Volume 7, Issue 2 (Spring 2019)                   PCP 2019, 7(2): 79-86 | Back to browse issues page


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Sayyar Khesmakhi S, Afshar zanjani H, Goli F, Omidi A, Eduard Scheidt C, Givehki R. Effectiveness of Acceptance and Commitment Therapy on Psychosomatic Symptoms and Mindfulness in Patients With Psychosomatic Disorders. PCP 2019; 7 (2) :79-86
URL: http://jpcp.uswr.ac.ir/article-1-639-en.html
1- Department of Psychology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
2- Department of Psyichiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
3- Faculty Instructor, Engery Medicine University, California, United States of America.
4- Department of Clinical Psychology, Faculty of Medicin, Kashan University of Medical Sciendes, Kashan, Iran.
5- Department of Psychosomatic, Albert Ludwigs University, Freiburg, Germany.
6- Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. , givaki-md@gmail.com
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1. Introduction
Along with widespread advances in the diagnosis and treatment of psychiatric disorders, special attention has been paid to Somatic Symptom Disorders (SSDs) (Sadock & Ruiz, 2014). These disorders include somatic symptoms disorder, illness anxiety disorder, factitious disorder, conversion disorder, and psychological conditions influencing physical diseases. The average prevalence of these disorders in the clinical population visiting medical centers varies from 6% to 15% (Sadock & Ruiz, 2014). Furthermore, up to 20% of the patients referring to medical centers report the high prevalence and the importance of such disorders (Fava, Cosci, & Sonino, 2017; Hüsing, Löwe, Piontek, & Shedden‐Mora, 2018; Sadock & Ruiz, 2014). Besides high prevalence, psychosomatic disorders are risk factor for specific diseases and exacerbate other medical conditions (Fava et al., 2017).
Medicinal treatment is the main therapeutic approach to SSDs. Scientific research have focused on the medical interventions for the treatment of SSDs; however, the clinical experiences of therapists and the results of trials indicate barriers to this approach, like non-compliance with the drug. Moreover, mental issues are both risk factor and the cause of these disorders, imposing numerous obstacles to medical services in improving them (Fallon, 2004; Givehki et al., 2018; Lee et al., 2007; Sadock & Sadock, 2011).
Besides illnesses and psychosomatic symptoms, many SSD patients demonstrate high levels of empirical avoidance. These patients often describe their inner experiences (thoughts, emotions, bodily sensations, impulses, or memories) unbearable, and attempt to avoid or reduce the severity of these experiences (Grossman, 2008). Moreover, SSD patients report a significant lack of flexibility and other mindfulness-related variables (Edinborough, 2011; Fjorback et al., 2013). Psychological interventions are often applied in the treatment of SSDs. Thus, Cognitive Behavioral Therapy (CBT) as one of the widely-used approaches in the treatment of most psychiatric disorders is of special importance in treating psychosomatic symptoms (Matsuoka, Chiba, Sakano, Toyofuku, & Abiko, 2017; Silverstein, Brown, Roth, & Britton, 2011). 
Although CBT has many benefits for psychosomatic patients, it has several limitations. First of all, CBT frequently challenges patients’ irrational thoughts and beliefs. However, many psychiatric patients are unable to cope with such challenges. Because of the nature of the disease, people cannot cope with their inferior thoughts (Cayoun, 2014; Matsuoka et al., 2017). Furthermore, CBT does not address abnormalities and fails to have a clear diagnostic prognosis. These severe constraints are among the factors behind the low rate of recovery through this treatment (Baker et al., 2014; Cayoun, 2014; Yazdanimehr, Omidi, Sadat, & Akbari, 2016).
An alternative option is Acceptance and Commitment Therapy (ACT). ACT, through education, improves positive attitude toward thoughts and emotions associated with flexibility; then, through daily mindfulness-based practice, promotes creative hopelessness toward personal control over thoughts and painful emotions, provide clients with feelings of frustration over their past practices to control patients' anxiety (Cayoun, 2014).
This condition facilitates acceptance as an alternative solution. With the adoption and reduction in the inner struggles, new scope and time are created for the patients to discuss their valuable and important lives. In fact, this shifts the focus of clients from their past unsuccessful solutions and concerns to problem-solving scope. This process reduces the concerns and breaks the loop of obsession. A significant reduction in concern also improves the person’s performance and creates new habits and attitudes. In other words, ACT through the creation and development of admission and value-based lives in clients promotes the treatment process. ACT with an experiential nature (without challenging thoughts), is beneficial for many people (Eifert & Forsyth, 2005; Hayes, Luoma, Bond, Masuda, & Lillis, 2006). it is a treatment in which awareness and acceptance of the body are important and can affect mental health (Blackledge, Ciarrochi, & Deane, 2009; Davoudi, Omidi, Sehat, & Sepehrmanesh, 2017). However, to our knowledge, no study has investigated these issues. Thus, the present study examined the effectiveness of ACT on psychosomatic symptoms and mindfulness in patients with psychiatric disorders. 
