医学上无法解释的症状障碍
医学上无法解释的症状障碍
医学上无法解释的症状障碍
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 practicing physicians and the health care system, with esti-
Somatization, initiated by the authors more than two mates of nine times the cost of general medical care per pa-
decades ago. Deliberations and opinions derive from tient and 10% of the total health care costs in the United
literature reviews and from our clinical experience consulting States.1 For our work group these observations have raised
with primary care physicians—a collective experience span- the question why treatment of these patients presents such
ning more than 100 years as consultation-liaison psychia- a challenge. Why are reputedly effective interventions with
trists. While an exhaustive review of the hundreds of articles somatizing patients not more readily applied or successful in
on somatization and medically unexplained symptoms is be- general practice? Why have these patients become such a
yond the scope of this article, we make selective reference to knotty problem? Although diagnosis is elusive, etiology non-
them in order to elaborate on opinions derived from personal specific, and treatment not definitive, some reports of success-
clinical experience witnessing the difficulties that physicians ful outcomes do appear in the medical literature.6,7
experience in encounters with somatizing patients. Authors of this commentary attempt to answer these
Extensive consideration of the prevalence of patients with questions by examining potential barriers to optimal care of
“medically unexplained symptoms” (previously referred to patients with medically unexplained symptoms and to offer
as somatizing or somatoform disorders) is accompanied by suggestions for possible remediation in areas thought to
the general observation of notoriously poor therapeutic out- be troublesome, including heterogeneity of symptoms and
comes in general practice.1,2 Their presence is well noted “diagnostic” labels, perplexity of treatments, doctor-patient
not only in primary care but also in specialty practices, with relations, medical education, and changes in the health
general prevalence levels for outpatient visits hovering around care system.
30%3 or higher in some specialty practices.4,5 In cost and mis-
use of resources, these patients pose a significant burden to BACKGROUND
Historically, presentations by patients of physical symptoms
yielding no demonstrable physiological explanations cap-
From Harvard Medical School and Cambridge Health Alliance, Cambridge, MA. tured the enduring scientific curiosity of Charcot, Breuer,
Original manuscript received 27 February 2014; revised manuscript received Freud, and others, and gave rise to the concepts of hysteria
5 June 2014, accepted for publication subject to revision 8 July 2014; revised
manuscript received 19 July 2014. and hysterical conversion.8 Symptoms without identifiable
Correspondence: Don R. Lipsitt, MD, 83 Cambridge Pkwy., Cambridge, MA etiologies were, for most of the nineteenth century, defined
02142. Email: don_lipsitt@hms.harvard.edu as either hysteria (mostly females) or hypochondriasis (mostly
© 2015 President and Fellows of Harvard College males). By 1950, one author noted that “doctors are not so
DOI: 10.1097/HRP.0000000000000055 confined as they were fifty years ago to the province of
Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Medically Unexplained Symptoms
physical disease, and . . . [they] are prepared to listen to any user-friendliness. Heated controversy surrounds this change,
complaint, whether of body or of mind . . . [A] doctor now with accusations of increased nonspecificity, overinclusiveness,
hesitates to say that a person with a multitude of complaints and risk of branding normal behavior as pathological.17
has nothing the matter.”9 By the mid twentieth century, fol- The history of this evolution of the somatizing conditions
lowing a number of iterations of labels for “undiagnosable” of hysteria and hypochondriasis is reflected in the changes
complaints, physicians were encouraged to be cognizant of in sequential editions of DSM, as summarized in Table 1.
interactions of mind and body, of psychosomatic medicine, With all these changes, do patients with medically unex-
and of the whole biopsychosocial patient,10 especially if plained symptoms receive better care or, instead, short shrift?
symptoms of baffling origin were to be addressed. Are there other explanations for substandard care? Are physi-
In 1980, publication of the third edition of the Diagnostic cians hampered in using their inherent skills by subtle and not-
and Statistical Manual of Mental Disorders (DSM-III) had so-subtle external forces?
