Psychosocial Treatments for Multiple Unexplained Physical Symptoms: A Review of the Literature

REVIEW

Psychosocial Treatments for Multiple Unexplained Physical Symptoms: A Reviewof the LiteratureLESLEY A. ALLEN, PHD, JAVIER I. ESCOBAR, MD, PAUL M. LEHRER, PHD, MICHAEL A. GARA, PHD, AND

ROBERT L. WOOLFOLK, PHD

Objective: Patients presenting with multiple medically unexplained physical symptoms, termed polysymptomaticsomatizers, often incur excessive healthcare charges and fail to respond to standard medical treatment. The presentarticle reviews the literature assessing the efficacy of psychosocial treatments for polysymptomatic somatizers.Methods: Relevant articles were identified by scanning Medline and PsychLit. Thirty-four randomized, controlledstudies were located. Whenever possible results from each study were transformed into effect sizes. An analysis ofthe efficacy of the psychotherapeutic approaches is provided. Results: Various psychosocial interventions havebeen investigated with polysymptomatic somatizers. Although the majority of studies suggest psychosocial treat-ments benefit this population, the literature is tarnished by methodological shortcomings. Effect sizes are modestat best. Long-term improvement has been demonstrated in fewer than one-quarter of the trials. Conclusions:Although seemingly beneficial, psychosocial treatments have not yet been shown to have a lasting and clinicallymeaningful influence on the physical complaints of polysymptomatic somatizers. Key words: somatization, irrita-ble bowel syndrome, chronic fatigue syndrome, fibromyalgia, treatment.

CBT � cognitive behavior therapy; CFS � chronicfatigue syndrome; DSM-IV � Diagnostic and Statisti-cal Manual of Mental Disorders, fourth edition; EMG� electromyographic; IBS � irritable bowel syndrome.

INTRODUCTION

Patients presenting with multiple medically unex-plained physical symptoms, termed polysymptomaticsomatizers, provide significant challenges to health-care providers. These patients’ physical symptomstend to be chronic and refractory to treatment (1, 2).Typically, polysymptomatic somatizers are dissatis-fied with the medical services they receive and repeat-edly change physicians (3). They incur excessivehealthcare bills, which reflect their overuse of diagnos-tic procedures, hospitalizations, and surgeries (4, 5). Inaddition, these patients present a theoretical challengein that the sources of their discomfort and their patho-

physiology remain unclear. Because of standard med-ical care’s limited success in treating somatizers, alter-native treatments have been developed for them.

Psychosocial treatments for somatic problemshave been reviewed elsewhere (6 –9). Most reviewsfocus on a single functional somatic syndrome, suchas irritable bowel syndrome (IBS) (6), or address oneunexplained symptom category, such as headaches(7) or dysmenorrhea (8). Alternatively, the most re-cent review examines the efficacy of only one formof treatment, cognitive behavior therapy (CBT), forpatients with either a single unexplained physicalsymptom or a single functional somatic syndrome(9). To date, no review has produced a comprehen-sive comparison of all psychosocial treatments forpolysymptomatic somatizing patients.

Accordingly, the present review aims to provide ananalysis of the relative efficacy of psychosocial treat-ments for polysymptomatic somatization with anemphasis on functional somatic syndromes and so-matization disorder. We focus on polysymptomaticsomatizers because patients experiencing multipleunexplained physical symptoms are not clearlycomparable to those experiencing just one unex-plained physical symptom. Research suggests thatthe number of unexplained physical symptoms re-ported correlates positively with the patient’s degreeof psychopathology and physical impairment (10).Polysymptomatic somatizers may not respond totreatment in exactly the way monosymptomatic so-matizers do. Also, individual syndrome reviews mayresult in conclusions that are narrow and specific to

From the Department of Psychiatry (L.A.A., J.I.E., P.M.L., M.A.G.),Robert Wood Johnson Medical School–University of Medicine andDentistry of New Jersey, Piscataway, New Jersey; and Department ofPsychology (R.L.W.), Rutgers University, New Brunswick, New Jersey.

Address reprint requests to: Lesley A. Allen, PhD, Department ofPsychiatry, RWJMS–UMDNJ, 671 Hoes Lane, Piscataway, NJ 08854.Email: [email protected]

Received for publication March 1, 2001; revision received November26, 2001.

DOI: 10.1097/01.PSY.0000024231.11538.8F

939Psychosomatic Medicine 64:939–950 (2002)

0033-3174/02/6406-0939Copyright © 2002 by the American Psychosomatic Society

that syndrome without allowing conclusions to becompared and contrasted across syndromes.

Overview of Polysymptomatic Somatizers

According to the Diagnostic and Statistical Manualof Mental Disorders (DSM-IV), somatization disorder ischaracterized by a lifetime history of at least four un-explained pain symptoms, two unexplained nonpaingastrointestinal symptoms, one unexplained sexualsymptom, and one pseudoneurological symptom (11).Although somatization disorder is classified as a dis-tinct disorder in DSM-IV, it has been argued that som-atization disorder represents the extreme end of a so-matization continuum (10, 12). Research suggests thatpatients experiencing multiple unexplained physicalsymptoms that fail to meet all DSM-IV criteria forsomatization disorder have similar characteristics tothose diagnosed with full somatization disorder (10,12, 13).

