PERSPECTIVES

Medically Unexplained Symptoms: Barriers to

Effective Treatment When Nothing Is the Matter
Don R. Lipsitt, MA, MD, Robert Joseph, MS, MD, Donald Meyer, MD,
and Malkah T. Notman, MD

Abstract: Patients with symptoms that elude medical explanation are a perennial challenge to practicing physicians of all
disciplines. Articles appear virtually monthly advising physicians how to care for them. Efforts at postgraduate education
have attempted to ameliorate the situation but have shown limited or disappointing results at best. Physicians continue
either to avoid these patients or to resort to a “seat-of-the-pants” approach to management. Literature on patients with
medically unexplained symptoms, along with extensive experience consulting with primary care physicians, suggests
that it is not primarily lack of physician skills but rather a series of barriers to adequate care that may account for subop-
timal management. Barriers to implementation of effective care reside in the nature of medical education, the doctor-
patient relationship, heterogeneity of symptoms and labels, changes in the health care system, and other variables. These
impediments are considered here, with suggested potential remedies, in the conviction that the proper care of patients
with medically unexplained symptoms can, among other things, bring satisfaction to both the patient and the physician,
and help to reduce ineffective health resource utilization.
Keywords: barriers to care, doctor-patient relationship, medically unexplained symptoms, patient care, somatization

T
his article emanates from an ongoing Work Group on
Somatization, initiated by the authors more than two
decades ago. Deliberations and opinions derive from
literature reviews and from our clinical experience consulting
with primary care physicians—a collective experience span-
ning more than 100 years as consultation-liaison psychia-
trists. While an exhaustive review of the hundreds of articles
on somatization and medically unexplained symptoms is be-
yond the scope of this article, we make selective reference to
them in order to elaborate on opinions derived from personal
clinical experience witnessing the difficulties that physicians
experience in encounters with somatizing patients.
Extensive consideration of the prevalence of patients with
“medically unexplained symptoms” (previously referred to
as somatizing or somatoform disorders) is accompanied by
the general observation of notoriously poor therapeutic out-
comes in general practice.1,2 Their presence is well noted
not only in primary care but also in specialty practices, with
general prevalence levels for outpatient visits hovering around
30%3 or higher in some specialty practices.4,5 In cost and mis-
use of resources, these patients pose a significant burden to
From Harvard Medical School and Cambridge Health Alliance, Cambridge, MA.
Original manuscript received 27 February 2014; revised manuscript received
5 June 2014, accepted for publication subject to revision 8 July 2014; revised
manuscript received 19 July 2014.
Correspondence: Don R. Lipsitt, MD, 83 Cambridge Pkwy., Cambridge, MA
02142. Email: don_lipsitt@hms.harvard.edu
© 2015 President and Fellows of Harvard College
DOI: 10.1097/HRP.0000000000000055
practicing physicians and the health care system, with esti-
mates of nine times the cost of general medical care per pa-
tient and 10% of the total health care costs in the United
States.1 For our work group these observations have raised
the question why treatment of these patients presents such
a challenge. Why are reputedly effective interventions with
somatizing patients not more readily applied or successful in
general practice? Why have these patients become such a
knotty problem? Although diagnosis is elusive, etiology non-
specific, and treatment not definitive, some reports of success-
ful outcomes do appear in the medical literature.6,7
Authors of this commentary attempt to answer these
questions by examining potential barriers to optimal care of
patients with medically unexplained symptoms and to offer
suggestions for possible remediation in areas thought to
be troublesome, including heterogeneity of symptoms and
“diagnostic” labels, perplexity of treatments, doctor-patient
relations, medical education, and changes in the health
care system.
BACKGROUND
Historically, presentations by patients of physical symptoms
yielding no demonstrable physiological explanations cap-
tured the enduring scientific curiosity of Charcot, Breuer,
Freud, and others, and gave rise to the concepts of hysteria
and hysterical conversion.8 Symptoms without identifiable
etiologies were, for most of the nineteenth century, defined
as either hysteria (mostly females) or hypochondriasis (mostly
males). By 1950, one author noted that “doctors are not so
confined as they were fifty years ago to the province of

