Somatic Symptom Disorder: The Daily PANCE Blueprint
A 34-year-old woman is seen for abdominal pain and fatigue that have persisted for two years. She has been evaluated by three gastroenterologists and a rheumatologist and has had two normal endoscopies, a normal colonoscopy, normal CT imaging, and repeatedly normal laboratory studies. She spends several hours a day researching her symptoms, keeps a detailed log of them, and has reduced her work hours because of the time and anxiety her health consumes. She becomes tearful describing how frightened she is that something serious is being missed. She is not fabricating or inducing her symptoms, and she is not seeking disability, opioids, or any other external gain. Physical examination is unremarkable. Which of the following is the most likely diagnosis?
A. Illness anxiety disorder
B. Factitious disorder
C. Somatic symptom disorder
D. Malingering
E. Conversion disorder
Answer and topic summary
The answer is C. Somatic symptom disorder
Distressing physical symptoms that are real to the patient, lasting more than six months, combined with disproportionate thoughts, feelings, and behaviors about them, is somatic symptom disorder. The single most important shift in DSM-5 is worth stating plainly: the diagnosis no longer requires that the symptoms be medically unexplained. The old framework asked you to prove a negative and left patients feeling accused of making it up. The current criteria are positive ones — the excessive time, energy, anxiety, and health-related behavior are what define the disorder — and a patient with genuine diabetes or migraine can carry this diagnosis alongside it. That is why her hours of daily research and her reorganized work life matter more to the diagnosis than her normal endoscopies. Two features separate this from everything else on the list, and both hinge on intent. Her symptoms are not consciously produced, and there is no external incentive — no disability claim, no controlled substance, no escape from obligation. Management is where most students lose points. The goal is not to convince her nothing is wrong, and it is not to keep testing until she is reassured, because each new negative test buys shorter and shorter relief while reinforcing the search. Instead: establish care with one primary provider, schedule regular brief visits on a fixed interval rather than symptom-triggered ones so that access is not contingent on being sick, perform a focused examination each visit, and limit new testing to genuine clinical indications. Legitimize the suffering explicitly — the pain is real, whatever the imaging shows — and shift the goal from cure to function. Cognitive behavioral therapy has the best evidence, and treating comorbid depression or anxiety, often with an SSRI, helps substantially. Now the distinctions, which the boards test relentlessly. Illness anxiety disorder is preoccupation with having or acquiring a serious disease with minimal or absent somatic symptoms — the fear itself is the complaint, whereas her pain and fatigue are prominent. Factitious disorder involves intentionally falsifying or inducing signs and symptoms to assume the sick role, with no external reward. Malingering is also intentional but driven by an obvious external incentive such as money, drugs, or avoiding work or prosecution, and it is not a psychiatric diagnosis. Conversion disorder, or functional neurological symptom disorder, produces neurologic deficits — weakness, nonepileptic seizures, blindness — that are internally inconsistent on examination, such as Hoover sign, and are not intentionally produced.
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