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Psychosomatics 48:294-303, August 2007
doi: 10.1176/appi.psy.48.4.294
© 2007 Academy of Psychosomatic Medicine
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A One-Session Treatment for Patients Suffering From Medically Unexplained Symptoms in Primary Care: A Randomized Clinical Trial

Alexandra Martin, Ph.D., Elisabeth Rauh, M.D., Manfred Fichter, M.D., and Winfried Rief, Ph.D.

Received March 15, 2006; accepted March 20, 2006. From the Philipps-University of Marburg, Section for Clinical Psychology and Psychotherapy. Send correspondence and reprint requests to Dr. Alexandra Martin; Philipps-University, Faculty of Psychology, Section for Clinical Psychology and Psychotherapy, Gutenbergstrasse 18 D-35032 Marburg, Germany. e-mail: martin{at}staff.uni-marburg.de
© 2007 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The aim of the study was to evaluate a one-session cognitive-behavior treatment (CBT) versus standard medical care for 140 primary-care patients with multiple somatoform symptoms. DSM–IV diagnoses were assessed with structured interviews. Primary outcome variables were healthcare utilization, number, and severity of somatoform symptoms, and secondary outcome measures were psychopathology dimensions. Assessments were done at study enrollment, at 4-weeks, and at 6-month follow-up. General acceptance of CBT was high (positive session evaluations, low dropout rate: 15%). Using an intent-to-treat analytic strategy, both groups improved. Yet results showed a stronger reduction in doctor visits and somatization severity in CBT versus standard care.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Patients suffering from medically unexplained symptoms are considered to constitute a relevant subgroup in healthcare systems. In the general population, and even more in medical treatment settings, the prevalence of somatoform syndromes is high.1–3 Somatoform disorders are characterized by physical complaints that cannot be fully explained by any pathophysiological condition.4 A history of multiple symptoms is associated with high disability and poor outcome,5 as well as high costs of treatment.6

In current models of somatoform disorders, the role of selective attention on body processes and the role of cognitive processes, such as catastrophizing misinterpretations of body reactions and the lack of normalizing attributions, have been outlined.7–10 It is assumed that these maladaptive cognitive and perceptual processes trigger dysfunctional illness behavior, such as inappropriate utilization of medical services, reassurance-seeking, and avoidance of physical activity, and that their interaction leads to chronic symptoms. In recent times, the cognitive-behavior model of somatization has provided the basis for several treatment approaches,11–13 and some controlled trials have shown cognitive-behavior therapy to be effective.14 There is still the challenge of engaging patients in such treatment; a considerable number of patients either refuse to participate or drop out of treatment.15 Engagement in psychological treatment often fails because "chronic somatizers tend to resist appropriate treatment, as they regard themselves as physically, and not mentally, ill."16 It still remains necessary to optimize management of somatoform and related disorders by improving early identification of cases and obtaining referral to adequate treatment. This might prevent the development of chronic conditions with dysfunctional illness-behavior. Interventions suggested by the patient’s physician, and, at best, conducted in the medical setting itself, appear to be a very promising approach, especially for engaging these patients in treatment.17

We therefore developed a one-session cognitive-behavior treatment focusing on patients who consult their primary-care physician because of medically unexplained symptoms (Table 1). The central interventions were adapted from a more intensive cognitive-behavior treatment that has been shown to be an effective treatment for somatoform disorders in tertiary care.18 Subjects were told the main aim of the treatment was to improve coping with somatic symptoms, rather than offering a cure. Elements included the development of an alternative explanation of medically unexplained symptoms, relaxation techniques, cognitive strategies to cope with catastrophizing and other dysfunctional cognitions, efforts to increase motivation to participate in graded physical activity, and the provision of information about healthcare services.


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TABLE 1. Overview of Relevant Etiological Factors in Somatization and Interventions of the One-Session Cognitive-Behavioral Treatment



The management of medically unexplained symptoms in primary care is especially challenged by time constraints and the lack of the resources to offer intensive treatment. With only one treatment session and the recruitment of subjects from primary-care practices, the treatment was tailored to the needs of primary-care management of somatization. We hypothesized such a treatment to be highly acceptable for patients who primarily seek help in medical settings. The aim of the study was to evaluate this treatment in comparison to a group receiving standard medical care, with the aim of achieving reduction in healthcare utilization and improvement in symptom severity.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
The randomized clinical trial was conducted in our outpatient treatment center at the University of Marburg between August 2001 and December 2002. A total of 25 of 70 general practitioners, who were contacted for their cooperation, agreed to support the intervention study and inform patients suffering from medically unexplained symptoms in their independent practice about the study. The physicians received 20 Euros per subject to cover expenses.