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physical disease, and . . . [they] are prepared to listen to any
complaint, whether of body or of mind . . . [A] doctor now
hesitates to say that a person with a multitude of complaints
has nothing the matter.”9 By the mid twentieth century, fol-
lowing a number of iterations of labels for “undiagnosable”
complaints, physicians were encouraged to be cognizant of
interactions of mind and body, of psychosomatic medicine,
and of the whole biopsychosocial patient,10 especially if
symptoms of baffling origin were to be addressed.
In 1980, publication of the third edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-III) had
coalesced all variations of the prototypes of hysteria and hy-
pochondriasis into one large category of somatoform disor-
ders to account for any physical symptoms that suggested,
but could not be confirmed as reflecting, physical illness.11
Recognition of the phenomenon of somatization seemed to
offer a palatable “explanation” for “unexplained” symp-
toms,12 especially for patients said pejoratively to have “noth-
ing the matter”—a less common expression in today’s
practice. Even this diagnostic modification, which had been
expected to facilitate diagnosis and management of somatiz-
ing patients, was found to be little used by practitioners “in
the trenches.”13 The term somatoform was poorly under-
stood, considered by some to be stigmatizing for patients,
and rarely diagnostically recorded except as undifferentiated
somatoform disorder.
With little demonstrable improvement in the management
of somatizing patients in ensuing years, Time magazine in
1989 questioned whether physicians were indeed “prepared
to listen to any complaint,” and reported that “the operating
room, where once the doctor was sovereign, is now so dense
with the second guesses of insurers, regulators, lawyers, con-
sultants and risk managers that the physician has little room
to breathe, much less heal.”14 And still, in 1996, even with
minor changes in a new DSM-IV, a patient reported of her
experience with doctors, that “I have these awful pains . . .
but eventually, after enough doctors say there is nothing
wrong, they go away.”15(emphasis added)
Now, DSM-IV has been replaced by DSM-5,16 with
somatoform disorders rolled into one large category of so-
matic symptom disorder, again with a rationale of improved
Table 1
Evolution of Somatization Diagnoses
Classification Hysteria
1952: DSM-I Conversion reaction
1968: DSM-II Hysterical neurosis
1980: DSM-III Conversion disorder
1992: ICD-10 Dissociative (conversion) disorder
1994: DSM-IV Conversion disorder
2013: DSM-5 Functional neurological symptom disorder
Harvard Review of Psychiatry
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Medically Unexplained Symptoms
user-friendliness. Heated controversy surrounds this change,
with accusations of increased nonspecificity, overinclusiveness,
and risk of branding normal behavior as pathological.17
The history of this evolution of the somatizing conditions
of hysteria and hypochondriasis is reflected in the changes
in sequential editions of DSM, as summarized in Table 1.
With all these changes, do patients with medically unex-
plained symptoms receive better care or, instead, short shrift?
Are there other explanations for substandard care? Are physi-
cians hampered in using their inherent skills by subtle and not-
so-subtle external forces?
PATIENTS WITH “NOTHING THE MATTER”
When the diagnosis is “nothing the matter,” the patient essen-
tially remains untreated, but does that mean they go to a doctor
for no reason at all? As a backdrop to our discussion of the
process by which patients with medically unexplained symp-
toms are typically encountered but remain untreated, it is in-
structive to consider a composite model patient, as follows:
A 32-year-old secretary awakens one day with
distressing belly pain. After two weeks of self-
medicating, she fleetingly and dismissively recalls
an aunt who died of ovarian cancer, and decides
to consult a physician. The usual workup includes
X-rays, blood tests, and a prescription for more
potent analgesics. In the brief time with her physi-
cian, the aunt’s ovarian cancer is not discussed, nor
does the patient, consumed with concerns about
her pain, think to raise it as significant. The physi-
cian does not expand history taking beyond ele-
ments of the patient’s pain. She returns to her
doctor after a week of medication and hears that
her X-rays and blood tests are normal. Her doctor
“reassures” her emphatically that she is OK. The
patient’s persistent complaining elicits referral to
a gynecologist. Again, with normal physical exam-
ination and pelvic and rectal exams, she is trans-
ferred back to her primary doctor. He reads her
the gynecologist’s report, tells her there is “nothing
wrong,” and advises her to return if symptoms
Hypochondriasis
Neurasthenia
Hypochondriacal neurosis (hypochondriasis)
Somatoform disorder
Hypochondriacal disorder (F45.2), 5 subseries
Hypochondriasis
Somatic symptom disorder (illness anxiety disorder)
www.harvardreviewofpsychiatry.org 439
D. R. Lipsitt et al.
worsen. Symptoms do worsen, and she returns to
experience the same cycle over again: examina-
tion, tests, referral, but no further discussion of
the patient’s concerns, beliefs, attitudes, anxieties,
fears, or recent-events history. Convinced of hav-
ing explored necessary pathways after several
more visits, the physician advises his patient to
seek psychiatric treatment. She feels misunder-
stood, rejected, disappointed, and angry. She de-
cides to find another doctor. The cycle repeats
for several months.
This scenario is repeated thousands of times daily in physi-
cians’ offices in the United States and also other countries.18
Inadequate diagnosis and treatment results in impaired qual-
ity of life, chronicity, suffering, and a high potential for iatro-
genic reinforcement of symptoms and social dysfunction.
Frustratingly referring patients for specialty consultation with
psychiatrists and others usually only intensifies the problem,
ultimately entrenching patients’ symptoms in deeper resis-
tance to treatment. Physicians need to understand this process
before they are in a position to provide effective care and
treatment of these patients. It is our position that these patient
presentations of “medically unexplained symptoms” are in-
deed “explainable,” but in terms other than those conven-
tionally adopted in “usual care” practice. What follows is
a selective, but probably limited, listing of the barriers to
achieving better care for these patients.
BARRIERS TO TREATMENT
Heterogeneity of Symptoms and Labels
Prevalence data on medically unexplained symptoms vary
widely, depending on the criteria used with this heteroge-
neous mix of conditions.19 Nevertheless, primary care physi-
cians are profoundly aware of their patients with medically
unexplained symptoms.20 Since it is part of the human condi-
tion to complain of discomfort, rates are unlikely to change;
reduction in prevalence would therefore seem more a distrac-
tion than a proper objective of treatment or management.
What remains the case is that practicing physicians repeat-
edly find these patients “difficult,” vexing, and unappealing
to treat.21
The dizzying array of changing labels and overlapping
presentations has led to complex classificatory efforts (see
Table 1). Somatization itself is not a diagnosis but a process
that is expressed through a broad spectrum of complex bodily
manifestations without discoverable etiologies.12 Finding
no solace in formal diagnoses, physicians have been known
to refer to these patients pejoratively with terms such as “tur-
key,” “frequent fliers,” “thick-chart patients,” “heartsink
patients”(Brit.), and “worried well.”22
The shifting nomenclature of somatizing disorders from
neurasthenia to hypochondriasis, somatoform disorder, and
others has been little used by primary care physicians. Various
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specialties, in caring for these patients, sometimes diagnose
chronic fatigue syndrome, irritable bowel syndrome, chemi-
cal sensitivity, and others.23 The label “medically unexplained
symptoms” is a recent iteration, thought to have less stigma
(but not much enlightenment), and said by some authors to
now be used in preference to “somatization.” Other attempts
at simplification have suggested “multisomatoform disorder”24
and “bodily distress syndrome.”25 Most recently, as mentioned,
DSM-5 has reduced the options by broadening the category
to “somatic symptom disorder.”16
SUGGESTED REMEDIES Given the feeling of futility in assigning
patients with “unexplainable” symptoms a parsimonious
definitive diagnosis, it may be sufficient to list symptom com-
plaints as part of a bodily distress profile or complex somatic
disorder. In that regard, the DSM-5 diagnosis of somatic
symptom disorder may be useful to practitioners. Symptoms
can then be addressed as the beginning of a general assess-
ment that gradually expands to include relevant interper-
sonal, social, and psychological stressors in the patient’s life.
Some primary physicians have found it useful to adopt a
biopsychosocial grid, based on Engel’s biopsychosocial model
of medical care,10 to chart symptoms and related data.26,27
Patients with medically unexplained symptoms commonly
distrust vague explanatory “diagnoses” but can be told that
more information is needed and will gradually emerge “as I
begin to know more about you (or your condition).” Pushed
for further elaboration, physicians can call attention to other
physiologic responses to stress or tension such as blushing,
nausea, diarrhea, headache, and so on to describe how unrec-
ognized stresses can cause physical symptoms. Even the diag-
nosis of “generalized inflammation,” so effectively used by
alternative practitioners to market supplements, can be too
elusive—though it is occasionally acceptable to patients.
Discordant Doctor-Patient Relationships
When a patient seeks medical consultation, the diagnosis
should never be “nothing is the matter,” since patients, other
than drug seekers, factitious-disordered patients, and malin-
gerers with deviant objectives, do not go to doctors simply to
waste their doctors’ or their own time. Pronouncements of
“nothing wrong” have been shown, in a randomized study, to
instill negative reactions and heightened anxiety in patients.28
Individuals generally turn to doctors only when their levels of
concern rise above their personal thresholds of self-care.
General medical practice inescapably includes many pa-
tients with recurrent symptoms that do not comport with
standard diagnostic and therapeutic criteria. For many de-
cades, this clinical reality has contributed to the perception
that patients with chronic patterns of medically unexplained
symptoms are difficult and ungratifying to treat, often chal-
lenging theoretical understandings of disease and illness behav-
ior and leading to strained doctor-patient relationships.20,29
Busy primary care practitioners are prone to perceive encoun-
ters with patients as “easy” or “difficult,”30 and articles appear
Volume 23 • Number 6 • November/December 2015

