Chapter
Consequences of persistent medically unexplained symptoms/somatisation
Medically unexplained symptoms and somatoform disorders
Impairment of health status increases with number or severity of medically unexplained symptoms
The impairment of health status associated with medically unexplained symptoms is comparable with that of depressive disorders or general medical disorders
Impairment of function when somatoform disorder occurs with concurrent anxiety and depression
Impairment in functional somatic syndromes
Impairment is greatest when there is accompanying somatisation
Costs associated with medically unexplained symptoms and somatoform disorders
Costs associated with functional somatic symptoms
Fibromyalgia (chronic widespread pain)
Costs of sickness benefits due to MUS/somatoform or functional disorders
Disability benefit/early retirement pension
Somatoform disorders and disability
Chapter 2 Terminology, classification and concepts
Medically unexplained symptoms
Ten criteria to evaluate terminology
Current classification in DSM-IV and ICD-10
Functional somatic syndromes
History of current classification
Positive description of cognitions and behaviour
Self-focused attention, bodily self-observation
Overinterpretation of bodily symptoms
Are somatic illness beliefs a necessary condition for somatisation?
Self-concept of bodily weakness
Health anxiety and health concerns
Abnormal illness behaviour
Avoidance of physical activity and of other stimuli seen as symptom-provoking
The preliminary classification of ‘medically unexplained symptoms’ before a diagnosis can be established
Two new proposals for the classification of clinically significant MUS
Complex somatic symptom disorder
Nosology and the value of a classification
Classification and pathopsychophysiology
Chapter 3 Evidence-based treatment
The different settings of primary and secondary care
Overview of the evidence for effective treatments
Recent studies of reattribution
Conclusions from studies of interventions of medically unexplained symptoms and somatisation
Interventions for health anxiety (hypochondriasis) reassurance
Interventions for functional somatic syndromes
CBT for functional somatic syndromes
Antidepressants for functional somatic syndromes
Updated systematic review of both CBT and antidepressants
Preliminary evidence for short-term psychodynamic psychotherapy
Rationale for psychological and exercise-based treatments of functional somatic syndromes
Rationale for the use of antidepressants in functional somatic syndromes
Evidence of efficacy of treatments in specific functional somatic syndromes
British Society of Gastroenterology review
Psychological treatment and exercise
Effectiveness and cost-effectiveness trials in functional somatic syndromes
Numbers of patients needing treatment
General ingredients of treatment and a stepped-care model
Chapter 4 Current state of management and organisation of care
Do current models of care provide a satisfactory service? Unmet needs
Evidence that specific appropriate treatment is not being offered
Secondary care – outpatients
Evidence of continuing symptoms with accompanying disability/high healthcare use
Patient-centred approaches to unmet need
Traditional, non-specialised services (Model A, Figure 4.2)
Service delivery in secondary care
General mental health services
Consultation-liaison psychiatry/psychosomatics approach
Syndrome-specific specialised clinics (Model B, Figure 4.3)
Specialised units for bodily distress syndromes (Model C, Figure 4.4)
Relevant services in Belgium and Germany
Expert centres for chronic fatigue syndrome and pain clinics
The German psychosomatic model
Level 1: Management of bodily distress by GPs – psychosomatic basic care
Level 2: Collaborative models of management of medically unexplained symptoms: specialists cooperating with physicians in primary care or in general hospital
Level 3: Specialised psychosomatic/psychotherapeutic treatment of patients with bodily distress syndromes
Recommended model of care
Assumptions (and challenges)
Location of a specialist clinic
Administration/affiliation
Chapter 5 Barriers to improving treatment
Problems in terminology and understanding
Problems in policy, planning and service organisation
The individual doctor–patient encounter
The patient’s role in the problem
The doctor’s role in the problem
The doctor–patient relationship
Chapter 6 Gender, lifespan and cultural aspects
Symptom perception and symptom processing
Body schemes, symptom attribution and illness beliefs
Personality, emotion, coping styles, and gendered roles
Psychosocial distress and psychiatric morbidity
Patient–doctor relationships and gendered communication
Gender differences in diagnostic and treatment actions
Epidemiology of somatic symptoms in older people
Diagnosing bodily distress syndromes in older people
Bodily distress and factors associated with general perception of health
Management of bodily distress syndromes in the elderly
Somatic presentation of distress
‘Culture-bound’ syndromes
