cognitive behavioural therapy for medically unexplained physical symptoms: a pilot study

Behavioural and Cognitive Psychotherapy, 1996, 24, 1-16

Cognitive Behavioural Therapy for MedicallyUnexplained Physical Symptoms:A Pilot Study

Anne E.M. Speckens and Philip Spinhoven

University Hospital Leiden

Keith E. Hawton

Warneford Hospital, Oxford

Jan H. Bolk and Albert M. van Hemert

University Hospital Leiden

The aim of the study was to develop a cognitive behavioural treatmentmodel for medically unexplained physical symptoms and assess its feasi-bility and effect in a small sample of patients. This study was the firststep in the realization of a randomized controlled trial. The studypopulation consisted of consecutive patients presenting at a generalmedical outpatient clinic, whose symptoms could not be explained byobjective abnormal findings. The treatment was based on a generalmodel of the disorder, consisting of the physical symptoms, the patient'sattribution and perceived control and the cognitive, behavioural, physi-cal and social consequences. It incorporated record keeping concerningphysical symptoms and emotions, identification of cognitions about thesymptoms, challenging dysfunctional thoughts and behavioural experi-ments. At 6-months follow-up, four of the five treated patients wereimproved with regard to frequency and intensity of the symptoms,psychological distress and functional impairment. The improvementwas sustained at 1-year follow-up.

Introduction

Many patients are seen in clinical practice with physical symptoms forwhich no medical explanation can be found. In a previous study among 191new referrals to a general medical outpatient clinic, the proportion of

Reprint requests to Anne E. M. Speckens, Department of Psychiatry, Bl-P, UniversityHospital Leiden, Postbox 9600, 2300 RC Leiden, The Netherlands.

© 1996 British Association for Behavioural and Cognitive Psychotherapies

2 A. E. M. Speckens et al.

patients in which the symptoms were unexplained was 52% (Van Hemert,Hengeveld, Bolk, Rooijmans and Vandenbroucke, 1993). This figure is com-parable to the percentage of unexplained symptoms in patients with abdomi-nal pain (Harvey, Salih and Read, 1983), fatigue (Cathe'bras, Robbins,Kirmayer and Hayton, 1992) and chest pain (Mayou, Bryant, Forfar andClark, 1994).

In comparison with patients with medical diagnoses, patients with unex-plained symptoms more often suffer from psychiatric disorders. In ourprevious study (Van Hemert et al., 1993), the prevalence of psychiatricdisorder was 42% in the unexplained versus 15% in the explained group.A similar contrast was found between patients with irritable bowel syn-drome and inflammatory bowel disease (Schwarz et al., 1993; Walker et al.,1990), chronic fatigue syndrome and both muscle disease (Wood, Bentall,Gopfert and Edwards, 1991) and rheumatoid arthritis (Katon, Buchwald,Simon, Russo and Mease, 1991), and patients with atypical chest pain andischaemic heart disease (Kisely, Creed and Cotter, 1992; McCroskery et al.,1991).

The association between unexplained symptoms and psychiatric disordersuggests that psychotherapy may be effective in patients with unexplainedcomplaints. Recently, several behavioural or cognitive-behavioural treat-ments have been developed for subgroups of patients with particular typesof symptoms, such as chronic pain (Philips, 1987), irritable bowel syndrome(Blanchard et al., 1992; Corney, Stanton, Newell, Clare and Fairclough,1991), chronic fatigue syndrome (Butler, Chalder, Ron and Wessely, 1991;Lloyd et al., 1993) and atypical chest pain (Hegel, Abel, Etscheidt, Cohen-Cole and Wilmer, 1989; Klimes, Mayou, Pearce, Coles and Fagg, 1990).Less is known about the effect of psychological approaches in patients withdivergent physical symptoms.

A general cognitive-behavioural treatment of functional somatic symp-toms has been described by Salkovskis (1989) and Sharpe, Peveler andMayou (1992). Central in the cognitive behavioural conceptualization ofsomatic symptoms is the way patients think about bodily sensations. Beliefsthat patients have about the nature of their symptoms can result in aconfirmatory bias with respect to illness-related information. As a result,such patients selectively notice and remember information that is consistentwith their beliefs about their problems. If benign bodily sensations areregarded as being symptomatic of disease, several consequences ensue. First,patients will experience emotional distress, which may cause further bodilysensations. Second, increased attention will be paid to these sensations.Third, the type of behaviours adopted to cope with the symptoms may bedysfunctional in that they act to exacerbate the problem rather than relieve

Unexplained physical symptoms 3

it. Fourth, other people including doctors may respond to patients in a waythat intensifies, rather than reduces their concern with disease, attention tobodily sensations and dysfunctional coping. All these processes may becomelinked in self-perpetuating vicious circles.

