Patients with medically unexplained symptoms fall into heterogeneous groupings ranging from selected impairment to behaviors meeting DSM-5 criteria for mood and somatic symptom disorders. Many patients do not report symptoms of anxiety and depression, the most common mental health disorders in the general population, but focus on physical concerns instead. Two-thirds of patients with depression, for example, present with physical complaints, and half report multiple unexplained or somatic symptoms. Furthermore, functional syndromes have been shown to "frequently co-occur and share key symptoms and selected objective abnormalities." Overlap rates for fibromyalgia and chronic fatigue syndrome in an analysis of 53 studies ranged from 34% to 70%. Failure to recognize the admixture of physical symptoms, functional syndromes, and common mental disorders — anxiety, depression, unexplained and somatoform symptoms, and substance abuse—add to the burden of patient undertreatment and poor quality of life. Authors of the first randomized controlled intervention trial for patients with medically unexplained symptoms advise viewing such symptoms as "a generalized warning sign of underlying psychological distress, of which

depression is an advanced manifestation."

The "Difficult Encounter." Patients with unexplained and somatic symptoms are often frequent users of the health care system and labeled as "difficult patients." Patient depression and anxiety "make physician ratings of difficult encounters three times more likely, and somatization increases this likelihood nine-fold." A growing literature reveals that 15% to 20% of primary care visits, or up to three to four visits a day, are considered difficult. In the difficult encounter dyad, clinician factors have emerged that include job stress and burnout, anxiety and depression in the clinician, less clinical experience, and aversion to the psychosocial aspects of care. Clinicians are urged to identify the many variables associated with these encounters, identify their own underlying negative emotions, adapt their approach and redirect the encounter, and explore what makes the encounter difficult with the patient. In the words of an expert:

"Celebrate the well-navigated difficult encounter. Dealing with difficulty signifies mastery rather than weakness. Olympic dives are rated in terms of difficulty, as are mountain climbs, hiking trails, musical works, crossword puzzles, and highly technical procedures. Partnering with patients in the challenging aspects of their health, lives, or medical care is a stepping stone to surmounting together the difficult encounter."

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