The association of depression and anxiety with medical symptom burden in patients with chronic medical illness

BACKGROUND: Primary care patients with anxiety and depression often describe multiple physical symptoms, but no systematic review has studied the effect of anxiety and depressive comorbidity in patients with chronic medical illnesses. METHODS: MEDLINE databases were searched from 1966 through 2006 using the combined search terms diabetes, coronary artery disease (CAD), congestive heart failure (CHF), asthma, COPD, osteoarthritis (OA), rheumatoid arthritis (RA), with depression, anxiety and symptoms. Cross-sectional and longitudinal studies with >100 patients were included as were all randomized controlled trials that measure the impact of improving anxiety and depressive symptoms on medical symptom outcomes. RESULTS: Thirty-one studies involving 16,922 patients met our inclusion criteria. Patients with chronic medical illness and comorbid depression or anxiety compared to those with chronic medical illness alone reported significantly higher numbers of medical symptoms when controlling for severity of medical disorder. Across the four categories of common medical disorders examined (diabetes, pulmonary disease, heart disease, arthritis), somatic symptoms were at least as strongly associated with depression and anxiety as were objective physiologic measures. Two treatment studies also showed that improvement in depression outcome was associated with decreased somatic symptoms without improvement in physiologic measures. CONCLUSIONS: Accurate diagnosis of comorbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and in optimizing the management of somatic symptom burden.     

Somatic complaints among pregnant women cared for in obstetrics: normal pregnancy or depressive and anxiety symptom amplification revisited?

Despite the extensive research documenting the significance of medically unexplained somatic symptoms in primary care patients, few studies have examined somatic symptoms as a predictor of depressive and anxiety disorders among pregnant women cared for in Obstetrics. We utilized the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PHQ) to assess current depressive and anxiety disorders and self-reported somatic symptoms among 186 women receiving prenatal care. We examined the bivariate relationships between depressive and anxiety disorders and mean number of somatic symptoms. Linear regression analyses assessed the unique association between maternal depression, anxiety and somatic symptoms, while controlling for selected demographics and maternal medical risk. Twenty three percent (N=43) of women met screening criteria for depressive and/or anxiety disorders. Women with depression and/or anxiety were significantly more likely to report somatic symptoms (mean=7.1, SD=2.6) compared to women without depression or anxiety (mean=5.0, SD=2.6) [t(df)=4.54(184), P<.001]. This association persisted in multivariate models. Our findings suggest that antenatal depressive and anxiety disorders are associated with an amplification of physical symptoms of pregnancy. Eliciting and tracking somatic symptoms during prenatal visits could potentially improve detection of depressive and anxiety disorders in the obstetrical sector.     

Somatic symptoms in late-life anxiety: treatment issues

Understanding and addressing somatic symptoms are complex in older adults, who have more comorbid medical illnesses. This article describes a systematic review of the literature on somatic symptoms in older patients with anxiety disorders. Additionally, the hypothesis was tested that somatic symptoms would respond to selective serotonin reuptake inhibitor treatment in 30 anxious patients aged 60 years and older who participated in a 32-week trial of citalopram. The literature review showed few original data articles about somatic symptoms in older patients with anxiety disorders. These articles suggest that such a relationship is common and that treatment of anxiety, or anxious depression, is associated with a reduction in somatic symptoms. In the analysis, citalopram treatment was associated with a significant decrease in several somatic symptoms from pretreatment baseline. It is concluded that somatic symptoms in older adults with anxiety disorders or anxious depression often improve with successful antidepressant treatment. However, additional treatment and integrated approaches are likely to be necessary for many such individuals.     

