Somatoform Disorders, Factitious Disorders and Malingering are among the most difficult disorders for clinical psychologists to diagnose and differentiate.
Somatoform Disorders are “problems that appear to be physical, or medical, but are actually due to psychosocial factors” and as such represent “psychological disorders masquerading as physical problems” (Comer, 2004, p. 200). This class of disorders does not represent a conscious or purposeful attempt by the patient to intentionally deceive medical and/or mental health practitioners, but instead, manifests as persistent or recurrent symptoms or impairments which the patients themselves believe to be physical in nature and consider beyond their control. The symptoms are generally accompanied by continual worry about the undiagnosed condition and exaggerated concern about minor physical defects or abnormalities (APA, 2013).
In contrast, Factitious Disorders represent a patients intentional feigning of symptoms in order to assume the sick role. Often patients will resort to dangerous extremes to create the appearance of particular illnesses, even undergoing serious but unnecessary medical interventions in order to maintain the façade. The purpose for assuming this role is psychological rather than for the receipt of any external benefit (Comer, 2004; APA, 2013).
Malingering represents another example of a patient intentionally faking medical conditions and symptoms. However, in this case, the feigning of symptoms is a calculated action for a specific practical gain, such as financial compensation or other benefits (Comer, 2004).
Thus, with all three, the similarity is the presentation of physical symptoms, but the differences lie in the motivations.
Associated Specific Symptoms – Conversion, Somatization, Pain, Hypochondriasis and Body Dysmorphic Disorder
Conversion – The specific diagnosis of Conversion Disorder falls under the category of Somatoform Disorder known as Hysterical Somatoform Disorders, which manifest as actual changes in physical functioning and are thus typically difficult to distinguish from actual medical conditions. In patients with Conversion Disorder, symptoms or deficits affect voluntary motor or sensory functioning. The symptoms are not the direct result of the ingestion of a substance, a neurological dysfunction or any other medical condition (Comer, 2004; APA, 2013). Regarding the above scenario, the woman described could manifest symptoms such as paralysis, blindness, loss of sensation in body parts, dizziness or nausea which would incapacitate her and interfere with her daily ability to function. Upon further investigation, the symptoms would be associated with an incident of stress or conflict, such as family discord.
Somatization – In contrast, Somatization Disorder represents a more generalized and long-term conglomeration of various physical ailments, including a combination of differing categories of pain symptoms, gastrointestinal symptoms, sexual symptoms and neurological symptoms, all present with no medical basis. Patients with this diagnosis typically have a history of seeking treatment or complaining of impairment in relation to multiple physical conditions that cannot be explained by a legitimate medical condition or are in excess of expected symptomology. Additionally, the symptoms exhibit exaggerated endurance and resistance to treatment. Typically, over time, the symptoms escalate in frequency and severity and cause a increasing degree of interference with life activities (Comer, 2004; APA, 2013). Specific symptoms experienced by the described patient could include combinations of recurrent complaints of and treatment for headaches, muscle aches, nausea, menstrual problems, dizziness, double-vision and paralysis.
Pain Disorder Associated with Psychological Factors – While the subjective report of pain may be an aspect of the above-mentioned disorders, it is the primary symptom of this category of Somatoform Disorders. Often springing from situations characterized by pain associated with actual medical and physical conditions, this disorder represents exaggerated complaints of severe pain with greater duration and severity than appropriate for the condition. Typically, psychological factors have a role in the onset, severity, exacerbation or maintenance of the pain. Specific symptoms include the continued report of recurrent and intense pain that causes distress and impairment in daily functioning (Comer, 2004; APA, 2013). In the described scenario, this pain could manifest in one or more of several ways, including headaches, back pain, or abdominal pain.
Hypochondriasis – Patients diagnosed with Hypochondriasis, a preoccupation Somatoform Disorder, have persistent and pervasive beliefs that they have one or more serious undiagnosed diseases, despite medical evidence to the contrary. Typically, the patient feels misunderstood by medical professionals and does not recognize his/her obsession as excessive (Comer, 2004; APA, 2013). The woman in the above scenario would exhibit extreme worry and preoccupation with her symptoms and the belief they indicate a serious illness, despite the lack of medical confirmation of her fears.
Body Dysmorphic Disorder – Individuals with Body Dysmorphic Disorder are excessively preoccupied with imagined or minor physical defects (Comer, 2004; APA, 2013). In the described scenario, the woman might manifest this disorder by ruminating over wrinkles or a birthmark or she could obsess about the size or shape of a particular body part such as eyes, hands or breasts. In order for these concerns to be considered a disorder, they have to be excessive and pervasive to the point of causing distress or interfering with daily living.
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Comer, R.J. (2004). Abnormal psychology (5th ed.). New York, NY: Worth Publishers
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