Malingering, Factitious Disorder & Somatization

This is a group of illnesses where the patient reports symptoms that have no medical explanation. The patient may be deliberately misleading the physician or unaware that their complaints have no identifiable cause. Each of these is a diagnosis of exclusion, and providers should not jump to the conclusion that a patient is “faking it” unless there is sufficient evidence to suggest that, because you could potentially miss what is really causing the patients symptoms. Even Hypochondriacs and drug seekers really do get sick so even a previous history should not automatically lead to a diagnosis. However, physicians must also avoid prescribing unnecessary treatments and diagnostics tests in these patients. Possible “treatments” include scheduling periodic office visits to discuss the patients concerns, refer the patient for therapy or trying to manage current stressors that could be contributing to the problem.
Malingering, Somatoform Disorder, Munchausen, Factitious Disorder Hypochondriac


Malingering = psychiatrically healthy patient is intentionally fabricating or exaggerating symptoms for personal gain such as obtaining narcotics, legal compensation, disability payments, a lesser criminal sentence, or trying to get out of school/work/military duty. After getting what they want (sometimes called an external or secondary gain) the symptoms disappear. The symptoms may also be absent when the doctor isn’t in the room. They are generally unwilling to undergo potentially harmful/painful treatments or tests. May become irritable when providers question symptoms.


Factitious Disorder = psychiatrically unwell patient is consciously fabricating or exaggerating symptoms to get attention or sympathy from medical providers, friends, or family. This is sometimes referred to as internal or primary gain. These patients are often willing to undergo potentially harmful/painful treatment or tests. Munchausen Syndrome is a now outdated term for a severe chronic form of factitious disorder. Factitious Disorder by Proxy is when a person “fakes” symptoms in a person they care for (child or elderly) in order to get attention or sympathy.


Somatization Disorder (A type of Somatoform Disorder) = psychiatrically unwell patient unconsciously fabricates symptoms. Their symptoms have no physical cause, but they are not aware of that. They perceive their symptoms as being real. They will have multiple vague complaints across various different organ systems. Conversion Disorder is an extreme type of somatization that results in the patient suddenly losing voluntary motor and/or sensory functions during a time of stress. For example sudden paralysis, blindness or paresthesia. It looks like a stroke, but isn’t. It is usually triggered by stress and most patients spontaneously recover. Oddly many of these patients are not very concerned about their symptoms.


* In the recently released DSM V, the name Somatoform Disorders was changed to “Somatic Symptom & Related Disorder.” Also the diagnosis of Hypochondriasis was removed. Patients who previously met the criteria for Hypochondriasis would now be classified as either Somatic Symptom Disorder or Illness Anxiety Disorder.  However, it takes years for the USMLE Step 1 exam to get updated so you will likely see the old nomenclature from DSM IV.


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