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5
Review of Treatments for
Comorbid and Related Conditions
Chronic multisymptom illness (CMI) is a serious condition that imposes
an enormous burden of suffering on our nation’s veterans. It can affect
every facet of a veteran’s health: physical, psychologic, social, economic,
and spiritual; it can impair a person’s capacities whether the person is a
soldier, worker, or family member. Despite its impact, CMI remains poorly
understood and in need of additional study. The medical community does
not yet know exactly which signs and symptoms should be part of the
diagnostic criteria, and, as science and discovery change, the definition and
diagnostic criteria of CMI may also change.
It is known, however, that a number of events or preconditions are fre-
quently seen in association with CMI. In some cases, a common exposure
can lead to more than one condition; for example, an explosion can cause
a concussion, deafness, body injury, and pain. Different but similar condi-
tions share symptoms; for example, cognitive impairment can be a feature
of CMI and traumatic brain injury (TBI). Some medical conditions can lead
to other clinical problems; for example, chronic pain can lead to depression,
and chronic lung disease can lead to anxiety. And some common conditions
may cluster without obvious explanation. CMI may include symptoms that
are not severe enough for diagnosis as a clinically recognized syndrome or
that are associated with defined disorders. It is clear that the possibilities
are many and that not all are fully defined.
The purpose of this report is to describe the current optimal approach
to care for patients who have CMI. In the quest to help patients, the entire
spectrum of their complaints must be considered and addressed. A compre-
hensive, individualized, patient-centered plan of care must acknowledge and
93
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94 GULF WAR AND HEALTH
address all conditions and comorbidities that are present and their possible
interrelationships. This chapter briefly describes 12 common conditions
that are comorbid with or related to CMI and presents treatments that
are known to be effective. The committee believes that symptoms shared
between CMI and those treatments may respond to similar approaches in
symptom management. Treatments that are recommended in evidence-based
clinical practice guidelines or that have been found effective in systematic
reviews are highlighted. The chapter concludes with a general therapeutic
approach to patients who have the most common diagnostic clusters.
FIBROMYALGIA
Primary fibromyalgia is a relatively common chronic condition that is
thought to be caused by abnormal processing of pain by the central nervous
system (Abeles et al., 2007). Using US population estimates from 2005, the
estimated prevalence of fibromyalgia in the United States was about 5 mil-
lion people (Lawrence et al., 2008). It is characterized by chronic wide-
spread pain, fatigue, cognitive symptoms, and sleep disturbance. Anxiety
and depression can accompany the syndrome (Wolfe et al., 1990). The
diagnostic criteria of the American College of Rheumatology are as follows
(Wolfe et al., 2010):
1. Pain over the preceding week identified from a list of 19 areas of
the body.
2. Fatigue, waking unrefreshed, and cognitive symptoms (memory
disturbance).
3. Symptoms lasting longer than 3 months.
4. Symptoms not explained by any other medical condition.
Other conditions may resemble fibromyalgia closely, including hypo
thyroidism, polymyalgia rheumatica, rheumatoid arthritis, and systemic
lupus erythematosus.
Fibromyalgia and Chronic Multisymptom Illness
Fibromyalgia and CMI share symptoms. The hallmark of fibromyalgia
is chronic widespread pain. In CMI, muscle pain and tenderness are very
common but are not required for the diagnosis.
Treatments for Fibromyalgia
Many pharmacologic and nonpharmacologic treatments have been
demonstrated to be effective for fibromyalgia. Many categories of phar-
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REVIEW OF TREATMENTS FOR COMORBID AND RELATED CONDITIONS 95
macologic medications are somewhat to very effective in treatment for this
syndrome. Systematic reviews identified several pharmacologic treatments
for fibromyalgia. Amitryptyline, a tricyclic medication, was found to have
a short-term benefit—6–8 weeks—when given at 25 mg/day (Nishishinya
et al., 2008). The serotonin–norepinephrine reuptake inhibitors duloxetine
and milnacipran also demonstrated beneficial effects on pain reduction,
fatigue, sleep, depression, and quality of life in systematic reviews (Sultan
et al., 2008; Uceyler et al., 2008). The neuropathic agent pregabalin has
proved to be effective (Choy et al., 2011; Nuesch et al., 2012; Siler et al.,
2011; Tzellos et al., 2010). Gabapentin, another neuropathic medication,
has also been shown to have modest benefits in patients who have fibro-
myalgia (Moore et al., 2011). Duloxetine, milnacipran, and pregabalin are
approved by the US Food and Drug Administration (FDA) for the manage-
ment of fibromyalgia. Other medications have shown less consistent ben-
eficial study results, including cyclobenzaprine and the atypical analgesic
tramadol (Hauser et al., 2011; Russell et al., 2000).