The term functional somatic syndrome is used todescribe groups of co-occurring symptoms that aremedically unexplained. Many functional somatic syn-dromes involve only one unexplained symptom, suchas jaw or chest pain. The three functional somaticsyndromes whose criteria require multiple unex-plained symptoms are IBS, chronic fatigue syndrome(CFS), and fibromyalgia. IBS is characterized by per-sistent abdominal pain along with altered bowel habitsand abdominal distension that cannot be explained byorganic pathology (14). A diagnosis of CFS is given forunexplained fatigue, lasting at least 6 months, thatcauses at least a 50% reduction in activity. Concomi-tant symptoms include memory impairment, sorethroat, tender lymph nodes, muscle pain, joint pain,headache, nonrestorative sleep, and postexertional fa-tigue (15). Fibromyalgia is characterized by chronicwidespread pain and multiple tender points that haveno known biological basis and are often accompaniedby nonrestorative sleep, fatigue, and malaise (16).

Despite the different physical complaints demarcat-ing the functional somatic syndromes described above,similar clinical, behavioral, demographic, and physio-logical characteristics are observed in each syndrome(17–19). Like somatization disorder patients, individ-uals diagnosed with one of these syndromes are morelikely to use healthcare services, report functional im-pairment, and suffer from psychopathology than areeither healthy or medically ill subjects (5, 14–27). Theoverwhelming majority of CFS, fibromyalgia, and so-matization disorder patients are female (12, 28, 29).The same pathophysiologic dysregulation and blunt-ing of the central nervous system’s response to stressmay be present in all of these syndromes (30). Finally,

many patients diagnosed with one of the functionalsyndromes meet diagnostic criteria for one or more ofthe other functional syndromes, resulting in multisys-tem comorbid functional syndromes (19, 31–34). As awhole, research suggests there is substantial overlapamong the functional somatic syndromes and somati-zation disorder (35). In fact, Wessely et al. (18) haveencouraged investigators not to distinguish among thefunctional somatic syndromes but instead to examinethem as a single classification of patients.

Because the illness behavior, psychopathology, andphysical complaints of the polysymptomatic somaticdisorders resemble each other, their treatments will bereviewed together. Integrating the findings from theseareas of literature may unearth the consistencies andinconsistencies as well as the merits and shortcomingsof the literature. The review aims to identify futuredirections for treating this difficult population.

Overview of the Rationales for PsychosocialTreatment Interventions

Psychodynamic theory has proposed that unex-plained physical symptoms are produced to protectthe somatizer from traumatic, frightening, and/or de-pressing emotional experiences. If an individual failsto process a trauma adequately, it is hypothesized, theoriginal affect later may be converted into physicalsymptoms (36). Short-term, dynamically orientedtreatments for somatizers focus on the stress and emo-tional distress associated with physical symptoms.

Psychophysiologists have described several mecha-nisms that produce somatic symptoms in the absence oforganic pathology (37, 38). These mechanisms includeoveractivity/dysregulation of the autonomic nervous sys-tem, smooth muscle contractions, endocrine overactiv-ity, and hyperventilation. Miscellaneous techniques,directed at reducing somatizers’ physiological arousaland physical discomfort, have been studied withincontrolled experimental designs, including hypno-therapy, progressive muscle relaxation, electromyo-graphic (EMG) biofeedback, autogenic training, andmultifaceted relaxation training programs.

The cognitive-behavioral model of somatization em-phasizes the interaction of physiology, cognition, emo-tion, behavior, and environment (39). Specifically, anindividual’s interpretation of physical sensations maybring on heightened awareness of bodily sensations,increased emotional distress, and self-defeating behav-ior (such as avoiding activities), all of which mayexacerbate the physical symptoms. In turn, the envi-ronment, including family, friends, and physicians,may respond in ways that reinforce the individual’ssomatic distress. Short-term CBT has been used with

L. A. ALLEN et al.

940 Psychosomatic Medicine 64:939–950 (2002)

somatizers to alter dysfunctional cognitive processesand behavior. These treatments typically include re-laxation training.

Some investigators have focused on either the cog-nitive or the behavioral component of CBT. Cognitivetherapy teaches patients to identify associations be-tween thoughts and physical symptoms and to modifydysfunctional beliefs. Relaxation and other behavioraltechniques are not included in cognitive therapy. Be-havior therapy for somatic complaints uses methodsfor pain management and for increasing avoided activ-ities based on operant conditioning.

Finally, exercise treatments have been developedfor somatizers in accordance with evidence suggestingthat exercise improves mood, pain thresholds, andsleep (40, 41). One theory explaining the benefits ofexercise proposes that exercise produces increases inserum levels of �-endorphin-like immunoreactivity,adrenocorticotropic hormone, prolactin, and growthhormone (42).

METHODS

Sample

Relevant articles were located with a computer search of Medlineand PsychLit from 1966 through January 2001. The following key-words were searched: unexplained physical symptoms, somatiza-tion, somatoform, psychogenic, functional somatic syndrome, irri-table bowel, fibromyalgia, and chronic fatigue. These terms werecross-referenced with the keywords: treatment, therapy, and out-come. To ensure a comprehensive review of the literature, the ref-erence lists of the articles generated from the above search wereexamined. Finally, we searched the Cochrane Library with theseterms (43).

Studies were included in the review if they compared any psy-chosocial intervention with a comparison control intervention in thetreatment of multiple unexplained physical symptoms. Clinical tri-als with patients suffering from single-symptom unexplained disor-ders, such as tension headaches or dysmenorrhea, were excludedfrom the review. Also excluded from the review were studies withmixed samples, that is, samples that comprised both single-symp-tom and polysymptomatic disorders. Only randomized experiments

were included. Studies that were unpublished or published in anon-English language were excluded. These inclusion criteria pro-duced 34 studies.

Estimating Treatment Effects

Whenever possible results were transformed into Cohen’s d asthe measure of treatment effect size. Cohen’s d provides a standard-ized estimate of the mean differences among treatment groups (44).When group means, standard deviations, and sample sizes wereunavailable, the statistical procedures described by Glass et al. (45)were used to estimate effect sizes.

