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Diagnosing somatisation in adults in the first consultation: moving beyond diagnosis by exclusion.

Many patients do not make the link between their anxiety or stress and their physical symptoms such as headache, abdominal pain, diarrhoea, shortness of breath, or even fainting. Instead, they present to their doctors wanting an explanation. Somatisation is one of many labels referring to bodily symptoms in relation to psychosocial distress.1 Other terms in current use are functional illness and medically unexplained symptoms (MUS).2,3

The incidence of somatising illness is about 30% of new presentations,4 while the cost to the NHS in the UK has been estimated in the billions.3 Many doctors find assessment and management difficult, using investigations to exclude disease before they feel sufficiently confident to explore the possibility of stress-related illness.5 This approach of ‘diagnosis by exclusion’ frequently wastes time and money. It can also lead to ‘somatic fixation’: an overemphasis on physical symptoms and investigations while avoiding personal and psychological issues.6

Somatisation can often be a positive diagnosis, rather than by exclusion.5 Diagnosis at the first consultation is possible by asking specific questions to identify common patterns of somatising illness. These questions can be readily incorporated within the standard biomedical enquiry and …