Nonpharmacologic interventions that have proved beneficial for
patients who have fibromyalgia include cognitive behavioral therapy (CBT)
(Bernardy et al., 2010) and aerobic exercise (Maquet et al., 2007). Many
studies of fibromyalgia have shown benefits of multimodal therapies: a
combination of treatments that include exercise, CBT, education, and self-
help tools (Hauser et al., 2009). It is well established that most patients
benefit from an interdisciplinary and integrative approach to the long-term
management of fibromyalgia and that medications alone are rarely benefi-
cial for maintaining effective reduction in chronic pain.
CHRONIC PAIN
Chronic pain is defined as pain that is associated with a chronic medical
condition or that persists beyond the expected time for tissue healing and
adversely affects the function or well-being of the person (American Society
of Anesthesiologists Task Force on Chronic Pain Management and Ameri-
can Society of Regional Anesthesia and Pain Medicine, 2010). Chronic pain
affects about 100 million adults in the United States (IOM, 2011b).
Chronic Pain and Chronic Multisymptom Illness
Chronic pain is one of the symptoms that might be associated with
CMI. Veterans of the 1991 Gulf War who have CMI may not have had a
specific injury but can have common and persistent diffuse chronic pain
(for example, joint pain).
Pain is the most frequent presenting complaint of troops returning from
the Iraq and Afghanistan wars who are treated at a VA polytrauma clinic
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96 GULF WAR AND HEALTH
(Lew et al., 2009). Many Iraq and Afghanistan war veterans have chronic
pain due to specific injuries. As discussed in Chapter 2, the most common
health outcome reported in that population is the triad of posttraumatic
stress disorder (PTSD), mild TBI, and pain (Walker et al., 2010). The preva-
lence of CMI in veterans of the Iraq and Afghanistan wars has not been well
studied, so it is not known whether the pain reported by these veterans is
associated with CMI.
Treatments for Chronic Pain
Treatment for chronic pain requires a long-term approach, coordinated
care, and periodic reevaluation. The scientific literature and clinical experi-
ence support a multidisciplinary approach to treatment for chronic pain as
recommended by guidelines of the American Society of nesthesiologists
A
Task Force on Chronic Pain Management and American Society of Regional
Anesthesia and Pain Medicine (2010).
Pharmacologic management of chronic pain includes nonsteroidal anti-
inflammatory drugs (NSAIDs), antidepressants, anticonvulsants, opioid
therapy, and other agents. Evidence supporting pharmacologic manage-
ment of chronic pain of varied etiology is strong. Tricyclic medications and
s
erotonin–norepinephrine reuptake inhibitors (SNRIs) are recommended for
chronic pain in conjunction with other therapies; there have been multiple
randomized controlled trials (RCTs), and the aggregated findings are sup-
ported by meta-analyses (American Society of Anesthesiologists Task Force
on Chronic Pain Management and American Society of Regional nesthesia
A
and Pain Medicine, 2010). Pregabalin has been shown to be effective for
central neuropathic pain (Moore et al., 2009). The use of NSAIDs or
t
ramadol for chronic back pain is supported by the results of multiple RCTs
(American Society of Anesthesiologists Task Force on Chronic Pain Man-
agement and American Society of Regional Anesthesia and Pain Medicine,
2010). Although there are data that show that opioids provide effective
relief of low back pain and some forms of neuropathic pain for periods
ranging from 1 to 9 weeks, the data are limited with respect to the safety
and efficacy of long-term opioid therapy for chronic pain. In addition, the
risks and potential harm associated with opioid therapy are serious, and
guidelines should be followed (VA and DOD, 2010b).
The use of radiofrequency ablation of branch nerves to facet joints for
low back pain is supported by results of multiple RCTs and meta-analyses
(American Society of Anesthesiologists Task Force on Chronic Pain Man-
agement and American Society of Regional Anesthesia and Pain Medicine,
2010). Ablative techniques also are recommended for neck pain, but the
evidence comes from a single RCT. The use of transcutaneous electric
nerve stimulation for chronic back pain and other types of pain as part of
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REVIEW OF TREATMENTS FOR COMORBID AND RELATED CONDITIONS 97
a multimodal treatment is supported by results of multiple RCTs, and the
aggregated findings are supported by meta-analyses. There is no strong
evidence supporting epidural injections for back pain, but there has been
a single RCT on relief of leg pain. Neither is there strong evidence to sup-
port intrathecal drug therapies for neuropathic pain or minimally invasive
spinal procedures for vertebral compression fractures (American Society of
Anesthesiologists Task Force on Chronic Pain Management and American
Society of Regional Anesthesia and Pain Medicine, 2010).