Outcome measures of primary interest were those assessing in-tensity and frequency of physical symptoms. Because many studiesexamined changes in psychological and functional symptoms aswell, effect sizes were calculated for each of these domains. Withinthese domains (ie, physical distress, psychological distress, andfunctional impairment), investigators often used multiple measuresto examine outcomes. Effect sizes for each domain represent themean effect size for the aggregated outcome measures within thatdomain.

RESULTS

Treatments for Somatization Disorder

Two groups of investigators have examined the ef-fect of psychotherapy on patients with diverse unex-plained physical symptoms (see Table 1). One study,using patients diagnosed with full somatization disor-der, demonstrated that group psychotherapy reducedphysical functioning and mental health complaintsmore than did standard medical care (46). The grouptreatment, which appeared to lack a theoretical basis,“aimed to enhance emotional expression, peer sup-port, and coping skills.” The second trial, studyingpatients experiencing five or more unexplained phys-ical symptoms, showed that individual CBT coincidedwith greater reductions in somatic complaints andphysician visits than did standard medical care (47).

TABLE 1. Psychosocial Treatments for Somatization

N Dropouts PopulationTreatmentCondition

ControlCondition(s)

Results

Kashner et al., 1995 (46) 70 Not reported Somatization disorderpatients referredfrom internists andadvertisements

Group therapy (82-hour sessions)

Standard medicalcare

Treatment group had greaterimprovements in physicalfunctioning,*a mentalhealth***a

Sumathipala et al., 2000 (47) 68 T: 30%C: 38%

Primary care patientswith �5unexplainedphysical symptoms

CBT (6-1⁄2 hoursessions)

Standard medicalcare

Treatment group had greaterreductions in healthcarevisits,*a physicalcomplaints***a

a Intent-to-treat analysis performed.* p � .05; ** p � .01; *** p � .001.

TREATMENTS FOR MEDICALLY UNEXPLAINED SYMPTOMS


Treatments for Irritable Bowel Syndrome

Various psychosocial interventions for IBS havebeen examined in controlled trials. Table 2 summa-rizes each of them.

Four different therapeutic approaches have ap-peared more efficacious in reducing bowel symptomsthan did the control intervention to which they werecompared. Short-term dynamic therapy, hypnother-apy, progressive muscle relaxation, and cognitive ther-apy each seemed to reduce IBS symptoms (48–54). Inthese studies dynamic therapy, hypnotherapy, andprogressive muscle relaxation were conducted indi-vidually, whereas cognitive therapy was conductedeither individually (52, 53) or in a group format (54).

CBT has had mixed results in seven different con-trolled trials with IBS sufferers (55–61). Three trialsshowed CBT, administered individually, relievedbowel symptoms more effectively than did either stan-dard medical care (55) or a waiting list (56, 57). In afourth study, CBT administered as a group treatmentresulted in greater improvements in IBS symptomsthan did a waiting list control condition (58). Threeother investigations found no difference between indi-vidual CBT and a control condition (59–61).

Only one study examined the efficacy of purelybehavioral methods for IBS. In this study Corney et al.(62) compared a combination of bowel retraining, op-erant pain management techniques, and increasing ac-tivity levels to the standard medical treatment of bulk-ing agents, antispasmodics, and laxatives. By the endof treatment, no differences were observed betweenthe experimental and control groups in their reportingof IBS symptoms.

Treatments for Chronic Fatigue Syndrome

Psychosocial interventions, specifically CBT andexercise programs, have had mixed results in con-trolled trials with CFS patients (see Table 3). In onestudy CBT was no more effective than the controltreatment (63), whereas in two other studies CBT re-duced fatigue significantly more than the control treat-ments did (64, 65). Another trial found that a gradedexercise program resulted in greater improvements infatigue, functioning, and general health than did arelaxation/flexibility intervention (66). In a study com-paring graded exercise, fluoxetine (a selective seroto-nin reuptake inhibitor), graded exercise plus fluox-etine, and a no-treatment control, neither exercise norfluoxetine was associated with improvements in fa-tigue (67).

Treatments for Fibromyalgia

Numerous interventions for fibromyalgia have beensubjected to empirical investigation (see Table 4).

Three trials compared the efficacy of a standardrelaxation intervention to an alternative treatment.Hypnotherapy and EMG biofeedback each resulted ingreater reductions in discomfort than did physicaltherapy (68) or false biofeedback (69), respectively.The third study, examining the effects of progressivemuscle relaxation and hydrogalvanic baths, showedno difference between the two treatments; participantsin each condition reported some pain relief (70).

The impact of exercise on fibromyalgia symptom-atology has been examined by four groups of investi-gators. Two trials showed a thrice per week exercisegroup resulted in greater reductions in objective mea-sures of tenderness than did a thrice per week flexibil-ity training (71) or relaxation program (72). A thirdstudy evaluated the effects of four different interven-tions, specifically an exercise group, a relaxationgroup, a combined exercise/relaxation group, and aneducation/control group (73). In this study the exerciseand exercise/relaxation groups experienced greaterimprovements in physical functioning than did thecontrol group. Despite there being no differencesamong the four groups’ myalgia scores or self-reportsof pain, all three treatment groups manifested greaterdecreases in tenderness than the control group did(73). The fourth trial failed to demonstrate reductionsin self-reported pain from an exercise treatment rela-tive to a no-treatment control condition (74).