In accordance with this conceptualization, patients with somatic symp-toms commonly believe that their symptoms have a physical cause (Kellner,Hernandez and Pathak, 1992; Robbins and Kirmayer, 1991). Functionalsomatic symptoms have been found to be associated with both anxiety anddepression, which appeared to be, at least in part, consequences of the dreador false beliefs of having a disease (Kellner, Abbott, Winslow and Pathak,1989; Kellner et al., 1985). Patients with high levels of health anxiety havebeen shown to consider more symptoms indicative of sickness (Barsky,Coeytaux, Sarnie and Cleary, 1993) and to have an enhanced perceptualsensitivity to illness cues (Barsky, Wyshak and Klerman, 1990; Hitchcockand Mathews, 1992). Salkovskis and Warwick (1986) demonstrated thatavoidance behaviour, such as reassurance seeking and checking bodily status,could be an important maintaining factor of health anxiety. In a study ofpatients admitted to a general medicine unit, Jones, Mabe III and Riley(1989) found that illness coping responses associated with hypochondriacaltraits were rather passive strategies that promoted increased vigilance andconcern about symptoms while providing few opportunities to reduceuncertainty regarding health status. In several studies, somatization hasappeared to be associated with functional impairment and the seeking ofmedical care (Barsky and Wyshak, 1990; Escobar et al., 1987; Simon, 1992).

The aim of this pilot study was to investigate the feasibility and effectsof a cognitive behavioural approach in a limited group of patients withvarious unexplained physical symptoms in preparation for a randomizedcontrolled intervention study.

Method

Subjects

The study took place from December 1991 till March 1992 at the outpatientclinic of general internal medicine of Leiden University Hospital. Thirty-two consecutive patients who were referred by their general practitionerwere invited to take part in the study. In 17 (53%) patients no objectiveabnormal findings were established that could account for the presentingsymptoms. Two patients with unexplained symptoms were excluded fromthe study because they lived more than 30 miles from the hospital. Theremaining 15 patients were invited for an interview. Of 12 (80%) patientswho were interviewed, five agreed to take part in the treatment phase of


the study, three were already receiving psychiatric or psychological treat-ment and four refused. Three of the patients who refused to participate didso because their symptoms had improved.

Assessments

During the interview, information was gathered on sociodemographiccharacteristics, the main presenting symptoms, the medical and psychiatrichistory and the use of medication. The Present State Examination (PSE)was used to assess psychiatric disorder (Slooff, Mulder-Hajonides van derMeulen and Van den Hoofdakker, 1983; Wing, Cooper and Sartorius, 1974).The patients were asked to indicate the average intensity of the symptomsduring the preceding month on a visual analogue scale ranging from 10(none) to 100 (intolerable) and the frequency on a 5 point-Likert scaleranging from 1 (never) to 5 (always). In addition, they were asked to indicatehow much the symptoms had affected their daily life on a visual analoguescale ranging from 10 (not affected) to 100 (could not be more affected).The Hospital Anxiety and Depression Scale (HADS) (Spinhoven et al.,submitted; Zigmond and Snaith, 1983) was also administered.

Six months and one year after the initial interview the patients were againasked to rate the frequency and intensity of the presenting symptoms duringthe preceding month, their functional impairment and to complete theHADS. At 1-year follow-up, the patients were also asked to indicatethe degree of change in the presenting symptoms in response to the follow-ing question: "When you visited the general medical outpatient clinic aboutone year ago you suffered from {presenting symptoms). How are thesesymptoms at present (recovered/improved/same/worse)}"

TreatmentIn view of the heterogeneity of the patient population we used a generaltreatment model that could be applied to a wide variety of symptoms, buton the basis of which a more or less individualized treatment plan could bemade (Figure 1).