A growing body of evidence demonstrates that acupuncture can be
useful for chronic pain (Lee et al., 2012; Manheimer et al., 2005; Vickers,
2012). The strongest evidence supports its use in treatment for headache,
but it may be effective for other forms of chronic pain, such as low back
pain and osteoarthritis. Therefore, acupuncture should be considered for
use in customizing pain treatment of patients who have CMI.
CHRONIC FATIGUE SYNDROME
Chronic fatigue syndrome (CFS), also known as myalgic encephalo
myelitis, affects an estimated 4 million people in the United States, according
to the Centers for Disease Control and Prevention (CDC), with prevalence
estimates ranging from 0.2% to 2.54% (Maquet et al., 2006; Reeves et
al., 2007). CFS is more common and more severe in women and people
who have Latino and African-American backgrounds, and its prognosis
w
orsens with age (Jason et al., 2011). People who have CFS often have
other omorbid conditions, such as obesity and metabolic disorders, depres-
c
sion, irritable bowel syndrome (IBS), fibromyalgia, and multiple chemical
sensitivity. Multiple symptoms of each of those conditions can overlap
substantially with CMI, including fatigue, nonrestorative sleep, tenderness
on palpation, and some mild cognitive dysfunction (CDC, 1994). Defini-
tions of CFS vary, but the diagnosis is the result of careful review of patient
history, physical health and mental health examinations, clinical laboratory
testing, and indicated imaging studies to rule out other medical and psy-
chologic diagnoses that may explain the symptoms of CFS. Definitions of
CFS used by CDC and UK National Health Service are included in Box 5-1.
Chronic Fatigue Syndrome and Chronic Multisymptom Illness
Much research on CFS has targeted infectious triggers associated with
low-grade fever, adenopathy, and influenza symptoms. Regardless, no con-
sistent viral agents (such as human herpesvirus 6 and Epstein-Barr virus)
have been definitively identified (Glaser and Kiecolt-Glaser, 1998). Fever,
adenopathy, and infection-like symptoms tend to decrease over time, and
fatigue and other somatic symptoms common in CMI become more promi-
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98 GULF WAR AND HEALTH
BOX 5-1
Definitions of Chronic Fatigue Syndrome
International CFS Case NICE Guidelines for CFS,
Definition, 1994a 2007b
Duration 6 months or longer 4 months or longer in adults
Fatigue Severe chronic fatigue not Fatigue with
explained by any medical or • ew or specific date
N
psychiatric diagnosis of onset, persistent or
recurrent, unexplained by
other conditions
• ubstantially reduced
S
activity level
• ostexertional malaise or
P
fatigue
Symptoms At least four of the following: At least one of the following:
• ostexertion malaise lasting
P • ifficulty in sleeping or
D
more than 24 hours insomnia
• nrefreshing or
U • uscle or joint pain without
M
nonrestorative sleep inflammation (swelling)
• ubstantial impairment
S manifested as tenderness
of short-term memory or on palpation in characteristic
concentration soft-tissue areas
• uscle pain
M • eadaches
H
• ain in joints without
P • ainful lymph nodes that are
P
swelling or redness not enlarged
• eadaches of a new type,
H • ore throat
S
pattern, or severity • oor mental function, such
P
• ender lymph nodes in the
T as difficulty in thinking
neck or armpit • orsening of symptoms
W
• ore throat that is frequent
S after physical or mental
or recurring exertion
• eeling of being unwell
F
or having influenza-like
symptoms
• izziness or nausea
D
• eart palpitations without
H
heart disease
And All other medical conditions have been ruled out.
NOTE: CFS = chronic fatigue syndrome; NICE = National Institute for Health
and Clinical Excellence.
aCDC, 1994.
bNHS, 2007.
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REVIEW OF TREATMENTS FOR COMORBID AND RELATED CONDITIONS 99
nent (Krilov et al., 1998). Many of the symptoms of CFS and CFS-like ill-
ness (meeting some but not all of the criteria for CFS) are similar to those
experienced by people who have CMI. Both CMI and CFS include a variety
of symptoms—fatigue, cognitive symptoms, and pain.
