Review

Management of functional somatic syndromes

Peter Henningsen, Stephan Zipfel, Wolfgang Herzog

Lancet 2007; 369: 94655 Although functional somatic syndromes (FSS) show substantial overlap, treatment research is mostly conned to
Published Online single syndromes, with a lack of valid and generally accepted diagnostic criteria across medical specialties. Here, we
February 6, 2007 review management for the full variety of FSS, drawn from systematic reviews and meta-analyses since 2001, and give
DOI:10.1016/S0140-
6736(07)60159-7
recommendations for a stepped care approach that dierentiates between uncomplicated and complicated FSS.
Non-pharmacological treatments involving active participation of patients, such as exercise and psychotherapy, seem
Department of Psychosomatic
Medicine and Psychotherapy, to be more eective than those that involve passive physical measures, including injections and operations.
University Hospital, Technical Pharmacological agents with CNS action seem to be more consistently eective than drugs aiming at restoration of
University of Munich, peripheral physiological dysfunction. A balance between biomedical, organ-oriented, and cognitive interpersonal
Langerstrasse 3,
approaches is most appropriate at this truly psychosomatic interface. In view of the iatrogenic component in the
81675 Munich, Germany
(P Henningsen MD); maintenance of FSS, doctor-centred interventions and close observation of the doctorpatient relationship are of
Department of Psychosomatic particular importance.
Medicine and Psychotherapy,
University Hospital, University
of Tuebingen, Germany
Introduction sensation); and complaints centring around fatigue and
(S Zipfel MD); and Department Functional somatic syndromes (FSS) are common exhaustion. The name of single FSS typically signies
of Psychosomatic and General worldwide and in practically all areas of medicine. FSS are the current lead symptoms, but denitions usually
Clinical Medicine, University a burden for suerers, they are also often dicult to treat include other bodily complaints as well, and some FSS
Hospital, University of
Heidelberg, Germany
for doctors and costly for society.13 Diagnostic and are named not according to the lead symptoms, but
(W Herzog MD) therapeutic approaches to FSS vary substantially across according to the implied cause.
Correspondence to: and within medical specialties, from biomedicine to There is no objective criterion to decide whether a
Prof Peter Henningsen psychology. In this review, we try to improve the under- pattern of bodily complaints should be seen as a functional
p.henningsen@tum.de standing of common factors across single FSS and hence somatic syndrome or as indicator of a medically explained
of common therapeutic strategies across medical disease or as something else, and lists drawn up by
specialities. We give an overview of current concepts under- dierent authors reect their particular backgrounds and
lying the management of FSS, of results of appropriate views. For instance, some reviewers concentrate more on
therapeutic trials in single syndromes and diagnostic FSS that are disputed, such as multiple chemical
analogues, and of practical steps for management. sensitivity,2 others emphasise those that are common and
undisputed in dierent branches of somatic medicine,
Denition, overlap, terminology, and such as chronic pelvic pain, and some also include single
classication symptoms, such as dizziness or tinnitus. Three syndromes
FSS are characterised by patterns of persistent bodily are mentioned more regularly than others: irritable bowel
complaints for which adequate examination does not syndrome, chronic fatigue syndrome, and bromyalgia,
reveal suciently explanatory structural or other specied probably because of the existence of well dened and
pathology. We dierentiate three main types of bodily popular research diagnostic criteria. The list of FSS
complaints in FSS: pain of dierent location (back, head, (table 1) is subject to change, as some fall out of use2 and
muscles or joints, abdomen, chest, etc); functional new syndromes are proposed almost every year.7,8
disturbance in dierent organ systems (eg, palpitation, Functional disturbances of voluntary movement and of
dizziness, constipation or diarrhoea, movement, sensation, so-called pseudoneurological symptoms, and
chronic low-back pain share the essential clinical features
of FSS and should be counted with them.4,9
Search strategy and selection criteria The delineation of FSS from disease with clear
We searched the Cochrane Library, MEDLINE , and PSYCINFO from 2001. We used a string structural pathology is problematic in clinical assessments
of search terms previously applied in a meta-analysis on FSS and diagnostic analogues and in research with structured diagnostic interviews.
and adapted it to the terms of FSS that are indicated in table 1. We included commonly However, an increasing number of bodily complaints is a
referenced and highly regarded publications from before 2001. We also searched the strong indicator of a non-organic nature,10 and for
reference lists of articles identied by this search strategy and selected those we judged assessment of the whole pattern of bodily complaints, a
relevant. For the section on therapeutic evidence we restrict presentation of search results systematic chart review achieves very good reliability
to systematic reviews and meta-analyses published since 2001. Reviews had to dene a between raters for the distinction of documented
comprehensive search strategy and quality evaluation of primary studies and present structural organic disease, documented non-organic
results in a systematic way. Whereas some of these reviews cover all aspects of treatment disease, and minor acute illness.11
of single FSS, others concentrate on particular treatment components for single FSS or Prevalence of some FSS like irritable bowel syndrome
across dierent types of medically unexplained symptoms. We did not include systematic reaches up to 15%,12 but reliable prevalence rates are
reviews on particular treatments not focused on FSS or diagnostic analogues. dependent on established research diagnostic criteria,
which exist for only a few FSS. Small variations in the

