9. Somatic Symptom and Related Disorders
9.1. Somatic Symptom Disorder
9.2. Illness Anxiety Disorder
9.3. Conversion Disorder (Functional Neurological SymptomDisorder)
9.4. Psychological Factors Affecting Other Medical Conditions
9.5. Factitious Disorder (includes Factitious Disorder Imposed on Self, Factitious Disorder Imposed on Another)
SomStiC symptom disorder and other disorders with prominent somatic symptoms
constitute a new category in DSM-5 called somatic symptom and related disorders. This
chapter includes the diagnoses of somatic symptom disorder, illness anxiety disorder, conversion
disorder (functional neurological symptom disorder), psychological factors affecting
other medical conditions, factitious disorder, other specified somatic sjnnptom and
related disorder, and unspecified somatic symptom and related disorder. All of the disorders
in this chapter share a common feature: the prominence of somatic symptoms associated
with significant distress and impairment. Individuals with disorders with prominent
somatic symptoms are commonly encoimtered in primary care and other medical settings
but are less commonly encountered in psychiatric and otiier mental health settings. These
reconceptualized diagnoses, based on a reorganization of DSM-IV somatoform disorder diagnoses,
are more useful for primary care and other medical (nonpsychiatric) clinicians.
The major diagnosis in this diagnostic class, somatic symptom disorder, emphasizes
diagnosis made on the basis of positive symptoms and signs (distressing somatic symptoms
plus abnormal thoughts, feelings, and behaviors in response to these symptoms)
rather than the absence of a medical explanation for somatic symptoms. A distinctive characteristic
of many individuals with somatic symptom disorder is not the somatic symptoms
per se, but instead the way they present and interpret them. Incorporating affective,
cognitive, and behavioral components into the criteria for somatic symptom disorder provides
a more comprehensive and accurate reflection of the true clinical picture than can be
achieved by assessing the somatic complaints alone.
The principles behind the changes in the somatic symptom and related diagnoses from DSM-IV are crucial in imderstanding the DSM-5 diagnoses. The DSM-IV term somatoform disorders was confusing and is replaced by somatic symptom and related disorders. In DSM-IV there was a great deal of overlap across the somatoform disorders and a lack of clarity about the boundaries of diagnoses. Although individuals with these disorders primarily present in medical rather than mental health settings, nonpsychiatric physicians foimd the DSM-IV somatoform diagnoses difficult to understand and use. The current DSM-5 classification recogruzes this overlap by reducing the total number of disorders as well as their subcategories.
The previous criteria overemphasized the centrality of medically unexplained symptoms. Such symptoms are present to various degrees, particularly in conversion disorder, but somatic symptom disorders can also accompany diagnosed medical disorders. The reliability of determining that a somatic symptom is medically unexplained is limited, and grounding a diagnosis on the absence of an explanation is problematic and reinforces mind-body dualism. It is not appropriate to give an individual a mental disorder diagnosis solely because a medical cause cannot be demonstrated. Furthermore, the presence of a medical diagnosis does not exclude the possibility of a comorbid mental disorder, including a somatic symptom and related disorder. Perhaps because of the predominant focus on lack of medical explanation, individuals regarded these diagnoses as pejorative and demeaning, implying that their physical symptoms were not "real." The new classification defines the major diagnosis, somatic symptom disorder, on the basis of positive symptoms (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms). However, medically unexplained symptoms remain a key feature in conversion disorder and pseudocyesis (other specified somatic symptom and related disorder) because it is possible to demonstrate definitively in such disorders that the symptoms are not consistent with medical pathophysiology.
It is important to note that some other mental disorders may initially manifest with primarily somatic symptoms (e.g., major depressive disorder, panic disorder). Such diagnoses may account for the somatic symptoms, or they may occur alongside one of the somatic symptom and related disorders in this chapter. There is also considerable medical comorbidity among somatizing individuals. Although somatic symptoms are frequently associated with psychological distress and psychopathology, some somatic symptom and related disorders can arise spontaneously, and their causes can remain obscure. Anxiety disorders and depressive disorders may accompany somatic symptom and related disorders. The somatic component adds severity and complexity to depressive and anxiety disorders and results in higher severity, functional impairment, and even refractoriness to traditional treatments. In rare instances, the degree of preoccupation may be so severe as to warrant consideration of a delusional disorder diagnosis.
A number of factors may contribute to somatic symptom and related disorders. These include genetic and biological vulnerability (e.g., increased sensitivity to pain), early traumatic experiences (e.g., violence, abuse, deprivation), and learning (e.g., attention obtained from illness, lack of reinforcement of nonsomatic expressions of distress), as well as cultural/social norms that devalue and stigmatize psychological suffering as compared with physical suffering. Differences in medical care across cultures affect the presentation, recognition, and management of these somatic presentations. Variations in symptom presentation are likely the result of the interaction of multiple factors within cultural contexts that affect how individuals identify and classify bodily sensations, perceive illness, and seek medical attention for them. Thus, somatic presentations can be viewed as expressions of personal suffering inserted in a cultural and social context.
