Learning objectives
By the end of this post, the learner should be able to:
- Explain the relationship between psychosomatic symptoms, somatic symptom disorder, illness anxiety and functional neurological disorder (FND).
- Recognise common presentations without implying that symptoms are imagined or “all in the mind”.
- Screen for medical emergencies, comorbidity, self-harm risk and safeguarding concerns before making a formulation.
- Make a positive, respectful diagnosis and build a coordinated biopsychosocial management plan.
- Use targeted investigations, safety-netting, rehabilitation and psychological treatment while avoiding harmful over-testing or stigma.
1. Core concepts and terminology
The body and mind are not separate clinical systems. Pain, breathlessness, palpitations, dizziness, weakness, bowel symptoms and fatigue are produced by interacting biological, psychological and social processes. Stress can amplify normal body signals, but the presence of stress does not prove that a symptom has no physical cause. A patient may have both a disease such as asthma, diabetes, epilepsy or anaemia and a co-existing disorder of bodily distress.
| Term | What it means clinically | Important caution |
|---|---|---|
| Psychosomatic symptoms | A broad, non-diagnostic term for symptoms influenced by emotional, behavioural and social factors through real physiological pathways. | Do not use it as shorthand for “fake” or “nothing is wrong”. |
| Somatic symptom disorder (DSM-5-TR) | One or more distressing bodily symptoms plus disproportionate, persistent thoughts, anxiety or behaviour related to the symptoms. Symptoms do not have to be medically unexplained. | The diagnosis describes the patient’s response and impairment, not whether the symptom is fabricated. |
| Bodily distress disorder (ICD-11) | Persistent bodily symptoms accompanied by excessive attention, worry or behaviour and significant distress or functional impairment. | Use the current classification adopted by your service; avoid forcing older labels onto complex patients. |
| Illness anxiety disorder / health anxiety | Preoccupation with having or acquiring a serious illness, usually with few or mild bodily symptoms, repeated checking or reassurance-seeking, or avoidance. | Assess real risk factors and repeat examination when the clinical picture changes. |
| Functional neurological disorder (FND) | Neurological symptoms such as weakness, tremor, attacks, gait disturbance or sensory loss caused by abnormal nervous-system functioning, identified by positive clinical features. | FND is not simply “normal tests” and should not be presented as a diagnosis of exclusion. |
| Factitious disorder | Deliberate production or feigning of illness to assume the sick role, without an obvious external reward. | It is uncommon and difficult to establish; suspicion is not proof. Maintain safety and dignity. |
| Malingering | Intentional symptom production for an external incentive such as money, medications, housing or avoidance of a duty. | It is not a mental disorder diagnosis. Do not accuse a patient without compelling evidence. |
2. Common clinical patterns
Bodily distress and persistent physical symptoms
Patients may report multiple symptoms across systems—pain, fatigue, dizziness, gastrointestinal discomfort, chest tightness, palpitations, sleep disturbance and cognitive fog—or a single persistent symptom with marked impairment. The intensity may fluctuate with attention, fear, activity, sleep and social stress. The symptom is experienced as physical and should be assessed physically.
Health anxiety
The dominant problem is fear of serious disease: repeated internet searches, checking pulse or body parts, requesting tests, visiting several facilities, or avoiding hospitals and health information. Ask what the person believes will happen, how certain they feel, and whether reassurance produces only brief relief.
Functional neurological symptoms
Presentations include functional seizures (also called dissociative seizures), limb weakness, abnormal movement, tremor, sensory symptoms, visual symptoms, speech difficulty and gait disturbance. Positive signs may include inconsistency with recognised neuroanatomical patterns, distractibility, entrainment of tremor, or Hoover-type findings when appropriately elicited. A positive diagnosis should be explained compassionately and confirmed by a clinician with relevant expertise; epilepsy, stroke, infection, metabolic disease and structural pathology must still be considered where indicated.
Persistent pain and gastrointestinal or cardiopulmonary symptoms
Chronic pain, irritable bowel-type symptoms, functional dyspepsia, globus, non-cardiac chest pain, palpitations and dyspnoea may coexist with genuine disease. The aim is not to prove that symptoms are psychological, but to reduce disability, fear and unnecessary harm while treating any disease that is present.
3. Immediate safety screen: never miss a medical emergency
Before discussing psychosocial contributors, repeat vital signs and perform an appropriate focused examination. Urgent assessment or referral is required for any concerning pattern, including:
- New central chest pain, severe breathlessness, cyanosis, shock, syncope on exertion, new arrhythmia or signs of acute coronary syndrome, pulmonary embolism, asthma or heart failure.
- Sudden focal neurological deficit, new severe headache, meningism, altered consciousness, first seizure, prolonged seizure or injury during an attack.
