Cochrane review: Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. 2014

Sly Saint · Sep 20, 2019

https://www.ncbi.nlm.nih.gov/pubmed/25362239
http://sci-hub.tw/10.1002/14651858.CD011142.pub2#

Compared with enhanced care, CBT was not more effective. The overall quality of evidence contributing to this review was rated low to moderate.The intervention groups reported no major harms. However, as most studies did not describe adverse events as an explicit outcome measure, this result has to be interpreted with caution.An important issue was that all studies in this review included participants who were willing to receive psychological treatment. In daily practice, there is also a substantial proportion of participants not willing to accept psychological treatments for somatoform disorders or MUPS.
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Of note

As we aimed to summarise interventions for multiple symptoms, we excluded studies that examined participants diagnosed with only one specific functional syndrome or symptom(e.g.fibromyalgia or fatigue).
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2.5 Adverse events
None of the studies comparing psychological therapy versus enhanced or structures care reported information about adverse events.
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a few specific domains were often rated as being at high risk of bias across the studies. Especially for blinding of the outcome measurement, we identified a high risk of bias in most of the included studies.
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Compared with enhanced or structured care, psychological therapies generally were not more effective for most of the outcomes.
CBT was also not superior to enhanced care. The question remains how specific CBT is over structured improvements of care.
No major adverse events were reported in the intervention groups,
although most studies did not describe adverse events as an explicit outcome measure. Apart from CBT, neither psychological nor other non-pharmacological therapies have been adequately studied
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Psychological treatments were not superior to enhanced care. It could be argued that an active comparator such as enhanced care underestimates treatment effects. However, as this comparative treatment is probably cheaper than more intensive psychological
interventions, it would deserve further study (cf.Rosendal 2013)
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curious that this Cochrane review doesn't get so much 'attention'

eta: see also Cochrane Clinical Answers
https://www.cochrane.org/news/cochrane-clinical-answers
Question:
What are the effects of psychological therapies for adults with somatic symptom disorder or medically unexplained physical symptoms (MUPS)?
March 2019
https://www.cochranelibrary.com/cca/doi/10.1002/cca.2344/full

Jonathan Edwards · Sep 20, 2019

It is very lukewarm, yet there is still the sort of sloppy wording that suggests that the people doing the study fail to understand the real problems. They say:

'For all studies comparing some form of psychological therapy with usual care or a waiting list that could be included in the meta‐analysis, the psychological therapy resulted in less severe symptoms at end of treatment'

What they mean is:

'For all studies comparing some form of psychological therapy with usual care or a waiting list that could be included in the meta‐analysis, allocation to the psychological therapy group resulted in less severe symptoms being reported at end of treatment'

The people doing these reviews do not seem to understand that if risk of bias is high you cannot talk of an 'effect' being small or moderate, only a difference.

ME/CFS Skeptic · Sep 20, 2019

Sharpe & Fink wrote an angry commentary about the Van Dessel review because their trial on bodily distress syndrome was not included. See: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00233-3/fulltext

rvallee · Sep 20, 2019

As we aimed to summarise interventions for multiple symptoms, we excluded studies that examined participants diagnosed with only one specific functional syndrome or symptom(e.g.fibromyalgia or fatigue).
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Rejecting reality and substituting one's own is always a bad idea. Taking diseases with multiple symptoms and arbitrarily reducing them to a single secondary symptom leads to completely absurd situations like this.

Not that FM and whatever they mean by fatigue should be in that list, but it's pretty ridiculous how the failures compound with one another in blatant rejection of reality. This is broken beyond repair. The whole EBM is broken beyond repair if it's not even self-consistent and leads to absurd contradictions like this.

Since I saw it yesterday, this quote is very fitting:

If the rule you followed brought you to this, of what use was the rule? This is the best deal you're going to get. I won't tell you that you can save yourself, because you can't.
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Sly Saint · Feb 2, 2020

Michiel Tack said: ↑

Sharpe & Fink wrote an angry commentary about the Van Dessel review because their trial on bodily distress syndrome was not included. See: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00233-3/fulltext
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according to this report Bodily distress syndrome (4 studies) was included in the review.
see page 109

SOM AT ISAT ION DISOR DER

SUMMARY OF EVIDENCE
There is a vast amount of research on conditions classified
under the term “medically unexplained physical symptoms”,
somatoform disorders more broadly, and “abridged somatisation
disorder” (generally defined as meeting four of the six somatic
symptoms for somatisation disorder). Furthermore, some
researchers conceptualise somatisation disorders as including
conditions such as chronic fatigue syndrome, fibromyalgia, and
irritable bowel syndrome. However, little research has been
conducted that addresses somatisation disorder defined as a
discrete diagnostic category.