Somatic symptoms of depression in elderly patients with medical comorbidities

OBJECTIVE: Somatic symptoms of depression such as fatigue create a diagnostic dilemma when assessing an older patient with medical comorbidities, since chronic medical illnesses may produce similar symptoms. Alternatively, somatic symptoms attributed to medical illness may actually be caused by depression. These analyses were designed to determine if somatic symptoms in older patients are more strongly associated with chronic physical problems or with depression. DESIGN: Reanalysis of data from an observational study of depression in primary care and a randomized trial of paroxetine and nortriptyline for the treatment of major depression. Patients were evaluated with a structured diagnostic interview and a battery of psychiatric, physical, and psychosocial measures. PARTICIPANTS: Two hundred and forty eight primary care and psychiatric patients aged >or= 60 years. METHODS: Associations among depression, somatization, and chronic physical problems were examined using correlations and regression modeling. RESULTS: Two somatization measures, the Asberg Side Effects Rating Scale and the Utvalg for Kliniske Undersogelser (UKU), were significantly associated with psychological symptoms of depression (r = 0.73 and r = 0.76, p < 0.0001) but not with medical comorbidities (r = 0.02, p = 0.16 and r = 0.10, p = 0.78). In multiple regression models, psychological symptoms of depression remained significant predictors of somatization (p < 0.0001) after controlling for age, gender, and medical comorbidities. CONCLUSIONS: In older patients with medical disorders and multiple somatic complaints, clinicians should consider the possibility of depression. Rating scales emphasizing somatic symptoms associated with depression may provide a more accurate measure of depression severity than those excluding such symptoms.     

Somatoform disorders. Clinical evidence, etiology, pathogenesis, and therapy

Patients presenting with bodily symptoms and complaints that are not explained by organic pathology or well-known pathophysiological mechanisms comprise a major challenge to any medical care system. From a perspective of psychiatric classification, such medically unexplained somatic symptoms are diagnosed as depressive and anxiety disorders on the one hand or somatoform disorders on the other. In clinical physical medicine a quite different diagnostic approach is taken to conceptualize functional somatic syndromes. Concepts of somatoform disorders are outlined, critical issues regarding existing diagnostic systems are discussed, and possible alternative approaches for upcoming versions of DSM-V and ICD-11 are mentioned. The main somatoform disorders are described in their clinical characteristics. Etiopathogenetically, somatoform disorders may best be considered within a multifactorial model. Some pragmatic guidelines for multimodal treatment of somatoform disorders are outlined.     

Use of the Adinfer diagnostic system in a study of somatic disorders in general practice]

Somatic complaints are very common in general medical practice. They are not identified as psychic disorders and are treated symptomatically. We explore two kind of problems: 1. methodological problems such as the instruments to use to examine somatic complaints (it is evident that a checklist does not give the best results with suggestible patients); and 2. the relationships between somatic complaints and psychic disorders such as anxiety, depression and somatoform disorders. Psychiatric nosology is by no means clear and includes many diagnoses from "hysteria" to "hypochondria" or "psychosomatic", "somatization". In this study, we compare the symptoms collected by general practitioners, and their clinical diagnoses to those obtained by an automatic DSM-III diagnostic program. Adinfer was modified so that three DSM decision trees were systematically scanned: depressive, anxiety and somatoform disorders. This allows for an epidemiological study of somatic complaints and their relationship to depression and anxiety. The subjects' score on rating scales for anxiety and depression are compared with the diagnoses made by the expert system. We discuss the significance of somatic symptoms, the DSM classes and the value of expert systems in epidemiological studies.     

Depression and public health: an overview

Depressive disorders are a significant public health issue. They are prevalent, disabling, often chronic illnesses, which cause a high economic burden for society, related to both direct and indirect costs. Depressive disorders also influence significantly the outcome of comorbid medical illnesses such as cardiac diseases, diabetes, and cancer. In primary care, underrecognition and undertreatment of depressive disorders are common, despite their relatively high prevalence, which accounts typically for more than 10% of patients. Primary care physicians should be aware of the common risk factors for depressive disorders such as gender, neuroticism, life events and adverse childhood experiences, and they should be familiar with associated features such as a positive psychiatric family history and prior depressive episodes. In primary care settings, depressive disorders should be considered with patients with multiple medical problems, unexplained physical symptoms, chronic pain or use of medical services that is more frequent than expected. Management of depressive disorders in primary care should include treatment with the newer antidepressant agents (given the fact they are typically well tolerated and safe) and focus on concomitant unhealthy behaviors as well as treatment adherence, which may both affect patient outcome. Programs aimed at improving patient follow-up and the coordination of the primary care intervention with that of specialists have been found to improve patient outcomes and to be cost effective.     