Universality of ‘medically unexplained’ symptoms
Medically unexplained symptoms in different ethnic groups
Bodily distress syndromes in single ethnic groups
Treatment seeking in low- and middle-income countries
Implications for delivering services in European countries
Chapter 7 Medically unexplained symptoms in children and adolescents
Classifications, definitions and current diagnostic categories
Normal development and age-appropriate coping mechanisms
Systemic considerations (family)
Genetics and biological factors
Wider systemic considerations
Assessment and management of medically unexplained symptoms in children and young people
Initial engagement and assessment
Management and treatment models
Specific psychosocial interventions
Cognitive behavioural therapy and pain syndromes
Headaches, biofeedback and relaxation
Dynamic psychotherapy and systemic psychotherapies
Solution-focused approach
Relationship to adult disorders
Chapter 8 Identification, assessment and treatment of individual patients
Identification of patients with bodily distress
Stratification according to levels of severity
A disease management approach to assessment
Complicated or uncomplicated functional somatic syndromes
Enhancing patient motivation for further therapy
Assessment in primary and secondary medical care settings
The detailed assessment of patients referred to a specialist mental health professional
Specific points of the history and examination
Assess the presenting symptom
Personal, developmental and past history of illness and mental state, including abuse and prior severe life events
Clinical assessment at the Research Clinic for Functional Disorders, Denmark
Impact of the diagnostic label
Acceptability of the biopsychosocial assessment used in Aarhus
Interpretation and communicative aspects of diagnostic tests
Further clinical management in primary and secondary care
Stepped-care approach to treatment
Based on risk management as used in the Dutch Multidisciplinary Guideline for MUS and Somatoform Disorder [8]
Complicated or uncomplicated functional somatic syndromes – review by Henningsen and colleagues [58]
Explanation, reassurance, broadening the explanatory model
Activation treatments for chronic fatigue syndrome
Aims of specialised treatment
Cognitive behavioural therapy
Getting CBT treatment started
An example of manualised CBT for severe bodily distress syndrome
Effect of the STreSS intervention
Modifications of CBT for hypochondriasis (health anxiety)
Health anxiety: the need to change the doctor’s response to patient worries
Psychodynamic interpersonal therapy
Antidepressant treatment of hypochondriasis and body dysmorphic disorder
Functional somatic syndromes
About bodily distress syndrome
What are the causes of BDS?
Long-standing stress and strain
Teaching primary care physicians and other non-psychiatrists to diagnose and manage bodily distress syndromes
Education of medical, psychological and other students
The TERM model: an educational programme for GPs and non-psychiatrists
Evaluation of effectiveness
After the scientific trial period and current status
Training of general non-psychiatric specialists
Training of the specialist in psychosomatics and consultation-liaison psychiatry
Education of specialists in bodily distress syndromes
Education of other healthcare professionals
Education of non-healthcare professionals, e.g. social workers
Training in the specialty of psychosomatic medicine in Germany
Training in Psychosomatic Basic Care
Improving the psychosomatic competence in diagnosing and treating bodily distress syndromes
Collaboration with mental-health specialists
Advanced training in psychotherapy and psychosomatics for physicians with any specialisation
Specialisation in psychosomatic medicine
Training curricula in consultation-liaison psychiatry and psychosomatic medicine
Chapter 10 Achieving optimal treatment organisation in different countries: Suggestions for service development applicable across different healthcare systems
General principles in defining the unmet need associated with bodily distress syndromes
Local healthcare planning arrangements
Components of a service to improve management of bodily distress syndromes
Developing a multidisciplinary team to treat severe bodily distress syndromes
Training of medical specialists
A systems approach to ‘medically unexplained’ symptoms in Plymouth, UK
Key messages from the literature
Plymouth healthcare system
Process and problems: some of the barriers met by the project
Referral management centre
Proposed next steps for NHS Plymouth
Key features of developing a service for bodily distress syndromes
Developing a steering group
The model to be developed
Local initiatives to demonstrate need
Suggested ways of meeting the need
Description of services for chronic fatigue syndrome
Leeds and West Yorkshire Chronic Fatigue Syndrome/Myalgic Encephalopathy Service
Medically Unexplained Symptoms, Somatisation and Bodily Distress
：Developing Better Clinical Services
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