The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review

doi:10.1016/j.cpr.2007.07.002

Clinical Psychology Review

Volume 27, Issue 7, October 2007, Pages 781-797

https://doi.org/10.1016/j.cpr.2007.07.002 Get rights and content

Abstract

The article is a narrative review of the theoretical standing and empirical evidence for the cognitive behavioural model of medically unexplained symptoms (MUS) in general and for chronic fatigue syndrome (CFS) and irritable bowel syndrome (IBS) in particular. A literature search of Medline and Psychinfo from 1966 to the present day was conducted using MUS and related terms as search terms. All relevant articles were reviewed. The search was then limited in stages, by cognitive behavioural therapy (CBT), condition, treatment and type of trial. Evidence was found for genetic, neurological, psychophysiological, immunological, personality, attentional, attributional, affective, behavioural, social and inter-personal factors in the onset and maintenance of MUS. The evidence for the contribution of individual factors, and their autopoietic interaction in MUS (as hypothesised by the cognitive behavioural model) is examined. The evidence from the treatment trials of cognitive behavioural therapy for MUS, CFS and IBS is reviewed as an experimental test of the cognitive behavioural models. We conclude that a broadly conceptualized cognitive behavioural model of MUS suggests a novel and plausible mechanism of symptom generation and has heuristic value. We offer suggestions for further research.

Section snippets

Introduction: defining terms

“The term medically unexplained symptoms names a predicament, not a specific disorder” wrote Kirmayer, Groleau, Looper, and Dao (2004). In the papers we have reviewed it is used in three overlapping ways: (a) to refer to the occurrence of symptoms in the absence of obvious pathology; (b) to refer to individual clinical syndromes such as chronic fatigue syndrome (CFS) and irritable bowel syndrome (IBS); (c) to refer to a subset of the DSM-IV somatoform disorders category. Whilst classification

The model

Historically, the classical CBT model of emotional distress as proposed by Beck distinguished between its developmental predispositions and precipitants, and its perpetuating cognitive, behavioural, affective and physiological factors (Beck, 1976). The CBT model of MUS retains this general structure and its “three Ps”: predisposing, precipitating and perpetuating factors (see for instance Sharpe, 1995; Suraway et al., 1995, Richardson and Engel, 2004, Hutton, 2005). Treatment tends to initially

Genetics and early experience

This is one of the least researched parts of the model. There is some evidence for a genetic influence in the development of both unexplained fatigue and somatisation (Kendler et al., 1995, Farmer et al., 1999, Hickie et al., 1999); however this could simply reflect the expression of an inheritable predisposition to general distress (see Section 3.1.2 below). There is also some evidence that certain types of early childhood environment increase the risk of developing MUS. Hotopf (2003) reported

The coherence of the model

We have reviewed some of the cognitive, behavioural and physiological factors that are thought to contribute to the onset and perpetuation of MUS. Overall, the evidence reflects a welcome move from purely “psychological” models to a more complex multifactorial approach. There is certainly evidence that factors in each domain are associated with MUS. However, the key feature of CBT model is that these individual components become locked into an autopoietic cycle. It is intuitively obvious how

Treatment studies

The proof of the CBT pudding must, at least in part, be in the treating. Treatment relies on the model to identify the elements maintaining the autopoietic cycles, and to identify what factors made the individual vulnerable in the first place. This is the explicit purpose of the CBT assessment: to form a coherent multi-factorial case conceptualisation that forms the rationale for treatment (see Deary & Chalder, 2006). In CFS inconsistent and reduced activity, disturbed sleep and catastrophic

Summary, conclusions and recommendations

There is fairly good evidence for the role of the elements of the CBT model in MUS, but less evidence for the patterns of interaction of these elements. There is general evidence that targeting maintaining factors leads to symptom reduction, but only limited evidence for what the key factors or interventions might be. The more vaguely conceptualised and diffuse conditions of general MUS and CFS provide clearer empirical support for CBT treatment than the more coherently conceptualised condition

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The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review

Abstract

Section snippets

Introduction: defining terms

The model

Genetics and early experience

The coherence of the model

Treatment studies

Summary, conclusions and recommendations

Journal of Psychosomatic Research

Psychoneuroendocrinology

Journal of Psychosomatic Research

Trends in Endocrinology and Metabolism

Psychoneuroendocrinology

Journal of Psychosomatic Research

Personality and Individual Differences

Journal of Psychosomatic Research

Personality and Individual Differences

Journal of Psychosomatic Research

General Hospital Psychiatry

Psychosomatics

Journal of Psychosomatic Research

Psychoneuroendocrinology

Psychoneuroendocrinology

Journal of Psychosomatic Research

Journal of Psychosomatic Research

Journal of Psychosomatic Research

Journal of Psychosomatic Research

Social Science & Medicine

Journal of Psychosomatic Research

Journal of Psychosomatic Research

Journal of Psychosomatic Research

Psychoneuroendocrinology

Journal of Psychosomatic Research

Psychoneuroendocrinology

Psychosocial treatments for multiple unexplained physical symptoms: a review of the literature

Psychosomatic Medicine

Using personality variables to predict cancer and heart disease

European Journal of Personality

Imaging how attention modulates pain in human beings using functional MRI

Brain

Functional somatic symptoms

Annals of Internal Medicine

The amplification of somatic symptoms

Psychosomatic Medicine

Cognitive therapy and the emotional disorders

Predictors of response to treatment for chronic fatigue syndrome

British Journal of Psychiatry

A critical review of cognitive, behavioral, and cognitive-behavioral therapies for irritable bowel syndrome

Journal of Cognitive Psychotherapy

Personality and problems in everyday life: the role of neuroticism in exposure and reactivity to daily stressors

Journal of Personality

Psychological mechanisms of medically unexplained symptoms: an integrative conceptual model

Psychological Bulletin

Beyond attentional strategies: a cognitive-perceptual model of somatic interpretation

Psychological Bulletin

The role of deconditioning and therapeutic exercise in chronic fatigue syndrome (CFS)

Journal of Mental Health

A systematic method for clinical description and classification of personality variants. A proposal

Archives of General Psychiatry

Neuroticism, somatic complaints, and disease: is the bark worse than the bite?

Journal of Personality

Life events and psychological disturbance in patients with low-back pain

Spin

Functional abdominal pain, psychiatric illness, and life events

Gut

Chronic Fatigue Syndrome: a case conceptualization approach

Temperament and attention: orientating toward and away from positive and negative threat signals

Journal of Personality and Social Psychology

Normalisation of unexplained symptoms by general practitioners: a functional typology

British Journal of General Practice

Exercise therapy for chronic fatigue syndrome (Cochrane Review)

Is disabling fatigue in childhood influenced by genes

Psychological Medicine

How the body shapes the mind