In keeping with the scope of the current review, only studies that
included participants diagnosed with somatisation disorders as
defined by ICD-10 or DSM have been included.
Based on these criteria, there is Level II evidence for CBT for
the treatment of somatisation disorder in adults. In the current
review, there was insufficient evidence to indicate that any of
the remaining interventions were effective
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Non-pharmacological interventions for somatoform disorders and medically
unexplained physical symptoms (MUPS) in adults
van Dessel, N., den Boeft, M., van der Wouden, J. C., Kleinstäuber, M., Leone, S. S., Terluin,
B., ... van Marwijk, H. (2014).
Cochrane Database of Systematic Reviews, 2014
(11),
CD011142. doi:10.1002/14651858.CD011142.pub2
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2,658 adults with medically unexplained physical symptoms (nine studies) or who met
diagnostic criteria for somatisation disorder or somatoform disorder (three studies),
somatisation symptoms (five studies), or bodily distress syndrome (four studies). The mean
age was 43 years in all included studies, ranging from 35 to 49 years. Most studies
comprised more females than males.
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Evidence-based psychological interventions in the treatment of Mental Disorders; 2018 review
The Australian Psychological Society Limited (APS)

https://www.psychology.org.au/getme...f26fae/Evidence-based-psych-interventions.pdf

Sean · Feb 3, 2020

https://www.psychology.org.au/getme...f26fae/Evidence-based-psych-interventions.pdf

These are our solutions. If you don't like them, there are plenty more where they came from.

Acceptance and commitment therapy (ACT)
Cognitive behaviour therapy (CBT)
Dialectical behaviour therapy (DBT)
Emotion-focused therapy (EFT)
Eye movement desensitisation and reprocessing (EMDR)
Family interventions (including behavioural parent-training interventions)
Hypnotherapy
Interpersonal psychotherapy (IPT)
Mindfulness-based cognitive therapy (MBCT)
Narrative therapy
Play therapy (for children)
Psychodynamic psychotherapy
Psychoeducation
Schema-focused therapy
Self-help therapy (also known as bibliotherapy)
Solution-focused brief therapy (SFBT)
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Hutan · Apr 20, 2022

This Cochrane review from 2014 posted by @SlySaint is worth reviewing in the context of the long promised new Cochrane review of exercise therapy for ME/CFS.

The 2014 review is about MUPS

Medically unexplained physical symptoms (MUPS) are physical symptoms for which no adequate medical explanation can be found after proper examination.
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It would be very interesting to know what the current Cochrane Exercise Review for ME/CFS team's stance is on whether ME/CFS is a MUPS condition. On the face of it, if you are going to allow MUPS to be a thing, I see no reason why ME/CFS isn't currently a type of it.

@Medfeb, this 2014 guideline is perhaps of use in making some arguments to those in Cochrane who need convincing that unblinded studies with no good objective outcomes typically have such a high risk of bias as to be useless. For example, how do therapists who swear that CBT is effective in MUPS reconcile that with these findings?

Especially for blinding of the outcome measurement, we identified a high risk of bias in most of the included studies.
Click to expand...

Compared with enhanced or structured care, psychological therapies generally were not more effective for most of the outcomes.
CBT was also not superior to enhanced care.
Click to expand...

Psychological treatments were not superior to enhanced care. It could be argued that an active comparator such as enhanced care underestimates treatment effects. However, as this comparative treatment is probably cheaper than more intensive psychological
interventions, it would deserve further study
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The authors seemed to have made a big effort on searching for relevant studies

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to November 2013. This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library, EMBASE, MEDLINE, and PsycINFO. We ran an additional search on the Cochrane Central Register of Controlled Trials and a cited reference search on the Web of Science. We also searched grey literature, conference proceedings, international trial registers, and relevant systematic reviews.

We included RCTs and cluster randomised controlled trials which involved adults primarily diagnosed with a somatoform disorder or an alternative diagnostic concept of MUPS, who were assigned to a non-pharmacological intervention compared with usual care, waiting list controls, attention or psychological placebo, enhanced care, or another psychological or physical therapy intervention, alone or in combination.
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Despite that effort,

All studies assessed the effectiveness of some form of psychological therapy. We found no studies that included physical therapy.
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Admittedly this study is a bit old, but still - no studies of physical therapy for MUPS at that time? Aside from the fact that they clearly excluded ME/CFS from the MUPS scope, it is incredibly hard to believe that if exercise therapy was of any use at all for MUPS, there was not a single RCT evaluating the therapy. I mean, with the funds sloshing around for BPS studies, surely if GET was great at fixing people with MUPS, someone would have done a study of it?

