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Keywords to 2017 and give recommendations for treatment for all lev-
Functional somatic syndromes · Bodily distress · els of care, concentrating on developments over the last 10
Management · Review years. We conclude that activating, patient-involving, and
centrally acting therapies appear to be more effective than
passive ones that primarily act on peripheral physiology, and
Abstract we recommend stepped care approaches that translate a
Functional somatic syndromes (FSS), like irritable bowel syn- truly biopsychosocial approach into actual management of
drome or fibromyalgia and other symptoms reflecting bodi- the patient. © 2018 S. Karger AG, Basel
ly distress, are common in practically all areas of medicine
worldwide. Diagnostic and therapeutic approaches to these
symptoms and syndromes vary substantially across and
within medical specialties from biomedicine to psychiatry. Introduction
Patients may become frustrated with the lack of effective
treatment, doctors may experience these disorders as diffi- Functional somatic syndromes (FSS) are well-recog-
cult to treat, and this type of health problem forms an impor- nized clusters of bodily symptoms that are common in
tant component of the global burden of disease. This review medical practice and can cause considerable disability.
intends to develop a unifying perspective on the under- Some, such as irritable bowel syndrome (IBS) and fibro-
standing and management of FSS and bodily distress. Firstly, myalgia, are clearly attributed to a single organ system.
we present the clinical problem and review current concepts Some assume a specific etiology such as in the electrosen-
for classification. Secondly, we propose an integrated etio- sitivity syndrome. Others are purely descriptive, such as
logical model which encompasses a wide range of biopsy- chronic fatigue syndrome. The umbrella concept of FSS
chosocial vulnerability and triggering factors and considers was introduced by Barsky and Borus [1] in 1999. It was
consecutive aggravating and maintaining factors. Thirdly, based on earlier work by Robert Kellner [2] on “psycho-
we systematically scrutinize the current evidence base in somatic syndromes” and included a list of speciality-spe-
terms of an umbrella review of systematic reviews from 2007 cific functional syndromes which was only marginally
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Sequelae of
prior inappropriate
Current treatment
subthreshold
organic disease Avoidance
and deconditioning
(Epi-)genetic Sensory input
profiles Sensory input
Chronic,
Prior organic Perception disabling
disease of bodily bodily
Adverse distress distress
childhood Expectation
experiences Expectation
Precedent life &XUUHQWOLIHVWUHVVRUV£
stressors
Cognitive and emotional
Cultural beliefs factors (anxiety, depression,
illness conviction)
Fig. 1. Schematic model of the etiology of bodily distress. Note: The distinction of vulnerability/triggering and
aggravating/maintaining factors is to some extent artificial as most factors have an influence on both sides.
FSS and bodily distress [60–64]. If persisting, these fac- with FSS and bodily distress. These include several na-
tors together with the effect of predisposing personality tional guidelines and Cochrane reviews for bodily distress
aspects and other important psychosocial state and trait and many systematic and Cochrane reviews for single
characteristics like health anxiety, illness convictions, and FSS. These reviews identified the moderate benefits of
avoidance behavior induce a shift to chronification and various treatments, but they also highlighted the unmet
contribute to the maintenance of the symptoms of FSS treatment needs of this large group of patients by describ-
and bodily distress. Further aggravating and maintaining ing the barriers to better diagnosis and treatment [2, 66–
factors arise from the often difficult interactions of these 71]. We focus here on the management approach to the
patients with the health care system, leading to missed or single patient, but the systemic public health aspects of
late correct diagnosis, inappropriate treatments, and this clinical problem and the reduction of barriers to bet-
frustrations on all sides. Somatizing communication be- ter management at this systemic level are also of great
havior and persistent beliefs about biomedical causations importance [2].
held by patients and doctors alike, but also systemic fac- Good management of this group of patients should
tors of the health care system, e.g. reimbursement struc- avoid the traps of entrenched dualistic “either mental-or
tures, contribute to these significant barriers for more ef- physical” thinking. The patient’s bodily symptoms must
fective diagnosis and treatment [65, 66]. be taken seriously by the doctor from the outset even
though investigations for possible organic disease tend to
focus the attention of patient and doctor on the possible
Management of FSS and Bodily Distress general medical diseases that might cause the symptom(s).
