rior to beginning work on this discussion, please read Chapters 8, 12, and 13 in DSM 5 Made Easy: The Clinician’s Guide to Diagnosis; Chapter 2 in Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises; Chapter 5 in The Psychiatric Interview: Evaluation and Diagnosis; all required articles; and review the PSY645 Fictional Sociocultural Case Studies (Links to an external site.)Links to an external site. document.

One of the most important aspects of developing competence in psychopathology is to be as honestly and completely aware as possible of your personal attitudes toward people who have mental health conditions. Through this awareness, we are better able to challenge our own biases and prejudicial views in order to be more open to the findings within scholarly research.

For your initial post in this discussion, choose one of the three case studies from the PSY645 Fictional Sociocultural Case Studies (Links to an external site.)Links to an external site. document, and write a detailed description of your uncensored personal observation of the patient depicted. Describe at least one theoretical orientation you would use to conceptualize your view of the patient’s problem and how it may have developed. Identify the issues you might focus on in treatment with this patient. Be sure to identify within your post which of the three case studies you have chosen.

CHAPTER 8

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: The Guilford Press.

Somatic Symptom and Related Disorders

Quick Guide to the Somatic Symptom and Related Disorders

When somatic (body) symptoms are a prominent reason for evaluation by a clinician, the diagnosis will often be one of the disorders (or categories) listed below. As usual, the link indicates where a more detailed discussion begins.

Primary Somatic Symptom Disorders

Somatic symptom disorder . Formerly called somatization disorder, this chronic condition is characterized by unexplained physical symptoms. It is found almost exclusively in women.

Somatic symptom disorder, with predominant pain . The pain in question has no apparent physical or physiological basis, or it far exceeds the usual expectations, given the patient’s actual physical condition.

Conversion disorder (functional neurological symptom disorder) . These patients complain of isolated symptoms that seem to have no physical cause.

Illness anxiety disorder . Formerly called hypochondriasis, this is a disorder in which physically healthy people have an unfounded fear of a serious, often life-threatening illness such as cancer or heart disease—but little in the way of somatic symptoms.

Psychological factors affecting other medical conditions . A patient’s mental or emotional issues influence the course or care of a medical disorder.

Factitious disorder imposed on self . Patients who want to occupy the sick role (perhaps they enjoy the attention of being in a hospital) consciously fabricate symptoms to attract attention from health care professionals.

Factitious disorder imposed on another . A person induces symptoms in someone else, often a child, possibly for the purpose of gaining attention.

Other specified, or unspecified, somatic symptom and related disorder . These are catch-all categories for patients whose somatic symptoms fail to meet criteria for any better-defined disorder.

Other Causes of Somatic Complaints

Actual physical illness. Psychological causes for physical symptoms should be considered only after physical disorders have been eliminated.

Mood disorders . Pain with no apparent physical cause is characteristic of some patients with major depressive disorder and bipolar I disorder, current or most recent episode depressed. Because they are treatable and potentially life-threatening, these possibilities must be investigated early.

Substance use . Patients who use substances may complain of pain or other physical symptoms. These may result from the effects of substance intoxication or withdrawal.

Adjustment disorder . Some patients who are experiencing a reaction to environmental circumstances will complain of pain or other somatic symptoms.

Malingering . These patients know that their somatic (or psychological) symptoms are fabricated, and their motive is some form of material gain, such as avoiding punishment or work, or obtaining money or drugs.

INTRODUCTION

For centuries, clinicians have recognized that physical symptoms and concerns about health can have emotional origins. DSM-III and its successors have gathered several alternatives to organic diagnoses under one umbrella. Collectively, these are now called the somatic symptom and related disorders, because their presentations resemble somatic (bodily) disease. Like so many other groups of disorders discussed in this book, these conditions are not bound together by common etiologies, family histories, treatments, or other factors. This chapter is simply another convenient collection—in this case, of conditions that are concerned primarily with physical symptoms.

Several sorts of problems can suggest somatic symptom disorder. These include the following:

•  Pain that is excessive or chronic

•  Conversion symptoms (see sidebar below)

•  Chronic, multiple symptoms that seem to lack an adequate explanation

•  Complaints that don’t improve, despite treatment that helps most patients

•  Excessive concern with health or body appearance

Patients with somatic symptom and related disorders have usually been evaluated (perhaps many times) for physical illness. These evaluations often lead to testing and treatments that are expensive, time-consuming, ineffective, and sometimes dangerous. The result of such treatment may be only to reinforce the patients’ fearful belief in some nonexistent medical illness. At some point, health care personnel recognize that whatever is wrong has strong emotional underpinnings, and refer these patients for mental health evaluation.

It is important to acknowledge that, with the obvious exception of factitious disorder, these patients are not faking their symptoms. Rather, they often believe that they have something seriously wrong; this belief can cause them enormous anxiety and impairment. Without meaning to, they inflict great suffering on themselves and on those around them.

On the other hand, we must also remember that the mere presence of a somatic symptom disorder does not ensure against the subsequent development of another medical condition. These patients can also develop other forms of mental disturbance.

F45.1 [300.82] Somatic Symptom Disorder

The DSM-5 criteria for somatic symptom disorder (SSD) require only a single somatic symptom, but it must cause distress or markedly impair the patient’s functioning. Nonetheless, the classical patient has a pattern of multiple physical and emotional symptoms that can affect various (often many) areas of the body, including pain symptoms, problems with breathing or heartbeat, abdominal complaints, and/or menstrual disorders. Of course, conversion symptoms (body dysfunctioning such as paralysis or blindness that has no anatomical or physiological cause) may also be encountered. Treatment that usually helps symptoms that are caused by actual physical disease is usually ineffective in the long run for these patients.

SSD* begins early in life, usually in the teens or early 20s, and can last for many years—perhaps the patient’s entire lifetime. Often overlooked by health care professionals, this condition affects about 1% of all women; it occurs less often in men, though the actual ratio is unknown, considering that the definition of SSD has only just been written. SSD may account for 7–8% of mental health clinic patients and perhaps nearly that percentage of hospitalized mental health patients. It has a strong tendency to run in families. Transmission is probably both genetic and environmental; SSD may be more frequent in patients with low socioeconomic status and less education.

Half or more of patients with SSD have anxiety and mood symptoms. There is an ever-present danger that clinicians will diagnose an anxiety or mood disorder and ignore the underlying SSD. Then the all-too-common result is that the patient receives treatment specific for the mood or anxiety disorder, rather than an approach that might actually address the underlying SSD.

Essential Features of Somatic Symptom Disorder

Concern about one or more somatic symptoms leads the patient to express a high level of health anxiety by investing excessive time in health care or being excessively worried as to the seriousness of symptoms.

The Fine Print

The D’s: • Duration (6+ months) • Differential diagnosis (DSM-5 does not state one; I would cite substance use and physical disorders, mood or anxiety disorders, psychotic or stress disorders, dissociative disorders)

Coding Notes

Specify if:

With predominant pain. For patients who complain mainly of pain. See the additional discussion on page 257.

Persistent. If the course is marked by serious symptoms, lots of impairment, and a duration greater than 6 months.

Consider the following behaviors related to seriousness of patient’s symptoms: excessive thoughts, persistent high anxiety, excessive energy/time expended. Now rate severity:

Mild. One of these behaviors.

Moderate. 2+.

Severe. 2+, along with numerous somatic complaints (or one extremely severe complaint).

