Clinical Practice Guideline
Functional Somatic Symptoms
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Background: Approximately 10% of the general population and around one third of adult patients in clinical populations suffer from functional somatic symptoms. These take many forms, are often chronic, impair everyday functioning as well as quality of life, and are cost intensive.
Methods: The guideline group (32 medical and psychological professional societies, two patients’ associations) carried out a systematic survey of the literature and analyzed 3795 original articles and 3345 reviews. The aim was to formulate empirically based recommendations that were practical and user friendly.
Results: Because of the variation in course and symptom severity, three stages of treatment are distinguished. In early contacts, the focus is on basic investigations, reassurance, and advice. For persistent burdensome symptoms, an extended, simultaneous and equitable diagnostic work-up of physical and psychosocial factors is recommended, together with a focus on information and self-help. In the presence of severe and disabling symptoms, multimodal treatment includes further elements such as (body) psychotherapeutic and social medicine measures. Whatever the medical specialty, level of care, or clinical picture, an empathetic professional attitude, reflective communication, information, a cautious, restrained approach to diagnosis, good interdisciplinary cooperation, and above all active interventions for self-efficacy are usually more effective than passive, organ-focused treatments.
Conclusion: The cornerstones of diagnosis and treatment are biopsychosocial explanatory models, communication, self-efficacy, and interdisciplinary mangagement. This enables safe and efficient patient care from the initial presentation onwards, even in cases where the symptoms cannot yet be traced back to specific causes.
The German clinical practice guideline on the management of patients with unspecific, functional, and somatoform physical symptoms (1, 2) expired in March 2017. Between November 2016 and July 2018, the guideline was updated and thoroughly revised by a group under the coordination of the German College of Psychosomatic Medicine (Deutsches Kollegium für Psychosomatische Medizin, DKPM) and the German Society of Psychosomatic Medicine and Medical Psychotherapy (Deutsche Gesellschaft für Psychosomatische Medizin und Ärztliche Psychotherapie, DGPM) and in accordance with the requirements of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft wissenschaftlicher medizinischer Fachgesellschaften, AWMF). Particular attention was paid to user-friendly language and relevance to daily practice. The long version of the guideline and the guideline methods report are available (in German) on the AWMF website (3). The patient guideline is currently undergoing revision.
Characterization of the clinical picture
- Persistent unspecific symptoms that are burdensome enough for the patient to consult a doctor but are not classified as disease (“medically unexplained symptoms” or “persistent physical symptoms”). These can nevertheless discernibly impair the patient’s everyday functioning.
- Defined symptom clusters present over an extended period in the form of functional somatic syndromes (such as fibromyalgia syndrome or irritable bowel syndrome). These are mostly associated with a significant limitation of everyday functioning.
- Conditions that fulfill the criteria of pronounced (multi)somatoform disorders and the newly defined somatic stress disorders. These presuppose considerable impairment of everyday functioning and are also associated with psychobehavioral symptoms.
Functional somatic symptoms as outlined above are to be distinguished from the commonly occurring transitory indispositions that rarely prompt a visit to the doctor and affect everyday functioning only slightly for a limited time, if at all. These are of no medical significance.
