in the hypnosis group and by half in the control group. There were similar differ¬ A total of 252

ments

were

=

=

between the uses of bronchodilators. Neither of these two differences reached a statistically significant level for the whole group but for both, the differences were significant in women. There were only small differences between the changes in the res¬ piratory function tests. Only in the hypnosis group was there any significant difference in the changes from zero. There were signif¬ icant differences between the ratings of changes: independent clinical assessors rated 59% of the hypnosis group "very much bet¬ ter," whereas only 43% in the control group received this rating. Trends during the year expressed as the percentage of changes for the whole period of the trial were examined. There was a sig¬ nificant reduction of the wheezing score in the hypnosis group as compared to the control group. Nine physicians participated in the trial. Of these, only four had previous experience in hypnosis. Experienced physicians had sig¬ nificantly better results than inexperienced physicians. ences

These studies showed several differences in outcome be¬ patients treated with hypnosis and those treated by other methods. In the second study, these results were achieved in spite of one half of the physicians having been inexperienced in hypnosis; moreover, patients in the con¬ trol groups in both studies were given treatments that are believed to be effective: In the first study, a new effective bronchodilator was prescribed with the suggestion that the new treatment would be helpful, and, in the second study, the patients in the control group were treated with breathing exercises, relaxation, and, probably inadver¬ tently, suggestion was also employed. Hypnotic suggestions combined with pharmacotherapy apparently had beneficial effects on the course of bronchial asthma; this effect appeared to be more noticeable in pa¬ tients who were good hypnotic subjects; the results were somewhat better with female patients, and when the treatment was carried out by experienced hypnotists. tween

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Moore18 compared in a crossover study the effects of three treatments in bronchial asthma. Twelve consecutive patients (six adults and six children) with intermittent asthma who were attending a chest clinic included in the study. No selection on grounds of pre¬ dominating psychological causes was made. The patients were moderately to severely handicapped; the mean number of asth¬ matic attacks was three per week. Subjective changes were measured by asking the patient to note the number of days on which attacks of wheezing occurred. The maximum peak flow (MPF) on the Wright Peak Flow meter was used as the measure of respiratory function and improvement in the MPF was also measured as a percentage of the total MPF af¬ ter isoproterenol (Isoprenaline) inhalation. An incomplete balanced-block design was used. The three treat¬ ments used were as follows: (1) The patients learned relaxation based on the Schultz' autogenic training and on Jacobson's pro¬ gressive relaxation: relaxing each muscle group producing a re¬ laxed state (merging with light hypnosis). The patients were in¬ structed to practice five minutes at home twice a day. (2) Relaxation with suggestion: Relaxation was induced as above; in addition, it was suggested to the patient that he would be a more relaxed person. (3) Relaxation with desensitization in imagery (re¬ ciprocal inhibition)20: Three hierarchies of graded situations, each based on asthmatic attacks, were constructed; one based on any situation productive of an allergic or infective reaction, one on a psychological stress, and one on a psychodynamic formulation. Each treatment was given for half an hour at weekly intervals for a period of two months with one week of rest between the severe were

treatments.

Subjective improvement occurred with all three treatments. The differences between the subjective reports were not signifi¬ cant.

Improvement in MPF occurred with all three treatments. The improvement with desensitization was significantly greater than with the other two treatments. The percentage efficiency (the per¬ centage of the MPF after inhalation of isoproterenol) increased significantly more with desensitization than with the other treat¬ ments.

Although

the author assessed the results herself and may have introduced a bias, the results in this study are remarkable largely because the treatment effects were achieved with only a few sessions, the number of patients in each group were small, and there were noticeable dif¬ ferences between the treatments in their effects on res¬ piratory functions. Diseases of the Skin Williams20 compared the effect of didactic counseling of the mother on the course of atopic eczema in the child with that of routine dermatological treatment.

