Source: Abnormal Psychology, University of Florida
Tags: somatic symptom disorder, illness anxiety disorder, conversion disorder, factitious disorder, Munchausen's syndrome, functional neurological symptom disorder, hypochondriasis, somatization, health anxiety, pseudocyesis
Difficulty: Intermediate | Prerequisites: Basic understanding of anxiety, depression, and CBT concepts
Somatic symptom and related disorders sit at the intersection of mind and body. These conditions involve physical complaints or health-related anxieties that cannot be fully explained by a known medical condition, or where psychological factors play a disproportionate role in how the person experiences and responds to their symptoms. This cluster of disorders is a prime example of the fluidity between psychological distress and physical experience. Understanding them requires moving past the idea that "it's all in their head" and recognising that these patients are genuinely suffering, even when organic causes are absent.
Somatic symptom and related disorders involve excessive concern over physical health or physical symptoms that are driven largely by psychological factors. They range from chronic health worry (illness anxiety disorder) to loss of neurological function without medical cause (conversion disorder) to deliberately faking illness (factitious disorder). Treatment usually involves CBT to challenge catastrophic thinking about health, though these patients are often difficult to engage because they believe their problem is medical, not psychological.
Somatic Symptom Disorder
One or more distressing physical symptoms (pain, neurological, or other bodily symptoms) accompanied by excessive thoughts, feelings, or behaviours related to those symptoms. Health concern becomes a core feature of identity and dominates interpersonal relationships.
Think of it as: the person's life revolves around their symptoms, even when doctors say they are fine.
Illness Anxiety Disorder
Worry that one will develop or already has a serious illness, but without necessarily experiencing severe physical symptoms. Distinguished from somatic symptom disorder by the relative absence of major somatic complaints.
Think of it as: the fear of illness itself, rather than the experience of physical symptoms.
Pseudocyesis
False pregnancy. An example of a somatic symptom in which the body mimics the signs of pregnancy without an actual pregnancy occurring.
Conversion Disorder (Functional Neurological Symptom Disorder)
Loss of neurological functioning (e.g. paralysis, blindness, mutism, seizures) with no identifiable medical cause. The newer name, functional neurological symptom disorder, avoids the assumption that psychological distress is the direct cause.
Think of it as: the brain "converts" psychological distress into a loss of bodily function.
Glove Anesthesia
Loss of all sensation in one hand, as though a glove is being worn. Considered neurologically implausible because nerves do not distribute in a glove-like pattern.
La Belle Indifference
An attitude of apparent unconcern about one's symptoms, historically described in soldiers with conversion symptoms such as paralysis or blindness.
Factitious Disorder (Munchausen's Syndrome)
Deliberate fabrication or exaggeration of illness in order to assume the sick role and receive medical attention. Differs from malingering, which involves faking symptoms for an external reward (e.g. avoiding work, obtaining drugs).
Factitious Disorder Imposed on Another
Falsifying illness in another person (e.g. a parent fabricating illness in a child).
Malingering
Faking symptoms or a disorder to achieve a concrete external benefit. Not classified as a mental disorder because the motivation is external gain, not the psychological need to be seen as ill.
Primary Gain
In Freud's theory, the reduction of anxiety that comes from converting psychological distress into physical symptoms.
Secondary Gain
The external benefits a person receives from their symptoms, such as attention from others or relief from responsibilities.
Patients are excessively concerned about their symptoms and spend large amounts of time worrying and seeking treatment
May insist on unnecessary medical procedures (e.g. surgery), avoid activities for fear of worsening symptoms, and become isolated and inactive
Health concern becomes central to identity and interpersonal relationships
Fears and complaints often focus on a particular organ system
More common in older adults, possibly because earlier generations expressed sadness and depression as physical pain rather than emotional distress
Young children commonly express psychological distress through somatic complaints
Tend to be long-term and disabling, associated with higher rates of disability, low income, impaired sleep, psychological distress, high blood pressure, obesity, high cholesterol, more hospitalisations, and earlier death
Diagnosis is harder when the individual has a real but difficult-to-detect physical disorder
Easier when clear psychological factors precede symptom onset, or when physical examination shows the symptoms are not physiologically possible
Cognitive factors: dysfunctional beliefs about illness, tendency to assume serious illness is common, misinterpretation of normal bodily changes as signs of danger, belief in personal vulnerability to a wide range of illnesses, more intense experience of bodily sensations, greater attention to physical symptoms, and catastrophising
Catastrophising can trigger physiological responses (e.g. elevated heart rate), maintaining and worsening the pain cycle
Cognitive style influences how patients present to doctors and family, leading physicians to prescribe more interventions and family members to offer more sympathy, both of which reinforce the behaviour
Multiple health complaints and excessive health concerns run in families, especially among female relatives; male relatives show higher rates of alcoholism and antisocial personality disorder
Not clearly genetically transmitted; children may model parents' catastrophising and health behaviours
Parents who somatise may neglect their children, who learn that illness is the route to receiving care
Somatic symptom disorder and illness anxiety disorder may be part of PTSD, expressed through physical symptoms
Psychodynamic therapies: focus on insight into connections between emotions and physical symptoms, recalling triggering events and memories
Behaviour therapies: identify and remove reinforcements for "sickness behaviour," increase rewards for healthy behaviour; hard to convince patients they are well when they reject medical reassurance
Cognitive therapies: help patients interpret physical symptoms accurately and avoid catastrophising; approach is similar to cognitive treatment of panic disorder