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criteria can produce wide variations in prevalence rates,

Number of reviews
for example, whereas the prevalence for chronic fatigue
syndrome in the population has been estimated to be Irritable bowel syndrome (IBS) 5

02%, it is 9% for chronic unexplained fatigue.13 For Chronic fatigue syndrome (CFS) 5

some syndromes, the published prevalence rates are also Fibromyalgia (FMS) 5
inuenced by the special interests of supporters of the Multiple chemical sensitivity 4
respective concept of FSS.14 Nonspecic chest pain 4
Premenstrual syndrome 3
Overlap of single FSS Non-ulcer dyspepsia 3
Many clinicians and researchers who focus on one specic Repetitive strain injury 3
FSS have the impression that it occurs in isolated form. Tension headache 3
Conceptually, however, the bodily symptoms used as Temporomandibular joint disorder 3
diagnostic criteria (ie, abdominal pain or fatigue) are not Atypical facial pain 3
specic but overlap for many FSS. Many patients full Hyperventilation syndrome 2
criteria for more than one syndrome. The extent of this Globus syndrome 2
empirical overlap between single FSS is from around 10% Sick building syndrome 2
in the general population to over 50% in clinic Chronic pelvic pain 2
populations.1,1518 Furthermore, multiple studies have Chronic whiplash syndrome 2
shown high self-reported scores of other unexplained Chronic lyme disease 2
bodily symptoms in dierent FSS, including pseudo- Silicone breast implant eects 2
neurological symptoms19 and chronic low-back pain.20 Candidiosis hypersensitivity 2
Common characteristics of FSS, in addition to the pattern Food allergy 2
of bodily complaints, are female preponderance18 and Gulf War syndrome 2
signicant overlap with anxiety and depression, which is Mitral valve prolapse 2
higher in FSS than in comparable, organically explained Hypoglycaemia 2
diseases (ie, irritable bowel syndrom vs inammatory Chronic low back pain 2
bowel disease or bromyalgia vs rheumatoid arthritis); Dizziness 2
however, many cases of FSS also occur without anxiety or Interstitial cystitits 1
depression. This association therefore neither can be seen Tinnitus 1
as an unspecic psychological reaction to the presence of Pseudoseizures 1
bodily complaints nor as masked or somatised depression
Insomnia 1
or anxiety alone.21 Further common features of FSS are the
substantial eect on quality of life, which is commonly as Table 1: Number of reviews in which individual FSS are mentioned1,2,46
large as in comparable diseases of clear organic origin,10,22
and the response to interventions that primarily inuence encourage a narrow or splitting view by the respective
the function of the CNS by behavioural, psychotherapeutic, specialist on the current main bodily symptom and
or psychopharmacological means. symptomatic treatment only; in addition, most of them
Taken together, the balancing of research and therapeutic give no indication of symptom severity. In parallel, there
practice between a splitting and a lumping view of FSS is is the possibility to classify organically unexplained bodily
a clinical and conceptual challenge,23,24 and this is related symptoms as mental disorders: in chapter V of ICD 10,
to the ongoing debate whether FSS should be classied as and in the Diagnostic and Statistical Manual, they are
a physical or mental disorder, or whether a truly psycho- classied as somatoform disorders, with somatisation
somatic third-way is possible. disorder as the rare, most serious prototype used for
patients with multiple symptoms over time. This type of
Terminology and classication classication encourages a lumping perspective (ie, to
Currently, no term or classication is fully satisfactory look at the whole pattern of current and previous bodily
when dealing with the clinical phenomenon of patients symptoms and also at psychological and behavioural
reporting persistent bodily complaints for which no clear characteristics of the patient). However, this perspective
organic reason can be found. The term medically historically implied a psychogenic origin of FSS that is
unexplained symptoms is not adequate because of the not only problematic from a scientic point of view, but
diculties in dening insucient explanation and also also oensive for patients who want to avoid being seen
because it implies that explanations that involve as mentally ill.
psychosocial or cultural factors are not part of medicine. Debates about future editions of the classications for
Many of the terms used for single FSS are classied in the mental disorders range from the contested suggestion to
dierent medical sections of International Classication of abolish the category somatoform disorders altogether to
Diseases 10th Revision (ICD 10). They generally have good the suggestion to introduce a category of general-
acceptance by patients and medical specialists, but they medicinepsychiatry interface disorders.2528 From a

