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Effectiveness of psychotherapy for severe somatoform disorder: meta-analysis

  • Jurrijn A. Koelen (a1), Jan H. Houtveen (a2), Allan Abbass (a3), Patrick Luyten (a4), Elisabeth H. M. Eurelings-Bontekoe (a5), Saskia A. M. Van Broeckhuysen-Kloth (a6), Martina E. F. Bühring (a6) and Rinie Geenen (a2)...

Patients with severe somatoform disorder (in secondary and tertiary care) typically experience functional impairment associated with physical symptoms and mental distress. Although psychotherapy is the preferred treatment, its effectiveness remains to be demonstrated.


To examine the effectiveness of psychotherapy for severe somatoform disorder in secondary and tertiary care compared with treatment as usual (TAU) but not waiting-list conditions.


Main inclusion criteria were presence of a somatoform disorder according to established diagnostic criteria and receiving psychotherapy for somatoform disorder in secondary and tertiary care. Both randomised and non-randomised trials were included. The evaluated outcome domains were physical symptoms, psychological symptoms (depression, anxiety, anger, general symptoms) and functional impairment (health, life satisfaction, interpersonal problems, maladaptive cognitions and behaviour).


Ten randomised and six non-randomised trials were included, comprising 890 patients receiving psychotherapy and 548 patients receiving TAU. Psychotherapy was more effective than TAU for physical symptoms (d = 0.80 v. d = 0.31, P<0.05) and functional impairment (d = 0.45 v. d = 0.15, P<0.01), but not for psychological symptoms (d = 0.75 v. d = 0.51, P = 0.21). These effects were maintained at follow-up.


Overall findings suggest that psychotherapy is effective in severe somatoform disorder. Future randomised controlled studies should examine specific interventions and mechanisms of change.

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Corresponding author
J. A. Koelen, University of Leuven, Tiensestraat 102, 3000 Leuven, Belgium. Email:
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The meta-analysis was funded in part by a voucher of SenterNovem grant X090109.

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Effectiveness of psychotherapy for severe somatoform disorder: meta-analysis

  • Jurrijn A. Koelen (a1), Jan H. Houtveen (a2), Allan Abbass (a3), Patrick Luyten (a4), Elisabeth H. M. Eurelings-Bontekoe (a5), Saskia A. M. Van Broeckhuysen-Kloth (a6), Martina E. F. Bühring (a6) and Rinie Geenen (a2)...
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Psychotherapy for severe somatoform disorder meta-analysis - problems with missing studies

Jon Stone, Consultant Neurologist and Honorary Senior Lectuere
06 January 2014

The recent review by Koehler and colleagues of psychotherapy for severe somatoform disorder is welcome in highlighting the need for better evidence in this area. It has unfortunately omitted a number of relevant studies, especially relating to conversion disorder. One major reason for this is the index date on which studies were searched for, March 2010, wasnearly four years prior to publication. It is a pity that the authors didn't update their analysis at the time of their last revision in June 2013 as they would, at this time, have been able to include a number of relevant studies, including a randomised trial of cognitive behavioural therapy for non-epileptic seizures (n=66)(2) and a randomised controlled trial of guided self for functional neurological symptoms (ie conversion disorder) (n=127)(17). These last two studies were published before one ofthe studies included in the analysis, the study by Sattel et al published in 2012(13).

There are further studies of psychotherapy in conversion disorder which were published before March 2010: a study of psychotherapy for non-epileptic seizures (n=20)(3), a study of psychotherapy for conversion disorder (n=91)(10), a study of psychotherapy for psychogenic movement disorders(4) (n=10) and a large controlled and negative trial of psychotherapy for patients with somatoform disorders in a general hospital(n also=91)(15) published prior to March 2010. The authors may have excluded them but they did not present a list of the 64 excluded studies as a supplemental file.

Other types of study that could arguably have been included using theauthors own criteria are some randomised trials in functional dysphonia, aform of conversion disorder treated in secondary care with voice therapy and sometimes psychotherapy(11). There are also treatment studies of children with conversion disorder which have not been included and would not have been excluded by the authors inclusion criteria(18)(16).

Further studies in conversion disorder have followed in the last two years which describe outcomes from multidisciplinary treatment including psychotherapy(1)(6,12)(5). Journal articles cannot always be up to date but the number of omissions here make this meta-analysis immediately in need of updating.

Two included studies were of hypnosis for motor conversion disorder(8)(7). Hypnosis is arguably a form of psychotherapy, but also arguably not. In addition, the inclusion of studies which randomised bioenergetic exercise against gym exercise in a setting where all patientsreceived psychotherapy(9) and a study of inpatient multidisciplinary rehabilitation in chronic pain (n=298) graded as 'extremely poor' (14) andthen included in a 'treatment as usual arm' are debatable.