The somatic symptoms themselves were the starting point of the model.The central part consisted of the patients' beliefs regarding the origin oftheir symptoms and what they could do about them. The beliefs wereconsidered to determine the different consequences of the somatic symp-toms: cognitive, behavioural, physical and interpersonal. The various conse-quences might interact with each other and could maintain or exacerbatethe symptoms themselves. Inactivity, for example, could preserve orworsen the feelings of tiredness in patients with chronic fatigue. It wasexplained to the patients that if one could break the vicious circles of the

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symptoms and their consequences, one would expect the physical symptomsand their impact on the patients' lives to diminish. The emphatic labellingof psychological and social factors as consequences of the physical symp-toms rather than possibly aetiological agents is the most important differ-ence between the treatment model we used and the treatments that werepreviously described by Salkovskis (1989) and Sharpe et al. (1992).

The main elements of the model, the illness attribution and perceivedcontrol, were changed by identification and modification of the patients'cognitions. Each of the consequences were dealt with by specific therapeutictechniques. Imaginary exposure and distraction techniques were used tobreak the vicious circles of cognitive avoidance and preoccupation. Todecrease avoidance behaviour, activity scheduling, exposure in vivo andresponse prevention were employed. Physical consequences were dealt withby relaxation training, breathing exercises and physical exercise. Problemsin interpersonal relationships were tackled with problem solving or socialskills training.

Assessment and engagement. In the first interviews with the patient theprimary aim was to gain confidence and to develop a fruitful workingalliance. Thus, in the beginning of the contact with the patient ampleattention was paid to the physical symptoms and the results of medicalinvestigations and treatments.

To avoid a discussion with the patients about whether the origin of thesymptoms was organic or psychological, the basis of the formulation wasthe acknowledgement of the somatic symptoms themselves. However, thepatients were encouraged to see that they had spent much time trying tofind out what had caused the symptoms, without much result. It wassuggested that therefore it might be more worthwhile examining the impactof the symptoms on their daily life, and the vicious circles resulting fromthem.

Treatment process. The treatment sessions took place in an examinationroom of the outpatient clinic of general internal medicine. The therapist wasa physician trained in cognitive behavioural therapy, who was supervisedby a behavioural therapist. The number of sessions depended on the severityof the problem. Usually, the sessions were more frequent in the earlystages of treatment and spaced out during the later stages.

Hand-outs were used in which the cognitive behavioural model andtreatment were explained. Additional chapters were available about theidentification of automatic thoughts, the challenging of dysfunctionalthoughts, distraction techniques, activity scheduling, breathing and relax-ation exercises and problem-solving.

Components of treatment. The first step was the recording of symptoms,


the situations in which they occurred and the corresponding feelings andthoughts. The composition of a 10—point Likert scale defining the intensityof the physical symptoms facilitated reliable recording of physical symp-toms. Furthermore, differentiation of feelings was needed to reveal a possi-ble relationship between the somatic symptoms and emotions. Usually, itwas not until then that the recording of automatic thoughts was employed.

Generally, the reported cognitions could be divided into symptom-relatedand situation-related thoughts. The first category involved the interpretationof the physical symptoms with anxiety-provoking thoughts such as: "I mayhave a stroke". The second category could best be regarded as "triggers" ofthe physical symptoms. An example of such a thought was: "I will get dizzyand fail in doing this job". By asking what would be the worst thing thatcould happen ("If I fail doing this job perfectly, my boss will sack me. If Iam sacked, this means I am a worthless person"), such situation-relatedcognitions often revealed the patients' dysfunctional assumptions (Beck andFreeman, 1993).

Helping patients change their dysfunctional thoughts initially involvedidentifying the evidence upon which they were based. Patients were encour-aged to examine whether they were making any thinking errors in evaluatingthe facts, such as only paying attention to the black side of things, overgener-alization, jumping to conclusions, thinking in all-or-nothing terms or pre-dicting the future. Then they were asked what alternative interpretationswere possible. Eventually, behavioural experiments were used to test theoriginal or alternative belief.

In essence, the therapeutic techniques used to change cognitive,behavioural, physical and interpersonal consequences of the somatic prob-lem could be regarded as "behavioural experiments". The interventionswere not only used to reduce the consequences or the physical symptomsthemselves, but also, and particularly, to challenge dysfunctional beliefs andto test alternative hypotheses.

Results

Patient A. This 26-year-old woman presented with palpitations. The patienthad no partner and lived alone. She had studied law and history, but hadprematurely left college. She was working as a secretary at an engineeringfirm. The palpitations had been present for three months and occurred threeor four times a day. They got worse when the patient was paying attentionto them or when she was tired. She believed the symptoms were due tosome kind of physical dysfunction. When the palpitations occurred shetried to distract herself by increasing her activity level. She had noticed thesymptoms were often followed by feelings of breathlessness, sickness and

8 A £. M. Speckens et al.

dizziness. In the past year, she had seldomly visited her general practitionerand she did not use any medication.