The efficacy of group CBT, but not individual CBT,for fibromyalgia has been assessed in three trials. Twotrials comparing a CBT/education group with a discus-sion/education group found no differences in paincomplaints or functioning between the two treatmentconditions (75, 76). The third trial, comparing the ef-ficacy of a group CBT to that of an autogenic traininggroup, also showed no differences between the condi-tions at posttreatment. However, 4 months later theCBT participants reported a greater reduction in painintensity than the relaxation participants did (77).

Finally, two groups of investigators have comparedthe efficacy of stress management interventions withexercise treatments. One study examined an exercisegroup, a stress management group, and standard med-ical care. Just after treatment, both the stress manage-ment and exercise participants reported greater reduc-tions in tenderness than the control participants. Theinvestigators found no differences between the stressmanagement and exercise groups just after treatmentnor 4 years later (78). In another study, participantswere randomly assigned to a stress management pro-

L. A. ALLEN et al.


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Wai

ting

list

(WL)

Trea

tmen

tgr

oup

repo

rted

grea

ter

impr

ovem

ent

inse

veri

tyan

ddu

ratio

nof

stom

ach

pain

**Po

sttr

eatm

ent

effe

ctsi

zefo

rIB

S:d

�0.

39N

odi

ffere

nce

betw

een

grou

pson

psyc

hiat

ric

sym

ptom

s44

%C

BT

vs.

11%

WL

had

CSI

b

Vol

lmer

and

Bla

ncha

rd,

1998

(54)

32T1

:0%

T2:

0%C

:0%

Ref

erra

lsfr

omM

Ds

and

adve

rtis

emen

ts

1.G

roup

CT

(10

90-m

inut

ese

ssio

ns)

2.In

divi

dual

CT

(10

1-ho

urse

ssio

ns)

1.W

aitin

glis

t/sym

ptom

mon

itori

ng(W

L)B

oth

trea

tmen

tgr

oups

repo

rted

grea

ter

impr

ovem

ent

inIB

Ssy

mpt

oms

than

WL*

*N

odi

ffere

nce

betw

een

grou

pan

din

divi

dual

CT

64%

grou

pC

Tvs

.55

%in

divi

dual

CT

vs.

10%

WL

had

CSI

b

CB

T�

cogn

itiv

ebe

hav

iora

lth

erap

y;C

SI

�cl

inic

ally

sign

ific

ant

imp

rove

men

t;IB

S�

irri

tabl

ebo

wel

syn

dro

me;

PR

M�

pro

gres

sive

mu

scle

rela

xati

on.

aIn

ten

t-to

-tre

atan

alys

isp

erfo

rmed

.b

CS

Iw

asin

dic

ated

byat

leas

ta

50%

red

uct

ion

inIB

Ssy

mp

tom

sbe

twee

nba

seli

ne

and

the

pos

ttre

atm

ent

orfo

llow

-up

asse

ssm

ent.

*p

�.0

5;**

p�

.01;

***

p�

.001

.



TA

BL

E3.

Psy

chos

ocia

lT

reat

men

tsfo

rC

hro

nic

Fat

igu

eS

ynd

rom

e

ND

ropo

uts

Popu

latio

nTr

eatm

ent

Con

ditio

nC

ontr

olC

ondi

tion(

s)R

esul

ts

CB

Ttr

eatm

ent

tria

lsLl

oyd

etal

.,19

93(6

3)90

T1:

0%T2

:0%

C1:

5%C

2:4%

Not

repo

rted

1.C

BT

�pl

aceb

o(6

sess

ions

)2.

CB

T�

dial

yzab

lele

ukoc

yte

1.St

anda

rdm

edic

alca

re�

plac

ebo

med

icat

ion

2.St

anda

rdm

edic

alca

re�

dial

yzab

lele

ukoc

yte

Post

trea

tmen

t:no

diffe

renc

esam

ong

the

4gr

oups

3-m

onth

follo

w-u

p:no

diffe

renc

esam

ong

the

4gr

oups

Shar

peet

al.,

1996

(64)

60T:

0%C

:0%

Infe

ctio

usdi

seas

ecl

inic

patie

nts

1.C

BT

(16

sess

ions

)1.

Stan

dard

med

ical

care

Post

trea

tmen

t:23

%C

BT

vs.

7%co

ntro

lha

dC

SIb

infa

tigue

a

8-m

onth

follo

w-u

p:73

%C

BT

vs.

23%

had

CSI

bin

fatig

uea

Dea

leet

al.,

1997

(65)

60T:

10%

C:

13%

Ref

erre

dfr

ompr

imar

yM

Ds

and

spec

ialis

ts1.

CB

T(1

3se

ssio

ns)

1.R

elax

atio

ntr

aini

ng(R

T)(1

0se

ssio

ns)

Post

trea

tmen

t:C

BT

mor

eef

fect

ive

than

RTa

Effe

ctsi

zefo

rfa

tigue

:d

�0.

46Ef

fect

size

for

func

tioni

ng:

d�

0.69

Effe

ctsi

zefo

rem

otio

nal

dist

ress

:d

�0.

496-

mon

thfo

llow

-up:

CB

Tm

ore

effe

ctiv

eth

anR

Ta

Effe

ctsi

zefo

rfa

tigue

:d

�0.

90Ef

fect

size

for

func

tioni

ng:

d�

1.13

Effe

ctsi

zefo

rem

otio

nal

dist

ress

:d

�0.

26Ex

erci

setr

eatm

ent

tria

lsFu

lche

ran

dW

hite

,19

97(6

6)66

T:12

%C

:9%

CFS

clin

icpa

tient

s1.