All of these disorders are characterized by the prominent focus on somatic concerns and their iiutial presentation mainly in medical rather than mental health care settings. Somatic symptom disorder offers a more clinically useful method of characterizing individuals who may have been considered in the past for a diagnosis of somatization disorder. Furthermore, approximately 75% of individuals previously diagnosed with hypochondriasis are subsumed under the diagnosis of somatic symptom disorder. However, about 25% of individuals with hypochondriasis have high health anxiety in the absence of somatic symptoms, and many such individuals' symptoms would not qualify for an anxiety disorder diagnosis. The DSM-5 diagnosis of illness anxiety disorder is for this latter group of individuals. Illness anxiety disorder can be considered either in this diagnostic section or as an anxiety disorder. Because of the strong focus on somatic concerns, and because illness anxiety disorder is most often encountered in medical settings, for utility it is listed with the somatic symptom and related disorders. In conversion disorder, the essential feature is neurological symptoms that are found, after appropriate neurological assessment, to be incompatible with neurological pathophysiology. Psychological factors affecting other medical conditions is also included in this chapter. Its essential feature is the presence of one or more clinically significant psychological or behavioral factors that adversely affect a medical condition by increasing the risk for suffering, death, or disability. Like the other somatic symptom and related disorders, factitious disorder embodies persistent problems related to illness perception and identity. In the great majority of reported cases of factitious disorder, both imposed on self and imposed on another, individuals present with somatic symptoms and medical disease conviction. Consequently, DSM-5 factitious disorder is included among the somatic symptom and related disorders. Other specified somatic symptom and related disorder and unspecified somatic symptom and related disorder include conditions for which some, but not all, of the criteria for somatic symptom disorder or illness anxiety disorder are met, as well as pseudocyesis.
Individuals with somatic symptom disorder typically have multiple, current, somatic symptoms
that are distressing or result in significant disruption of daily life (Criterion A), although
sometimes only one severe symptom, most commonly pain, is present. Symptoms
may be specific (e.g., localized pain) or relatively nonspecific (e.g., fatigue). The symptoms
sometimes represent normal bodily sensations or discomfort that does not generally signify
serious disease. Somatic symptoms without an evident medical explanation are not
sufficient to make this diagnosis. The individual's suffering is authentic, whether or not it
is medically explained.
The symptoms may or may not be associated with another medical condition. The diagnoses of somatic symptom disorder and a concurrent medical illness are not mutually exclusive, and these frequently occur together. For example, an individual may become seriously disabled by symptoms of somatic symptom disorder after an uncomplicated myocardial infarction even if the myocardial infarction itself did not result in any disability. If another medical condition or high risk for developing one is present (e.g., strong family history), the thoughts, feelings, and behaviors associated with this condition are excessive (Criterion B).
Individuals with somatic symptom disorder tend to have very high levels of worry about illness (Criterion B). They appraise their bodily symptoms as unduly threatening, harmful, or troublesome and often think the worst about their health. Even when there is evidence to the contrary, some patients still fear the medical seriousness of their symptoms. In severe somatic symptom disorder, health concerns may assume a central role in the individual's life, becoming a feature of his or her identity and dominating interpersonal relationships.
Individuals typically experience distress that is principally focused on somatic symptoms and their significance. When asked directly about their distress, some individuals describe it in relation to other aspects of their lives, while others deny any source of distress other than the somatic symptoms. Health-related quality of life is often impaired, both physically and mentally. In severe somatic symptom disorder, the impairment is marked, and when persistent, the disorder can lead to invalidism.
There is often a high level of medical care utilization, which rarely alleviates the individual's concerns. Consequently, the patient may seek care from multiple doctors for the same symptoms. These individuals often seem unresponsive to medical interventions, and new interventions may only exacerbate the presenting symptoms. Some individuals with the disorder seem unusually sensitive to medication side effects. Some feel that their medical assessment and treatment have been inadequate.
Cognitive features include attention focused on somatic symptoms, attribution of normal
bodily sensations to physical illness (possibly with catastrophic interpretations), worry
about illness, and fear that any physical activity may damage the body. The relevant associated
behavioral features may include repeated bodily checking for abnormalities, repeated
seeking of medical help and reassurance, and avoidance of physical activity. These
behavioral features are most pronounced in severe, persistent somatic symptom disorder.
These features are usually associated with frequent requests for medical help for different
somatic symptoms. This may lead to medical consultations in which individuals are so focused
on their concerns about somatic symptom(s) that they cannot be redirected to other
matters. Any reassurance by the doctor that the symptoms are not indicative of serious
physical illness tends to be short-lived and/or is experienced by the individuals as the
doctor not taking their symptoms with due seriousness. As the focus on somatic symptoms
is a primary feature of the disorder, individuals with somatic symptom disorder typically
present to general medical health services rather than mental health services. The
suggestion of referral to a mental health specialist may be met with surprise or even frank
refusal by individuals with somatic symptom disorder.
