Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Somatic Symptom and Related Disorders; Nonadherence to Medical Treatment (Pearls)

Psychiatry and Behavioral Health Rotation

Factitious Disorder, Illness Anxiety Disorder, and Somatic Symptom Disorder

Feature	Factitious Disorder	Illness Anxiety Disorder	Somatic Symptom Disorder
PEARLS	Factitious = faked symptoms, internal gain (e.g., attention)	Illness Anxiety = fear of illness despite little/no symptoms	Somatic Symptom = actual symptoms + excessive worry about them
Symptoms Present?	Yes or fabricated	No or minimal symptoms	Yes — real physical symptoms
Intentional?	Yes — symptoms are consciously falsified	No — fears are real, but irrational	No — symptoms are not intentionally produced
Motivation	Internal gain (desire to assume sick role)	Anxiety about having or developing illness	Excessive preoccupation with symptoms and distress
Insight	Often poor insight into deceptive behavior	Variable insight; patients believe they are ill	Poor insight; patients focus on the physical symptoms
Duration	Variable	≥6 months	≥6 months (though specific symptoms may change)
Associated Behavior	Multiple hospital visits, inconsistent history, dramatic presentation	Frequent doctor visits, health-related checking or avoidance	High health care use, multiple complaints across systems
Key Diagnostic Clue	Intentional falsification without external incentives	High health anxiety without significant physical findings	One or more symptoms + excessive health-related thoughts
Treatment	Psychotherapy; limit unnecessary medical procedures	CBT is first-line; SSRIs if comorbid anxiety/depression	CBT + regular follow-up; treat comorbid conditions

SOMATIC SYMPTOM AND RELATED DISORDERS; NONADHERENCE TO MEDICAL TREATMENT
Factitious disorder	Patient consciously reports false symptoms, or induces symptoms, with the goal of playing the "sick role A condition in which a person, without a motive for reward, acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain (for themselves or for another) a patient's role. Factitious disorder imposed on self (Munchausen syndrome) The patient falsifies physical or psychological symptoms or induces injury or disease to themselves When in another person (e.g., a child) it is termed factitious disorder imposed on another (Munchausen syndrome by proxy) Treatment: Conjoint confrontation by the PCP and the psychiatrist In factitious disorder imposed on another (e.g., in a child) Children must be removed by child protective services
Illness anxiety disorder (Hypochondriasis)	Obsession with the idea of having a serious but undiagnosed medical condition Patient's are worried about having or developing a serious illness and This preoccupation is present for at least 6 months and Is not better explained by another mental disorder (e.g., obsessive-compulsive disorder and somatic symptom disorder) Treatment: Group/insight-oriented therapy Regular appts with a provider for reassurance Medications: (SSRIs) if concurrent/underlying anxiety or major depressive disorder
Somatic symptom disorder	Preoccupation with having a serious illness More than 1 somatic symptom(s) which are distressing to the patient or leads to a significant amount of disruption in the patient's life. The patient experiences excessive thoughts, feelings, and behaviors in relation to their somatic symptoms or their health concerns. The somatic symptom must be persistent for ≥ 6 months although these symptoms don't have to always be present Treatment Have a single clinician as the designated primary caretaker Schedule monthly visits and psychotherapy Avoid unnecessary diagnostic testing unless indicated

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