Fifty-three children with chronic flexural eczema were included study: 33 in the experimental group and 20 in the control group. The method of allocating patients to the groups is not de¬ scribed. The children in the experimental group had a "minimum of bland topical therapy; the physician explained to the mother in the

how to behave to fulfill the child's emotional needs." After this ini¬ tial discussion, the mother and child were seen at increasing inter¬ vals, "mainly for the purpose of counseling." The total number of sessions is not listed. The patients in the control group were treated by application of 1% coal tar ointment with the occasional addition of ammoniated mercury. Phénobarbital sedation was given "in a few instances for only a short period." The children were followed up for 24 months. Apparently, the author assessed the outcome himself.

Fifteen percent of the children in the experimental group and 2% in the control group were free from dermatitis on follow-up. The rate of recovery was decidedly faster in the experimental group than in the control group.

Although the findings in this study suggest that didac¬ tic counseling of the mother had a beneficial effect on the course of atopic eczema of the child, it is not certain whether the two groups were comparable. Moreover, the therapist also having been the assessor may have biased the findings. Zhukov21 evaluated the effect of hypnosis on dermato¬ logie disorders. Patients with eczema (N 270), various forms of neurodermatitis (N 166), and psoriasis (N 144) were each divided into a treatment group (treated with 17 sessions of hypnosis) and a con¬ trol group. All patients were at two seaside resorts in the Soviet Union where they were taking regular sulphur baths. The method of allocating patients to the treatments is not described nor whether the assessor knew which treatment the patient had, nor whether the patients had any additional treatments. In all three experimental groups there was a noticeably greater proportion of patients who were rated as having completely recov¬ ered or showing substantial improvement than were in the control groups. A follow-up questionnaire was mailed to the patients. Ac¬ cording to the author, the "answers overwhelmingly testified to the permanent nature of the improvement." =

=

=

The findings suggest that the patients with eczema, neurodermatitis, and psoriasis benefited from treatment with hypnosis. However, no definite conclusions can be drawn from this report because it is not possible to judge from the description of the study whether or not the de¬

sign was adequate, for example, whether or not the exper¬ imental groups and control groups were comparable. Brown and Bettley22 compared the effects of a combina¬ tion psychiatric treatment and dermatologie treatment with that of dermatologie treatment alone in patients with

eczema.

The allocation of patients to the two treatment groups was ran¬ dom. About half of the patients who received psychiatric treat¬ ment had psychotherapy and received psychotropic drugs, very few received drugs alone, and the remainder had various psy¬ chotherapeutic techniques and no psychotropic drug therapy. The psychiatric treatment lasted for four months. Eighty-two patients participated and of these 72 could be followed up for 18 months. Before treatment, the patients were rated on a symptom rating scale, their motivation was rated, and they were administered the Cornell Medical Index. The assessment of the improvement in ec¬ zema was carried out by the patients themselves and indepen¬ dently by the dermatologist who was apparently unaware of which of the patients had had psychiatric treatment. There was a nonsignificant trend for patients who received psy¬ chiatric treatment to show a larger proportion of recoveries than those who had dermatologie treatment alone. Additional analysis disclosed that patients with high Cornell Medical Index scores im¬ proved more with psychiatric treatment than patients who had low scores. Patients who had been judged before the study to have had relevant psychological events preceding the onset of eczema had a significantly better outcome with psychiatric treatment than without. Among the patients who had no psychiatric treat¬ ment, the outcome varied with several prestudy characteristics: those who had been judged to be highly motivated for psychother¬ apy had a poor outcome and those who were judged to have a low motivation for psychotherapy had a good outcome. Apparently,

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patients with high symptom rating scale scores, who experienced a relevant psychological event before the onset of the eczema and were highly motivated for psychotherapy and did not receive psy¬ chiatric treatment, had the worst outcome.