As part of this balanced “mental as well as physical” ap-
The 10 years since the last review have seen consider- proach, the doctor should ask about the whole pattern of
able efforts to aggregate evidence and develop evidence- bodily symptoms together with symptoms of depression
based recommendations for the management of patients and anxiety as these frequently accompany the bodily
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DOI: 10.1159/000484413
Rifaximin + [94, 99, 100] Tricyclic antidepressants Yoga + [123] Pre- and synbiotics o [133]
Bulking agents o [97©] + [108, 111] Minimal-contact psychological treatments Lactobacillus + [144]
Mebeverine o [101] SSRI + [94]/o [111] + [124]/o [110]
Fibromyalgia Botulinum toxin o [145©]/ Tricyclic antidepressants Hypnotherapy +++ [168] Balneo-/hydrotherapy Homeopathy + [197]
(including myofascial pain/ + [146] ++ [149, 150] Multidisciplinary therapy +++ [169]/ ++ [147, 180, 191–193] Acupuncture o [147, 198–200,
Henningsen/Zipfel/Sattel/Creed
Tension headache, Dipyrone + [241] Tricyclic antidepressants CBT ++ [137] Multimodal manual therapy Acupuncture + [252, 253©]
chronic neck pain Ibuprofen + [242©] + [247]/o [248] Multimodal treatments + [250] ++ [251] Education o [240]
Paracetamol + [243©] SSRI/SNRI (venlafaxine) o [249©] Exercise + [250] Manual therapy, spinal/
Ketoprofen + [244©] thoracic manipulation + [250]
Aspirin o [245©] Infrared laser o [250]
Botulinum toxin A o [246]
Temporomandibular Botulinum toxin o [254] – Manual therapy and therapeutic Occlusal stabilization –
joint disorder exercise + [255] splint + [257–259]
Exercise o [256] Musculoskeletal manual
approach + [260]
Temporomandibular
lavage o [261]
Atypical face pain/ Systemic α-lipoic acid Clonazepam + [262, 263] – – –
myofacial pain/ + [262] Amitriptyline o [264©]
DOI: 10.1159/000484413
estrogen-containing
preparations + [288©]
Atypical/nonspecific – Antidepressants + [292] Psychological interventions ++ [293©] – –
chest pain
Tinnitus Ginkgo biloba o [294] Tricyclic CBT + [298©]/++ [299] Repeated transcranial Acupuncture o [302, 303]
IBS, irritable bowel syndrome; C, constipation; D, diarrhea; SSRI, selective serotonin reuptake inhibitors; SNRI, selective serotonin and norepinephrine reuptake inhibitor; CBT, cognitive behavioral therapy; 5-HT, 5-hy-
droxytryptamine. We do not list treatments with scarce empirical basis (≤2 source randomized controlled trials per intervention × FSS). For simplicity, strength of evidence for efficacy of a specific treatment type is indicated in
4 different grades, with the reviews contributing to this summary estimate. The ratings represent integrated “composite grades of evidence”: +++, strong level; ++, moderate level; +, low level; o, no evidence/recommendation for
efficacy of treatment and strength of recommendation; –, no reviews included. “©” denotes Cochrane review (68 Cochrane reviews are included). For such an integration of systematic reviews, which use different criteria as well
as an extensive variety of outcomes and represent different opinions in heterogeneous clinical fields, an estimation of effect sizes was not feasible. General empirical trends in FSS management are shown; it is not an adequate ba-
sis for individual treatment recommendations. The terms used were taken from the systematic reviews and vary in grade of differentiation (e.g., for some FSS the reviews state the evidence for psychotherapy, whereas for others
they state the evidence for different forms of psychotherapy separately).
21
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• Among passive physical interventions, there is only i.e., the types of treatment typically offered, among oth-
one form with consistently moderate evidence for ef- ers, by mental health specialists and psychotherapists. For
ficacy in several reviews, balneo-/hydrotherapy (treat- all other types of treatment, the evidence is more mixed
ment with baths/water). and often negative. In view of the overwhelmingly nega-
• In chronic fatigue syndrome, surprisingly few system- tive results of reviews of trials of passive physical inter-
atic reviews were detected, confirming a trend already ventions, this type of treatment should require special
apparent in 2007. For both CBT and exercise therapy, justification to be tested at all in future trials.
there is low to moderate evidence for efficacy. For All in all, there is no doubt that there is a need for fur-
most other forms of treatments, there are no reviews ther broadening of the evidence base in the treatment of
available since 2007 which fulfill the criteria set de- patients with bodily distress and FSS.
fined here. To obtain larger treatment effects in future trials, the
• In nonspecific chronic low-back pain, there is evi- following should be considered:
dence of low quality for the efficacy of nonsteroidal • In view of the large heterogeneity of patients also with-
anti-inflammatory drugs and capsaicin, but not for in one diagnostic group, patient cohorts also in trials
paracetamol. There is neither evidence for the efficacy of single FSS should regularly be stratified according
of antidepressants nor for the efficacy of most passive to the total number of bodily symptoms and other in-
physical interventions except for radiofrequency dicators of severity, and other specifiers like illness-
denervation or – different to the fibromyalgia syn- related cognitions should also be taken into account in
drome – for massage. order to achieve personalized, potentially more effec-
• For activating therapies and psychotherapy, there is tive treatments.
