Malingering

Intentional falsification with obvious external rewards (financial benefits, housing, medications)

Factitious disorder

• Intentional falsification of symptoms/inducing injury
• External rewards absent; goal is to assume the patient role

Somatic symptom and related disorders

Excessive illness anxiety/preoccupation with somatic symptoms & treatment seeking; no intention to deceive

• Illness anxiety disorder
  • Fears of having a serious, undiagnosed illness and are rarely reassured by negative findings on physical examination or laboratory testing.
  • Have minimal or no somatic symptoms
  • The key is illness
• Somatic symptom disorder
  • Have prominent and typically multiple somatic symptoms
  • The key is symptom
  • Both panic disorder and somatic symptom disorder feature multiple physical symptoms and high health care use.  In somatic symptom disorder, patients experience physical symptoms persistently (eg, daily, unrelenting fatigue) whereas in panic disorder, physical symptoms are unexpected, episodic, and of short duration, typically lasting <10 minutes.
• Conversion disorder (Functional neurological symptom disorder)
  • CAN'T (They really feel the symptoms and they can't stand them)
    • Clinically unexplained
    • Abnormalities
    • Nervous symptoms
    • Trigger (sometimes)
  • No anxiety
• Management of somatic symptom disorder
  • Schedule regular visits with same provider
  • Limit unnecessary workup & referral to specialists
  • Reassure that serious illness has been ruled out
  • Legitimize symptoms but make functional improvement the treatment goal
    • Decrease stress
    • Improve coping strategies
  • Mental health referral only once physician-patient relationship is well established

Personality disorders

• Enduring patterns of maladaptive interpersonal behavior that may include deliberate self-harm (borderline)
• Desire to be taken care of (dependent) but do not involve intentional deception