No separate analyses are reported for patients who re¬ ceived a combination of psychotherapy and psychotropic drugs, and for those who received psychotherapy alone or drugs alone. The differences between the two treatment groups in this study may have been caused, in part, by the effects of psychotropic medications. The findings suggest that patients with eczema who have certain character¬ istics benefit from psychiatric treatment. In patients with eczema who have low motivation for psychiatric treat¬ ment and a low level of emotional disturbance, psycho¬ therapy might be contraindicated.

Warts In several studies, the effects of waking suggestion and those of hypnotic suggestion on the remission of warts were examined. Studies with waking suggestion are sum¬ marized first. In 1931, Memmesheimer and Eisenlohr23 published their con¬ trolled study of the effects of suggestion on patients with warts. This is apparently the first published controlled study of a treat¬ ment of a physical disorder by psychological means. A total of 140 patients with either common warts or plane warts were included in the study. One half were treated with suggestion (verbal sug¬ gestion, painting of the warts with méthylène blue, and, in a few cases, a faradic current was applied to the warts); the other half of the patients comprised an untreated control group. The study showed that there was a substantially greater proportion of re¬ missions in the early months in the treatment group; after six months, there was still a tendency for the treated group to have a larger proportion of remissions, however, toward the end, remis¬ sions became more frequent in the untreated group. It appeared that suggestion had merely accelerated the recovery. Clarke24 treated patients with multiple warts by suggestion using a mild electric shock to several groups of warts; other groups of warts, usually on the same limb, were regarded as un¬ treated controls. There was no evidence that patients with warts treated by suggestion disappeared more rapidly. Sinclair-Gieben and Chalmers25 reported a remarkable outcome in a study of treatment of patients with warts by hypnosis. Four¬ teen patients who had multiple warts for at least six months were examined. Ten of these patients were found to be adequate hypnotic subjects and were chosen for the study. Hypnotic suggestions were given that warts would disappear on one side of the body only. In six patients there was a complete dis¬ appearance of the warts on the suggested side of the body, whereas there was no change on the control side. In one patient, there was a complete disappearance of warts on the suggested side and the warts disappeared six weeks later on the control side. In two patients, there was a disappearance of warts on the sug¬ gested side except one large one that was fading at the time of follow-up and there was no improvement on the control side. In one patient, there was no improvement on either side of the body. This was the only patient who could not carry out posthypnotic

suggestions.

Stankler26 repeated this study using waking suggestion instead of hypnosis. Sixty-seven patients with multiple warts remained for follow-up. Twenty-two of these had lost their warts but there was no case of unilateral disappearance of warts. Tenzel and Taylor27 carried out a similar study with 20 patients. It was suggested to them under hypnosis that the warts on one

half of their body would disappear; the warts on the other side of the body were treated with waking suggestion. At the end of five weeks, there was no change in the warts. Fifteen patients were followed up by telephone after five months. Only two reported dis¬ appearance of warts on the side treated with hypnosis only and in both cases these were single warts. Thus, in this study, the out¬ come was poor and failed to show substantial differences between the two treatments. Surman and his colleagues28 used the same design as SinclairGieben and Chalmers had used and included an untreated control group. Twenty-four patients participated; 17 were hypnotized and disappearance of the warts was suggested on one side of the body only. There were substantially more warts initially on the side treated with hypnosis than on the control side, which may have biased the results, since disappearance on the treated side only was less likely. Seven patients comprised an untreated group. Af¬ ter three months there was only one patient in whom the warts disappeared more rapidly on the suggested side. One half of the patients in the treated group showed significant improvements on both sides of the body and none of the control patients showed im¬ provement. Thus, hypnosis had little or no effect on unilateral dis¬ appearance of warts but appeared to have an effect on both sides in the treated group.

