Internet-based emotional awareness and expression therapy for functional somatic disorders

Background: Patients with Functional Somatic Disorders (FSD) make up one of the largest and most challenging patient groups in primary care. FSD are characterized by physical symptoms that have a major impact on the person’s life and usually have a chronic course. Somatic and psychiatric comorbidity is common. Few patients with FSD receive adequate care, which can lead to frustration with the healthcare system. Moreover, medical treatment, such as surgery or pharmacological therapy, has at best limited efficacy or at worst iatrogenic effects. Among psychological treatments, cognitive behavioral therapy has been most extensively studied. Research indicates small effect sizes with some effects tending to disappear at follow-up. New psychological treatment avenues are developing in the field, with one of them being the short-term treatment known as Emotional Awareness and Expression Therapy (EAET). EAET is based on a psychodynamically informed treatment model that underlines the importance of emotional processing of stressful life events as one possible vehicle of change in FSD.

Aims: The major aim of the thesis was to develop and evaluate an internet-based EAET (I-EAET) for participants with FSD while exploring emotional processing as a potential mediator in I-EAET. Specific aims of Study I were to develop I-EAET and ascertain its feasibility and credibility in patients with FSD. Study II aimed at investigating emotional processing as a potential mediator in I-EAET. The aim of Study III was to do more rigorous testing of I-EAET where participants were randomized to either I-EAET or a wait list control, to investigate if I-EAET was more effective than the control in reducing somatic symptoms. A secondary aim was to study emotional processing as a mediator of treatment effects within the trial. Study IV aimed at describing the implementation of main treatment principles in I-EAET.

Methods: Study I was an uncontrolled trial of I-EAET assessing treatment credibility, feasibility, initial efficacy, and possible negative effects with pre-post and 4-month follow-up assessments. Study II encompassed a mediational analysis using linear mixed models to study changes in emotional processing capacity and somatic symptom reduction with data from Study I. Study III was a two-arm randomized controlled trial, comparing 10-week of I-EAET to a wait list control, where the primary outcomes were reductions of somatic symptoms and pain at post-treatment and 4-month follow-up. Moreover, a mediation analysis of emotional processing with depression as a competing mediator was conducted. Study IV was a theoretical review with descriptions of text-based interactions between internet therapists and participants from Study I and III.

Results: Study I indicated that I-EAET was feasible, credible, and associated with a decrease in somatic symptoms. Study II showed that facets of improved emotional processing capacity were associated with decreases in somatic symptoms in I-EAET. In Study III, I-EAET decreased somatic symptoms at both post-treatment and 4-month follow-up compared with controls. The effect sizes were small to moderate (d = 0.44 at post-treatment and d = 0.46 at follow-up). Moreover, participants in I-EAET had lower pain intensity at post-treatment (d = 0.36), although the effect did not remain at follow-up. Even when using depression as a competitive mediator, a facet of emotional processing mediated the treatment effect on somatic symptoms. In contrast to previous work on internet-delivered treatments, where text material has been proposed to be the most important treatment mechanism, Study IV described a therapeutic alliance in I-EAET that might foster or hinder emotional processing.

Conclusions: I-EAET is a promising treatment for FSD (Studies I–IV). It is feasible, credible, and has acceptable negative effects (Studies I and III). Small to moderate between effect sizes of somatic symptom reduction was demonstrated, both post-treatment and at 4-month follow-up in Study III. The effect of I-EAET was partially mediated by increased emotional processing; when feelings became less intrusive and overwhelming, somatic symptoms tended to reduce (Studies II and III). Important treatment principles of I-EAET include using the therapeutic alliance to foster and deepen emotional processing in treatment (Study IV). Future research should be performed to corroborate these results and compare I-EAET to active treatments, preferably in routine care. Moreover, future research should refine and develop I-EAET further and distinguish and focus on the patients who respond best to I-EAET, to enhance treatment outcomes.

List of scientific papers

I. Maroti, D., Ek, J., Widlund, R-M., Schubiner, H., Lumley, M. A., Lilliengren, P., Bileviciute-Ljungar, I., Ljotsson, B., & Johansson, R. (2021). Internet-administered emotional awareness and expression therapy for somatic symptom disorder with centralized symptoms: A preliminary efficacy trial. Frontiers in Psychiatry. 12, 620359.
https://doi.org/10.3389/fpsyt.2021.620359

II. Maroti, D., Ljótsson, B., Lumley, M. A., Schubiner, H., Hallberg, H., Olsson, P-Å., & Johansson, R. (2021). Emotional processing and its association to somatic symptom change in emotional awareness and expression therapy for somatic symptom disorder: A preliminary mediation investigation. Frontiers in Psychology. 12, 712518.
https://doi.org/10.3389/fpsyg.2021.712518

III. Maroti, D., Lumley, M. A., Schubiner, H., Lilliengren, P., Bileviciute-Ljungar, I., Ljótsson, B., & Johansson R. (2022). Internet-based emotional awareness and expression therapy for somatic symptom disorder: A randomized controlled trial. Journal of Psychosomatic Research. 22;163:111068.
https://doi.org/10.1016/j.jpsychores.2022.111068

IV. Maroti, D., Hallberg, H., Lindqvist, K., & Mechler, J. (2022). Using psychodynamic principles in guided internet-delivered therapy (IPDT). Psychoanalytic Psychotherapy. 162;1–21.
https://doi.org/10.1080/02668734.2022.2124441