Distress and functioning in mixed anxiety and depressive disorder

The aim of the present study was to evaluate the validity of mixed anxiety and depressive disorder (MADD) with reference to functional characteristics and symptomatic characteristics in comparison with anxiety disorders, depressive disorders, and groups showing subthreshold symptoms (exclusively depressive or anxiety related). The present study was carried out in the following three medical settings: two psychiatric and one primary care. Patients seeking care in psychiatric institutions due to anxiety and depressive symptoms and attending primary medical settings for any reason were taken into account. A total of 104 patients (65 women and 39 men, mean age 41.1 years) were given a General Health Questionnaire (GHQ-30), Global Assessment of Functioning (GAF) and Present State Examination questionnaire, a part of Schedules for Clinical Assessment in Neuropsychiatry, Version 2.0. There were no statistically relevant differences between MADD and anxiety disorders in median GHQ score (19 vs 16) and median GAF score (median 68.5 vs 65). When considering depressive disorders the median GHQ score (28) was higher, and median GAF score (59) was lower than that in MADD. In groups with separated subthreshold anxiety or depressive symptoms, median GHQ scores (12) were lower and median GAF scores (75) were higher than that in MADD. The most frequent symptoms of MADD are symptoms of generalized anxiety disorder (GAD) and depression. Mixed anxiety and depressive disorder differs significantly from GAD only in higher rates of depressed mood and lower rates of somatic anxiety symptoms. Distinction from depression was clearer; six of 10 depressive symptoms are more minor in severity in MADD than in the case of depression. Distress and interference with personal functions in MADD are similar to that of other anxiety disorders. A pattern of MADD symptoms locates this disorder between depression and GAD.     

Somatization: a spectrum of severity

OBJECTIVE: The DSM-III-R diagnosis of somatization disorder requires that a patient have a specific number of medically unexplained somatic symptoms. This number of symptoms was developed by committee consensus, and it is not clear whether patients with this specific number of symptoms can be differentiated from patients with lower but still substantial numbers of somatic symptoms. METHOD: Fifty-one percent of 767 high utilizers of two primary care clinics were identified as distressed by an elevated SCL anxiety, depression, or somatization scale score or by their primary care physician. The Diagnostic Interview Schedule (DIS) was completed on 119 distressed high utilizers who were randomly assigned to an intervention group in a controlled trial of psychiatric consultation. The 119 distressed high utilizers were separated into four categories according to the number of unexplained somatic symptoms found on the DIS and were compared on demographic, psychiatric distress, disability, medical, and health utilization variables. RESULTS: The data suggest that many clinical and behavioral features of somatization are significantly more common in patients with four to 12 medically unexplained somatic symptoms rather than changing dramatically at the diagnostic threshold for somatization disorder. The data also showed that patients who meet the DSM-III-R criteria for somatization disorder are severely ill and have a high burden of psychiatric illness and disability. CONCLUSIONS: The results suggest that the DSM-IV somatoform disorders section should include somatization disorder, an abridged definition of somatization disorder often associated with anxiety and depression, as well as a type of somatization associated with an adjustment disorder.     

Prevalence and determinants of depressive disorders in primary care practice in Spain

OBJECTIVE: Depressive disorders are considered to be a public health problem. Primary health care plays an important role in the treatment of such disorders. Our aim is to determine the prevalence and determinant factors of major depression and dysthymia in consecutive primary care attenders. METHOD: The study took place in medical consultations in 10 Primary Care Centers in Tarragona (Spain). It was designed as a two-phase cross-sectional study. In the first phase we screened 906 consecutive patients according to Zung's Self-Rating Depression Scale. In the second phase the 209 patients whose results were positive and 97 patients whose results were negative (1/7 chosen at random) were given the Structured Clinical Interview for DSM-IV Axis I Disorders, plus a series of questionnaires. We evaluated the link between major depression and dysthymia and several sociodemographic and clinical variables using non-conditional logistic regression. RESULTS: Weighted prevalence was 14.3% (CI 95%: 11.2-17.4) for major depression and 4.8% (CI 95%: 2.8-6.8) for dysthymia. Independently linked to the presence of major depression were female sex, panic disorder, generalized anxiety disorder, frequency of primary care visits, and clinical presentation in the form of explicitly psychosocial symptoms as opposed to exclusively somatic symptoms. Independently linked to the presence of dysthymia were age, generalized anxiety disorder and psychosocial symptoms. CONCLUSION: In our area, depressive disorders in primary care attenders are very common. General practitioners should be aware of this fact so that these disorders can be detected and treated correctly.     