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Precipitating factors for the development of FSS can be

Organic Dysfunctional Dysfunctional organic illness,36,37 accidents,38 stressful life events,18,39 and
disease peripheral early and current wider psychosocial mechanisms, such as media coverage
stimuli relationships
of potentially pathogenic environmental health hazards
or mass hysteria.40
Apart from organic comorbidity, maintaining factors
have mainly been described on the psychosocial level,
Experience of Experience of
bodily stress anxiety and
such as personality factors that contribute to pre-
depression disposition, mental comorbidity, a persisting organic
illness attribution, and context factors surrounding so-
called secondary gain. However, the behaviour of treating
Interpretation as Body image, physicians also contributes to maintenance and exacer-
symptoms of a illness representations,
disease and cultural beliefs bations of FSS.41 For example, qualitative research in
primary care showed that patients with so-called un-
explained symptoms often voice psychosocial clues that
Seeking medical are not taken up by their doctors; instead, doctors and
help not patients themselves somatiseie, commonly initiate
further diagnostic testing despite the assumption that
the complaint is not explained by structural disease.42,43
Experience of Interpretation as Sociocultural factors clearly aect symptom perception
chronic bodily severe disease or and reporting, and knowledge of explanatory models of
symptoms as imagined illness
bodily distress for patients from dierent cultural
backgrounds is useful in the establishment of a stable
Maintaining Emotional distress doctorpatient relationship.44 Cultural dierences also
interpersonal or loss of directly aect prevalence of FSS. For instance, German
and organic factors self-esteem
citizens reported up to twice the frequency of back pain
compared with those in the UK, and the dierence is not
attributable to dierent risk-factor proles.45
Loss of
functioning
The model of causation for FSS suggests that the
central clinical phenomena, such as experience of chronic
bodily symptoms and loss of functioning, are inuenced
Figure: Hypothetical model for the cause of FSS by multiple, but speciable biological, psychological,
Pink=core symptoms of FSS. Grey=accompanying symptoms. Purple=psychological and sociocultural factors. interpersonal, and social factors (gure).
Green=behavioural and interpersonal factors. Blue=organic factors.
Views on pathophysiological changes in FSS reect the
dierent foci for treatment, with the debates centring
treatment perspective, the latter suggestion might be a around two dichotomies: peripheral changes (eg, immuno-
good way to increase awareness for the necessity to use a logical, endocrine, muscular, cardiac, and intestinal)
lumping perspective in many patients with FSS without versus CNS changes and changes specic for one FSS
resorting to the idea of a purely mental or psychogenic versus general changes for all FSS.24,46,47 In addition,
disorder. whether pathophysiological changes are causally relevant
or, for instance, a consequence of behavioural changes
Aetiology and pathophysiology due to FSS is unclear.48 There is currently a general
Management of FSS must be informed by knowledge tendency to view central dysfunctions, and in particular a
about the diversity of predisposing, precipitating, and propensity for sensitisation of certain parts of the CNS
maintaining factors for FSS. In terms of predisposing (ie, an increasingly enhanced reaction to actual or
factors, no clear pattern of genetic inuences has been anticipated peripheral stimuli), as particularly important
identied, and the heritability of FSS seems to be in the maintenance of FSS.49,50
small.29,30 Childhood adversities are not restricted to
sexual or physical abuse.31 Childhood experience of Balanced approaches to FSS
organically unexplained symptoms, parental ill health, There is not one single focus in the management of FSS,
and increased parental illness behaviour for bodily and this ambiguity has to be seen as a characteristic feature
symptoms in the child increase the risk of FSS later in of these syndromes (panel 1). Some patients (eg, those
life.32 Personality factors, such as cognitive styles and with uncomplicated irritable bowel syndrome) will benet
attachment patterns, might aect the maladaptive most from typical medical interventions that are limited to
illness behaviour in patients with FSS,33,34 and in more reassurance and symptomatic relief focussed on gut
severe cases, co-morbidity of FSS with personality functioning, but diagnostic elements of the cognitive
disorders is high.35 interpersonal approach have to be integrated to assure that

