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Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults
Open accessAbstract
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 s
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“Cognitive behavioral therapy (CBT) has been shown effective for health anxiety [17] and seems promising for PPS, although, with generally modest effects and limited data on environmental intolerance [18].”
From Work Ability and Functioning Among Individuals with Persistent Indoor Environment-Related Symptoms or Chronic Fatigue: Nine-Month Follow-Up of a Web-Based Randomized Controlled Trial. (2026) · cites this paper as [18]
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“Similarly, CBT has shown more pronounced effects on diagnosed health anxiety [17] than PPS [18].”
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“Selection bias may exist due to voluntary enrollment, as intervention studies in general [18], and only those capable of using the online program via computer or smartphone could participate, affecting representativeness.”
From Work Ability and Functioning Among Individuals with Persistent Indoor Environment-Related Symptoms or Chronic Fatigue: Nine-Month Follow-Up of a Web-Based Randomized Controlled Trial. (2026) · cites this paper as [18]
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“CBT has demonstrated both short-term and long-term efficacy with small effect sizes for MUS (Van Dessel et al., 2014) yet larger treatment effects are seen in specific syndromes such as CFS (White et al., 2011) and IBS (Altayar et al., 2015).”
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CBT to reduce healthcare use for medically unexplained symptoms: systematic review and meta-analysis
Jones, B., & Williams, A. C. D. C. (2019) · British Journal of General Practice · doi:10.3399/bjgp19x701273 · Cited by 37
Electroencephalography During Nociceptive Stimulation in Chronic Pain Patients: A Systematic Review
Lenoir, D., Willaert, W., Coppieters, I., Malfliet, A., Ickmans, K., Nijs, J., Vonck, K. E. J., Meeus, M., & Cagnie, B. J. (2020) · Pain Medicine · doi:10.1093/pm/pnaa131 · Cited by 36
Behm, A. C., Hüsing, P., Löwe, B., & Toussaint, A. C. (2021) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2021.152265 · Cited by 34
Geraghty, K., & Blease, C. R. (2016) · Journal of Health Psychology · doi:10.1177/1359105316667798 · Cited by 37
Röhricht, F., Sattel, H. C., Kuhn, C., & Lahmann, C. (2019) · BMC Psychiatry · doi:10.1186/s12888-019-2095-6 · Cited by 49
Maroti, D., Ek, J., Widlund, R.-M., Schubiner, H. H., Lumley, M. A., Lilliengren, P., Bilevičiūtė-Ljungar, I., Ljótsson, B., & Johansson, R. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.620359 · Cited by 32
Mewes, R. (2022) · Frontiers in Public Health · doi:10.3389/fpubh.2022.1033203 · Cited by 33
“They supported the rationale of treatment approaches focusing on cognitivebehavioral factors in general (94), as well as approaches considering negative affectivity and emotion regulation (95, 96) and avoidance (97) in particular.”
BackgroundChalder, T., Patel, M., James, K., Hotopf, M. H., Frank, P., Watts, K., McCrone, P., David, A. S., Ashworth, M. J., Husain, M., et al. (2019) · BMC Psychiatry · doi:10.1186/s12888-019-2297-y · Cited by 31
“The results indicated a beneficial effect of CBT for PPS [7, 8].”
Negative affect as mediator between emotion regulation and medically unexplained symptoms
Schwarz, J., Rief, W., Radkovsky, A., Berking, M., & Kleinstäuber, M. (2017) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2017.08.010 · Cited by 30
Self-citationSitnikova, K., Leone, S. S., van Marwijk, H., Twisk, J. W. R., van der Horst, H. E., & van der Wouden, J. C. (2019) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2019.109745 · Cited by 29
“Non-pharmacological interventions such as cognitive behavioural therapy (CBT) may improve functioning of patients with somatoform symptoms and reduce symptom severity (15).”
BackgroundResultSelf-citationSomatic symptom disorder: a diagnostic dilemma
Dunphy, L., Penna, M., & Kafsi, J. E. (2019) · BMJ Case Reports · doi:10.1136/bcr-2019-231550 · Cited by 29
den Boeft, M., Huisman, D., Morton, L., Lucassen, P. L., van der Wouden, J. C., Westerman, M. J., van der Horst, H. E., & Burton, C. D. (2016) · Family Practice · doi:10.1093/fampra/cmw113 · Cited by 29
Poloni, N., Ielmini, M., Caselli, I., Ceccon, F., Bianchi, L., Isella, C., & Callegari, C. (2018) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2018.00626 · Cited by 28
Early response in cognitive-behavior therapy for syndromes of medically unexplained symptoms
Kleinstäuber, M., Lambert, M. J., & Hiller, W. (2017) · BMC Psychiatry · doi:10.1186/s12888-017-1351-x · Cited by 29
“Under consideration of an average dropout rate of 15% at post-treatment which was found in previous RCTs being comparable to our trial [19, 20], we estimated a total sample size of N = 106.”