In my own professional lifetime, this mental disorder has borne four different names. Hysteria was created over 2,000 years ago by the Greeks, who famously believed that its symptoms arose from a uterus that wandered throughout the body, producing pain or stopping the breath or clogging the throat. That ancient term remained in use until the middle of the 20th century, when it received a new label and a more complicated definition.

Briquet syndrome was coined to honor the 19th-century French physician who first described the disorder’s typical polysymptomatic presentation. For diagnosis, it required 25 symptoms (of a possible 60), each of which the clinician had to determine to be unsubstantiated by physical or laboratory examination. The list included pseudoneurological symptoms (such as temporary blindness and aphonia), but also emotional symptoms such as depression, anxiety attacks, and hallucinations—plus a lot more.

Twenty-five symptoms were just too many for some clinicians. In 1980, the authors of DSM-III devised the term somatization disorder to highlight new criteria that reduced the number of symptoms, along the way discarding all the mental and emotional symptoms from the Briquet symptoms list. DSM-III-R and DSM-IV further redefined and shortened the list (“dumbed it down,” some would say). The Briquet symptoms yielded excellent results in terms of isolating a group of patients who later did not turn out to have actual physical disease and who responded well to psychological and behavioral treatment. Even with the simpler somatization disorder symptoms, however, few patients were ever diagnosed; perhaps clinicians didn’t want to take the trouble, or perhaps the symptoms were simply too restrictive for practical purposes.

Now, with SSD, we are back where we started: A single symptom, attended by a certain degree of concern on the part of the patient, will suffice for a DSM-5 diagnosis. It is noteworthy that as the names have progressively lengthened, the criteria sets have been getting shorter—with the obvious exception of hysteria itself, which was a seat-of-the-pants diagnosis that entailed identifying but a single symptom, often of the pseudoneurological “conversion” type. It remains to be seen how well the DSM-5 criteria for SSD will discriminate these patients from those with other diagnoses in the somatic symptoms and related disorders group, and from patients with physical illness. But I fear that we really may have truly come full circle, to the point where we are once again in danger of misidentifying people whose symptoms are perplexing, even mysterious, but which may well presage ultimate physical disease.

There’s one other issue that deserves our scrutiny: Nowhere do the DSM-5 criteria require that other causes of the patient’s symptoms be ruled out. That places the SSD criteria in select company (intellectual disability, personality disorders, substance use disorders, anorexia nervosa, and the paraphilic disorders) as requiring no consideration of a differential diagnosis.

Here’s the bottom line. I can indeed make this part of DSM-5 truly easy: Other than for the pain specifier, don’t use it! Until the data are in that persuade me SSD is a useful concept that promotes the wellbeing of my patients, I will personally continue to use either the old DSM-IV somatization disorder guidelines (see the next sidebar) or the even older Briquet syndrome criteria. And here’s my guarantee: Any patient diagnosed by either of these standards will also qualify for a diagnosis of DSM-5 SSD.

Cynthia Fowler

When Cynthia Fowler told her story, she cried. At age 35, she was talking with the most recent in her series of health care professionals. Her history was a complicated one; it began in her mid-teens with arthritis that seemed to move from one joint to another. She had been told that these were “growing pains,” but the symptoms had continued to come and go over the intervening 20 years. Although she was subsequently diagnosed as having various types of arthritis, laboratory tests never substantiated any of them. A long succession of treatments had proven fruitless.

In her mid-20s, Cynthia was evaluated for left flank pain, but again nothing was found. Later, abdominal pain and vomiting spells were worked up with gastroscopy and barium X-rays. Each of these studies was normal. A histamine antagonist was added to her growing list of medications, which by now included various anti-inflammatory agents, as well as prescription and over-the-counter analgesics.

Cynthia had thought at one time that many of her symptoms were aggravated by her premenstrual syndrome, which she had recognized in herself after reading about it in a women’s magazine. She had invariably been irritable with cramps before her period, which used to be so heavy that she would sometimes stay in bed for several days. When she was 26, therefore, she’d had a total hysterectomy. Six months later, persistent vomiting led to endoscopy; other than adhesions, no abnormalities were found. Alternating diarrhea and constipation then caused her to experiment with a series of preparations to regulate her bowel movements.

When she was questioned about sex, Cynthia shifted uncomfortably in her chair. She didn’t care much for it and had never experienced a climax. Her lack of interest was no problem to her, though each of her three husbands had complained a lot. When she was a young teenager, something sexual might have happened to her, she finally admitted, but that was a part of her life she really couldn’t recall. “It’s as if someone cut a whole year out of my diary,” she explained.

When she was 2 and her brother was 6 months old, Cynthia’s father had deserted the family. Her mother subsequently worked as a waitress and lived with a succession of men, some of whom she married. When Cynthia was 12, her mother escaped from one of Cynthia’s stepfathers; she then placed the two children in foster care.

One way or another, each of Cynthia’s former clinicians had disappointed her. “None of the others knew how to help me. But I just know you’ll find out what’s wrong. Everyone says you’re the best in town.” Through her tears, she managed a confident smile.

Evaluation of Cynthia Fowler

At a glance, we can affirm that Cynthia had distressing somatic symptoms (criterion A) that for years (C) had occupied a great deal of time and effort (B). That, in essence, earns her a DSM-5 diagnosis of SSD. However, I’d prefer to analyze her condition in light of the old DSM-IV somatization disorder guidelines (see the next sidebar).

Cynthia needed to have at least eight symptoms across the four symptom areas, and she did: pain (abdominal, flank, joint, and menstrual); gastrointestinal (diarrhea, vomiting); sexual (excessive menstrual bleeding, sexual indifference); and a lone pseudoneurological symptom (amnesia). The DSM-IV criteria require that these symptoms not be explainable on the basis of physical disease, and that they impair the patient’s functioning in some way—I don’t think I’ll get much disagreement there, either. They started well before she turned 30, and there is nothing to suggest that she was intentionally feigning them. Q.E.D.

Even so, as with nearly every mental disorder, another medical condition is the first possibility that I would seek to rule out. Among the medical and neurological disorders to consider are multiple sclerosis, spinal cord tumors, and diseases of the heart and lungs. Cynthia had already been worked up for a variety of medical conditions and had been prescribed multiple medications, none of which had done her much good. Judging by the last paragraph of the vignette, her previous clinicians might have been at a loss to diagnose or treat her effectively.

Setting Cynthia’s experience apart from patients with actual physical disease are (1) the number and variety of the symptoms (though neither is required by SSD criterion A); (2) the absence of an adequate explanation for the symptoms based on history, lab findings, or physical examination; and (3) inadequate relief from treatments that are ordinarily helpful for the symptoms in question. Note once again that although the SSD criteria allow a diagnosis based on far fewer symptoms than Cynthia had, her history is typical of a group of patients whom clinicians have been attempting to help for millennia.

Certain other somatic symptom and related disorders require discussion. In SSD with predominant pain, the patient focuses on severe, sometimes incapacitating somatic pain. Although Cynthia complained of pain in a variety of locations, it was only one aspect of a much broader picture of somatic illness. Patients with illness anxiety disorder (formerly hypochondriasis) can have multiple physical symptoms, but their concern focuses on the fear of having a specific physical disease, not, as with Cynthia, particular symptoms. Cynthia did not have any classical physical conversion symptoms (e.g., stocking or glove anesthesia, hemiparalysis), but many patients with SSD do. Then conversion disorder (functional neurological symptom disorder) enters the differential diagnosis. However, as with SSD with predominant pain, conversion disorder should not be diagnosed in any patient who fulfills criteria for the more encompassing SSD. In addition, Cynthia’s amnesia might qualify for the diagnosis of dissociative amnesia if it were the predominant problem.

