These disorders center on physical symptoms or health concerns accompanied by significant distress and impairment. In DSM-5-TR the diagnosis rests on positive features — excessive thoughts, feelings, and behaviors about symptoms, or clinical findings of a functional neurological disorder — not simply on the absence of a medical explanation. A person can have a somatic symptom disorder and a diagnosed medical illness at the same time.
Contributing factors
- Biological: heightened attention to and amplification of body sensations; altered central pain and interoceptive processing; genetic vulnerability
- Psychological: catastrophic interpretation of sensations, health anxiety, childhood adversity, difficulty identifying and expressing emotions (alexithymia), comorbid depression and anxiety
- Social and learned: illness modeling in the family; reinforcement of the sick role; cultural norms that make physical complaints more acceptable than emotional distress
- Primary gain: relief of internal anxiety or conflict by the symptom. Secondary gain: psychological or environmental benefits obtained because of the symptom (attention, sympathy, avoidance of duties or conflict, relief from work)
DSM-5-TR disorders
| Disorder | Key features |
|---|
| Somatic symptom disorder (SSD) | ≥ 1 distressing somatic symptom plus excessive thoughts, feelings, or behaviors (disproportionate worry about seriousness, persistent high anxiety about health, or excessive time and energy devoted to symptoms); symptomatic state typically more than 6 months. Specifier: with predominant pain (replaces the former "pain disorder") |
| Illness anxiety disorder | Preoccupation with having or acquiring a serious illness; somatic symptoms absent or mild; high health anxiety; excessive checking or maladaptive avoidance; ≥ 6 months. Types: care-seeking or care-avoidant |
| Functional neurological symptom disorder (conversion disorder) | ≥ 1 symptom of altered voluntary motor or sensory function (weakness or paralysis, abnormal movements, gait disorder, functional seizures, swallowing or speech symptoms, anesthesia, visual loss) with clinical findings showing incompatibility with recognized neurological disease. An identifiable psychological stressor is not required |
| Psychological factors affecting other medical conditions | Behavioral or psychological factors worsen a medical illness (e.g., denial of chest pain, stress-triggered asthma) |
| Factitious disorder | Deliberate falsification or induction of signs or symptoms, without obvious external reward, to assume the sick role. Imposed on self or imposed on another (usually a caregiver fabricating illness in a child — the perpetrator receives the diagnosis) |
| Other specified / unspecified | Includes pseudocyesis (false belief of pregnancy with signs of pregnancy) |
"Hypochondriasis" was retired in DSM-5 — people with prominent somatic symptoms are diagnosed with SSD and those without with illness anxiety disorder. Body dysmorphic disorder belongs to the obsessive-compulsive and related disorders.
Malingering is not a mental disorder: symptoms are intentionally produced for external incentives (money, avoiding work or prosecution, obtaining drugs).
| Symptom production | Motivation |
|---|
| SSD, illness anxiety, functional neurological disorder | Not intentional | Not deliberate |
| Factitious disorder | Intentional | Internal — to be seen as ill |
| Malingering | Intentional | External reward |
- Detailed symptom history, effect of symptoms on daily functioning, work, and relationships (priority assessment — care focuses on function)
- Frequent visits, multiple providers ("doctor shopping"), repeated tests, and requests for more testing; or, in care-avoidant illness anxiety, avoidance of all medical care
- Health anxiety, catastrophic thinking, body checking, internet searching for symptoms
- Depression, anxiety, suicidal ideation, substance use (including prescribed opioids and sedatives)
- Family responses that may reinforce symptoms
- Functional neurological disorder: onset may be sudden; "la belle indifference" (apparent lack of concern) is not reliable for diagnosis and also occurs in neurological disease
- Factitious disorder clues: dramatic but inconsistent history, symptoms only when observed, unexplained laboratory findings (e.g., hypoglycemia with exogenous insulin), eagerness for invasive procedures, extensive medical knowledge, many hospitals. Imposed on another: a child's symptoms occur only in the caregiver's presence and resolve with separation
| Test / tool | Use |
|---|
| Appropriate medical workup | Exclude and treat medical disease; new or changed symptoms always need assessment — people with somatic disorders also develop physical illness |
| Patient Health Questionnaire-15 (PHQ-15); Somatic Symptom Scale-8 | Somatic symptom burden |
| Short Health Anxiety Inventory; Whiteley Index | Health anxiety |
| Video-EEG monitoring | Gold standard to distinguish functional (psychogenic nonepileptic) seizures from epileptic seizures |
| Neurological signs of FND | Hoover's sign (weak voluntary hip extension on the affected side becomes normal when the client flexes the opposite hip against resistance), give-way weakness, tremor that entrains to another rhythm, eyes forcibly closed during a seizure-like event, side-to-side head movement, asynchronous limb movements |
| Covert video surveillance, toxicology, medical record review | Suspected factitious disorder (per institutional policy and legal advice) |
- One consistent primary care provider with regularly scheduled visits (not only when symptoms worsen) — reduces crisis visits and unnecessary testing
- Validate symptoms as real; explain findings clearly; order tests based on objective findings rather than to reassure
- Cognitive behavioral therapy — the best-supported psychotherapy for SSD and illness anxiety disorder: challenges catastrophic beliefs about symptoms, reduces checking and reassurance-seeking, increases activity
- Functional neurological disorder: a clear, positive explanation of the diagnosis ("your nervous system is not sending and receiving signals correctly; this is common and can improve"), specialized physiotherapy focused on retraining movement, occupational and speech therapy, and CBT-based psychotherapy for functional seizures
- Medications: SSRIs or SNRIs for comorbid depression, anxiety, or health anxiety; duloxetine or tricyclics for pain-predominant presentations. Standard antidepressant safety applies — suicidality warning under 25, serotonin syndrome, hyponatremia, BP elevation with SNRIs, anticholinergic and cardiac effects of tricyclics. Avoid long-term opioids and benzodiazepines (dependence, worsening function)
- Factitious disorder: nonpunitive team confrontation with a consistent plan; treat comorbid conditions; prevent unnecessary procedures. Factitious disorder imposed on another is child (or dependent adult) maltreatment — protect the victim and report
Listed in priority order.