The treatment consisted of 9 sessions and lasted 22 weeks. Based onthe patient's observation that the palpitations were often accompanied bybreathlessness, breathing exercises were started. The patient noticed that thedifficulty in breathing actually preceded the palpitations and, in turn, waspreceded by muscle tension. Therefore, the reduction of her activity leveland relaxation exercises were added to the regime. Her symptoms startedto improve. Gradually, the patient succeeded in recognizing that she usuallyfelt tense when she made high demands on herself or did not stand up forherself. The dysfunctional cognitions underlying these behaviours wereexplored, challenged and tested in behavioural experiments. However, thepatient often cancelled her appointments and did not do her homeworkexercises as carefully as before. Even after several calls, she did not turn upfor her last treatment session.

At 6-months follow-up, the patient reported that her symptoms had notoccurred during the preceding month and that she had not experienced anycorresponding functional impairment or psychological distress (see Table1). Only partial information was available from the 1-year follow-up. Thepatient reported having had a temporary relapse of the symptoms becauseof exams she had to take as part of training she had started. However, sheindicated that she was not impaired by the symptoms and was able to copewith them using the breathing and relaxation exercises. She had not visitedher general practitioner in the year following her first visit to the medicalclinic.

Patient B. The second patient was a 42-year-old woman who had com-plaints of nausea. The patient had married four years ago and did not haveany children. She worked as a geriatric helper for four days a week. Thesymptoms had started at the time she had stopped smoking one year earlierand presently occurred two or three times a week. At first the patientbelieved the nausea to be a withdrawal symptom, but later she attributedthe symptoms to a gall bladder dysfunction. She tried to prevent the symp-toms by avoiding particular foods, such as fried fish and coffee. If thenausea still occurred, the patient tried to deny and suppress it. She did notlet the symptoms interfere with her work and avoided burdening colleagueswith her problems. When she arrived home after work she was usuallyfeeling very tired and often got into conflict with her husband. She did notuse any medication and had visited her general practitioner four times inthe past year.

The treatment lasted 18 weeks, in which eight sessions took place. The


TABLE 1. Baseline and follow-up characteristics of patients A-E*

Baseline 6-months 1-year

Patient A- Frequency- Intensity- Impairment- HADS- Overall improvement

Patient B- Frequency- Intensity- Impairment- HADS- Overall improvement

Patient C- Frequency- Intensity- Impairment- HADS- Overall improvement

Patient D- Frequency- Intensity- Impairment- HADS- Overall improvement

Patient E- Frequency- Intensity- Impairment- HADS- Overall improvement

daily40-

4

weekly4020

8

daily658522

weekly405027

daily758517

never10104

never1010

1

weekly557520

never151010

monthly2525

8

monthly5015-improved

never10103

recovered

weekly459522improved

never101014improved

weekly353513improved

^Intensity and impairment were measured with visual analogue scales ranging from 10-100,psychological distress was assessed with the Hospital Anxiety and Depression Scale.

patient was very compliant in keeping her appointments and doing herhomework exercises. Her daily records revealed that the symptoms seemedto increase when she was feeling tense and tired. Therefore, the first aim oftreatment was relaxation. The therapeutic strategies were reduction of thepatient's activity level and relaxation exercises. However, the patient did notthink the measures were effective in diminishing her symptoms and believedher diet was of more importance. She was encouraged to design abehavioural experiment to test her hypothesis, and indeed, the nausea disap-


peared when she did not use fats in her diet and reappeared when she atefoods with a high fat content. She was able to construct a diet on whichshe did not have many symptoms and at the same time did not have torefrain from eating all the foods she liked.

At both 6-months and 1-year follow-up, the patient no longer reportedany symptoms, psychological distress or functional limitations. In the yearfollowing her first visit to the medical clinic, she had visited her generalpractitioner once.

