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Medically Unexplained
Symptoms, Somatisation
and Bodily Distress
Developing Better Clinical Services
Medically Unexplained
Symptoms, Somatisation
and Bodily Distress
Developing Better Clinical Services
Edited by
Francis Creed
Professor of Psychological Medicine, School of Community-Based Medicine, University of Manchester, Manchester, UK

Peter Henningsen
Professor of Psychosomatic Medicine, Technical University Munich, Munich, Germany

Per Fink
Professor of Functional Disorders, Research Clinic for Functional Disorders and Psychosomatics,
Aarhus University Hospital, Aarhus, Denmark
c a mbrid g e un iv e r si t y pres s
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Cambridge University Press
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First published 2011

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Library of Congress Cataloguing in Publication data

Medically unexplained symptoms, somatisation, and bodily distress : developing better clinical
services / [edited by] Francis Creed, Peter Henningsen, Per Fink.
â•… p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-521-76223-6 (hardback)
1.╇ Somatoform disorders.╅ 2.╇ Medicine, Psychosomatic.╅ 3.╇ Neuroses.╅ I.╇ Creed,
Francis.╅ II.╇ Henningsen, Peter, M.D. III. Fink, Per.
[DNLM:╅ 1.╇ Neurotic Disorders.╅ 2.╇ Somatoform Disorders.╅ 3.╇ Psychophysiologic Disorders.
WM 170]
RC552.S66M43 2011
616.85′24–dc22
2011011503

ISBN 978-0-521-76223-6 Hardback

Cambridge University Press has no responsibility for the persistence or

accuracy of URLs for external or third-party internet websites referred to in
this publication, and does not guarantee that any content on such websites is,
or will remain, accurate or appropriate.

Every effort has been made in preparing this book to provide accurate and up-to-date information
which is in accord with accepted standards and practice at the time of publication. Although case
histories are drawn from actual cases, every effort has been made to disguise the identities of the
individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that
the information contained herein is totally free from error, not least because clinical standards are
constantly changing through research and regulation. The authors, editors and publishers therefore
disclaim all liability for direct or consequential damages resulting from the use of material contained
in this book. Readers are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Contents
Prefaceâ•… vi
List of contributorsâ•… vii

1 Epidemiology:€prevalence, causes Peter Henningsen,

and consequencesâ•… 1 Winfried Rief, Andreas Schröder
Francis Creed, Arthur Barsky and Kari and Peter White
Ann Leiknes 9 Trainingâ•… 217
2 Terminology, classification and Per Fink, Kurt Fritzsche, Wolfgang
conceptsâ•… 43 Söllner and Astrid Larisch
Peter Henningsen, Per Fink, Constanze 10 Achieving optimal treatment
Hausteiner-Wiehle and Winfried Rief organisation in different
3 Evidence-based treatment╅ 69 countries:€suggestions for service
Francis Creed, Kurt Kroenke, Peter development applicable across
Henningsen, Alka Gudi and Peter White different healthcare systemsâ•… 236
Francis Creed, Peter Henningsen and
4 Current state of management and Richard Byng
organisation of careâ•… 97
Per Fink, Chris Burton, Jef de Bie,
Wolfgang Söllner and Kurt Fritzsche
5 Barriers to improving Indexâ•… 253
treatmentâ•… 124
Peter Henningsen, Christian Fazekas
and Michael Sharpe
6 Gender, lifespan and cultural
aspectsâ•… 132
Constanze Hausteiner-Wiehle,
Gudrun Schneider, Sing Lee, Athula
Sumathipala and Francis Creed
7 Medically unexplained symptoms in
children and adolescentsâ•… 158
Emma Weisblatt, Peter Hindley and
Charlotte Ulrikka Rask
8 Identification, assessment
and treatment of individual
patientsâ•… 175
Francis Creed, Christina van der
Feltz-Cornelis, Else Guthrie,