The results of the studies of the treatment of warts are somewhat conflicting; no definite conclusions can be drawn because the studies differed in design and, when the design was similar, the results were not replicated. Asher29 and Ullman and Dudek30 found that the response to hypnotic suggestion in the treatment of warts de¬ pended largely on the hypnotizability of the patient; thus, differences between the samples might be one of the rea¬ sons for the differences between the results of various studies. On the whole, the findings suggest that hypnosis, and, perhaps to lesser extent, waking suggestion acceler¬ ates the remission of warts. It is uncertain at present in what proportion of patients with multiple warts unilateral disappearance can be achieved with hypnosis.

Migraine

Headaches

Mitchell and Mitchell31 described two controlled studies of behavior therapy in the treatment of migraine. In the first study there were 17 volunteers who suffered from and these randomly allocated to three groups: (1) no treatment; (2) relaxation training; and (3) a method consisting of relaxation, desensitization, and assertive training ("combined de¬ sensitization"). A battery of psychological tests was administered at regular intervals and the subjects filled in a questionnaire about each attack at the time when it occurred. The treatment consisted of 15 sessions of 50 to 60 minutes twice a week. There were only three subjects in the no treatment control group and the remainder were divided between the two treatment groups. After treatment, patients in the combined desensitization group had significantly fewer and shorter attacks than had the patients in the control group. There were no significant differences in out¬ come between the relaxation group and the no treatment control group. In the second study, 20 volunteer migraine sufferers partici¬ pated. The design of the second study was the same as that of the first with the exception that there were four groups and the treat¬ ments employed were somewhat different: (1) a no treatment group; (2) a desensitization group; (3) a combined desensitization group that consisted of patients who had no previous prophylactic pharmacotherapy; and (4) a combined desensitization group con¬ sisting of patients who had previous pharmacotherapy and who

migraine

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failed to benefit. On follow-up, the reduction in the frequency of migraine at¬ tacks was again significantly greater in the combined desensitiza¬ tion group than in the no treatment control group and also greater than in the desensitization group. There was no significant differ¬ ence in outcome between the desensitization group and the no treatment control group.

The assessment in this study was apparently not inde¬ pendent and may have been biased, but the replication of the results and the methods of evaluation of outcome sug¬ was more effective than the other treatments.

gest that combined desensitization COMMENT

In recent years, a large number of controlled studies of various psychotherapeutic techniques have been pub¬ lished,3234 but only a small proportion of these studies in¬ cluded patients with psychosomatic disorders. Yet there are fewer methodological obstacles to the evaluation of ef¬ fects of psychotherapy in these disorders than in purely psychiatric conditions; it is easier to define target symp¬ toms and more objective criteria of outcome are avail¬ able.32 In the controlled studies summarized in this report, dif¬ ferent methods of treatment were employed and only a few of the studies have been replicated. Several of the de¬ signs were either liable to bias or the description of the method was insufficient to assess the adequacy of experi¬ mental design. Only a few conclusions can be drawn from the available research evidence. There is evidence to suggest that there are substantial differences among patients who apparently suffer from the same psychosomatic disorder in their response to the same psychotherapeutic technique. For example, patients who suffered from ulcerative colitis and schizophrenia re¬ sponded less well to psychotherapy than patients with ul¬ cerative colitis who were not schizophrenic. The results suggest that some psychosomatic disorders (for example, peptic ulcers, asthma, and migraine head¬ aches) may be more amenable to psychotherapy than oth¬ ers (for example, hypertension and ulcerative colitis) but the evidence is inconclusive because there are too few ade¬ quately designed studies available. It is not possible to predict whether or not a technique that has been found effective in one psychosomatic dis¬ order will be equally effective in another. This is exem¬ plified in studies with hypnotic suggestion; patients with multiple warts, particularly if they are good hypnotic sub¬ jects, show an earlier resolution of warts when treated with hypnosis than other patients. At present there is no evidence that other psychological treatments (except, perhaps, waking suggestion) will achieve a similar dis¬ appearance of warts. Conversely, hypnosis may be less ef¬ fective than other methods in the treatment of other psychosomatic disorders as the results of the studies with asthmatic patients would suggest. The studies with asthmatic patients also illustrate the problems of choosing the most effective psychotherapeutic method. Some of these patients improved after direct sug¬ gestion under hypnosis; the evidence that asthmatic pa¬ tients are helped by insight group psychotherapy is not