regularly in the medical literature, though with uncertain im-
pact, on the management of “difficult” patients.31
The literature for decades has offered advice about manag-
ing the patient with “whining” complaints without organic
explanation.32 Some physicians say that patients are reluctant
to have their psychosocial lives intruded upon, but studies
of patients’ expectations and wishes suggest otherwise.33,34
Even so, physicians knowledgeable about the impact of
patient-physician relations and psychosocial factors on treat-
ment outcome continue to regard patients with medically unex-
plained symptoms as “untreatable” and intimidating, leaving
these patients essentially marginalized in medicine.21,35,36
By training and motive, physicians are committed to the
well-being of their patients, with the objective to comfort al-
ways and to cure sometimes, and, above all, to do no harm.
Gratification in their work comes from seeing improvement
in their patients’ state of health and quality of life. Medical
training instills an unwavering desire for accuracy and for
clinical astuteness that should result in patients’ health better-
ment. But this outcome may come late or not at all in patients
with medically unexplained symptoms. When patients do not
fit the rubric of “good patient,” practicing physicians may
“forget” their inherent principles of care.37
These needy patients make physicians aware of their own
unacceptable fear of “not knowing.” Those with an enduring
fear of malpractice accusations are prone to overstudy their
patients. Patients whose complaints do not lend themselves
to resolution “get under the doctor’s skin,” inducing a wish
to withdraw from and extrude the patient,35 and to fix blame
on the patient for the physician’s distress. Blaming the patient
for one’s own discomfort may serve to protect the physician’s
self-esteem but iatrogenically worsens the patient’s condition.38
Certainty and causal explanations elude the physician.
In the absence of an effective management strategy, the pa-
tient’s help-seeking and abnormal illness behavior, as well
as the fear of an unrecognized illness, persist, while frustra-
tion and tension escalate between physician and patient.
Terms like neurasthenia, hypochondriasis, psychosomatic ill-
ness, and somatization have been used to confer a (false) sense
of diagnostic certainty on these poorly understood symp-
tomatic states. If we consider our hypothetical patient, who
is fixated on her pain, she has long since “forgotten” about
her aunt, and the physician, focused too exclusively on her
pain, has neglected the need to provide “triggers” to foster
free-reign on her narrative. He has also—finally, perhaps
out of frustration—attempted to force the patient into a
psychological/psychiatric paradigm of thinking specifically
about her illness, which she is either unready or unable to
do. Physician and patient have yet to establish a common
language and agenda for discussing her illness; instead, they
were engaged in discordant narratives—at an impasse, with
no working alliance.39
When complaints and elusive diagnosis persist, relation-
ships can be severely tested, whether in adult or pediatric
practice.40 Patients who somatize illustrate this dynamic in
Harvard Review of Psychiatry
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Medically Unexplained Symptoms
the extreme. The above hypothetical illustrates that relation-
ships once on good terms can readily deteriorate into dysfunc-
tional states. Physicians’ frustration can turn to anger, with
demeaning and dismissive behaviors toward the patient,
resulting in the predictable discordant relationship and the
patient’s “shopping” for another physician.41,42 Doctor
shopping is a term traditionally applied to drug-seeking pa-
tients but commonly applied in this context to patients whose
otherwise expectable behavior as patients turns into “abnor-
mal illness behavior” in the face of dysfunctional doctor-
patient relationships.43 The patient’s migration to a different
physician may offer the physician relief while perpetuating
the patient’s behavior and the attendant risk, cost, and dis-
tress of redundant workups. Showing little disappointment
when these “undesirable” patients move on to other physi-
cians, doctors may intensify these patients’ feelings of rejection.
In our “case,” the patient seeks a doctor who “understands,”
preventing establishment of a trusting and constant health-
promoting relationship.
Psychiatric referral is usually not helpful. Patients with
medically unexplained symptoms are generally unreceptive,
do not understand the reasons for the referral, resent the
implication that “it is all in your head,” and usually do not
follow through. Frequently, the reasons given for the referral
are not comprehended and are experienced as the physician’s
disposing of the patient—and in the direction of a psychia-
trist, which simply exacerbates the situation. Psychiatrists,
thought to possess expertise in the care of these patients,
nonetheless experience the same frustration as their primary
care colleagues, and often find these patients ungratifying to
treat when they do not respond to psychiatric intervention.
Because patients with medically unexplained symptoms gen-
erally do not seek psychiatric consultation on their own,
psychiatrists usually have had little experience with them,
except when they are resentfully referred. If patients actu-
ally do accept referral, they typically show significant psy-
chiatric comorbidity but do not move beyond the somatic
view of their illness, with the consequence that they are
often dismissed as “lacking insight,” “untreatable,” or
“alexithymic.”44 Mental health interventions tend to be re-
sisted because they contradict patients’ explanatory model for
their distress (something physical, not psychological). On rare
occasions, premature referral may miss an underlying organic
disease, but thoughtful referral can avoid such mishaps.45
Although the primacy of the physician-patient relation-
ship is noted in most positive reports of management tech-
niques and is a general principle emphasized in medical
education, physicians with an allegedly strong commitment
to the doctor-patient relationship seem hesitant to make
maximal use of this familiar parameter in treating their
somatizing patients. In such situations, patients are on their
way to becoming “unexplainable.”
SUGGESTED REMEDIES The general physician is left to a “seat-of-
the-pants” approach to treating these patients. Given little