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there are no symptoms or problems beyond the typical
features of the disorder. In other patients, multiorgan
bodily and mental symptoms and persistent organic causal
attribution suggest cognitive interpersonal interventions,
such as psychotherapy, from the outset. Nevertheless inter-
ventions aimed at symptomatic relief via physiological
means are advisable especially in the initial phase. This
necessary balance of therapeutic approaches is in parallel
with the need in research to determine empirically the
relative value of interventions based on organ-oriented and
experience-oriented approaches.
Evidence for the management of FSS
Description of treatment foci and types
We could not identify trials that tested treatments of
groups of patients fullling criteria for more than one
FSS. Dierentiation of the following ve treatment foci
and types is useful for the organisation of the evidence
on the treatment of single FSS and diagnostic analogues,
such as somatoform disorders (table 2),51119 Peripheral
pharmacotherapy is primarily aimed at peripheral physio-
logical processes (eg, bowel function, muscle tension,
inammation, nociceptive pain, etc). Central pharma-
cotherapy is primarily aimed at central processes of
sensation, cognition, and aect (the distinction of
peripheral and central is blurred in some cases, such as
with drugs that alter serotonin metabolism). Active
behavioural intervention is aimed at change of bodily
and interpersonal behaviours, sensations, and cognition
and is eected with active participation of patients in
treatments, such as exercise and dierent psycho-
therapies. Multidisciplinary treatments are also included
in this group because active behavioural components are
essential parts of them. Passive physical intervention is
aimed at passive, non-pharmacological change of
peripheral features of the syndrome via physical
(including surgical and other skin penetrating) means.
For the nal treatment group, the rationale is either
outside that of those mentioned above (usually seen as
part of complementary or alternative medicine) or is not
patient-centred but doctor-centred (ie, aimed at doctors
behaviour via education and training).
Treatment of single FSS and diagnostic analogues
Irritable bowel syndrome
Research on treatment in irritable bowel syndrome is more
extensive than for other classic FSS, although, until
recently, most research of this subject was thought to be
rather low quality.57 Current evidence is unequivocal on the
value or not for some peripheral pharmacological agents:
bulking agents and loperamide seem ineective, the
5-HT4-agonist tegaserod and the 5-HT3-antagonist alosetron
seem eective in selected subgroups (female patients with
irritable bowel syndrome dominated by constipation or
diarrhoea, respectively). There is moderate evidence for
the ecacy of antidepressants and psychotherapy; for the
latter, there is not enough evidence to dierentiate between
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Review
Panel 1: Dierent foci in the management of FSS
Focus on patient
Organ-oriented approach
Current main bodily lead symptoms
Focus on dysfunction of peripheral organs
Interventions aimed at peripheral physiology and
restoration of organ function
Cognitive interpersonal approach
Pattern of bodily and mental symptoms over time
Focus on dysfunction of central processing and context
factors
Interventions aimed at sensations, cognitions, aects,
behaviours, and restoration of overall functioning
Focus on doctor
Early recognition
Communication skill
Avoidance of iatrogenic harm
Focus on context factors
Doctor reimbursement system
Patient compensation schemes
Health-care system
Workplace characteristics
Cultural beliefs
dierent forms.62 However, there are signicant dierences
in the interpretation of primary studies among reviews.
For the interpretation of psychotherapies for irritable bowel
syndrome in particular, there is an ongoing debate of
whether the application of standard criteria for drug
treatments is feasible for the assessment of psychotherapies
or not.52,62 Dierences of opinion in this matter are apparent
between gastroenterological and psychological-medicine
specialists and even among groups of North American
gastroenterologists.12,52
There are also dierences of opinion about the value of
generic outcome measures for functioning or quality of
life. These measures are particularly important for a
behaviour-centred approach, and there is growing
consensus about their necessity for trials testing periph-
eral pharmacological agents in irritable bowel syndrome;51
however, some researchers view a treatment as a failure
if functioning and quality of life, but not symptoms such
as pain or bowel-movement frequency, have improved.120
Fibromyalgia
One of the weak spots of treatment research for
bromyalgia syndrome is the heterogeneous nature of
outcome measures beyond pain. Attendees of a recent
workshop rated global patient-rated improvement, fatigue,
health-related quality of life, and multidimensional
function as clinically most important outcome measures
after pain, whereas manual tender-point examination
loses signicance in view of the limited validity and
usefulness of this criterion.121 However, there seems to be
mounting evidence that drugs with primarily central
949
 Review