Treatments for Chronic Fatigue Syndrome
Both US and UK treatment guidelines emphasize the lack of a particular
medication or therapy to cure CFS. However, an individualized treatment
program and a patient-centered care model to tailor symptom management
to a patient’s needs are recommended. Symptoms of CFS may be man-
aged in primary care (CDC, undated; Mayo Clinic staff, 2011; National
C
ollaborating Centre for Primary Care, 2007).
Two specific therapies are recommended for people who have CFS: CBT
and graded exercise therapy (GET) (CDC, 1994; Mayo Clinic staff, 2011;
National Collaborating Centre for Primary Care, 2007). CBT provides a
framework for patients to change how they think and feel about their illness
and teaches behaviors that provide patients with a greater sense of control
over symptoms (CDC, undated; National Collaborating Centre for Primary
Care, 2007). Exercise has been associated with the body’s natural release of
endorphins, natural pain relievers. Both exercise and endorphins have been
shown to improve a number of the symptoms of CFS and related syndromes
(Cleare, 2003; Harber and Sutton, 1984).
Additional CFS management strategies can be recommended to improve
quality of life. Pacing to balance activities and rest throughout the day may
be helpful to avoid “crashing” after too much activity; however, evidence
is insufficient to determine efficacy (CDC, 1994; National Collaborat-
ing Centre for Primary Care, 2007). Disturbance of restorative or deep
sleep may play a role in triggering symptoms of CFS (Moldofsky, 1993).
Sleep patterns should be changed gradually to introduce a regular sleep-
ing schedule, bedtime routine, noise and light control, and avoidance of
c
affeine, alcohol, and tobacco (CDC, 1994; National Collaborating Centre
for Primary Care, 2007). Clinicians should also encourage patients to learn
coping skills through counseling and support groups and to maintain their
independence as much as possible (CDC, 1994; Mayo Clinic staff, 2011).
Management may focus on treating specific symptoms. Drug therapy
is recommended to manage some symptoms, but clinicians are encour-
aged to use as few drugs as possible and to use minimal doses because
people who have CFS are often more sensitive to medications. Pain may
be managed with acetaminophen, aspirin, or NSAIDs, but narcotics are
not recommended. Sleep medications or treatments, such as melatonin
and continuous positive airway pressure, may be useful if indicated by the
patient’s history and improvements are not seen with good sleep hygiene
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100 GULF WAR AND HEALTH
(CDC, 1994; Mayo Clinic staff, 2011; National Collaborating Centre for
Primary Care, 2007). It is clear that CFS is not depression, but it may be
associated with depression.
Multivitamins can be useful for patients who do not have a balanced
diet. Clinicians may offer recommendations to reduce stress and improve
sleep, such as relaxation techniques and limitation of caffeine intake. Such
relaxation techniques as visualization can be used to manage pain, sleep
problems, and comorbid anxiety. Alternative therapies (for example, yoga,
Tai Chi, acupuncture, and massage) may help to lessen pain and increase
energy (CDC, 1994; Mayo Clinic staff, 2011; National Collaborating
C
entre for Primary Care, 2007).
SOMATIC SYMPTOM DISORDERS
There appears to be a tendency to experience and communicate psycho-
logic distress in the form of physical symptoms and to seek medical atten-
tion for these symptoms (Katon and Walker, 1998; Shorter, 1993). Often,
the physical symptoms remain medically unexplained and are associated
with increased medical visits and unnecessary medical tests, which may
result in iatrogenic complications. Among the many terms used in the litera-
ture to label these somatic presentations, somatization symptoms was the
most common for decades. That designation has been gradually replaced
with more descriptive terms, such as medically unexplained symptoms,
unexplained symptoms, and functional somatic symptoms.
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edi-
tion (DSM-5), the new criteria being developed by the American Psychiatric
Association, those syndromes are classified under the heading “Somatic
Symptom Disorders” (SSDs). Their key characteristic is the presence of or
preoccupation with physical symptoms that suggest a medical condition but
cannot be satisfactorily explained with traditional physical and laboratory
assessments (APA, 2012). DSM-5’s SSDs include illness anxiety disorder,
functional neurologic disorder (conversion disorder), psychologic problems
that affect a medical condition, and disorders not elsewhere classified. A
distinctive characteristic of patients who have SSDs is not a somatic symp-
tom itself but how a patient experiences it, interprets it, and presents it to a
clinician. Despite the relevance of these somatic presentations in medicine,
their definition and classification remain difficult and controversial, and this
has led to frequent revisions of nomenclatures that move the target used to
designate “cases” and complicate the clinical recognition and management
of the syndromes.