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D. R. Lipsitt et al.
reason for further testing and essentially no practical treat-
ment to prescribe, treatment realistically devolves onto the
relationship itself. Although difficult to achieve, appropriate
management may require modifications in physicians’ styles
of practice.
The impulse to label and dismiss the patient should be
resisted, and rather than dismissal or referral, patients should
be offered (perhaps counterintuitively) another appointment
for further exploration. Early detection of somatizing patterns,
though difficult, can curtail excessive unnecessary exploration.
While some physicians depend on screening instruments to
define problem areas, time is better spent in face-to-face ex-
change with the patient. Relevant data usually emerge if pa-
tients’ narratives are not prematurely interrupted.46 Greater
freedom in the narrative can build trust and lead to etiologic
clues to relevant clinical data, fostering expansion of history
taking beyond the restrictive cataloging of physical com-
plaints; it is possible to derive a psychological profile of a
patient without being psychologically probing; for example,
understanding how patients interact with family members
can shed light on the meaning of patients’ symptoms.40,47
All physicians possess the ability to ask questions and
to encourage the patient to “tell me more”—a simple inter-
vention sufficient to widen the discussion beyond a narrow
litany of bodily symptoms. Helping patients recognize their
own effective coping patterns in past stressful experiences
reminds them of their available internal resources. Many
physicians refrain from asking about “personal” concerns
because they consider it intrusive, but studies indicate patients
actually want to be asked about nonmedical or personal
(social) events in their lives, with 85% nevertheless reporting
that such questions have been rarely, if ever, asked.33 Current
curricular modifications in primary care and family medicine
have begun to improve this situation.48
Given that physicians’ time is limited, and reimbursement
(for talk) often lacking, physicians naturally hesitate to “open
Pandora’s box.”49 Nevertheless, patients can be comfortably
interrupted with “This is interesting; let’s discuss it further in
your next appointment.” Physicians burdened with compet-
ing demands and shortages of time often rush in with “treat-
ment” before knowing what actually is being treated; hastily
offered treatment of vague symptoms may be experienced by
the patient as a promise that cannot be kept or as a wish to
eject the patient. Offers of “strong” medicines generally do
not work either, since patients usually need to cling to their
symptoms, at least until a trusting relationship is established
or the strong-medicine approach has already been tried (and
failed). These patients feel strongly, rightly or wrongly, that
“no one listens,” and until they believe that someone is listen-
ing, symptoms will not be relinquished.
When depression and anxiety accompany somatic com-
plaints, psychopharmacotherapy has been successful, but both
accurate diagnosis and the choice of drug require specific un-
derstanding and knowledge to avoid reflexive responses—by
both patient and physician—to garden variety discomfort.50,51
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“Curbside” discussion with psychiatrist colleagues can be
helpful, especially to help the primary care physician make
an appropriate referral.
In each visit, at least part of a physical examination should
be done, reminding patients that the “physicalness” of their
complaint is taken seriously. Premature proposals of psycho-
logical interpretation or referral, as mentioned, generally fail
since these patients want a physical doctor, not a psychiatrist.
Expecting to cure the “incurable” generally leads to exasper-
ation, while a caring, rather than curing, approach to the pa-
tient is likely to produce improvement over time.
Premature reassurance is often ineffective and cannot au-
thentically be offered until it is understood what experience,
thought, or feelings accompany the reasons that have initi-
ated the patient’s decision to seek help. Offering a “shotgun”
remedy without evidence is merely “a shot in the dark.”52,53
DSM-IV defines hypochondriacal patients as unresponsive
to “appropriate medical reassurance”; however, as with any
medical intervention, patients are more reassured and respon-
sive when treated with understanding, respect, and caring.
Somatizing patients present physicians with difficulty in
deciding which symptoms to pursue and which to defer. Leav-
ing some investigational pathways unexplored or symptoms
not pursued results in discomfort for the physician who seeks
certainty. If physicians can train themselves to live with
the “irreducible minimum of uncertainty that is inherent in
medicine,”54 they will achieve a degree of comfort working
with patients with medically unexplained symptoms. Deny-
ing this uncertainty places physicians and patients at peril
of futile workups and frequently only serves to iatrogenically
reinforce patients’ complaints. Perhaps Sir William Osler said
it best: “Medicine is a science of uncertainty and an art of
probability.”55(p 122)
A Perplexity of Treatments
How does one choose from the confusing abundance of
“diagnostic” labels for these patients? Therapy in the tradi-
tional psychiatric sense is not effective for these patients,
who do not even find such treatment acceptable except as a
potential means of support. “There are no adequate outcome
studies on which definite recommendations for treatment
of somatoform disorders can be based.”56(p 2119). And since
“no curative or ameliorative therapies have been found (for
somatization disorder), treatment necessarily focuses on the
management of symptoms.” Likewise, since “there have been
few formal treatment or management studies, recommenda-
tions are based on a broad consensus among experienced cli-
nicians.”6(p 1743) Thus, in spite of limited understanding of
the etiology and pathophysiology of medically unexplained
symptoms, effective management strategies are reported reg-
ularly to show beneficial clinical outcomes.57–69 However,
these techniques apparently are not readily incorporated into
general practice.
Treatment may offer some degree of improvement in func-
tional capacity, quality of life, satisfaction, or decreased health
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 Medically Unexplained Symptoms

