Introduces The BodyMind Approach as an intervention to support people with a range of medically unexplained symptoms.

1. {
Medically Unexplained Symptoms: The
BodyMind Approach® to Promote
Wellbeing in Primary Care
Pathways2Wellbeing is a University of Hertfordshire spin-out company
Professor Helen Payne, PhD University of Hertfordshire,
UK; Founding Director Pathways2Wellbeing Ltd
Korean Dance Therapy Conference 2013

2.  Malingerers
 Hypochondriasis
 Mental illness
 Psychosomatic conditions
 Medically unexplained physical symptoms (MUPS)
 Medically unexplained symptoms (MUS)
 Persistent physical symptoms without a medical diagnosis
 Body distress syndrome (BDS)
Historical Terminology

3. Definition:
 A clinical and social predicament
 Broad spectrum of persistent presentations
 Difficulty in accounting for symptoms based on known pathology
With this we can avoid the challenge of choosing either an organic or
a psychological explanation for MUS.
Instead it enables a comprehensive, bio-psychosocial treatment that
addresses both hypotheses simultaneously
Medically Unexplained Symptoms

4. Worldwide high health utilizers in Primary and Secondary care West -East
 25-50% of all GP visits and 50% outpatients first visits and 50%
cardiology/neurology/gastroenterology are with MUS patients [1; 2a; 2b]
 10 most common problems =40% of all visits, but GPs can identify a
biological cause for the concern in only 26% [3]
 There are 8 common physical complaints (fatigue, backache, headache,
dizziness, chest pain, dyspnea, abdominal pain, physical effects of anxiety)
accounting for 80 million physician visits annually, yet an organic cause
found for less than 25% of these symptoms [4]
 For 1,000 medical outpatients, 16% of the presenting symptoms had a
documented organic cause, 10% were presumed to be causally related to
psychological variables, leaving 3 out of 4 complaints unexplained
medically [5].
 £3 billion rising to £18 billion per year lost productivity/quality of life [6]
Scale of the problem

5. NHS England:
 CBT RCTs IBS/fibromyalgia/fatigue (standard) [7a] but no better than
TAU [7b]
 Psychoanalytical psychotherapy [8] (variable)
Outside NHS:
 DMT [9a; b; c; d; e]
 Meditation [10]
 Tai Chi [11;12]
 Massage [13]
 Hypnotherapy [14]
 Bioenergetics [15a]; Body related therapy [15b]
Methodologies for Treatment

6.  Poorer general health/quality of life & wellbeing
 More likely to be absent from work/study/unemployed
 Comparable/greater impairment of physical health
 Worse mental health
 Psychologically-minded & Psychologically-resistant
 More females/ethnic communities
 Lower educational attainment
 Poorer economic background & mostly isolated
 Poor affect regulation and alexithymia
 Trauma, sexual abuse correlation in women
 Commonly back/chest/abdominal pain, fatigue, dizziness, headache,
swelling, shortness of breath, insomnia, numbness
 Co morbidity depression/anxiety/disrupted attachment style
Patient Profile

7.  GP visits longer and more frequent
 Feelings of frustration
 Persistent symptoms without organic cause
 Need more emotional support
 Often past/current family dysfunction and/or history of trauma or abuse
 High medication costs
 Higher health care costs due to frequent GP visits/secondary medical
referrals
How to recognise this patient in the
surgery

8.  No choice - CBT in mental health setting for specific conditions
 Pain management clinics - physiotherapists
 GP attitude - ‘heart-sink’
 Many secondary care investigations - negative
 Frequent GP consultations – frustrating for both
 Secondary care interventions - unnecessary
 Medication usage – unwanted
 Isolation - problematic
Lack of hope results and spiral downwards
Current Pathway for MUS Patients

