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“Unexplained” Somatic Symptoms, Functional Syndromes, and
Somatization: Do We Need a Paradigm Shift?
Michael Sharpe, MA, MRCP, MRCPsych, and Alan Carson, MB, MRCPsych, MPhil
Medically unexplained functional or somatization symptoms are
somatic disorders that are not adequately explained by physical
disease processes. The way in which these disorders have been
understood and managed has varied over the history of medicine.
However, only in the past 100 years has the “mental” explanation
predominated. A benefit of this trend has been the development
of effective treatments in the form of “antidepressant” drugs and
cognitive–behavioral therapies; a cost has been limited integration
of these treatments into medical practice and lack of acceptability
to patients.
We suggest that there is much to learn from physicians of
the pre-Freudian era. Their etiologic theories are now supported
by new scientific evidence, and their clinical practice provided
ways of making psychological treatment acceptable to patients.
We propose a paradigm shift in which unexplained symptoms are
remedicalized around the notion of a functional disturbance of the
nervous system and treatments currently considered “psychiatric”
are integrated into general medical care.
Ann Intern Med. 2001;134:926-930. www.annals.org
For author affiliations and current addresses, see end of text.
P
atients seek help from physicians for symptoms.
Physicians diagnose diseases to explain the symp-
toms. Symptoms are the patient’s subjective experience
of changes in his or her body, whereas diseases are ob-
jectively observable abnormalities in the body. Difficul-
ties arise when the physician can find no pathologically
defined disease to explain a patient’s somatic symptoms.
These symptoms are referred to as poorly understood, or
“unexplained,” functional or somatization symptoms (1).
POORLY UNDERSTOOD,UNEXPLAINED, OR FUNCTIONAL
SYNDROMES
Many syndromes made up of combinations of “un-
explained” symptoms have been described. Although the
research literature suggests the presence of biochemical
and physiologic abnormalities in many of these disorders
(2), they share a lack of the pathologically defined
changes in tissue that designate medical conditions, such
as cancer, as a disease. Each medical specialty has at least
one of these medically unexplained or functional syn-
dromes. For example, rheumatologists may diagnose un-
explained muscle pain and tenderness as fibromyalgia,
gastroenterologists may diagnose unexplained abdomi-
nal pain with altered bowel habit as the irritable bowel
syndrome, and infectious disease specialists may diag-
nose unexplained chronic fatigue and myalgia as a post-
viral or chronic fatigue syndrome (3).
MANY SYNDROMES OR ONE?
The long list of apparently discrete functional syn-
dromes may be misleading. To the contrary, they have
much in common. First, the published diagnostic crite-
ria for specific syndromes frequently overlap with those
of others; second, patients identified as having one syn-
drome also frequently meet diagnostic criteria for others;
and finally, similarities are seen across syndromes in
non–symptom-related patient characteristics, such as
sex, coexisting emotional disorder, proposed cause,
prognosis, and response to treatment (3–5). For the pur-
poses of this review, we consider unexplained symptoms
and syndromes together.
HOW HAVE UNEXPLAINED SYMPTOMS BEEN
CONCEPTUALIZED HISTORICALLY?
Symptoms are defined as “unexplained” after disease
has been excluded. Historically, which diseases have
been considered necessary to exclude (and the means of
detecting them) has depended on the state of medical
science. Some symptoms that were previously regarded
as medically unexplained become explained when causes
are discovered; one example is fatigue in patients in
whom Lyme borreliosis was identified (6). However,
this process is not unidirectional; new evidence has also
caused symptoms previously considered medically ex-
plained to become unexplained. For instance, chronic
infection with Epstein–Barr virus has been discredited as
the explanation for most cases of chronic fatigue (7).
At present, a large proportion of patients’ symptoms
remain unexplained even after modern medical assess-
ment (8). The way in which such symptoms are concep-
tualized and treated presents a challenge to medicine
that we address here. We begin with a brief review of
Innovations in Symptom Management
926 © 2001 American College of Physicians–American Society of Internal Medicine
how these symptoms have been conceptualized and
treated at different times in the history of medicine.