coalesced all variations of the prototypes of hysteria and hy-
pochondriasis into one large category of somatoform disor-
PATIENTS WITH “NOTHING THE MATTER”
ders to account for any physical symptoms that suggested,
When the diagnosis is “nothing the matter,” the patient essen-
but could not be confirmed as reflecting, physical illness.11
tially remains untreated, but does that mean they go to a doctor
Recognition of the phenomenon of somatization seemed to
for no reason at all? As a backdrop to our discussion of the
offer a palatable “explanation” for “unexplained” symp-
process by which patients with medically unexplained symp-
toms,12 especially for patients said pejoratively to have “noth-
toms are typically encountered but remain untreated, it is in-
ing the matter”—a less common expression in today’s
structive to consider a composite model patient, as follows:
practice. Even this diagnostic modification, which had been
expected to facilitate diagnosis and management of somatiz- A 32-year-old secretary awakens one day with
ing patients, was found to be little used by practitioners “in distressing belly pain. After two weeks of self-
the trenches.”13 The term somatoform was poorly under- medicating, she fleetingly and dismissively recalls
stood, considered by some to be stigmatizing for patients, an aunt who died of ovarian cancer, and decides
and rarely diagnostically recorded except as undifferentiated to consult a physician. The usual workup includes
somatoform disorder. X-rays, blood tests, and a prescription for more
With little demonstrable improvement in the management potent analgesics. In the brief time with her physi-
of somatizing patients in ensuing years, Time magazine in cian, the aunt’s ovarian cancer is not discussed, nor
1989 questioned whether physicians were indeed “prepared does the patient, consumed with concerns about
to listen to any complaint,” and reported that “the operating her pain, think to raise it as significant. The physi-
room, where once the doctor was sovereign, is now so dense cian does not expand history taking beyond ele-
with the second guesses of insurers, regulators, lawyers, con- ments of the patient’s pain. She returns to her
sultants and risk managers that the physician has little room doctor after a week of medication and hears that
to breathe, much less heal.”14 And still, in 1996, even with her X-rays and blood tests are normal. Her doctor
minor changes in a new DSM-IV, a patient reported of her “reassures” her emphatically that she is OK. The
experience with doctors, that “I have these awful pains . . . patient’s persistent complaining elicits referral to
but eventually, after enough doctors say there is nothing a gynecologist. Again, with normal physical exam-
wrong, they go away.”15(emphasis added) ination and pelvic and rectal exams, she is trans-
Now, DSM-IV has been replaced by DSM-5,16 with ferred back to her primary doctor. He reads her
somatoform disorders rolled into one large category of so- the gynecologist’s report, tells her there is “nothing
matic symptom disorder, again with a rationale of improved wrong,” and advises her to return if symptoms
Table 1
Evolution of Somatization Diagnoses
Classification Hysteria Hypochondriasis
1952: DSM-I Conversion reaction Neurasthenia
1968: DSM-II Hysterical neurosis Hypochondriacal neurosis (hypochondriasis)
1980: DSM-III Conversion disorder Somatoform disorder
1992: ICD-10 Dissociative (conversion) disorder Hypochondriacal disorder (F45.2), 5 subseries
1994: DSM-IV Conversion disorder Hypochondriasis
2013: DSM-5 Functional neurological symptom disorder Somatic symptom disorder (illness anxiety disorder)
Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
D. R. Lipsitt et al.
worsen. Symptoms do worsen, and she returns to specialties, in caring for these patients, sometimes diagnose
experience the same cycle over again: examina- chronic fatigue syndrome, irritable bowel syndrome, chemi-
tion, tests, referral, but no further discussion of cal sensitivity, and others.23 The label “medically unexplained
the patient’s concerns, beliefs, attitudes, anxieties, symptoms” is a recent iteration, thought to have less stigma
fears, or recent-events history. Convinced of hav- (but not much enlightenment), and said by some authors to
ing explored necessary pathways after several now be used in preference to “somatization.” Other attempts
more visits, the physician advises his patient to at simplification have suggested “multisomatoform disorder”24
seek psychiatric treatment. She feels misunder- and “bodily distress syndrome.”25 Most recently, as mentioned,
stood, rejected, disappointed, and angry. She de- DSM-5 has reduced the options by broadening the category
cides to find another doctor. The cycle repeats to “somatic symptom disorder.”16
for several months.