9.  ‘The MUS Clinic’ using TBMA in Symptoms Groups to GPs - access
 Integrates DMP/Authentic Movement in experiential learning
 Caters for generic chronic (over 6 months presentation) symptoms
 Engaging as non-stigmatising - no reference to mental health
 Bio-psychosocial model bridges mental & physical health systems
 Recovery - learning to ‘live well’; own coping strategies designed
 Complimentary to CBT/Psychotherapy if indicated
 GPs trained/refer to Symptoms Groups in local community setting
 2 out of 3 patients referred complete treatment
 10 patients per group, 3 groups per programme
 Training TBMA x 4 days plus assessment for MA DMPs as facilitators
 Manualised, standardised approach, quality control systems
 In UK for 50 patients completing Groups saves approximately £22K (2008
figures [16]) (after cost of programme deducted)
The MUS Clinic

10. Positive patient outcomes [17]:
 Improved patient wellbeing & activity levels
 Decreased symptom distress/anxiety/depression
 Self-management of symptoms
 Choice and accessibility
Positive NHS outcomes:
 Reduced attendance at GP surgeries- freed up time
 Reduced secondary care referrals
 Medication usage same or reduced
 Helps to meet GP Quality Outcomes Framework targets
Overall reduced costs compared to TAU/cost savings increase year on year
Cost benefit analysis showed cost effective compared with CBT [18]
Market research analysis GPs keen to refer and that patients would commit [19]
Outcomes from MUS/TBMA Research

11.  Integrated into the NHS system/on line [20]
 Implemented April 2012 as ‘Symptoms Groups’ x 3 to patients
 Programme - 3 groups, each 12 x 2 hour sessions x 8 weeks
 GP awareness raised/screening tools/narrative for
consultation/referral criteria to support GP decision-making
 Facilitator DMP/AM/group work training/attitude of mind crucial
 Termed ‘The MUS Clinic’ to GPs
 19 patients completed treatment, 5 withdrew; 18 waiting list
Outcomes = 90-100% attendance; reduced symptom
distress/anxiety, increased activity/wellbeing [21]
Embedding TBMA as ‘The MUS Clinic’ in
Hertfordshire, NHS England

12.  Practices to promote mindful movement and body awareness (intra-
awareness)
 Discussion, witnessing, meaning-making, reflection
 Experiences to help re-association with the body
 Relaxation/meditation/3-dimensional breathing/movement/witnessing
 Exercises for self-regulation/self management
 Exploration of symptom as symbol/dream/subjective experience
 Validates the symptom starting with the sensory experience
 Considers lifestyle, goals and action planning
 Uses a variety of embodied, enactive, expressive methods
 Examines patient’s perception of their symptom
 Works with disrupted attachment and body signals (inter-personal)
 Honours the wisdom of the body
 Promotes ways for listening to body signals/disrupting previous
interpretations of somatic cues [22]
 Specific themes exploring somatisation introduced as group needs [23]
What is TBMA®?

13. Practice based evidence at baseline, post and at 6 months follow up using
standardised instruments for:
 depression; anxiety; general functioning; wellbeing/somatisation/symptom
severity:
PHQ9; GAD; GAF; MYMOP2
 Data for analysis of patient profile to further refine inclusion/exclusion criteria
(what works for whom):
socio-economic; age; gender; leisure pursuits; medication; life stressors;
frequency of secondary & GP visits; employment status; absence from work;
educational attainment; social support; ethnicity; symptoms; reasons for
registering; whether believes way think/feel effects symptoms and vice versa
 Case Report Forms completed by GP (post/follow up)
 GP receives Attendance record & outcome summary at discharge
Measurement of Outcomes

14. Cross referrals from Symptoms Group to
CBT/Psychotherapy and vice versa
Referral Flow Chart
GP discusses with patient the treatment options
Will the patient accept and commit to a psychological treatment option?
Yes No/don’t know
CBT/Psychotherapy/Symptoms Group

15.  GP completes referral form/brochure to patient
 Patient registers/welcome letter
 Pre group Assessment (week group commences)
 Individual Intake meeting with facilitator
 Group sessions
 Text reminders of all appointments
 Individual Exit meeting with facilitator
 Post group Assessment (week group ends)
Phase 1