- Fever with toxicity, persistent vomiting, gastrointestinal bleeding, severe abdominal tenderness, bowel obstruction, jaundice or rapidly progressive symptoms.
- Unintentional weight loss, progressive dysphagia, persistent fever, night sweats, anaemia, a new mass, recurrent nocturnal symptoms or a significant family history.
- Pregnancy or postpartum status with headache, hypertension, neurological symptoms, chest pain, severe abdominal pain, psychosis or suicidal thoughts.
- Hypoxia, severe hypoglycaemia or hyperglycaemia, suspected poisoning or withdrawal, or a medication adverse effect.
- Suicidal intent, self-harm, inability to care for self, abuse, exploitation or immediate safeguarding danger.
4. A structured assessment
A. Build a shared symptom narrative
- Symptom: onset, location, quality, severity, frequency, duration, associated features and the patient’s own words.
- Time course: first episode, relapses, progression, relation to meals, menstruation, exertion, sleep, trauma, infection, medication or substance use.
- Function: school/work attendance, mobility, self-care, relationships, sleep, appetite and financial impact.
- Meaning: “What do you think is happening?” “What worries you most?” “What were you hoping we could do today?”
- Behaviour: checking, avoidance, reassurance-seeking, repeated tests, emergency visits, use of analgesics or sedatives, and activity restriction.
- Context: depression, anxiety, trauma, bereavement, domestic violence, stigma, poverty, caregiving burden, cultural explanations and access barriers.
B. Review records and perform targeted examination
Review previous diagnoses, test results, admissions, prescriptions, allergies and substance use. Obtain collateral information with consent when symptoms, function or safety are unclear. Perform a respectful general, cardiovascular, respiratory, abdominal and neurological examination guided by the presentation. Document positive findings, negative findings that matter, and the reason for each investigation.
C. Choose investigations rationally
Investigate red flags and plausible disease, not anxiety alone. Depending on presentation, this may include a full blood count, glucose, renal and liver tests, thyroid testing, pregnancy test, ECG, chest assessment, infection tests or neuroimaging—only when clinically indicated. Repeating normal tests without a new question can reinforce fear, cause iatrogenic harm and delay rehabilitation. Conversely, do not stop investigating when symptoms evolve or objective abnormalities emerge.
D. Screen common comorbidities
- Depression, generalised anxiety, panic, trauma-related symptoms, obsessive checking and sleep disorder.
- Alcohol, stimulant, sedative, opioid or cannabis use; withdrawal can mimic or worsen bodily symptoms.
- Medication effects, polypharmacy and health literacy.
- Suicidal thinking, self-neglect, violence risk, abuse and safeguarding.
5. Communicating a positive diagnosis
Communication is a treatment. Start with the patient’s suffering and the findings that have been established:
- Validate: “I can see this is frightening and disabling. I believe that you are experiencing these symptoms.”
- Explain what has been checked: “Your examination and tests today do not show evidence of a heart attack; your oxygen level and ECG are reassuring.”
- Name a positive mechanism: “The nervous system can become over-alert and produce real pain, breathlessness or weakness. This pattern is consistent with bodily distress/functional symptoms.”
- Offer a plan: one clinician or team, scheduled follow-ups, graded activity, symptom-management skills, treatment of comorbidity and clear red-flag advice.
- Invite questions and check understanding: Ask the patient to explain the plan in their own words.
Avoid “nothing is wrong”, “it is all in your head”, confrontation, premature accusations, endless reassurance, and a succession of uncoordinated tests. Use the patient’s preferred language and an interpreter when needed.
6. Management: an integrated, stepped plan
1. Establish continuity and shared goals
Agree on functional goals such as walking to class, returning to work, sleeping regularly, eating safely or reducing emergency visits. Schedule regular reviews rather than making attendance dependent on symptom escalation. Coordinate primary care, emergency clinicians, mental-health services, physiotherapy, occupational therapy and relevant specialists.
2. Psychological and behavioural interventions
WHO mhGAP guidance supports psychological treatment based on cognitive-behavioural principles for persistent medically unexplained somatic complaints, including reattribution, problem-solving, relaxation, graded activity and relapse planning. Treatment should be collaborative and adapted to literacy, culture, trauma history and available services. CBT is not an assertion that symptoms are imaginary; it targets fear, attention, avoidance, sleep and disability.
- Reattribution: link symptoms to understandable interactions between physiology, attention, stress, sleep and behaviour.
- Graded activity: increase safe activity gradually, with pacing rather than boom-and-bust cycles.
- Relaxation and breathing skills: useful for hyperventilation and autonomic arousal after dangerous causes have been excluded.
- Problem-solving: address medication access, food insecurity, family conflict, transport, work and school accommodations.
- Trauma-informed care: offer choice, privacy and control; do not force disclosure of trauma.
