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In Chapter 1, we presented 3 axioms of mental health care for medical settings: (1) The comorbidity of medical and mental disorders is frequent; (2) chronic physical symptoms are a common presentation in patients with a mental disorder; and (3) chronic physical symptoms may be due to medical disease and/or medically unexplained symptoms (MUS).

Because physical symptoms are prominently associated “red flags” for mental disorders, we now address the diagnostic approach to them, with the understanding that all physical disease problems are not associated with a mental disorder. One caveat is that patients occasionally present only with psychological symptoms. In that case, we of course proceed directly to develop the details needed to establish a mental disorder diagnosis, as outlined in later chapters. In most instances, however, physical symptoms are so common that they usually are considered first, then inquiring about psychological symptoms when you can better focus on a possible mental disorder.

You may say that you already know medical diagnostics; after all, that’s what has been emphasized throughout your medical training. Here’s the problem. There can be diagnostic uncertainties when the symptoms are difficult to explain in MUS. Consequently, we will provide guidelines for evaluating physical symptoms that will allow you to comfortably expand your evaluation to the psychological realm without worrying that you have missed some physical disease. We now address the medical diagnostic approach in the presence of prominent physical symptoms. In later chapters, we address how to diagnose the psychological symptoms needed to make a specific mental health diagnosis.


We have defined a mental disorder as a mental or substance use disorder. We define a disease as a disorder included in current classifications of diseases (eg, editions of the International Classification of Diseases).1,2 These are the diseases you might find listed in medical textbooks, characterized by a unique pathophysiologic basis.

Medically unexplained symptoms are the opposite—physical symptoms with little or no disease or pathophysiologic explanation, also referred to as somatization or somatoform disorders. Patients who have an organic disease can also have MUS when the symptoms are not attributable to the disease or are out of proportion to what would be expected. MUS poses a far greater diagnosis problem for clinicians, so we address it in detail.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has provided an influential classification. DSM-4 defined the following MUS disorders in the somatoform category: somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, and somatoform disorder not otherwise specified.3 While useful for research, none had sufficient validity to use clinically nor were they comprehensive enough to capture more than a few of the chronic MUS patients commonly seen in medical settings.4,5 Widespread dissatisfaction led to a change where many of the DSM-4 disorders were combined into ...

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