Somatic Symptom and Related Disorders

Between 5-10% of patients initially diagnosed with conversion or somatoform disorders are later found to have a medical condition explaining their symptoms. MS, myasthenia gravis, lupus, and rare neurological conditions are commonly missed. Complete an appropriate medical workup before applying a somatic diagnosis, and remain open to diagnostic revision if the clinical course changes.

This phrase — and its clinical equivalents ('nothing is wrong,' 'the tests are normal so you're fine,' 'this is just stress') — destroys the therapeutic alliance, drives further care-seeking, and is factually imprecise. Pain that is centrally mediated is still processed by the nervous system and is still real. Validate the suffering while identifying the disproportionate response as a treatable target.

Conversion disorder symptoms are not under voluntary control. The patient is not choosing to be paralyzed or to have seizures. Telling a conversion disorder patient they are faking is clinically harmful. The diagnosis is made by positive examination findings (Hoover's sign, tremor entrainment) that demonstrate internal inconsistency — not by catching the patient 'in the act' of normal function.

When a caregiver is suspected of fabricating or inducing illness in a child or dependent, the priority is protecting the victim. This is a mandatory reporting situation. Suspect it when: the child has unexplained recurrent illnesses that occur only in the caregiver's presence, symptoms resolve when the child is separated from the caregiver, or the caregiver seems inappropriately comfortable in the medical setting.

Every normal test result provides approximately 48 hours of reassurance before health anxiety returns. Each test carries risks — incidental findings that trigger further workup, false positives, procedural complications. The goal is medically indicated testing, not reassurance-driven testing. The clinician must tolerate the patient's distress without reflexively ordering scans.