BACKGROUND: Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.OBJECTIVES: To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation {\&} Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.SELECTION CRITERIA: We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.DATA COLLECTION AND ANALYSIS: One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.MAIN RESULTS: We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95{\%} CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2{\%}; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95{\%} CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63{\%}). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95{\%} CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0{\%}).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42{\%}; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0{\%}).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95{\%} CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23{\%}).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95{\%} CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0{\%}; low-quality evidence) or NPs and placebo (RR 0.85, 95{\%} CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0{\%}; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95{\%} CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14{\%}; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95{\%} CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0{\%}; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0{\%} to 32{\%}), but low for NPs (0{\%} to 1.7{\%}).The risk of bias was high in many domains across studies. Seventeen trials (65.4{\%}) gave no information about random sequence generation and only two (7.7{\%}) provided information about allocation concealment. Eighteen studies (69.2{\%}) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.AUTHORS' CONCLUSIONS: The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.

Pharmacological interventions for somatoform disorders in adults.

In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications. The study of mental health of lesbian, gay, and bisexual (LGB) populations has been complicated by the debate on the classification of homosexuality as a mental disorder during the 1960s and early 1970s. That debate posited a gay-affirmative perspective, which sought to declassify homosexuality, against a conservative perspective, which sought to retain the classification of homosexuality as a mental disorder (Bayer, 1981). Although the debate on classification ended in 1973 with the removal of homosexuality from the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 1973), its heritage has lasted. This heritage has tainted discussion on mental health of lesbians and gay men by associating— even equating— claims that LGB people have higher prevalences of mental disorders than heterosexual people with the historical antigay stance and the stigmatization of LGB persons (Bailey, 1999). However, a fresh look at the issues should make it clear that whether LGB populations have higher prevalences of mental disorders is unrelated to the classification of homosexuality as a mental disorder. A retrospective analysis would suggest that the attempt to find a scientific answer in that debate rested on flawed logic. The debated scientific question was, Is homosexuality a mental disorder? The operationalized research question that pervaded the debate was, Do homosexuals have high prevalences of mental disorders? But the research did not accurately operationalize the scientific question. The question of whether homosexuality should be considered a mental disorder is a question about classification. It can be answered by debating which behaviors, cognitions, or emotions should be considered indicators of a mental

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Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence

studies from the Center for Mindfulness in Medicine, Health Care, and Society not reviewed by Baer but which raise a number of key questions about clinical applicability, study design, and mechanism of action, and (7) current opportunities for professional training and development in mindfulness and its clinical applications.

https://onlinelibrary.wiley.com/doi/pdf/10.1093/clipsy.bpg016

Mindfulness-Based Interventions in Context: Past, Present, and Future

http://science.sciencemag.org/content/sci/201/4359/899.2.full.pdf

Phenomenology of perception.

An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results

Part I: Introduction. Woolfolk, Lehrer, Allen, Conceptual Issues Underlying Stress Management. McGrady, Psychophysiological Mechanisms of Stress: A Foundation for the Stress Management Therapies. Smith, The Psychology of Relaxation. Part II: Stress Management Methods. Muscle Relaxation. McGuigan, Lehrer, Progressive Relaxation: Origins, Principles, and Clinical Applications. Bernstein, Carlson, Schmidt, Progressive Relaxation: Abbreviated Methods. Hypnotic Methods. Karlin, Hypnosis in the Management of Pain and Stress: Mechanisms, Findings, and Procedures. Linden, The Autogenic Training Method of J. H. Schultz. Norris, Fahrion, Oikawa, Autogenic Feedback Training in Psychophysiological Therapy and Stress Management. Biofeedback. Gevirtz, Psychophysiological Perspectives on Stress-related and Anxiety Disorders. Lehrer, Biofeedback Training to Increase Heart Rate Variability. M. Thompson, L. Thompson, Neurofeedback for Stress Management. Breathing Retraining and Exercise. van Dixhoorn, Whole-body Breathing: A Systems Perspective on Respiratory Retraining. Sime, Exercise Therapy for Stress Management. Methods Based on Eastern Meditative and Therapeutic Disciplines. Carrington, Modern Forms of Mantra Meditation. Kristeller, Mindfulness Meditation. Chen, Qigong Therapy for Stress Management. Khalsa, Yoga as a Therapeutic Intervention. Cognitive Methods. Pretzer, Beck, Cognitive Approaches to Stress and Stress Management. Meichenbaum, Stress Inoculation Training: A Preventative and Treatment Approach. Other Methods. Dileo, Bradt, Music Therapy: Applications to Stress Management. Hyer, Kushner, Eye Movement Desensitization and Reprocessing and Stress: Research, Theory, and Practical Suggestions. Papp, Pharmacological Approach to the Management of Stress and Anxiety Disorders. Part III: Integration. Davis, Sime, Robertson, Sport Psychophysiology and Peak Performance Applications of Stress Management. Feldman, Eisenberg, Gambini-Suarez, Nassau, Differential Effects of Stress Management Therapies on Emotional and Behavioral Disorders. Giardino, McGrady, Andrasik, Stress Management and Relaxation Therapies for Somatic Disorders. Lehrer, Woolfolk, Research on Clinical Issues in Stress Management.