The authors could have done more to highlight one of the obvious drawbacks of their review. There is a paradox in reporting on treatment for patients who had been defined as having a somatoform disorder (often needing only to have three symptoms like pain, fatigue, dizziness or irritable bowel syndrome) whilst ignoring studies on psychotherapy for individual functional somatic disorders such as irritable bowel syndrome and fibromyalgia. Most patients with functional somatic disorders also have other symptoms such as fatigue and pain(19) and probably would, for example, meet criteria for multisomatoform disorder. It is at times highlyarbritary whether authors decide, for example, to use the term somatoform pain disorder or chronic pain disorder. A broader overview of studies in all these fields or at least greater acknowledgement of the overlap wouldhave been helpful for the reader

1. Aybek S, Hubschmid M, Mossinger C, Berney A, Vingerhoets F. Early intervention for conversion disorder: neurologists and psychiatrists working together. Acta Neuropsychiatr 2013; 25:52-6.

2. Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, et al. Cognitive-behavioral therapy for psychogenic nonepilepticseizures: a pilot RCT. Neurology 2010; 74:1986-94.

3. Goldstein LH, Deale AC, Mitchell-O'Malley SJ, Toone BK, Mellers JD. An evaluation of cognitive behavioral therapy as a treatment for dissociative seizures: a pilot study. Cogn BehavNeurol 2004; 17:41-9.

4. Hinson VK, Weinstein S, Bernard B, Leurgans SE, Goetz CG. Single-blind clinical trial of psychotherapy for treatment of psychogenic movement disorders. Park Disord 2006; 12:177-80.

5. Kompoliti K, Wilson B, Stebbins G, Bernard B, Hinson V. Immediate vs. delayed treatment of psychogenic movement disorders with short term psychodynamic psychotherapy: Randomized clinical trial. Parkinsonism RelatDisord 2013; :7-10.

6. McCormack R, Moriarty J, Mellers JD, Shotbolt P, Pastena R, LandesN, et al. Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study. J Neurol Neurosurg Psychiatry2013;

7. Moene FC, Spinhoven P, Hoogduin CA, Van Dyck R. A randomized controlled clinical trial of a hypnosis-based treatment for patients with conversion disorder, motor type. Int J Clin Exp Hypn 2003; 51:29-50.

8. Moene FC, Spinhoven P, Hoogduin KA, Van Dyck R. A Randomised Controlled Clinical Trial on the Additional Effect of Hypnosis in a Comprehensive Treatment Programme for In-Patients with Conversion Disorderof the Motor Type. PsychotherPsychosom 2002; 71:66-76.

9. Nickel M, Cangoez B, Bachler E, Muehlbacher M, Lojewski N, Mueller-Rabe N, et al. Bioenergetic exercises in inpatient treatment of Turkish immigrants with chronic somatoform disorders: a randomized, controlled study. J Psychosom Res 2006; 61:507-13.

10. Reuber M, Burness C, Howlett S, Brazier J, Grunewald R. Tailored psychotherapy for patients with functional neurological symptoms: a pilot study. JPsychosomRes 2007; 63:625-32.

11. Ruotsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH. Interventions for treating functional dysphonia in adults. CochraneDatabaseSystRev 2007; :CD006373.

12. Saifee TA, Kassavetis P, Parees I, Kojovic M, Fisher L, Morton L,et al. Inpatient treatment of functional motor symptoms: a long-term follow-up study. JNeurol 2012; 259:1958-63.

13. Sattel H, Lahmann C, G?ndel H, Guthrie E, Kruse J, Noll-Hussong M, et al. Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomised controlled trial. Br J Psychiatry 2012; 200:60-7.

14. Schneider J, Rief W. Selbstwirksamkeitserwartungen und Therapieerfolge bei Patienten mit anhaltender somatoformer Schmerzst?rung (ICD-10: F45.4). Z Klin Psychol Psychother 2007; 36:46-56.

15. Schweickhardt A, Larisch A, Wirsching M, Fritzsche K. Short-term psychotherapeutic interventions for somatizing patients in the general hospital: a randomized controlled study. PsychotherPsychosom 2007; 76:339-46.

16. Schwingenschuh P, Pont-Sunyer C, Surtees R, Edwards MJ, Bhatia KP. Psychogenic movement disorders in children: a report of 15 cases and areview of the literature. Mov Disord 2008; 23:1882-8.

17. Sharpe M, Walker J, Williams C, Stone J, Cavanagh J, Murray G, etal. Guided self-help for functional (psychogenic) symptoms: a randomized controlled efficacy trial. Neurology 2011; 77:564-72.

18. Turgay A. Treatment outcome for children and adolescents with conversion disorder. Can J Psychiatry - Rev Can Psychiatr 1990; 35:585-9.

19. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: oneor many? Lancet 1999; 354:936-9.

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