Pharmacotherapy Non-pharmacological therapy Other

Irritable bowel syndrome
Fibromyalgia
Peripheral Central Psychotherapy and active behavioural Passive physical
therapy intervention
Tegaserod +++ (IBS-C, w)51,5254 Tricyclic antidepressants Psychotherapy (CBT, hypnotherapy, Chinese herbal medicine +65,66
++52,53,57,59,61 psychodynamic-interpersonal) ++52,6165
Alosetron +++ (IBS-D, w)52,53,55,56
Spasmolytic agents ++52,53,57,58,59
Bulking agents 52,53,57,59,60
Prokinetic agents 53
Loperamide 52
Corticosteroids 67 Tricyclic antidepressants CBT ++64,67,69 Trigger point or tender Acupuncture ++67,71
+++67 point injections 67
NSAID67 Cyclobenzaprine +++67,68 Aerobic exercise +++64,67,69,70 Chiropractic therapy +67
SSRI +67 Patient education +++67 Massage therapy +67
SNRI ++67 Multidisciplinary therapy +++67 Manual therapy +67
Tramadol ++ 67
Hypnotherapy ++ 67

Biofeedback ++67
Strength training ++67
Chronic fatigue syndrome Immmunoglobulin + 72,73
Antidepressants + 61,72,73
CBT +++61,64,7274
Interferon 73 Aerobic exercise +++61,64,7275
Corticosteroids 72,73
Non-ulcer dyspepsia Proton pump inhibitors ++76 .. Psychotherapy ++81 .. ..
Helicobacter pylori eradication ++77,78
H2-Receptor agonists ++76,79,80
Prokinetics +76,80
Antacids 76
Tension headache Botulinum toxin +82 Tricyclic antidepressants Behavioural therapy +++86 Spinal manipulation 8790 Acupuncture +91
+++84,85
Niacin83 SSRI ++84,85 Physiotherapy 90
Non-specic chest pain .. .. Psychological interventions ++ 74,92
.. ..
Chronic pelvic pain Progestogen Sertraline 93 Counselling and ultrasound Adhesiolysis 93 ..
scanning +93
Goserelin +93 Multidisciplinary treatment +93 Uterine nerve ablation 93 ..
Manual techniques 94
Premenstrual syndrome Progesterone/progestogen 95 SSRI +++97 .. .. Complementary or
alternative therapies 98
GnRHa +++96 .. ..
Temporomandibular joint Analgesics 99 Tricyclic .. Splint therapy 100,101 ..
disorder antidepressants +99
Environmental illness or .. .. CBT for electromagnetic Screen lters or shields 102 Selenium for environmental
electromagnetic hypersensitivity ++102 illness 103
hypersensitivity
Chronic low-back pain Nonsteroidal anti-inammatory Tricyclic and tetracyclic CBT +++104,107 Radiofrequency Acupuncture +104,117,118
drugs +++104 antidepressants +++104106 denervation +104,111,112
Muscle relaxants ++104 SSRI 105 Multidisciplinary treatment +++104,108 Prolotherapy 104,113
Opioid analgesics ++104 Exercise therapy ++104,109 Transcutaneous electrical
nerve stimulation 104,114,115
Back schools ++104,110 Spinal manipulation +104,116
Diagnostic analogues .. .. CBT for SD or MUS ++ 64,74
.. Consultation letter to doctor
(MUS, SD, CD) for SD or MUS ++74
Hypnosis for CD +74,119
Paradoxical intention for CD +119