v
Preface
It is very common that patients present to their doctor with bodily symptoms, such as head-
aches, fatigue, back, chest and other pains, which cannot be explained by a recognised phys-
ical disease. All medical specialists and GPs see large numbers of such patients and these
symptoms are the fifth most common reason for patients visiting doctors in the USA. Some
doctors and many patients express despair about our lack of knowledge regarding the origin
of these symptoms and how best to treat them.
This book addresses several aspects of this problem. The most important is the continued
suffering endured by patients who have persistent symptoms without appropriate treatment.
Another is the high cost associated with these symptoms because of frequent doctor visits,
expensive investigations and the associated disability, which leads to time missed from work.
They form one of the most expensive categories of healthcare expenditure in Europe. This
book makes the case for shifting some of this expenditure away from numerous investiga-
tions for organic disease and towards effective treatment of bodily distress.
Another problem addressed by this book is that of classification and nomenclature.
Throughout the book the authors make it clear that the problem of numerous bodily symp-
toms is one which encompasses both body and mind. As such, it is served poorly by our
healthcare system which is sharply divided into ‘mental’ and ‘physical’ domains. Since the
traditional labels ‘medically unexplained symptoms’ or ‘somatisation’ are so unhelpful, we
propose the term ‘bodily distress’ as a more useful name for these disorders, which need to
be recognised in their own right if patients are to receive appropriate treatment.
This book is timely because the major diagnostic systems in psychiatry (the American
‘Diagnostic and Statistical Manual’ and the World Health Organisation’s ‘International
Classification of Diseases’) are currently being revised and it is important to present up-to-
date information about diagnosis and nomenclature.
The international authors who have contributed to this book provide a detailed review
of the epidemiology of bodily distress and the current evidence concerning the efficacy of
treatment. On this basis, we make evidence-based recommendations for improving the man-
agement of bodily distress syndromes. This involves helping doctors to acquire the necessary
skills to manage these problems appropriately and enabling them to find adequate time to
do so. We must seek to overcome the negative attitudes towards psychological illnesses in
our society and modify the way that patients, doctors and social agencies approach these
problems. There are a few examples of new service provision and good practice, which we
have highlighted.

vi
Contributors

Arthur Barsky Constanze Hausteiner-Wiehle

Director of Psychiatric Research, Brigham Technical University Munich, Munich,
and Women’s Hospital, Boston, MA, USA Germany
Chris Burton Peter Henningsen
Centre for Population Health Sciences, Technical University Munich, Munich,
University of Edinburgh, Edinburgh, UK Germany
Richard Byng Peter Hindley
University of Plymouth, Plymouth, UK Department of Child Psychiatry,
St George’s Hospital Medical School,
Francis Creed London, UK
School of Community-Based Medicine,
University of Manchester, Manchester, UK Kurt Kroenke
Department of Medicine, Indiana University,
Jef de Bie Indianapolis, IN, USA
Liaison Psychiatrist, Liege, Belgium
Astrid Larisch
Christian Fazekas University of Marburg, Marburg, Germany
Medical Psychology and Psychotherapy
Department, Medical University Graz, Sing Lee
Graz, Austria Hong Kong Mood Disorders Center, Prince
of Wales Hospital, Shatin, Hong Kong
Per Fink
Research Clinic for Functional Disorders Kari Ann Leiknes
and Psychosomatics, Aarhus University Department of Psychiatry, Norwegian
Hospital, Aarhus, Denmark Knowledge Centre for the Health Services,
Oslo, Norway
Kurt Fritzsche
Department of Psychosomatic Medicine Charlotte Ulrikka Rask
and Psychotherapy, University Medical Aarhus University Hospital, Aarhus,
Center Freiburg, Freiburg, Germany Denmark
Alka Gudi Winfried Rief
Newham Centre for Mental Health, University of Marburg, Marburg,
East London NHS Foundation Trust, Germany
London, UK
Gudrun Schneider
Else Guthrie Department of Psychosomatics and
School of Community-Based Medicine, Psychotherapy, University Hospital
University of Manchester, Manchester, UK Münster, Münster, Germany

vii
viii List of contributors

Andreas Schröder Christina van der Feltz

Aarhus University Hospital, Aarhus, Netherlands Institute of Mental Health,
Denmark Utrecht, The Netherlands
Michael Sharpe Emma Weisblatt
Psychological Medicine Research, Laboratory for Research into Autism;
Royal Edinburgh Hospital, Edinburgh, UK Department of Experimental Psychology,
University of Cambridge, Cambridge, UK
Wolfgang Söllner
Department of Psychosomatic Medicine Peter White
and Psychotherapy, General Hospital Centre for Psychiatry, Wolfson Institute
Nuremberg, Nuremberg, Germany of Preventative Medicine, Queen Mary
University of London, St Bartholomew’s
Athula Sumathipala Hospital, London, UK
Institute of Psychiatry,
King’s College London, London, UK and
Institute for Research and Development,
Colombo, Sri Lanka
 Chapter Epidemiology:€prevalence, causes

1
and consequences
Francis Creed, Arthur Barsky and Kari Ann Leiknes

Introduction
The epidemiology of medically unexplained symptoms will be considered under the follow-
ing headings:€prevalence, causes and consequences. For the first and last of these headings
the data will be considered in three categories:€medically unexplained symptoms, somato-
form disorders and functional somatic syndromes (see Chapter 2). These ‘diagnostic’ labels
describe different groups of patients but they also overlap considerably. The term ‘medic-
ally unexplained symptoms’ is a broad one; somatoform disorders and functional somatic
syndromes are subgroups within it. These subgroups are represented diagrammatically in
Figure 1.1 and are described below.

