Somatic Symptom & Related Disorders

A cluster of conditions in which physical symptoms and/or health-related worry are prominent, but aren’t fully explained by (or are disproportionate to) any identifiable medical condition. These presentations are common in general practice and are frequently missed or mislabelled — the diagnosis is made by the presence of characteristic psychological features, not simply by the absence of organic disease.

Somatic symptom disorder (SSD)

One or more distressing or life-disrupting physical symptoms, plus excessive thoughts, feelings, or behaviours related to the symptoms (or associated health concerns), shown by at least one of:

• Disproportionate and persistent thoughts about the seriousness of the symptoms.
• Persistently high anxiety about health or symptoms.
• Excessive time and energy devoted to the symptoms or health concerns.

Symptoms need not be medically unexplained — SSD can coexist with a genuine medical condition; the distinguishing feature is the degree of associated distress and preoccupation, present for ≥6 months (though the specific symptom may vary).

Illness anxiety disorder

Preoccupation with having or acquiring a serious illness, without significant somatic symptoms (or only mild symptoms) — this is what’s colloquially called “health anxiety” or hypochondriasis in older terminology. High health-related anxiety, easily alarmed about personal health status, and either excessive health-related behaviours (repeated body-checking, doctor-shopping) or maladaptive avoidance (avoiding appointments/hospitals). Present for ≥6 months, though the specific illness feared may change.

Conversion disorder (functional neurological symptom disorder)

One or more symptoms of altered voluntary motor or sensory function (weakness, abnormal movement, non-epileptic seizures, sensory loss, speech disturbance) that are incompatible with recognised neurological or medical conditions on clinical examination — not that no organic cause has been sought and simply not found, but that the pattern itself is physiologically inconsistent (e.g. Hoover’s sign, give-way weakness, non-anatomical sensory loss). Not better explained by another medical or mental disorder, and causes significant distress or functional impairment.

Management: a clear, non-judgemental explanation of the diagnosis (framing it as a real, disabling, and treatable disorder of nervous system function rather than structure) is central — how the diagnosis is communicated strongly affects engagement and outcome. Physiotherapy (for motor symptoms) and psychological therapy (CBT, sometimes alongside specialist neuropsychiatry input) are the main treatment modalities; there’s no specific pharmacotherapy for the disorder itself, though comorbid anxiety/depression should be treated.

Factitious disorder

Deliberate falsification or induction of physical or psychological signs/ symptoms, associated with identified deception, in the absence of obvious external reward (distinguishing it from malingering). The person presents themselves (or, in factitious disorder imposed on another — previously “Munchausen by proxy” — another person, typically a dependent child) as ill, impaired, or injured. Often involves extensive, sometimes self-inflicted, investigation and treatment-seeking, and can be genuinely dangerous (through repeated invasive investigations, unnecessary surgery, or direct harm in the imposed-on-another form).

Factitious disorder imposed on another is a child protection emergency when identified or strongly suspected — mandatory reporting obligations apply; this is not primarily a “treat the caregiver” presentation, it is a safeguarding one.

Malingering

Not classified as a mental disorder in DSM-5 — intentional production of false or exaggerated symptoms, motivated by an identifiable external incentive (avoiding work/military duty, obtaining financial compensation, evading criminal prosecution, or obtaining drugs). Distinguish from factitious disorder (no external incentive) and from genuine SSD/conversion disorder (no intentional deception).

General principles for the somatic-symptom spectrum

• Avoid repeated, escalating investigation once a reasonable medical work-up has excluded serious pathology — this tends to reinforce illness anxiety rather than reassure, and carries its own iatrogenic risk.
• One regular GP, scheduled (not symptom-triggered) review — regular appointments not contingent on new symptoms reduce the pressure to “prove” illness to get seen, and build a therapeutic relationship that tolerates uncertainty.
• Validate the symptom as real (the patient’s distress and functional impairment are genuine) while gently reframing the explanatory model away from a purely structural/organic one.
• CBT has the best evidence across this symptom cluster; graded exercise and physiotherapy involvement matter particularly for conversion/functional neurological symptoms.
• Actively screen for and treat comorbid depression/anxiety, which are common and can drive symptom burden.
• Avoid inadvertently colluding with an overly narrow biomedical framing (e.g. ordering a test primarily to “reassure,” which usually doesn’t achieve durable reassurance and can suggest the doctor also suspects serious disease).