services utilization, even if symptoms remain constant. The
strongest evidence to date is for cognitive-behavioral therapy.61
However, incorporating this technique into general practice
is difficult; patients are not easily referred; and specialty re-
sources are minimally available. A “consultation letter” from
a psychiatrist to the primary care physician has shown some
benefit in the clinical encounter, with both patient improve-
ment and cost savings.62 This structured approach recom-
mends organizing the doctor-patient relationship around
regularly scheduled visits independent of symptom genera-
tion, frequency, or intensity.
Some have recommended group therapy,66 reattribution
efforts,67 and heightened focus on communication.68 These
strategies as well as typical “usual care” have been largely
disappointing. Various interventions, with randomized, con-
trolled studies, are rated in Table 2.
Because of diagnostic blurring and the heterogeneity of
symptom complexes, it is difficult to compare treatments
and efficacies. This multitude of treatments is characteristic
of situations in which no definitive treatment actually exists
or has been identified.
SUGGESTED REMEDIES The multifaceted reality of medically un-
explained symptoms precludes a one-size-fits-all approach.
Until a definitive treatment is identified, physicians should
select the interventional approach that best suits their practice
style and comfort, incorporating effective elements alluded to
here, as distilled and summarized in Text Box 1. A technique
that emphasizes behavioral management of symptoms—and
a “caring” rather than “curing” attitude toward the patient—
may be most tolerable and effective for both patient and
physician; this approach has much in common with strategies
of chronic disease management.70 If the attributes of good
patient-physician relations prevail, both parties will eventually
experience satisfaction. Difficult as it is to tolerate uncertainty,
chronicity, and temporal restraints, physicians who can take a
wait-and-see approach to these patients will stave off the haz-
ards of burnout (and postpone early retirement).71
Medical Education
Medical education usually focuses on preventable, treat-
able diseases, whereas diseases of uncertain or inexplicable
cause tend to be neglected. Disproportionate interest in
“fascinomas” and “zebras” does not help students know
what to expect in general practice. The psychosocial and emo-
tional realities of daily life receive scant attention or are de-
meaned; a focus exclusively on physical complaints leaves
the relevance of affect, personality, and psychosocial topics
underrepresented. Overt and covert messages are conveyed
in medical education that affect is something to be controlled,
denied, or repressed rather than acknowledged.72 These em-
phases risk dehumanizing oneself and one’s patients, and the
process produces students and graduates with a distorted ex-
pectation of the real world of medical practice.
The training in hospital settings focuses primarily on acute
physical illness, not the chronic and emotional distress of the
average patient seen in daily practice. Most physicians will
thus find greater comfort in physical (rather than emotional)
medicine, with objective findings that have clear demonstrable
remedies. In time—the indeterminate future, but not now—
new discoveries of biological and genomic markers and brain
mapping may illuminate puzzling disorders and reassure those
physicians searching for greater certainty of etiology.73