Gra

ded

exer

cise

(1se

ssio

n/w

kfo

r12

wk)

1.Fl

exib

ility

/rel

axat

ion

(FR

)(1

sess

ion/

wk

for

12w

k)Po

sttr

eatm

ent:

exer

cise

mor

eef

fect

ive

than

FRa

Effe

ctsi

zefo

rfa

tigue

:d

�0.

73Ef

fect

size

for

func

tioni

ng:

d�

0.69

55%

exer

cise

vs.

27%

FRra

ted

them

selv

esas

muc

hor

very

muc

hbe

tter

Wea

rden

etal

.,19

98(6

7)13

4T1

:42

%T2

:32

%C

1:29

%C

2:15

%

Dep

artm

ent

ofM

edic

ine

patie

nts

1.G

rade

dex

erci

se�

fluox

etin

e2.

Gra

ded

exer

cise

�

plac

ebo

1.N

oex

erci

se�

fluox

etin

e2.

No

exer

cise

�pl

aceb

o

Post

trea

tmen

t:no

diffe

renc

esbe

twee

ngr

oups

onch

ange

infa

tigue

a

Bot

hex

erci

segr

oups

repo

rted

high

erfu

nctio

nal

wor

kca

paci

tyth

anth

eno

-exe

rcis

egr

oups

*a

aIn

ten

t-to

-tre

atan

alys

isp

erfo

rmed

.b

CS

I(c

lin

ical

lysi

gnif

ican

tim

pro

vem

ent)

was

ind

icat

edby

atle

ast

a50

%re

du

ctio

nin

fati

gue

betw

een

base

lin

ean

dth

ep

ostt

reat

men

tor

foll

ow-u

pas

sess

men

t.*

p�

.05.

L. A. ALLEN et al.


TA

BL

E4.

Psy

chos

ocia

lT

reat

men

tsfo

rF

ibro

mya

lgia

ND

ropo

uts

Popu

latio

nTr

eatm

ent

Con

ditio

nC

ontr

olC

ondi

tion(

s)R

esul

ts

Rel

axat

ion

trea

tmen

ttr

ials

Haa

nen

etal

.,19

91(6

8)40

T:15

%C

:0%

Not

repo

rted

1.H

ypno

ther

apy

(8se

ssio

ns)

1.Ph

ysic

alth

erap

ygr

oup

mas

sage

�re

laxa

tion

Trea

tmen

tgr

oup

repo

rted

grea

ter

impr

ovem

ent

inpa

in,*

*a

psyc

hic

dist

ress

*a

No

diffe

renc

ebe

twee

ngr

oups

inTM

S3-

mon

thfo

llow

-up:

diffe

renc

esm

aint

aine

dFe

rrac

ciol

iet

al.,

1987

(69)

12T:

0%C

:0%

Rhe

umat

olog

ycl

inic

patie

nts

1.EM

Gbi

ofee

dbac

k(1

5se

ssio

ns)

1.Fa

lse

EMG

biof

eedb

ack

(15

sess

ions

)Tr

eatm

ent

grou

pha

dfe

wer

tend

erpo

ints

*an

dse

lf-re

port

edpa

in*

Mea

npo

sttr

eatm

ent

effe

ctsi

zefo

rpa

inan

dte

nder

ness

:d

�

4.01

Gun

ther

etal

.,19

94(7

0)26

T:0%

C:

8%R

heum

atol

ogy

clin

icpa

tient

s1.

Prog

ress

ive

mus

cle

rela

xatio

n(1

0se

ssio

ns)

1.H

ydro

galv

anic

bath

s(1

0tr

eatm

ents

)N

odi

ffere

nce

inse

lf-re

port

edpa

inB

oth

grou

psex

peri

ence

dre

duct

ions

inpa

inEx

erci

setr

eatm

ent

tria

lsM

cCai

net

al.,

1988

(71)

42T:

10%

C:

9%R

heum

atol

ogy

clin

icpa

tient

s1.

Fitn

ess

grou

p(E

X)

(3tim

es/w

kfo

r20

wk)

1.Fl

exib

ility

grou

p(F

LEX

)(3

times

/wk

for

20w

k)EX

had

grea

ter

impr

ovem

ent

inTM

S*67

%EX

vs.

15%

FLEX

had

CSI

bin

TMS

39%

EXvs

.10%

FLEX

had

�50

%de

crea

sein

self-

repo

rted

pain

No

diffe

renc

ebe

twee

ngr

oups

onps

ychi

atri

csy

mpt

oms

Mar

tinet

al.,

1996

(72)

60T:

40%

C:

33%

Ref

erre

dfr

omM

Ds

(rhe

umat

olog

yfa

mily

med

icin

e)an

dsu

ppor

tgr

oups

1.Ex

erci

segr

oup

(EX

)(3

times

/wk

for

6w

k)1.

Rel

axat

ion

grou

p(R

EL)

(3tim

es/w

kfo

r6

wk)

EXha

dgr

eate

rim

prov

emen

tin

TMS*

*Po

sttr

eatm

ent

effe

ctfo

rte

nder

poin

ts:

d�

0.92

No

diffe

renc

ebe

twee

ngr

oups

onse

lf-re

port

edpa

inB

ucke

lew

etal

.,19

98(7

3)10

9T1

:23

%T2

:13

%C

1:14

%C

2:10

%

Ref

erre

dfr

omM

Ds

(rhe

umat

olog

y,ps

ycho

logy

,ot

her)

1.Ex

erci

se�

biof

eedb

ack

(EX

B)

2.Ex

erci

seal

one

(EX

)1.

Bio

feed

back

alon

e(B

)2.