You should always inquire carefully about substance-related disorders, which are found in one-quarter or more of patients with SSD. And when patients come to the attention of mental health providers, it is often because of a concomitant mood disorder or anxiety disorder.

Many patients with SSD also have one or more personality disorders. Especially prevalent is histrionic personality disorder, though borderline and antisocial personality disorders may also be diagnosed. Cynthia’s words to the clinician in the last paragraph suggest a personality disorder, but with insufficient information, I’d defer that diagnosis for now. There’s no way to code it out, so I would mention “possible personality disorder,” or some such verbiage, in my summary.

With a GAF score of 61, Cynthia’s current diagnosis would read as follows:

F45.1 [300.82]

Somatic symptom disorder

Here’s an outline of the DSM-IV somatization disorder (SD):

•  From an early age, these patients have numerous physical complaints that wax and wane, with new ones often beginning as old ones resolve. With treatment typically ineffective, patients tend to switch health care providers in search of cure.

•  The wide variety of possible symptoms fall into several groups.

•  Pain (several different sites are required): in the head, back, chest, abdomen, joints, arms or legs, or genitals; or related to body functions, such as urination, menstruation, or sexual intercourse

•  Gastrointestinal (other than pain): bloating, constipation, diarrhea, nausea, vomiting spells (except during pregnancy), or intolerance of several foods (nominally, three or more)

•  Sexual or reproductive systems (other than pain): difficulty with erection or ejaculation, irregular menses, excessive menstrual flow, or vomiting that persists throughout pregnancy

•  Pseudoneurological (not pain): blindness, deafness, double vision, lump in throat or trouble swallowing, inability to speak, poor balance or coordination, weak or paralyzed muscles, retention of urine, hallucinations, numbness to touch or pain, seizures, amnesia (or any other dissociative symptom), or loss of consciousness (other than fainting)

•  The typical patient will have eight or more symptoms, with four (or more) from the pain group, two from the gastrointestinal group, and at least one each from the other two groups. Most patients will have far more symptoms than eight. Symptoms require treatment or impair social, personal, or occupational functioning.

•  DSM-IV required an onset by age 30, but most patients have been ill from their teens or early 20s on. SD symptoms must be unexplained by any medical condition (including substance misuse). Patients who also have actual physical illnesses often react to them with greater anxiety than you might expect.

•  Of course, actual physical illness should be first on the list of differential diagnoses. And, because SD can be difficult to treat, there are many other mental and emotional disorders that need to be ruled out. These include mood or anxiety disorders, psychotic disorders, and dissociative or stress disorders. Substance use disorders can be comorbid with SD. I would include factitious disorder and malingering on the differential list, but these belong very near the bottom.

With Predominant Pain Specifier for Somatic Symptom Disorder

Some patients with SSD experience mainly pain, in which case the specifier with predominant pain is indicated. DSM-IV called it pain disorder, an independent condition with its own criteria. (From here on, I refer to it as SSD–Pain.) Whatever we call it, we need to keep in mind these facts:

•  Pain is subjective—individuals experience it differently.

•  There is no gross anatomical pathology.

•  Measuring pain is hard.

So it’s hard to know that a patient who complains of chronic or excruciating pain, and apparently lacks adequate objective pathology, has a mental disorder at all. (In DSM-5, patients who have actual pain but show excessive concern can be diagnosed with SSD–Pain.)

The pain in question is usually chronic and often severe. It can take many forms, but especially common is pain in the lower back, head, pelvis, or temporomandibular joint. Typically, SSD–Pain doesn’t wax and wane with time and doesn’t diminish with distraction; it may respond only poorly to analgesics, if at all.

Chronic pain interferes with cognition, causing people to have trouble with memory, concentration, and completing tasks. It is often associated with depression, anxiety, and low self-esteem; sleep may be disturbed. Such patients may experience slower response to stimuli; fear of worsening pain may reduce their physical activity. Of course, work suffers. In over half the cases, chronic pain is managed inadequately by clinicians.

SSD–Pain usually begins in the 30s or 40s, often following an accident or some other physical illness. It is more often diagnosed in women than in men. As its duration extends, it often leads to increasing incapacity for work and social life, and sometimes to complete invalidism. Although some form of pain affects many adults in the general population—perhaps as high as 30% in the United States—no one knows for sure the prevalence of SSD–Pain.

Ruby Bissell

Ruby Bissell placed a hand on each chair arm and shifted uncomfortably. She had been talking for nearly half an hour, and the dull, constant ache had worsened. Pushing up with both hands, she hoisted herself to her feet. She winced as she pressed a fist into the small of her back; the furrows on her face added a decade to her 45 years.

Although Ruby had had this problem for nearly 6 years, she wasn’t sure exactly when it began. It could have started when she helped to move a patient from the operating table to a gurney. But the first orthopedist she ever consulted explained that her pulled ligament was mild, so she continued to work as an operating room nurse for nearly a year. Her back hurt whether she was sitting or standing, so she’d had to resign from her job; she couldn’t maintain any physical position longer than a few minutes at a time.

“They let me do supervisory work for a while,” she said, “but I had to quit that, too. My only choices were sitting or standing, and I have to spend part of each hour flat on my back.”

From her solidly blue-collar parents, Ruby had inherited a work ethic. She’d supported herself from the age of 17, so her forced retirement had been a blow. But she couldn’t say she felt depressed about it. In fact, she had never been very introspective about her feelings and couldn’t really explain how she felt about many things. She did deny ever having hallucinations or delusions; aside from her back pain, her physical health had been good. Although she occasionally awakened at night with back pain, she had no real insomnia; appetite and weight had been normal. When the interviewer asked whether she had ever had death wishes or suicidal ideas, she was a little offended and strongly denied them.

A variety of treatments had made little difference in Ruby’s condition. Pain medication provided almost no relief at all, and she had quit them all before she could get hooked. Physical therapy made her hurt all the more, and an electrical stimulation unit seemed to burn her skin.

A neurosurgeon had found no anatomical pathology and explained to Ruby that a laminectomy and spinal fusion were unlikely to improve matters. Her own husband’s experience had caused her to distrust any surgical intervention. He had been injured in a trucking accident a year before her own difficulty began; his subsequent laminectomy had left him not only disabled for work, but impotent. With no children to support, the two lived in reasonable comfort on their combined disability incomes.

“Mostly we just stay at home,” Ruby remarked. “We care a lot for each other. Our relationship is the one part of my life that’s really good.”

The interviewer asked whether they were still able to have any sort of a sex life. Ruby admitted that they did not. “We used to be very active, and I enjoyed it a lot. After his accident, and he couldn’t perform, Gregory felt terribly guilty that he couldn’t satisfy me. Now my back pain would keep me from having sex, regardless. It’s almost a relief that he doesn’t have to bear all the responsibility.”

Evaluation of Ruby Bissell

For several years (far longer than the 6 months required by SSD criterion C), Ruby had complained of severe pain (A) that had markedly affected her life, especially her ability to work. She had clearly spent a great deal of time and effort (B) trying to manage her pain. There, in a nutshell, we’ve covered the three requirements for SSD–Pain.

Although the criteria don’t require us to rule out other causes, we’re responsible clinicians, so of course we will do so anyway. Principally, we need to know that her pain wasn’t caused by another medical condition. The vignette makes clear that she had been thoroughly evaluated by her orthopedist, who determined that she did not have pathology adequate to account for the severity of her symptoms. (Even if she did have some defined pathology, SSD–Pain might also be suspected if the distribution, timing, or description of the pain was atypical of a physical illness.)