mixed evidence, with some therapies like Pilates-based • To enhance comparability, all clinical trials in this het-
exercise showing no evidence, whilst other exercise- erogeneous field should use a common set of core out-
based interventions demonstrate low evidence, or, fi- come domains – a European working group recently
nally, CBT showing moderately good evidence for ef- suggested the following: (1) classification, (2) intensity
ficacy. and interference, (3) associated psychobehavioral fea-
• For tension headache and chronic neck pain, there is tures and biological markers, (4) illness consequences
only low to no evidence for the efficacy of nonsteroidal (quality of life, disability, health care utilization, and
analgesics, which, moreover, intend only short-term health care costs), (5) global improvement or treat-
pain relief. ment satisfaction, and (6) unwanted negative effects
• For CBT, exercise, and multimodal therapies, there is [78].
low to moderate evidence for efficacy. Among the oth- • Innovative treatment approaches (e.g., expectation
er forms of treatment, a review of multimodal manual management in early stages of secondary prevention)
therapy shows moderate evidence for efficacy, and 2 have to be tested.
reviews of acupuncture show low evidence. Other • Predictors and mechanisms of change should be inves-
forms of therapy show no evidence for efficacy. tigated (e.g., in dismantling studies).
• The pattern of reviews and the evidence reported
therein is heterogeneous for the other FSS in Table 1,
and in many syndromes only 1 or 2 types of treatment Conclusions
are documented in systematic reviews. In syndromes
like interstitial cystitis or functional dyspepsia, several Stepped care approaches appear to be best suited at all
reviews report trials with peripherally acting agents, levels of care considering the large spectrum of severity in
with mostly low to no evidence for efficacy. In others patients with FSS and bodily distress. Initially and in un-
like dizziness or tinnitus, different forms of activating complicated cases, an encompassing biopsychosocial at-
therapy and psychotherapies show low or moderate titude, a focus on symptomatic relief, patient activation,
evidence for efficacy. and avoidance of iatrogenic harm is particularly helpful.
In summary, the evidence base has evolved consider- In more chronic and/or severe cases, management works
ably but in essence has not changed profoundly since our best when not only the patients but also their doctors
last review in 2007 [7]. It still documents low to moderate achieve a reframing of the clinical problem: from cure to
evidence with small to moderate effect sizes, with overall care and coping, from classical biomedical explanations
best evidence for activating, patient-involving treatments, to a broader view of biologically and psychosocially ag-
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References
1 Barsky AJ, Borus JF: Functional somatic syn- 13 Tomenson B, Essau C, Jacobi F Ladwig KH, 21 Garcia-Campayo J, Alda M, Sobradiel N, Oli-
dromes. Ann Intern Med 1999;130:910–921. Leiknes KA, Lieb R, Meinlschmidt G, McBeth van B, Pascual A: Personality disorders in so-
2 Kellner R: Psychosomatic syndromes, soma- J, Rosmalen J, Rief W, Sumathipala A, Creed matization disorder patients: a controlled
tization and somatoform disorders. Psycho- F; EURASMUS Population Based Study study in Spain. J Psychosom Res 2007;62:675–
ther Psychosom 1994;61:4–24. Group: Total somatic symptom score as a pre- 680.
3 Creed F, Henningsen P, Fink P (eds): Medi- dictor of health outcome in somatic symptom 22 Creed F, Guthrie E, Fink P, Henningsen P,
cally Unexplained Symptoms, Somatization disorders. Br J Psychiatry 2013;203:373–380. Rief W, Sharpe M, White P: Is there a better
and Bodily Distress. Developing Better Clini- 14 Tomenson B, McBeth J, Chew-Graham CA, term than “medically unexplained symp-
cal Services. Cambridge, Cambridge Univer- MacFarlane G, Davies I, Jackson J, Littlewood toms”? J Psychosom Res 2010;68:5–8.
sity Press, 2011. A, Creed FH: Somatization and health anxiety 23 Picariello F, Ali S, Moss-Morris R, Chalder T:
4 Fink P: Syndromes of bodily distress or func- as predictors of health care use. Psychosom The most popular terms for medically unex-
tional somatic syndromes – where are we Med 2012;74:656–664. plained symptoms: the views of CFS patients.
heading. J Psychosom Res 2017;97:127–130. 15 Bobevski I, Clarke DM, Meadows G: Health J Psychosom Res 2015;78:420–426.