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REVIEW OF TREATMENTS FOR COMORBID AND RELATED CONDITIONS 101
Somatic Symptom Disorders and Chronic Multisymptom Illness
Because SSDs typically present with multiple physical symptoms of
unclear etiology that tend to persist, the syndromes often overlap with CMI,
and differential diagnosis is difficult.
Treatments for Somatic Symptom Disorders
Effective treatments for SSDs include nonpharmacologic approaches,
such as CBT and communication with the primary care physician by the
psychiatrist or psychologist via consultation letters (Escobar, 2009). Other
forms of psychotherapy and biofeedback are also effective (Katsamanis et
al., 2011). In some instances, particularly when SSD symptoms are accom-
panied by anxiety and depression symptoms (a common co-occurrence,
particularly in primary care settings), such antidepressants as venlafaxine
may be helpful (Kroenke et al., 2006). However, treatments have to be
adapted to give proper attention to the somatic component because tradi-
tional treatments alone (for example, antidepressants) may not be sufficient.
SLEEP DISORDERS
Sleep disorders are a group of about 70 syndromes characterized by
persistent disturbance in sleep that interferes with activities of daily living.
The most common syndromes are chronic insomnia, nightmare dis rder, o
rapid eye movement (REM) sleep behavior disorder, circadian-rhythm sleep
disorders, and obstructive sleep apnea. Like CMI, sleep disorders are asso-
ciated with fatigue, mood disturbances, cognitive difficulties, and other
somatic symptoms; comorbidity with depression, anxiety, and substance
abuse is common.
Sleep Disorders and Chronic Multisymptom Illness
Several types of sleep disorders are among the common symptoms
associated with CMI. Nightmare disorders, subjective perceptions of dif-
ficulty with sleep initiation or duration, and early awakening (insomnia)
have been described in persons who have PTSD, chronic pain disorders,
and other comorbid conditions, including general medical and neurologic
dis rders (Chokroverty, 2000). Other types of sleep disorders are less
o
common in people who have CMI. REM sleep behavior disorder may be
idiopathic or secondary to neurologic disorders, such as Parkinson’s disease,
stroke, multiple sclerosis, and spinocerebellar ataxia. Obstructive sleep
apnea is most common among those who are obese or have congestive heart
failure, stroke, or pulmonary hypertension. Circadian-rhythm sleep dis
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102 GULF WAR AND HEALTH
TABLE 5-1 Best-Practice Guidelines and Recommendations for
Treatment for Nightmare Disorders and Chronic Insomnia
Type of Intervention Nightmare Disordera Chronic Insomniab
Pharmacologic Prazosin (for PTSD- Pharmaceutical agent selected on
associated nightmares) basis of symptom pattern, treatment
goals, past treatment response, patient
preference, cost, availability of other
treatments, comorbid conditions,
concurrent medication interactions, and
side effects
Nonpharmacologic CBT, including image At least one behavioral intervention
rehearsal therapy of these: stimulus-control therapy,
relaxation therapy, or combination CBT
aAmerican
Academy of Sleep Medicine (Aurora et al., 2010).
bAmerican
Academy of Sleep Medicine (Schutte-Rodin et al., 2008).
NOTE: CBT = cognitive behavioral therapy; PTSD = posttraumatic stress disorder.
orders may be exogenous (for example, jet lag or difficulties in shift work)
or ndogenous (for example, advanced sleep-phase disorder or irregular
e
sleep–wake rhythm). Nightmare disorders and insomnia are the two sleep
disorders more commonly associated with CMI.
Treatments for Sleep Disorders
Because of the large number of sleep disorders and evidence that
effective treatment varies among them, it is vital to evaluate the patient
adequately and accurately to characterize the specific symptoms, identify
potential comorbid conditions or risk factors, and diagnose the specific
type of disorder. Table 5-1 summarizes best-practice guidelines and recom-
mendations for treatment for nightmare disorder and chronic insomnia.
The clinician should consider a number of other approaches that may
be useful when individualizing the treatment and management of CMI, such
as good sleep hygiene, exercise, acupuncture, and mind–body approaches.
Some of those approaches, such as acupuncture, have been documented
with systematic reviews (Lee et al., 2012), but they have not yet risen to
the level of guidelines.