Could Ruby have been malingering? This question is especially relevant to anyone who receives compensation for a work-related injury. However, Ruby’s suffering seemed genuine, and the vignette gives no indication that she was physically more able-bodied at leisure that at work. Her referral had not been made within a legal context, and she cooperated fully with the examination. Furthermore, malingering would not seem consistent with her long-held work ethic.

Pain is often a symptom of depression; indeed, many practitioners will automatically recommend a course of antidepressant medication for nearly anyone who complains of severe or chronic pain. Although Ruby denied feeling especially depressed, her pain symptoms could still be a stand-in for a mood disorder. But she had no suicidal ideas, disturbance of sleep, or disturbance of appetite that would support such a diagnosis. Although patients with substance-related disorders will sometimes fabricate (or imagine) pain in order to obtain medications, Ruby had been careful to avoid becoming dependent on analgesics.

Several other somatic symptom disorders should be briefly considered. People with illness anxiety disorder tend to have symptoms other than pain, and they fluctuate with time. Pain is not a symptom typical of conversion disorder. People with adjustment disorder will sometimes have physical symptoms, but such conditions are associated with identifiable precipitants and disappear with the stressor.

DSM-5 doesn’t require us to identify psychological factors that could underlie pain. Indeed, the presumption that there be a psychological mechanism is no longer a criterion for SSD. It is useful, however, to think about possible psychological factors that could contribute to the production or maintenance of a given patient’s pain experience. Ruby’s history includes several such possibilities. These included her perception of her husband’s feeling about his impotence, her anxiety at being left as the sole breadwinner, and possibly her own resentment at having worked since she was a teenager. (Many patients have multiple psychological considerations.)

Psychological factors that might be causing or worsening Ruby’s pain thus include stress resulting from relationships, work, and finances. With her GAF score of 61, her diagnosis would be as follows:

F45.1 [300.82]	Somatic symptom disorder, with predominant pain
Z65.8 [V62.89]	Health problems and disability in husband

An occasional patient like Ruby will be completely unable to describe the emotional component of pain. The inability to verbalize the emotions one feels has been termed alexithymia, Greek for “without expression of mood.”

F45.21 [300.7] Illness Anxiety Disorder

People with illness anxiety disorder (IAD) are terribly worried that they might have a serious illness. Their anxiety persists despite medical evidence to the contrary and reassurance from health care professionals. Common examples include fear of heart disease (which might start with an occasional heart palpitation) and of cancer (ever wonder about that mole—it seems to have darkened a bit?). These patients are not psychotic: They may agree temporarily that their symptoms could be emotional in origin, though they quickly revert to their fearful obsessing. Then they reject any suggestion that they do not have physical disease, and may even become outraged and refuse mental health consultation.

Many such patients have physical symptoms that would qualify them for somatic symptom disorder, as just discussed. However, about a quarter of such patients have all the concern about being sick, but not much in the way of somatic symptoms. Occasionally patients will have demonstrable organic disease, but their hypochondriacal symptoms are out of proportion to the seriousness of the actual medical condition. To delineate these patients more clearly, the condition has been renamed (hypochondria is considered pejorative), and new criteria have been written.

Though known for centuries, IAD still hasn’t been carefully studied; for example, it isn’t even known whether it runs in families. By all accounts, however, it is fairly common (perhaps 5% of the general population), especially in the offices of non-mental health practitioners. It tends to begin in the 20s or 30s, with peak prevalence at about 30 or 40. It is probably about equally frequent in men and women. Although they do not have high rates of current medical illnesses, such patients report a high prevalence of childhood illness.

Historically, hypochondriasis has been a source of fun for cartoonists and playwrights (read Molière’s The Imaginary Invalid), but in reality the disorder causes genuine misery. Although it can resolve completely, it more often runs a chronic course, for years interfering with work and social life. Many patients go from doctor to doctor in the effort to find someone who will relieve them of the serious disorders they feel sure they have; for a few, like Molière’s poor creature, Argan, it leads to complete invalidism.

Essential Features of Illness Anxiety Disorder

Despite the absence of serious physical symptoms, the patient is inordinately concerned about being ill. High anxiety coupled with a low threshold for alarm yields recurring behaviors concerning health (seeking reassurance, checking over and over for physical signs). Some patients cope instead by avoiding hospitals and medical appointments.

The Fine Print

The D’s: • Duration (6+ months, though the concerns may vary) • Differential diagnosis (substance use and physical disorders, mood or anxiety disorders, psychotic or stress disorders, body dysmorphic disorder, somatic symptom disorder)

Coding Notes

Specify subtype:

Care-seeking type. The patient uses medical services more than normal.

Care-avoidant type. Due to heightened anxiety levels, the patient avoids seeking medical care.

Julian Fenster

“Wow! That chart must be 2 inches thick.” Julian Fenster was being checked in for his third emergency room visit in the past month. “That’s just Volume 3,” the nurse told him.

At age 24, Julian lived with his mother and a teenage sister. Years ago, he’d started attending a college several hundred miles away. After only a semester, he’d moved back home. “I didn’t want to be that far from my doctors,” he remarked. “When you’re trying to prevent heart disease, you can’t be too careful.” With a practiced hand, he adjusted the blood pressure cuff around his upper arm.

When Julian was a young teenager, his dad had died. “His death was self-inflicted,” Julian pointed out. “He’d had rheumatic fever as a child, which gave him an enlarged heart. And the only thing he ever exercised was his right to eat anything fried, including Twinkies. And he smoked—he was a proud two-pack-a-day man. Look where that got him.”

None of these health risks applied to Julian, who was nothing if not careful about what he put into his body. He had spent hours searching the Internet for information on diet, and he’d attended a lecture by Dean Ornish. “I’ve followed a plant-based diet ever since,” Julian said. “I’m especially keen on tofu. And broccoli.”

Julian had never complained much of symptoms—just the odd palpitation, maybe “hot flushes” on an especially humid day. “I don’t feel bad,” he explained. “I just feel scared.”

This time, he’d heard a report on NPR about young people with heart disease. It had startled him so much he’d dropped the dish he had been putting into the cupboard. Without even cleaning up the mess, he caught the next bus to the ER.

Julian agreed that he needed a different approach to his health care needs, and thought he might be willing to give cognitive-behavioral therapy a try. “But first,” he asked, “could you check my blood pressure just once more?”

Evaluation of Julian Fenster

The requirements for IAD are not onerous; Julian met them handily. He had a disproportionate concern for a condition he had been assured he did not have (criterion A). He had both high anxiety and a low threshold for alarm (it took only a report on the radio to frighten him into the ER once again, C). His actual symptoms weren’t just mild—they were pretty much nonexistent (B)—so we can rule out somatic symptom disorder.He invested huge amounts of time in trolling the Internet for health information (D). Finally, he had had these symptoms far longer than the 6-month minimum required (E) for the diagnosis of IAD.

As with any other condition discussed in this chapter (other than the disparaged [by me] somatic symptom disorder), the first issue on our list to rule out is another medical condition: Marked, if not inordinate, health anxiety is pretty common in medical outpatients. Physical illnesses can be easy to miss, especially if the patient has had a long history of complaints that seem without physical basis. However, Julian’s symptoms had been evaluated over and again, to the point that there was little danger anything had been missed. Still, even people with hypochondriacal behavior are not immortal, so physical disorders would remain a significant rule-out that his clinicians must always keep in mind.