Table 2
Selected Randomized, Controlled Studies of Medically Unexplained Symptom Treatment
Study
Speckens et al. (1995) 61
62
Smith GR Jr et al. (1995)
Luo et al. (2007)63
Gili et al. (2014)64
65
Aiarzaguena et al. (2007)
Schaefert et al. (2013)66
Morriss et al. (2007)67
Smith RC et al. (2006)69
CBT, cognitive-behavioral therapy; GP, general practitioner; MD, medical doctor.
Modality Results Efficacy
CBT by psychiatrist Improved social activities, symptoms, “illness behavior” +++
Consultation letter to primary Improved physical function; decreased cost ++
care physician
CBT, antidepressants No significant cost savings; increased antidepressant ++
use; improved mental health
Group vs. individual CBT Better quality of life with individual CBT ++
MD training in communication Improved MD attitudes +
? Benefits to patients
Collaborative group Improved mental (not physical) quality of life +
GPs and psychiatrists
GP “reattribution” training Improved doctor-patient communication; no change +
in outcomes
Long-term multidimensional Improved mental and physical symptoms +++
intervention

Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 443

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D. R. Lipsitt et al.

Text Box 1

Management Guidelines for Medically Unexplained Symptoms

• Consider symptoms valid, and respect patient’s narrative
• Perform thorough standard workup (abbreviated physical exam each visit)
• Establish regular follow-up appointments (not based on symptom intensity)
• Curb endless searching for organic explanation
• Treat obvious comorbid psychiatric syndromes (depression, anxiety)
• Use reassurance sparingly, especially until trust established
• Resist the impulse to quickly offer psychological explanations
• Explore psychosocial history slowly
• Harness physician “rescue fantasies” (others have probably tried)
• Normalize symptoms and uncertainty (“others have same problems”)
• Make specialty referrals sparingly (use “curbside” consultation)
• Be slow to write prescriptions (but consider appropriate psychopharmacology)
• Regard patient-physician relationship paramount (rather than zealous symptomatic treatment—“care” vs. “cure”)