Functional somatic symptoms affect a considerable portion (around 10%) of the general population (e1). In the medical context, rates of 20% to 50% are reported for patients visiting primary care physicians and 25% to 66% in particular specialties (e.g., rheumatology, pain medicine, and gynecology) (e2–e5). Functional somatic symptoms are frequently self-limiting (e6, e7). In at least 20%, more likely 50%, of patients who have multiple somatic symptoms and fulfill the criteria of “(multi)somatoform disorder” or “bodily distress syndrome”, the symptoms are enduring (e8–e11). Over the course of time 50% to 75% of patients report improvement, while in 10% to 30% the symptoms worsen (e10–e12). Life expectancy appears not to be affected, apart from an increased prevalence of suicidal behavior (e13–e17): passive death wishes occur in over half of patients with functional disorders (56%), concrete suicidal thoughts in around one third (24% to 34%); 13% to 18% have attempted to commit suicide earlier in life (e13, e14). Comorbidity with mental disorders (principally anxiety and depression), with a rate of around 50%, occurs just as frequently as the overlapping of different functional syndromes (e18–e28). Moreover, persons with functional somatic symptoms may very well show organic findings, e.g., as normal variants, trivial findings, expression of underlying functional organ dysfunctions, or in the presence of (somatic) illness (comorbidity or differential diagnosis) (4–6, e29, e30). Swift, unambiguous classification of symptoms as functional is therefore rarely possible. The prevailing etiological models of functional disorders and bodily distress postulate a multifactorial genesis with interaction of biological, psychological, and sociocultural factors in predisposition, triggering, and maintenance (Figure 1) (4–6). Functional somatic symptoms generate high healthcare costs (e31–e33).
The guideline was revised by the members of a large, representative group of experts from 32 professional medical and psychological societies and two organizations representing the interests of patients (eBox 1). Evidence was derived from an updated systematic literature survey that identified 3795 clinical studies and 3345 systematic reviews, as well as from all relevant source guidelines (eFigure 1, eTable 1). The Table shows the main results of selected reviews on interventions for functional somatic symptoms. A steering group then formulated 109 recommendations, based on the requirements specified by the AWMF and the Center for Quality in Medicine (Ärztliches Zentrum für Qualität in der Medizin) (e37, e38). These recommendations were discussed by the members of the guideline group as a whole in an online Delphi process and at a consensus conference moderated by the AWMF, modified if deemed necessary, and finally adopted. In almost all cases there was a strong consensus for approval. Balancing the great importance of the particularly high degree of interdisciplinary expert consensus for these recommendations against the heterogeneity of the evidence, all recommendations were implemented as “clinical consensus points” (CCP) with the recommendation level “recommended” (e34–e36) (eFigure 2). A more detailed description of the methods can be found in eBox 2.
Diagnosis and treatment of functional somatic symptoms
Because of the great variability in the course and severity of functional somatic symptoms, the recommendations are grouped into three stages of treatment (Figure 2). Recommendations for the initial stages are still valid for later stages in more severe courses, but are then supplemented by further measures (e39). The assessment of severity is based on the present protective factors and risk factors (green/yellow/red flags) (eBox 3, Figure 2) (1, 2, 4–6, e40, e41). Basic care is carried out by the primary care physician or the appropriate somatic specialist, who then coordinates any multimodal treatment that may be required later.
The guidelines recommend from the outset an integrative approach, with the systematic consideration of both, somatic and psychosocial aspects of the symptoms (“as well/as attitude”), and alignment of the boundaries between general and specialist medical care and between organic and psychosocial medicine (4–6, e42–e44). Inappropriate, superfluous, and obsolete drug treatments and invasive interventions are listed in eBox 4.
Initial basic care
The recommendations for “initial basic care” (Figure 2) advise early consideration of the possible presence of functional somatic symptoms by careful questioning and examination of the patient (consensus: strong; evidence level: weak) (e45–e53). Even in this early stage, diagnostic alertness paired with diagnostic restraint together with empathetic communication of information and reassurance enable a broad diagnostic perspective without fixation on a somatic cause, an informed and calmer attitude on the patient’s side in dealing with the symptoms, and higher treatment satisfaction—and exert a positive impact on the course and prognosis by, for example, amelioration of symptoms and reduced consumption of healthcare resources (consensus) (e54).