Prevalence
For each of the three groups, medically unexplained symptoms, somatoform disorders and
functional somatic syndromes, the nature of the group will be described briefly and then the
prevalence of these will be described in cross-sectional studies in primary, secondary care
and population-based studies. Then each section will include data from longitudinal studies
that show the outcome of medically unexplained symptoms.

Medically unexplained symptoms

The term ‘medically unexplained symptoms’ has been used widely and there is a consider-
able amount of data concerning the prevalence and outcome of these symptoms. The find-
ings from secondary care will be considered first as this is where the concept was developed.
It arose because many patients attending secondary care clinics had symptoms that, after
appropriate (and sometimes very extensive) investigation, could not be explained by organic
pathology or well-recognised physiological dysfunction [1;11]. In this way the term ‘medi-
cally unexplained symptoms’ describes a group of patients by what they do not have. The
next section examines how often this occurs.

Prevalence of medically unexplained symptoms in secondary care

Secondary care studies in the Netherlands, UK and Germany have shown that medically
unexplained symptoms are the presenting problem for 35–53% of new outpatients at spe-
cialist medical clinics (Table 1.1). The most common symptoms are:€headache; back, joint,
abdominal, chest and limb pains; fatigue; dizziness; bloating; palpitations; hot or cold sweats;

Medically Unexplained Symptoms, Somatisation and Bodily Distress, ed. Francis Creed, Peter Henningsen
and Per Fink. Published by Cambridge University Press. © Cambridge University Press 2011.
1
2 Chapter 1:€Epidemiology:€prevalence, causes, consequences

Figure 1.1╇ Diagram to show how the term ‘medically

unexplained symptoms’ embraces a wide group of
patients, and that somatoform disorders and functional
somatic syndromes are smaller subgroups within the
Functional
somatic
wider group.
syndromes

Somatoform
disorders

Medically
unexplained
symptoms

Table 1.1╇ Proportion of patients attending secondary care clinics whose presenting complaint is diagnosed as
‘medically unexplained’

Per cent diagnosed

Number of with ‘medically
patients included unexplained
Study Type of clinic in the study symptoms’
Van Hemert et al., 1993 [2] General medical 191 52
Hamilton et al., 1996 [3] Gastroenterology, 324 35
neurology and
cardiology
Nimnuan et al., 2001 [4] Seven different 550 52
specialties
Fiddler et al., 2004 [5] Gastroenterology, 295 39
neurology and
cardiology
Kooiman et al., 2004 [6] General medical 321 53
Targosz et al., 2001 [7] Neurology 57 30
Carson et al., 2000 [8] Neurology 300 30
Stone et al., 2009 [9] Neurology 3781 30
Mangwana et al., 2009 [10] General medical 200 50

nausea; trembling or shaking; and numbness or tingling sensations [11;12] In seven clinics
in one UK hospital, the proportion of patients with medically unexplained symptoms varied
between 24% in the chest clinic to 64% in the neurology clinic (mean 52%) [4].
The high prevalence of medically unexplained symptoms in neurology clinics has
led to numerous studies and a summary of data from seven neurology clinics showed
prevalence rates between 26% and 45% (median 30%) [9]. In the largest survey, the
most common categories of diagnosis were:€(i) headache disorders (26%); (ii) an organic
 Chapter 1:€Epidemiology:€prevalence, causes, consequences 3

Table 1.2╇ Proportion of patients attending primary care whose presenting complaint is diagnosed as
‘medically unexplained’

Per cent diagnosed

with ‘medically
Number of unexplained
Clinics patients symptoms’
Mumford et al., 1991 Primary care patients 554 7–12.6
[14] consulting with illness (i.e.
excluding ‘routine’ visits
Peveler et al., 1997 Booked consultations 170 19
[15]
Kirmayer and Primary care attenders 685 23.6
Robbins, 1991 [16]
Palsson, 1988 [17] Sweden 16
Kisely et al., 1997 [18] Weighted sample of 5447 15.4
primary care attenders Had 5+ medically
unexplained
symptoms
Duddu et al., 2008 119 119 33
[19]

neurological disease was present but the presenting symptoms were not explained by it
(26%); and (iii) conversion symptoms (motor, sensory or non-epileptic attacks) (18%)
[13]. The second category is important as it indicates that medically unexplained symp-
toms commonly occur in people who have physical illness but the presenting symptoms
cannot be explained by that physical illness. Examples include non-epileptic attacks,
which occur in people who also have epilepsy, and non-cardiac chest pain in people with
heart disease.

