Somatisation/medically unexplained physical symptoms

Specialties > General practice

Differential Diagnosis Schema 🧠

Somatic Symptom Disorder

Somatic symptom disorder: Multiple physical symptoms, disproportionate and persistent thoughts about the seriousness of symptoms, anxiety about health.
Illness anxiety disorder: Preoccupation with having or acquiring a serious illness, despite few or no symptoms.
Conversion disorder: Neurological symptoms (e.g., paralysis, blindness) inconsistent with medical findings, often linked to psychological stress.
Factitious disorder: Deliberately producing or exaggerating symptoms for psychological gain, often without external incentives.
Malingering: Intentional production of symptoms for external gain (e.g., financial compensation, avoiding work).

Functional Syndromes

Irritable bowel syndrome (IBS): Recurrent abdominal pain with altered bowel habits, no structural abnormalities found.
Chronic fatigue syndrome (CFS): Persistent, unexplained fatigue not improved by rest, associated with multiple somatic complaints.
Fibromyalgia: Widespread musculoskeletal pain, fatigue, and tenderness in specific areas, often with associated sleep disturbances.
Tension-type headaches: Recurrent headaches, often associated with stress or psychological factors, without clear neurological cause.
Non-cardiac chest pain: Chest pain mimicking angina, but with normal cardiac investigations.

Psychiatric Disorders

Depression: May present with multiple physical symptoms such as fatigue, pain, or gastrointestinal disturbances.
Anxiety disorders: Can cause physical symptoms such as palpitations, chest pain, and shortness of breath.
Panic disorder: Recurrent panic attacks with physical symptoms including chest pain, dizziness, and dyspnoea.
Post-traumatic stress disorder (PTSD): May present with physical symptoms such as headaches, gastrointestinal disturbances, and chronic pain.
Obsessive-compulsive disorder (OCD): Physical symptoms may result from compulsive behaviours or severe anxiety.

Key Points in History 🥼

Symptom Onset and Course

Onset: Sudden onset of symptoms may suggest conversion disorder; gradual onset is more typical of somatic symptom disorder or functional syndromes.
Symptom duration: Chronic symptoms without clear cause may suggest a somatisation disorder or a functional syndrome.
Exacerbating factors: Stress, anxiety, or depression often exacerbate symptoms; explore any recent psychosocial stressors.
Response to treatment: Lack of response to standard treatments may suggest a non-organic cause of symptoms.

Symptoms and Psychosocial Context

Number and variety of symptoms: Multiple symptoms across different organ systems suggest somatisation.
Psychosocial history: Explore recent stressors, trauma, or significant life events that may relate to symptom onset.
Coping mechanisms: Assess how the patient deals with stress and illness; maladaptive coping may contribute to symptom persistence.
Functional impairment: Explore the impact of symptoms on daily activities, work, and social interactions; significant impairment is common in somatisation.

Background

Past Medical History: History of multiple, often unexplained, medical consultations and investigations.
Drug History: Consider possible side effects of medications, including psychiatric medications.
Family History: Family history of somatisation, functional syndromes, or psychiatric disorders.
Social History: Occupational history, social support, and impact of symptoms on relationships; assess for disability claims or litigation, which may influence presentation.

Possible Investigations 🌡️

Basic Investigations

Full blood count: To rule out anaemia or infection as potential contributors to symptoms.
Thyroid function tests: To exclude thyroid disorders, which can present with somatic symptoms.
Electrolytes and renal function: To assess for underlying metabolic causes of symptoms such as fatigue or confusion.
ECG: To rule out cardiac causes of symptoms such as palpitations or chest pain.

Psychological Assessment

Screening for depression and anxiety: Using validated tools such as PHQ-9 or GAD-7 to assess for underlying psychiatric conditions.
Cognitive assessment: If cognitive symptoms are present, consider a screening tool like the MMSE or MoCA.
Referral to psychiatry: For comprehensive evaluation if there is significant psychiatric comorbidity or unclear diagnosis.

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