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Review
. 2014 Nov 1;2014(11):CD011142.
doi: 10.1002/14651858.CD011142.pub2.

Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults

Nikki van Dessel  1 , Madelon den Boeft, Johannes C van der Wouden, Maria Kleinstäuber, Stephanie S Leone, Berend Terluin, Mattijs E Numans, Henriëtte E van der Horst, Harm van Marwijk
Affiliations
Review

Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults

Nikki van Dessel et al. Cochrane Database Syst Rev. .

Abstract

Background: Medically unexplained physical symptoms (MUPS) are physical symptoms for which no adequate medical explanation can be found after proper examination. The presence of MUPS is the key feature of conditions known as 'somatoform disorders'. Various psychological and physical therapies have been developed to treat somatoform disorders and MUPS. Although there are several reviews on non-pharmacological interventions for somatoform disorders and MUPS, a complete overview of the whole spectrum is missing.

Objectives: To assess the effects of non-pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform disorders unspecified, somatoform autonomic dysfunction, pain disorder, and alternative somatoform diagnoses proposed in the literature) and MUPS in adults, in comparison with treatment as usual, waiting list controls, attention placebo, psychological placebo, enhanced or structured care, and other psychological or physical therapies.

Search methods: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to November 2013. This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library, EMBASE, MEDLINE, and PsycINFO. We ran an additional search on the Cochrane Central Register of Controlled Trials and a cited reference search on the Web of Science. We also searched grey literature, conference proceedings, international trial registers, and relevant systematic reviews.

Selection criteria: We included RCTs and cluster randomised controlled trials which involved adults primarily diagnosed with a somatoform disorder or an alternative diagnostic concept of MUPS, who were assigned to a non-pharmacological intervention compared with usual care, waiting list controls, attention or psychological placebo, enhanced care, or another psychological or physical therapy intervention, alone or in combination.

Data collection and analysis: Four review authors, working in pairs, conducted data extraction and assessment of risk of bias. We resolved disagreements through discussion or consultation with another review author. We pooled data from studies addressing the same comparison using standardised mean differences (SMD) or risk ratios (RR) and a random-effects model. Primary outcomes were severity of somatic symptoms and acceptability of treatment.

Main results: We included 21 studies with 2658 randomised participants. All studies assessed the effectiveness of some form of psychological therapy. We found no studies that included physical therapy.Fourteen studies evaluated forms of cognitive behavioural therapy (CBT); the remainder evaluated behaviour therapies, third-wave CBT (mindfulness), psychodynamic therapies, and integrative therapy. Fifteen included studies compared the studied psychological therapy with usual care or a waiting list. Five studies compared the intervention to enhanced or structured care. Only one study compared cognitive behavioural therapy with behaviour therapy.Across the 21 studies, the mean number of sessions ranged from one to 13, over a period of one day to nine months. Duration of follow-up varied between two weeks and 24 months. Participants were recruited from various healthcare settings and the open population. Duration of symptoms, reported by nine studies, was at least several years, suggesting most participants had chronic symptoms at baseline.Due to the nature of the intervention, lack of blinding of participants, therapists, and outcome assessors resulted in a high risk of bias on these items for most studies. Eleven studies (52% of studies) reported a loss to follow-up of more than 20%. For other items, most studies were at low risk of bias. Adverse events were seldom reported.For all studies comparing some form of psychological therapy with usual care or a waiting list that could be included in the meta-analysis, the psychological therapy resulted in less severe symptoms at end of treatment (SMD -0.34; 95% confidence interval (CI) -0.53 to -0.16; 10 studies, 1081 analysed participants). This effect was considered small to medium; heterogeneity was moderate and overall quality of the evidence was low. Compared with usual care, psychological therapies resulted in a 7% higher proportion of drop-outs during treatment (RR acceptability 0.93; 95% CI 0.88 to 0.99; 14 studies, 1644 participants; moderate-quality evidence). Removing one outlier study reduced the difference to 5%. Results for the subgroup of studies comparing CBT with usual care were similar to those in the whole group.Five studies (624 analysed participants) assessed symptom severity comparing some psychological therapy with enhanced care, and found no clear evidence of a difference at end of treatment (pooled SMD -0.19; 95% CI -0.43 to 0.04; considerable heterogeneity; low-quality evidence). Five studies (679 participants) showed that psychological therapies were somewhat less acceptable in terms of drop-outs than enhanced care (RR 0.93; 95% CI 0.87 to 1.00; moderate-quality evidence).

