Core concepts

• Somatic symptoms are bodily experiences that are distressing and/or disrupt daily life; they may or may not have an identifiable medical cause.
• When presentation is insufficiently specified for a particular diagnosis (e.g., duration unclear, mixed features), “unspecified” is used to allow clinical care and follow‑up while gathering more information.
• Key goals: validate symptoms, avoid unnecessary investigations, reduce unhelpful illness behaviours, and improve function through biopsychosocial interventions.

Common presenting symptoms

• Chronic pain (headache, back pain), persistent fatigue, GI symptoms (nausea, bloating), functional neurological complaints (dizziness, non‑epileptic events) and multiple multisystem complaints.
• High healthcare utilisation, frequent investigations and often frustration for both patient and clinician when tests are inconclusive.

Assessment checklist

1. Detailed symptom history: onset, pattern, triggers, temporal relation to stressors, prior investigations and treatments, and impact on daily function.
2. Focused physical exam and targeted investigations to exclude serious or treatable medical conditions—avoid blanket extensive testing; interpret results in clinical context.
3. Mental health review: screen for depression, anxiety, PTSD, substance use, and health anxiety; assess functional impairment and social factors (work, litigation, access to care).
4. Medication and substance review—identify iatrogenic contributors (opioids, sedatives) that may perpetuate symptoms or disability.

Differential diagnosis

• Primary medical disorders (autoimmune, metabolic, neurologic), psychiatric conditions (major depression, somatic symptom disorder, illness anxiety disorder), medication effects, and factitious disorder — consider referral when clinical picture unclear.
• Balance between ruling out red flags and avoiding excessive testing that reinforces illness behaviour.

Initial investigations — pragmatic approach

• Base investigations on symptom‑directed red flags: basic labs (CBC, metabolic panel, TSH), targeted imaging only if indicated, and ECG if cardiopulmonary symptoms present.
• Avoid repeated normal tests without new clinical indication; document rationale for investigations and discuss limits of tests with the patient.

Management principles

1. Validation & explanation: acknowledge symptom reality, provide a clear biopsychosocial formulation and set collaborative goals focused on function (return to work, increase activity).
2. Co‑ordinated care plan: agree on an initial medical workup, timeframe for follow‑up, and a plan to manage new red‑flag symptoms—use a single point of contact where possible to reduce fragmented care.
3. Limit unnecessary investigations: set boundaries around repeat testing unless new features emerge; explain the reasons compassionately to maintain therapeutic alliance.
4. Treat comorbid mental health conditions: depression, anxiety and PTSD frequently coexist and their treatment often reduces somatic burden and disability.

Evidence‑based therapies

• Cognitive Behavioural Therapy (CBT): adapted for somatic symptoms—targets catastrophic beliefs, maladaptive behaviours (avoidance, checking), and promotes activity pacing and graded exposure.
• Acceptance and Commitment Therapy (ACT): helps patients engage in valued activities despite symptoms and reduce experiential avoidance.
• Mindfulness‑based interventions: reduce symptom preoccupation and improve coping; useful as adjuncts.
• Functional Rehabilitation: physiotherapy/occupational therapy for chronic pain/fatigue focusing on graded activity, pacing and return‑to‑work strategies.

Pharmacologic approaches

• No medications specifically treat unspecified somatic presentations; pharmacotherapy is for comorbid conditions (SSRIs/SNRIs for depression/anxiety, low‑dose antidepressants for chronic pain) and symptom relief where appropriate.
• Avoid long‑term opioids and benzodiazepines for functional somatic symptoms due to risk of dependence and worsening function—consider tapering plans if present.

Red flags — when to re‑evaluate urgently

• New focal neurological deficits, unexplained weight loss, haemoptysis, severe chest pain suggestive of cardiac ischaemia, persistent high fevers, or other features indicating serious organic disease—urgent medical review.
• Suicidal ideation, severe mood disorder, or escalating disability—urgent psychiatric input required.

Key takeaways

• Use “unspecified” pragmatically to allow care when presentations are incomplete; prioritise symptom validation, targeted investigations and a clear plan focused on functional recovery.
• CBT, ACT and functional rehabilitation are effective for reducing symptom burden and improving function; treat comorbid mental health conditions actively.
• Coordinate care, limit unnecessary testing, and use measurable activity goals to guide progress.