Can recovery from depression be achieved?

Even though a variety of treatments are available for depression, many patients experience an incomplete response, resulting in chronic functional impairment. The authors present a therapeutic heuristic that derives, in part, from a body of research that suggests that symptoms of mood disorders can be separated into three distinct components: somatic anxiety, which is most prominent in anxiety disorders, such as panic; anhedonia or low positive affect, which is most specific to depression; and general distress, which is present with both anxiety and depressive disorders. General distress and somatic anxiety appear to be significantly modulated by serotonin, and serotonergic drugs may exert their effects most significantly on these symptoms. On the other hand, positive affect, the dimension of reward-oriented motivation and enjoyment, appears to be most dependent on dopamine and, indirectly, norepinephrine. Thus a theoretical heuristic can be derived on the basis of the predominance of residual symptoms. Serotonergic agents would be chosen for monotherapy or augmentation for symptoms of distress. Alternatively, catecholaminergic drugs would be the first choice for anhedonia and decreased motivation.     

Overview and clinical presentation of generalized anxiety disorder.

1. To distinguish GAD from panic disorder is not difficult if a patient has frequent, spontaneous panic attacks and agoraphobic symptoms, but many patients with GAD have occasional anxiety attacks or panic attacks. Such patients should be considered as having GAD. An even closer overlap probably exists between GAD and social phobia. Patients with clear-cut phobic avoidant behavior may be distinguished easily from patients with GAD, but patients with social anxiety without clear-cut phobic avoidant behavior may overlap with patients with GAD and possibly should be diagnosed as having GAD and not social phobia. The cardinal symptoms of GAD commonly overlap with those of social phobia, particularly if the social phobia is more general and not focused on a phobic situation. For example, free-floating anxiety may cause the hands to perspire and may cause a person to be shy in dealing with people in public, and thus many patients with subthreshold social phobic symptoms have, in the authors' opinion, GAD and not generalized social phobia. The distinction between GAD and obsessive-compulsive disorder, acute stress disorder, and posttraumatic stress disorder should not be difficult by definition. At times, however, it may be difficult to distinguish between adjustment disorder with anxious mood from GAD or anxiety not otherwise specified, particularly if the adjustment disorder occurs in a patient with a high level of neuroticism or trait anxiety or type C personality disorder. Table 2 presents features distinguishing GAD from other psychiatric disorders. 2. Lifetime comorbid diagnoses of other anxiety or depression disorders, not active for 1 year or more and not necessitating treatment during that time period, should not effect a diagnosis of current GAD. On the other hand, if concomitant depressive symptoms are present and if these are subthreshold, a diagnosis of GAD should be made, and if these are full threshold, a diagnosis of MDD should be made. 3. If GAD is primary and if no such current comorbid diagnosis, such as other anxiety disorders or MDD, is present, except for minor depression and dysthymia, or if only subthreshold symptoms of other anxiety disorders are present, GAD should be considered primary and treated as GAD; however, patients with concurrent threshold anxiety or mood disorders should be diagnosed according to the definitions of these disorders in the DSM-IV and ICD-10 and treated as such. 4. Somatization disorders are now classified separately from anxiety disorders. Some of these, particularly undifferentiated somatization disorder, may overlap with GAD and be diagnostically difficult to distinguish. The authors believe that, as long as psychic symptoms of anxiety are present and predominant, patients should be given a primary diagnosis of GAD. 5. Two major shifts in the DSM diagnostic criteria for GAD have markedly redefined the definition of this disorder. One shift involves the duration criterion from 1 to 6 months, and the other, the increased emphasis on worry and secondary psychic [table: see text] symptoms accompanied by the elimination of most somatic symptoms. This decision has had the consequence of orphaning a large population of patients suffering from GAD that is more transient and somatic in its focus and who typically present not to psychiatrists but to primary care physicians. Therefore, clinicians should consider using the ICD-10 qualification of illness duration of "several months" to replace the more rigid DSM-IV criterion of 6 months and to move away from the DSM-IV focus on excessive worry as the cardinal symptom of anxiety and demote it to only another important anxiety symptom, similar to free-floating anxiety. One also might consider supplementing this ICD-10 criterion with an increased symptom severity criterion as, for example, a Hamilton Anxiety Scale of 18. Finally, the adjective excessive, not used in the definition of other primary diagnostic criteria, such as depressed mood for MDD, should be omitted (Table 3). 6. One may want to consider the distinction of trait (chronic) from state (acute) anxiety, but whether the presence of some personality characteristics, particularly anxious personality or Cluster C personality and increased neuroticism, as an indicator of trait [table: see text] anxiety is a prerequisite for anxiety disorders; occurs independently of anxiety disorders; or is a vulnerability factor that, in some patients, leads to anxiety symptoms and, in others, does not, is unknown. 7. Symptoms that some clinicians consider cardinal for a diagnosis of GAD, such as extreme worry, obsessive rumination, and somatization, also are present in other disorders, such as MDD. (ABSTRACT TRUNCATED)     

