Somatic Symptom, Factitious & Dissociative Disorders

The Framework: Intent and Gain

Two questions. Once medical disease has been evaluated and findings are absent or out of proportion, ask whether the symptom is deliberately produced and, if so, what the patient gains. In somatic symptom, illness anxiety, and conversion disorders, symptoms are genuinely experienced and not consciously produced. In factitious disorder, symptoms are consciously faked to occupy the sick role (internal, or primary, gain). In malingering, they are consciously faked for an external (secondary) reward such as money, drugs, or escape from work or jail.

Somatic Symptom and Related Disorders

Somatic symptom disorder. One or more distressing bodily symptoms plus disproportionate worry, persistent anxiety, or excessive time and energy devoted to them, with a symptomatic course lasting more than 6 months. The reaction is the illness: DSM-5 dropped the requirement that symptoms be medically unexplained, so the diagnosis can coexist with real disease. The best management is regularly scheduled visits with a single primary care physician, limited testing, and CBT; repeated tests and multiple specialists reinforce illness behavior.

Illness anxiety disorder. Preoccupation for ≥6 months with having or getting a serious illness despite absent or mild symptoms and repeated normal workups; it was formerly called hypochondriasis. Patients are either care-seeking, checking and requesting tests compulsively, or care-avoidant, avoiding doctors altogether. The belief persists despite reassurance but lacks delusional fixity, which separates it from delusional disorder, somatic type.

Pseudocyesis. A nonpsychotic woman firmly believes she is pregnant and develops objective signs (amenorrhea, abdominal distension, breast changes, even felt fetal movements), yet hCG and ultrasound are negative. It is classified as an other specified somatic symptom disorder and is linked to infertility, pregnancy loss, or an intense desire for a child.

Conversion Disorder

Functional neurological symptom disorder. Weakness, paralysis, abnormal movements, nonepileptic seizures, blindness, aphonia, or numbness incompatible with known neurologic disease, often starting abruptly after a psychological stressor. It is most common in young women, and some patients show striking unconcern (la belle indifférence).

Bedside signs. In the Hoover sign, hip extension of the "paralyzed" leg is absent on command but returns involuntarily when the patient flexes the opposite hip against resistance, so the examiner's hand under the weak heel feels firm downward pressure. Other clues are give-way weakness, numbness splitting exactly at the midline, tremor that entrains to a tapped rhythm, and nonepileptic seizures with the eyes closed and a normal video-EEG.

Factitious Disorder and Malingering

Factitious disorder imposed on self. Conscious falsification or induction of illness with no external reward; the goal is the sick role itself. Clues include work in healthcare, a dramatic but inconsistent history, eagerness for invasive tests and surgery, many scars, and leaving against medical advice when confronted. Munchausen syndrome is the chronic, physically dominant form. Laboratory clues can expose the method: surreptitious insulin produces high insulin with undetectable C-peptide, whereas an insulinoma or sulfonylurea raises both.

Factitious disorder imposed on another. Formerly Munchausen syndrome by proxy: a caregiver, usually the mother, fabricates or induces illness in a dependent through poisoning, suffocation, or tampered specimens. Suspect it when signs appear only in the caregiver's presence and resolve once the child is separated. The caregiver carries the diagnosis.

Factitious illness imposed on a child is child abuse: the physician must report it to child protective services.

Malingering. Intentional production or exaggeration of symptoms for secondary gain: money, lawsuit or disability awards, opioids, or avoiding work, military duty, or prosecution. It is not a mental disorder. Complaints are vague, cooperation with evaluation is poor, and symptoms vanish once the reward is secured.

Dissociative Disorders

Depersonalization/derealization disorder. Depersonalization is feeling detached from one's own body or mind, like an outside observer; derealization is feeling that the surroundings are unreal, dreamlike, or foggy. Reality testing stays intact, because the patient knows the experience is not literally true, and this separates the disorder from psychosis.

Dissociative amnesia. An inability to recall important autobiographical information, usually about a trauma or stressor, beyond ordinary forgetting, while new learning is preserved. With dissociative fugue, the patient suddenly travels or wanders away, confused about or unaware of personal identity, and may adopt a new one.

Dissociative identity disorder (DID). Formerly multiple personality disorder: ≥2 distinct personality states with discontinuity in the sense of self and agency, plus recurrent memory gaps for everyday events. It is strongly linked to severe childhood physical or sexual abuse and is more common in women, with frequent PTSD, depression, borderline personality disorder, self-harm, and suicide attempts. DID fragments identity, whereas schizophrenia is a break from reality. Treatment is long-term trauma-focused psychotherapy.