What psychological conditions can exist when no physiological condition is identified?

Somatic Symptom and Related Disorders

When no physiological condition is identified to explain physical symptoms, somatic symptom and related disorders should be documented, which are characterized by distressing physical symptoms accompanied by excessive thoughts, feelings, or behaviors related to those symptoms. 1

Specific Diagnostic Categories to Document

The DSM-5 recognizes seven distinct somatic symptom and related disorders that can exist when medical evaluation fails to identify a physiological cause: 1

Primary Diagnoses

• Somatic Symptom Disorder (SSD): Requires both distressing somatic symptoms (Criterion A) AND excessive thoughts, feelings, or behaviors about those symptoms (Criterion B), resulting in significant psychosocial impairment 1, 2

  • Affects 10-15% of adult primary care patients 1
  • In children, recurrent abdominal pain and headaches account for 5% and 20-55% of pediatric office visits respectively 1
  • Common presentations include neurologic, pain, autonomic, or gastrointestinal symptoms 1

• Illness Anxiety Disorder: Preoccupation with having or acquiring a serious illness despite minimal or absent somatic symptoms 1

• Conversion Disorder (Functional Neurologic Symptom Disorder): Neurological symptoms that are incompatible with recognized neurological or medical conditions 1

• Psychological Factors Affecting Other Medical Conditions: Psychological factors that adversely affect a medical condition 1

• Factitious Disorder: Intentionally produced symptoms without material gain 1

• Other Specified/Unspecified Somatic Symptom and Related Disorder: For presentations that don't meet full criteria for above categories 1

Key Diagnostic Features to Document

Clinical Presentation Characteristics

• Vague, poorly described complaints that fluctuate with activity or stress 1
• Multiple visits for the same symptoms across different healthcare settings 1
• Recent or current stressful events temporally associated with symptom onset 1
• Lack of physical findings and laboratory abnormalities despite extensive workup 1
• Significant impairment in psychosocial functioning (relationships, academic/occupational difficulties) 1

Critical Distinction from Malingering

The symptoms must NOT be intentionally produced for material gain (which would be malingering rather than a somatic symptom disorder). 1 Symptoms that are intentionally created without material gain are classified as factitious disorders. 1

Common Comorbidities to Screen For

When documenting somatic symptom disorders, actively screen for these frequently co-occurring conditions:

• Anxiety disorders: 81% of pediatric ED patients with unexplained chest pain met criteria for anxiety disorders, with 28% meeting full criteria for panic disorder 1
• Depression: Commonly co-occurs with somatic symptom presentations 1, 3
• Multiple somatic complaints: Patients often report headaches, abdominal pain, and back pain concurrently 1

Patients diagnosed with comorbidity of somatoform, depressive, and anxiety disorders show the largest degrees of impairment (OR=9.5; 95% CI=4.6-19.4) compared to reference groups. 3

Important Clinical Pitfalls to Avoid

Do Not Prematurely Attribute Symptoms to Psychology

• Vague somatic complaints may mask underlying mental health conditions such as suicidal ideation, with individuals who committed suicide frequently visiting healthcare providers in the months preceding their death 1
• Medical diseases must be adequately ruled out first: Studies show 19-63% of ED psychiatric patients have underlying medical problems including diabetes, uremic/hepatic encephalopathy, pneumonia, urinary tract infections, and sepsis 1
• Anxiety should only be considered after appropriate cardiac testing is completed and negative, particularly for chest pain presentations 4, 5, 6

Recognize Diagnostic Complexity

• Depression and anxiety may be consequences rather than causes of chronic unexplained symptoms, as these psychological symptoms can improve when the troublesome cough or pain improves 1
• The presence of depression/anxiety alone should NOT be used as diagnostic criteria for somatic symptom disorders in adults with persistently troublesome symptoms 1

Documentation Approach

When documenting somatic symptom disorders, include:

1. Detailed symptom description: Type, duration, frequency, and triggers 1
2. Extent of medical workup performed: Specific tests completed and their negative results 1
3. Psychological B criteria: Excessive thoughts about symptom seriousness, persistently high anxiety about health, excessive time/energy devoted to symptoms 1, 2
4. Functional impairment: Specific impacts on work, school, relationships, and daily activities 1
5. Comorbid conditions: Document any co-occurring anxiety, depression, or other mental health diagnoses 1, 3
6. Absence of intentional production: Explicitly note symptoms are not feigned or produced for material gain 1

Some clinicians prefer the term "medically unexplained symptoms" to reduce stigma and improve patient acceptance of the diagnosis. 1