SUGGESTED REMEDIES Given the feeling of futility in assigning
This scenario is repeated thousands of times daily in physi-
patients with “unexplainable” symptoms a parsimonious
cians’ offices in the United States and also other countries.18
definitive diagnosis, it may be sufficient to list symptom com-
Inadequate diagnosis and treatment results in impaired qual-
plaints as part of a bodily distress profile or complex somatic
ity of life, chronicity, suffering, and a high potential for iatro-
disorder. In that regard, the DSM-5 diagnosis of somatic
genic reinforcement of symptoms and social dysfunction.
symptom disorder may be useful to practitioners. Symptoms
Frustratingly referring patients for specialty consultation with can then be addressed as the beginning of a general assess-
psychiatrists and others usually only intensifies the problem,
ment that gradually expands to include relevant interper-
ultimately entrenching patients’ symptoms in deeper resis-
sonal, social, and psychological stressors in the patient’s life.
tance to treatment. Physicians need to understand this process
Some primary physicians have found it useful to adopt a
before they are in a position to provide effective care and
biopsychosocial grid, based on Engel’s biopsychosocial model
treatment of these patients. It is our position that these patient
of medical care,10 to chart symptoms and related data.26,27
presentations of “medically unexplained symptoms” are in-
Patients with medically unexplained symptoms commonly
deed “explainable,” but in terms other than those conven-
distrust vague explanatory “diagnoses” but can be told that
tionally adopted in “usual care” practice. What follows is more information is needed and will gradually emerge “as I
a selective, but probably limited, listing of the barriers to
begin to know more about you (or your condition).” Pushed
achieving better care for these patients.
for further elaboration, physicians can call attention to other
physiologic responses to stress or tension such as blushing,
BARRIERS TO TREATMENT nausea, diarrhea, headache, and so on to describe how unrec-
ognized stresses can cause physical symptoms. Even the diag-
Heterogeneity of Symptoms and Labels nosis of “generalized inflammation,” so effectively used by
Prevalence data on medically unexplained symptoms vary alternative practitioners to market supplements, can be too
widely, depending on the criteria used with this heteroge- elusive—though it is occasionally acceptable to patients.
neous mix of conditions.19 Nevertheless, primary care physi-
cians are profoundly aware of their patients with medically Discordant Doctor-Patient Relationships
unexplained symptoms.20 Since it is part of the human condi- When a patient seeks medical consultation, the diagnosis
tion to complain of discomfort, rates are unlikely to change; should never be “nothing is the matter,” since patients, other
reduction in prevalence would therefore seem more a distrac- than drug seekers, factitious-disordered patients, and malin-
tion than a proper objective of treatment or management. gerers with deviant objectives, do not go to doctors simply to
What remains the case is that practicing physicians repeat- waste their doctors’ or their own time. Pronouncements of
edly find these patients “difficult,” vexing, and unappealing “nothing wrong” have been shown, in a randomized study, to
to treat.21 instill negative reactions and heightened anxiety in patients.28
The dizzying array of changing labels and overlapping Individuals generally turn to doctors only when their levels of
presentations has led to complex classificatory efforts (see concern rise above their personal thresholds of self-care.
Table 1). Somatization itself is not a diagnosis but a process General medical practice inescapably includes many pa-
that is expressed through a broad spectrum of complex bodily tients with recurrent symptoms that do not comport with
manifestations without discoverable etiologies.12 Finding standard diagnostic and therapeutic criteria. For many de-
no solace in formal diagnoses, physicians have been known cades, this clinical reality has contributed to the perception
to refer to these patients pejoratively with terms such as “tur- that patients with chronic patterns of medically unexplained
key,” “frequent fliers,” “thick-chart patients,” “heartsink symptoms are difficult and ungratifying to treat, often chal-
patients”(Brit.), and “worried well.”22 lenging theoretical understandings of disease and illness behav-
The shifting nomenclature of somatizing disorders from ior and leading to strained doctor-patient relationships.20,29
neurasthenia to hypochondriasis, somatoform disorder, and Busy primary care practitioners are prone to perceive encoun-
others has been little used by primary care physicians. Various ters with patients as “easy” or “difficult,”30 and articles appear
Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Medically Unexplained Symptoms
regularly in the medical literature, though with uncertain im- the extreme. The above hypothetical illustrates that relation-
pact, on the management of “difficult” patients.31 ships once on good terms can readily deteriorate into dysfunc-
The literature for decades has offered advice about manag- tional states. Physicians’ frustration can turn to anger, with
ing the patient with “whining” complaints without organic demeaning and dismissive behaviors toward the patient,
explanation.32 Some physicians say that patients are reluctant resulting in the predictable discordant relationship and the
to have their psychosocial lives intruded upon, but studies patient’s “shopping” for another physician.41,42 Doctor
of patients’ expectations and wishes suggest otherwise.33,34 shopping is a term traditionally applied to drug-seeking pa-
Even so, physicians knowledgeable about the impact of tients but commonly applied in this context to patients whose
patient-physician relations and psychosocial factors on treat- otherwise expectable behavior as patients turns into “abnor-
ment outcome continue to regard patients with medically unex- mal illness behavior” in the face of dysfunctional doctor-
plained symptoms as “untreatable” and intimidating, leaving patient relationships.43 The patient’s migration to a different
these patients essentially marginalized in medicine.21,35,36 physician may offer the physician relief while perpetuating
By training and motive, physicians are committed to the the patient’s behavior and the attendant risk, cost, and dis-
well-being of their patients, with the objective to comfort al- tress of redundant workups. Showing little disappointment
ways and to cure sometimes, and, above all, to do no harm. when these “undesirable” patients move on to other physi-
Gratification in their work comes from seeing improvement cians, doctors may intensify these patients’ feelings of rejection.