Principles and practice of stress management

http://web.missouri.edu/segerti/capstone/darley.pdf

Identification, situational constraint, and social cognition : studies in the attribution of moral responsibility

Background Patients diagnosed as having somatization disorder (SD) who present with a lifetime history of multiple, medically unexplained physical symptoms represent a significant challenge to health care providers. To date, no psychotherapeutic or pharmacologic intervention has been found to produce clinically meaningful improvement in symptoms or functioning of patients with SD. We examined the efficacy of cognitive-behavioral therapy (CBT) for SD. Methods Eighty-four participants meeting criteria for SD were randomly assigned to 1 of 2 conditions: (1) standard medical care augmented by a psychiatric consultation intervention or (2) a 10-session, manualized, individually administered CBT regimen added to the psychiatric consultation intervention. Assessments were conducted at baseline and 3, 9, and 15 months after baseline. The primary outcome measure was the severity scale of the Clinical Global Impression Scale for Somatization Disorder (CGI-SD). Secondary outcome measures were responder status as determined by clinical ratings, self-reported measures of physical functioning and somatic symptoms, and health care utilization assessed via medical records. Results Fifteen months after baseline, somatization symptoms were significantly less severe in the group treated with CBT (0.84 points on the CGI-SD 7-point scale) (P Conclusion For patients diagnosed as having SD, CBT may produce clinical benefits beyond those that result from the current state-of-the-art treatment.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/410675/ioi60041.pdf

Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial.

We expand the conceptualization of positive leadership and hypothesize that leaders' ability to influence followers across varied complex situations will be enhanced through the development of a rich and multifaceted self-construct. Utilizing self-complexity theory and other aspects of research on self-representation, we show how the structure and structural dynamics of leaders' self-constructs are linked to their varied role demands by calling forth cognitions, affects, goals and values, expectancies, and self-regulatory plans that enhance performance. Through this process, a leader is able to bring the “right stuff” (the appropriate ensemble of attributes) to bear on and succeed in the multiple challenges of leadership. We suggest future research to develop dimensional typologies related to leadership-relevant aspects of the self and also to link individual positive self-complexity to more aggregate positive organizational processes. Copyright © 2009 John Wiley & Sons, Ltd.

Leader self-structure: A framework for positive leadership

Objective Patients presenting with multiple medically unexplained physical symptoms, termed polysymptomatic somatizers, often incur excessive healthcare charges and fail to respond to standard medical treatment. The present article reviews the literature assessing the efficacy of psychosocial treatments for polysymptomatic somatizers. Methods Relevant articles were identified by scanning Medline and PsychLit. Thirty-four randomized, controlled studies were located. Whenever possible results from each study were transformed into effect sizes. An analysis of the efficacy of the psychotherapeutic approaches is provided. Results Various psychosocial interventions have been investigated with polysymptomatic somatizers. Although the majority of studies suggest psychosocial treatments benefit this population, the literature is tarnished by methodological shortcomings. Effect sizes are modest at best. Long-term improvement has been demonstrated in fewer than one-quarter of the trials. Conclusions Although seemingly beneficial, psychosocial treatments have not yet been shown to have a lasting and clinically meaningful influence on the physical complaints of polysymptomatic somatizers.

Robert L. Woolfolk

Papers

Principles and practice of stress management

Identification, situational constraint, and social cognition : studies in the attribution of moral responsibility

Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial.

Leader self-structure: A framework for positive leadership

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