Anxious concern about health can occur in other mental disorders, but we can find some differences to help discriminate. Among these are body dysmorphic disorder and anxiety and related disorders (for example, generalized anxiety disorder, panic disorder, and obsessive–compulsive disorder). Julian had no symptoms suggesting any of these. When somatic concerns emerge in schizophrenia, they tend to be delusional and bizarre (“My brain is turning to bread”). In major depressive disorder, they are ego-syntonic but may be influenced by melancholia (“My bowels have turned to cement”). As keen as I am on looking for depression in almost every mental health patient, I don’t see depressive symptoms here. I’d give him a GAF score of 65.

The girth of Julian’s chart would support the care-seeking subtype specifier.

F45.21 [300.7]

Illness anxiety disorder, care-seeking type

Conversion Disorder (Functional Neurological Symptom Disorder)

Let’s define a conversion symptom as (1) a change in how the body functions when (2) no causative physical or physiological malfunctioning can be found. These symptoms are often termed pseudoneurological, and they include both sensory and motor symptoms—with or without impaired consciousness.

Conversion symptoms usually don’t conform to the anatomical pattern we’d expect for a condition with a well-defined physical cause. An example would be a stocking anesthesia, in which the patient complains of numbness of the foot that ends abruptly in a line encircling the lower leg. The actual pattern of nerve supply to the foot is quite different; it would not occasion numbness defined by such a neat line. Other examples of sensory conversion symptoms include blindness, deafness, double vision, and hallucinations. Examples of motor deficits that are conversion symptoms include impaired balance or staggering gait (at one time called astasia-abasia), weak or paralyzed muscles, lump in throat or trouble swallowing, loss of voice, and retention of urine.

For decades, criteria for conversion disorder required the clinician to judge that causation by an emotional conflict or specific psychological stress cause the conversion symptom (for example, a man develops blindness after finding his wife in bed with a neighbor). DSM-5 has abandoned this requirement, in view of the potential for disagreement as to causation: One clinician may see a “causal link” between nearly any two events, while another strenuously argues against any such connection.

Conversion symptoms occur widely, throughout various medical populations; up to one-third of adults have had at least one such symptom lifetime. However, conversion disorder is rarely diagnosed in mental health patients—perhaps in only 1 of 10,000. It is usually a disorder of young people and is probably far more common among women than men. It is somewhat more likely to be found in patients who are undereducated and medically unsophisticated, and who live where medical practice and diagnosis are still emerging. It may be diagnosed more often among patients seen in consultation in a general hospital.

Note that the criteria don’t require patients to undergo laboratory or imaging tests. The requirement is only that, after a careful physical and neurological evaluation, the patient’s symptom cannot be explained by a known medical or neurological disease process. The stocking anesthesia I have mentioned above would fill that requirement; so would total blindness in a patient whose pupils constrict in response to a bright light. There is a rich and entertaining literature of clinical tests for pseudoneurological symptoms.

Having a conversion symptom may not allow meaningful predictions about a patient’s future course. Follow-up studies find that many people who have had a conversion symptom do not have a mental disorder. Years later, many are well, with no physical or mental disorders. Some have somatization (or somatic symptom) disorder or another mental disorder. A few turn out to have an actual physical (sometimes neurological) illness, including brain or spinal cord tumors, multiple sclerosis, or a variety of other medical and neurological disorders. Although clinicians have undoubtedly improved in their ability to discriminate conversion symptoms from “real disease,” it remains distressingly easy to make mistakes.

Essential Features of Conversion Disorder

The patient’s symptom or symptoms—changes in sensory or voluntary motor functioning—seem clinically inconsistent with any known medical illness.

The Fine Print

A “normal” exam or a bizarre test result isn’t enough to affirm the diagnosis; there must be positive supportive evidence. Such evidence would include a change in findings from positive to negative when a different test is used (or the patient is distracted), or impossible findings such as tunnel vision.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood or anxiety disorders, body dysmorphic and dissociative disorders)

Coding Notes

Specify if:

Acute episode. Symptoms have lasted under 6 months.

Persistent. Symptoms have lasted 6+ months.

Specify: {With}{Without} psychological stressor

Specify type of symptom:

F44.4 [300.11] With weakness or paralysis; with abnormal movement (tremor, dystonia, abnormal gait); with swallowing symptoms; or with speech symptom

F44.5 [300.11] With attacks or seizures

F44.6 [300.11] With anesthesia or sensory loss; or with special sensory symptom (hallucinations or other disturbance of vision, hearing, smell)

F44.7 [300.11] With mixed symptoms

There’s something missing from the DSM-5 criteria for conversion disorder. In DSM-IV, we clinicians had to rule out intentional production of symptoms—specifically, malingering and factitious disorder. Although we are still asked to assure ourselves that no other diagnosis better explains the symptom, those two diagnoses aren’t explicitly mentioned. In my opinion, this is a good thing, because it’s hard (sometimes impossible) to determine for sure that a patient is faking. But with conversion symptoms, we should always keep the possibility in mind and do all we can to rule it out, along with every other confounding diagnosis.

Rosalind Noonan

Rosalind Noonan came to her university’s student health service because of a stutter. This was remarkable because she was 18 and she had only been stuttering for 2 days.

It had begun on Tuesday afternoon during her women’s issues seminar. The class had been discussing sexual harassment, which gradually led to a consideration of sexual molestation. To foster discussion, the graduate student leading the seminar asked each participant to comment. When Rosalind’s turn came, she stuttered so badly that she gave up trying to talk at all.

“I still ca-ca-ca-can’t understand it,” she told the interviewer. “It’s the first time I’ve ever had this pr-pr-pro-pro—difficulty.”

Rosalind was a first-year student who had decided to major in psychology, she said, “to help me learn more about myself.” What she already knew included the following.

Rosalind had no information about her biological parents. She had been adopted when she was only a week old by a high school physics teacher and his wife, who had no other children. Her father was a rigid and perfectionistic man who dominated both Rosalind and her mother.

As a young child, Rosalind was overly active; during her early school years she’d had difficulty focusing her attention. She would probably have qualified for a diagnosis of attention-deficit/hyperactivity disorder, but the only evaluation she had ever had was from their family physician, who thought it was “just a phase” that she would soon outgrow. Despite that lack of diagnostic rigor, when she was 12 she did begin to grow out of it. By the time she entered high school, she was doing nearly straight-A work.

Although she had had many friends in high school and had dated extensively, she’d never had a serious boyfriend. Her physical health had been excellent, and her only visits to doctors had been for immunizations. Her mood was almost always bright and cheerful; she had no history of delusions or hallucinations, and she had never used drugs or alcohol. “I g-g-grew up healthy and happy,” she protested. “That’s why I d-d-d-don’t understand this!”

“Hardly anyone reaches adulthood without having some problems.” The interviewer paused for a response, but received none, and so continued: “For example, when you were a child, did anyone ever approach you for sex?”

Rosalind’s gaze seemed to lose focus as tears trickled from her eyes. Haltingly at first, then in a rush, the following story emerged. When she was 9 or 10, her parents had become friendly with a married couple, both English teachers at her father’s school. When she was 14, the woman had suddenly died; subsequently, the man was invited for dinner on a number of occasions. One evening he consumed too much wine and was put to bed on their living room sofa. Rosalind awakened to find him lying on top of her in her bed, his hand covering her mouth. She was never certain whether he actually entered her, but her struggles apparently caused him to ejaculate. After that, he left her room. He never again returned to their home.

