Box 1. Stepped-care approach in clinical guidelines for MUS
Dutch GP guidelineDanish GP guidelineGerman multidisciplinary guidelineDutch multidisciplinary guideline
Mild MUS
  • Psycho-education

  • (Self-)management advice

  • Shared time-contingent plan

  • Follow-up

Symptoms and mild functional disorders
  • Normalisation, explanation, biopsychosocial approach

  • Follow-up

Step 1
  • General principles of therapy (empathy, watchful waiting, acknowledgement of the symptoms, explanation)

  • Therapy by GP or medical specialist, or psychosomatic primary health care

Mild MUS
  • Biopsychosocial approach by GP

  • Psycho-education

  • Short-term CBT

  • Psychosomatic physio/exercise therapy

  • Mental health nurse practitioner

  • Social psychiatric nurse

Moderate functional disorders
  • Explanations and TERM model

  • Regular consultations

  • Cooperation with specialist (in charge of assessment, treatment plan, and supervision)

Step 2
  • Regular consultations

  • Therapy by GP or medical specialist PLUS psychotherapy

  • Pain as core symptom: antidepressant

  • Pain not as core symptom: antidepressant in case of psychiatric comorbidity

Moderate MUS
  • Case management by medical specialist, psychiatrist or GP

  • Medication (for comorbidity)

  • CBT

  • Multidisciplinary team / treatment centre

Severe functional disorders
  • Specialist clinic

  • Multidisciplinary treatment

  • CBT and GET

  • Consider pharmacological treatment

Step 3
  • Specialist clinic with multidisciplinary treatment

Severe MUS
  • CBT

  • Treatment by a multidisciplinary team in tertiary care

  • CBT = cognitive behavioural therapy. GET = graded exercise therapy. MUS = medically unexplained symptoms. TERM = The Extended Reatribution and Management model.