ABRIEF HISTORY OF MEDICALLY UNEXPLAINED
SYMPTOMS
Early explanations for illness in which the cause was
not apparent focused on hypothesized disturbance of
bodily organs, in particular the uterus. Unexplained
symptoms were often subsequently referred to as “hys-
terical.” Management included applications of oint-
ments to the labia and direct manipulation of the organ
(9). After the Renaissance, increasing understanding of
anatomy led to disease of the nervous system being re-
garded as the origin of unexplained symptoms. Hence,
in 1667, Thomas Willis, the father of neurology, wrote,
“As we have shown before the passions vulgarly called
hysterical do not always proceed from the womb, but
often from the head’s being affected” (10). Unfortu-
nately, this new insight did not produce any greater
sophistication in treatment: Willis advocated hitting
such patients with a stick (10).
By the end of the 17th century, psychological fac-
tors were beginning to be considered in the etiology of
unexplained symptoms. The great physician Thomas
Sydenham declared that “[in hysteria] the mind sickens
more than the body” (11). It was probably with Syden-
ham that such illnesses began to be seen as “diseases of
the mind.” Sydenham recommended physically oriented
treatments for purifying and fortifying the blood, but he
also encouraged regular exercise and emphasized per-
sonal interest in the patient’s welfare. By the early 18th
century, Giorgio Baglivi, the chair of medical theory at
the Collegio della Sapienza in Rome, not only advocated
exercise and change of social circumstances but also en-
couraged physicians to enquire about the patient’s men-
tal state and to try to instill hope and optimism (9).
The 19th century saw a return to predominantly
physical explanations for unexplained symptoms. How-
ever, the development of pathologic enquiry had dem-
onstrated the absence of observable anatomic abnormal-
ity in the brain or elsewhere. This led physical
disturbances to be regarded as subtle or “functional.”
Charcot, writing about hysteria in 1889, said, “There is
without doubt a lesion of the nervous centres but where
is it situated and what is its nature?...Certainly it is
not of the nature of a circumscribed organic lesion of a
destructive nature...oneofthose lesions which escape
our present means of anatomical investigation, and
which for want of a better term, we designate dynamic
or functional lesion” (12). This physical model was as-
sociated with predominantly physical interventions—in
Charcot’s case, pressure on the ovaries.
Only at the turn of the 19th century was an explic-
itly and ultimately exclusive psychological or mental or-
igin for these symptoms proposed. Charcot’s pupils
Babinski, Janet, and Freud (13) proposed the impor-
tance of psychological factors. With the 20th century
came psychoanalysis. The idea of a functional distur-
bance of the brain was largely displaced by the idea of
psychogenesis. Thus, treatment of unexplained somatic
symptoms became explicitly psychological and subse-
quently the province of psychiatry. Somatization was
proposed to explain how mental problems could mani-
fest as somatic symptoms (14). With psychogenesis
came the inevitable implications of imaginary disease
and fraud: “These patients are veritable actresses; they
do not know of a greater pleasure than to deceive” (15).
Many, perhaps the majority, of such patients appear to
have been largely unconvinced by this “psychologiza-
tion” of their somatic illnesses and unconvinced of the
desirability of seeing a psychiatrist or psychologist rather
than a physician (13).
AGOLDEN AGE?
There was a period, however, just before the ascen-
dance of psychoanalysis, when the accepted etiology of
unexplained symptoms was a reversible functional dis-
turbance of the nervous system, and the accepted treat-
ment included attention to psychological aspects of
medical management. For example, in the late 1800s,
George Beard proposed the diagnosis of neurasthenia
(16) as a reversible functional disturbance of nervous
functioning, although he emphasized physical rather
then psychological treatments. Clearly, the physicians of
that time had no direct scientific evidence of functional
disturbance of the central nervous system.
Many other physicians of this age held the view that
psychological aspects of treatment were also important
and, to be effective, had to be delivered in a way that
was congruent with the patients’ somatic view of their
illness. An example of such an approach is that of Silas
Weir Mitchell, who espoused bed rest as a paradoxical
incentive to activity in patients with functional fatigue
(17). Paul Dubois, a Swiss physician, further developed
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this medical psychotherapy. He described his approach
to such functional nervous disorders as “rational persua-
sion” (18), a psychotherapy delivered within a medical
context and idiom. The principles of rational persuasion
were as follows. First, the physician should obtain the
patient’s confidence and demonstrate sympathy with the
patient’s experience; second, he or she should listen to
the patient’s history without impatience; third, he or she
was to use medical authority and the therapeutic rela-
tionship to convey to patients the belief that they would
recover; and finally, the relationship between patient
and physician should be collaborative, and the treatment
approach should also be explained to family members.
