Box 1. Stepped-care approach in clinical guidelines for MUS

Dutch GP guideline		Danish GP guideline		German multidisciplinary guideline		Dutch 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
Moderate MUS	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
Severe MUS	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.