Subjects
The inclusion criterion of subjects was the presentation of at least two medically unexplained symptoms within the last 6 months, resulting in significant clinical distress. Subjects were excluded if they had a severe current medical condition or chronic medical disease (such as diabetes) that could explain the physical symptoms. Subjects were also excluded if they presented with psychotic symptoms or substance dependence.

The majority of patients were recruited in primary-care practices, either by referral from the physician or by identification through a screening questionnaire of somatoform symptoms (68%; N=95; control group [CG]: 71%, cognitive-behavioral therapy group [CBT]: 64%), some by self-referral when they became interested in the study as a result of reading a newspaper report (22%; N=31; CG: 17%, CBT: 27%), and some in other ways (10%; N=14; CG: 11%, CBT: 8.6%). The two groups did not differ significantly in method of subject recruitment ({chi}2 [df 4]=5.4; NS). A structured diagnostic interview was used to determine whether subjects met the study criteria and to assess for DSM–IV psychiatric diagnoses. Medical conditions were ruled out by the patients’ general practitioners (GPs) and by the diagnostic interview. Six subjects were excluded because diagnostic investigations revealed chronic medical conditions in four cases, substance dependence in one case, and a psychotic syndrome in one case.

A final total of 140 subjects met the inclusion criteria and were randomly assigned to either the cognitive-behavior therapy (CBT) intervention group (N=70) or the standard medical care waiting control group (CG; N=70). Randomization was based on a predefined list of binary variables, using blocking procedures to ensure comparable sample sizes. Study assistants enrolled and assigned participants to the groups according to the randomization list. All subjects were informed about the nature of the study, and written informed consent was obtained.

Procedure and Assessment Times
All subjects were assessed three times: At study intake (Baseline or T1), 4 weeks (T2), and 6 months later (T3). The first assessment consisted of a structured interview to determine DSM–IV diagnoses and healthcare utilization, as well as a self-report questionnaire battery. Four weeks later, a second assessment was conducted with a brief telephone interview to check for changes in the diagnoses and in questionnaire responses. The follow-up was conducted 6 months after study intake, with interview and questionnaires. Four trained and supervised research assistants conducted the assessments.

Subjects in the intervention (CBT) group attended the one-session treatment 2 weeks after the baseline assessment. Subjects of the control group (CG) were offered attendance at the intervention after the third assessment, 6 months later.

Treatments
The Intervention Group (CBT) Patients in the CBT group attended a single cognitive-behavior treatment session totaling 3 to 4 hours. It was offered in a group format, with small groups of two to four patients. Two different therapists conducted the treatment sessions (a clinical psychologist and a medical specialist for psychotherapeutic medicine, both licensed cognitive-behavior therapists). The treatment followed a structured manual with five central modules (in German), available on request:

  1. Psychophysiological explanation of symptoms. The session started with a general overview and highlighted the idea that the central aim of the treatment was to improve coping (instead of curing). The idea was presented that medically unexplained symptoms are a common phenomenon and might be the result of various factors. Patients were encouraged to discuss multiple reasons, and the role of stress was introduced as a normalizing explanation of physical symptoms.
  2. Relaxation. Describing the role of stress and the resulting physiological arousal, the exercise of progressive muscle relaxation was introduced as a self-help strategy. All patients received a CD with verbal instructions.
  3. The importance of cognitions. An example of the role of cognitions was given and applied to subjects’ individual experience. The main purpose was to demonstrate the effect of thoughts on symptoms and behavior and to encourage patients to identify and challenge their own dysfunctional beliefs.
  4. Activity instead of avoidance behavior. The vicious circle of physical deconditioning was explained, and the short-term positive and long-term negative consequences of avoidance of physical activity were identified. On the basis of this model, patients were encouraged to improve their physical well-being by gradually increasing their physical activity, and a graded exercise program was designed for each subject.
  5. Treatment options and healthcare utilization. Further treatment options for their medically unexplained symptoms were discussed, as well as the question of how to optimize healthcare utilization (e.g., in cases of frequent reassurance-seeking and asking the physician for regular appointments). Patients also received a booklet summarizing the main components of the session.

