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Chapter 59: Somatic Symptom Disorder (Previously Somatoform Disorder), Factitious Disorder, & Malingering

William G. Elder

GENERAL CONSIDERATIONS

Somatic symptom disorder (SSD) involves unexplained physical symptoms that bring significant functional impairment. It presents one of the more common and most difficult problems in primary care. SSD is seldom “cured” and should be approached as a chronic disease. Recognition, a patient-centered approach, and specific treatments may help alleviate symptoms and distress. Factitious disorder and malingering, although not true SSD, are addressed separately in this chapter because of their similarity in the form of medically unexplained symptoms.

Somatic symptom disorder (SSD) is a new diagnostic term that replaces somatoform disorder in DSM-5, the latest ­version of the diagnostic manual published by the American Psychiatric Association. Use of SSD as the prevalent term will likely increase after DSM-5 becomes widely disseminated following publication in May 2013. The diagnostic labels previously subsumed by somatoform disorders in DSM-4 will also be subsumed by SSD in DSM-5. These disorders have specific courses, symptoms, complaints, and treatments, listed in Table 59-1.

Table 59-1.Somatoform disorders, factitious disorder, and malingering.a
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Table 59-1.Somatoform disorders, factitious disorder, and malingering.a
Disorder Symptoms Volitional Symptom Presentation Type of Symptoms Symptom Duration Treatment Modalities
Somatic Symptom Disorder No Excessive concern about one or more physical complaints

Disproportionate and persistent thoughts about seriousness of symptoms

High anxiety about health or ­symptoms

Excessive time and energy devoted to symptoms

 Chronic, recurring, and/or stable Frequent visits, therapeutic relationship with provider, active listening, avoidance of excessive or invasive treatments, focus on management vs cure, consider CAM modalities
Conversion disorder No Onset after acute stress Pseudoneurologic symptom or symptom complex such as strokelike weakness, sensory loss, or pseudoseizure Sudden onset; short duration

Reassurance that symptom will resolve over days

Avoid labeling as mental illness
Pain disorder No Preoccupation with pain; examination out of proportion with disease or injury Pain insufficiently explained by any organic cause; frequently associated with disability, relationship disruptions, depression, anxiety Sudden onset; worsens with time Focus on functionality, symptom management, and nonnarcotic therapy
Illness Anxiety Disorder also known as Hypochondriasis No Fearful of disease; preoccupied with symptoms; not reassured Multiple symptoms over time; misinterpretation of normal sensations, may have unusual health and prevention behaviors Long history, worsens after actual illness SSRI may be beneficial, otherwise similar to somatization
Body dysmorphic disorder No Excessive concern about imagined defect in appearance Specific complaints of defect (other than obesity); behaviors to hide or avoid public exposure of “defect” Usually several years SSRI may be beneficial, otherwise similar to somatization
Factitious disorder with physical symptoms Yes—motivation primary gain: sick role, attention Unexplained fever, bleeding, injuries Nonhealing and unremitting; tend to receive multiple procedure/operations over time; falsify records Chronic; multiple admissions; remits with confrontation Accurate diagnosis, may remit with confrontation
Malingering Yes—motivation secondary gain: money, disability, drugs, etc

Similar to above

Protest; demand for medical help

 Vague pain and/or paralysis common; belligerent with providers if ...

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