Educ

atio

ngr

oup

(ED

)N

odi

ffere

nces

amon

ggr

oups

onTM

S,se

lf-re

port

edpa

in,

orps

ychi

atri

csc

ales

EX,

B,

EXB

had

few

erte

nder

poin

tsth

anED

EXB

,EX

had

grea

ter

impr

ovem

ents

inph

ysic

alac

tivity

than

ED**

Men

gsho

elet

al.,

1992

(74)

35T:

39%

C:

18%

Ref

erre

dfr

ompa

tient

orga

niza

tion

1.A

erob

ics

grou

p(2

times

/wk

for

20w

k)1.

No

trea

tmen

tN

odi

ffere

nces

betw

een

grou

pson

self-

repo

rted

pain

CB

Ttr

eatm

ent

tria

lsV

laey

enet

al.,

1996

(75)

125

T:22

%C

1:23

%C

2:3%

Rhe

umat

olog

ycl

inic

patie

nts

1.C

BT/

educ

atio

n(1

2se

ssio

ns)

2.W

aitin

glis

t

1.Ed

ucat

ion/

disc

ussi

on(D

isc)

(12

sess

ions

)N

odi

ffere

nce

amon

ggr

oups

onse

lf-re

port

edpa

in,

activ

ityle

vel,

and

depr

essi

onD

isc

repo

rted

grea

ter

impr

ovem

ents

infe

arth

anC

BT*

*12

-mon

thfo

llow

-up:

nodi

ffere

nces

betw

een

CB

Tan

dD

isc

Nic

assi

oet

al.,

1997

(76)

86T:

25%

C:

8%R

heum

atol

ogy

clin

ican

dsu

ppor

tgr

oup

1.B

ehav

iora

lgr

oup

(10

sess

ions

)1.

Educ

atio

n/di

scus

sion

grou

p(1

0se

ssio

ns)

No

diffe

renc

esbe

twee

ngr

oups

onse

lf-re

port

edpa

in,

TMS,

func

tioni

ng,

orde

pres

sion

Kee

let

al.,

1998

(77)

32T:

13%

C:

19%

Rhe

umat

olog

ists

and

othe

rsp

ecia

lists

1.C

BT/

exer

cise

(1tim

e/w

kfo

r15

wk)

2.A

utog

enic

trai

ning

(15

wee

kly

sess

ions

)Po

sttr

eatm

ent:

nodi

ffere

nces

betw

een

grou

psin

self-

repo

rted

pain

4-m

onth

follo

w-u

p:C

BT

repo

rted

grea

ter

redu

ctio

nsin

pain

than

cont

rol

Follo

w-u

pef

fect

for

self-

repo

rted

pain

:d

�0.

35Ex

erci

seve

rsus

CB

Ttr

eatm

ent

tria

lsW

iger

set

al.,

1996

(78)

60T1

:20

%T2

:25

%C

:15

%

Ref

erre

dfr

ompa

tient

orga

niza

tion

and

phys

ical

med

icin

ecl

inic

1.A

erob

ics

grou

p(E

X)

(3tim

es/w

kfo

r14

wk)

2.St

ress

man

agem

ent

(SM

)

1.St

anda

rdm

edic

alca

reEX

and

SMha

dgr

eate

rre

duct

ion

inte

nder

ness

than

cont

rol*

*a

75%

EXvs

.47

%SM

vs.

12%

cont

rol

repo

rted

feel

ing

bette

ror

muc

hbe

tter

Effe

ctsi

zes

for

pain

:EX

vs.

cont

rol:

d�

0.67

SMvs

.co

ntro

l:d

�0.

684-

year

follo

w-u

p:no

diffe

renc

esbe

twee

nEX

and

SMB

urck

hard

tet

al.,

1994

(79)

99T1

:15

%T2

:10

%C

:14

%

Ref

erre

dfr

ompr

imar

yca

reph

ysic

ians

and

occu

patio

nal

heal

th

1.Fi

tnes

str

aini

ng(E

X)

(1tim

e/w

kfo

r6

wk)

2.St

ress

/edu

catio

ngr

oup

(ED

)

1.W

aitin

glis

tN

odi

ffere

nce

betw

een

any

grou

pson

self-

repo

rted

pain

EXan

dED

had

grea

ter

incr

ease

sin

qual

ityof

life*

and

self-

effic

acy

for

func

tioni

ng**

No

diffe

renc

esbe

twee

nEX

and

EDon

pain

,qu

ality

oflif

e,se

lf-ef

ficac

y

TM

S(t

otal

mya

lgic

scor

e)�

pai

nth

resh

old

acro

ssa

stan

dar

dse

tof

site

s.a

Inte

nt-

to-t

reat

anal

ysis

per

form

ed.

bC

SI

(cli

nic

ally

sign

ific

ant

imp

rove

men

t)w

asin

dic

ated

by�

10-k

g/cm

2im

pro

vem

ent

inT

MS

betw

een

base

lin

ean

dth

ep

ostt

reat

men

tor

foll

ow-u

pas

sess

men

t.*

p�

.05;

**p

�.0

1;**

*p

�.0

01.



gram, a stress management plus exercise program, or awaiting list (79). Immediately after treatment, therewere no differences among any of the groups’ reportsof pain (79).

Aggregating the Studies

The majority of studies suggest that psychosocialinterventions provide some benefit to polysymptom-atic somatizers. Twenty-two of the 33 (67%) studies,using change in physical symptoms as the primaryoutcome measure, reported the treatment group im-proved significantly more than the control group did.Similarly, 8 of the 10 (80%) investigators, assessingefficacy with physical functioning scores, found theexperimental intervention outperformed the controlintervention. Eight of the 17 (47%) trials evaluating theimpact of treatment on psychological distress showedgreater improvement in the experimental group thanin the control group.