Prevalence of medically unexplained symptoms in primary care

In primary care, the general practitioner (GP) will usually make a clinical judgement that
a symptom is not explained by organic disease, without necessarily using special investiga-
tions. Such symptoms generally form between 10% and 33% of presenting complaints in pri-
mary care (Table 1.2). A systematic review concluded that medically unexplained symptoms
constitute the primary reason for consulting the GP in 15–19% of patients [20].
The proportion of all patients whose symptoms are classified as ‘medically unex-
plained’ varies greatly between GPs and this variation cannot be attributed to variation
in the GPs’ patient populations; instead it reflects GPs’ tendency to use this categorisation
[21]. There is, however, a relevant diagnostic category in the International Classification
of Diseases (ICD), under which many of these patients may be classified:€‘Signs, symptom
and ill-defined conditions’ (ICD code 780–789). In the UK, this accounts for the one of
the largest diagnostic categories of hospital outpatients and the fourth largest category in
primary care. In USA, it is the fifth most frequent reason for visiting a doctor (60 million
per annum)€– see Table€1.3 [22].
4 Chapter 1:€Epidemiology:€prevalence, causes, consequences

Table 1.3╇ Number of visits to the doctor in USA by diagnostic group (2005) [22]

Diseases of Million visits per annum Per cent of total

Respiratory system 110 11.5
Nervous system 86 8.9
Circulatory system 81 8.5
Musculoskeletal 80 8.4
Symptoms, signs; ill-defined 60 6.3
conditions
Endocrine, nutritional and 56 5.9
metabolic
Mental disorders 47 4.9

Prevalence of medically unexplained symptoms in population-based studies

Surveys in the general population show that pain is the most common medically unexplained
symptom€– headache and back, joint, abdominal and limb pain being the most common;
fatigue, dizziness, bloating, food intolerance and sexual difficulties are also common [23;24].
These symptoms are reported by over a fifth of the population but only a small proportion
report that they are severe [24].

Outcome of medically unexplained symptoms

Prospective studies are concerned usually with one of two outcomes:€Does an organic dis-
ease come to light that explains the symptom(s)? Do the symptoms persist over time?
With regard to the first question, follow-up studies have been performed to assess whether
medically unexplained symptoms turn out to have a medical cause after a period of time. In
fact, this rarely occurs even though it is uppermost in some doctors’ minds and contributes
to their decision to perform repeated investigations. In a German one-year follow-up study,
five out of 284 patients classified as having medically unexplained physical symptoms later
turned out to have a physical illness that could explain their symptoms [6]. In the largest
neurology survey, only four out of 1030 patients (0.4%) had acquired an organic disease
diagnosis that was unexpected at initial assessment and could plausibly be the cause of the
patient’s original symptoms [9].
With regard to the second question, population-based studies suggest that most medically
unexplained symptoms wane over time; fewer than half persist over one year [24;25;26;27]
and two-thirds recede over a longer period [28]. The long Norwegian study reported that
painful medically unexplained symptoms may persistent over many years in approximately
8% of the general population, mostly women [28].
Although up to a fifth of new symptoms presented to GPs are medically unexplained
[15;29], only 10% of these (i.e. 2.5% of all patients attending the GP) had persistent symp-
toms that led to repeated consultation€– the rest consulted for a single episode only [30].
In secondary care clinics symptoms tend to be more severe and persistent than those seen
in primary care. Over a one-year follow-up period, approximately two-thirds of patients
report improvement in medically unexplained symptoms but about 40% report some con-
tinued symptoms causing ill health [6;31]. The proportion may be higher in neurology
�clinics [9].
 Chapter 1:€Epidemiology:€prevalence, causes, consequences 5

Therefore, we can conclude that medically unexplained symptoms are very common
both in the general population and in primary and secondary care, but at least in the first
two settings most are transient. These may not require medical intervention other than reas-
surance about their frequency in healthy people and a check that they do not indicate physi-
cal disease. In secondary care the symptoms tend to be more persistent and may have more
severe consequences (see below). In both primary and secondary care, doctors need to use
appropriate strategies in managing patients with these symptoms. The rest of this section is
concerned with medically unexplained symptoms that persist over six months or more.

