Many people have been in a situation where they have felt an inexplicable pain in some part of their body for weeks on end, or feel especially tired lately. So you go to the doctor, who may run a test or two, but can’t find out what’s causing these symptoms. Despite a dizzying array of high-tech medical tests, the reality is that many of the symptoms, such as fatigue and headaches, have no explanation. For the most part, patients were relieved after their doctors ruled out the possibility of a major illness. But there are other patients who are still plagued by mysterious symptoms and go back to the doctor again and again, worried that they may have some malady that the doctor hasn’t detected. Now, for patients who are plagued by medically unexplained symptoms, some family physicians and internists are using treatments such as cognitive-behavioral therapy and relaxation therapy to help them see these symptoms in a different light. This reflects the fact that giving too much attention to such symptoms usually makes patients feel worse. The goal of this type of treatment is to teach patients to make peace with their symptoms and to see them as harmless, or even to ignore them. Recent studies have shown that this type of treatment can reduce symptoms and ease the worry that comes with those symptoms (which is perhaps just as important). Unexplained symptoms frustrate doctors and patients alike. Patients may feel that their concerns are not being taken seriously and that they are imagining things. Doctors may feel powerless to do anything about it – and may resent the time taken up by these patients. Most people don’t want to hear things like, ‘Actually, I’m not sure,'” says Susan H. McDaniel, associate director of the department of family medicine at the University of Rochester Medical Center in Rochester, New York. Most people don’t want to hear ‘I’m actually not sure,’ but the truth is often that we’re not sure.” Arthur Barsky, a professor of psychiatry at Harvard Medical School, says, “We think the good outcome is not necessarily that the symptoms go away, but that they no longer cause distress or worry.” Medically unexplained symptoms are extremely common, and a 2011 study of 620 first-time patients in Germany found that medically unexplained symptoms accounted for two-thirds of all reported symptoms. The study was published in the journal Psychosomatics. Other studies estimate that 10 to 20 percent of first-time patients in the U.S. have medically unexplained symptoms that impair their health in some way. About 5 to 7 percent have a more serious mental illness, somatization disorder, in which patients have symptoms (both medically explainable and unexplained) that last more than six months and are accompanied by severe anxiety. This is different from hypochondriasis, which is a condition in which a patient has no or mild physical symptoms but suspects that he or she is suffering from a serious illness. Hypochondriasis is no longer a diagnostic term and has been replaced by the term “illness anxiety disorder” in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders. Any symptom may be medically unexplained. The most common are fatigue, back pain, headaches and abdominal pain, doctors say. Dizziness, vertigo and numbness sometimes have no exact medical cause. Hannah Letterman was 17 years old in high school when she suddenly felt nausea, headaches and dizziness. She says, “At the time, I could feel that I was stuck in circles with my feet. I couldn’t read, I couldn’t do my homework, and talking to people only lasted a few minutes.” Letterman is 19 years old and is in her freshman year of college in Rochester, NY. The feeling lasted for months. She went to several doctors and underwent numerous tests. Eventually, at the University of Rochester Epilepsy Center, she was referred to see psychologist William Watson. Dr. Watson asked her to keep a symptom diary: to note behaviors, thoughts and feelings that seemed to cause her symptoms to lessen or intensify. During weekly psychotherapy sessions, Letterman says, she tried to work on “really accepting my emotions, whatever they were.” That approach paid off. Leitman says she still has some remaining symptoms, but her physical functioning “has been completely restored.” She initially thought it was silly to attribute her symptoms to psychological causes, but now she’s slowly coming around to the idea. Robert C. Smith, a professor of medicine and psychiatry at Michigan State University College of Human Medicine, says some patients with medically unexplained symptoms who see their doctors almost once a month may have underlying psychological problems that trigger them. Robert C. Smith, MD, says that some patients with medically unexplained symptoms who see a doctor almost every month may have underlying psychological problems that trigger the symptoms and the “doctor-seeking” behavior. These symptoms are red flags for underlying mental illnesses” such as depression or anxiety, he said. Dr. Smith and colleagues developed a treatment for first-time patients. It includes antidepressants and removes narcotic painkillers, which can worsen depression, supplemented with relaxation therapy, exercise, and other methods. The Journal of General Internal Medicine published a 2006 paper on a study of 206 patients who averaged more than 13 visits to the doctor per year before the study, and found that about 60 percent of them had major depression. Compared to the control group, those who received treatment (four nurse practitioners visited the patients 12 times in a year and treated them) had less psychological distress and were better able to cope with their illness. A study published in 2013 looked at 89 patients. These 89 patients had frequent visits to their primary care physicians for medically unexplained symptoms and were very concerned about their health. In that study, Dr. Barsky and his colleagues found that both cognitive-behavioral therapy and relaxation training relieved symptoms and improved mental well-being, reducing the damage caused by the symptoms. Within a year of the study’s conclusion, the number of doctor visits for these patients decreased to an average of about 8.8, compared to 10.3 before the study began. Cognitive-behavioral therapy is divided into four to eight phases and is administered by nurse practitioners or physician assistants who have received multiple seminar trainings. During treatment, Dr. Barsky said, the nurse practitioner or physician’s assistant first teaches patients to change their “bad ideas” about health and disease, such as the misconception that “health is the absence of any disease. They are then guided to stop “bad disease behaviors,” such as excessively searching the Internet for information about their disease or visiting the doctor constantly in search of a diagnosis. Patients were also asked to learn to take their mind off their symptoms. As soon as they find themselves thinking about the symptoms, they turn to a range of enjoyable things. Patients who received cognitive behavioral therapy also learned relaxation techniques like meditation. Wanda Filer, a family physician in York, Pennsylvania, says she doesn’t readily refer patients with medically unexplained symptoms to a bunch of specialists or have them run a lot of tests, which she considers a “therapeutic disaster. The likelihood of misdiagnosis increases. You can “find a small cyst that might not have been a problem, but that causes a lot of distress for the patient,” she says. Molly Cooke, MD, president of the American College of Physicians and a practicing internist in San Francisco, says some of her patients are “very observant,” especially those with chronic abdominal pain. Dr. Cooke tells her patients, “You’re a superb observer of what’s going on in your body. The activity of the gastrointestinal tract is actually very active, but many people don’t perceive this.” For patients with vague symptoms in this category, she agrees with them on a time frame to continue probing. If the illness continues to plague them over the next few months or weeks, depending on the situation, she will perform more testing on the patient. My hope is that these vague symptoms will either go away or be replaced by a range of other symptoms,” she says. Many people feel that it’s not too good to go to the doctor with no symptoms.”