Because emotions are typically given short shrift by both
physician and patient, they can rigidly fixate somatic symp-
toms within a reductionist (biomedical) framework for under-
standing and treating illness—a framework with a dualistic
distinction between psyche and soma.74 Historically, medi-
cine has divided symptoms between the “real,” which are said
to reside in the body with an identifiable pathophysiologic
cause, and the “not real,” said to reside in the mind. This bi-
nary view of illness fosters the perception that the latter
are not worthy of inquiry and that they remain outside the
responsibility of most physicians—a perception that con-
tributes to physicians’ reluctance to treat these patients. Med-
ical training and practice have seen little change in decades,
with some holding that the languages of the two domains
are incompatible.75
Physicians with a reductionist view of illness are unlikely to
believe that their own behavior, skills, and personal qualities
can affect the structure of the doctor-patient relationship in
ways that can be beneficial to patients’ responses to treatment
of unexplained somatic distress.37,76 But it is well documented
that physicians’ attitudes and behavior can, in and of them-
selves, have a salutary effect upon the patient and lead to im-
proved functioning.77 In the 1970s, internist-psychoanalyst
George Engel sought to rescue medicine from its reductionist,
seventeenth-century base by proposing a new model that rec-
ognized that biological, psychological, and social factors all
contributed to medical care.10
Deleterious physician-patient relationships often have been
explained in terms of organizational and administrative fac-
tors, as well as the burden of overwork.78 Undoubtedly,
such factors are relevant, but the more likely explanation
is that, as Peabody wrote more than 70 years ago, “young
graduates . . . are too ‘scientific’ and do not know how to take
care of patients.”79(p 877)
While medical schools today do emphasize the importance
of doctor-patient relationships, communication skills, and “pro-
fessionalism” as preparation for medical practice, graduating
physicians continue to be poorly equipped and unprepared for
the often elusive and troublesome interpersonal aspects of
caring for patients regarded as “difficult.”80(pp 383–85)
SUGGESTED REMEDIES Although the medical school curriculum
has become more humanized since the 1980s, curriculum
change is a very slow process. Perhaps, as medical school ad-
missions committees begin to assess students for their ability
to be empathic and effective communicators, to appreciate
the role of affect in medical care, and to tolerate uncertainty
in their lives, a different kind of physician will emerge.81,82
Changes must be made in curricula to enhance the pro-
fessionalization of the graduate. Psychiatry and psychology
need to be more integrated into the entire curriculum, with
attention not merely to mental illness but to human develop-
ment, personality, and the expression of, and interconnections
among, affect, cognition, and behavior. Faculty who demon-
strate comprehensive approaches to medical care should be
encouraged to serve as mentors. Students need tutoring in
how to respond to highly affective situations without shame
or embarrassment and without harboring or cultivating neg-
ative biases toward patients.38
During medical education, ways must be found to help
students monitor their own and also patients’ emotional
responses—a difficult but invaluable challenge. Potentially
excellent teaching opportunities arise in the context of dissect-
ing cadavers, “sophomore hypochondriasis,” and first en-
counters with live patients.83,84
Physicians unable to engage in the language of emotion
will be greatly handicapped in responding to the patient’s
search for medical help. Issues of control, autonomy, depen-
dency, and flexibility—elements inherent in doctor-patient
relationships—need to be addressed directly, not left to the
“hidden curriculum,”85 those “noncognitive objectives of ed-
ucation like attitudes, values, character and professional iden-
tity” that shape the “grander educational experience that
[comes] out of the general culture of medical school.80(p 70)

444 www.harvardreviewofpsychiatry.org Volume 23 • Number 6 • November/December 2015

Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.

