False positives
False positives occur when the patient has a rise or fall in symptoms during the test for other reasons—eg, coincidental shifts in episodic conditions like muscle spasm or symptom reduction due to distraction during the test itself. It is important in these cases to repeat the test more than once and see if the results are reproducible.
Treatment: short-term dynamic psychotherapy
STDP is clinically effective for patients with somatization
Short-term dynamic psychotherapy (STDP) formats specifically help a patient to examine trauma and loss-related emotions that result in somatization, depression, anxiety, and self-defeating behaviors. Case-series videotaped research over the past 30 years has established the effectiveness of the methods in both short and long term follow-up.21
STDP is efficacious in controlled trials and meta-analyses
In 1995, Anderson and Lambert22 conducted a meta-analysis of 26 controlled studies and found STDP to be superior to minimal treatment controls and wait lists including in samples with somatization. It was found to be as effective in removing anxiety and depressive symptoms as cognitive behavioral therapy. A recent meta-analysis,23 using more strict inclusion criteria, yielded the same findings. In a recent randomized controlled trial of symptomatic patients with personality disorders, STDP brought significant symptom reduction while cognitive therapy did not, suggesting that STDP may have added benefits in more resistant and complex symptomatic patients.24
In our current Cochrane review search,25 we have found 40 published randomized controlled trials supporting its efficacy with a range of disorders including ulcer disease, irritable bowel syndrome, dyspepsia, and urethral syndrome.26-29 Our review has likewise found STDP to be superior to minimal treatment or waitlist controls and that the gains are maintained in follow-up averaging over 1 year.
STDP is cost-effective and reduces health care utilization
STDP has been shown to reduce healthcare utilization and to be cost-effective in treating patients with dyspepsia, irritable bowel syndrome, depression, and self-harm and treatment-resistant conditions.30 Of specific cost figures cited in reviewed papers, 27 out of 34 showed cost savings with STDP including reduction in total costs, medication costs, disability, hospital, and physician use.
Case Illustrations
Case 1: Striated muscle anxiety
This 42-year-old man had chronic fatigue and fibromyalgia which lead to a 13 month disability up to the time of consultation. He came to the office with longstanding pain in his shoulders. His hands were clenched during the interview, and he appeared tense while giving his history.
- DOCTOR: Can you tell about a specific time when you had an emotional upset so we can understand how exactly it affects you?
- PATIENT: Yeah, problems at home with my wife…. Saturday she wanted me to do some work on the garage. She started to yell. Every day it’s the same thing and I’m getting tired of it.… DOCTOR: So how do you feel toward her?
- PATIENT: [Takes a deep sigh, hands become clenched] Mad.
- DOCTOR: You mean mad … angry?
- PATIENT: Yeah.
- DOCTOR: How do you experience the anger inside physically?
- PATIENT: Very, very… tense
- DOCTOR: That is tension…anxiety?
- PATIENT: Yeah.
- DOCTOR: How did you experience the anger?
- PATIENT: I start to ignore her.
- DOCTOR: Is that a mechanism to deal with anger?
- PATIENT: It’s really hard to put a word on it…. I get really mad…it’s like a rage.
- DOCTOR: So how do you experience the rage?
- PATIENT: [Patient takes a big sigh and clenches his hands tightly]
- DOCTOR: Do you notice you sigh and become tense when you talk about the rage.
- PATIENT: No, I didn’t. I don’t feel anxious.
- DOCTOR: But, do you notice the sigh and your hands?
- PATIENT: I do now, but didn’t see it before.
- DOCTOR: Is this what is happening to you … that you are getting all tensed up about these feelings?
- PATIENT: Yeah, it must be.
At a later point in the 1-hour session, the patient was able to feel the visceral emotions of rage, guilt about the rage, and sadness over several years of conflict. When the feelings were experienced in the office, he had an abrupt drop in muscle tension and bodily pain: this was further evidence he had been somatizing, or as he said, “bottling up” these complex feelings.
As is typical of patients with primarily striated muscle anxiety, he denies being nervous despite showing obvious anxiety in the interview. He denies anxiety because it has been unconscious to him, thus free to create fibromyalgia pain. Through this single interview a link is made for both patient and doctor between blocked feelings and body pain. With 10 treatment sessions focused on this process, his fibromyalgia resolved; he returned to work and no longer needed antidepressants.