Patient C. This 31-year-old man was referred to the general medicalclinic because of abdominal pain and diarrhoea. The patient was married,had a three year old son with diabetes and his wife was pregnant with theirsecond child. He was working as a maintenance engineer at the nationaltelephone service. The patient had been battered and emotionally neglectedin his youth by his parents, with whom he no longer had any contact. Hehad received psychological treatment for two years because of outbursts ofaggression, impulsive buying and marital problems. His abdominal pain anddiarrhoea had been present for more than 11 years. Usually, he had to goto the toilet more than ten times a day. The patient had noticed the symp-toms were strongly influenced by stress and anxiety. He was constantlyworrying about the possibility of having diarrhoea in embarassing circum-stances. His working day was organized around the availability of toiletfacilities. Although he used to enjoy playing soccer, he no longer partici-pated in any leisure activities. He had noticed that his physical conditionhad gradually deteriorated. He felt ashamed of his symptoms, tried to hidethem from others and his social contacts had lessened. He had visited hisgeneral practitioner four times in the past year and used spasmolytics onceor twice a week because of his diarrhoea.

This patient met PSE-criteria for depressive disorder. Treatment included24 sessions and lasted 70 weeks. Since the patient recognized that hissymptoms were worse when he was feeling tense, relaxation exercises werestarted. He was encouraged to reduce his working hours and to resume hisformer leisure activities. Social skills training was needed to help him tocomplete these tasks. After the first nine sessions, the patient successfullyapplied most of the acquired skills and his symptoms gradually improved.Then, his wife was admitted to a psychiatric hospital with a post-partumpsychosis after the birth of the second child. The family-in-laws accusedthe patient of having caused her nervous breakdown. In addition, his sonwas admitted to a pediatric ward because of a deregulation of his diabetes.In the meantime, the patient had to organize a move of house that involvedconsiderable expense. As a result of these external circumstances, thepatient's symptoms worsened. In addition, the patient often cancelled his


appointments and had difficulty doing his homework exercises. Problemsolving techniques were used to help the patient to cope with the stressfulevents.

Although the frequency of the symptoms decreased from daily at baselineto weekly at follow-up, the intensity only showed slight improvementover time. The associated psychological distress and functional limitationsremained high. In the year following his first visit to the clinic, he hadconsulted his general practitioner three times. About six months after thelast follow-up, the patient contacted the therapist to report that his symp-toms were now much improved. He had to go to the toilet only once ortwice a day. He was still using his relaxation exercises and problem solvingskills. The relationship with his wife had improved.

Patient D. This 58-year-old woman presented with attacks of headache,tingling throughout her body and general weakness. Since her divorce fifteenyears previously, she lived alone. Apart from her three children she did nothave many social contacts. Three years previously, she was involved in aroad traffic accident in which her lower leg was crushed. She was admittedto a rehabilitation centre for three months and was still convalescing. Herpresenting symptoms began two years previously and occurred three orfour times a week. The patient thought that the attacks meant she was likelyto suffer a stroke. Therefore, she felt very anxious whenever the symptomsoccurred and continuously checked her body to see if anything was wrong.She avoided physical exercise and social activities. Her only daily pursuitsconsisted of visiting her general practitioner, about once a month, and herphysiotherapist. She used benzodiazepines because of her symptoms.

This patient met PSE-criteria for depressive disorder and DSM-III-Rcriteria for somatization disorder. The number of sessions was nine and theduration of treatment was 28 weeks. The patient always kept her appoint-ments and carefully did her homework exercises. The evidence for the mainbelief of the patient, her worry about having a stroke, was discussed withher. In the fifth session, a hyperventilation provocation test made the patientconsider alternative explanations for her symptoms. After this, her symp-toms started to improve. The patient was encouraged to use the breathingand relaxation exercises she had previously learnt from her physiotherapist.The patient was reinforced in her efforts to increase her physical exerciseand to undertake more social activities.

Both at six months and at one year the patient reported that the symptomshad disappeared and that she no longer experienced any functional impair-ment. Her level of psychological distress also decreased over time. Shecontinued to visit her general practitioner, but the frequency of her visitsdiminished to eight times a year.


Patient E. The fifth patient was a 19-year-old man who presented withchronic fatigue. He was the son of a farmer and still living with his parents.He had recently finished his education, but had not yet obtained a job. Thefatigue had started with "influenza" eight months beforehand. The patientnow felt tired more than half of the time. He thought he was suffering from"ME" and believed the only thing he could do about his symptom was torest. He did not feel able to face every day life and complained of difficultyconcentrating and being slowed up. He slept more than twelve hours a dayand was not able to carry on with his usual work at the farm. Since he hadrefrained from his former physical activities, such as skating and cycling,his physical condition had deteriorated. In addition, he no longer saw manyof his friends. The patient had visited his general practitioner four times inthe past year and did not use any medication.