IBS=irritable bowel syndrome (C=constipation, D=diarrhoea). NSAID=non-steroidal anti-inammarory drug. SSRI=selective serotonin reuptake inhibitors. SNRI=selective serotonin and norepinephrine reuptake
inhibitor. GnRHa=gonadotrophin releasing hormone analogue. CBT=cognitive behavioural therapy. MUS=multiple unexplained physical symptoms. SD=somatoform disorders. CD=conversion disorder. +++=strong
evidence; ++=moderate evidence; +=weak evidence; =no evidence for ecacy of treatment. This table does not list all treatments with weak or no evidence dealt with in the systematic reviews. For simplicity,
strength of evidence for ecacy of a specic treatment type is indicated in four dierent grades, with the reviews contributing to this summary estimate. 23 Cochrane reviews are included.51,59,66,70,7577,81,84,91,93,97,101,107110,112,11
3,115,116,118,119
For such an integration of systematic reviews, which use dierent criteria and represent dierent opinions in heterogeneous clinical elds, estimation of eect sizes was not feasible. The table shows general
empirical trends in the management of functional somatic syndromes; it is not an adequate basis for individual treatment recommendations. The terms used in the table were taken from the systematic reviews and
vary in grade of dierentiation (eg, for some FSS the reviews state the evidence for psychotherapy, whereas for others they state the evidence for dierent forms of psychotherapy separately).

