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Some people with unexplained dizziness, headaches or weakness may find some relief with behavioural therapy done partly at home, a study suggests.
The study, reported in Neurology, looked at patients with functional neurological symptoms – dizziness, headaches, weakness, pins and needles sensations, general pain – that can't be traced to an underlying medical condition.
It's not clear how common these symptoms are in the general population. One study found that a third of patients referred to Scottish neurology clinics had functional symptoms, according to Dr Michael Sharpe, a professor at the University of Edinburgh in the UK who led the new study.
"The problem is therefore a large one," Dr Sharpe told Reuters Health in an email.
CBT may help in functional neurological symptoms
There's no agreement on how to best help people with functional neurological symptoms. But there's evidence that cognitive behavioural therapy (CBT) may work for some.
CBT is a form of psychological counselling aimed at helping people recognize and change the thought patterns and behaviours that feed their health problems.
But people with functional neurological symptoms often resist CBT because they think they are being told that their physical problems are all in their head.
"Many patients interpret being told that it is psychological as being dismissive," Dr Sharpe said.
Distance between patients and therapist forced formation of self help
On top of that obstacle, he noted, many people do not live close enough to a therapist to make intensive face-to-face CBT sessions reasonable.
So for the new study, his team tested a type of guided self-help, based on CBT principles.
The researchers randomly assigned 127 patients to either usual care for functional neurological problems or to usual care plus self-help.
The self-help group had a few in-person or telephone sessions with a counsellor over three months, but otherwise used a workbook that taught them self-help tactics – like how to manage unhelpful thoughts about their symptoms.
How self-helping aided
After three months, 30% of patients in the self-help group rated their overall health as better or much better, versus 17% in the group that had only standard care.
After six months that difference was no longer significant between the two groups, but the self-help group was faring better in other ways. Overall, 47% said the specific symptoms that had sent them to the doctor in the first place were better or much better, versus 30% of the comparison group.
"This is a study that points in a positive direction," said Dr David Newman-Toker, an associate professor of neurology at Johns Hopkins University in Baltimore.
But a key weakness is that patients were aware of their group assignment, said Dr Newman-Toker, who was not involved in the research. So people in the self-help group knew they were getting the "real" treatment.
Doubts arise due to increase in results
"That increases the chances that any results you produce could be a placebo effect," he noted.
Another question is, if the benefit is real, how much of it can be attributed to the self-help part of the therapy. That is, can some people buy a book on CBT and find relief on their own?
"This wasn't purely self-help," Dr Newman-Toker pointed out. "Maybe the face time with therapists alone was the effective part."
Despite those limitations, though, Dr Newman-Toker said that people with functional neurological symptoms can be cautiously optimistic.
Unexplained symptoms could result in patients changing doctors
"Perhaps addressing this in a structured way with cognitive behavioural therapy could be of some benefit to them," he said.
That's important because people with unexplained symptoms can end up being shuffled among doctors with little to show for it.
Typically, Dr Newman-Toker said, if a neurologist cannot find a structural problem to explain the symptoms, a patient will be told it's "good news" and probably sent back to their primary care doctor – or, occasionally, referred to a psychiatrist.
At the same time, a psychiatrist who cannot find a definite diagnosis, like major depression, may say the problem must be neurological.
How CBT explanation helped the patients
"This area is something of a badlands between neurology and psychiatry," Dr Newman-Toker said.
According to Dr Sharpe, the CBT used in this study might have helped because patients were given an explanation of how the technique is relevant to physical symptoms.
"We do not explain the symptoms as all psychological, but explain that a physical symptom usually has a basis in changed functioning of the nervous system," Dr Sharpe said. "These changes are influenced by how they think about their symptom and how they cope with it."
The question of whether a less-intense form of CBT, using manuals, with occasional support from a therapist, is truly effective requires further study. Some other unanswered questions are: how long do the benefits last, and would booster sessions with a therapist be needed? How much would it all ultimately cost, and would the benefits be worth it?
"This is a preliminary trial," Dr Sharpe said
(Reuters Health, July 2011)
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