in their patients’ state of health and quality of life. Medical In our “case,” the patient seeks a doctor who “understands,”
training instills an unwavering desire for accuracy and for preventing establishment of a trusting and constant health-
clinical astuteness that should result in patients’ health better- promoting relationship.
ment. But this outcome may come late or not at all in patients Psychiatric referral is usually not helpful. Patients with
with medically unexplained symptoms. When patients do not medically unexplained symptoms are generally unreceptive,
fit the rubric of “good patient,” practicing physicians may do not understand the reasons for the referral, resent the
“forget” their inherent principles of care.37 implication that “it is all in your head,” and usually do not
These needy patients make physicians aware of their own follow through. Frequently, the reasons given for the referral
unacceptable fear of “not knowing.” Those with an enduring are not comprehended and are experienced as the physician’s
fear of malpractice accusations are prone to overstudy their disposing of the patient—and in the direction of a psychia-
patients. Patients whose complaints do not lend themselves trist, which simply exacerbates the situation. Psychiatrists,
to resolution “get under the doctor’s skin,” inducing a wish thought to possess expertise in the care of these patients,
to withdraw from and extrude the patient,35 and to fix blame nonetheless experience the same frustration as their primary
on the patient for the physician’s distress. Blaming the patient care colleagues, and often find these patients ungratifying to
for one’s own discomfort may serve to protect the physician’s treat when they do not respond to psychiatric intervention.
self-esteem but iatrogenically worsens the patient’s condition.38 Because patients with medically unexplained symptoms gen-
Certainty and causal explanations elude the physician. erally do not seek psychiatric consultation on their own,
In the absence of an effective management strategy, the pa- psychiatrists usually have had little experience with them,
tient’s help-seeking and abnormal illness behavior, as well except when they are resentfully referred. If patients actu-
as the fear of an unrecognized illness, persist, while frustra- ally do accept referral, they typically show significant psy-
tion and tension escalate between physician and patient. chiatric comorbidity but do not move beyond the somatic
Terms like neurasthenia, hypochondriasis, psychosomatic ill- view of their illness, with the consequence that they are
ness, and somatization have been used to confer a (false) sense often dismissed as “lacking insight,” “untreatable,” or
of diagnostic certainty on these poorly understood symp- “alexithymic.”44 Mental health interventions tend to be re-
tomatic states. If we consider our hypothetical patient, who sisted because they contradict patients’ explanatory model for
is fixated on her pain, she has long since “forgotten” about their distress (something physical, not psychological). On rare
her aunt, and the physician, focused too exclusively on her occasions, premature referral may miss an underlying organic
pain, has neglected the need to provide “triggers” to foster disease, but thoughtful referral can avoid such mishaps.45
free-reign on her narrative. He has also—finally, perhaps Although the primacy of the physician-patient relation-
out of frustration—attempted to force the patient into a ship is noted in most positive reports of management tech-
psychological/psychiatric paradigm of thinking specifically niques and is a general principle emphasized in medical
about her illness, which she is either unready or unable to education, physicians with an allegedly strong commitment
do. Physician and patient have yet to establish a common to the doctor-patient relationship seem hesitant to make
language and agenda for discussing her illness; instead, they maximal use of this familiar parameter in treating their
were engaged in discordant narratives—at an impasse, with somatizing patients. In such situations, patients are on their
no working alliance.39 way to becoming “unexplainable.”