Table 2: Management of FSSevidence from systematic reviews since 2001

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action and active behavioural interventions are eective,
whereas peripheral drugs and passive physical inter-
ventions show only weak or no evidence for ecacy.
Chronic fatigue syndrome
Few studies have been added to the therapy research
literature on chronic fatigue syndrome since 2001. The two
treatments with best evidence for ecacy since the 1990s
are graded exercise and cognitive behavioural therapy,
whereas there is little evidence to support the use of
antidepressants and dierent immunological and steroidal
drugs. In one systematic review,72 around 130 dierent
outcome measures were identied in 44 studies, thus
limiting the generalisability of the ndings
Non-ulcer dyspepsia
The evidence for peripheral drugs is best for proton-pump
inhibitors. Evidence for others is weaker, with many
contradicting studies and systematic reviews from the
past122 currently distilled into evidence for a consistent
but limited eect of proton-pump inhibitors, H2-receptor
agonists, and prokinetics and of Helicobacter pylori
eradication in infected patients. Antidepressants have
not been tested rigorously in this type of functional
gastrointestinal disorder. All four studies on psycho-
therapy showed positive eects for dierent types of
psychotherapy each, but interpretation is limited by small
sample sizes and adjustments for dierences between
intervention and control groups.
Tension headache
Behavioural psychotherapies and tricyclic antidepressants
seem to have the best treatment eects in patients with
tension headache. Patients given acupuncture improved
relative to waiting-list controls, but this intervention is
probably no more eective than minimum or sham acu-
puncture. Botulinum toxin, although showing promise
in open trials, shows contradictory results in randomised
controlled trials.123
Non-specic chest pain
The only systematic reviews we could identify were of
psychological interventions for which there is moderate
evidence of ecacy. This syndrome refers to chest pain
but no evidence of underlying coronary, gastrointestinal,
or other organic pathology, therefore it is more exclusive
than the category non-cardiac chest pain. For the latter,
there is some indication that typical gastrointestinal
drugs, such as proton-pump inhibitors, are eective.124
Chronic pelvic pain
The term is used dierently by gynaecologists and
urologists. The former see it as dierent from FSS with
primarily urological symptoms,93 whereas the latter use it
as superordinate category with subcategories like interstitial
cystitis and chronic prostatitis.125 In terms of treatment
ecacy, the lack of eect of surgical procedures is as
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Review
noteworthy as the weak to moderate eect of hormones
and counselling with reassuring ultrasound scanning.
Premenstrual syndrome, temporomandibular disorder, and
environmental illness
The therapeutic evidence as reported in systematic
reviews is very limited for these syndromes. For temporo-
mandibular joint disorder, there has recently been an
upsurge of interest in the role of somatisation and its
combination with organic joint ndings.28
Chronic low-back pain
The evidence for treatments of chronic low-back pain is
broader than for most other syndromes, with nine
dierent Cochrane reviews and a large systematic review
initiated by the European commission attesting to this.
Treatments with active involvement (in the form of
psychotherapy or exercise or other) and drugs with a
central rather than peripheral mode of action seem to be
Panel 2: Management recommendations for FSS
Assessment
Think of the possibility of FSS in patients with enduring physical symptoms; do not
equate them with malingering
Be attentive to clues of the patient indicating bodily or emotional distress beyond the
current lead symptom and outside your specialist eld
Assess functioning, patient expectations, and illness behaviour
Avoid repetitive investigations only to calm the patient or yourself
Decide whether patient has uncomplicated single FSS or complicated FSS. Are there
bodily or mental symptoms clearly beyond single FSS? Is there excessive loss of
functioning? Is there dysfunctional expectations or illness behaviour?
Dierential stepped care
Step 1a: uncomplicated FSS
Reassurance with positive explanation of FSS; do not only convey negative test results
Symptomatic measures like pain relief
Advise graded activation or exercise rather than rest
Step 1b: complicated FSS
Measures as in step 1a for current main symptom
Consider antidepressant treatment
Advise on dysfunctional attributions and illness behaviour and encourage reframing
of symptoms within biopsychosocial framework (ie, incorporate both the patients
beliefs about the organic nature of their symptoms and how these can be aected by a
range of psychological and contextual factors)
If appropriate: appointments at regular intervals rather than patient-initiated
Step 2: if either step 1a or step 1b prove to be insucient
Prepare referral to psychotherapist or mental-health specialist with reappointment
Ensure that traumatic stressors and maintaining context factors, such as litigation, are
assessed
Continue with appointments at regular intervals rather than patient-initiated
Liaise with psychotherapist or mental-health specialist on further treatment planning
and diculties
Step 3: If step 2 proves insucient and if appropriate in your country
Multidisciplinary treatment including symptomatic measures, activating
physiotherapy, and psychotherapy
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 Review
Panel 3: Issues for further research on management of FSS
Establishment of valid and generally accepted diagnostic
criteria and procedures across medical specialties
Extension of good quality evidence to poorly researched
syndromes
Extension of evidence base to doctor-centred and
context-centred interventions
Systematic consideration of overlap cases and psycho-