BackgroundMethodResultInfluentialSelf-citationThe Four-Cluster Spectrum of Mind-Body Interrelationships: An Integrative Model
Ezra, Y., Hammerman, O., & Shahar, G. (2019) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2019.00039 · Cited by 29
“In these conditions, treatment should focus on physical exercise and mind-body treatments such as meditation, CBT, and hypnosis (93, 97).”
BackgroundMethodPsychologic treatment of functional neurologic disorders
Goldstein, L. H., & Mellers, J. D. C. (2016) · Handbook of clinical neurology · doi:10.1016/b978-0-12-801772-2.00046-1 · Cited by 28
Petricone‐Westwood, D., Jones, G., Mutsaers, B., Leclair, C. S., Tomei, C., Trudel, G., Dinkel, A., & Lebel, S. (2018) · International Journal of Behavioral Medicine · doi:10.1007/s12529-018-9748-6 · Cited by 27
“Furthermore, a recent Cochrane systematic review of somatoform disorders and medically unexplained physical symptoms reported CBTas having the most positive intervention trial results for these disorders [16].”
BackgroundMedically unexplained symptom management
Schröder, A., Sharpe, M., & Fink, P. (2015) · The Lancet Psychiatry · doi:10.1016/s2215-0366(15)00233-3 · Cited by 27
The Relationship Between Vulvovaginal Candidiasis and Provoked Vulvodynia: A Systematic Review
Leusink, P., van de Pasch, S., Teunissen, D. A. M., Laan, E. T. M., & Lagro-Janssen, A. L. M. (2018) · The Journal of Sexual Medicine · doi:10.1016/j.jsxm.2018.07.011 · Cited by 27
Vink, M., & Vink-Niese, A. (2019) · Health Psychology Open · doi:10.1177/2055102919840614 · Cited by 32
“A Cochrane review of non-pharmacological interventions for functional syndromes, including CFS (14 of the 21 RCTs used CBT) (Van Dessel et al., 2014), and a recent meta-analysis of 33 RCTs of mindfulness-based interventions (Dunning et al., 2018), both not only concluded that most benefits…”
MethodContacting of authors by systematic reviewers: protocol for a cross-sectional study and a survey
Reynders, R. M., Ladu, L., & Girolamo, N. D. (2017) · Systematic Reviews · doi:10.1186/s13643-017-0643-z · Cited by 26
“Such methods have provided important research data that have permitted systematic reviewers to (1) assess the eligibility of studies [18, 19], (2) assess conflicts of interest [20], (3) obtain research protocols [21], (4) assess the study design [19], (5) obtain information on groups of participants [22], (6) obtain o…”
BackgroundEvangelidou, S., NeMoyer, A., Cruz-Gonzalez, M. A., O’Malley, I. S., & Alegria, M. M. (2020) · Cultural Diversity & Ethnic Minority Psychology · doi:10.1037/cdp0000319 · Cited by 26
“Currently, there is limited evidence for any effective treatment of MUPS (Creed, Kroenke, Henningsen, Gudi, & White, 2011), and generally, psychological therapies have been no more effective than enhanced care from medical doctors (Van Dessel et al., 2014).”
BackgroundCoping with Medically Unexplained Physical Symptoms: the Role of Illness Beliefs and Behaviors
Sullivan, N., Phillips, L. A., Pigeon, W. R., Quigley, K. S., Graff, F., Litke, D. R., Helmer, D. A., Rath, J. F., & McAndrew, L. M. (2019) · International Journal of Behavioral Medicine · doi:10.1007/s12529-019-09817-z · Cited by 25
“Furthermore, CBT does not outperform other standard treatments [6] and is even less effective for certain sub-populations, including patients exposed to trauma, those with chronic fatigue syndrome, and veterans with Gulf War Illness [7, 8].”