As far as we can tell from accounts by Dubois and oth-
ers, patients welcomed this approach, although its effec-
tiveness was of course never evaluated in randomized trials.
CURRENT APPROACHES TO TREATMENT
Medical Management Strategies
Many patients with somatic symptoms present to
physicians for assessment. The usual approach would be
to obtain a history and perform examination and, if
required, laboratory testing. Patients are often regarded
as having problems that are “not physical” or “purely
psychological.” Treatments regarded as “psychiatric” or
“psychological” have proven efficacy in many such pa-
tients, but they are not in widespread use. Nor are they
likely to be acceptable to many patients if they were (19).
The outcome of this process for patients whose
symptoms are found to be unexplained by disease has
been little studied, but evidence indicates that it may be
poor (20). A striking example comes from a 10-year
follow-up of patients who had negative coronary angiog-
raphy for chest pain. At follow-up, three quarters of the
patients remained symptomatic and disabled (21). Nor
has there been much study of the effect on the patient of
the explanations they are given for symptoms that are
found to be medically unexplained. It seems, however,
that neglect of the psychological impact of certain expla-
nations can be harmful, for example, by suggesting to
patients that they are sick when they are not (22).
Psychiatric Management Strategies
By and large, patients with unexplained symptoms
present to physicians rather than to psychiatrists. How-
ever, given the predominant psychological model of ex-
planation, it is perhaps not surprising that psychiatric
and psychological therapies have undergone substantial
development and systematic examination of their effec-
tiveness. In particular, considerable evidence supports
the effectiveness of antidepressant drugs and psychother-
apy. A recent systematic review of 96 randomized trials
of treatment with antidepressant drugs found it to be
moderately effective (23). The odds ratio for improve-
ment with antidepressant drug therapy compared with
placebo was 3.4, and the effect size was homogenous
across the functional syndromes studied. In addition, a
systematic review of psychotherapy was published re-
cently (24). The most commonly recommended form is
behavioral or cognitive–behavioral therapy. These ex-
plicitly psychological treatments aim to achieve recovery
by helping the patient change beliefs and behaviors that
perpetuate illness. In 70% of the 27 randomized trials
reviewed, cognitive– behavioral therapy was superior to
comparison treatments in reducing symptoms.
Most of these trials, however, evaluated treatment
given by “mental health professionals” in “psychiatric”
settings. It is therefore likely that such treatments were
acceptable to only a minority of the potentially eligible
patients. Thus, although treatments regarded as psychi-
atric or psychological can be helpful, they are neither
available nor, in their current form, acceptable to many
or most patients who visit nonpsychiatric physicians.
Why should this be? One reason may be that patients
experience their illness as a physical rather than mental
state. In addition, they may find a mental explanation
not only less plausible but also less appealing. Western
dualistic metaphysics continues to imply that “mental”
illnesses are distinct from physical illness. Furthermore,
mental illnesses are in general less acceptable and often
regarded as “not real,” with an implication of weakness,
fault, or loss of reason in patients who have them (25).
Shortcomings of the Current Approaches
As a result of this lack of availability and acceptabil-
ity of psychological treatment, specialist physicians and
surgeons manage patients with unexplained illness in a
medical context by using the procedures available to
them. They may carry out repeated but often unproduc-
tive medical investigation and intervention (26), or they
may more commonly regard these patients as having
psychiatric problems outside their scope of expertise and
suggest referral to psychiatry, which the patient sees as
both misguided and stigmatizing and thus declines. Pa-
Innovations in Symptom Management “Unexplained” Somatic Symptoms
928 1 May 2001 Annals of Internal Medicine Volume 134 • Number 9 (Part 2) www.annals.org
tients may therefore be left in a “no-man’s land” be-
tween a narrow biomedical approach that rejects their
physical view of their symptoms and a psychiatric ap-
proach that they themselves reject (27). Neither medi-
cine nor psychiatry seems to serve these patients well.
DO WE NEED A PARADIGM SHIFT?
A Return to the Psychologically Sophisticated Functional
Nervous Paradigm
We suggest that much can be learned from both the
etiologic model and clinical management of unexplained
somatic symptoms that physicians used more than 100
years ago. The predominant model was the functional
nervous paradigm, as expounded by such physicians as
George Beard. This model explicitly acknowledged the
neurobiological correlates of the patients’ somatic symp-
toms as well as the influence of psychological factors.
Symptoms were seen as a manifestation of a reversible
functional disturbance rather than as fixed pathology of
a purely psychological nature. Recent evidence has be-
gun to provide support for this viewpoint. Endocrine
and functional neurologic as well as psychological fac-
tors are being identified in relation to functional syn-
dromes. Examples include the irritable bowel syndrome
(28); chronic pain and fatigue (29); repetitive strain in-
jury (30); and even the archetypal psychogenic condi-
tion, conversion hysteria (31). Therefore, in part, pa-
tients may be correct that their symptoms are physical.
The Psychologically Augmented Medical Consultation
We also propose that modern medical practice can
learn from the way in which such physicians as Dubois
used medical consultation as a psychological interven-
tion. We now have much more evidence than did
Dubois and his colleagues of the effectiveness of psycho-
logical and psychiatric interventions in patients with un-
explained symptoms, and there is an urgent need to
make these treatments more available and acceptable by
delivering them in the context of medical consultation.
The case was recently argued for increased attention to
how current medical assessment and investigation can
be explained in a way that maximizes its psychothera-
peutic effect (32). One example is an investigation of the
benefits of using explanation and visual feedback of ul-
trasonography for abdominal pain in gynecology (33).
We also advocate that attention be paid to the psy-
chological effects of how symptoms are explained to
patients. A randomized trial in British primary care
compared the effect of a physician giving a positive ex-
planation, indicating that he or she understood the pa-
tient’s experience, with the effect of giving no explana-
tion. Patients who received the positive explanation had
a better outcome (34). These studies provide clues about
how we may psychologically augment the standard
medical consultation by incorporation of simple and
time-efficient cognitive–behavioral techniques. It may
therefore be possible to integrate the principles of
psychological and psychiatric treatment into medical
care rather than regarding them as separate.
A New Research Agenda
Such a paradigm shift would influence the research
agenda in many ways. First, we will not only continue to
explore the psychological mechanisms that produce
symptoms but also integrate these studies with biological
investigations. The way in which psychological factors
operate need not be cloaked under a mysterious process
such as that suggested by “somatization,” but rather ex-
plicitly examined. This is starting to happen. An exam-
ple is the study of functional brain imaging in patients
with unexplained motor weakness (31).
Second, we must evaluate the psychotherapeutic ef-
fect of medical management and determine what is
helpful and what is harmful. These factors could then
have a similar status as pharmacology in our understand-
ing of therapeutics. We also need to evaluate the effec-
tiveness of medical assessments augmented by the inclu-
sion of proven cognitive–behavioral principles.
Finally, and most important, we must rekindle the
interest of the medical community as a whole in what is
a substantial but neglected area of medical practice.
From University of Edinburgh and Royal Edinburgh Hospital, Edinburgh,
United Kingdom.
Grant Support: By the University of Edinburgh.
Requests for Single Reprints: Michael Sharpe, MA, MRCP,
MRCPsych, University Department of Psychiatry, Kennedy Tower,
Royal Edinburgh Hospital, Edinburgh EH10 5HF, United Kingdom;
e-mail, michael.sharpe@ed.ac.uk.
Current Author Addresses: Dr. Sharpe: University Department of
Psychiatry, Kennedy Tower Royal Edinburgh Hospital, Edinburgh
EH10 5HF, United Kingdom.
Dr. Carson: Royal Edinburgh Hospital, Edinburgh EH10 5HF, United
Kingdom.
Innovations in Symptom Management“Unexplained” Somatic Symptoms
www.annals.org 1 May 2001 Annals of Internal Medicine Volume 134 • Number 9 (Part 2) 929
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