Control-group (CG) patients received standard medical care and were offered the treatment 6 months later.

Assessment and Outcome Measures
DSM–IV diagnoses were assessed by a diagnostic clinical interview, using the International Diagnostic Checklists for Somatoform and Affective Disorders19,20 and the Mini-DIPS21 for anxiety disorders, eating disorders, substance-related disorders, and psychotic symptoms. The primary outcome measures were healthcare utilization and somatoform symptom variables.

Healthcare utilization over the past 6 months was assessed with help of a structured interview.22 To increase the validity of this interview, we asked for specific healthcare use in detail (e.g., one specific item for each of 20 medical specialties), and memory cues were used to avoid underreporting of healthcare utilization. Subjects were asked to report how often they had consulted each specialist during the previous 6 months. The total number of doctor visits was derived from the sum of visits to the GP and the medical specialists. The number of visits to mental health professionals was also counted.

Subjects were asked about their medication use within the last 6 months. For each type of medication reported, subjects were asked how many days they had used it. From that, an indicator, "total days of medication intake," was derived from the number of medications multiplied by number of days of intake. All working subjects were asked to report their number of sick leave days over the past month.

The Brief Symptom Inventory (BSI),23 a 53-item version of the Derogatis Symptom Check List SCL-90–R, was presented to assess the severity of somatoform symptoms (Somatization Subscale: BSI–SOM) and general psychopathological symptoms (Global Severity Index: GSI). Each score ranges between 0 and 4, with higher scores indicating greater symptom severity.

The "state" version of the Screening for Somatoform Symptoms (SOMS–7)24 was used to identify the number of somatoform symptoms subjects suffered from during the last 7 days. The scale has been shown to be a reliable and valid instrument for the evaluation of treatment effects in patients with somatoform disorders. For each of 53 symptoms (covering all bodily symptoms mentioned as occurring in Somatization Disorder in DSM–IV and ICD–10), the subjects indicated on a 5-point Likert scale the degree of resulting disability. Only symptoms related to at least moderate disability were counted.

The degree of hypochondriacal anxiety and concern was assessed by the Whiteley Index (WI).25,26 The WI consists of 14 items with dichotomous response alternatives; thus sum scores could vary between a minimum of 0 and a maximum of 14.

The Beck Depression Inventory (BDI)27,28 was used as a secondary outcome measure to assess the severity of depressive symptoms.

Health-related locus of control was assessed by the 7 items of the subscale "Internal Control" of the Multidimensional Self-Report Questionnaire (KKG),29 which has sufficient reliability and good validity. Scores range between 7 and 42, with higher scores representing more internal control.

Session Evaluation
At the end of the treatment session, all subjects were asked to fill in a session evaluation scale to report their satisfaction with the intervention.

Statistical Analyses
Group differences at baseline were tested with chi-square analysis for frequencies and t-test when appropriate (for normally distributed data). An intention-to-treat approach was used in all analyses, comparing baseline and follow-up data. For patients who dropped out of the study, baseline values were used to replace follow-up data.

Primary outcomes were healthcare utilization (outpatient doctor visits and medication) and somatoform symptoms (symptom severity: BSI–SOM; number of symptoms: SOMS–7; health anxiety: WI). Secondary outcome measures included severity of general psychopathology and depression (BSI–GSI, BDI), number of sick-leave days, and degree of health-related internal control (KKG–I).

Separate repeated-measures analyses of variance (MANOVA) were performed to test hypotheses, with one between-factor (CBT versus control group) and one within-factor (Assessment Times T1, T3 for interview-based data, and Times T1, T2, and T3 for questionnaire-based data). Because of missing values, the number of subjects varied slightly for different outcome measures. This difference is indicated by degrees of freedom (df) for each statistical comparison. Effect sizes ({eta}2) were calculated, as follows: {eta}2=0.01 indicates a small, {eta}2=0.059, a moderate, and {eta}2=0.138, a large effect size.30 All analyses were conducted with the SPSS Statistical Package (Version 11.0).