When complaints and elusive diagnosis persist, relation-
ships can be severely tested, whether in adult or pediatric SUGGESTED REMEDIES The general physician is left to a “seat-of-
practice.40 Patients who somatize illustrate this dynamic in the-pants” approach to treating these patients. Given little
Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
D. R. Lipsitt et al.
reason for further testing and essentially no practical treat- “Curbside” discussion with psychiatrist colleagues can be
ment to prescribe, treatment realistically devolves onto the helpful, especially to help the primary care physician make
relationship itself. Although difficult to achieve, appropriate an appropriate referral.
management may require modifications in physicians’ styles In each visit, at least part of a physical examination should
of practice. be done, reminding patients that the “physicalness” of their
The impulse to label and dismiss the patient should be complaint is taken seriously. Premature proposals of psycho-
resisted, and rather than dismissal or referral, patients should logical interpretation or referral, as mentioned, generally fail
be offered (perhaps counterintuitively) another appointment since these patients want a physical doctor, not a psychiatrist.
for further exploration. Early detection of somatizing patterns, Expecting to cure the “incurable” generally leads to exasper-
though difficult, can curtail excessive unnecessary exploration. ation, while a caring, rather than curing, approach to the pa-
While some physicians depend on screening instruments to tient is likely to produce improvement over time.
define problem areas, time is better spent in face-to-face ex- Premature reassurance is often ineffective and cannot au-
change with the patient. Relevant data usually emerge if pa- thentically be offered until it is understood what experience,
tients’ narratives are not prematurely interrupted.46 Greater thought, or feelings accompany the reasons that have initi-
freedom in the narrative can build trust and lead to etiologic ated the patient’s decision to seek help. Offering a “shotgun”
clues to relevant clinical data, fostering expansion of history remedy without evidence is merely “a shot in the dark.”52,53
taking beyond the restrictive cataloging of physical com- DSM-IV defines hypochondriacal patients as unresponsive
plaints; it is possible to derive a psychological profile of a to “appropriate medical reassurance”; however, as with any
patient without being psychologically probing; for example, medical intervention, patients are more reassured and respon-
understanding how patients interact with family members sive when treated with understanding, respect, and caring.
can shed light on the meaning of patients’ symptoms.40,47 Somatizing patients present physicians with difficulty in
All physicians possess the ability to ask questions and deciding which symptoms to pursue and which to defer. Leav-
to encourage the patient to “tell me more”—a simple inter- ing some investigational pathways unexplored or symptoms
vention sufficient to widen the discussion beyond a narrow not pursued results in discomfort for the physician who seeks
litany of bodily symptoms. Helping patients recognize their certainty. If physicians can train themselves to live with
own effective coping patterns in past stressful experiences the “irreducible minimum of uncertainty that is inherent in
reminds them of their available internal resources. Many medicine,”54 they will achieve a degree of comfort working
physicians refrain from asking about “personal” concerns with patients with medically unexplained symptoms. Deny-
because they consider it intrusive, but studies indicate patients ing this uncertainty places physicians and patients at peril
actually want to be asked about nonmedical or personal of futile workups and frequently only serves to iatrogenically
(social) events in their lives, with 85% nevertheless reporting reinforce patients’ complaints. Perhaps Sir William Osler said
that such questions have been rarely, if ever, asked.33 Current it best: “Medicine is a science of uncertainty and an art of
curricular modifications in primary care and family medicine probability.”55(p 122)
have begun to improve this situation.48
Given that physicians’ time is limited, and reimbursement A Perplexity of Treatments
(for talk) often lacking, physicians naturally hesitate to “open How does one choose from the confusing abundance of
Pandora’s box.”49 Nevertheless, patients can be comfortably “diagnostic” labels for these patients? Therapy in the tradi-
interrupted with “This is interesting; let’s discuss it further in tional psychiatric sense is not effective for these patients,
your next appointment.” Physicians burdened with compet- who do not even find such treatment acceptable except as a
ing demands and shortages of time often rush in with “treat- potential means of support. “There are no adequate outcome
ment” before knowing what actually is being treated; hastily studies on which definite recommendations for treatment
offered treatment of vague symptoms may be experienced by of somatoform disorders can be based.”56(p 2119). And since
the patient as a promise that cannot be kept or as a wish to “no curative or ameliorative therapies have been found (for
eject the patient. Offers of “strong” medicines generally do somatization disorder), treatment necessarily focuses on the
not work either, since patients usually need to cling to their management of symptoms.” Likewise, since “there have been
symptoms, at least until a trusting relationship is established few formal treatment or management studies, recommenda-
or the strong-medicine approach has already been tried (and tions are based on a broad consensus among experienced cli-
failed). These patients feel strongly, rightly or wrongly, that nicians.”6(p 1743) Thus, in spite of limited understanding of
“no one listens,” and until they believe that someone is listen- the etiology and pathophysiology of medically unexplained
ing, symptoms will not be relinquished. symptoms, effective management strategies are reported reg-
When depression and anxiety accompany somatic com- ularly to show beneficial clinical outcomes.57–69 However,
plaints, psychopharmacotherapy has been successful, but both these techniques apparently are not readily incorporated into
accurate diagnosis and the choice of drug require specific un- general practice.
