CCFP priority topic 92 of 105
Somatization on the CCFP exam
9 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 9 key features for Somatization. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 9
Work up first
Look for physical and mental illness before you label symptoms somatic, and check again over time.
CFPC skill Clinical reasoning, patient-centred approach, selectivityPhase Hypothesis generation, diagnosis, follow-upSources Choosing Wisely Canada
On the exam
A woman has eight months of tiredness, palpitations and tingling, seven visits and a normal exam. Expect a short menu (pick several from a list).
Pick the history and tests that matter today.
Common mistakes
Chasing her fears with questions about an aunt's multiple sclerosis, dental fillings or mould. Or calling it somatic before you ask about mood, the hidden diagnosis you must not miss.
Approach
- Take a full history and examine her. Ask about low mood, worry, panic, alcohol and drugs.
- Order only the tests her symptoms point to.
- Skip routine screening panels. Blood tests without a reason tend to give false positives and lead to more tests.
- Skip history questions whose answer would not change today's plan.
- Tell her what you found and what you did not find.
- Book follow-up and check her symptoms again at set visits. Some turn into a clear diagnosis later; many stay unexplained.
- New signs, weight loss, fever or an abnormal test restart the work-up.
Key feature 2 of 9
Name it right
Tell a stressed patient with body complaints apart from somatic symptom disorder by its formal criteria.
CFPC skill Clinical reasoning, selectivityPhase Diagnosis
On the exam
A night-shift worker has many symptoms, constant health worry and lost shifts for eight months. Expect one best answer for the diagnosis.
Pick the diagnosis that meets the criteria.
Common mistakes
Calling it a stress reaction because of night shifts. Or illness anxiety because she fears multiple sclerosis: that needs mild or absent symptoms, and hers are many and distressing.
Approach
- Somatic symptom disorder: one or more distressing body symptoms, plus too much thought, worry or time spent on them.
- The state lasts for months, even if single symptoms come and go.
- Base it on how she thinks, feels and acts about her symptoms. The symptoms do not have to be unexplained.
- A stress reaction or adjustment disorder fits only when another disorder's criteria are not met.
- Many visits at many clinics do not mean she is faking. Faking needs signs she invents or causes symptoms.
| Diagnosis | Core feature | Points against it |
|---|---|---|
| Somatic symptom disorder | Distressing symptoms with excess worry, thought or time spent on them | Worry in proportion to the symptoms |
| Illness anxiety disorder | Fear of a serious disease, with mild or no symptoms | Many distressing symptoms at the centre of the worry |
| Functional neurological disorder | Exam findings that do not fit nerve disease | A normal exam, or symptoms across many body systems |
| Factitious disorder | Faking or causing symptoms, with no outside gain | No sign she invents or causes her symptoms |
| Stress reaction or adjustment disorder | Distress after a clear stressor | Criteria for another disorder are met |
Key feature 3 of 9
Old label, new symptom
When somatic symptom disorder is already known, still look for a cause of each new symptom.
CFPC skill Clinical reasoning, patient-centred approachPhase Hypothesis generationSources Choosing Wisely Canada
On the exam
A woman with known somatic symptom disorder says her headaches changed five months ago. Expect a short menu (pick several from a list).
Pick the questions that find a dangerous or new cause.
Common mistakes
Accepting the old label and the word stress. Or asking only about triggers and fears: neither rules out danger or finds the near-daily codeine behind the change.
Approach
- Treat a new or changed symptom as new. The disorder describes how she responds to symptoms, not what causes them.
- Ask about red flags first. For headache: sudden thunderclap onset, fever with a stiff neck, new nerve signs, odd triggers, onset after 50.
- Look at the back of her eyes for a swollen optic disc, and do a full nerve exam.
- Ask how many days a month she takes painkillers. Opioid or combination tablets on 10 or more days can cause rebound headache.
- Anti-inflammatories or acetaminophen on 15 or more days a month can do the same.
- Ask about her fears and stress after you have asked about danger.
Key feature 4 of 9
Shared plan
Accept that the symptoms are real to the patient, and agree together on the diagnosis, tests and plan.
