1. Non-Pharmacologic Therapies for medically unexplained symptoms Dr. Engel

2. Maximum Benefit cognitive behavioral therapy graded aerobic exercise

3. MUPS Increased Functional Status Improved Quality of Life Improved Health Behaviors Improved Health Beliefs Decreased Psychosocial Distress CBT GAE MUPS Decreased Functional Status Decreased Quality of Life Harmful Health Behaviors Harmful Health Beliefs Increased Psychosocial Distress

4. What is Cognitive-Behavioral Therapy (CBT) ? not medically curative targets factors that perpetuate disability

5. Unexplained Symptoms The Patient’s Initial Model “[ cause ] made me sick...” “…and I can’t [ activity ]” IllnessLoss of Function Symptoms “…so I feel bad...”

6. Unexplained Symptoms Expanding The Model IllnessLoss of Function Environment doctor’s opinions relatives opinions loss of intimacy/friends Emotions depression/anxiety frustration/anger pessimism Symptoms Deactivation loss of conditioning cycling levels of activity Health Beliefs exercise worsens symptoms rest improves symptoms

7. Environment doctor’s opinions relatives opinions loss of intimacy/friends Emotions depression/anxiety frustration/anger pessimism Symptoms Deactivation loss of conditioning cycling levels of activity Health Beliefs exercise worsens symptoms rest improves symptoms IllnessLoss of Function

8. A Reverberating System The factors determining prognosis among chronic illnesses are more complex than those that cause the illness.

9. Common Cognitive Components examining assumptions – about pathogenesis – about appropriate management – about prognosis problem solving strategies relaxation strategies early symptom-recognition

10. Common Behavioral Components behavioral activation strategies sleep hygiene leisure activity planning memory management skills goal setting relapse prevention

11. What is Graded Aerobic Exercise IT’S NOT: airborne physical training IT IS: a program of gradually increasing physical activity -- usually involves leisure activities rather than “aerobics” per se guideline describes a sample program

12. Possible Benefit relaxation response training therapeutic massage acupuncture stretching biofeedback hypnosis chiropractic

13. Possibly Harmful Bed Rest

14. Quality of Life Pathology Disability Functional Limitation Impairment Lifestyle Behavior Environment social & physical Biology Precipitating Event (e.g., fall, infection) Predisposing Factors Disabling Process IoM. Disability in America. NAS. 1991; p. 85