Synopsis
Recognise persistent physical symptoms without dismissing physical disease, construct a credible biopsychosocial formulation, and coordinate proportionate care that restores function while preserving safety-netting.
- Persistent physical symptoms are real and potentially disabling even when available pathology does not fully explain their pattern or burden.
- Use a positive formulation that links symptoms, nervous-system responses, attention, activity, sleep, mood and social context without implying that symptoms are imagined.
- Review previous records and investigations before ordering more tests, but investigate new red flags and meaningful clinical change in the usual way.
- Known physical disease and persistent symptom mechanisms can coexist; neither diagnosis cancels the other.
- Agree one coordinated plan with named clinical responsibility, functional goals, scheduled review and explicit thresholds for earlier reassessment.
- Psychological treatment is offered to improve coping, distress and function, not as proof that symptoms are psychiatric or fabricated.
- Avoid abrupt withdrawal of long-term medicines; review benefit and harm collaboratively and taper dependence-forming drugs when indicated.
- Repeated reassurance without a shared explanation is short-lived and can reinforce checking, uncertainty and fragmented attendance.
Key red flags
Abnormal vital signs, collapse, acute confusion, focal neurology or severe unremitting pain require prompt medical assessment.
Progressive weight loss, persistent fever, bleeding, a new mass or reproducible objective deficit needs investigation for physical disease.
A substantial change in the pattern, severity or context of established symptoms should not be attributed automatically to the existing formulation.
Suicidal intent, severe self-neglect, medication toxicity, domestic abuse or exploitation requires urgent risk and safeguarding action.
Investigation priorities
Map onset, change, previous diagnoses, completed tests, treatments and the patient's feared explanation before selecting further investigation.
Management branches
Persistent symptoms impair function despite prior assessment or treatment.
- Acknowledge the symptoms and their impact, ask what the person fears or hopes the assessment will explain, and clarify the agenda.
- Summarise physical findings, coexisting disease and uncertainty, then offer a mechanism-based formulation using the person's own examples and language.
- Agree one or two functional goals, a focused clinical plan, who coordinates it and when the formulation will be reviewed.