Somatic Symptom & Related Disorders
A Step 2 CK–focused walkthrough of DSM-5 somatic symptom and related disorders — criteria, durations, and epidemiology — with vignette buzzwords and next-best-step management, plus the factitious-vs-malingering framework and the insulin/C-peptide pearl. Corrected the SSD onset claim (no DSM-5 age criterion), clarified that factitious disorder imposed on another is diagnosed in the perpetrator, and verified all durations, first-line treatments, and the hypoglycemia lab triad.
Overview: it's about the reaction, not the symptom
Somatic Symptom and Related Disorders are conditions in which physical symptoms or health preoccupation cause real distress or dysfunction, and the patient's thoughts, feelings, and behaviors about those symptoms are disproportionate — regardless of whether an organic cause is found. The big DSM-5 shift: diagnosis rests on the excessive response, NOT on symptoms being "medically unexplained." Symptoms are not intentionally produced — that is what separates this whole family from factitious disorder and malingering, where symptoms are deliberately faked.
On Step 2 CK, points come from two moves: (1) match the vignette to the right label using duration and symptom pattern, and (2) pick the NEXT BEST STEP — which is almost always regularly scheduled visits with a single primary provider plus CBT, while resisting the urge to order more tests, refer out, or confront the patient.
- Somatic symptom disorder (SSD): ≥1 distressing somatic symptom (often a real symptom) + excessive thoughts, anxiety, or behaviors about it. The symptomatic state is persistent, typically >6 months. F>M; usually begins in early adulthood; prevalence ~5–7%. Specifier: with predominant pain.
- Illness anxiety disorder (IAD): preoccupation with having or acquiring a serious illness with minimal or no actual somatic symptoms; present ≥6 months (the specific feared illness may change). Care-seeking vs care-avoidant type. M ≈ F.
- Conversion disorder (functional neurological symptom disorder): ≥1 altered motor/sensory symptom with exam features incompatible with recognized disease (Hoover sign, normal EEG during a "seizure," tubular/tunnel vision). No minimum duration; often follows a stressor. La belle indifférence is neither sensitive nor specific.
- Factitious disorder: intentional falsification or induction of illness to assume the sick role, without external reward. When imposed on another (usually caregiver→child), the diagnosis is assigned to the perpetrator, not the victim.
- Caveats: malingering is NOT a DSM-5 disorder (external incentive); body dysmorphic disorder & OCD sit in the OCD-related chapter, not here.
Side-by-side comparison
| Disorder | Hallmark clue | Duration | Symptom made on purpose? | Motivation | First-line management |
|---|---|---|---|---|---|
| Somatic symptom disorder | ≥1 real, distressing symptom + excessive health anxiety; many doctors/tests | Persistent, >6 mo | No | Internal (unconscious) | Scheduled visits w/ 1 PCP + CBT; SSRI/SNRI if comorbid |
| Illness anxiety disorder | Fear of having illness, few/no actual symptoms | ≥6 mo | No | Internal | CBT, scheduled reassurance visits |
| Conversion (FND) | Neuro deficit + positive incompatibility (Hoover sign, normal EEG) | No minimum | No | Internal | Reassure + physiotherapy, CBT |
| Factitious disorder | Fabricates/induces illness; wants the sick role | — | Yes | Internal (sick role) | Nonpunitive; single provider; limit harm |
| Malingering (not a dx) | Fakes for external reward; inconsistent, better when unobserved | — | Yes | External (2° gain) | Objective documentation; not a psych dx |
- 28F, 3 years of shifting complaints (abdominal pain, fatigue, palpitations), several normal workups, spends hours researching her symptoms, highly anxious about her health. → Somatic symptom disorder. Next step: regularly scheduled visits with one PCP + CBT; do NOT order more tests.
- 46M convinced he has ALS for >1 year despite repeatedly normal neuro exams; barely any symptoms, checks his tongue and limbs daily. → Illness anxiety disorder. Next step: CBT and scheduled reassurance visits; add an SSRI if comorbid anxiety/depression.
- 19F, sudden bilateral leg paralysis the day after a breakup; Hoover sign positive, reflexes normal, MRI normal. → Conversion disorder. Next step: reassurance + physical therapy (± CBT); avoid an extensive workup and do not confront. Good prognosis given acute onset + clear stressor.
- 34F nurse with recurrent hypoglycemia; labs show HIGH insulin + LOW C-peptide → exogenous (surreptitious) insulin injection = factitious disorder (motivation is the sick role). Contrast: sulfonylurea abuse = high insulin + high C-peptide + positive sulfonylurea screen; insulinoma = high insulin, high C-peptide, high proinsulin. Next step: nonconfrontational approach, one coordinating provider, prevent iatrogenic harm; if imposed on another, the diagnosis is the caregiver's — ensure the dependent's safety.
- Prisoner reports vivid hallucinations to obtain transfer or opioids; symptoms are inconsistent and improve when he believes he is unobserved. → Malingering (external / secondary gain). Next step: objective documentation — this is not a psychiatric diagnosis and should not be reinforced.
- One primary provider + regularly scheduled brief visits (not PRN) — reduces symptom reinforcement and ER-shopping.
- Goal is to restore function, not to chase a cure or a missing diagnosis.
- Minimize unnecessary labs, imaging, referrals, and invasive procedures.
- CBT = first-line psychotherapy for SSD and IAD.
- SSRIs/SNRIs for comorbid depression/anxiety; SNRIs or TCAs (e.g., amitriptyline) help pain-predominant SSD.
- Conversion: educate/reassure + physiotherapy; treat comorbid mood/anxiety. Best prognosis with acute onset, identifiable stressor, and early treatment — most acute cases remit.
- Factitious: avoid aggressive confrontation; focus on limiting harm.
- Always validate distress ("your symptoms are real to you") — never dismiss the patient as "faking."
Separate the somatic spectrum from factitious and malingering by asking:
(1) Is the symptom produced on purpose (conscious)? (2) Is the payoff internal (psychological) or external (money, drugs, avoiding jail/work)?
Classic teaching framework:
- Conversion / SSD / IAD = unconscious symptom + unconscious/internal gain → the patient truly experiences it.
- Factitious = conscious symptom + unconscious/internal motive (the sick role).
- Malingering = conscious symptom + conscious/external gain (secondary gain).
One-liner: *"Conversion — unconscious/unconscious; Factitious — conscious/unconscious; Malingering — conscious/conscious."*
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