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Completion Rates
Figure 1 presents patient flow according to the CONSORT criteria. A total of 140 subjects with medically unexplained symptoms were consecutively recruited. Of these, 18 subjects (12.9%) refused further participation after randomization/interview. Three more subjects (2.1%) dropped out of the study before the second assessment. In sum, the total dropout rate was 15% (N=21; CBT group: N=10, CG: N=11). With respect to this dropout rate, the two groups did not differ significantly from each other ({chi}2[1]=0.4).


Figure 1
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FIGURE 1.  Design and Patient Flow (See CONSORT Criteria.)


The comparison between central characteristics of completers versus dropouts is based on structured interview data that were available for all subjects. For almost all variables, the groups were highly similar. They did not differ in gender ratio ({chi}2[1]=0.4), age (t[137]=0.8), somatoform symptoms (prevalence of a somatoform disorder: {chi}2[1]=0.9; number of somatoform symptoms: t[137] = –0.7; duration of symptoms t[107] = –1.1); and the number of healthcare visits (t[136]=0.6). The only difference was that dropouts had a significantly lower ratio of comorbid affective disorders than completers (35% versus 63%; {chi}2[1]=5.6).

Completed data were provided as follows: Baseline interview data were obtained of all participants (one with incomplete interview data). Attrition was low, with a response rate of 97.5% (115 of 118) at the 4-week follow-up and 88.1% (104 of 118) at 6-month follow-up. The return rate of the questionnaires was marginally lower. Again, the groups did not differ with respect to their return rates for interview data and for questionnaire data (chi-square values from 0.0 to 1.4).

Baseline Characteristics
The sociodemographic characteristics of the two groups are shown in Table 2. Subjects were predominately women, married, and middle-aged. The only significant group difference at baseline was for age of the subjects, with control subjects being slightly older than subjects in the intervention group. The average number of somatoform symptoms was 7.6 in the CBT group and 6.6 in the CG; they reported an approximate mean of 9 to 12 years’ history of symptoms. Most subjects in both groups fulfilled DSM–IV criteria for at least one somatoform disorder (CBT: 91.4%; CG: 87.1%), of whom 13.6% had Somatization Disorder (CBT: N=13; CG: N=6), 48.6%, Undifferentiated Somatoform Disorder (CBT: N=30; CG: N=38), 17.1%, Pain Disorder (CBT: N=17; CG: N=7), 1.4% with Conversion Disorder (CBT: N=2), 7.8%, Hypochondriasis (CBT: N=4; CG: N=7), and 9.3%, Somatoform Disorder, not otherwise specified (CBT: N=5; CG: N=8). The remaining patients were suffering from medically unexplained symptoms that could be explained by other psychiatric disorders. Comorbidity with depressive disorder or anxiety disorders was generally high (Table 2). The treatment and control group did not differ significantly in any clinical variable at baseline.


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TABLE 2. Sociodemographic and Clinical Sample Characteristics (Baseline)



Healthcare Utilization
Results for healthcare utilization are shown in Table 3. There was a statistically significant interaction effect for group x time with respect to doctor visits. In the CBT group, the overall number of medical healthcare visits was reduced more than in the CG (F[1, 137]=4.4; p <0.05; {eta}2=0.031). The improvements in number of healthcare visits were stronger in the CBT than the CG, especially for visits at general practitioners (F[1, 136]=4.3; p <0.05; {eta}2=0.031) but not for visits at medical specialists (F[1, 136]=2.7; p=0.104; {eta}2=0.019). No significant interaction effect was observed with respect to visits at psychotherapists (F[1, 127]=0.40; {eta}2=0.003). Moreover, CBT subjects reduced their medication intake more than CG subjects, as was indicated by the number of days with medication intake (F[1, 134]=4.03; p <0.05; {eta}2=0.029).


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TABLE 3. Healthcare Utilization, Last 6 Months, Mean Score (Standard Deviation) at Baseline and 6-Month Follow-Up



The main time effect was significant for the overall number of doctor visits (F[1, 137]=14.0; p <0.001), as well as, separately, for GP visits (F[1, 136]=11.3; p <0.01), visits at medical specialists (F[1, 136]=8.7; p <0.01), and for days of medication intake (F[1, 134]=6.1; p <0.05). No time effect was observed for visits at psychotherapists (F[1, 127]=3.3). No main group effect was observed for any variable of healthcare utilization (Fs[1, 137]: 0.01 to 0.7).