derstanding and knowledge to avoid reflexive responses—by Treatment may offer some degree of improvement in func-
both patient and physician—to garden variety discomfort.50,51 tional capacity, quality of life, satisfaction, or decreased health
Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Medically Unexplained Symptoms
services utilization, even if symptoms remain constant. The physician; this approach has much in common with strategies
strongest evidence to date is for cognitive-behavioral therapy.61 of chronic disease management.70 If the attributes of good
However, incorporating this technique into general practice patient-physician relations prevail, both parties will eventually
is difficult; patients are not easily referred; and specialty re- experience satisfaction. Difficult as it is to tolerate uncertainty,
sources are minimally available. A “consultation letter” from chronicity, and temporal restraints, physicians who can take a
a psychiatrist to the primary care physician has shown some wait-and-see approach to these patients will stave off the haz-
benefit in the clinical encounter, with both patient improve- ards of burnout (and postpone early retirement).71
ment and cost savings.62 This structured approach recom-
mends organizing the doctor-patient relationship around Medical Education
regularly scheduled visits independent of symptom genera- Medical education usually focuses on preventable, treat-
tion, frequency, or intensity. able diseases, whereas diseases of uncertain or inexplicable
Some have recommended group therapy,66 reattribution cause tend to be neglected. Disproportionate interest in
efforts,67 and heightened focus on communication.68 These “fascinomas” and “zebras” does not help students know
strategies as well as typical “usual care” have been largely what to expect in general practice. The psychosocial and emo-
disappointing. Various interventions, with randomized, con- tional realities of daily life receive scant attention or are de-
trolled studies, are rated in Table 2. meaned; a focus exclusively on physical complaints leaves
Because of diagnostic blurring and the heterogeneity of the relevance of affect, personality, and psychosocial topics
symptom complexes, it is difficult to compare treatments underrepresented. Overt and covert messages are conveyed
and efficacies. This multitude of treatments is characteristic in medical education that affect is something to be controlled,
of situations in which no definitive treatment actually exists denied, or repressed rather than acknowledged.72 These em-
or has been identified. 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.
SUGGESTED REMEDIES The multifaceted reality of medically un- The training in hospital settings focuses primarily on acute
explained symptoms precludes a one-size-fits-all approach. physical illness, not the chronic and emotional distress of the
Until a definitive treatment is identified, physicians should average patient seen in daily practice. Most physicians will
select the interventional approach that best suits their practice thus find greater comfort in physical (rather than emotional)
style and comfort, incorporating effective elements alluded to medicine, with objective findings that have clear demonstrable
here, as distilled and summarized in Text Box 1. A technique remedies. In time—the indeterminate future, but not now—
that emphasizes behavioral management of symptoms—and new discoveries of biological and genomic markers and brain
a “caring” rather than “curing” attitude toward the patient— mapping may illuminate puzzling disorders and reassure those
may be most tolerable and effective for both patient and physicians searching for greater certainty of etiology.73
Table 2
Selected Randomized, Controlled Studies of Medically Unexplained Symptom Treatment
Study Modality Results Efficacy
Speckens et al. (1995) 61
CBT by psychiatrist Improved social activities, symptoms, “illness behavior” +++
62
Smith GR Jr et al. (1995) Consultation letter to primary Improved physical function; decreased cost ++
care physician
Luo et al. (2007)63 CBT, antidepressants No significant cost savings; increased antidepressant ++
use; improved mental health
Gili et al. (2014)64 Group vs. individual CBT Better quality of life with individual CBT ++
65
Aiarzaguena et al. (2007) MD training in communication Improved MD attitudes +
? Benefits to patients
Schaefert et al. (2013)66 Collaborative group Improved mental (not physical) quality of life +
GPs and psychiatrists
Morriss et al. (2007)67 GP “reattribution” training Improved doctor-patient communication; no change +
in outcomes
Smith RC et al. (2006)69 Long-term multidimensional Improved mental and physical symptoms +++
intervention
CBT, cognitive-behavioral therapy; GP, general practitioner; MD, medical doctor.
Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
D. R. Lipsitt et al.
Text Box 1
Because emotions are typically given short shrift by both physicians continue to be poorly equipped and unprepared for
physician and patient, they can rigidly fixate somatic symp- the often elusive and troublesome interpersonal aspects of
toms within a reductionist (biomedical) framework for under- caring for patients regarded as “difficult.”80(pp 383–85)
standing and treating illness—a framework with a dualistic
distinction between psyche and soma.74 Historically, medi- SUGGESTED REMEDIES Although the medical school curriculum
cine has divided symptoms between the “real,” which are said has become more humanized since the 1980s, curriculum
to reside in the body with an identifiable pathophysiologic change is a very slow process. Perhaps, as medical school ad-
cause, and the “not real,” said to reside in the mind. This bi- missions committees begin to assess students for their ability
nary view of illness fosters the perception that the latter to be empathic and effective communicators, to appreciate
are not worthy of inquiry and that they remain outside the the role of affect in medical care, and to tolerate uncertainty
responsibility of most physicians—a perception that con- in their lives, a different kind of physician will emerge.81,82
tributes to physicians’ reluctance to treat these patients. Med- Changes must be made in curricula to enhance the pro-
ical training and practice have seen little change in decades, fessionalization of the graduate. Psychiatry and psychology
with some holding that the languages of the two domains need to be more integrated into the entire curriculum, with
are incompatible.75 attention not merely to mental illness but to human develop-
Physicians with a reductionist view of illness are unlikely to ment, personality, and the expression of, and interconnections
believe that their own behavior, skills, and personal qualities among, affect, cognition, and behavior. Faculty who demon-
can affect the structure of the doctor-patient relationship in strate comprehensive approaches to medical care should be
ways that can be beneficial to patients’ responses to treatment encouraged to serve as mentors. Students need tutoring in
of unexplained somatic distress.37,76 But it is well documented how to respond to highly affective situations without shame
that physicians’ attitudes and behavior can, in and of them- or embarrassment and without harboring or cultivating neg-
selves, have a salutary effect upon the patient and lead to im- ative biases toward patients.38
proved functioning.77 In the 1970s, internist-psychoanalyst During medical education, ways must be found to help
George Engel sought to rescue medicine from its reductionist, students monitor their own and also patients’ emotional
seventeenth-century base by proposing a new model that rec- responses—a difficult but invaluable challenge. Potentially
ognized that biological, psychological, and social factors all excellent teaching opportunities arise in the context of dissect-
contributed to medical care.10 ing cadavers, “sophomore hypochondriasis,” and first en-
Deleterious physician-patient relationships often have been counters with live patients.83,84
explained in terms of organizational and administrative fac- Physicians unable to engage in the language of emotion
tors, as well as the burden of overwork.78 Undoubtedly, will be greatly handicapped in responding to the patient’s
such factors are relevant, but the more likely explanation search for medical help. Issues of control, autonomy, depen-
is that, as Peabody wrote more than 70 years ago, “young dency, and flexibility—elements inherent in doctor-patient
graduates . . . are too ‘scientific’ and do not know how to take relationships—need to be addressed directly, not left to the
care of patients.”79(p 877) “hidden curriculum,”85 those “noncognitive objectives of ed-
While medical schools today do emphasize the importance ucation like attitudes, values, character and professional iden-
of doctor-patient relationships, communication skills, and “pro- tity” that shape the “grander educational experience that
fessionalism” as preparation for medical practice, graduating [comes] out of the general culture of medical school.80(p 70)
Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Medically Unexplained Symptoms
According to Ludmerer, efforts to understand or to change gap of large proportion, often resulting in hasty referral by the
medical curricula that ignore the role of the hidden curricu- doctor and in doctor shopping by the patient. Furthermore,
lum do so “at great risk of failure.”80(p 72) the physician’s wariness of missing a diagnosis and the fear
Some physicians have found postgraduate courses helpful of malpractice suits make treatment of medically unexplained
in sharpening their psychosocial skills. Balint groups, so- symptoms the more taxing.
