PI Brief Update

You Say Somatic, I Say Psychosomatic: Diagnostic Dilemmas in Post-Injury Pain - Dr Justin Savage and Mr John Mackinnon

30/09/25. Pain is both a universal experience and a clinical enigma. Following personal injury, pain can persist beyond expected healing times, evolving into chronic conditions that defy straightforward diagnosis. The challenge lies not only in identifying the source of pain but in discerning its nature—somatic or psychosomatic—and recommending appropriate treatment. This article explores the complexities of diagnosing post-injury pain, the shifting landscape of psychiatric classification between DSM-IV and DSM-5, and the implications for clinical practice.

The Somatic–Psychosomatic Divide

Somatic pain is typically linked to identifiable tissue damage or physiological dysfunction. Psychosomatic pain, by contrast, lacks a clear organic cause and is influenced by psychological factors. Yet in practice, this binary is rarely clear. Conditions such as fibromyalgia, complex regional pain syndrome (CRPS), and chronic back pain often straddle both domains, challenging clinicians to adopt a biopsychosocial model of care.

Diagnostic Challenges Post-Injury

Diagnosing pain after personal injury is fraught with uncertainty:

• Subjectivity of Pain: Pain is inherently subjective, relying on patient self-reporting. Without objective biomarkers, clinicians must interpret symptoms through functional assessments and psychological screening.
• Overlap with Psychiatric Disorders: Chronic pain symptoms often mimic or coexist with depression, anxiety, and somatic symptom disorders, complicating differential diagnosis.
• Fluctuating Symptomatology: Many pain conditions exhibit episodic flare-ups, making consistent diagnostic criteria difficult to apply.
• Medicolegal Implications: In cases involving compensation, clinicians must navigate the risk of malingering while respecting the legitimacy of patient suffering.

Functional Neurological Disorder: A Related Diagnostic Challenge

Functional Neurological Disorder (FND) presents with neurological symptoms such as weakness, movement disorders, or non-epileptic seizures that are not explained by structural disease. A neurologist is typically instructed to assess and diagnose FND. Like psychosomatic pain, FND occupies a diagnostic grey zone, often misunderstood and misdiagnosed; caused by potentially mysterious psychological/emotional factors.

• Overlap with Pain Syndromes: FND may coexist with chronic pain, further complicating clinical assessment.
• Diagnostic Criteria: Diagnosis relies on positive signs (e.g., Hoover's sign for functional leg weakness) rather than exclusion, emphasizing the need for specialist evaluation.
• Stigma and Misconceptions: Patients with FND often face skepticism, which can hinder access to appropriate care and exacerbate psychological distress.
• Treatment Approaches: Multidisciplinary management—including physiotherapy, psychotherapy, and education—has shown promise in improving outcomes.

Medicolegal Considerations in Personal Injury and Medical Negligence Claims

Pain and FND present unique challenges in the context of personal injury and medical negligence compensation claims:

• Complex Causation: Establishing a clear causal link between the injury and ongoing symptoms is difficult when pain or neurological dysfunction lacks objective findings.
• Credibility and Malingering: The subjective nature of symptoms may lead to disputes over credibility, with allegations of exaggeration or malingering complicating proceedings.
• Expert Testimony: Medical experts must provide balanced, evidence-based opinions that acknowledge diagnostic uncertainty while avoiding bias.
• Legal Strategy: Solicitors should ensure that claimants undergo thorough multidisciplinary assessment and that reports address both physical and psychological dimensions.
• Judicial Interpretation: Courts may struggle to interpret complex medical evidence, especially when psychiatric and neurological diagnoses intersect.

DSM-IV vs DSM-5: A Shift in Perspective

The transition from DSM-IV to DSM-5 marked a significant shift in how pain-related psychiatric conditions are classified:

DSM-5’s introduction of Somatic Symptom Disorder (SSD) reflects a paradigm shift: the presence of a medical explanation is no longer required for diagnosis. Instead, emphasis is placed on excessive thoughts, feelings, or behaviours related to somatic symptoms. This change acknowledges the complex interplay between mind and body, but also risks pathologizing normal responses to injury.

Treatment Implications

The diagnostic ambiguity surrounding post-injury pain has direct consequences for treatment:

• Pharmacological Limitations: Opioids and analgesics offer limited long-term relief and carry risks of dependency.
• Psychological Interventions: Cognitive Behavioural Therapy (CBT), mindfulness, and Pain Management Programmes (PMPs) have shown efficacy in improving coping and function.
• Interdisciplinary Care: Best outcomes arise from integrated approaches involving physiotherapists, psychologists, and pain specialists.

Suggestions for those involved in their cases

It is important for solicitors and those involved in the care of patients with SSD and similar conditions to reassure them that their symptoms are real and not "all in their head." Patients need to understand that their pain and discomfort are valid and that their condition is recognised and treatable. Building a supportive and empathetic relationship with the patient can help alleviate some of the associated distress. Solicitors should also work closely with medical professionals to ensure that patients receive appropriate treatment and support throughout the legal process. As in general cases, encouraging open communication and providing clear information about the legal proceedings can help reduce anxiety and improve the patient's overall well-being.

Conclusion

“You say somatic, I say psychosomatic”—this rhetorical tension encapsulates the diagnostic and therapeutic complexity of chronic pain following personal injury. As classification systems evolve and our understanding deepens, clinicians must remain vigilant, empathetic, and evidence-informed. The goal is not merely to label pain, but to alleviate it.

References

• British Pain Society. Guidelines for Pain Management Programmes for Adults.
• Medicolegal Partners. The Medicolegal Challenges of Chronic Pain.
• Faculty of Pain Medicine. Challenges of Long Term Pain Management.
• Cambridge Core. Differences Between DSM-IV and DSM-5.
• APA. Highlights of Changes from DSM-IV-TR to DSM-5.

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