Patients should be questioned about their principal symptoms and about any other symptoms or problems. Furthermore, they should be asked how they feel about their symptoms, how the symptoms affect their daily life, and what strategies they use to ease or avoid these symptoms (strong consensus) (4–6, 28, 29, e43, e55). A thorough physical examination should be carried out to detect further findings or limitations (consensus) (4–6, 28, 29, e52, e53). During both the initial conversation and the subsequent physical examination, the physician observes the patient’s behavior (e.g., reluctance to perform certain movements, dramatizing symptoms) (strong consensus) (e56, e57). Based on the (preliminary) findings, any further diagnostic testing should be planned in a systematic and reserved manner and communicated with the patient in a reassuring way (strong consensus) (4–6, 28, 29, e58–e60). On the overall basis of the findings and the information gleaned, signs of an avoidable dangerous course (red flags) or risk factors for a chronic course (yellow flags) are assessed (eBox 3).
If no warning signals are detected, the patient should be reassured, but without playing down or negating the symptoms (strong consensus) (4–6, 28, 29, e44, e47, e54, e61–e64). The credibility of the symptoms and the carefulness and reliability of the physician’s assessment are conveyed without necessarily using a “diagnostic label” (strong consensus). Therapeutic interventions in the stage of initial basic care are generally restricted to encouraging patients to modify their behavior in terms of a healthy, physically active lifestyle (strong consensus) (4–7, 28, 29, e65)—ideally activities that they are familiar with and have benefited from in the past. Additionally, a further appointment in 2 to 4 weeks should be offered if required (strong consensus) (e66–e69), while emphasizing that the symptoms will probably resolve, or that there is no need for concern if they should persist (watchful waiting) (strong consensus) (e70).
Extended basic care
Extended basic care begins if a patient presents again because his/her symptoms have persisted or have started to impair quality of life and everyday functioning. It is carried out predominantly by primary care physicians or appropriate somatic specialists and is divided into two phases (Figure 2):
- Simultaneous diagnostic assessment: extension of physical and psychosocial diagnostic investigations simultaneously and with equal weight (which in itself may have a therapeutic effect)
- From explanatory model to coping: integration of all identified issues/problems into an individual explanatory model, from which coping-oriented treatment measures are derived.
In view of the prognostic relevance of reflective management, the extra time required for extended basic care is well invested (e47).
Simultaneous diagnostic assessment
A somewhat less rushed, customized treatment setting can be achieved by reviewing office organization and billing procedures for ways to dedicate more time to patients; a clear schedule with fixed regular appointments in a calm atmosphere irrespective of symptoms, with the potential for delivering measures of “psychosomatic basic care” and other specific training courses; focused management of these patients by the whole treatment team (strong consensus, evidence level: weak) (4–6, 28, 29, e71–e80).
Careful, attentive listening and questioning, also during physical examinations, strengthen the doctor–patient relationship and yield valuable information about the patient’s previous symptoms and treatments (strong consensus) (e44, e66, e81, e82). If deemed appropriate, clinical and physical examinations should be repeated at regular intervals, also to detect warning signals for (new-onset) somatic disease or any harmful consequences of previous (physical) inactivity or incorrect treatment (strong consensus) (4–6, 28, 29, e46). Well-considered diagnostic testing and prescribing, advance discussion of examinations (including the anticipation of normal findings), and normalizing explanation of the findings are central aspects of a systematic, stepped diagnostic work-up free of redundancies. The goal is to rule out the presence of serious conditions and complications and to recognize when medical action is required—but not necessarily to define a clear cause for each symptom (consensus). Repeated testing, particularly invasive techniques, should be avoided if they serve primarily to reassure the patient and/or the physician (strong consensus) (4–6, 28, 29, e83–e85). If a test is unnecessary, the physician should explain clearly why that is the case; necessary investigations should be announced in reassuring fashion, perhaps mentioning the high likelihood of age-appropriate normal findings (strong consensus) (4–6, 28, 29, e86, e87). Any known previous test results and any incidental or trivial findings with no diagnostic or therapeutic relevance should be interpreted using lay terms, in a reassuring, normalizing manner, with the aid of information materials; occasional “summarizing discussions” can help (re-)evaluate all medical results together with the patient (strong consensus) (e88–e90).
