Real body signals. Disproportionate mind loops. Know which diagnosis matches which pattern before you order the tenth scan.
A 38-year-old woman has had diffuse abdominal pain, fatigue, and headaches for 14 months. Extensive workup including CT, colonoscopy, and labs is unrevealing. She spends hours daily researching diseases online, demands repeat testing, and says her physicians "are missing something deadly." She misses work weekly because of symptom fear. On exam today she has mild diffuse tenderness without peritoneal signs.
What is the most likely diagnosis?
Generalized anxiety disorder
Somatic symptom disorder
Illness anxiety disorder
Major depressive disorder
The Clue
Mind → Body → More Mind
Not faking. Not "all in the head." A feedback loop where sensation, threat detection, and behavior amplify each other.
What starts the loop?
A real somatic sensation (pain, fatigue, paresthesia) or normal body noise gets flagged as dangerous by the amygdala and insula. The sensation may be medically unexplained, but it is experienced as real.
What keeps it spinning?
Catastrophic interpretation ("this cramp means cancer") drives checking behaviors: ER visits, googling, body scanning, repeated testing. Each negative test gives brief relief, then anxiety rebounds ("they just have not found it yet").
Why do symptoms persist?
Attention and avoidance maintain the circuit. Hypervigilance amplifies interoceptive signals. Deconditioning and social withdrawal remove corrective experiences that would disprove the threat.
How is conversion different?
In functional neurologic symptom disorder, the output is motor or sensory (weakness, tremor, non-epileptic events, blindness) with exam findings incompatible with known neuroanatomy. Stress often precedes onset, but la belle indifference is NOT reliable in clinical practice.
The board move: match the disproportionate response to the symptom burden, not the lab panel.
Biopsychosocial anchors (high yield)
SSD: distressing somatic symptoms + excessive thoughts/feelings/behaviors about health
Illness anxiety: disease preoccupation with minimal somatic symptoms
Conversion (FND): neurologic deficit incompatible with exam
Factitious: intentional falsification, internal gain (sick role)
Malingering: intentional falsification, external gain (money, drugs, avoiding duty)
The Pattern
Spectrum at the Bedside
Tap each card. Front = what you see. Back = the board discriminator.
Somatic Symptom Disorder
CLUE: real symptoms + excessive reaction
Multiple physical complaints over months. Workup may be negative or show minor findings that do not explain disability.
DSM-5: one or more distressing somatic symptoms plus disproportionate/persistent thoughts, high health anxiety, or excessive time/energy on symptoms. State is persistent (typically >6 months). Not diagnosed just because workup is negative.
Illness Anxiety Disorder
CLUE: minimal body, maximal disease fear
Convinced of serious illness despite little or no somatic symptoms. Either care-seeking (frequent visits/tests) or care-avoidant (fear of diagnosis).
Former hypochondriasis without prominent somatic symptoms. Preoccupation ≥6 months. If somatic symptoms become prominent, diagnose SSD instead.
Conversion Disorder (FND)
CLUE: neuro sign that breaks anatomy
Sudden weakness, gait disorder, tremor, sensory loss, or paroxysmal events after stress. Patient is often sincerely distressed.
Positive signs: Hoover sign (hip extension weakness improves with contralateral hip flexion), give-way weakness, tremor entrainment, non-epileptic spells with preserved awareness/rapid recovery. Rule out stroke, MS, myasthenia first.
Factitious Disorder
CLUE: deception for the sick role
Intentionally produces or feigns symptoms. May have factitious disorder imposed on another (formerly Munchausen by proxy).
Internal incentive: attention, nurturance, hospital environment. History of multiple providers, inconsistent stories, knowledge of medical terms, scars from self-induced illness. Confrontation is usually counterproductive early.
Malingering
CLUE: external reward
Not a DSM mental disorder. Symptom production is intentional and motivated by identifiable external gain.
Examples: disability benefits, opioid access, avoiding jail/military duty, lawsuit settlement. Suspect when onset aligns with incentive and exam inconsistencies appear.
Work the Clues
Diagnosis Without Over-Testing
One reasonable medical workup, then pivot to pattern recognition and functional exam maneuvers.
Rule out organic disease (once)
Targeted history, exam, and labs/imaging guided by symptoms. Avoid endless reassurance testing; it reinforces illness behavior.
Board trap: ordering more scans instead of naming the psychiatric syndrome.
Measure the disproportionate response
SSD requires excessive thoughts, anxiety, or behaviors relative to symptom severity. Ask: time spent on symptoms, impairment, doctor shopping, catastrophizing.
Chronic pain alone is not SSD without the cognitive/behavioral excess.
Separate illness anxiety from SSD
Illness anxiety = disease conviction with minimal somatic symptoms. SSD = somatic symptoms are central and distressing.
If both are present and somatic symptoms dominate, choose SSD.
Functional neuro exam for conversion
Look for inconsistency: symptoms that vary with attention, non-anatomic sensory loss, positive FND signs (Hoover, tremor entrainment, tubular visual fields).
Do not rely on indifference to emotion; patients with FND are often quite distressed.
Screen mood and anxiety comorbidity
MDD and GAD commonly overlap. Treat comorbid conditions; somatic focus may improve.
Somatic symptoms in depression do not automatically equal SSD unless health preoccupation is excessive.
Board traps
La belle indifference is classically taught with conversion but is neither sensitive nor specific. Many patients with FND are anxious and upset.
SSD is not a diagnosis of exclusion after normal labs; it is a positive diagnosis based on symptom plus maladaptive response for ≥6 months.
Malingering is not a mental disorder in DSM; factitious is. The split is internal vs external incentive.
The Punch
Management That Actually Works
Validate suffering, stop the test spiral, reframe the mechanism, treat comorbidity.
First visit move?
Acknowledge symptoms are real while explaining that testing so far has not revealed a dangerous structural disease. Name the pattern (health anxiety loop, functional neurologic symptoms) without calling the patient a faker.
Visit structure?
Regular, time-limited appointments with the same clinician. Brief physical exam each time. Avoid unplanned urgent workups unless new red flags appear.
Best evidence treatment?
CBT tailored to somatic preoccupation, interoceptive exposure, and reduction of checking/safety behaviors. For FND: physiotherapy and multidisciplinary rehab with transparent diagnosis.
Medications?
Treat comorbid depression/anxiety (SSRIs/SNRIs). No medication cures SSD or FND by itself. Avoid benzodiazepines and opioid escalation.
Factitious disorder?
Protect safety, document carefully, involve psychiatry. Direct accusation often leads to abrupt departure and next hospital. Address underlying needs and boundaries.
Scheduled visits + CBT + one thorough workup beats endless CTs every time.
Prove It
Board Walkthrough
10-vignette bank, 5 dealt per round, answer choices shuffled, never-repeat within a round. Tap a wrong answer first to see why it almost works, then read the glowing clues.
Medically reviewed by Fatima Ali, DO and Kaitlyn Cocuzzo, MD · Last reviewed June 2026
Bone Wizardry is an independent educational resource for visual learning in the medical sciences. It is not affiliated with, endorsed by, or sponsored by any licensing or examination board, contains no real or recalled examination questions, and does not guarantee any educational or examination outcome.