Somatoform disorders
This term includes several disorders where a high number of medically unexplained symp-
toms is the main feature. It is a diagnostic category in both the Diagnostic and Statistical
Manual of Mental Disorders (DSM)-IV and ICD-10 classification systems [32;33], where it
also includes several other diagnoses (see below). This book is concerned with the first two
main categories (a and b below) but there have been several modifications, two of which
(c and d) are also included here. In this chapter we used ‘somatoform disorder’ as an umbrella
term to include the following disorders:
(a) ‘somatisation disorder’, defined by numerous bodily symptoms that are disabling and/
or lead to medical help-seeking [32]; there are slight differences in the way the two
diagnostic systems define this disorder but both require multiple somatic symptoms
spread throughout the body (Table 1.4)
(b) ‘undifferentiated somatoform disorder’, which requires presence of one or more
unexplained physical symptoms causing clinically significant distress or impairment for
six months [32]
(c) ‘abridged somatisation disorder’, which is defined by the somatoform symptom index
(SSI) either as four medically unexplained symptoms in men and six in women (SSI-
4/6) or by three medically unexplained in men and five in women (SSI-3/5) [34;35]
(d) ‘multisomatoform disorder’, which requires presence of three current medically
unexplained symptoms, one of which must have been present for two years [36].
This large number of diagnoses reflects the fact that ‘somatisation disorder’ as originally
defined, had a very high number of medically unexplained symptoms, which meant that
this disorder was very rare in population-based studies [37]. The other diagnoses have been
developed as they have a lower threshold and are more relevant in primary care and popula-
tion settings.
The remaining major group of disorders concerns high health anxiety (hypochondria-
sis), which also has rather a high threshold. Persistent disease conviction (the worry that one
has a serious illness) occurs in approximately 6.5% of the population but the additional cri-
teria of seeking medical help and refusal to accept appropriate medical reassurance reduces
the prevalence of the diagnosis in population-based samples to less than 1% [37;38;39].
The diagnostic category ‘somatoform disorders’ includes also the diagnoses of pain
disorder (pain not fully explained by organic disease and associated with psychological
factors) and conversion disorder, which refers to sensory or motor symptoms for which
no medical explanation can be found, but which are disabling and lead to medical help-
seeking [32;33]. Pain disorder is not considered separately from the somatoform disorders
as the epidemiology is similar; many people have multiple pains [40]. Conversion disorder
6 Chapter 1:€Epidemiology:€prevalence, causes, consequences

Table 1.4╇ Selected somatoform disorders in DSM-IV and ICD-10 [32; 33]

DSM-IV ICD-10 F45

Somatisation disorder: 300.81 Somatisation disorder: F45.0
–╇a history of many – at least two-year history of medically
medically unexplained unexplained symptoms
symptoms before age 30
–╇resulting in treatment sought – resulting in repeated (three or more)
or psychosocial impairment primary care or specialist consultations
–╇a total of eight or more – a total of six or more medically
medically unexplained unexplained symptoms, from at
symptoms from across least two separate organ groups
the four groups: (gastrointestinal, cardiovascular,
• at least four pain genitourinary, skin and pain)
• two gastrointestinal
• one sexual
• one pseudoneurological
Undifferentiated 300.81 Undifferentiated somatoform disorder F45.1
somatoform disorder
Hypochondriasis 300.7 Hypochondriacal disorders F45.2
Pain disorder associated 307.80 Persistent somatoform pain disorder F45.4
with psychological factors
Somatoform autonomic dysfunction F45.3
Body dysmorphic disorder 300.7 Hypochondriacal€– dysmorphophobia F45.2
Neurasthenia F48.1

is not considered in detail in this book as it is rare in clinical practice and has not been stud-
ied widely [41;42]. Body dysmorphic disorder is a condition characterised by a distressing
and disabling preoccupation with an imagined or slight defect in appearance [43;44;45]. It
differs considerably from the very common disorders which are the main concern of this
book.
ICD-10 includes neurasthenia (chronic fatigue), as one of the somatoform disorders.
This is considered here as chronic fatigue syndrome under the heading of functional som-
atic �syndromes. ICD-10 also includes somatoform autonomic dysfunction, which refers to
symptoms of autonomic arousal with preoccupation and distress relating to a particular
organ [33].

Prevalence of somatoform disorders in primary and secondary care

The prevalence of somatoform disorders in primary care studies is shown in Table 1.5. The
third column of Table 1.5 shows the prevalence of somatoform disorders as a whole, i.e.
somatisation disorder, undifferentiated somatoform disorder, somatoform disorder, not
otherwise specified, pain disorder, hypochondriasis, conversion and abridged somatisa-
tion (SSI-4/6) and multisomatoform disorder. It can be seen in the last column that the