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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.

SSD is a new diagnostic term appearing in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the latest version of the diagnostic manual published by the American Psychiatric Association. SSD replaces somatoform disorder as used in the previous edition of DSM, and the diagnostic labels previously subsumed by somatoform disorders will also be subsumed by SSD in DSM-5. These disorders have specific courses, symptoms, complaints, and treatments, as listed in Table 59–1.

Table 59–1.Somatic symptom disorders, factitious disorder, and malingering.a
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Table 59–1. Somatic symptom disorders, factitious disorder, and malingering.a
Disorder Symptoms Volitional Symptom Presentation Type of Symptoms Symptom Duration Treatment Modalities

Somatic symptom disorder (SSD)

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 versus 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

Cognitive behavioral therapy

Trauma-focused therapy

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 nonopioid therapy

Cognitive behavioral therapy

Illness anxiety disorder, also known as hypochondriasis

No

Intense fear 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 SSD

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 SSD

Factitious disorder with physical symptoms

Yes—motivation primary gain: sick role, attention

Unexplained fever, bleeding, injuries

Nonhealing and unremitting; tend to receive multiple procedures/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

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