What are the guidelines to diagnose and treat a patient with suspected psychosomatic (psychological) symptoms, with no underlying physical condition, and potential mental health conditions such as depression or anxiety?

Diagnosing Psychosomatic (Somatic Symptom) Disorders

A diagnosis of somatic symptom disorder requires ruling out organic pathology through targeted history and physical examination, followed by identification of specific psychological features including symptom preoccupation, disproportionate health anxiety, and excessive time/energy devoted to health concerns, with symptoms persisting for at least 6 months. 1

Essential Diagnostic Criteria

Primary Requirements

• Physical symptoms must lack adequate organic explanation after appropriate medical evaluation, though this does not mean symptoms are intentionally produced or feigned 1, 2
• Symptoms must persist for at least 6 months and cause significant impairment in psychosocial functioning 1, 3
• Psychological features must be present, including excessive thoughts, feelings, or behaviors related to somatic symptoms 1, 4

Key Clinical Features to Identify

Symptom Characteristics:

• Vagueness and inconsistency in symptom description 2
• Varying intensity without clear pattern 2
• Multiple symptoms occurring simultaneously 2
• Chronic course despite apparent good health 2
• Delay in seeking care with paradoxical lack of concern 2

Psychological Features:

• Disproportionate and persistent thoughts about symptom seriousness 3
• Persistently high anxiety about health 3
• Excessive time and energy devoted to health concerns 1
• Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance 3

Critical Diagnostic Steps

1. Medical Evaluation First

History and physical examination have 94% sensitivity for identifying true medical conditions in patients presenting with psychiatric complaints 1. You must actively exclude organic pathology before labeling symptoms as psychosomatic.

Targeted medical workup should include:

• Comprehensive medical and psychosocial history 2
• Thorough physical examination with vital signs 1
• Targeted laboratory testing based on clinical presentation (not routine screening) 1
• Toxicology screening when substance use is suspected 5
• Neuroimaging only for atypical presentations, abnormal neurological findings, or focal deficits 5

Common pitfall: Routine laboratory testing in psychiatric patients yields clinically meaningful results in less than 2% of cases, with false-positives occurring 8 times more frequently than true-positives 1. Order tests based on clinical suspicion, not as screening.

2. Distinguish from Other Conditions

Rule out intentional symptom production:

• Factitious disorder involves intentionally created symptoms 1
• Malingering involves symptoms produced for material gain 1
• Neither qualifies as somatic symptom disorder 1

Differentiate from appropriate health concerns:

• Worry must be disproportionate to actual medical risk 3
• Symptoms persist despite appropriate medical evaluation showing no serious pathology 3
• Distinguish from normal anxiety in patients with actual serious medical illness 3

Recognize delirium, which mimics psychosomatic presentation:

• Fluctuating consciousness and disorientation distinguish delirium from somatic symptoms 5
• Delirium requires urgent medical evaluation for underlying causes 1, 5

3. Assess for Psychiatric Comorbidity

Screen for depression and anxiety systematically:

• Approximately 31% of patients with anxiety disorders have comorbid major depressive disorder 3
• Depression and anxiety symptoms may develop secondary to chronic unexplained symptoms 1
• Do not use presence of depression/anxiety alone as diagnostic criteria for psychosomatic disorder, as these can be consequences rather than causes of persistent symptoms 1

Consider psychiatric assessment when:

• Patients have frequent recurrent symptoms with multiple other somatic complaints 1
• Initial evaluation raises concerns for stress, anxiety, or other psychiatric disorders 1
• Symptoms include excessive health preoccupation beyond what medical findings warrant 1, 3

4. Apply Specific Diagnostic Frameworks

Use the Diagnostic Criteria for Psychosomatic Research (DCPR) for enhanced sensitivity:

• DCPR identifies 12 psychosomatic syndromes including somatization, hypochondriacal fears, illness denial, alexithymia, type A behavior, demoralization, and irritable mood 4
• DCPR is more sensitive than DSM-IV in identifying subthreshold psychological distress and characterizing patients' psychological response to medical illness 4
• DCPR provides incremental information beyond standard psychiatric classification 4

Special Populations and Contexts

Pediatric Patients

• Psychosomatic complaints occur in 10-25% of children and adolescents 2
• Common presentations include abdominal pain, headaches, chest pain, fatigue, limb pain, back pain, health worry, and breathing difficulty 2
• Symptoms often represent responses to stress from schoolwork, family problems, peer pressure, chronic parental illness, family moves, or parental psychiatric disorders 2

Emergency Department Presentations

• Somatic symptom disorders account for approximately 9% of ED chest pain presentations 1
• 81% of pediatric ED patients with unexplained chest pain meet criteria for anxiety disorders 1
• Patients with psychogenic non-epileptic seizures (PNES) average multiple previous ED visits, often receive unnecessary anticonvulsants and invasive procedures 1
• 72% of PNES patients show symptom resolution after psychiatric treatment 1

Elderly Patients

• Patients over 65 years, those with substance use histories, disoriented patients, and those of lower socioeconomic status benefit from more extensive medical testing 1
• Medical history identifies active medical problems in approximately 50% of elderly psychiatric patients 1

Treatment Implications

Once diagnosis is established:

• Appropriate mental health consultation should be obtained for further evaluation and treatment 2
• Psychotherapy and targeted pharmacotherapy have demonstrated efficacy for psychosomatic syndromes 6
• Avoid unnecessary medical testing, procedures, and medications that risk iatrogenic harm 1
• Do not prescribe antidepressants solely based on presence of somatic symptoms without clear indication for mood or anxiety disorder 7

Monitor for treatment-emergent complications:

• Antidepressants carry risk of increased suicidality, especially in patients under 24 years 7
• Screen for emergence of agitation, irritability, unusual behavior changes, and suicidality 7
• Abnormal bleeding risk increases with combined use of SSRIs and NSAIDs, aspirin, or anticoagulants 7