16.  Letter written in session by patient (sent to patient month 2)
 Personalised letter from facilitator (sent month 4)
 Text ‘How are You?’ (sent month 5)
 Follow up assessment (at 6 months from baseline)
 Self help group if indicated
 Further facilitated group if indicated
 Cross referral via GP to CBT/PP if indicated
Phase 2

17.  LN - middle aged woman, full time work, tense, a bundle of nerves
 Symptoms: muscular cramps, insomnia, migraine & depression
 Onset after traumatic events in past, with them frequent visits to GP
 When in stressful situations L had panic attacks - unable to function
 Unable to sleep well, hard going to work as felt tired/lacked
concentration, often absent from work as a result
 L attended every session apart from two
 L realised something different in her breathing
 After discovering the ‘right’ way of breathing L practised it all the time
 Looked happier/energised, reported slept better /enjoyed work
 L took the new breathing pattern as her second nature now
 She increased in confidence every session
 Through the bodywork L found she was well co-ordinated and gracious
in her movement, a good sense of rhythm and could dance!
 She now enjoys dancing around in her big kitchen! As part of her self
management action plan decided to work part time.
Case Study

18. ‘relevant techniques, communication skills, overall wellbeing, friendly
atmosphere’;
‘I need to think more of myself rather than being involved in other people’s
problems’; ‘new strategies for coping with my symptoms’;
‘it gives hope’; ‘improved quality of life’; ‘I will be better now’;
‘the facilitator was inspiring;’ ’we slowed down the pace of life during
the sessions and talked about how to apply that to everyday life’;
‘how to breathe in a more beneficial way while sitting and moving’;
‘we thought carefully about our bodies and became familiar with our own
movements’;
‘how to bring movement to the body in order to relax and exercise
well’; ‘I became more conscious of the 'moment' and how to become
sensitive to living in the now‘
GP Comment: “This should be the first port of call for patients with
MUS, it can do no harm” Wendy Sainsbury, GP, Watcom (March 2012)
Participant Experience Form Question: What did
you find helpful about the group?

19.  Info@pathways2wellbeing.com www.pathways2wellbeing.com
 H.L.Payne@herts.ac.uk www.herts.ac.uk
Copies of my books and articles are available to purchase during this
conference
The University is always interested to collaborate on doctoral research
projects. Please contact me to discuss.
Thank you for your attention
Any Questions?

20. 1. Barsky AJ, Borus JF (1995) Somatization & medicalization in the era of managed care. JAMA; 274, 24:1931-34
2. Bass, C. (2003) Somatisation and medically unexplained symptoms. Psychiatry, 1 January ;15-19.
3.Nimnuan C; Hotopf, M & Wessely S (2001) MUS: an epidemiological study in seven specialties. Psychosomatic
Research, 51, 361-67.
4.Lipsett DR (1996) Primary care of the somatizing patient: A collaborative model. Hospital
Practice, 31,77-88.
5. Kroenke K; Mangelsdorff A (1989) Common symptoms in ambulatory care: incidence, evaluation, therapy &
outcome. American J of Medicine; 86:262–6.
6. Bermingham, S., Cohen, A., Hague, J. & Parsonage, M. (2010) The cost of somatisation among the working-
age population in England for the year 2008-09. Mental Health in Family Medicine, 7, 71-84.
7a. Kroenke, K., & Swindle, R. (2000). Cognitive-behavioral therapy for somatization and symptom syndromes: A
critical review of controlled clinical trials. Psychotherapy and Psychosomatics, 69, 205–215.
7b. Sumathipala, A., Siribaddana, S., Abeysingha, M.R.N., de Silva, P., Dewey, M., Prince,
M., et al. (2008). Cognitive-behaviour therapy v. structured care for medically unexplained symptoms:
Randomised controlled trial. British Journal of Psychiatry,193, 51–59.
8. Kuechenhoff J(1998)The body and ego boundaries: A case study on psychoanalytic therapy with
psychosomatic patients. Psychoanalytic Inquiry,18,3,368-82.
9a Thulin K (1997) When words are not enough: Dance therapy as treatment for patients with psychosomatic
disorders. AJDT, 19,1, 25–43.
9b Chrysou M (1999) Psychosomatic aspects of pain: An exploration of physical and psychic pain in dance
movement therapy. Unpublished MA dissertation, Laban Centre for Movement and Dance, London.
9c.Mueller-Braunschweig, H. (1998). The effects of body-related psychotherapy in psychosomatic illnesses.
Psychoanalytic Inquiry, 18(3), 424–444. 9d.
9d. Silberman-Deihl L, Komisaruk B(1985) Treating psychogenic somatic disorders through body metaphor. AJDT
8, 37–45.
9e. Horwitz, E.B., Theorell, T., & Anderberg, U.M. (2003). Dance Movement Therapy and changes in stress
related hormones: A study of fibromyalgia patients with video interpretation. Arts in Psychotherapy, 30, 255–264.
10. Bonadonna R (2003) Meditation’s impact on chronic illness. Holistic Nursing Practice, 17,6, 309–319.
11. Jin P (1992) Efficacy of Tai Chi, brisk walking, meditation, reading in reducing mental & emotional stress.
Psychosomatic Res. 36, 361–370.
12. Taggart, H.M., Arslanian, C.L., Bae, S., & Singh, K. (2003). Effects of Tai Chi exercise on fibromyalgia
symptoms and health-related quality of life. Orthopaedic Nursing, 22, 5, 353–360.
References

