Psychiatric Symptoms with Physical Roots: What Are We Missing?

“They said it was all in my head.”

It’s a phrase many psychiatrists hear—often with equal parts frustration, grief, and resignation. The patient sitting across from me has been to specialist after specialist. The GI workup was normal. The cardiologist cleared her. The rheumatologist ran labs but found nothing conclusive. Eventually, the referral makes its way to psychiatry.

Sometimes it reads: “Somatic Symptom Disorder.”Other times: “Unexplained fatigue, ?psych overlay.”Or the classic: “R/o conversion disorder.”

But here’s the thing: just because something hasn’t been found, doesn’t mean nothing is there.

The Limitations of Our Diagnostic Tools

Modern medicine is powerful—but not omniscient. It’s designed to catch the big things: tumors, heart attacks, autoimmune flare-ups with textbook labs. What it doesn’t always catch? The subtle dysfunctions. The early or atypical presentations. The conditions without a clear ICD-10 label.

And when that happens—when a person’s suffering doesn’t fit into a neat diagnostic box—they’re often told it’s “just stress” or “probably anxiety.”

Of course, sometimes that’s true. Psychiatric symptoms can absolutely manifest as physical sensations. Panic attacks can feel like heart attacks. Trauma can live in the gut. Depression can masquerade as pain, fatigue, or cognitive fog. But we do harm when we stop the inquiry there.

Invisible Illness Isn’t Imagined Illness

Conditions like POTS, mast cell activation, Lyme and coinfections, mold-related illness, Ehlers-Danlos Syndrome, and autoimmune disease often show up first in a psychiatrist’s office. They might look like panic disorder, ADHD, or even conversion disorder. But beneath the surface, the nervous system is inflamed, destabilized, or compensating for something deeper.

These patients are often young, highly sensitive, disproportionately female, and carrying trauma histories—which can bias even the most well-meaning clinicians to assume their symptoms are psychological.

But the mind and body don’t work in silos. We must learn to read between the lines.

A Neuropsychiatric Lens: Looking Beyond the DSM

As psychiatrists, we’re trained to ask about mood, thought content, trauma history. But when someone presents with fatigue, dizziness, sensory sensitivity, or temperature regulation issues, we need to expand that intake.

Neuropsychiatry reminds us that mental health symptoms are often downstream effects of physical processes—immune activation, autonomic dysregulation, subclinical inflammation, metabolic stress.

Including a broader screening of symptoms—asking about lightheadedness, chemical sensitivities, food reactions, joint pain, temperature swings, or unexplained rashes—can open the door to crucial clues. These aren’t tangents. They’re part of the picture.

When psychiatric symptoms co-occur with physical complaints, especially across multiple systems, it may be a sign the nervous system is responding to a deeper physiologic threat.

When Should Psychiatry Dig Deeper?

As psychiatrists—or therapists or primary care providers—there are red flags that might warrant a second look or collaboration with integrative-minded clinicians:

Symptom clusters that don’t match a typical psychiatric diagnosis (e.g., heat intolerance, dizziness, rashes, and panic—could this be mast cell activation or POTS?)
Multiple medication intolerances or paradoxical reactions
Family history of autoimmune or connective tissue disease
Neuropsychiatric symptoms following an infection, mold exposure, or travel (think: tick-borne illness or immune activation)
Fluctuating cognitive symptoms (“brain fog”) with physical triggers
“Medical trauma” from prior invalidation—a clue that we should approach with humility and curiosity

A Call for Integrative Collaboration

Psychiatry has a powerful role to play—not just in managing distress, but in being part of the diagnostic team. Sometimes our tools (therapy, medication, lifestyle work) are exactly what’s needed. But other times, we’re the first ones who need to raise the flag: “Could something else be going on here?”

We don’t have to be functional medicine doctors. But we can be bridge-builders—referring to collaborative providers, considering inflammatory pathways, or simply validating that a patient’s symptoms are real, even when the answers are still unfolding.

For Clinicians: Some Starting Points

If you’re a psychiatrist or therapist noticing these patterns, here are a few small steps that can go a long way:

Ask about symptom patterns across systems—not just mental but also immune, endocrine, GI, and autonomic
Include a broader review of physical symptoms in psychiatric intakes—especially when cognitive or mood symptoms fluctuate with food, stress, sleep, or environmental exposure
Consider screening tools like the COMPASS-31 for dysautonomia, or a basic inflammatory lab panel (CRP, ESR, ANA, TSH, Vitamin D, B12)
Build relationships with clinicians in integrative, allergy/immunology, or ME/CFS-informed care
Name and challenge medical gaslighting—our patients often carry deep shame from not being believed

When we stop at “somatic,” we risk missing the story. We risk missing the root.

Psychiatry is uniquely positioned to hold the uncertainty that complex, invisible illness brings. We can help patients manage the very real emotional toll. But we also owe it to them—and to ourselves—to keep our minds open.

A kind reminder: This blog post is designed as a general guide. This is not a substitute for personalized medical advice, nor is a patient-physician relationship established in this blog post.