Simultaneous diagnostic assessment concludes with an evaluation of the medical significance of the symptoms and the (suspected) diagnosis/diagnoses, and a decision about further treatment needs. This serves to determine whether treatment is required (strong consensus). If no sound diagnosis can be established, using ICD-10 symptom or health care utilization codes should be preferred over assigning stopgap diagnostic codes (strong consensus).
From explanatory model to coping
Supporting the patient in making individual sense of the symptoms (Box 2) plays a central therapeutic role in the context of extended basic care: Even if the the patient’s own attributions seem one-sided or implausible, step by step a comprehensible biopsychosocial explanatory model should be developed that integrates the patient’s subjective assumptions, taking account of individual risk factors as well as context factors (e.g., mental illness). Based on this individual, multifactorial etiological model, therapeutic goals should be developed, consisting of concrete and realistic small-step goals but also establishing superordinate values and motivators (strong consensus) (4–6, e43, e65–e69, e87). To alleviate the patient’s bodily symptoms, selected symptom-oriented passive measures can be recommended, stressing their generally transitory effects and concomitant role: analgesics, psychopharmaceuticals, as well as primarily peripherally acting medication, passive physical and physiotherapeutic interventions, and passive complementary medicine treatments such as acupuncture and phytotherapy (strong consensus, recommended, evidence level: strong) (eTable 1) (4, 10, 12–17, 21, 24, 26, 27, e91–e105). More sustained effects can be achieved through active coping strategies to reinforce self-efficacy and self-help skills. These include (re)initiating social and particularly physical activity (at the patient’s own initiative, from pleasurable exercise to systematic activation programs; also short-term physiotherapy and ergotherapy), (re)exposure in the case of avoidance and protective behavior, self-help literature and possibly self-help groups, as well as taking advantage of offers beyond the healthcare system, e.g., evening classes, where one is not in the patient role (strong consensus, recommended, evidence level: strong) (eTable 2) (4–7, 9, 10, 19, 22, 24, e100, e106–e108).
Multimodal treatment, psychotherapy, and rehabilitation
The third stage of treatment is required for severe cases with considerable impairment of everyday functioning and high healthcare utilization (Figure 2). It involves further forms of treatment, including psychotherapy and rehabilitation, as required and as available as outpatient, inpatient, or day-care treatment (strong consensus, evidence level: strong) (eTable 3) (4–6, 10, 11, e104, e109, e110). To enable the provision of multimodal treatment, an outpatient treatment network should be established, with the treating primary care physician or somatic specialist remaining the principal coordinator (gatekeeper) (strong consensus, recommended, evidence level: strong) (e111, e112). Any referrals that become necessary, e.g., for psychiatric, psychosomatic, or psychotherapeutic treatment, should be prepared with empathy (4–6).
Particularly in the case of major psychosocial stress factors and/or mental comorbidity, relevant dysfunctional disease models, significant functional impairment, or a persistently conflictual therapist–patient relationship, psychotherapy is recommended (consensus). The efficacy of (cognitive) behavioral therapy, psychodynamic psychotherapy, and hypnotherapy is well substantiated in the literature (strong consensus, recommended, evidence level: strong) (eTable 3) (4–6, 8, 18, 23–25, 30, e113, e114). Further therapeutic elements that have proved efficacious in multimodal treatment models include body-oriented and/or mindfulness-based approaches. Psychotherapy and psychiatric treatments go beyond the usual schemes, so that treatment motivation is the first important treatment goal (strong consensus, recommendation, evidence level: strong) (4–6, 30, e115).
- The altered “embodied self,” i.e., all bodily perceptions, feelings, attitudes, and beliefs
- Dysfunctional experience with one’s own illness, role models, (supposed) serious illness in the patient’s environment, traumatic loss, violence, or neglect
- Potential disease-maintaining factors, primary or secondary gain (such as ongoing conflict situations, desire to retire from work, or compensation payments)
- Mental comorbidities (anxiety, depression, trauma sequelae, addiction, personality disorders (e116).