Anxiety and Depression: Optimizing Treatments

Properly diagnosing and treating patients with anxiety, depression, or both is a challenging aspect of practicing medicine in the primary care setting. Patients often present with somatic complaints rather than classic psychiatric symptoms. In addition, there is significant overlap between anxiety and depression in this patient population. Comorbid anxiety and depression is often more resistant to pharmacologic treatment, and patients with coexisting disorders have a poorer medical prognosis than do patients with either disorder alone. Fortunately, many new therapies are available to assist the clinician in managing these patients. The newer antidepressants, in particular, are playing an increasingly important role in the treatment of both anxiety disorders alone and comorbid anxiety and depression. These new choices enable our goal of treatment to encompass not only improvement but also sustained complete remission. Of the newer agents, the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have been studied quite extensively in these patient populations. The specific profiles of individual agents may assist the clinician in individualizing treatment. Characteristics such as robust efficacy, speed of onset of activity, the potential for drug-drug interactions, dose response, and tolerability are important considerations in optimizing treatment.     

The relation between anger management style, mood and somatic symptoms in anxiety disorders and somatoform disorders

The objective of this study was to examine the relationship between anger management style, depression, anxiety and somatic symptoms in anxiety disorder and somatoform disorder patients. The subjects comprised 71 patients with anxiety disorders and 47 with somatoform disorders. The level of anger expression or anger suppression was assessed by the Anger Expression Scale, the severity of anxiety and depression by the Symptom Checklist-90-Revised (SCL-90-R) anxiety and depression subscales, and the severity of somatic symptoms by the Somatization Rating Scale and the SCL-90-R somatization subscale. The results of path analyses showed that anger suppression had only an indirect effect on somatic symptoms through depression and anxiety in each of the disorders. In addition, only anxiety had a direct effect on somatic symptoms in anxiety disorder patients, whereas both anxiety and depression had direct effects on somatic symptoms in somatoform disorder patients. However, the anxiety disorder group showed a significant negative correlation between anger expression and anger suppression in the path from anger-out to anger-in to depression to anxiety to somatic symptoms, unlike the somatoform disorder group. The results suggest that anger suppression, but not anger expression, is associated with mood, i.e. depression and anxiety, and somatic symptoms characterize anxiety disorder and somatoform disorder patients. Anxiety is likely to be an important source of somatic symptoms in anxiety disorders, whereas both anxiety and depression are likely to be important sources of somatic symptoms in somatoform disorders. In addition, anger suppression preceded by inhibited anger expression is associated with anxiety and somatic symptoms in anxiety disorders.     

Anxiety in medically ill children/adolescents

Anxiety disorders are thought to be one of the most common psychiatric diagnoses in children/adolescents. Chronic medical illness is a significant risk factor for the development of an anxiety disorder, and the prevalence rate of anxiety disorders among youths with chronic medical illnesses is higher compared to their healthy counterparts. Anxiety disorders may develop secondary to predisposing biological mechanisms related to a child's specific medical illness, as a response to being ill or in the hospital, a threatening environment, as a result of other genetic and psychological factors, or as a combination of all these factors. Additionally, exposure to physical pain early in one's life and/or frequent painful medical procedures are correlated with fear and anxiety during subsequent procedures and treatments, and may lead to medical nonadherence and other comorbidities. Anxiety disorders can have serious consequences in children/adolescents with chronic and/or life‐limiting medical illnesses. Therefore, proper identification and treatment of anxiety disorders is necessary and may improve not only psychiatric symptoms but also physical symptoms. Behavioral and cognitive methods as well as psychotropic medications are used to treat anxiety disorders in pediatric patients. We will review current treatments for anxiety in children/adolescents with medical illnesses and propose future research directions. Depression and Anxiety, 2011. © 2010 Wiley‐Liss, Inc.     