- Assess and rule out physical causes — assess every new or changed complaint objectively; never assume symptoms are "all psychological"; monitor for suicidal ideation
- Establish a therapeutic, accepting relationship
- Acknowledge that the symptoms and distress are real ("I can see how much this pain is affecting you. Let's work out ways to manage it together")
- Never tell the client symptoms are fake or "in your head"; avoid arguing or minimizing
- Focus on function, not on symptoms
- After symptoms are assessed, limit time spent discussing them and shift conversation to feelings, stressors, and daily activities
- Give attention and praise for healthy behaviors and participation in activities rather than for complaints (reduces secondary gain)
- Set realistic goals: increase functioning with symptoms, not total symptom elimination
- Functional neurological disorder — after organic disease is excluded, encourage gradual, active participation in physiotherapy and self-care; do not do everything for the client, keep the client on bed rest, or force the client to walk; avoid drawing attention to the deficit
- Illness anxiety — empathize with the worry, then agree on a structured plan of scheduled follow-up visits; avoid repeated reassurance and unplanned testing; teach alternatives to body checking
- Teach coping skills — relaxation, assertive expression of needs and feelings, problem-solving, regular exercise, stress management
- Factitious disorder — document objectively, share observations with the team, maintain consistent limits, and follow abuse reporting requirements when another person is harmed
Common nursing diagnoses: ineffective coping; chronic pain; anxiety; impaired physical mobility (FND); ineffective health self-management.
- Symptoms are real; stress and emotions can strongly affect how the body feels and works
- Keep regular appointments with one main provider; report new or different symptoms rather than seeking many providers
- Track activity and mood, not just symptoms; gradually increase activity and exercise
- Learn relaxation and breathing methods; practice them daily
- Limit internet symptom searching and body checking
- Take antidepressants as prescribed; they take weeks to help and should not be stopped abruptly
- Avoid relying on opioids, sedatives, or alcohol for symptom relief
- Family: acknowledge the person's distress but avoid frequent questioning and long discussions about symptoms; praise and share healthy activities; support keeping regular appointments
| Complication | What to watch for |
|---|
| Missed medical illness | New, changed, or objective findings dismissed as psychological |
| Iatrogenic harm | Repeated imaging, invasive procedures, surgery, medication adverse effects |
| Opioid or sedative dependence | Escalating requests, multiple prescribers |
| Suicide | Comorbid depression, chronic pain, hopelessness |
| Disability, deconditioning | Prolonged bed rest, loss of role functioning |
| Harm to a child or dependent | Factitious disorder imposed on another |
| Self-injury, infection, death | Induced illness in factitious disorder |
- SSD = distressing symptom(s) + excessive thoughts, feelings, or behaviors, usually more than 6 months; can coexist with medical disease
- Illness anxiety disorder = fear of having a serious illness with minimal symptoms; care-seeking or care-avoidant
- Former "pain disorder" → SSD with predominant pain; "hypochondriasis" retired
- FND (conversion) = motor or sensory symptoms incompatible with neurological disease; stressor not required; la belle indifference is unreliable
- Nursing goal = improve functioning despite symptoms
- Acknowledge symptoms as real; never call them fake
- After assessment, shift focus from symptoms to feelings and activities; reward healthy behavior
- Secondary gain = benefits from being ill (attention, avoiding duties)
- One consistent provider, scheduled visits, CBT
- Factitious = intentional, internal motive; malingering = intentional, external reward
- Factitious disorder imposed on another = abuse — report
- Always assess new symptoms objectively
Country Notes
United States
- Factitious disorder imposed on a child must be reported to child protective services under state mandatory reporting laws.
- Prescription drug monitoring programs help identify multiple prescribers of controlled substances.
Philippines
- The Mental Health Act (Republic Act 11036, 2018) requires written informed consent for treatment and protects confidentiality of mental health information.
- The NCMH Crisis Hotline (1553 from landlines) is available 24 hours for clients with suicidal thoughts; check the NCMH website for the mobile numbers.