What is the appropriate evaluation and management for a patient with unexplained somatic complaints suggestive of psychosomatisation?

Evaluation and Management of Psychosomatisation

For patients with unexplained somatic complaints, validate symptoms as real through detailed history and physical examination, screen for anxiety and depression (present in 81% of cases), initiate cognitive-behavioral therapy as primary treatment, and avoid antidepressants unless comorbid depression is documented. 1, 2

Initial Evaluation Framework

History-Taking Priorities

Take a detailed, time-intensive history that systematically explores symptom characteristics, psychosocial stressors, healthcare utilization patterns, and the patient's cognitive-emotional response. 2

• Document specific somatic complaints, which most commonly involve neurologic symptoms (headaches), pain (chest, back, abdominal), autonomic symptoms (palpitations, difficulty breathing), or gastrointestinal complaints (cramping, bowel symptoms) 3
• Identify vague, poorly described complaints that fluctuate with activity or stress levels and lack specific anatomic localization 2, 3
• Assess chronicity—symptoms must be persistent, typically more than 6 months, to meet DSM-5 criteria 4, 2
• Count previous emergency department visits and document all prior diagnostic testing, procedures, and medications prescribed, as multiple encounters with extensive negative workup are characteristic 2

Assess Cognitive-Emotional Response (DSM-5 Criterion B)

Explicitly assess for excessive thoughts, feelings, or behaviors related to symptoms—this distinguishes somatic symptom disorder from other conditions. 2

• Ask what the patient believes is causing their symptoms and what they fear might happen to elicit disproportionate thoughts about symptom seriousness 2
• Directly question about worry frequency and intensity to assess persistently high anxiety levels about health 2
• Document time spent researching symptoms or seeking care to identify excessive time and energy devoted to health concerns 2
• At least one of these three features must be present for diagnosis 4

Screen for Psychiatric Comorbidities

Screen all patients for anxiety disorders and depression, which are present in the majority of somatizing patients and require specific treatment. 1

• Among pediatric patients with medically unexplained chest pain, 81% meet criteria for anxiety disorders, with 28% having panic disorder 4, 1
• Assess for psychosocial stressors including domestic violence and, in children, abuse or neglect 1, 2
• In pediatric cases, evaluate maternal somatic symptoms using the Patient Health Questionnaire-15, as mothers with high somatic symptom scores report greater ED use for their children 4

Physical Examination and Testing

Perform a comprehensive physical examination to build rapport and identify any objective findings, but avoid excessive diagnostic testing once organic pathology has been reasonably excluded. 4

• Look for absence of physical findings that explain the severity or nature of complaints 3
• Note that laboratory abnormalities are typically absent or do not correlate with symptom intensity 3
• Recognize that diagnostic uncertainty can lead to harm from either over-investigation or missed diagnoses 2

Management Algorithm

Communication and Therapeutic Alliance

Convey to the patient and family that symptoms are being heard and taken seriously—this is the foundation of successful management. 4, 1

• Reassure patients that symptoms are not life-threatening while acknowledging their distress and impact on functioning 4, 1
• Never use dismissive language or imply symptoms are "all in their head"—this damages the therapeutic relationship and increases healthcare-seeking behavior. 1, 2
• Directly address the patient's and family's specific fears about their symptoms, which provides clinical insight and reduces anxiety 4, 1, 2
• Emphasize collaboration between patient, family, and all caregivers while identifying common goals 4

Primary Treatment: Cognitive-Behavioral Therapy

Initiate psychological treatment based on cognitive-behavioral therapy (CBT) principles as the primary evidence-based treatment, which produces clinically meaningful improvements in symptom severity, functioning, and healthcare utilization. 1

• Administer 4-12 sessions of individual or group CBT with a mental health clinician, or via self-help/internet-based formats 1
• CBT targets psychological stress, negative emotions, maladaptive cognitive processes, avoidance behaviors, and somatization patterns 1
• 40% of CBT-treated patients achieve "very much improved" or "much improved" status 1
• Frame referral to psychology or psychiatry as helping with coping and functioning rather than implying symptoms are not real 4, 1

Alternative Psychological Interventions

• Consider problem-solving therapy for repeat adult help-seekers with medically unexplained somatic complaints who are in substantial distress 1
• Gut-directed hypnotherapy (7-12 sessions) or mindfulness-based stress reduction (8-12 sessions) are alternatives when CBT is unavailable 1
• In children when CBT is unavailable, use suggestion therapy, hypnosis, or combinations of reassurance and counseling 1

Pharmacological Management

Do NOT initiate antidepressants or benzodiazepines for initial treatment of somatic complaints in the absence of current or prior depressive episode/disorder. 1

• Treat comorbid depression conservatively with antidepressants only when diagnostic criteria are met 1
• Do not use opiates or conventional analgesia as primary pain management strategies 1

Ongoing Management Structure

Schedule regular, time-contingent appointments to provide ongoing support and prevent emergency department visits. 1

• Emphasize improving daily functioning over complete symptom resolution as the primary treatment goal 1
• Use quality of life measures and functional assessments to guide treatment success rather than symptom elimination alone 1
• Educate patients and families about the limitations of emergency department settings for chronic symptom evaluation 4, 1

Special Diagnostic Considerations

Distinguishing Tic Cough from Somatic Cough Disorder

• For chronic cough that remains medically unexplained, diagnose tic cough when the patient manifests core clinical features of tics: suppressibility, distractibility, suggestibility, variability, and presence of a premonitory sensation 4
• Somatic cough disorder (not tic cough) is diagnosed when DSM-5 criteria for somatic symptom disorder are met, representing transfer of psychological distress into physical symptoms 4
• These conditions require distinct therapies—pharmacologic and behavioral therapies for vocal tics differ from those for conversion reactions 4

Excluding Malingering and Factitious Disorder

Explicitly assess whether symptoms are intentionally produced or associated with material gain—this distinguishes somatic symptom disorder from factitious disorder and malingering. 2

• Evaluate for obvious secondary gain (financial or emotional benefits) that would suggest malingering 4, 2
• Assess for conscious symptom fabrication that would indicate factitious disorder 2
• Somatic symptom disorder involves symptoms that are not intentionally produced 3

Common Pitfalls to Avoid

• Do not rush the history-taking process—taking time to obtain detailed history builds therapeutic alliance 2
• Do not assume absence of organic disease prematurely, as some patients may have both true medical disorders and somatic symptom disorder 2
• Do not initiate antidepressants without documented depressive episode 1
• Avoid using outdated terms like "psychogenic," "habit," or "medically unexplained symptoms" in favor of DSM-5 terminology 4