FUNCTIONAL GASTROINTESTINAL DISORDERS: IRRITABLE
BOWEL SYNDROME AND FUNCTIONAL DYSPEPSIA
The functional gastrointestinal disorders (FGIDs) are best understood
as disorders that affect gastrointestinal functioning; the ones most recog-
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REVIEW OF TREATMENTS FOR COMORBID AND RELATED CONDITIONS 103
nized and most relevant to this discussion are IBS and functional dyspepsia
(FD) (Drossman, 2006). IBS and FD present as recurrent or prolonged
clusters of gastrointestinal symptoms that remain consistent in their fea-
tures over time and among populations. IBS and FD are common in young
adults and are associated with wartime deployment of Gulf War veterans
(IOM, 2010).
The diagnosis of an FGID is made by fulfilling standardized symptom-
based criteria (“Rome criteria”) for a minimal period, usually 6 months.
The criteria for IBS and FD are shown in Boxes 5-2 and 5-3.
Functional Gastrointestinal Disorders and Chronic Multisymptom Illness
The most common symptoms of IBS are abdominal pain or discomfort,
diarrhea, constipation, and abdominal bloating, and common symptoms of
FD are early satiety with upper abdominal fullness, burning, or pain—all
in the absence of other structural abnormalities that explain the symptoms.
The symptoms are common in veterans deployed to the 1991 Gulf War
(IOM, 2010). There is overlap between symptoms associated with IBS and
FD and the gastrointestinal symptoms associated with CMI. A veteran may
fulfill criteria for IBS and also have other extraintestinal symptoms and
receive a diagnosis of IBS, at another time have gastrointestinal symptoms
that are not sufficient for a diagnosis of IBS, and, by virtue of having several
other unexplained symptoms, be classified as having CMI. Therefore, from
a therapeutic standpoint, these conditions that share symptoms are likely
BOX 5-2
Rome III Diagnostic Criteriaa for Irritable Bowel Syndrome
Recurrent abdominal pain or discomfort at least 3 days per month in
last 3 months associated with two or more of
1. Improvement with defecation.
2. Onset associated with a change in frequency of stool.
3. Onset associated with a change in form (appearance) of stool.
aCriteriafulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
SOURCE: Reprinted from Gastroenterology 130(5), Longstreth et al., Functional bowel disor-
ders, pages 1480–1491, Copyright 2006, with permission from Elsevier.
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122 GULF WAR AND HEALTH
TABLE 5-3 Continued
Condition Pharmacologic Nonpharmacologic
Substance-use For alcohol-use disorders: For alcohol-use disorders:
and addictive • Naltrexone • Behavioral couples therapy
disorders • Acamprosate • CBT
• Disulfiram • Social network and
• Topiramate (possibly) environment-based therapies
For tobacco-use disorders: • Other behavioral therapies
• Nicotine-replacement therapy (for example, cue exposure,
• Bupropion behavioral self-control
• Varenicline training, aversion therapy, and
For opioid-use disorders: contingency management)
• Methadone For tobacco-use disorders:
• Buprenorphine • Individual and group behavioral
• Naltrexone interventions focused on
smoking cessation
For opioid-use disorders:
• Referral to a pain specialist
or center that specializes in
withdrawal treatment
Self-harm • SSRIs • CBT, including dialectic
behavior therapy
• Interpersonal therapy
NOTES: CBT = cognitive behavioral therapy; CPAP = continuous positive airway pressure;
NSAIDs = nonsteroidal anti-inflammatory drugs; SNRIs = serotonin–norepinephrine reuptake
inhibitors; SSRIs = selective serotonin reuptake inhibitors.
There also is substantial evidence in guidelines and from systematic
reviews that CBT is effective in managing more than one of the related
conditions. CBT has been shown to be effective in nearly all the conditions
examined in this chapter. It is important to note that there are multiple
types of CBT and that the choice of the appropriate type to use for a par-
ticular patient will depend on the person’s symptoms.
As summarized in this chapter, many other treatments, both phar-
macologic and nonpharmacologic, have been shown to be effective in
managing conditions related to and comorbid with CMI. Because symp-
toms of CMI have a pattern of presentation similar to those of the other
conditions, treatments found to be effective for the conditions should be
considered as parts of an integrated and multimodal treatment plan for
patients who have CMI.
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REVIEW OF TREATMENTS FOR COMORBID AND RELATED CONDITIONS 123
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