Multiple Fisher’s exact analyses were performed todetermine whether any of the following variables wasassociated with treatment outcome: patient’s diagnosis(IBS vs. CFS vs. fibromyalgia vs. somatization), type oftreatment (CBT vs. relaxation vs. exercise), format oftreatment (individual vs. group), and type of controlcondition (no or minimal treatment vs. attention-con-trol treatment). None of these analyses yielded signif-icant results. Of course, given the small effect sizes inthese analyses, none of the analyses had sufficientpower to reject the null hypothesis definitively. Forexample, the statistical power was only 11% for theanalysis of treatment outcome by type of controlcondition.

To calculate the magnitude of the interventions’impact, effect sizes were examined. Eleven studiesreported sufficient data to calculate effect sizes. Inthese studies, effect sizes ranged from 0.20 (for dy-namic therapy vs. standard medical care for IBS pa-tients) (49) to 4.01 (for EMG biofeedback vs. false EMGbiofeedback for fibromyalgia patients) (69). The meaneffect size for these 11 studies, weighted by samplesize, is 0.68.

The number of participants experiencing clinicallymeaningful improvement is often calculated to dem-onstrate a treatment’s effect on individual participants.Clinically significant change was defined a priori in 11studies, 9 of those addressing IBS. The percentage ofexperimental patients that achieved clinically signifi-cant change ranged from 44% to 80%, as comparedwith 25% to 55% of pseudotreatment patients and 0%to 32% of inactive control patients.

Follow-up assessments were conducted with bothtreatment and control participants in nine trials. Seven

of the nine studies showed treatment gains had beenmaintained or enhanced at the follow-up evaluation.The two studies resulting in no long-term differencesbetween treatment and control patients had alsoshown no differences at the posttreatment evaluation.The time frame of follow-up assessments ranged from3 to 12 months with a mean of 6.4 months.

Participants in the trials were usually treated intertiary care centers. Almost half of the studies (16 of34) accepted referrals only from specialists, such asgastroenterologists or rheumatologists. Three investi-gators (9%) treated primary care or internal medicinepatients; one investigator conducted treatment in theprimary care setting. The remaining studies eitherfailed to report their referral sources or recruited pa-tients from a variety of sources (ie, from various typesof physicians, advertisements, patient organizations,and support groups).

DISCUSSION

Our decision to aggregate the research on IBS, CFS,fibromyalgia, and somatization disorder may invitecontroversy. Many medical specialists, focusing on thebodily organ or system of their specialization, assumethese disorders have distinct pathophysiologicalcauses and distinguish among these syndromes. Otherinvestigators have suggested these syndromes beviewed as one disorder. Despite the disputes over thebiological mechanisms involved, all agree there is sig-nificant overlap in these patients’ behaviors, beliefsregarding their condition, and psychological function-ing (17–19). Polysymptomatic somatizers tend toadopt the sick role (80) by overutilizing health careand withdrawing from their activities. Assuming theirsymptoms are signs of a serious, disabling illness thatis likely to worsen, these individuals often think cat-astrophically about their health. Also, they frequentlysuffer from emotional disorders (17–19).

Grouping IBS, CFS, fibromyalgia, and somatizationdisorder into one category, termed polysymptomaticsomatization, has a number of implications. First, suchclassification highlights the importance of environ-mental, behavioral, and psychological factors. Second,this classification implies that a biopsychosocialmodel is superior to a biological model in the under-standing and treatment of these patients.

The theories underlying the interventions assessedin this review are predicated on a biopsychosocialmodel. Although each approach has its own distinctrationale, the similarities of the rationales and treat-ments should be noted. None of the theories nor theirassociated treatments is organ-specific. Instead, it isassumed that any one or more organs can be affected

L. A. ALLEN et al.


by various psychosocial processes. Each interventionencourages the patient to make changes in thinkingand/or conduct.

On the whole, this review suggests psychosocialtreatments may be modestly effective in reducing thephysical discomfort and disability of polysymptomaticsomatizers. Benefits may last for at least 3 months aftertreatment has ended. No one intervention seems morepotent than the others. None of the syndromes seemsmore responsive to such interventions than the others.The conclusions must be tempered with a few caveats.First, because only one study has been published onfull somatization disorder, as defined in DSM, little isknown about treatment efficacy with this population.Second, methodological shortcomings are present inmuch of the literature, rendering all conclusions un-certain. These methodological weaknesses will be dis-cussed below.

A chief criticism of the literature is the paucity ofintent-to-treat analyses conducted. Often investigatorsexcluded premature withdrawals from the data analy-sis, resulting in biased findings. Nineteen studies re-ported either using intent-to-treat analyses or havingno premature withdrawals. Both of the somatizationand four (80%) of the CFS studies reported findingsusing intent-to-treat analyses. Only 3 of the 12 fibro-myalgia investigators handled premature withdrawalsproperly; one other fibromyalgia trial had no dropouts.Intent-to-treat analyses were not used in any of the IBStrials, of which 10 (67%) reported premature with-drawals. Thus, the effect sizes from the IBS and fibro-myalgia literature are debatable and may have beenoverestimated.

The mean effect size across studies was 0.68. Thiseffect size is based on data from only 11 trials, 3 ofwhich failed to use intent-to-treat analyses. Given thatdata from so few trials were included in this calcula-tion, interpretation is problematic. To raise additionalquestions about the effect size, only published studieshave been included in this review. If one assumes thatadditional studies on psychosocial interventions havenot been published because of their negative findings(ie, the file drawer effect), one must assume the trueeffect size to be lower than 0.68.

