How are psychosomatic disorders diagnosed? Why do these types of disorders exist on a spectrum?
Douglas Hoffman is an orthopedist with decades of experience in sports medicine. He takes a particular interest in how psychological and social factors lead to mindbody disorders, and diagnosing them with a thorough exam.
Check out how Hoffman conducts a psychosomatic disorder diagnosis to help struggling patients.
Diagnosing Physical vs. Psychosomatic Disorders
To make a solid psychosomatic disorder diagnosis, Hoffman makes two important observations about mindbody disorders:
1. Even when a condition is psychosomatic, it often has a physical trigger. For example, someone who twisted their ankle while running might still feel pain in that ankle years later. This makes it difficult to diagnose a mindbody disorder because it seems obvious that the cause is physical: In this case, the ankle must not have healed properly.
(Shortform note: Although we’ve been discussing repressed emotions so far, some experts say that repressing physical sensations (like the pain from an injury) can also lead to psychosomatic symptoms. This helps to explain why some people continue to feel pain long after their injuries have healed. For example, in The Body Keeps the Score, psychiatrist Bessel van der Kolk writes that trauma survivors often experience intense flashbacks that include physical sensations—meaning they aren’t just remembering their past trauma, they’re re-experiencing it with all of their senses. To escape this pattern of reliving their trauma, they often try to suppress those physical sensations, leading to psychosomatic symptoms just like Sarno describes in The Divided Mind.)
2. Physiological conditions and psychosomatic conditions aren’t a simple binary, but instead exist on a spectrum. In other words, chronic conditions often have both physical and psychological causes. Therefore, the doctor must determine on a case-by-case basis how much the patient’s psychology is contributing to their condition.
(Shortform note: No matter where someone’s condition falls on this physiological-psychosomatic spectrum, a psychologist can be an invaluable part of their treatment plan. For one thing, a mental health professional can help the patient overcome unhelpful thought patterns about chronic pain—such as overstating how much the pain interferes with their life or living in fear of their next pain flareup—thereby helping them resume a more normal life. However, recent research also suggests that a person’s mental state changes how they experience pain; for instance, someone who’s sad, anxious, or frustrated will feel pain more intensely. Therefore, therapy doesn’t just help patients cope with pain, it can actually lessen the pain itself.)
Hoffman says that the best way to diagnose a patient is to get a thorough history and conduct a complete physical exam. From there, the doctor can create a differential diagnosis: a list of conditions, both physical and psychosomatic, that could explain the patient’s symptoms. The patient’s medical history is crucial because it will include psychological conditions such as depression and anxiety that would make psychosomatic disorders more likely. It will also note if they’ve ever been diagnosed with a psychosomatic condition before.
Hoffman adds that traditional treatments for pain like painkillers and physical therapy reinforce the idea that there’s something wrong with the patient’s body. This makes it harder for them to recover from their mindbody disorder. Therefore, it’s crucial to identify whether the patient’s condition is physical or psychosomatic because the wrong treatment plan could prevent their recovery or make their condition worse.
| The Harm of Misdiagnoses Misdiagnosis—incorrectly identifying a patient’s condition—is a widespread and costly problem in health care. For instance, a 2023 study estimated that there could be as many as 50 million to 100 million cases of misdiagnosis each year in the US alone. Most of those misdiagnoses are relatively harmless because most patients don’t have serious or life-threatening conditions. However, around 800,000 US citizens die or become permanently disabled annually because of a misdiagnosis. While that number is alarming, the researchers also offered cause for hope. Just five conditions (stroke, sepsis, pneumonia, blood clots, and lung cancer) account for nearly 40% of those 800,000 cases. Therefore, finding ways to reduce misdiagnoses on just those five conditions would have enormous benefits for patients and the health care system alike. |
An Unexpected Problem: Patients Don’t Believe the Diagnosis
Hoffman adds that one major challenge in treating mindbody disorders is getting the patient to accept their diagnosis. This is because, like many doctors, patients usually believe that pain must be the result of a problem with the body.
Not only does this seem logical—how could they be in pain if nothing is wrong?—that lesson gets constantly reinforced by the world at large. For instance, many people spend their lives treating headaches with painkillers, minor injuries with rest and ice, and so on. As a result, they learn from a young age to treat only physical causes of pain, and are never taught that their minds can produce similar symptoms.
Overcoming that programming so the patient can recover from a psychosomatic disorder is difficult, often impossible. Hoffman says that many people reject the idea that pain can exist without a physiological cause, and therefore they never repair the connection between their mind and their body.