The utility of somatic symptoms as indicators of depression and anxiety in military veterans with chronic obstructive pulmonary disease

The interrelationship between medical illnesses and psychological distress has received increasing attention in the last several years. Partly at issue is the best way to diagnose mental health problems such as depression and anxiety in medical populations. Specifically, are somatic symptoms a valid indicator of depression and anxiety in a medical population? Furthermore, do anxiety and depression remain as distinct constructs for this population, or do they combine to represent general distress? We examine these issues using confirmatory factor analysis in a sample of 202 military veterans with chronic obstructive pulmonary disease. Results indicate best fit for a model of depression and anxiety for which the constructs remained separate rather than as combined indicators of general distress. Furthermore, in this model, somatic symptoms are retained as valid indicators of psychological distress for this sample. Depression and Anxiety 23:42–49, 2006. © 2005 Wiley‐Liss, Inc.     

Depression in Brazil and other Latin American countries.

Minor psychiatric disorders, specially depression and anxiety, are highly prevalent in Latin American (LA) countries including Brazil. Some important social factors specially present in medium and large LA cities such as violence, migration and homelessness probably contribute to large number of people suffering of different forms of depressive and anxiety disorders. Latin America was colonized about 500 years ago by Spain and Portugal and their cultural identity is still very much influenced by Ibero-American attitudes and beliefs. Probably as a consequence of this situation, depression is usually expressed in LA countries more through somatic symptoms such as headaches, gastrointestinal disturbances, or complaints of "nerves" than through subjective feelings of sadness or guilty. So, depression is much more seen in primary care services than in psychiatric clinics and as in other parts of the World is not recognized. Nevertheless, primary care patients from different cultural backgrounds with somatic complaints due to depression differ in their preferred explanations or attributions for these symptoms. Somatic complaints many times represent just a different idiom of distress related to depression; to understand their origin and role for patients from different cultures will certainly help health professionals to better identify and treat them.     

Unexplained fatigue syndromes in a multinational primary care sample: specificity of definition and prevalence and distinctiveness from depression and generalized anxiety

OBJECTIVE: The authors investigated whether narrow definitions of unexplained fatigue syndromes that require additional minor somatic symptoms are more strongly associated with psychiatric morbidity than wider ones. METHOD: This was a secondary analysis of the World Health Organization Collaborative Project on Psychological Problems in General Health Care. A total of 5,438 primary care patients from 14 countries were assessed with the Composite International Diagnostic Interview. RESULTS: The prevalence of fatigue syndromes fell from 7.99 to 1.69 as somatic criteria were added. Patients with depression or anxiety were more likely to report unexplained fatigue, but this association was stronger for definitions of unexplained fatigue with more somatic criteria. CONCLUSIONS: Definitions of unexplained fatigue syndromes that require more somatic criteria selected more patients with psychiatric disorders in this culturally diverse sample. These findings might have implications for the revision of existing international diagnostic criteria for neurasthenia or chronic fatigue syndrome.     

Behavioural and psychological management of somatic symptom disorders: An overview

Abstract

The number of patients who seek help at primary and secondary care for somatic symptoms which cannot be explained by any known medical condition is enormous. It has been proposed to rename ‘somatoform disorders’ in DSM-IV as ‘somatic symptom disorders’ in DSM-5. This is supposed to include disorders such as somatization disorder, hypochondriasis, undifferentiated somatoform disorder, pain disorder and factitious disorder. The reason for the renaming and grouping is that all these disorders involve presentation of physical symptoms and/or concern about medical illness. In the literature, there is considerable variation adopted with respect to diagnosis and in the approaches adopted for intervention. However, the common feature of these disorders is the chronicity, social dysfunction, occupational difficulties and the increased healthcare use and high level of dissatisfaction for both the clinician and the patient. A number of behavioural and psychological interventions for somatic symptoms have been carried out at primary, secondary and tertiary care settings and recently there have been more attempts to involve the primary care physicians in the psychological interventions. This review aims at giving an overview of the components of the behavioural and other psychological interventions available for addressing medically unexplained somatic symptoms and to present their efficacy.