CFPC skill Patient-centred approach, communicationPhase Diagnosis, treatmentSources Choosing Wisely Canada
On the exam
A woman with somatic symptom disorder has headaches that fit migraine and a normal exam, and asks for a brain scan. Expect one best answer for your reply.
Pick the reply that keeps her trust.
Common mistakes
Ordering the scan, or a scan without radiation instead: the problem is the reason, not the machine. Or saying nothing is wrong, which loses her trust.
Approach
- Say the symptoms are real and that you see how they affect her life.
- Ask what she thinks is causing them, what she fears and what she hopes for today.
- Explain your exam and why a scan would not help. A chance finding can cause worry and lead to more tests.
- When she wants reassurance, a careful explanation of the diagnosis may help more than a scan.
- Agree on what you will watch for, and what would change the plan.
- Keep her care with you. A referral to settle the question signals that you are unsure.
Key feature 5 of 9
Test less, explain more
With frequent, puzzling but low-risk complaints, test sparingly and explain how stress shows up in the body.
CFPC skill Clinical reasoning, selectivity, patient-centred approach, communicationPhase Investigation, treatmentSources Choosing Wisely Canada
On the exam
A woman with eight months of vague symptoms and a normal exam. Expect a short menu (pick several from a list) of tests.
Pick the tests to order, and those to skip.
Common mistakes
An antinuclear antibody (ANA) test, a vitamin D level, a cortisol test or a head scan to be sure. Each brings false alarms and more tests.
Approach
- Order only the tests her symptoms point to.
- No ANA without specific signs of lupus, such as joint, skin or kidney findings. Up to about 20% of healthy people test positive.
- No vitamin D level in low-risk adults.
- No brain or sinus imaging for headache that fits migraine, when the exam is normal and there are no red flags.
- Explain how worry and stress cause real body symptoms: a racing heart, tingling, tiredness. Use her own symptoms as the examples.
| Test | Order it when | Why not by default |
|---|---|---|
| ANA | Specific signs of lupus or another autoimmune disease | Often positive in healthy people; a positive starts a chain of tests |
| Vitamin D level | Kidney or liver disease, poor gut absorption, parathyroid disease, seizure drugs or steroids | No agreed cut-off and no proven fracture benefit in low-risk adults |
| Brain imaging for headache | Red flags or an abnormal exam | Harmless findings cause worry and more tests |
Key feature 6 of 9
Mental illness, new symptom
In a patient with a mental illness, assess each new body complaint before calling it somatic.
CFPC skill Clinical reasoning, selectivityPhase Treatment, follow-up
On the exam
A man with long-standing depression has new chest pain when he walks uphill. Expect one best answer for the next step.
Pick the next step for the new symptom.
Common mistakes
Putting it down to his mood or anxiety and changing his antidepressant. The new symptom needs the same work-up anyone else would get.
Approach
- Take the history and examine him as you would any patient with this symptom.
- Order the tests the symptom calls for, without delay.
- Think of his medicines: some cause new symptoms, and some raise heart and blood sugar risks.
- Ask about alcohol, smoking and drug use and their harms.
- Write down what you found, so the next doctor does not assume it is his mental illness.
Key feature 7 of 9
Your own reaction
Notice the feelings these patients stir in you, and keep them out of your decisions.
CFPC skill Professionalism, patient-centred approachPhase Treatment, follow-up
On the exam
A woman's fourth visit this month brings a new symptom, and you feel irritated. Expect one best answer for the next step.
Pick the response that keeps care safe.
Common mistakes
Ordering a test or a referral to end the visit. Or rushing her out and missing a real change. Both come from your frustration, not her findings.
Approach
- Name the feeling to yourself: frustration, helplessness, boredom or a wish to rescue.
- Ask whether that feeling is driving a test, a referral or a short visit.
- Set a clear frame: booked visits of a set length, with the agenda agreed at the start.
- Talk it through with a colleague, or with a Balint group, where doctors discuss hard patient relationships.