The following day she confided her story to her mother, who at first assured Rosalind that she must have been dreaming. When confronted with the evidence of the stained sheets, her mother urged her to say nothing about the matter to her father. It was the last time the subject had ever been discussed in their house.

“I’m not sure what we thought Daddy would do if he found out,” Rosalind commented, with notable fluency, “but we were both afraid of him. I felt I’d done something to be punished for, and I suppose Mom must have worried he’d attack the other teacher.”

Evaluation of Rosalind Noonan

Rosalind’s stuttering is a classic conversion symptom: It suggested or mimicked a medical condition, and its sudden, de novo appearance at college age wasn’t what we’d expect for the stuttering of speech fluency disorder (criteria A, B). Many clinicians would agree that it was precipitated by the stress of discussing long-buried sexual abuse. This aspect of the disorder—the putative psychological factors related to the symptoms—is one criterion for diagnosis that has been eliminated from the DSM-5 revision. However, it is still something to note when you encounter it.

The most serious mistake a clinician can make in this context is to diagnose conversion disorder when the symptom is caused by another medical condition (C). Some very peculiar symptoms eventually turn out to have a medical basis. However, the abrupt onset of stuttering in an adult is almost certain to have no identifiable organic cause. The fact that Rosalind’s difficulty disappeared during the discussion would be additional evidence that this was a conversion symptom.

Rosalind stated that her health had always been good, but her clinician would nonetheless be well advised to ask about other symptoms that could indicate somatic symptom disorder, in which conversion symptoms are so commonly encountered. The fact that she focused on the symptom, rather than on the fear of having some serious disease, would eliminate illness anxiety disorder (hypochondriasis) from consideration. Although pain is not excluded in the criteria, by convention conversion symptoms don’t usually include pain; when pain occurs as a symptom that is caused or increased by psychological factors, the diagnosis is likely to be somatic symptom disorder, with predominant pain.Another condition in which conversion symptoms are sometimes encountered is schizophrenia, but there was no evidence that Rosalind had ever been psychotic. Neither was there evidence that she had consciously feigned her symptom, which would rule out factitious disorder and malingering.

Rosalind was concerned about her stuttering (D), which is quite the opposite from the unconcerned indifference (sometimes called la belle indifférence) often associated with conversion symptoms. Although many of these patients will also have a diagnosis of histrionic, dependent, borderline, or antisocial personality disorder, there was no indication of any of these in Rosalind’s case. As in somatic symptom disorder, mood, anxiety, and dissociative disorders are often associated with conversion disorder.

Although Rosalind was terribly stressed by the sexual molestation, her overall functioning was overall pretty good; hence her GAF score would be 75. The type of symptom and presumed psychological stressor are detailed in the final diagnosis:

F44.4 [300.11]

Conversion disorder, with speech symptom (stuttering), acute episode, with psychological stressor (concerns about molestation)

F54 [316] Psychological Factors Affecting Other Medical Conditions

Mental health professionals deal with all sorts of problems that can influence the course or care of a medical condition. The diagnosis of psychological factors affecting other medical conditions can be used to identify such patients. Although it is coded as a mental disorder and with mental disorders, it does not actually constitute one, so I’ve not provided a full vignette—just a few snippets to illustrate how the diagnosis might be applied. In truth, this condition should have been given a Z-code and stuck in the back with other such conditions, but that wasn’t a possibility: ICD-10 makes the rules. Still, it doesn’t belong up in the front seat, either.

Essential Features of Psychological Factors Affecting Other Medical Conditions

A physical symptom or illness is affected by a psychological or behavioral factor that precipitates, worsens, interferes with, or extends the patient’s need for treatment.

The Fine Print

The D’s: • Differential diagnosis (other mental disorders, such as panic disorder, mood disorders, other somatic symptom and related disorders, posttraumatic stress disorder)

Coding Notes

Specify current severity:

Mild. The factor increases medical risk.

Moderate. The factor worsens the medical condition.

Severe. It causes an ER visit or hospitalization.

Extreme. It results in severe, life-endangering risk.

Code the name of the relevant medical condition first.

Some Examples

DSM-IV included six specific categories of factors that could change the course of a medical condition. Partly because they were hardly ever used, DSM-5 has ditched these categories. However, I’ve used them as examples that might alert clinicians to the sorts of issue that can affect treatment decisions. If more than one psychological factor is present, choose the one most prominent.

Mental disorder. For 15 years Philip’s compliance with treatment for schizophrenia has been spotty. Now his voices warn him to refuse dialysis.

Psychological symptoms (insufficient for a DSM-5 diagnosis). With few other mental symptoms, Alice’s mood has been so low that she hasn’t bothered filling prescriptions for her type II diabetes.

Personality traits or coping style. Gordon’s lifelong hatred of authority figures has led him to reject his doctor’s recommendation for a stent.

Maladaptive health behaviors. Weighing nearly 400 pounds, Tim knows that he should avoid sweetened drinks, but nearly every day his love of Big Gulps wins out.

Stress-related physiological response. April’s job as the Governor’s spokesperson is so demanding that she’s had to double up on her antihypertensive drugs.

Other or unspecified psychological factors. Harold’s religion prohibits him from accepting a blood transfusion. In Nanja’s culture, a woman mustn’t allow any man not her husband to see her unclothed; her internist is Derek.

Of course, you might find a psychological factor or two at play in nearly any medical condition. To use this diagnosis effectively, reserve it for situations in which it is clear that the psychological factor is adversely influencing the course of the illness.

F68.10 [300.19] Factitious Disorder

Factitious means something artificial. In the context of mental health patients, it means that a disorder looks like bona fide disease, but isn’t. Such patients accomplish this by simulating symptoms (for example, complaining of pain) or physical signs (for instance, warming a thermometer in coffee or submitting a urine specimen that’s been supplemented with sand). Sometimes they will complain of psychological symptoms, including depression, hallucinations, delusions, anxiety, suicidal ideas, and disorganized behavior. Because they are subjective, manufactured mental symptoms can be very hard to detect.

DSM-5 includes two subtypes of factitious disorder: one in which behaviors affect the person of the perpetrator, and one in which the behaviors affect another individual.

Factitious Disorder Imposed on Self

People affected by factitious disorder imposed on self (FDIS) can have remarkably dramatic symptoms, accompanied by outright lying about the severity of the distress. The overall pattern of signs and symptoms may be atypical for the alleged illness, and some patients change their stories upon retelling; either sort of evidence of inconsistency aids identification. Other patients with FDIS, however, know a lot about the symptoms and terminology of disease, which can make their behavior harder to detect. Some willingly undergo many procedures (some of them painful or dangerous) to continue in the patient role. With treatment that is ordinarily adequate to address their “disease,” their symptoms either do not remit or evolve into new complications.

Once hospitalized, patients with FDIS often tend to complain bitterly and to argue with staff members. They characteristically remain hospitalized for a few days, have few if any visitors, and leave against medical advice once their tests prove negative. Many travel from city to city in the quest for medical care. The most persistent travelers and confabulators among these are sometimes said to have Münchausen’s syndrome, named for the fabled baron who told outrageous lies about his adventures.

Contrary to its immediate predecessor, DSM-5 doesn’t require speculation as to possible motives for FDIS (or its sibling, FDIA, discussed below)—a blessing for those clinicians who reject the implication that they can read minds. It is enough to detect a pattern of such behavior in a patient whose behavior involves no other person.