named after the Hungarian-British psychoanalyst who met
with general physicians to help them explore the nuances SUGGESTED REMEDIES The control of the health care system by
of doctor-patient relations, are found by some to be highly in- insurance companies and others presents a difficult barrier in-
structive.86 Others have spent elective time rounding with deed. Some physicians have elected limited boutique (concierge)
consultation-liaison psychiatrists in hospital-based depart- practices, allowing more time for patients, whereas others have
ments of psychiatry.87 The focus in such experiences is not shifted from private practice to employed status in hospitals
on studying major psychiatric disorders but on the comorbid and other sites.95 To some, the individuality of private practice
psychosocial aspects of medical illness and the impact of seems to be sacrificed for “cookie cutter” medicine.
doctor-patient relationships on illness. An appreciation of the Unfortunately, reimbursement for time beneficially spent
psychodynamic aspects of relationships also can add to one’s listening, communicating, and supporting patients with regu-
interest and skill in understanding and managing patients with larly scheduled visits is poorly or not at all valued by those
medically unexplained symptoms.88,89 Goldberg and associ- who control medical claims. They are unlikely to listen to
ates in England have offered training to general practitioners the argument that spending 15 minutes preventively with a
(shunned by many) on how to help patients transition from so- troubled patient may avoid much higher costs of emergency
matic preoccupation to psychological understanding through services or hospitalization. But if this argument is made re-
“reattribution” of symptoms to psychological meaning, an ap- peatedly, it may eventually be heard. Lobbying through med-
proach now found to have limited results.90,91 ical societies and associations, letters to newspapers, and
In much the same way that their nonpsychiatrist colleagues written complaints to the chief executive officers of managed
can benefit from rounding with consultation-liaison psychia- care companies—pointing to the unwise practice of denying
trists, psychiatrists and psychiatry residents can benefit from justifiable reimbursement for interventions that reduce costs
increased experience in general medical practice.92 of excessive utilization—may help.
Integrated or collaborative practices with ancillary health
Medical System Transformation providers offer economies of time.96,97 A nurse, psychologist,
Medical practice has gradually seen profound changes in or health care assistant affiliated with the physician’s practice
some or all aspects of caring for the sick (and the well).93 can offer continuity of care that is most beneficial to patients
Patient-doctor relationships have experienced erosion result- with medically unexplained symptoms seeking a caring per-
ing from the impact of shifts in autonomy, practice sites, and son. Evaluation of new care models of “medical homes”
professional conduct imposed by corporate and regulatory and other forms of integrated care designed to offer mental
agencies, most particularly since the advent of managed health, preventive, and comprehensive services awaits data
care.80(p 372) A Wall Street Journal article quoted a health on cost-effectiveness and patient outcomes.98 In treating med-
maintenance organization executive as saying, “We see peo- ically unexplained symptoms, one should expect the process
ple as numbers, not patients . . . [W]e’re a mass-production to be extended, and one should also keep one’s expectations
medical assembly line, and there is no room for the human realistically modest.99
equation in our bottom line.”94
Matters of reimbursement, legal vulnerability, and record CONCLUSION
keeping, previously taken in stride, have moved front-and- Individuals take themselves to doctors with a variety of perturba-
center in everyday practice. Access to cybertechnology has tions that do not fit readily into common medical nosology.100
altered the fundamental ways that medical knowledge is ac- Patients whose unexplainable medical symptoms result in
quired, retrieved, and transmitted, significantly affecting the deviant illness behavior constitute a significant part of general
nature of communication and interaction. medical practice, and for most physicians, these patients arouse
All of these factors complicate the physician’s day-to-day varying degrees of vexation, intolerance, and negativism. Even
life. The pressure to see more patients in limited time, the need though helpful interventions are available—ones well within
for more meticulous record keeping and disease coding, and the existing skills of today’s physicians—this patient population
the regulatory enforcement of reimbursement schedules have continues to exert a heavy burden on practitioners and the
been noted in cases of early burnout or retirement of physi- health care system. This article has therefore focused on
cians. In such settings, faced with patients who appear to be other potential barriers to optimal care for patients with
“needlessly” taking up time, energy, and resources, physi- medically unexplained symptoms.
cians are unlikely to feel free enough to engage patients with We examine ways of improving symptom containment,
medically unexplained symptoms in ways that are supportive lessening excessive use of health care services, enhancing qual-
and productive.85 The unease that ensues creates an empathy ity of life, and improving physician-patient relations, thereby
Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
D. R. Lipsitt et al.
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