This patient fulfilled the research criteria for chronic fatigue syndrome(Sharpe et al., 1991) as well as those for PSE diagnosis of depression.Treatment consisted of 12 sessions over a period of 21 weeks. The patientused to keep his appointments, but his record keeping was somewhatsuperficial. Rather than discussing the patient's conviction that he was suf-fering from ME, treatment was focused on his belief that he could not doanything about it. It was suggested to him that sleeping more and doingless might in fact cause his symptoms to deteriorate rather than improve.To test this hypothesis, a gradual decrease in his amount of sleep andincrease in his activity level was planned. Cognitions that impeded theimplementation of his activity schedule (e.g. "I will not be able to completethis job. It will only make me feel worse.") were identified and challenged.After the ninth treatment session, his fatigue started to decrease. He wasencouraged to restart cycling and to get in touch again with his old friends.Eventually, the patient made plans about how to get himself an independentjob.

Although this patient's fatigue did not entirely disappear, his symptomssubstantially improved over the next six months and remained muchreduced at one year follow-up. A similar reduction was established in theassociated functional limitations. He did not visit his general practitionerany more in the year following the first visit to the medical clinic.

Discussion

Cognitive behavioural therapy appears from the results of this pilot studyto be a feasible and potentially effective treatment for patients with hetero-geneous unexplained symptoms. Four of the five treated patients improvedwith regard to frequency and intensity of the presenting symptoms, psycho-


logical distress and functional impairment. This improvement was sustainedat one year follow-up.

Although the number of patients studied was limited, much attentionwas paid to the representativeness of the sample. The population consistedof consecutive referrals to the medical clinic. The symptoms were classifiedas medically explained or unexplained according to the opinion of theattending physician, which was based on the results of a standardizedhistory, physical examination and laboratory tests. Apart from currentpsychological or psychiatric treatment no exclusion criteria were used. Dueto the diversity of the symptoms, to some extent heterogeneity of treatmentcontent was inevitable. However, the implementation of the treatment wasas structured and well documented as possible.

For some patients the cognitive-behavioural model was more appropriatethan for others. In patient B, for example, the nausea could very well havebeen maintained by a dysfunctional gall bladder rather than by psychologi-cal factors. Clearly, the absence of objective abnormal findings by itselfdoes not necessarily indicate a psychological data to provide an acceptablerationale for the symptoms and their treatment (Salkovskis, 1989). However,in the case of patient B an experimental approach to her symptoms, as oftenused in cognitive behavioural therapy, proved effective in confirming herbeliefs concerning her symptoms.

Engagement in treatment is perhaps the most important aspect of psycho-logical treatment of patients with somatic symptoms. Care was taken tomaximize the likelihood that the patients would accept treatment. The factthat the treatment took place in the general medical outpatient clinic helpedto prevent the patients from feeling dismissed by the physician. Engagementin treatment was also aided by the therapist's labelling of illness-relatedcognitions, behaviour and social interactions as consequences of the physicalsymptoms rather than possible aetiological agents.

An important factor impeding progress during treatment was the presenceof dysfunctional assumptions and schemata. Whereas automatic thoughtswere quite easy to change, underlying assumptions and schemes oftenproved very resistant to modification. Both in patient A and in patient C,dysfunctional assumptions and schemes played an important role in themaintenance of the symptoms. One of the assumptions of patient A was:"If I do something imperfectly, this means I am a failure." Consequently,her symptoms tended to re-occur in related situations, such as taking exams.The core belief of patient C was: "I am worthless". Dysfunctional assump-tions and schemes could be included in the treatment model as predisposingfactors, which increase the probability of the occurrence of somatic symp-toms in situations that are triggering these basic beliefs. It usually takes


longstanding therapy and different techniques, such as working with con-tinuum concepts and a historical test, to change these basic schemata (Beckand Freeman, 1993).

In conclusion, cognitive behavioural therapy seems a feasible and poten-tially effective approach in patients with medically unexplained symptoms.The treatment model, based on the acknowledgement of the physical symp-toms and the labelling of psychological factors as their consequences, facili-tates the engagement of the patient. Moreover, it helps to structure theassessment, it provides a treatment rationale and forms a sound basis forevaluating progress. Obviously, the next step necessary to demonstratethe effect of cognitive behavioural therapy in patients with unexplainedsymptoms is a randomized controlled trial, in which we are presentlyengaged.

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cognitive behavioural therapy for medically unexplained physical symptoms: a pilot study

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