Patients with FDIS differ profoundly from malingerers, who may show some of the same behaviors—silting a urine specimen, embellishing the subjective reports of their suffering. However, malingerers do these things to qualify for financial compensation (such as insurance payments), to obtain drugs, or to avoid work, punishment, or, in days gone by, military service. The motivation in FDIS is apparently more complex: These patients may need the feeling of being cared for, of duping medical personnel, or simply of receiving a whole lot of attention from important people. For whatever reason, they manufacture physical or psychological symptoms in a way that they may claim they cannot control.

The diagnosis of FDIS is made by excluding physical disease and other disorders. (Although it is conceivable that a patient might manufacture a personality disorder, I know of no such cases.) However, many patients with FDIS also have genuine personality disorders.

This disorder begins early in life. No one knows how rare it is, though it is probably more common in males than in females. Often it starts with a hospitalization for genuine physical problems. It results in severe impairment: These people are often unemployed and do not maintain close ties with family or friends. Their lives are complicated (and sometimes put at risk) by tests, medications, and unnecessary surgical procedures.

Factitious Disorder Imposed on Another

A condition that has been around for only a few years, factitious disorder imposed on another (FDIA) has just now emerged from an appendix to enter the body of the DSM (there’s a somewhat unsettling image). It used to be called factitious disorder (or Münchausen’s) by proxy, because the symptoms are not endured by the patient. Rather, it is the caregiver who both causes factitious symptoms in another person and bears the diagnosis. That “other” is almost always a child, though my Medline search revealed the occasional elderly person and at least one dog.

Three-quarters, sometimes more, of the perpetrators are female—usually the mothers of children exhibiting the symptoms. Because many of these people have a background in health care, it can be hard to catch them out. When apprehended, they often turn out to have a mood or personality disorder, or both; actual psychosis is rare. Some perpetrators have a history of FDIS.

Some parents with FDIA appear to believe that the children are ill; they tend to behave as “doctor addicts” who need the attention that comes with having a desperately ill child. These people usually limit themselves to the false reporting of signs and symptoms of disease, such as seizures or apnea. Others, however, will actually induce symptoms—most commonly by suffocation or poisoning, but also by falsifying urine or stool samples or other lab specimens. Perhaps half the victims have a real physical illness, in addition.

Overall, FDIA is rare, with an annual incidence of just 0.4–2 per 100,000 population. This translates to perhaps 600 new cases in the United States each year. Most are not single parents; often they are described as exemplary parents, though they may react inappropriately (for example, excitement) upon receiving bad news. Three-quarters of instances of FDIA occur in hospitals.

Victims are about equally male and female. Though most are under age 5, some are older. As you might expect, when a teen is involved, there is often a degree of collusion with the perpetrator. The death rate overall is an appalling 10%, most often when poisoning or suffocation is involved.

Medical personnel may be persuaded to prescribe for the child treatment that is unneeded and perhaps harmful. Indeed, the doctor may be the one most taken in; an occasional physician even becomes angry at staff members who accumulate evidence of the caregiver’s perfidy. Indeed, some experts recommend against informing the doctor when covert surveillance is planned, to lessen the risk that the perpetrator will be tipped off.

The suspicions of medical personnel may be alerted by a parent who seems insufficiently concerned about a sick child, by symptoms that seem to make no sense, or by a child whose symptoms continue despite treatment that should be adequate. In some cases, however, the parent perpetrator appears so distraught that the physician remains steadfastly unaware of the potential for foul play. Then the injuries will continue until the perpetrator is apprehended, the child dies, or with the march of time, the perpetrator moves on to involve a younger child. In one survey, over 70% of victims sustained disfigurement or permanent disability.

Patients with factitious disorder sometimes take on symptoms of new (and often poorly investigated) illnesses—the “disorder du jour” phenomenon. The criteria for the diagnoses are not very specific, and the patients are difficult to manage and often disagreeable. It is far too easy to dismiss them with a diagnosis of factitious disorder without first taking steps to ensure that we have first ruled out every other possible causative mental (and physical) condition.

I’d also point out that here in the differential diagnosis, I’ve used the term malingering—a rare occurrence in this book. Why is that? Surely people malinger other symptoms and disorders. Of course they can, and sometimes do. But I feel strongly that it is incumbent on clinicians to be extremely chary of malingering as a diagnostic formulation.

Essential Features of Factitious Disorder

To present a picture of someone who is ill, injured, or impaired, {the patient}{another person, acting for the patient} feigns physical or mental symptoms or signs of illness, or induces a disease or injury. This behavior occurs even without evident benefits (such as financial gain, revenge, or avoiding legal responsibility).

The Fine Print

The D’s: • Differential diagnosis (substance use and physical disorders, mood or anxiety disorders, psychotic disorders, trauma- and stressor-related disorders, dissociative and cognitive disorders, malingering)

Coding Notes

Diagnose:

Factitious disorder imposed on self. The perpetrator is also the patient.

Factitious disorder imposed on another. The perpetrator and victim are separate individuals. (The perpetrator receives the factitious disorder code; the victim receives a Z-code reflecting the abuse.)

For either type, specify:

Single episode.

Recurrent episodes.

Jason Bird

Jason Bird carried no health care card—he claimed he had lost his billfold to a mugger a few hours before he came to the emergency room of a Midwestern hospital late one Saturday night, complaining of crushing substernal chest pain. Although his electrocardiogram (EKG) was markedly abnormal, it did not show the changes typical of an acute myocardial infarction. The cardiologist on call, noting his ashen pallor and obvious distress, ordered him admitted to the cardiac ICU, then waited for the cardiac enzyme results.

The following day, Jason’s EKG was unchanged, and the serum enzymes showed no evidence of heart muscle damage. His chest pain continued. He complained loudly that he was being ignored. The cardiologist urgently requested a mental health consultation.

At age 47, Jason was a slightly built man with a bright, shifting gaze and a 4-day growth of beard. He spoke with a nasal Boston accent. His right shoulder bore the tattoo of a boot and the legend “Born To Kick Ass.” Throughout the interview he frequently complained of chest pain, but he breathed and talked normally, and he showed no evident anxiety about his medical condition.

He said he had grown up in Quincy, Massachusetts, the son of a physician. After high school he had attended college for several years, but found he was “too creative” to stick with a profession or a conventional job. Instead, he had turned to inventing medical devices, and numbered among his successes a positive-pressure respirator that bore his name. Although he had made several fortunes, he had lost nearly everything to his penchant for playing the stock market. He had been visiting in the area, relaxing, when the chest pain struck.

“And you’ve never had it before?” asked the interviewer, looking through the chart.

Jason denied that he’d had any previous heart trouble. “Not even a twinge. I’ve always been blessed with good health.”

“Ever been hospitalized?”

“Nope. Well, not since a tonsillectomy when I was a kid.”

Further questioning was similarly unproductive. As the interviewer left, Jason was demanding extra meal service.

Playing a hunch, the interviewer began telephoning emergency room physicians in the Boston area to ask about a patient with Jason’s name or peculiar tattoo. The third try struck pay dirt.

“Jason Bird? I wondered when we’d hear from him again. He’s been in and out of half the facilities in the state. His funny-looking EKG—probably an old MI—looks pretty bad, so he always gets admitted, but there’s never any evidence that anything acute is going on. I don’t think he’s addicted. A couple of years ago, he was admitted for a genuine pneumonia and got through a week without pain medication and with no withdrawal symptoms. He’ll stay in the ICU a couple of days and rag on the staff. Then he’ll split. He seems to enjoy needling medical people.”

“He told me that he was the son of a physician and that he was a wealthy inventor.”