Authors' conclusions: When all psychological therapies included this review were combined they were superior to usual care or waiting list in terms of reduction of symptom severity, but effect sizes were small. As a single treatment, only CBT has been adequately studied to allow tentative conclusions for practice to be drawn. Compared with usual care or waiting list conditions, CBT reduced somatic symptoms, with a small effect and substantial differences in effects between CBT studies. The effects were durable within and after one year of follow-up. Compared with enhanced or structured care, psychological therapies generally were not more effective for most of the outcomes. Compared with enhanced care, CBT was not more effective. The overall quality of evidence contributing to this review was rated low to moderate.The intervention groups reported no major harms. However, as most studies did not describe adverse events as an explicit outcome measure, this result has to be interpreted with caution.An important issue was that all studies in this review included participants who were willing to receive psychological treatment. In daily practice, there is also a substantial proportion of participants not willing to accept psychological treatments for somatoform disorders or MUPS. It is unclear how large this group is and how this influences the relevance of CBT in clinical practice.The number of studies investigating various treatment modalities (other than CBT) needs to be increased; this is especially relevant for studies concerning physical therapies. Future studies should include participants from a variety of age groups; they should also make efforts to blind outcome assessors and to conduct follow-up assessments until at least one year after the end of treatment.

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Conflict of interest statement

Nikki van Dessel: none known.

Madelon den Boeft: none known.

Johannes C van der Wouden: none known.

Stephanie S Leone: none known.

Berend Terluin: none known.

Maria Kleinstauber: none known.

Mattijs Numans: none known.

Henriëtte E van der Horst: none known.

Harm WJ van Marwijk: none known

Figures

1
1
6 Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Funnel plot of comparison: 1 Psychological therapies versus usual care or waiting list, outcome: 1.4 Acceptability.
1.1
1.1. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 1 Severity of somatic symptoms at end of treatment.
1.2
1.2. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 2 Severity of somatic symptoms within 1 year after treatment.
1.3
1.3. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 3 Severity of somatic symptoms > 1 year after treatment.
1.4
1.4. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 4 Acceptability.
1.5
1.5. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 5 Severity of anxiety symptoms at end of treatment ‐ participant rated.
1.6
1.6. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 6 Severity of anxiety symptoms at end of treatment ‐ clinician rated.
1.7
1.7. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 7 Severity of anxiety symptoms within 1 year after treatment ‐ participant rated.
1.8
1.8. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 8 Severity of anxiety symptoms within 1 year after treatment ‐ clinician rated.
1.9
1.9. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 9 Severity of anxiety symptoms > 1 year after treatment ‐ clinician rated.
1.10
1.10. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 10 Severity of depressive symptoms at end of treatment ‐ participant rated.
1.11
1.11. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 11 Severity of depressive symptoms at end of treatment ‐ clinician rated.
1.12
1.12. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 12 Severity of depressive symptoms within 1 year after treatment ‐ participant rated.
1.13
1.13. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 13 Severity of depressive symptoms within 1 year after treatment ‐ clinician rated.
1.14
1.14. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 14 Severity of depressive symptoms > 1 year after treatment ‐ clinician rated.
1.15
1.15. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 15 Dysfunctional cognitions, emotions and behaviours at end of treatment.
1.16
1.16. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 16 Dysfunctional cognitions, emotions, and behaviours within 1 year after treatment.
1.17
1.17. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 17 Adverse events.
1.18
1.18. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 18 Treatment response at end of treatment.
1.19
1.19. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 19 Treatment response within 1 year after treatment.
1.20
1.20. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 20 Treatment response > 1 year after treatment.
1.21
1.21. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 21 Functional disability and quality of life at end of treatment.
1.22
1.22. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 22 Functional disability and quality of life within 1 year after treatment.
1.23
1.23. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 23 Functional disability and quality of life > 1 year of treatment.
1.24
1.24. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 24 Healthcare use at end of treatment.
1.25
1.25. Analysis
Comparison 1 Psychological therapies versus usual care or waiting list, Outcome 25 Healthcare use within 1 year after treatment.
2.1
2.1. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 1 Severity of somatic symptoms at end of treatment.
2.2
2.2. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 2 Severity of somatic symptoms within 1 year after treatment.
2.3
2.3. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 3 Severity of somatic symptoms > 1 year after treatment.
2.4
2.4. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 4 Acceptability.
2.5
2.5. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 5 Severity of anxiety or depressive symptoms (or both) at end of treatment.
2.6
2.6. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 6 Severity of anxiety or depressive symptoms (or both) within 1 year after treatment.
2.7
2.7. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 7 Severity of anxiety or depressive symptoms (or both) > 1 year after treatment.
2.8
2.8. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 8 Dysfunctional cognitions, emotions, and behaviours at end of treatment.
2.9
2.9. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 9 Dysfunctional cognitions, emotions, and behaviours within 1 year after treatment.
2.10
2.10. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 10 Dysfunctional cognitions, emotions, and behaviours > 1 year after treatment.
2.11
2.11. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 11 Functional disability and quality of life at end of treatment.
2.12
2.12. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 12 Functional disability and quality of life within 1 year after treatment.
2.13
2.13. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 13 Functional disability and quality of life > 1 year of treatment.
2.14
2.14. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 14 Healthcare use at end of treatment.
2.15
2.15. Analysis
Comparison 2 Psychological therapies versus enhanced care, Outcome 15 Healthcare use within 1 year after treatment.
3.1
3.1. Analysis
Comparison 3 Cognitive behavioural therapy versus behavioural therapy, Outcome 1 Severity of somatic symptoms at end of treatment.
3.2
3.2. Analysis
Comparison 3 Cognitive behavioural therapy versus behavioural therapy, Outcome 2 Acceptability.
3.3
3.3. Analysis
Comparison 3 Cognitive behavioural therapy versus behavioural therapy, Outcome 3 Severity of anxiety or depressive symptoms (or both) at end of treatment.
3.4
3.4. Analysis
Comparison 3 Cognitive behavioural therapy versus behavioural therapy, Outcome 4 Functional disability and quality of life at end of treatment.
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    1. Hiller W, Kroymann R, Leibbrand R, Cebulla M, Korn HJ, Rief W, et al. Effects and cost‐effectiveness analysis of inpatient treatment for somatoform disorders [Wirksamkeit und Kosten‐Nutzen‐Effekte der stationären Therapie somatoformer Störungen]. Fortschritte der Neurologie ‐ Psychiatrie 2004;72:136‐46. - PubMed
Houtveen 2013 {published data only}
    1. Houtveen JH, Lintmeijer L, Broeckhuysen S. The clinical effectiveness of a long‐term multidisciplinary integrative psychological treatment with a focus on body‐related mentalisation for patients with severe somatoform disorder. Journal of Psychosomatic Research 2013;74(6):547.
Klapow 2001 {published data only}
    1. Klapow JC, Schmidt SM, Taylor LA, Roller P, Li Q, Calhoun JW, et al. Symptom management in older primary care patients: feasibility of an experimental, written self‐disclosure protocol. Annals of Internal Medicine 2001;134:901‐11. - PubMed
Kocken 2008 {published data only}
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Larisch 2004 {published data only}
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Lopez‐Garcia‐Franco 2012 {published data only}
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Lupke 1996 {published data only}
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McLeod 1997 {published data only}
    1. McLeod CC, Budd MA, McClelland DC. Treatment of somatization in primary care. General Hospital Psychiatry 1997;19(4):251‐8. - PubMed
Morriss 2007 {published data only}
    1. Morriss R, Dowrick C, Salmon P, Peters S, Dunn G, Rogers A, et al. Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. British Journal of Psychiatry 2007;191:536‐42. - PubMed
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Nanke 2003a {published data only}
    1. Nanke A, Rief W. Biofeedback in the treatment of somatoform disorders [Biofeedback‐Therapie bei somatoformen Störungen]. Verhaltenstherapie 2000;10:238‐48.
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Payne 2009 {published data only}
    1. Payne H. Pilot study to evaluate dance movement psychotherapy (the body mind approach) in patients with medically unexplained symptoms: participant and facilitator perceptions and a summary discussion. Body, Movement and Dance in Psychotherapy 2009;4(2):77‐94.
Peters 2002 {published data only}
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Pols 2008 {published data only}
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Rasmussen 2006 {published data only}
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Rosendal 2007 {published data only}
    1. Rosendal M, Olesen F, Fink P, Toft T, Sokolowski I, Bro F. A randomized controlled trial of brief training in the assessment and treatment of somatization in primary care: effects on patient outcome. General Hospital Psychiatry 2007;29(4):364‐73. - PubMed
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References to studies awaiting assessment