Even if a large effect size had been observed, thepractical utility of these treatments would still be un-certain. Large effect sizes convey little informationabout individuals’ responses to an intervention. Forinstance, it is possible for investigators using largesamples, for example, Svedlund et al. (49), to detect astatistical difference without achieving clinically sig-nificant change in any participant. Researchers havenot uniformly assessed whether psychosocial treat-ments have a clinically meaningful impact on individ-

ual subjects. Only one CFS, one fibromyalgia, and nosomatization studies examined clinical significance.The nine IBS studies assessing clinically meaningfulimprovement suggest the effect of the active treatmentwas modest relative to that of the control treatment.Changes in illness behavior, such as use of medicalservices and absenteeism from work, are other “clini-cally meaningful” measures of change that should alsobe reported in future studies.

Long-term follow-up assessments are critical in de-termining the efficacy of any intervention. The findingthat a substantial number of control participants expe-rienced improvements at the post-treatment evalua-tion (59–62, 70) implies that a placebo response mayhave occurred. Given that the benefits placebo re-sponders derive from treatment may disappear duringthe follow-up period, such follow-up may help distin-guish placebo treatments from active treatments. Also,practically effective treatments should be enduring intheir impact. If treated patients return to their formerlevels of functioning within a year of treatment, thevalue of these interventions is limited. Although mostof the reviewed trials reporting follow-up data supportthe long-term efficacy of psychosocial treatments, toooften follow-up data have been incomplete or nonex-istent. Only 26% of the trials reported long-term as-sessment data for both control and treated patients.

Despite the high rates of emotional distress experi-enced by polysymptomatic somatizers, the impact oftreatment on psychiatric symptoms has not been ade-quately addressed. Two investigators excluded partic-ipants who met DSM criteria for a psychiatric disorder(66, 76). Only half of the investigators measuredchanges in psychiatric symptoms as a secondary out-come variable. Although many trials showed that emo-tional and physical symptoms improved concurrently(48, 52, 53, 65), others reported no association betweenthe changed physical and emotional symptoms (49, 50,71). Additional research is needed to determinewhether psychiatric symptomatology mediates the re-lationship between psychosocial treatments and unex-plained physical symptoms. One review has alreadyconcluded that no such mediation exists for CBT. Ex-amining only CBT trials for somatizers, Kroenke andSwindle (9) found that psychiatric symptoms oftenfailed to benefit from CBT even when physical symp-toms did. The present review’s failure to show such aclear distinction between the impact of psychosocialtreatments on psychiatric, relative to physical, symp-toms may be attributable to the broader range of inter-ventions reviewed here.

Unexplained physical symptoms may be amelio-rated by many active or control treatments. The au-thors of the studies showing no difference between the



experimental and control conditions noted that partic-ipants in both the experimental and control groupsimproved significantly over time (59–62, 70). Differ-ent psychosocial interventions seem to have similareffects on patients’ symptoms. Taken together, thesefindings suggest that none of the treatments alters spe-cific dysfunctions, but instead the treatments includesome common factor or factors that benefit these pa-tients. The active component(s) of treatment may bethe patient’s expectation of improvement, attentionfrom a healthcare provider, or encouragement to re-sume healthy functioning. Alternatively, it is possiblethat the treatments relieve feelings of helplessness,hopelessness, depression, and/or anxiety, which maypromote a reduction in physical discomfort. Futureresearch should explore the mechanism of change as-sociated with these treatments.

Few investigators examined the acceptability oftheir treatment to the general somatization population.Most trials were advertised for and conducted in ter-tiary care centers instead of in the primary care clinicswhere these patients typically are treated. The numberof patients screened and refusing treatment as well asthe number of missed treatment sessions frequentlywere not reported. Because most somatizing patientsattribute their discomfort to medical illnesses and seekmedical treatment, patients treated in psychiatric clin-ics may not adequately represent the population.Thus, the generalizability of the findings is uncertain.

Two previous reviews of psychosocial treatmentstudies have been conducted with patient populationsthat are similar to ours. After systematically evaluatingthe quality as well as the content of psychosocial treat-ment trials for IBS, Talley et al. (6) state that the effi-cacy of these treatments has not yet been establishedbecause of the literature’s methodological weaknesses.In a separate review summarizing only CBT trials withpatients diagnosed with one or more unexplainedphysical symptoms, Kroenke and Swindle (9) foundCBT to be effective in reducing physical discomfort.The discrepancies between these conclusions may be afunction of not only the populations and interventionsreviewed but also the authors’ criteria. Talley et al.’sreview (6) is somewhat more methodologically strin-gent than Kroenke and Swindle’s review (9) in that theformer found only one study that met their standard of“methodological acceptability.”

The present review suggests that psychosocial treat-ments, although seemingly beneficial, have not yetbeen shown to have a lasting and clinically meaningfulinfluence on the physical complaints of polysymptom-atic somatizers. To demonstrate unequivocal supportof a treatment, investigators should report effect sizesusing intent-to-treat analyses, the number of patients

experiencing clinically significant change, and long-term follow-up results. At present, the methodologi-cally sound studies suggest the interventions may lackpotency. Future research should assess the efficacy ofmore intensive treatments. No investigator examinedan intervention requiring more than 16 sessions, andmost interventions lasted only 6 to 12 sessions. Suchbrief treatment is in vogue as third-party payers limitcoverage of long-term treatment. Chronic somatic com-plaints, however, may require treatment of a durationlonger than 2 months.

This work was supported by Grants K08 MH01662and R01 MH60265 from the National Institute of Men-tal Health.

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Psychosocial Treatments for Multiple Unexplained Physical Symptoms: A Review of the Literature

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