The voice on the other end of the line chuckled. “The old respirator story. I checked into that one when he was admitted here for the third time. That was a different Bird altogether. I don’t know that Jason’s ever invented anything in his life—other than his medical history. As for his father, I think he was a chiropractor.”

Returning to the ward to add a note to the chart, the interviewer discovered that Jason had discharged himself against advice and departed, leaving behind a letter of complaint to the hospital administrator.

Evaluation of Jason Bird

Jason illustrates the principal difficulty of diagnosing factitious disorder: The criteria depend heavily on the clinician’s ability to determine that the signs and symptoms presented are intentionally falsified (criterion A). Sometimes that’s easy, as when you find the patient scratching open a wound or parking the thermometer on a radiator. But often the intent to deceive must be inferred, as in Jason’s case, from a string of visits to diverse health care facilities for the same complaint. Jason’s EKG did not change and his cardiac enzymes were not elevated, so his interviewer inferred that Jason was feigning or markedly exaggerating his chest pain. That assumption may have been correct, but it was supported not by proof, only by reports from the emergency room.

Jason presented himself as ill (B), even in the absence of external motivation such as monetary gain or escape from punishment (C). That was important, for such behavior is the principal ingredient that differentiates factitious disorder from malingering—which of course we must consider, if only to refute it. Malingering carries with it no criteria, but we commonly agree that it occurs when a person consciously pretends to have a disorder in order to gain something of value: money (from insurance, a lawsuit, compensation); drugs (from a sympathetic physician); avoidance of a conviction for a crime; or release from, for example, military service. For Jason, no such gain was apparent.

The list of other differential diagnoses is predictable. Most important, of course, FDIS must be differentiated from physical illnesses. This was soon accomplished in Jason’s case. Then other mental disorders must be ruled out. Patients with somatic symptom disorder may also complain of symptoms that have no apparent organic basis. Those with antisocial personality disorder may lie about symptoms, but they usually have some material gain in mind (to avoid punishment, to obtain money). Some patients with schizophrenia have a bizarre lifestyle that could be confused with the wanderings of classic Münchausen’s syndrome, but their content of thought will usually include clear delusions and hallucinations. Patients who feign psychological symptoms may look as though they have dementia or brief psychotic disorder. None of these disorders could be supported by Jason’s history or cross-sectional presentation.

Several other disorders may accompany FDIS. These include substance-related disorders (involving sedatives and analgesics) and dependent, histrionic, and borderline personality disorders. Many patients with FDIS have a serious personality disorder, but of course we have far too little information for such a diagnosis in Jason’s case. We’d need to mention the possibility in the summary we dictate. With a GAF score of 41, here is how I’d diagnose Jason Bird:

F68.10 [300.19]

Factitious disorder imposed on self

Claudia Frankel

Police reports are usually pretty dry; they don’t often moisten the eye. The Frankel case proved the exception to that rule.

When Rose Frankel was only 2 years old, she began to experience intestinal and other symptoms that would fill the next 6 years of her life. It started with spells of vomiting that seemed intractable to treatment. In all, she was carried back and forth to the pediatrician’s office, and frequently to the hospital, some 200 times. Each visit led to new tests, new attempts at treatment that led nowhere. She had undergone nearly two dozen operative procedures, and swallowed numerous medications for diarrhea, infections, seizures, and spells of vomiting, when finally nurses on the pediatric intensive care unit noticed that Rose would appear to be on the mend until her mother, Claudia, arrived and would take her to a private room. They’d hear Rose crying, and her health would take another turn for the worse—sometimes, just when she was thought ready for discharge.

In all, Rose suffered nearly a dozen serious infections; one of them, a life-threatening sepsis, involved multiple organisms. Through it all, Claudia worked closely with their family doctor. They would speak in person or on the phone several times a day, and Dr. Bhend often spoke of Claudia as his “good right arm” in trying to get to the bottom of the calamity that was engulfing their patient.

During the 4 years of her medical ordeal, the only time that Rose remained healthy longer than a month was when Claudia left town to nurse her own mother, during what proved to be that old lady’s final illness. For the last few weeks of her kindergarten year, Rose bloomed. But she sickened again, shortly after Grandma died and Claudia returned home.

Several on the hospital nursing staff were beyond suspicious. Once, they’d found a bottle of Ipecac discarded in the room Rose had occupied. On another occasion, a monitoring device that three staff members had checked within the hour had been found turned off. As they told the investigating officers, most staff members had concluded that Claudia was directly responsible for her daughter’s illness, so they hid a camera in the private room Claudia always used during Rose’s many admissions. When he found out, Dr. Bhend, concerned about the loss of trust, warned Claudia of the “impending sting.” That afternoon, she checked Rose out of the hospital, and they were lost to follow-up. The staff revealed the full details to the police, who opened a file but were never able to pull together solid information.

FDIA is just one of the new DSM-5 disorders that was included in an appendix of DSM-IV as a possible diagnosis that needed further study. Also making the big time after years of study are premenstrual dysphoric disorder, mild neurocognitive disorder, binge-eating disorder, and (my personal favorite) caffeine withdrawal. Welcome aboard, all!

Evaluation of Claudia Frankel

Two of the criteria required for a diagnosis of factitious disorder were easily satisfied. There was nothing to suggest an external reward for Claudia’s behavior such as financial gain (criterion C), and she certainly did present Rose as being impaired (D). Two others we have to take on faith: although the circumstantial evidence was strong that Rose’s symptoms were fabricated, the staff just missed nailing down the proof (A). And, we cannot be sure that Claudia had no other mental disorder such as a delusional disorder that could better explain her behavior (D). Therefore, our current diagnosis should be treated as provisional. I would make a note in her chart to the effect that further investigation would be needed in regard to a personality disorder; in ICD-10, we can no longer code “diagnosis deferred” in that category.

Assigning Claudia’s GAF score prompts some discussion. Should we base our judgment on the fact that she was able to function well in most areas of her life, or on the effect of her behavior on Jennifer and on their relationship? In my opinion, the disastrous consequences of her impaired judgment would be the deciding factor here; hence the very low GAF score of 30. However, others might see her situation quite differently and choose to argue.

Note that Rose herself would be given the code Z69.010 [V61.21] to reflect the fact that she had suffered from physical abuse by a parent.

F68.10 [300.19]

Factitious disorder imposed on another (provisional)

F45.8 [300.89] Other Specified Somatic Symptom and Related Disorder

This category is for patients whose somatic symptoms do not fulfill criteria for any of the somatic symptom and related disorders discussed above, but about which we have some information. Any diagnosis suggested here has not as yet been studied enough for formal inclusion in DSM-5, and should be considered provisional. Keep in mind that with more information, such a patient may qualify for a diagnosis in a different chapter or for another diagnosis in this one.

Pseudocyesis. The word pseudocyesis means “false pregnancy,” and it refers to patients’ incorrect belief that they are pregnant. They develop signs of pregnancy such as protruding abdomen, nausea, amenorrhea, and breast engorgement—and even symptoms such as the sensation of fetal movement and labor pains.

Brief illness anxiety disorder. Duration less than 6 months.

Brief somatic symptom disorder. I’ll leave the definition as homework.

F45.9 [300.82] Unspecified Somatic Symptom Disorder

Use this category for cases in which full criteria for any of the disorders discussed in this chapter are not met, and you do not wish to specify a reason or a possible presentation.

*Much of the information presented here and elsewhere in this chapter is based on studies of patients defined by DSM-IV criteria. When DSM-5 criteria were written, there simply weren’t data available for disorders defined by the new criteria.