Makindo Medical Notes

🌡️ Somatisation refers to the experience and presentation of physical symptoms that cannot be fully explained by a medical condition. It reflects a complex interaction between psychological, biological, and social factors. 👉 Patients are not “faking” — their distress is real, even when investigations are normal.

📖 About

• Part of the spectrum of somatic symptom and related disorders in DSM-5.
• Characterised by multiple, recurrent physical complaints (pain, GI upset, fatigue, neurological symptoms).
• Common in primary care: up to 20–30% of consultations may involve medically unexplained symptoms.
• Associated with significant distress, impaired functioning, and healthcare utilisation.

🧬 Pathophysiology

• Disruption of the brain–gut axis and altered central pain processing.
• Heightened interoception (increased awareness of normal bodily sensations).
• Psychological factors: stress, depression, anxiety, and early trauma influence perception of symptoms.
• Social reinforcement: repeated medical investigations can unintentionally perpetuate illness behaviour.

🩺 Clinical Features

• Multiple physical symptoms across systems: GI (abdominal pain, nausea), musculoskeletal (aches, fatigue), neurological (numbness, “fits”).
• Symptoms persist despite negative investigations.
• High healthcare use: repeated visits, multiple specialists, dissatisfaction with care.
• Often comorbid with anxiety or depression.
• Patients may resist psychological explanations, fearing stigma or dismissal.

📊 Differential Diagnosis

• ✅ True medical illness (must be excluded carefully).
• ✅ Factitious disorder / malingering (deliberate symptom production, unlike somatisation).
• ✅ Anxiety disorders (esp. health anxiety, panic disorder).
• ✅ Conversion disorder (functional neurological symptoms).

🔬 Investigations

• Targeted baseline tests: FBC, U&E, LFTs, TFTs, urinalysis, CRP/ESR.
• Directed tests only if red flags (weight loss, night sweats, bleeding, neurological deficit).
• ⚠️ Avoid repeated unnecessary investigations → reinforces illness behaviour.

🛠️ Management Principles

• 🤝 Therapeutic alliance: Validate the patient’s distress; avoid dismissing symptoms as “all in the head.”
• 📅 Regular, structured follow-up: Short scheduled appointments reduce crisis visits.
• 🧠 Psychological therapy: CBT for health anxiety, stress management, mindfulness.
• 💊 Medications: Antidepressants (SSRIs, SNRIs) may help if comorbid depression/anxiety.
• 🩺 Single coordinating clinician: Prevents unnecessary referrals and investigations.
• 🛑 Avoid iatrogenesis: Repeated scans or procedures can cause harm and reinforce illness beliefs.

🚩 Red Flags (do not miss organic disease)

• Unexplained weight loss
• Persistent fever, night sweats
• Objective neurological deficit
• GI bleeding or anaemia
• Late-onset symptoms in older adults

🧑‍⚕️ Case Scenarios — Somatic Symptom & Related Disorders

Case 1 (Recurrent abdominal symptoms): A 35-year-old woman presents with a 5-year history of abdominal pain, bloating, and fatigue. Extensive investigations including colonoscopy, bloods, and abdominal imaging are all normal. She has consulted multiple specialists and feels her symptoms are “not being taken seriously.” Likely diagnosis: Somatic symptom disorder with predominant GI features (often overlaps with functional GI syndromes like IBS). Plan: Validate her experience (“your symptoms are real, even if tests are normal”), arrange regular GP follow-up to provide continuity, avoid repeated unnecessary investigations, and offer referral for CBT or gut-directed hypnotherapy. Address contributing fatigue with lifestyle and sleep advice.
• Case 2 (Chest pain with health anxiety): A 28-year-old man attends A&E repeatedly with sharp chest pain. Multiple ECGs, troponins, chest X-rays, and even a CT angiogram have been normal. He has a background of significant anxiety and recent life stressors (job loss, relationship breakdown). Likely diagnosis: Somatisation with strong health anxiety component. Plan: Establish a single point of care with his GP to reduce duplication of tests, provide clear explanation of benign findings, explore stress triggers, and consider SSRI (if anxiety severe). Offer CBT focused on health anxiety. Crisis plan given to avoid repeated ED visits unless red flags emerge.
• Case 3 (Multiple physical complaints): A 50-year-old patient reports diffuse joint pains, frequent headaches, and episodic abdominal upset. Extensive rheumatology and neurology workup is negative. They feel dismissed when told “it’s nothing” and have developed frustration with the healthcare system. Likely diagnosis: Somatic symptom disorder, possibly complicated by underlying depression or anxiety.Plan: Empathise and acknowledge distress. Emphasise supportive management over endless tests. Coordinate care with a named GP to avoid fragmented management. Screen for mood disorder; if positive, consider an antidepressant (e.g. SSRI/SNRI). Encourage pacing strategies and gradual activity to maintain function.

🧑‍⚕️ Teaching Commentary

Somatic symptom and related disorders are characterised by distressing physical symptoms not explained fully by medical disease, leading to high healthcare use. 🌟 Principles of good management: • Validate symptoms as real and distressing (never “all in the head”). • Provide continuity of care with a trusted clinician. • Avoid unnecessary investigations once serious pathology excluded. • Use psychological therapies (CBT, mindfulness, stress management). • Treat comorbid mood or anxiety disorders where present. The goal is not to eliminate all symptoms but to improve quality of life, reduce health-seeking behaviour, and build trust in care.

✅ Conclusion

Somatisation is common, complex, and often frustrating for both patients and clinicians. 🌟 Key approach = validate symptoms, rule out red flags, avoid over-investigation, provide continuity and psychological support. Early recognition prevents iatrogenic harm and improves quality of life.