Cognitive-behavioural treatments: identify and challenge illness beliefs and misinterpretations of physical sensations; shown to produce positive effects
Antidepressants can reduce somatic symptoms
Some clinicians incorporate the patient's cultural belief system and healing traditions to motivate engagement in therapy
Common symptoms: paralysis, blindness, mutism, seizures, hearing loss, severe loss of coordination, limb anaesthesia
Usually involves a single symptom, but patients can have multiple episodes affecting different parts of the body
Unexplained neurological symptoms are common in the general population, but full conversion disorder is rare
Patients are often highly hypnotisable, supporting the idea that conversion symptoms may result from a form of self-hypnosis
Freud: symptoms result from transfer of psychic energy attached to repressed emotions or memories into physical form; symptoms often symbolise the specific concern being repressed
Behavioural theories: emphasise the role symptoms play in removing the person from a distressing environment or allowing them to avoid unwanted responsibilities (e.g. soldiers whose paralysis prevented return to the front line)
Children with conversion disorder typically mimic the symptoms of someone close to them who is genuinely ill
Neuroimaging suggests that anxiety may impair connectivity in sensory or motor areas of the brain
Can be difficult to treat because patients do not believe they have a psychological problem
Psychoanalytical treatment: focuses on expressing painful emotions and memories and developing insight into their relationship with the physical symptoms
Behaviour treatment: focuses on relieving anxiety related to the initial trauma and reducing any benefits derived from the symptoms (e.g. exposure therapy, systematic desensitisation)
Person deliberately fakes illness for the purpose of receiving medical attention and assuming the sick role
Differs from somatic symptom disorder because there is evidence of deliberate fabrication or deceptive behaviour
Differs from malingering because the motivation is the sick role itself, not avoiding an obligation or gaining an external reward
Factitious disorder imposed on another: an individual falsifies illness in someone else (e.g. a caregiver fabricating a child's symptoms)
"These patients are faking it." Somatic symptom disorder and illness anxiety disorder are not the same as malingering or factitious disorder. The distress and symptoms are genuinely experienced, even if the underlying cause is psychological.
"If no medical cause is found, there is no real problem." These conditions cause significant disability, emotional suffering, and impaired functioning regardless of the absence of a detectable organic cause.
"Conversion disorder and factitious disorder are the same thing." In conversion disorder the patient genuinely experiences the loss of function; in factitious disorder the patient deliberately fabricates symptoms.
"Somatic symptom disorder and illness anxiety disorder are identical." The key distinction is that somatic symptom disorder involves prominent physical symptoms, while illness anxiety disorder centres on fear and worry about illness with fewer or milder somatic complaints.
⚠️ Know the distinctions between somatic symptom disorder, illness anxiety disorder, conversion disorder, factitious disorder, and malingering. The exam is likely to test your ability to differentiate these.
⚠️ Primary gain vs. secondary gain is a classic exam topic tied to Freud's theory of conversion.
⚠️ Glove anesthesia is the textbook example of a neurologically implausible symptom in conversion disorder.
⚠️ Be clear that factitious disorder involves deliberate deception for the sick role, while malingering involves deception for external gain.
⚠️ Cognitive-behavioural treatment has the strongest support for somatic symptom disorder and illness anxiety disorder.
True or False: Illness anxiety disorder requires the presence of severe physical symptoms.
Fill in the blank: __________ is the term for loss of sensation in a hand that follows a glove-like pattern, which is neurologically implausible.
True or False: Malingering and factitious disorder have the same underlying motivation.
Fill in the blank: In Freud's model, the reduction of anxiety achieved by converting distress into physical symptoms is called __________ gain.
True or False: Somatic symptom disorder is more common in older adults.
Q: What is the primary distinction between somatic symptom disorder and illness anxiety disorder?
A: Somatic symptom disorder involves one or more distressing physical symptoms with excessive health-related thoughts and behaviours, while illness anxiety disorder centres on worry about developing or having a serious illness but without necessarily experiencing severe physical symptoms.
Q: How does factitious disorder differ from malingering?
A: In factitious disorder, the person fabricates symptoms to assume the sick role and receive medical attention. In malingering, the person fakes symptoms to gain a concrete external benefit such as avoiding work, obtaining compensation, or escaping legal consequences.
Q: According to behavioural theories, why do conversion symptoms persist?
A: Conversion symptoms persist because they serve a functional role: they remove the individual from a distressing environment or allow avoidance of unwanted responsibilities, providing reinforcement for the symptom behaviour.
Q: What is la belle indifference, and which disorder is it associated with?
A: La belle indifference is an attitude of seeming unconcern or indifference about one's own symptoms (e.g. being unbothered by sudden paralysis). It is classically associated with conversion disorder.
Q: Name two cognitive factors that contribute to somatic symptom disorder.
A: Dysfunctional beliefs about the prevalence and seriousness of illness, and the tendency to catastrophise normal bodily sensations, interpreting them as signs of serious disease.
This material connects to anxiety disorders, particularly panic disorder, because the cognitive treatment approach (challenging catastrophic misinterpretation of bodily sensations) is essentially the same. It also links to PTSD, since somatic symptom disorder can be a manifestation of post-traumatic stress. The concept of secondary gain recurs in discussions of behavioural reinforcement across the course.
somatic symptom disorder, illness anxiety disorder, hypochondriasis, conversion disorder, functional neurological symptom disorder, factitious disorder, Munchausen syndrome, Munchausen by proxy, malingering, pseudocyesis, false pregnancy, glove anesthesia, la belle indifference, primary gain, secondary gain, somatization, health anxiety, psychosomatic, mind-body, catastrophising, sick role, PSYCH 302, abnormal psychology, exam 2