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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Somatic symptom disorder = distressing somatic symptoms plus excessive thoughts/feelings/behaviors for >6 months
- Illness anxiety disorder = high health anxiety with minimal/no symptoms
- Functional neurological symptom disorder has neuro symptoms incompatible with recognized disease
- Factitious = falsification without obvious external reward; malingering = intentional symptoms for external gain
- Management: validate, one clinician, scheduled visits, treat comorbidity, avoid unnecessary tests/opioids, use CBT
Overview
Somatic symptom and related disorders involve bodily symptoms, health anxiety, or abnormal illness behaviors causing distress or impairment. Diagnosis does not require proving symptoms are medically unexplained; disproportionate cognitive/behavioral response is central.
Epidemiology
These disorders are common in primary care/ED and coexist with anxiety, depression, trauma, chronic pain, and functional GI syndromes. Repeated reassurance-seeking and multi-specialist care can cause iatrogenic harm.
Clinical Features
Symptoms
Persistent physical symptoms with high distress and health preoccupation
Repeated checking, reassurance seeking, internet searching, frequent visits/tests
Avoidance due to feared illness/injury
Functional weakness, nonepileptic seizures, aphonia, tremor, nonanatomic sensory symptoms
Weight loss, GI bleeding, focal deficit, fever, abnormal vitals, progressive objective findings
Signs
Exam may be normal or inconsistent
Functional signs: Hoover sign, distractible tremor, nonanatomic sensory loss
Objective signs of genuine disease require appropriate evaluation
Self-induced injury or falsified illness suggests factitious disorder
Investigations
First-line
Focused medical evaluationAppropriate tests for red flags; avoid endless repetition of prior negative tests
DSM-5-TR assessmentDuration, distress, health anxiety, behaviors, impairment, trauma, anxiety/depression, SUD, suicide
Review prior recordsPrevents duplicated testing and missed objective abnormalities
Second-line
Functional neurological assessmentNeurology when new neuro symptoms; positive functional signs support diagnosis
Screening toolsPHQ-9, GAD-7, pain interference, health anxiety scales
Medication/substance reviewOpioids, sedatives, stimulants, steroids, withdrawal worsen symptoms/disability
Specialist
Psychotherapy referralCBT, trauma-informed therapy, functional neurological disorder programs
Specialist referralOnly objective red flags or focused diagnostic questions; avoid uncoordinated shopping
1
Communication
- Validate suffering: symptoms are real and distressing
- Use one coordinating clinician with scheduled visits
- Explain brain-body amplification rather than “nothing is wrong”
2
Avoid harm
- Avoid repeated low-yield tests, invasive procedures, opioids, benzodiazepines
- Continue age-appropriate screening and evaluate new red flags
- Review previous investigations before more tests
3
Treatment
- CBT can reduce symptom burden and health anxiety
- Functional neurological symptoms benefit from explanation and PT/OT retraining
- Treat comorbid depression, anxiety, PTSD, pain
Complications
- Iatrogenic harm:
- Functional disability and deconditioning:
- Comorbid anxiety/depression:
- Therapeutic rupture from dismissive communication:
- Missed medical disease if anchoring:
USMLE Step 2 CK Exam Tips
- 1Somatic symptom disorder can coexist with real medical disease
- 2Illness anxiety has minimal somatic symptoms
- 3Conversion disorder is not conscious faking
- 4Factitious = no obvious external reward; malingering = external gain
- 5Best next step is scheduled visits with one clinician
- 6Validate symptoms; do not say it is all in your head
practicetest your knowledge on somatic symptom & related disordersApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — psychiatry and beyond.
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