21. 13. Browlee S, Dattilo J (2002) Therapeutic massage as a therapeutic recreation facilitation technique.
Therapeutic Recreation 36,4, 369–381.
14. Williamson, A (2002) Chronic psychosomatic pain alleviated by brief therapy. Contemp Hypnosis, 19, 118-124.
15a. Nickel, M., Cangoeza, B., Bachlerc, E., Muehlbacher, M., Lojewski, N., Mueller-Rabea, N., (2006).
Bioenergetic exercises in inpatient treatment of Turkish immigrants with chronic somatoform disorders: A
randomized, controlled study. Psychosomatic Research, 61, 507–513.
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Psychoanalytic Inquiry, 18, 3, 424-44.
16. Bermingham S; Cohen A; Hague J & Parsonage M (2010) The cost of somatisation among the working-age
population in England for the year 2008-09. Mental Health in Family Medicine, 7, 71-84.
17. Payne H, Stott D (2010) Change in the moving bodymind: Quantitative results from a pilot study on the
BodyMind Approach (BMA) to group work for patients with medically unexplained symptoms (MUS). Counselling
and Psychotherapy Research. 10, 4, 295-307
18. Payne H, Fordham R (2008) Group BodyMind Approach to Medically Unexplained Symptoms: Proof of
Concept & Potential Cost Savings. Unpublished Report, EEDA/University of Hertfordshire.
19. Payne H; Eskioglou M; Story J (2009) Medically unexplained symptoms: A holistic bodymind approach to
group therapy for depression and anxiety in primary care. Unpublished report by Category Consulting Ltd.
supported by the East of England Development Agency (EEDA)
20. Payne H (2013) The BodyMind Approach™: Supporting the wellbeing of patients with chronic medically
unexplained symptoms in primary health care in the UK. Submitted V Karkou (ed) Dance & Wellbeing. Oxford
International Handbook.
21. Payne H (2013) Knowledge transfer: Embedding The BodyMind Approach for patients with Medically
Unexplained Symptoms: Indicative Outcomes. Submitted to Arts in Psychotherapy
22. Payne, H. (2009) Pilot study to evaluate Dance Movement Psychotherapy (The BodyMind Approach) with
patients with medically unexplained symptoms: participant and facilitator perceptions and a summary discussion.
International Journal for Body, Movement & Dance in Psychotherapy. 5, 2, 95-106.
23. Payne H (2009) The BodyMind Approach (BMA) to psychotherapeutic group work with patients with medically
unexplained symptoms (MUS): A review of the literature, description of approach & methodology for pilot study.
European Journal for Psychotherapy & Counselling, 11: 3, 287 — 310.