- Watch for burnout in yourself, and get help if these visits wear you down.
Key feature 8 of 9
Therapy and follow-up
Once somatic symptom disorder is the likely diagnosis, offer proven talking therapy and keep up regular visits.
CFPC skill Patient-centred approach, clinical reasoningPhase Treatment, referral
On the exam
A night-shift worker with somatic symptom disorder has no health benefits and no money for therapy. Expect a short menu (pick several from a list).
Pick the plan she can actually use.
Common mistakes
A private psychologist she cannot pay for, or come back when needed. Visits tied to new symptoms reward new complaints and send her to walk-in clinics.
Approach
- Offer cognitive behavioural therapy (CBT), a talking therapy that changes unhelpful thoughts and habits.
- Match it to what she can reach: publicly funded or online CBT if she has no benefits.
- Book short visits at set times, not when a new symptom appears. Long gaps send her to walk-in clinics.
- Stay her main doctor. Keep tests and specialist referrals to what her findings need.
- Treat depression or anxiety alongside it.
- Refer to psychiatry for doubt about the diagnosis, suicide risk or no progress. Psychiatry advises; you keep giving her care.
Key feature 9 of 9
Coping and relief
Ask what the patient tries for relief, and offer safe ways to ease and live with symptoms.
CFPC skill Professionalism, patient-centred approachPhase History, treatmentSources Choosing Wisely Canada
On the exam
A woman with somatic symptom disorder asks for something to calm her. Expect one best answer for what to offer.
Pick the safest option that helps.
Common mistakes
A benzodiazepine for her distress. It does not treat the disorder, and it brings dependence and slowed thinking and reactions.
Approach
- Ask what she already uses: natural products, other healers, cannabis, alcohol, store-bought painkillers.
- Check those for harms and drug interactions. Count her painkiller days, since frequent use can cause rebound headache.
- Suggest regular meals and sleep, exercise, relaxation training, stress skills and pacing her activity.
- Avoid a benzodiazepine for her distress. If one is used, agree on a plan to taper and stop it from the start.
- Aim for better function, not a cure.
Flashcards
Answer it first, then check.
KF 1Eight months of vague symptoms and a normal exam. What do you ask about first?
Mood, worry and panic. Look for depression and anxiety before you call it somatic.
KF 2She has few body symptoms but is sure she has a serious disease. Which diagnosis?
Illness anxiety disorder. Somatic symptom disorder needs distressing symptoms at the centre of the worry.
KF 3Known somatic symptom disorder, and her headaches changed months ago. What do you ask first?
Red flags, then how many days a month she takes painkillers. Source: Choosing Wisely Canada
KF 4Her headaches fit migraine, with no red flags and a normal exam. She asks for an MRI. Fair?
No. Neither scan helps here, and a chance finding brings more tests and more worry. Source: Choosing Wisely Canada
KF 5No joint, skin or kidney signs. Should you order an ANA?
No. Up to about 20% of healthy people test positive, and a positive starts more tests. Source: Choosing Wisely Canada
KF 7You feel irritated at her fourth visit this month. What is the risk?
Acting on it: a test to end the visit, or rushing her and missing a real change.
KF 8Somatic symptom disorder is the diagnosis. When is her next visit?
At a set time, soon. Visits that need a new symptom reward new complaints.
KF 9She asks for a benzodiazepine to calm her. What do you offer instead?
Exercise, relaxation, pacing and CBT. A benzodiazepine brings dependence and slowed thinking, and needs a plan to stop. Source: Choosing Wisely Canada
FAQ
Is somatization the same as somatic symptom disorder?
No. Somatization is a process: distress felt in the body, which everyone has at times. Somatic symptom disorder is a diagnosis with set criteria, built on excess worry about symptoms.
Do the symptoms have to be medically unexplained?
No. Under current criteria, a patient with a known illness can also have the disorder. It rests on the response to symptoms, so you still look for a cause of each one.
Does this topic come up in children?
Yes. Children often show distress as stomach aches or headaches. Look for illness first, ask about school, family and bullying, and keep the child going to school during the work-up.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada