Difficulty: Intermediate | Prerequisites: General introduction to abnormal psychology (Chapters 1-5)
These notes cover the somatic symptom and related disorders from Chapter 6 of Abnormal Psychology. This is one half of the chapter; the other half covers dissociative disorders in a separate document. The material sits at the intersection of mind and body, exploring how psychological distress can manifest as physical symptoms. You should already be comfortable with basic DSM-5 diagnostic structure and the major theoretical perspectives (psychodynamic, behavioural, cognitive, biological).
Somatic symptom and related disorders involve physical symptoms or health preoccupations driven largely by psychological factors. The key distinction between the disorders in this group is whether the person has real physical symptoms (somatic symptom disorder), fears illness without major symptoms (illness anxiety disorder), loses neurological function without medical cause (conversion disorder), or deliberately fakes illness (factitious disorder). Treatment is difficult across the board because patients typically believe the problem is physical, not psychological.
Somatic symptom disorder (SSD)
A condition in which a person experiences one or more distressing physical symptoms and devotes excessive time, energy, and anxiety to those symptoms and related health concerns. Think of it as: the person has real physical complaints, but their worry and behaviour around those complaints are wildly out of proportion to anything a doctor can find.
Illness anxiety disorder (IAD)
A condition characterised by preoccupation with having or developing a serious illness, with minimal or no actual somatic symptoms. In simple terms, this is the person who is convinced they are gravely ill even though their body is not producing significant symptoms. Formerly overlapped with the colloquial term "hypochondria."
Conversion disorder (functional neurological symptom disorder, FNSD)
A disorder in which a person loses voluntary motor or sensory function (e.g. paralysis, blindness, seizures) with no compatible neurological or medical explanation. Think of it as: psychological distress gets "converted" into a genuine loss of bodily function. The DSM-5 prefers the neutral name "functional neurological symptom disorder" because it does not presume a psychological cause.
Factitious disorder (Munchausen's syndrome)
A disorder in which a person deliberately fabricates or induces illness in themselves in order to assume the sick role and receive medical attention. In simple terms, the person is faking, but the goal is not money or avoiding work; it is the medical attention itself.
Factitious disorder imposed on another (factitious disorder by proxy)
Diagnosed when an individual falsifies or induces illness in someone else, typically a child, a pet, or an elderly dependent, to gain attention through the caretaker role.
Malingering
Deliberately faking or exaggerating symptoms to achieve an external reward such as avoiding military service, escaping criminal prosecution, or obtaining financial compensation. Think of it as: the person is also faking, but the motive is a tangible benefit rather than the sick role itself. Malingering is not a mental disorder.
Pseudocyesis
False pregnancy. A person believes they are pregnant and may even display physical signs, but medical testing confirms no pregnancy is present.
Primary gain
In psychoanalytic theory, the immediate reduction in anxiety that results from converting psychological distress into a physical symptom. The symptom keeps the distressing thought or memory out of conscious awareness.
Secondary gain
The external benefits a person receives as a result of having symptoms, such as attention, sympathy, or being excused from responsibilities. These rewards reinforce the symptom pattern.
La belle indifference
A striking lack of concern shown by some individuals with conversion disorder about their serious neurological symptoms (e.g. seeming unbothered by sudden paralysis or blindness). Historically observed in wartime soldiers with conversion symptoms.
Glove anaesthesia
Loss of sensation in the hand that follows the shape of a glove rather than the actual distribution of nerves, a classic example of a conversion symptom that is neurologically impossible.
These two disorders sit at the centre of the somatic spectrum. Both involve excessive health concern and both are associated with anxiety and depression, but they differ in whether the person experiences significant physical symptoms.
The person has one or more genuine, distressing physical symptoms
Health concerns are excessive given the person's actual medical status and persist even when the person is well
The person may insist on unnecessary medical procedures, avoid activities for fear of worsening symptoms, and become socially isolated
Health worries dominate interpersonal relationships
The condition tends to be long-term and disabling: higher rates of disability, low income, impaired sleep, high blood pressure, obesity, high cholesterol, more frequent hospitalisation, and earlier mortality
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life
B. Excessive thoughts, feelings, or behaviours related to the somatic symptoms, shown by at least one of:
Disproportionate and persistent thoughts about symptom seriousness
Persistently high anxiety about health or symptoms
Excessive time and energy devoted to symptoms or health concerns
C. The state of being symptomatic is persistent (typically more than 6 months), even if individual symptoms come and go
The person is preoccupied with developing or having a serious illness but does not experience the severe physical symptoms seen in SSD
Becomes very alarmed and is more likely to seek immediate care
Moves from physician to physician ("doctor shopping"), convinced they have a serious disease
May attribute health problems to toxins or environmental conditions despite contrary evidence
About 20% of patients seeking medical care have IAD
Older adults who will not accept a diagnosis of depression or anxiety may channel distress through somatic complaints instead
Young children who lack the vocabulary to describe mental distress may express it as physical symptoms
A. Preoccupation with having or acquiring a serious illness
B. Somatic symptoms are absent or mild. If another medical condition or high-risk factor is present (e.g. family history), the preoccupation is clearly excessive
C. High anxiety about health; easily alarmed about personal health status
D. Excessive health-related behaviours or maladaptive avoidance
E. Illness preoccupation present for at least 6 months (the specific feared illness may change)
F. Not better explained by another mental disorder
Both are prone to periods of anxiety or depression; symptom changes tend to mirror emotional wellbeing
Distress may be expressed as physical symptoms or masked by alcohol misuse or antisocial behaviour
Depression can exacerbate a range of physical diseases in these patients
Heightened bodily awareness: people with SSD experience bodily sensations more intensely, pay more attention to physical symptoms, and catastrophise those symptoms
Reinforcement cycle: catastrophising leads to stronger medication, being excused from responsibilities, and receiving sympathy, all of which reinforce the misinterpretation of symptoms
Familial patterns: anxiety and depression are common in female relatives of people with these disorders. Children may model illness behaviour, and parents who are consumed by their own symptoms may inadvertently teach children that being ill is the only way to get attention
PTSD link: 17% of people with PTSD also show somatic symptom patterns; somatic concerns can be part of the PTSD presentation
A core challenge: convincing patients they need psychological, not physical, treatment.
Psychodynamic: helps the person see connections between emotional experiences and physical symptoms by recalling events or memories that may have triggered the symptoms
Behavioural: identifies what reinforcements the person receives for being symptomatic and works to eliminate those reinforcements while rewarding healthy behaviour
Cognitive: teaches the person to interpret symptoms appropriately and to avoid catastrophising
Cognitive-behavioural (CBT): identifies and challenges illness beliefs and misinterpretations of physical sensations. This is the most widely studied approach for these disorders
Pharmacological: antidepressants can reduce somatic symptoms
Cultural considerations: belief systems and cultural traditions can be used to motivate engagement in therapy and help patients overcome physical complaints
Conversion disorder is the most dramatic of the somatic spectrum disorders. The person loses neurological functioning in part of the body, with no underlying medical cause. The term "conversion" comes from the psychodynamic idea that psychological distress is "converted" into physical symptoms. The DSM-5 uses the more neutral label "functional neurological symptom disorder" (FNSD) to avoid presuming a psychological cause.
Symptoms include paralysis, blindness, mutism, seizures, loss of hearing, severe loss of coordination, and limb anaesthesia (e.g. glove anaesthesia, where sensation is lost in a hand in a pattern that does not correspond to nerve distribution)
Typically involves a single symptom, though a person can have repeated episodes affecting different parts of the body
About 20% of patients in neurological clinics present with symptoms that have no apparent medical cause
Prevalence of full diagnostic criteria: approximately 20 per 100,000
A. One or more symptoms of altered voluntary motor or sensory function
B. Clinical findings provide evidence of incompatibility between the symptom and recognised neurological or medical conditions
C. The symptom is not better explained by another medical or mental disorder
D. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, or warrants medical evaluation
Freud (psychodynamic): conversion symptoms result from the transfer of psychic energy attached to repressed emotions or memories into physical symptoms. Symptoms symbolise the specific concerns being repressed. This produces primary gain (anxiety reduction) and secondary gain (attention, relief from obligations)
Behavioural: conversion symptoms serve to remove the person from difficult environments and allow avoidance of unwanted responsibilities. The symptom is maintained because it is functional for the individual
Wartime evidence: conversion disorder was common during the world wars. Soldiers would become inexplicably paralysed or blind and therefore unable to return to the front. Some displayed la belle indifference, appearing unconcerned about their condition. In some cases, symptoms represented the traumas they witnessed
Modelling in children: children with conversion symptoms often mimic the symptoms of someone close to them who has a real illness
Self-hypnosis model: people with conversion disorder tend to be highly hypnotisable. This supports the idea that conversion symptoms arise from spontaneous self-hypnosis, where motor functions are dissociated from consciousness in reaction to extreme stress
Neurological models: conversion symptoms may arise when sensory or motor areas of the brain are disrupted by anxiety. Research shows impaired connectivity between motor control areas and brain regions that regulate anxiety
Treatment is difficult because patients do not believe anything is psychologically wrong.
Psychoanalytic: encourages expression of painful emotions and memories and helps the patient gain insight into the connection between those experiences and the conversion symptoms
Behavioural: focuses on relieving anxiety related to the initial trauma that triggered the symptoms and on reducing any secondary benefits the person receives from being symptomatic
The person deliberately fakes an illness to gain medical attention and play the sick role (historically called Munchausen's syndrome)
Involves providing false information or behaving deceptively to appear ill
The motivation is internal: the person wants the experience of being a patient and receiving care. There is no external reward such as money or avoiding obligations
Also known as factitious disorder by proxy
An individual falsifies or induces illness in another person, most often a child, but sometimes a pet or an elderly dependent
The caretaker gains attention and concern through the other person's apparent illness
The person fakes or exaggerates symptoms to obtain a tangible external benefit: avoiding military service, escaping criminal charges, collecting insurance, etc.
Malingering is not classified as a mental disorder
The critical distinction from factitious disorder is motivation. In factitious disorder the goal is medical attention itself. In malingering the goal is something concrete outside the medical setting
This distinction matters in forensic and legal contexts. Clinicians are sometimes asked to evaluate whether a defendant's amnesia or symptoms are genuine (a dissociative or somatic condition), factitious (internally motivated), or malingered (externally motivated). Getting this wrong has significant consequences for how a patient is treated and, in legal settings, for the outcome of a case.
Students often confuse somatic symptom disorder with illness anxiety disorder. The key: SSD involves prominent, distressing physical symptoms. IAD involves preoccupation with illness but minimal or no physical symptoms
Students often think conversion disorder means the person is faking. It does not. The symptoms are involuntary and genuinely experienced, unlike in factitious disorder or malingering
Students often assume malingering and factitious disorder are the same because both involve faking. They are not. The difference is motivation: factitious disorder is about gaining the sick role; malingering is about gaining an external reward
Students sometimes think la belle indifference is a diagnostic criterion for conversion disorder. It is not required for the diagnosis; it is an associated clinical feature that is sometimes observed
⚠️ Be able to distinguish SSD, IAD, conversion disorder, factitious disorder, and malingering from one another. Exam questions commonly present a vignette and ask you to identify which disorder is described
⚠️ Know the DSM-5 criteria for SSD, IAD, and conversion disorder. Pay particular attention to Criterion B for SSD (the three manifestations of excessive thoughts/feelings/behaviours) and Criterion B for IAD (symptoms are absent or mild)
⚠️ Understand the reinforcement cycle: catastrophising symptoms leads to stronger medication, being excused from duties, and sympathy, which reinforces the misinterpretation
⚠️ Know the difference between primary gain (anxiety reduction) and secondary gain (external benefits) in conversion disorder
⚠️ The 20% statistic appears twice: 20% of medical care seekers have IAD, and 20% of neurological clinic patients have medically unexplained symptoms
True or false: In somatic symptom disorder, the person must not have any real medical condition. False. The person may or may not have a medical condition; what matters is that the psychological response (worry, behaviours) is excessive.
Fill in the blank: The main difference between factitious disorder and malingering is ________. Motivation. Factitious disorder is motivated by the desire for medical attention; malingering is motivated by external gain.
True or false: Conversion disorder requires that a specific psychological stressor be identified as the cause. False. The DSM-5 criteria do not require identification of a psychological cause; clinical findings must show incompatibility with neurological conditions.
Fill in the blank: The term for the striking lack of concern shown by some conversion disorder patients about their symptoms is ________. La belle indifference.
True or false: Illness anxiety disorder requires prominent physical symptoms. False. Physical symptoms are absent or mild in IAD.
Q: A patient visits multiple doctors, insists she has a serious disease, and becomes very alarmed at minor bodily changes, but physical exams consistently come back normal. Which disorder is most likely?
A: Illness anxiety disorder. The defining features are preoccupation with having a serious illness, high alarm, doctor-shopping, and absent or mild physical symptoms.
Q: How does somatic symptom disorder differ from illness anxiety disorder?
A: In SSD, the person has one or more distressing physical symptoms and devotes excessive time, energy, and anxiety to them. In IAD, the person is preoccupied with having or developing a serious illness but does not have significant physical symptoms.
Q: A soldier in World War I suddenly loses the ability to move his legs after a battle, but neurological exams find nothing wrong. He appears unconcerned about this. What disorder does this describe, and what is the term for his lack of concern?
A: Conversion disorder (functional neurological symptom disorder). His apparent indifference to the paralysis is called la belle indifference.
Q: What is the reinforcement cycle that maintains somatic symptom disorder?
A: The person catastrophises symptoms, which leads to receiving stronger medication, being excused from responsibilities, and gaining sympathy. These outcomes reinforce the misinterpretation of symptoms, perpetuating the cycle.
Q: A mother repeatedly brings her child to the hospital with symptoms of illness, but the child's symptoms only appear when the mother is present and seem to be induced by the mother. What is this disorder called?
A: Factitious disorder imposed on another (factitious disorder by proxy).
Q: Name three treatment approaches for somatic symptom disorder and illness anxiety disorder, and briefly describe each.
A: (1) Psychodynamic: helps the patient connect emotional and physical symptoms by recalling triggering events. (2) Behavioural: removes reinforcements for symptoms and rewards healthy behaviour. (3) Cognitive-behavioural: identifies and challenges illness beliefs and misinterpretations of physical sensations. (Also acceptable: cognitive therapy to reduce catastrophising; antidepressants to reduce somatic symptoms.)
Q: What is the critical difference between factitious disorder and malingering?
A: Both involve deliberate symptom fabrication. In factitious disorder, the motivation is to assume the sick role and gain medical attention. In malingering, the motivation is an external reward (money, avoiding responsibility, escaping legal consequences).
This material connects directly to the dissociative disorders covered in the second half of Chapter 6 (see the companion study notes). Conversion disorder in particular overlaps conceptually with dissociation, as both involve a splitting of functions that are normally integrated (motor control, sensory awareness, consciousness).
The role of anxiety and depression in maintaining somatic symptoms links back to the mood and anxiety disorders from earlier chapters. Understanding reinforcement cycles (behavioural perspective) and cognitive distortions (cognitive perspective) from those chapters will help you make sense of the theoretical models here.
The distinction between factitious disorder and malingering is especially relevant to forensic psychology, where clinicians must assess the authenticity of reported symptoms in legal contexts.
Somatic symptom disorder, illness anxiety disorder, hypochondria, hypochondriasis, conversion disorder, functional neurological symptom disorder, FNSD, factitious disorder, Munchausen's syndrome, Munchausen by proxy, factitious disorder by proxy, factitious disorder imposed on another, malingering, pseudocyesis, false pregnancy, la belle indifference, glove anaesthesia, primary gain, secondary gain, catastrophising, doctor shopping, psychosomatic, somatoform disorders, medically unexplained symptoms, DSM-5 somatic disorders, abnormal psychology Chapter 6