behavioural features for trial design (including testing of
eects outside specic focus of treatment)24
Determination of relevant outcome criteria (symptoms vs
functioning)121
Investigation of variability of placebo response129,130
Investigation of dierential eects of treatments in
syndrome-specic clinics versus generic treatments for all
FSS in specialised consultation-liaison clinics
Investigation of dierential treatment eects in primary
versus secondary care61
most eective, whereas there is little to no evidence that
many dierent passive physical interventions (including
invasive ones) are eective.
Diagnostic analogues
Much less research has been done on the treatment of
patients described with the diagnostic analogues of FSS
used primarily in psychological medicine, such as
somatoform disorders, multiple unexplained physical
symptoms, conversion disorder (hypochondriasis is ex-
cluded because health anxiety exceeds bodily symptoms).27
Most research into these analogues involves psychotherapy
and psychopharmacotherapy (there is no systematic review
for the latter in the period covered by this review).
Though limited in extent, studies that describe
patient-centred eects of interventions aimed at the doctor
highlight the importance of adequate doctorpatient
interaction in the treatment of patients with FSS.126 Most of
the work with educational programmes aimed at doctors
who treat patients with FSS has been done in primary care.
The most noteworthy of these educational interventions is
the so-called TERM (the extended reattribution and
management) model for the assessment and treatment of
functional disorders in general practice,127 with rst results
of a cluster randomised trial showing that it favourably
changes the attitudes of general practitioners towards
patients with unexplained or functional symptoms.128
Management of functional somatic syndromes
as a whole
The eect of non-pharmacological passive treatments, be
they invasive or non-invasive, seems to be weaker than the
eect of non-pharmacological treatments that involve
active patients cooperation. The evidence for ecacy of
the latter across dierent FSS, in particular graded exercise
and psychotherapy, underlines the importance of common
952
factors in FSS, as the therapeutic rationale of these
treatments typically aims at overall function and not at the
alleviation of specic symptoms. The eect of pharmaco-
logical treatments that primarily aim at peripheral
physiological disturbances linked to the dierent FSS is
more variable across dierent FSS, with best eects shown
for functional gastrointestinal syndromes, but little eect
in many other FSS. In contrast, the moderate to good eect
of antidepressive treatments seems to be distributed more
evenly among the dierent FSS.
Taken together, the current state of evidence appears to
support a balanced approach to the management of FSS,
with organ-oriented and cognitive interpersonal treatment
foci each having their merit in the treatment of single
syndromes. The clinical importance of cognitive
interpersonal approaches is particularly apparent for the
treatment of overlap and other complicated cases, but
there is still a lack of evidence to support this claim
(panels 2 and 3).
On the basis of the balanced approach model and the
evidence presented above, we make several recom-
mendations for diagnosis and treatment of FSS in
primary and secondary care (panel 2).4,131 The essence of
these recommendations is: to convey to the patient that
his symptoms are real, to oer positive advice and
treatment and to engage the patient in an active role in
alleviating the often chronic symptoms.
Conclusion
The evidence base for the management of FSS has grown
considerably over the last years and many patients are
served well with the treatments applied in dierent
subspecialities of medicine. However, there is still a
predominance of a splitting view on single FSS and a
lack of diagnostic criteria and classications that are valid
and generally agreed upon. This not only leads to
confusion, but also to the neglect of important therapeutic
options for many patients. Stigmatisation of psychosocial
factors that are relevant in FSS and the mistaken tendency
to view patients with FSS as the worried well further
enhance this diculty.
The future classication of FSS should reect the
need for a balance between biomedical and more
integrative approaches. Training of medical students
and doctors requires systematic integration of
problem-specic communication skills into the training
curricula of general medicine and integration of
symptom-focussed organ-oriented know-how into the
training curricula of psychological medicine. Health
care and reimbursement systems have to adapt to the
objective needs of doctors and patients at the
psychosomatic interface (eg, by testing the value of
specialised clinical services for it). Last but not least,
practitioners in dierent specialties of medicine should
discover the importance and the rewards of caring for
patients with FSS in a balanced way, rather than purely
biomedical or psychological approaches.
www.thelancet.com Vol 369 March 17, 2007

The management of FSS will most likely continue to be
an important health-care focus on all levels of care. Its
future outlook will reect the state of integration, the
dierent elds of general and specialist somatic as well as
psychological medicine will achieve. Competent communi-
cation, between the elds of medicine as well as between
doctors and patients, will be a mainstay in this endeavour.
Contributors
All authors contributed equally to the preparation and writing of this review.
Conict of interest statement
We declare that we have no conict of interest.
Acknowledgments
We are grateful to Heribert Sattel for help with the literature search and
to Bernd Lwe for valuable support. We are also indebted to Paul Enck
and three anonymous reviewers for comments on an earlier draft.
Supported in part by DFG (PISO) and BMBF (Funktional).
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