Patients with severe and enduring somatoform disorders (SESD) characteristically present with multiple, recurrent and frequently changing physical symptoms that have usually been present for several years before referral to a psychiatrist/psychologist. Many patients report long histories of contact with both primary and tertiary care services, have undergone repeated fruitless investigations and have high levels of disability. SESD are responsible for disproportionately high healthcare costs and are the third most common cause of workplace absence. Identification of patients with SESD by psychiatrists requires particular skills: collaboration with colleagues is vital and there are risks of iatrogenic harm. We describe the obstacles encountered in identifying these patients as well as methods of assessment and management. Treatment pathways best suited to managing this large and as yet untended group of patients are described.