Somatic symptom and related disorders

Disorder	Symptom Production	Motivation	Primary Feature
Somatic Symptom	Unconscious	Unconscious	Distress from actual (though medically unexplained) physical symptoms
Illness Anxiety	Unconscious	Unconscious	Fear of having an illness, with minimal/no symptoms
Conversion	Unconscious	Unconscious	Neurologic symptom incompatible with pathology
Factitious	Conscious	Unconscious (to be sick)	Faking/inducing illness for internal gain (the “sick role”)
Malingering	Conscious	Conscious (external gain)	Faking illness for external/secondary gain (e.g., money, avoiding work/jail). This is not a psychiatric disorder.

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

Mnemonic

Malingering Always Leaves once their need has been met whereas Factitious disorder Always Comes back for more.

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

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Pseudocyesis (Pseudopregnancy)

• Definition: Somatization/neuroendocrine disorder causing false conviction and physical signs of pregnancy in a non-pregnant female.
• Risk Factors:
  • Infertility or recurrent pregnancy loss.
  • Intense desire for, or severe fear of, pregnancy.
  • Comorbid psychiatric history (MDD, somatic symptom disorder, severe trauma).
• Clinical Presentation:
  • Symptoms: Amenorrhea, breast tenderness, galactorrhea, nausea/vomiting, weight gain, perceived fetal movements (quickening).
  • Signs: Abdominal distension (normal/inverted umbilicus), breast enlargement, normal non-gravid uterus, absent fetal heart tones (FHT).
• Diagnostics:
  • Initial: Urine or serum β-hCG $\to$ negative.
  • Confirmatory / Next Step: Pelvic/TVUS $\to$ empty uterus (thin endometrial stripe, no gestational sac).
• Key Differentials:
  • True pregnancy: (+) β-hCG, intrauterine gestational sac/fetal pole on TVUS.
  • Factitious disorder / Malingering: Intentional falsification for internal role/external gain (pseudocyesis is unintentional/genuine conviction).
  • Delusional disorder (somatic type): Fixed false belief without classic neuroendocrine somatic features (galactorrhea, abdominal enlargement).
• Management:
  1. Direct, non-judgmental presentation of objective evidence: Concurrently show the negative β-hCG and empty uterus on TVUS.
  2. Psychiatric consultation & psychotherapy: CBT and grief counseling for underlying infertility/loss.
  3. Pharmacotherapy: SSRIs for comorbid MDD/anxiety; short-term atypical antipsychotics for refractory fixed beliefs.
• Complications: Acute depressive episode, grief reaction, or suicidal ideation upon confronting reality.