[Dealing with medically unexplained symptoms in general practice: from irritation to 'the tricks of the trade']

Patients with medically unexplained symptoms pose a problem for medical professionals. Doctors usually lack tools to handle these complaints adequately. Over the past decades much research has been done in the areas of classification and intervention both in general practice and in specialist care. If the doctor responds to the patient by offering to prescribe medicinal symptom relief, the first step into the vicious circle is taken. The patient is polite enough to try the medication but when it does not help, returns to the doctor. If the doctor continues to think along somatic lines the phenomenon known as iatrogenically enforced somatic fixation may arise. The main development in intervention stems from cognitive behavioural therapy, which is now considered the gold standard for all patients, regardless of their symptoms. In the Netherlands, a postgraduate course has been developed to implement the fundamentals of this approach into general practice. On this course, the doctor learns not to be deterred by the somatizing patient and to effectively close off their somatic treatment trajectory. He or she teaches the patient to look at the situation from a new perspective and instead of being preoccupied with what is not functioning well to concentrate on training those activities which can be carried out effectively. This shift in emphasis can help to cause the preoccupation of the patient to slowly disappear. Initial results are encouraging: both patients and general practitioners have responded favourably.