Psychiatry and Behavioral Health Rotation

Patient consciously reports false symptoms, or induces symptoms, with the goal of playing the "sick role"

• Deliberate production or feigning of illness without external incentive — vs malingering: feigned for external gain (money, work excuse, drugs); malingering is not a mental disorder
• Munchausen syndrome = chronic, dramatic factitious disorder imposed on self
• ⚠️ Imposed on another (e.g., a child — Munchausen by proxy) is child abuse — report and protect the child

DX: DSM-5 — falsification of physical or psychological signs/symptoms, or induction of injury or disease, associated with identified deception

• Presents self (or another) as ill, impaired, or injured; deception occurs even in the absence of external rewards
• Not better explained by another mental disorder (e.g., delusional disorder)

TX: Nonconfrontational, supportive approach — a single PCP coordinating with psychiatry

• Minimize unnecessary tests and procedures; treat comorbid psychiatric illness
• Imposed on another: ensure the child's safety via child protective services

Neurologic symptoms incompatible with recognized disease — diagnosed by positive rule-in signs, NOT by exclusion

• Rule-in signs: Hoover sign · tremor entrainment · eyes-closed resistance during a "seizure"; normal video-EEG during an event is the gold standard for nonepileptic spells
• Symptoms are real and involuntary — this is not faking; "la belle indifférence" is classic exam flavor but unreliable
• Screen for comorbid depression, anxiety, PTSD, and coexisting neurologic disease

DX: DSM-5 — ≥ 1 symptom of altered voluntary motor or sensory function

• Clinical findings demonstrate incompatibility between the symptom and recognized neurologic/medical conditions — the positive rule-in requirement
• Specify symptom type; acute (< 6 months) vs persistent (≥ 6 months); a stressor is common but no longer required

TX: Deliver the diagnosis positively — name it, explain it is real, common, and reversible, and show the patient their own rule-in signs

• Physical therapy for motor symptoms; CBT for nonepileptic spells and sensory symptoms; treat comorbid mood disease
• Avoid repeated negative workups and "there's nothing wrong with you" — both entrench symptoms

Obsession with the idea of having a serious but undiagnosed medical condition — with few or no actual somatic symptoms

• Excessive health behaviors (body checking, doctor shopping) or maladaptive avoidance of care
• vs somatic symptom disorder: there, distressing physical symptoms dominate the picture

DX: DSM-5 — preoccupation with having or acquiring a serious illness for ≥ 6 months, with somatic symptoms mild or absent

• Specify care-seeking vs care-avoidant type
• Not better explained by another mental disorder (OCD, somatic symptom disorder, GAD)

TX: Regularly scheduled visits with a single provider

• CBT first-line; SSRI for comorbid anxiety or depression
• Avoid unnecessary diagnostic testing — it reinforces the cycle

≥ 1 distressing physical symptom + excessive thoughts, feelings, or behaviors about it

• The symptoms are real to the patient — the disorder is the disproportionate response to them
• vs illness anxiety disorder: there, the anxiety is about having a disease with minimal somatic symptoms

DX: DSM-5 — ≥ 1 distressing or disruptive somatic symptom plus ≥ 1 of: disproportionate persistent thoughts · persistently high health anxiety · excessive time and energy devoted to the symptoms

• Persistently symptomatic state, typically > 6 months — the specific symptom may shift
• Specify: with predominant pain; severity by number of criterion-B symptoms

TX: A single clinician with regularly scheduled short visits + CBT

• Avoid unnecessary testing unless clearly indicated
• Treat comorbid depression and anxiety