conclusive at present. Desensitization by relaxation and imagery seems to be more effective than the other meth¬ ods because of greater changes in respiratory functions that occurred after desensitization than after other treat¬ ments. However, treatment results with groups tend to hide differences between the responses of individuals; even if these results are replicated, that is, if it can be con¬ clusively shown that improvement with desensitization is, on the average, greater than with other methods, this would not necessarily mean that desensitization would be the treatment of choice for all patients. A greater im¬ provement, as shown by the mean values for one group, does not disclose the failure of treatment in a few who might have benefited more from the treatment that the other group received. For example, Mason and Black3536 reported remarkable changes after hypnosis in a few pa¬ tients who were good hypnotic subjects and who suffered from asthma or allergies. These experiments were carried out without untreated control groups but careful physio¬ logical measurements were used, such as changes in the dose/response curve of the Prausnitz-Küstner reaction or abolishing responses to an allergen in the skin of one limb only. In the controlled studies of hypnosis summarized here, the improvement in asthma was associated with cer¬ tain patients' characteristics, such as the depth of trance and the ability to learn autohypnosis. For a few asthmatic patients who are good hypnotic subjects, direct suggestion under hypnosis might be the most effective psychothera¬ peutic method. It may be that the choice of psychotherapeutic tech¬ nique should depend in part on the personality and psychopathologic disorder of the patient. A good hypnotic subject might derive the greatest benefit from direct sug¬ gestion under hypnosis (conceivably only in some psycho¬ somatic disorders but not in others), whereas a person with the same psychosomatic disorder who has great diffi¬ culty in interpersonal relationships might derive a greater benefit from group psychotherapy; another, in whom the fear of the attack is a link in a vicious cycle of autonomie overactivity and more fear, will probably benefit most from one of the methods of systematic desensitization. The research evidence from controlled studies can serve as a rough guide to the choice of the initial treatment. In patients with peptic ulcers, group directive therapy with

explanatory therapy (and probably psychoanalysis) ap¬ peared to be highly effective. In patients with bronchial asthma, desensitization by imagery and relaxation should probably be the treatment of choice unless the patient is a good hypnotic subject, in which case hypnosis can be tried first. In patients with musculoskeletal psychophysiologic symptoms, a combination of explanatory therapy, reassur¬ ance, and insight therapy with relaxation exercises was found to be effective. This combination should probably be the treatment also for other psychophysiologic disorders in which there is no demonstrable organic illness, al¬ though there are no controlled studies of the treatment of other psychophysiologic disorders. Perhaps patient and re¬ peated reassurance and explanatory therapy should be tried first and only if the simple treatments fail should the other methods be added. Of the treatments for migraine that have been compared, a combination of desensitiza-

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tion in imagery with assertive training was the only psy¬ chotherapeutic method that was found to reduce the fre¬

quency and duration of the attacks. Patients with certain characteristics who suffer from eczema appeared to bene¬ fit from psychiatric treatment, although it is not certain the extent to which psychotherapy contributed to the im¬

provement. The results of the other studies summarized in the present survey are inadequate to serve as a guide for

choosing a psychotherapeutic

method. The experimental evaluation of the effects of psycho-

therapies in physical illness is at an early stage. It seems likely that psychological treatments will become more common; newer methods, such as some techniques of be¬ havior therapy or biofeedback, will supplement older methods in some patients and replace them in some oth¬ ers. At our present state of knowledge, it seems good management to try a course of the appropriate type of psychotherapy in patients with psychosomatic disorders who have not responded adequately to routine medical care.