Jonathan Edwards said: ↑

It is very lukewarm, yet there is still the sort of sloppy wording that suggests that the people doing the study fail to understand the real problems. They say:
'For all studies comparing some form of psychological therapy with usual care or a waiting list that could be included in the meta‐analysis, the psychological therapy resulted in less severe symptoms at end of treatment'

What they mean is:
'For all studies comparing some form of psychological therapy with usual care or a waiting list that could be included in the meta‐analysis, allocation to the psychological therapy group resulted in less severe symptoms being reported at end of treatment'
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What they mean is even more limited than that, if you consider the effect of survivorship bias on top of the selection bias and the outcome interpretation bias. The people allocated to psychological therapy who got worse and couldn't physically make it to the sessions, and the people told the therapist exactly where they could put their false illness beliefs I am sure were not well represented in those filling out the questionnaires at the end of the studies.

@Caroline Struthers, @Hilda Bastian

(I may well have missed something in the ongoing Cochrane saga)

Medfeb · Apr 20, 2022

@Hutan - speaking for myself, MUPS is a clinical thing only in the minds of those who promote it. IMO, it's unscientific to base a clinical entity solely on the lack of evidence and lack of current scientific knowledge.

Hutan · Apr 20, 2022

Thanks

Medfeb said: ↑

@Hutan - speaking for myself, MUPS is a clinical thing only in the minds of those who promote it. IMO, it's unscientific to base a clinical entity solely on the lack of evidence and lack of current scientific knowledge.
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Indeed, and yet Cochrane seems to embrace the term.

I note that Cochrane reinterpreted the 2014 MUPS report in 2019 with a Cochrane Clinical Answers entry

Cochrane Clinical Answers
Question:
What are the effects of psychological therapies for adults with somatic symptom disorder or medically unexplained physical symptoms (MUPS)?

Jane Burch, Adrian Preda
1 March 2019
https://doi.org/10.1002/cca.2344
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excerpt said:

Psychological therapies for adults with somatic symptom disorder or MUPS seem to provide some symptom relief, although benefits may be small. RCTs reported that adherence was high and adverse event rates low in both psychological therapy and control groups, although withdrawal from psychological therapy was more frequent than withdrawal from usual care/waitlist control.

For adults (mean age, 35 to 49 years; 56% to 89% women) with somatic symptom disorder, or MUPS, low‐certainty evidence suggests small reductions in the severity of somatic symptoms immediately after treatment and at one year with psychological therapy when compared with usual care, waitlist control, or enhanced care (clinician‐offered structured appointments but no specific therapy for MUPS). Researchers also observed small to moderate benefits with psychological therapy post treatment and within one year in terms of anxiety and/or depressive symptoms (most consistently when these were clinician‐rated; quality of evidence was not assessed) and functional disability and quality of life (low‐ to moderate‐certainty evidence).
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This Clinical Answer removes much of the uncertainty expressed in the 2014 review, making psychological therapies sound more helpful for MUPS.
For example, on harms:

2014 review said:

The intervention groups reported no major harms. However, as most studies did not describe adverse events as an explicit outcome measure, this result has to be interpreted with caution....
2.5 Adverse events
None of the studies comparing psychological therapy versus enhanced or structures care reported information about adverse events.
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2019 interpretation said:

RCTs reported that adherence was high and adverse event rates low in both psychological therapy and control groups... The rate of adverse events was low for both psychological therapy and usual care/waitlist control groups (3% vs 2%).
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I would be very interested to know if Cochrane officially regards ME/CFS as a MUPS condition.

Mithriel · Apr 22, 2022

The intervention groups reported no major harms. However, as most studies did not describe adverse events as an explicit outcome measure, this result has to be interpreted with caution....
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That sounds like a line from a comedy show.

Sean · Apr 23, 2022

The intervention groups reported no major harms... because the researchers didn't measure them.

rvallee · Apr 23, 2022

If you de-medicalize harms, no medical harms occurred.

100% success if you define success as not finding failure, by not allowing it to be found. It's infallible!

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Cochrane review: Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. 2014

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