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By Amy Norton
NEW YORK (Reuters Health) - Some people with unexplained dizziness, headaches or weakness may find some relief with behavioral therapy done partly at home, a study out Wednesday suggests.
The study, reported in the journal Neurology, looked at patients with so-called functional neurological symptoms.
It refers to symptoms related to the nervous system -- dizziness, headaches, weakness, 'pins and needles' sensations, general pain -- that can't be traced to an underlying medical condition, like multiple sclerosis, Parkinson's disease or migraines.
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,' Sharpe told Reuters Health in an email.
There's no agreement on how to best help people with functional neurological symptoms. But there's evidence that cognitive behavioral therapy (CBT) may work for some.
CBT is a form of psychological counseling aimed at helping people recognize and change the thought patterns and behaviors 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,' Sharpe said.
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, Sharpe's 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 counselor over three months, but otherwise used a workbook that taught them self-help tactics -- like how to manage 'unhelpful' thoughts about their symptoms.
After three months, 30 percent of patients in the self-help group rated their overall health as 'better' or 'much better,' versus 17 percent 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 percent said the specific symptoms that had sent them to the doctor in the first place were better or much better, versus 30 percent 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 Newman-Toker, who was not involved in the research. So people in the self-help group knew they were getting the 'real' treatment.
'That increases the chances that any results you produce could be a placebo effect,' Newman-Toker said, referring to the phenomenon where people get better because they believe a treatment will work.
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,' Newman-Toker pointed out. 'Maybe the face time with therapists alone was the effective part.'
Despite those limitations, though, Newman-Toker said that people with functional neurological symptoms can be 'cautiously optimistic.'
'Perhaps addressing this in a structured way with cognitive behavioral 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, Newman-Toker explained, 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.
'This area is something of a badlands between neurology and psychiatry,' Newman-Toker said.
According to 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,' Sharpe said. 'These changes are influenced by how they think about their symptom and how they cope with it.'
Worrying about symptoms, or avoiding your normal activities because of that worry, may only make the problem worse, he explained.
But the question of whether a less-intense form of CBT -- using manuals, with occasional support from a therapist -- is truly effective requires further study. 'This is a preliminary trial,' Sharpe said.
Some of the unanswered questions: 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?
Newman-Toker offered another caveat to people with dizziness and other neurological symptoms: Be sure you are properly evaluated for an underlying medical condition before turning to CBT.
'Just because one or two doctors have said there's no obvious explanation, that doesn't mean it's true,' he said.
Besides getting second and third opinions, what can you do to make sure you've been adequately checked out? Some clues might come from your interaction with the doctor, according to Newman-Toker.
If, for example, the doctor seems to 'read your mind' during discussions, it's likely he or she has seen cases like yours before. Another positive sign, he said, is when a doctor does not dismiss your concerns and is 'humble' enough to acknowledge that he doesn't have all the answers.
SOURCE: http://bit.ly/Q5TNl Neurology, online July 27, 2011.
Reuters Health
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