Burwell‐Walsh 2002 {unpublished data only}
    1. Burwell‐Walsh SR. Emotion‐Focused Couples Therapy as a Treatment of Somatoform Disorders: an Outcome Study [Doctoral dissertation]. Blacksburg, VA: Virginia Polytechnic Institute and State University, 2002.
Crompton 2003 {published data only}
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Gournay 1998 {published data only}
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Lopez‐Garcia‐Franco 2009 {published data only}
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Mussgay 2006 {published data only}
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Nickel 2006 {published data only}
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Woolfolk 2007 {published data only}
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References to ongoing studies

Agger 2012 {published data only}
    1. Agger JL. Treatment of multi‐organ bodily distress syndrome. A randomized controlled trial of the effects of acceptance and commitment therapy given as group therapy or workshop compared to standard treatment (Stress‐4). clinicaltrials.gov/show/NCT01518647 (accessed 27 October 2014).
Hassett 2007 {published data only}
    1. Hassett AL. A computer‐based intervention for medically unexplained physical symptoms. clinicaltrials.gov/ct2/show/NCT00468013 (accessed 27 October 2014).
Olde Hartman 2013 {published data only}
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Rief 2013 {published data only}
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Schröder 2014 {unpublished data only}
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Sitnikova 2014 {published data only}
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Steel 2011 {published data only}
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Zimmermann 2014 {published data only}
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