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