BackgroundInfluentialDevelopment and validation of 21-item outcome inventory (OI-21)
Wongpakaran, N., Wongpakaran, T., & Kövi, Z. (2022) · Heliyon · doi:10.1016/j.heliyon.2022.e09682 · Cited by 25
Brownell, A. K. W., Atkins, C. ̈. G. K., Whiteley, A., Woollard, R. F., & Kornelsen, J. (2016) · BMJ Open · doi:10.1136/bmjopen-2016-012379 · Cited by 24
Weiss, F. D., Rief, W., & Kleinstäuber, M. (2016) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2016.10.003 · Cited by 24
Self-citationChavooshi, B., Saberi, M., Tavallaii, A., & Sahraei, H. (2017) · Psychosomatics · doi:10.1016/j.psym.2017.01.003 · Cited by 26
Goldstein, L. H., Robinson, E. J., Pilecka, I., Perdue, I., Mosweu, I., Read, J., Jordan, H., Wilkinson, M., Rawlings, G. H., Feehan, S. J., et al. (2021) · Health Technology Assessment · doi:10.3310/hta25430 · Cited by 24
Wortman, M. S. H., Lucassen, P. L., van Ravesteijn, H. J., Bor, H. H. J., Assendelft, W. J., Lucas, C., & Hartman, T. O. (2016) · Family Practice · doi:10.1093/fampra/cmw023 · Cited by 25
den Boeft, M., Huisman, D., van der Wouden, J. C., Numans, M. E., van der Horst, H. E., Lucassen, P. L., & Hartman, T. O. (2016) · BMC Family Practice · doi:10.1186/s12875-016-0451-x · Cited by 26
Self-citationImplementing a Psychotherapy Service for Medically Unexplained Symptoms in a Primary Care Setting
Cooper, A. M., Abbass, A. A., Zed, J., Bedford, L. G., Sampalli, T., & Town, J. M. (2017) · Journal of Clinical Medicine · doi:10.3390/jcm6120109 · Cited by 24
“Whilst CBT is currently the most adequately studied treatment for MUS [49], brief emotion-focused interventions offer the potential for an alternative approach to patients with MUS.”
BackgroundBuilding-Related Environmental Intolerance and Associated Health in the General Population
Karvala, K., Sainio, M. A., Palmquist, E., Claeson, A., Nyback, M.-H., & Nordin, S. (2018) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph15092047 · Cited by 24
“The parallels with functional somatic syndromes suggest that conditions might respond to similar interventions, such as active behavioral interventions, which focus on encouraging patients to challenge distorted cognitions and change harmful patterns of behavior [41].”
BackgroundSimilar association between objective and subjective symptoms in functional and organic tremor
Kramer, G., Dominguez‐Vega, Z. T., Laarhoven, H. S., Brandsma, R., Smit, M., van der Stouwe, A. M. M., Elting, J. W. J., Maurits, N. M., Rosmalen, J. G. M., & Tijssen, M. A. J. (2019) · Parkinsonism & Related Disorders · doi:10.1016/j.parkreldis.2019.05.026 · Cited by 25
“We excluded patients with psychological treatment in the previous six months as this might influence symptom report [9].”
BackgroundHeimann, P., Herpertz‐Dahlmann, B., Buning, J., Wagner, N., Stollbrink-Peschgens, C., Dempfle, A., & von Polier, G. G. (2018) · Child and Adolescent Psychiatry and Mental Health · doi:10.1186/s13034-018-0253-0 · Cited by 23
Clinical Practice Guideline: Psychotherapies for Somatoform Disorders
Agarwal, V., Nischal, A., Praharaj, S. K., Menon, V., & Kar, S. K. (2020) · Indian Journal of Psychiatry · doi:10.4103/psychiatry.indianjpsychiatry_775_19 · Cited by 23
“Nonpharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults (2014) [10] Cochrane database systematic review 21 randomized controlled trials; pooled n =2658 Psychotherapy: CBT, Mindfulness CBT, Behaviour therapies, Psychodynamic therapies,…”
Gouraud, C., Thoreux, P., Vedrines, C. O., Pitron, V., Betouche, S., Bolloch, K., Caumes, É., Guemouni, S., Xiang, K., Lemogne, C., et al. (2023) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2023.111475 · Cited by 23
Hüsing, P., Smakowski, A., Löwe, B., Kleinstäuber, M., Toussaint, A. C., & Mora, M. C. S. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1142484 · Cited by 24
“The identification of relevant psychological factors holds the great chance that these are modifiable and, therefore, a promising gateway to improve the currently only moderately effective treatment for PSS and related syndromes and disorders (37, 47, 63).”
BackgroundSelf-citationLee, T.-Y., Hsieh, T., Sung, H., & Chen, W. (2019) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph16050708 · Cited by 21
“The Cochrane review of non-pharmacological interventions for functional syndromes (14 of the 21 RCTs used CBT) showed small positive effects when CBT was learnt by participants [42].”