2. Methods
This was a single-blind clinical trial study with Pre-test-Post-test design and a three-month follow-up period with two control groups. The study population included all patients diagnosed with psychosomatic disorders by a psychiatrist, an internal medicine specialist, or a clinical psychologist at the treatment center in Kashan City, Iran, from December 1, 2017, to March 30, 2018.
The inclusion criteria were as follows: aged 18-60 years; diagnosed with a psychosomatic disorder based on Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5); not hospitalized for a schizophrenia spectrum or other psychosis disorders; no comorbid psychiatric disorder; and no history of substance abuse. The exclusion criteria were substance abuse during the interventions and follow-up, more than two sessions absence, and unwillingness to continue the treatment.
Based on the previous research (Vowles, Fink, & Cohen, 2014), the sample size calculated for each group was about 20 at the confidence interval of 95%, with a type II error of 20%. However, considering the potential sample dropout and other possible confounding factors, this number was increased by 10% to have 22 in each group (n=66). After selecting the patients, each person was assigned a code and based on permuted block randomization by a computerized random number generator, the study participants randomized into three groups (number of each: 22). Then, the intervention group received ACT with medicinal treatment. The first control group received psychological interventions and the second control group received medicinal treatment without any psychological interventions. The study tools included the demographic data questionnaire, used for assessing the variables such as age, gender, mental disorders, educational level, and occupational status Figure 1.
Freiburg Mindfulness Inventory (FMI)-Short Form has been used to examine psychometric properties in many cultures (Ghasemi Jobaneh, Arab Zadeh, Jalili Nikoo, Mohammad Alipoor, & Mohsenzadeh, 2015). This is a psychometric tool for evaluating mindfulness in clinical and non-clinical populations. Moreover, many researchers consider it as an exact and proper tool for measuring mindfulness-related factors. Studies indicate that the total score of FMI short form is valid for practical and functional purposes; e.g. its internal consistency was 0.827. FMI with the Cronbach alpha coefficient of 0.92 on the Iranian population has an acceptable validity (Ghasemi Jobaneh, et al. 2015).
The Diagnostic Criteria for Psychosomatic Research (DCPR) represent a diagnostic and conceptual framework that aims to translate psychosocial variables derived from psychosomatic research into operational tools whereby individual patients can be identified. A set of 12 syndromes was developed, including disease phobia, health anxiety, illness denial, persistent somatization, functional somatic symptoms secondary to a psychiatric disorder, conversion symptoms, anniversary reaction, irritable mood, type A behavior, demoralization, and alexithymia (Ebrahimi et al., 2018; Sirri & Fava, 2013).
The treatment plan was designed using the proposed theoretical model of ACT for body image dissatisfaction and improvement in mindfulness skills, developed by Pearson et al. (Follette, Heffner, & Pearson, 2010). Table 1 describes the treatment protocol with the sessions’ details. The obtained data were analyzed in SPSS. Prior to conducting the research, a brief session was held for the patients. In that session, ethical considerations and research project were explained to the patients. Afterward, the written informed consent was obtained from all the study participants. Furthermore, the study participants were assured about the confidentiality of their personal records and that their medical information would be disclosed to the medical team. This research was approved by the Ethics Committee of Kashan University of Medical Sciences (IR.KAUMS.MEDNT.REC; code of ethics: 1396.6).
3. Results
Of the 66 study participants, two from the experimental group were unwilling to continue participation in the study. Finally, data analysis was performed on 64 samples (20 in the experimental group and 22 in the active control group and 22 in the conventional treatment group). The samples’ demographic data are listed in Table 2. The mean age of the study participants in the experimental and control groups was determined. There was no significant difference between the two groups in terms of age (P>0.05). Additionally, there was no significant difference between the two groups in the type of diagnosis, gender, marital status, and educational level (P>0.05).
The FMI results in all three groups were evaluated by repeated measures Analysis of Variance (ANOVA). As per Table 3, before the intervention, there was no significant difference between the three groups in the level of mindfulness (P<0.05). However, in the post-test and follow-up phases, the experimental group had significant improvements, compared to the control and conventional treatment groups (P<0.05).