Somatoform Symptoms
The results for outcomes of somatoform symptoms are shown in Table 4. There was a statistically significant interaction effect for group x time for somatization severity (BSI–SOM). The CBT group showed a stronger reduction in Somatization Severity score from pretreatment to 6-month follow-up, whereas the CG did not improve (Fs[1, 114]=5.7; p=0.018; {eta}2=0.048). The overall Time main effect was significant (F[1, 114]=4.7; p <0.05), whereas the group main effect was not (BSI–SOM F[1, 114]=0.70).


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TABLE 4. Primary Outcome (Somatoform Symptoms) and Secondary Outcome Measures, Mean (Standard Deviation)



The number of somatoform symptoms was reduced significantly from baseline to follow-up in both groups (SOMS–7 Time main effect (F[1, 114]=10.4; p <0.01). With respect to this criterion, the intervention group did not improve more than the control group (F[1, 114]=1.3). Again, the main group effect was not significant (SOMS–7: F[1, 114]=2.5).

Health Anxiety (Whiteley Index) was reduced significantly from baseline to follow-up (F[1, 114]=4.9; p <0.05). Descriptive data suggested the reduction to be observed mainly in the CBT group, but the interaction effect of group x time failed to reach significance (F[1, 114]=2.6; p=0.108). The main group effect of Health Anxiety was not significant (F[1, 114]=1.9).

Secondary Outcome Measures
Secondary outcome measures included general indicators of psychological problems (BSI–GSI), and depression (BDI; Table 4). The Time main effects were significant for BSI–GSI (F[1, 114]=4.9; p <0.05) and for BDI score (F[1, 109]=9.5; p <0.01). Groups did not differ significantly on these clinical variables: BSI–GSI: F[1, 114]=1.90; BDI: F[1, 109]=2.7; nor did either of the groups improve more than the other one (interaction, BSI–GSI: F[1, 114]=2.6; p=0.108; and BDI: F[1, 114]=0.2; p >0.05).

The rationale of the treatment was to improve coping with symptoms—and we were therefore interested in changes in perceived health-related control (KKG–I). The interaction effect failed to reach significance, but revealed a trend, with CBT subjects, but not CG subjects, improving in internal control (F[1, 114]=3.8; p=0.055).

An indicator of illness-behavior was the number of sick-leave days, with results suggesting a reduction in the intervention (CBT), but not the control group (F[1,87]=3.8; p=0.053; {eta}2=0.042). However, we must take into account that the analysis of this measure was based on a smaller number of subjects, because only subjects with paid employment were asked to report the number of sick-leave days.

Consumer Satisfaction
The CBT patients were asked to rate the treatment directly after the session (Table 5). The ratings were very positive, with near-unanimous endorsement of the following: 96% of the subjects would recommend it to a friend with comparable complaints; 96% felt that it should be offered more often; 94% felt understood by the therapist; and 92% rated the strategies as promising for the management of their complaints. The negative ratings, as follows, were very low (between 0% and 4%). Although side effects were not assessed systematically, no adverse events were spontaneously reported.


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TABLE 5. Session Rating of CBT Group (Percent of Subjects Endorsing Item)



Reanalysis to Control for Age
Because the groups differed with respect to age (control being older than CBT subjects), the main outcome measures were reanalyzed, controlling for age. The ANCOVAs showed the same pattern of results: the CBT group showed a stronger reduction in outpatient doctor visits (F[1, 136]=4.0; p <0.05; {eta}2=0.028) and days of medication intake (F[1, 133]=4.3; p <0.05; {eta}2=0.031), and Somatization Severity improved more than in control subjects (F[1, 113]=5.3; p <0.05; {eta}2=0.045).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The main aims of the present study were to develop and to evaluate a brief cognitive-behavior intervention tailored to the needs of primary care and to improve management of somatization at an early stage.