BackgroundBakken, A. K., Mengshoel, A. M., Synnes, O., & Strand, E. B. (2023) · International Journal of Qualitative Studies on Health and Well-Being · doi:10.1080/17482631.2023.2223420 · Cited by 21
“As is the case in recommendations for CFS/ME, current non-pharmacological therapeutic methods for other persistent symptoms often aim at improvement and coping rather than full recovery (Peter Henningsen, Gündel, et al., 2018; Roenneberg et al., 2019; van Dessel et al., 2014).”
MethodA Qualitative Study on the Experiences of Women With Breast Implant Illness
Tang, S., Anderson, N. E., Faasse, K., Adams, W. P., & Newby, J. M. (2021) · Aesthetic Surgery Journal · doi:10.1093/asj/sjab204 · Cited by 21
Hanssen, D. J. C., Bos, L. R., Finch, T. L., & Rosmalen, J. G. M. (2021) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2021.10.004 · Cited by 22
Morton, L., Elliott, A., Thomas, R. E., Cleland, J., Deary, V., & Burton, C. D. (2016) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2016.03.008 · Cited by 21
“While there is evidence for modest effectiveness of psychological interventions for MUS in specialist settings[7], there is currently no strong evidence for effectiveness of treatment for patients with multiple MUS in primary care.”
BackgroundRanque, B., & Nardon, O. (2017) · La Revue de Médecine Interne · doi:10.1016/j.revmed.2016.12.005 · Cited by 22
Chalder, T., Patel, M., Hotopf, M. H., Moss-Morris, R. E., Ashworth, M. J., Watts, K., David, A. S., McCrone, P., Husain, M., Garrood, T., et al. (2021) · Psychological Medicine · doi:10.1017/s0033291721001793 · Cited by 20
“…reviews/meta-analyses published that assess the evidence for cognitive behavioural therapy (CBT) for PPS (Jones & de C. Williams, 2019; Kleinstäuber, Witthöft, & Hiller, 2011; Liu, Gill, Teodorczuk, Li, & Sun, 2019; Menon, Rajan, Kuppili, & Sarkar, 2017; Sumathipala, 2007; Van Dessel et al., 2014).”
BackgroundInfluentialPourová, M., Klocek, A., Řiháček, T., & Čevelíček, M. (2020) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2020.110124 · Cited by 20
Metadata
- Authors
- van Dessel, N., den Boeft, M., van der Wouden, J. C., Kleinstäuber, M., Leone, S. S., Terluin, B., Numans, M. E., van der Horst, H. E., & van Marwijk, H.
- Affiliations
- EMGO Institute for Health and Care Research, VU University Medical Center; Department of General Practice and Elderly Care Medicine; Van der Boechorststraat 7, room D-550 Amsterdam Netherlands 1081 BT
- VU University Medical Center; Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research; PO Box 7057 Amsterdam Netherlands 1007 MB
- Philipps University of Marburg (DE)
- Trimbos Institute (NL)
- Amsterdam Public Health (NL)
- Leiden University Medical Center (NL)
- Venue
- Cochrane Database of Systematic Reviews
- Publisher
- Wiley
- Published
- 2014-11-01
- Volume
- 2014
- Issue
- 11
- Pages
- CD011142-CD011142
- ISSN
- 1361-6137 (ISSN-L)
- 1465-1858
- PMC
- PMC10984143
- OpenAlex
- W1603996513
- Cited by
- 302
- References
- 199
- Citations by year
- 2026: 9 · 2025: 22 · 2024: 19 · 2023: 24 · 2022: 18 · 2021: 35 · 2020: 23 · 2019: 41 · 2018: 32 · 2017: 36 · 2016: 23 · 2015: 18 · 2014: 1
- FWCI
- 3.58
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Cochrane Database of Systematic Reviews (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
- Digital Commons - USU (Utah State University) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Leiden Repository (Leiden University) (submittedVersion)
- Pure Amsterdam UMC (submittedVersion)
- Research Explorer (The University of Manchester) (submittedVersion)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Life Sciences › Neuroscience › Cognitive Neuroscience › Pain Management and Placebo Effect
- Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
- Keywords
- somatoform disorders, medically unexplained physical symptoms, non-pharmacological treatment, psychotherapy, cognitive behavioral therapy, mindfulness-based interventions, psychodynamic psychotherapy, integrative therapy, somatization disorder, undifferentiated somatoform disorder, pain disorders, treatment acceptability, somatic symptom severity, adults, third-wave CBT, behavior therapy
- MeSH terms
- Adult, Humans, Psychotherapy, Somatoform Disorders, Waiting Lists, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic
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