3. Rehabilitation for FND and persistent pain
Physiotherapy may use normal movement retraining, attention diversion, functional tasks and a graded home programme. Occupational therapy addresses self-care, school/work and energy management. Speech and language therapy may help functional voice or swallowing symptoms. Neurology or a trained FND team should guide complex cases. For persistent pain, combine education, exercise, sleep improvement, psychological strategies and treatment of the underlying disease.
4. Medicines: treat a defined target
| Target | Possible approach | Safety points |
|---|---|---|
| Depression or clinically significant anxiety | An SSRI such as sertraline or fluoxetine may be considered according to the relevant local guideline, patient preference, interactions and comorbidity. | Explain delayed benefit and early adverse effects; review suicidality, activation, serotonin toxicity and discontinuation. Do not prescribe solely to prove that symptoms are psychological. |
| Acute severe anxiety | Non-drug grounding, breathing and crisis support are preferred. A benzodiazepine, if used at all, should be short-term and closely supervised for a clear indication. | Dependence, falls, impaired driving, respiratory depression and dangerous interaction with alcohol/opioids; avoid routine long-term use. |
| Pain or other physical disease | Use condition-specific treatment after diagnosis; combine with rehabilitation. | Avoid escalating opioids, sedatives or repeated rescue medicines without a clear indication and review of harms. |
5. Follow-up and relapse prevention
At each review record symptom change, function, sleep, medicines, new red flags, mood and safety. Reinforce the same explanatory model across clinicians. Agree in advance how urgent problems will be assessed and what constitutes a routine review. Relapse is common during infection, bereavement or major stress; a written plan reduces emergency cycling.
7. Special clinical situations
Functional seizures
Obtain a careful event history and, when possible, witness description or video. Protect the patient from injury, avoid unnecessary restraint, and do not place objects in the mouth. Check glucose and vital signs and treat a genuine prolonged epileptic seizure according to emergency protocol. Once FND is established, explain that attacks are involuntary and treatable; neurology and psychological/rehabilitation referral is appropriate. Antiseizure medication should not be continued solely for functional seizures unless epilepsy is also present.
Children, adolescents and families
Assess development, school stress, bullying, abuse, parental anxiety and family responses. Speak with the young person privately when appropriate, while maintaining safeguarding duties. Coordinate school and family plans; avoid rewarding sickness behaviour while still providing warmth and protection.
Pregnancy and postpartum
Do not attribute headache, breathlessness, abdominal pain, neurological symptoms or severe anxiety to psychosomatic illness without obstetric assessment. Postpartum patients require screening for depression, mania, psychosis, pre-eclampsia and safeguarding risk.
8. Clinical cases
Quick self-test
- Why is “normal testing” alone insufficient to diagnose FND?
- Name four red flags that require urgent reassessment before a psychosomatic formulation.
- How does somatic symptom disorder differ from factitious disorder?
- List three communication phrases that validate symptoms without promising that every test will be repeated.
- Why are regular planned reviews safer than symptom-triggered emergency visits for persistent bodily distress?
Answers
- FND should be supported by positive clinical features demonstrating altered function; normal tests alone do not exclude epilepsy, stroke, infection or other disease.
- Examples include new focal neurological deficit, hypoxia, exertional syncope, gastrointestinal bleeding, persistent fever, progressive weight loss, severe chest pain, pregnancy-related danger signs or suicidal intent.
- Somatic symptom disorder concerns distress and disproportionate thoughts/behaviour around symptoms; factitious disorder requires intentional production or feigning to assume the sick role. Neither should be assumed without careful evidence.
- For example: “I believe that you are experiencing this”; “today’s examination does not show evidence of an emergency”; “we have a plan and clear warning signs for returning urgently.”
- Continuity reduces reassurance-seeking and fragmented testing, allows function and safety to be monitored, and still provides a route for reassessment when the pattern changes.
Key take-home messages
- Symptoms are real even when a structural lesion is not found.
- Medical illness and bodily distress can coexist; reassess changing symptoms.
- Use positive diagnostic features, especially for FND, not dismissal or accusation.
- Validate, explain a biopsychosocial mechanism, coordinate care and set safety-net instructions.
- Prioritise function, rehabilitation and evidence-based psychological treatment; use medicines for clear comorbid indications.
References and further reading
- World Health Organization. Other significant emotional and bodily distress complaints (mhGAP Evidence Centre): WHO mhGAP.
- World Health Organization. Psychological treatment based on cognitive behavioural therapy principles for managing medically unexplained somatic complaints: WHO recommendation.
- NICE Clinical Knowledge Summary. Functional neurological disorder—diagnosis: NICE CKS.
- World Health Organization. ICD-11 Clinical Descriptions and Diagnostic Requirements: WHO ICD-11 CDDR.
- World Health Organization. mhGAP guideline for mental, neurological and substance use conditions, 2023 update: WHO mhGAP guideline.