5 Fava GA, Cosci F, Sonino N: Current psycho- anxiety and its relationship to disability and 24 World Health Organization: The ICD-10
somatic practice. Psychother Psychosom service use: findings from a large epidemio- Classification of Mental and Behavioural Dis-
2017;86:13–30. logical survey. Psychosom Med 2016; 78: 13– orders: Diagnostic Criteria for Research. Ge-
6 Rice AS, Smith BH, Blyth FM: Pain and the 25. neva, WHO, 1993.
global burden of disease. Pain 2016;157:791– 16 Carson A, Stone J, Hibberd C, Murray G, 25 Drossman DA: Functional gastrointestinal
796. Duncan R, Coleman R, Warlow C, Roberts R, disorders: what’s new for Rome IV? Lancet
7 Henningsen P, Zipfel S, Herzog W: The man- Pelosi A, Cavanagh J, Matthews K, Goldbeck Gastroenterol Hepatol 2016;1:6–8.
agement of functional somatic syndromes. R, Hansen C, Sharpe M: Disability, distress 26 Wolfe F, Clauw DJ, Fitzcharles MA, Golden-
Lancet 2007;369:946–955. and unemployment in neurology outpatients berg DL, Katz RS, Mease P, Russell AS, Russell
8 Desai G, Chaturvedi SK: Do diagnostic criteria with symptoms ‘unexplained by organic dis- IJ, Winfield JB, Yunus MB: The American
for psychosomatic research explain diagnosis ease.’ J Neurol Neurosurg Psychiatry 2011;82: College of Rheumatology preliminary diag-
of medically unexplained somatic symptoms. 810–813. nostic criteria for fibromyalgia and measure-
Psychother Psychosom 2016;85:121–122. 17 Joustra ML, Janssens KA, Bültmann U, Ros- ment of symptom severity. Arthritis Care Res
9 Stone J, Carson A, Duncan R, Coleman R, malen JG: Functional limitations in function- 2010;62:600–610.
Roberts R, Warlow C, Hibberd C, Murray G, al somatic syndromes and well-defined medi- 27 American Psychiatric Association: Diagnos-
Cull R, Pelosi A, Cavanagh J, Matthews K, cal diseases. Results from the general popula- tic and Statistical Manual of Mental Disor-
Goldbeck R, Smyth R, Walker J, Macmahon tion cohort LifeLines. J Psychosom Res 2015; ders. DSM-5, ed 5. Arlington, American Psy-
AD, Sharpe M: Symptoms ‘unexplained by 79:94–99. chiatric Publishing, 2013.
organic disease’ in 1144 new neurology out- 18 Rask MT, Rosendal M, Fenger-Grøn M, Bro 28 Dimsdale JE, Creed F, Escobar J, Sharpe M,
patients: how often does the diagnosis change F, Ørnbøl E, Fink P: Sick leave and work dis- Wulsin L, Barsky A, Lee S, Irwin MR, Leven-
at follow-up? Brain 2009;132:2878–2888. ability in primary care patients with recent- son J: Somatic symptom disorder: an impor-
10 Eikelboom EM, Tak LM, Roest AM, Ros- onset multiple medically unexplained symp- tant change in DSM. J Psychosom Res 2013;
malen JG: A systematic review and meta-anal- toms and persistent somatoform disorders: a 75:223–228.
ysis of the percentage of revised diagnoses in 10-year follow-up of the FIP study. Gen Hosp 29 Toussaint A, Murray AM, Voigt K, Herzog A,
functional somatic symptoms. J Psychosom Psychiatry 2015;37:53–59. Gierk B, Kroenke K, Rief W, Henningsen P,
Res 2016;88:60–67. 19 GBD 2013 DALYs and HALE Collaborators, Löwe B: Development and validation of the
11 Hansen HS, Rosendal M, Oernboel E, Fink P: et al: Global, regional, and national disability- Somatic Symptom Disorder-B Criteria Scale
Are medically unexplained symptoms and adjusted life years (DALYs) for 306 diseases (SSD-12). Psychosom Med 2016;78:5–12.
functional disorders predictive for the illness and injuries and healthy life expectancy 30 Rief W, Martin A: How to use the new DSM-
course? A two-year follow-up on patients’ (HALE) for 188 countries, 1990–2013: quan- 5 somatic symptom disorder diagnosis in re-
health and health care utilisation. J Psycho- tifying the epidemiological transition. Lancet search and practice: a critical evaluation and
som Res 2011;71:38–44. 2015;386:2145–2191. a proposal for modifications. Annu Rev Clin
12 Creed F, Tomenson B, Chew-Graham C, 20 Henningsen P, Zimmermann T, Sattel H: Psychol 2014;10:339–367.
Macfarlane GJ, Davies I, Jackson J, Littlewood Medically unexplained physical symptoms, 31 Gureje O, Reed GM: Bodily distress disorder
A, McBeth J: Multiple somatic symptoms pre- anxiety and depression: a meta-analytic re- in ICD-11: problems and prospects. World
dict impaired health status in functional so- view. Psychosom Med 2003;65:528–533. Psychiatry 2016;15:291–292.
matic syndromes. Int J Behav Med 2013; 20:
194–205.
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