According to Ludmerer, efforts to understand or to change
medical curricula that ignore the role of the hidden curricu-
lum do so “at great risk of failure.”80(p 72)
Some physicians have found postgraduate courses helpful
in sharpening their psychosocial skills. Balint groups, so-
named after the Hungarian-British psychoanalyst who met
with general physicians to help them explore the nuances
of doctor-patient relations, are found by some to be highly in-
structive.86 Others have spent elective time rounding with
consultation-liaison psychiatrists in hospital-based depart-
ments of psychiatry.87 The focus in such experiences is not
on studying major psychiatric disorders but on the comorbid
psychosocial aspects of medical illness and the impact of
doctor-patient relationships on illness. An appreciation of the
psychodynamic aspects of relationships also can add to one’s
interest and skill in understanding and managing patients with
medically unexplained symptoms.88,89 Goldberg and associ-
ates in England have offered training to general practitioners
(shunned by many) on how to help patients transition from so-
matic preoccupation to psychological understanding through
“reattribution” of symptoms to psychological meaning, an ap-
proach now found to have limited results.90,91
In much the same way that their nonpsychiatrist colleagues
can benefit from rounding with consultation-liaison psychia-
trists, psychiatrists and psychiatry residents can benefit from
increased experience in general medical practice.92
Medical System Transformation
Medical practice has gradually seen profound changes in
some or all aspects of caring for the sick (and the well).93
Patient-doctor relationships have experienced erosion result-
ing from the impact of shifts in autonomy, practice sites, and
professional conduct imposed by corporate and regulatory
agencies, most particularly since the advent of managed
care.80(p 372) A Wall Street Journal article quoted a health
maintenance organization executive as saying, “We see peo-
ple as numbers, not patients . . . [W]e’re a mass-production
medical assembly line, and there is no room for the human
equation in our bottom line.”94
Matters of reimbursement, legal vulnerability, and record
keeping, previously taken in stride, have moved front-and-
center in everyday practice. Access to cybertechnology has
altered the fundamental ways that medical knowledge is ac-
quired, retrieved, and transmitted, significantly affecting the
nature of communication and interaction.
All of these factors complicate the physician’s day-to-day
life. The pressure to see more patients in limited time, the need
for more meticulous record keeping and disease coding, and
the regulatory enforcement of reimbursement schedules have
been noted in cases of early burnout or retirement of physi-
cians. In such settings, faced with patients who appear to be
“needlessly” taking up time, energy, and resources, physi-
cians are unlikely to feel free enough to engage patients with
medically unexplained symptoms in ways that are supportive
and productive.85 The unease that ensues creates an empathy
Harvard Review of Psychiatry
Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Medically Unexplained Symptoms
gap of large proportion, often resulting in hasty referral by the
doctor and in doctor shopping by the patient. Furthermore,
the physician’s wariness of missing a diagnosis and the fear
of malpractice suits make treatment of medically unexplained
symptoms the more taxing.
SUGGESTED REMEDIES The control of the health care system by
insurance companies and others presents a difficult barrier in-
deed. Some physicians have elected limited boutique (concierge)
practices, allowing more time for patients, whereas others have
shifted from private practice to employed status in hospitals
and other sites.95 To some, the individuality of private practice
seems to be sacrificed for “cookie cutter” medicine.
Unfortunately, reimbursement for time beneficially spent
listening, communicating, and supporting patients with regu-
larly scheduled visits is poorly or not at all valued by those
who control medical claims. They are unlikely to listen to
the argument that spending 15 minutes preventively with a
troubled patient may avoid much higher costs of emergency
services or hospitalization. But if this argument is made re-
peatedly, it may eventually be heard. Lobbying through med-
ical societies and associations, letters to newspapers, and
written complaints to the chief executive officers of managed
care companies—pointing to the unwise practice of denying
justifiable reimbursement for interventions that reduce costs
of excessive utilization—may help.
Integrated or collaborative practices with ancillary health
providers offer economies of time.96,97 A nurse, psychologist,
or health care assistant affiliated with the physician’s practice
can offer continuity of care that is most beneficial to patients
with medically unexplained symptoms seeking a caring per-
son. Evaluation of new care models of “medical homes”
and other forms of integrated care designed to offer mental
health, preventive, and comprehensive services awaits data
on cost-effectiveness and patient outcomes.98 In treating med-
ically unexplained symptoms, one should expect the process
to be extended, and one should also keep one’s expectations
realistically modest.99
CONCLUSION
Individuals take themselves to doctors with a variety of perturba-
tions that do not fit readily into common medical nosology.100
Patients whose unexplainable medical symptoms result in
deviant illness behavior constitute a significant part of general
medical practice, and for most physicians, these patients arouse
varying degrees of vexation, intolerance, and negativism. Even
though helpful interventions are available—ones well within
the existing skills of today’s physicians—this patient population
continues to exert a heavy burden on practitioners and the
health care system. This article has therefore focused on
other potential barriers to optimal care for patients with
medically unexplained symptoms.
We examine ways of improving symptom containment,
lessening excessive use of health care services, enhancing qual-
ity of life, and improving physician-patient relations, thereby
www.harvardreviewofpsychiatry.org 445
D. R. Lipsitt et al.
reducing the burden on the health care system, if not the ac-
tual number of patients presenting with medical unexplained
symptoms. The authors of this commentary believe that vari-
ous factors, discussed above, are likely to compromise or
completely negate physicians’ access to their own inherent at-
titudes and skills—such as empathy, engagement, capacity to
communicate effectively—that are needed to care for this par-
ticular group of patients. Several structural features of today’s
health care system, including the medical education system
itself, are also likely to impede effective management.
This article addresses those potential barriers and suggests
remedies for overcoming them, thereby promoting effective
care for these patients. Until results of qualitative and quanti-
tative studies are available—as proposed in the systematic
review by Murray and colleagues101—our selection of reme-
dies is based on circumscribed literature reviews and analy-
sis, clinical anecdotes, reliance on clinical observation, and
extensive experience working with primary care physicians.
Our presentation is limited in scope, and no definitive treat-
ment is currently available for somatizing disorders; further
studies are needed.
In the meantime, we have presented in Text Box 1 the
principles for managing patients with medically unexplained
symptoms. Physicians who can surmount some of the barriers
described here and incorporate those principles into patient
care will reclaim the pleasure of practice—eroded by pro-
found changes in health care—and experience the satisfac-
tion of healthier, more grateful patients.
Declaration of interest: The authors report no conflicts
of interest.
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Volume 23 • Number 6 • November/December 2015