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Med 60:587-602, 1964. 10. Draspa LJ: Psychological factors in muscular pain. Br J Med Psychol 32:106-116, 1959. 11. Titchener JL, Sheldon MB, Ross WD: Changes in blood pressure of hypertensive patients with and without group psychotherapy. J Psychosom Res 4:10-12, 1959. 12. Smith JM, Burns CLC: The treatment of asthmatic children by hypnotic suggestion. Br J Dis Chest 54:78-81, 1960. 13. Sclare AB, Crocket JA: Group psychotherapy in bronchial asthma. J Psychosom Res 2:157-171, 1957. 14. Groen JJ, Pelser HE: Experiences with, and results of, group psychotherapy in patients with bronchial asthma. J Psychosom Res 4:191-205,1960. 15. Barendregt JT: A psychological investigation of the effect of group psychotherapy in patients with bronchial asthma. J Psychosom Res 2:115119, 1957. 16. Maher-Loughnan GP, MacDonald N, Mason AA, et al: Controlled trial of hypnosis in the symptomatic treatment of asthma. Br Med J 2:371374, 1962. 17. British Tuberculosis Association: Hypnosis for asthma-a controlled trial: A report to the research committee of the British Tuberculosis Association. Br Med J 4:71-76, 1968. 18. Moore N: Behaviour therapy in bronchial asthma: A controlled study.

Psychosom Res 9:257-276, 1965. 19. Wolpe J: Psychotherapy by Reciprocal Inhibition. Stanford, Calif, Stanford University Press, 1958. 20. Williams DH: Management of atopic dermatitis in children: Control of the maternal rejection factor. Arch Dermatol 63:545-560, 1951. 21. Zhukov IA: Hypnotherapy of dermatoses in resort treatment, in Winn RB (ed): Psychotherapy in the Soviet Union. New York, Philosophical Library, 1961, pp 178-181. 22. Brown DG, Bettley FR: Psychiatric treatment of eczema: A conJ

trolled trial. Br Med J 2:729-734, 1971. 23. Memmesheimer AM, Eisenlohr E: Untersuchungen \l=u"\berdie Suggestivbehandlung der Warzen. Dermatol Z 62:63-68, 1931. 24. Clarke GHV: The charming of warts. J Invest Dermatol 45:15-21,

1965. 25. Sinclair-Gieben AHC, Chalmers D: Evaluation of treatment of warts by suggestion. Lancet 2:480-482, 1959. 26. Stankler L: A critical assessment of the cure of warts by suggestion. Practitioner 198:690-694, 1967. 27. Tenzel JH, Taylor RL: An evaluation of hypnosis and suggestion as treatment for warts. Psychosomatics 10:252-257, 1969. 28. Surman OS, Gottlieb SK, Hackett TP, et al: Hypnosis in the treatment of warts. Arch Gen Psychiatry 28:439-441, 1973. 29. Asher R: Respectable hypnosis. Br Med J 1:309-313, 1956. 30. Ullman M, Dudek SZ: On the psyche and warts: II. Hypnotic suggestion and warts. Psychosom Med 22:68-76, 1960. 31. Mitchell KR, Mitchell DM: Migraine: An exploratory treatment application of programmed behaviour therapy techniques. J Psychosom Res 15:137-157, 1971. 32. Kellner R: The evidence in favour of psychotherapy. Br J Med Psychol 40:341-358, 1967. 33. Strupp HH, Bergin AE: Research in Individual Psychotherapy, Public Health Service, US Government Printing Office, 1944. 34. Meltzoff J, Kornreich M: Research in Psychotherapy. New York, Atherton Press, 1970. 35. Mason AA, Black S: Allergic skin responses abolished under treatment of asthma and hayfever by hypnosis. Lancet 1:877-1129, 1958. 36. Black S: Shift in the dose response curve of Prausnitz-Kiistner reaction by direct suggestion under hypnosis. Br Med J 1:990-992, 1963.

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