The mean values of the study variables of the groups are not equal according to the mean of the Least Significant Difference (LSD). According to Table 4, the mean score of consciousness is different in the three groups. Therefore, the mean consciousness awareness is represented in the intervention and acceptance intervention groups, followed by the general treatment group TAU, and the active control group.

4. Discussion 
The obtained results revealed that ACT could improve mental health and mindfulness. Despite the existence of few studies in this area, the results of earlier investigations were consistent with the present study findings. For example, Hoffman investigated the effectiveness of ACT through website on people with severe anxiety disorder. Fifteen people were treated with adherence and commitment in online video sessions. The achieved results indicated that ACT could be effective in the treatment of anxiety in these people (Hoffmann, Rask, Hedman-Lagerlöf, Ljótsson, & Frostholm, 2018).
Furthermore, patients with anxiety problems were investigated in terms of the efficacy of group ACT. The collected results indicated the effectiveness of ACT in the reduction of anxiety in these patients (Eilenberg, Hoffmann, Jensen, & Frostholm, 2017). Sebastián Sánchez et al. (2017) evaluated the efficacy of ACT on irritable bowel syndrome. They reported that this treatment improved samples’ psychosomatic symptoms. Another study evaluated the effectiveness of group ACT on the rehabilitation of female patients with chronic headache; the obtained results indicated improvements in samples' headaches and tension (Mo’tamedi, Rezaiemaram, & Tavallaie, 2012). Moreover, McCarthy and Wolves explored the efficacy of ACT on chronic pain. They found that this treatment, by improving mindfulness in these people, would reduce the patients’ response to chronic pain (McCracken & Vowles, 2014).
People with psychosomatic problems are drowned in their past- and future-related thoughts. ACT teaches them to focus on the present moment with the use of metaphors, including the metaphor of “body’s touch”, and reminds the clients that “life is here and now”. This approach leads to experience a new relationship with ones’ own body (Dahl, Luciano, & Wilson, 2005).
This experience leads to a better understanding of visceral and physical states in people; thus, reduces quick and sometimes unplanned responses in these people. In this treatment, the therapist tells the clients that you should behave in a way to enjoy being at the moment, like enjoy eating while eating (McCracken, 2011). Problems arise because people are drowned in the past or future; thus, lose contact with the current moment. Attention to here-and-now undermines avoidance and conflicts. ACT does not seek to change the content of thoughts but is a behavioral therapy that uses the skills of mindfulness, acceptance, and cognitive impairment to increase flexibility (Batten, 2011). Relationship with the present moment is a process through which people learn to focus on their present emotions and re-experience present. It consequently reduces their problems (Hayes et al., 2006; Hayes, Strosahl, & Wilson, 2012).
The current study had some limitations, as follows: the follow-up period was short. The study examined the general score of mindfulness and overlooked itssubscales. It is suggested that future studies consider a longer follow-up period. Additionally, we can compare the components of mindfulness and ACT, that have contributed to the samples’ improvement. The high costs of treatment and the need for a short-term version are very important matters. 
The obtained data revealed the efficacy of ACT in psychosomatic symptoms among psychosomatic patients. Clinicians learn to aid the clients in a method of mindful self-study that helps patients become aware of body sensations and bodily experiences. Furthermore, this study highlighted that ACT interventions for mindfulness are promising, and investment in future research using larger sample sizes and higher quality randomized controlled trials is required to confirm the effectiveness of ACT in psychosomatic-related variables. 
Ethical Considerations
Compliance with ethical guidelines
This research was approved by the Ethics Committee of Kashan University of Medical Sciences (code: IR.KAUMS.MEDNT.REC.1396.6). Prior to conducting the research, a brief session was held for the patients. Ethical considerations and research project were explained to the patients. Afterward, the written informed consent was obtained from all study participants. Furthermore, the study participants were assured about the confidentiality of their personal records and that their medical information would be disclosed to the medical team. 
Funding
The Research and Technology Department of Rahnamed Sazan Sepahan funded this research. 
Authors' contributions
All authors equally contributed to design and conduct the research and write the manuscript.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors hereby express their gratitude to the honorable people of Rahnemod Sazan Sepahan of Isfahan, who provided help in the course of this research. The authors are also thankful to the esteemed Research and Technology Department, Rahnamed Sazan Sepahan, for funding this research. 


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Type of Study: Research | Subject: Cognitive behavioral
Received: 2018/11/23 | Accepted: 2019/02/12 | Published: 2019/04/1

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