We therefore defined inclusion criteria rather broadly, with the subjects having at least two distressing medically unexplained symptoms during the past 6 months. Subjects were only excluded if medical conditions or substance effects were present that explained the physical symptoms. Unexpectedly, the subjects who were recruited on the basis of these broad criteria were already highly disabled and suffering from chronic somatoform conditions. Almost 90% of the subjects fulfilled criteria of any somatoform disorder, with a mean of seven lifetime symptoms. Affective disorders were prevalent in almost 60%, and anxiety disorders in 37% of cases.

The overall acceptance of the treatment was high; the total dropout rate of 15% was rather low. The direct assessment of treatment satisfaction indicated that the approach was highly acceptable to subjects (for example, 96% of the subjects would recommend the treatment to a friend with comparable complaints and considered such an intervention worth being offered more often).

A high level of initial healthcare utilization characterized the study patients. The number of outpatient doctor visits was found to be twice as high as the average rate in the German general population.31 Frequent use of healthcare services is a typical feature of somatoform disorders.22,32–34 One main result of this trial was that the number of healthcare visits was reduced more in CBT group subjects than in control-group subjects, who were receiving standard medical care in the same period. Detailed analyses revealed this improvement to be mainly due to reduced GP visits (a reduction of almost 50%). Also, results indicated that subjects in the intervention group reduced their medication intake more than controls. One limitation of the study was that data on healthcare utilization were solely based on patients’ self-report. We used a structured interview with memory cues to avoid underreporting or other recall biases, but future studies should consider the additional use of medical records.

Another positive outcome of the intervention was the reduction of somatization severity, which was found to be stronger in subjects attending the one session of CBT than in control-group subjects. However, in other variables, such as the number of current somatoform symptoms, and in health anxiety, the improvements of the two groups did not differ significantly.

Effect sizes of the main outcome effects ranged from small to medium (for doctor visits: {eta}2=0.031; for somatization severity: {eta}2=0.048). In many other outcome variables, improvements were found for both groups (highly significant Time effects). This might be explained by spontaneous improvements in a subgroup of "transient sufferers" from medically unexplained symptoms. The improvement in the control subjects might also be due to the positive effect of being enrolled in a treatment study, with the expectation of attending the treatment session 6 months later and with three individual diagnostic interviews. Another confounding factor, which might have had an impact on these results, was that the majority of patients were recruited or referred by their physician. Consequently, the physicians might have known about the study intake of some patients. This might have changed their behavior toward the patients and their management of the case, although we did not ask the physicians to change their methods.

The overall Time effects for most of the variables could also be due to regression to the mean, but, given that baseline levels were not significantly different between the treatment and control group, this cannot account for the significantly stronger improvements in the CBT group in variables of doctor visits and somatization severity.

Despite the improvements, subjects were still highly impaired, and their degree of somatization, health anxiety, and depression remained above the levels of healthy populations at the 6-month follow-up. This suggests that one cannot expect a one-session treatment to have tremendous effects. Meanwhile, a few randomized-controlled trials have been conducted to evaluate cognitive-behavior therapies of somatoform disorders and related syndromes.14,35 These CBT interventions ranged from 6 to 16 sessions. Encouraging results have been especially reported for hypochondriasis,15,36–38 whereas the treatment effects for multiple somatoform symptoms (as in our study) were in the modest range.39,40 The effects of a one-session intervention may be smaller than those of the more-intensive CBT approaches. Still, it remains an advantage of such a brief intervention that more subjects suffering from medically unexplained symptoms could be treated. Therefore, it could improve general management of somatization in primary care and could facilitate enrollment into more intense therapies, if necessary.

Alternative approaches in medical settings would be consultation letters to physicians or training of medical care providers to improve management of somatoform conditions. These types of interventions have also been shown to reduce healthcare costs and utilization in somatoform disorders.22,41 The importance of early intervention in somatization and hypochondriasis still needs to be emphasized because the condition becomes more refractory once the patient has developed a stable adaptation to the sick role.32 A brief treatment, such as the one outlined here, could be a first stage in a stepped-care model42 to improve the management of medically unexplained symptoms.


  ACKNOWLEDGMENTS

 
This study was supported by grants from the German Ministry of Research, Education, and Science BMBF (Grant 01 GI 9926).


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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Efficacy of Treatment for Somatoform Disorders: A Review of Randomized Controlled Trials
Psychosom Med, November 1, 2007; 69(9): 881 - 888.
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