Psychotherapy for functional somatic symptoms and bodily distress should focus primarily on the somatic symptoms, the existing explanatory model, and symptom-related attitudes and behavior patterns (4–6, 30). The treatment focuses on positive self-perception and body awareness, self-regulation techniques, interpersonal relationships, encouragement of creativity, and openness to change (strong consensus, recommendation, evidence level: weak) (4–6, 30, e43, e117). Psychological aspects of symptom formation and maintenance as well as individual vulnerability factors (context, personality, biography) should be addressed only indirectly, or later in the treatment course.
If outpatient treatment is not possible or proves inadequate, multimodal treatment in a suitable day-care or inpatient facility is indicated. If the focus is on improving participation, including maintenance/restoration of ability to work and thus prevention of (further) chronification, one should consider interdisciplinary rehabilitation with sufficient elements of counseling, psychodiagnostics, and psychotherapy, or alternatively psychodynamic treatment (strong consensus, recommendation, evidence level: weak) (4–6, e118, e119).
Functional somatic symptoms are not defined in the same way as diseases with circumscribed organic pathology. Instead, their course is greatly determined by how the symptoms are experienced, coped with, and responded to by physicians. Therefore, many of the recommendations in the updated guidelines relate to the interaction with affected patients, i.e., the comprehension and modification of the individual symptom context and explanatory model. With few exceptions, active therapeutic interventions designed to promote self-efficacy (especially psychoeducation, relaxation and mindfulness, self-help, and physical activation) carry less risk and have more sustained effects than passive, organ-related measures. In severe cases, multimodal treatment and psychotherapy have been shown to be effective. Drug treatment should be reserved for temporary relief of symptoms or management of comorbidity. Much more research is needed into prevention, psychophysiology, and the differential treatment of patients with different manifestations of functional somatic symptoms.
The authors are grateful to the AWMF and to all colleagues, professional societies, and patient organizations (eBox 1) who helped to compile this revised guideline.
Conflict of interest statement
Dr. Roenneberg, MHBA and Dipl-Psych. Sattel declare that no conflict of interest exists.
Prof. Schäfert has received payment from Springer-Verlag and from the journal Psychotherapeut for authorship.
Prof. Hausteiner-Wiehle and Prof. Henningsen have received payments from the publishers Schattauer and Elsevier for writing textbook chapters on the subject of functional somatic symptoms.
Manuscript received on 18 March 2019, revised version accepted on 12 June 2019
Translated from the original German by David Roseveare
Deutsches Ärzteblatt, in common with many other journals, does not subject German clinical practice guidelines to peer review because they have already been intensively assessed and discussed by experts who have broadly agreed on the final wording.
Dr. med. Casper J. Roenneberg, MHBA
Klinik und Poliklinik für Psychosomatische Medizin und Psychotherapie
Klinikum rechts der Isar der Technischen Universität München
Ismaninger Str. 22, 81675 München, Germany
Cite this as:
Roenneberg C, Sattel H, Schaefert R, Henningsen P, Hausteiner-Wiehle C; on behalf of the guideline group “Functional Somatic Symptoms”: Clinical practice guideline: Functional somatic symptoms. Dtsch Arztebl Int 2019; 116: 553–60. DOI: 10.3238/arztebl.2019.0553
For eReferences please refer to:
eBoxes, eFigures, and eTables:
Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich (TUM): Dr. Casper Roenneberg, MHBA; Dipl.-Psych. Heribert Sattel, Prof. Peter Henningsen, Prof. Constanze Hausteiner-Wiehle
Department of Psychosomatics, University and University Hospital, Basel, Switzerland: Prof. Rainer Schaefert
Department of General Internal Medicine and Psychosomatic Medicine, University Hospital Heidelberg: Prof. Rainer Schaefert
Psychosomatic Medicine/Neurocenter, Berufsgenossenschaftliche Unfallklinik Murnau:
Prof. Constanze Hausteiner-Wiehle
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