Since somatic symptom disorder is associated with depressive disorders, there is an increased suicide risk. It is not known whether somatic symptom disorder is associated with suicide risk independent of its association with depressive disorders.
The prevalence of somatic symptom disorder is not known. However, the prevalence of somatic symptom disorder is expected to be higher than that of the more restrictive DSMIV somatization disorder (<1%) but lower than that of undifferentiated somatoform disorder (approximately 19%). The prevalence of somatic symptom disorder in the general adult population may be around 5%-7%. Females tend to report more somatic symptoms than do males, and the prevalence of somatic symptom disorder is consequently likely to be higher in females.
Somatic sjmnptoms are prominent in various "culture-bound syndromes." High numbers
of somatic symptoms are found in population-based and primary care studies aroimd the
world, with a similar pattern of the most commonly reported somatic symptoms, impairment,
and treatment seeking. The relationship between number of somatic symptoms and
illness worry is similar in different cultures, and marked illness worry is associated with
impairment and greater treatment seeking across cultures. The relationship between numerous
somatic symptoms and depression appears to be very similar around the world
and between different cultures within one country.
Despite these similarities, there are differences in somatic symptoms among cultures and ethnic groups. The description of somatic symptoms varies with linguistic and other local cultural factors. These somatic presentations have been described as "idioms of distress" because somatic symptoms may have special meanings and shape patient-clinician interactions in the particular cultural contexts. "Burnout," the sensation of heaviness or the complaints of "gas"; too much heat in the body; or burning in the head are examples of symptoms that are common in some cultures or ethnic groups but rare in others. Explanatory models also vary, and somatic symptoms may be attributed variously to particular family, work, or environmental stresses; general medical illness; the suppression of feelings of anger and resentment; or certain culture-specific phenomena, such as semen loss. There may also be differences in medical treatment seeking among cultural groups, in addition to differences due to variable access to medical care services. Seeking treatment for multiple somatic symptoms in general medical clinics is a worldwide phenomenon and occurs at similar rates among ethnic groups in the same country.
The disorder is associated with marked impairment of health status. Many individuals
with severe somatic symptom disorder are likely to have impaired health status scores
more than 2 standard deviations below population norms.
Most individuals with hypochondriasis are now classified as having somatic symptom
disorder; however, in a minority of cases, the diagnosis of illness anxiety disorder applies
instead. Illness anxiety disorder entails a preoccupation with having or acquiring a serious,
undiagnosed medical illness (Criterion A). Somatic symptoms are not present or, if
present, are only mild in intensity (Criterion B). A thorough evaluation fails to identify a
serious medical condition that accounts for the individual's concerns. While the concern
may be derived from a nonpathological physical sign or sensation, the individual's distress
emanates not primarily from the physical complaint itself but rather from his or her
anxiety about the meaning, significance, or cause of the complaint (i.e., the suspected medical
diagnosis). If a physical sign or symptom is present, it is often a normal physiological
sensation (e.g., orthostatic dizziness), a benign and self-limited dysfunction (e.g., transient
tinnitus), or a bodily discomfort not generally considered indicative of disease (e.g., belching).
If a diagnosable medical condition is present, the individual's anxiety and preoccupation
are clearly excessive and disproportionate to the severity of the condition (Criterion
B). Empirical evidence and existing literature pertain to previously defined DSM hypochondriasis,
and it is unclear to what extent and how precisely they apply to the description
of this new diagnosis.
The preoccupation with the idea that one is sick is accompanied by substantial anxiety about health and disease (Criterion C). Individuals with illness anxiety disorder are easily alarmed about illness, such as by hearing about someone else falling ill or reading a healthrelated news story. Their concerns about undiagnosed disease do not respond to appropriate medical reassurance, negative diagnostic tests, or benign course. The physician's attempts at reassurance and symptom palliation generally do not alleviate the individual's concerns and may heighten them. Illness concerns assume a prominent place in the individual's life, affecting daily activities, and may even result in invalidism. Illness becomes a central feature of the individual's identity and self-image, a frequent topic of social discourse, and a characteristic response to stressful life events. Individuals with the disorder often examine themselves repeatedly (e.g., examining one's throat in the mirror) (Criterion D). They research their suspected disease excessively (e.g., on the Internet) and repeatedly seek reassurance from family, friends, or physicians. This incessant worrying often becomes frustrating for others and may result in considerable strain within the family. In some cases, the anxiety leads to maladaptive avoidance of situations (e.g., visiting sick family members) or activities (e.g., exercise) that these individuals fear might jeopardize their health.
Because they believe they are medically ill, individuals with illness anxiety disorder are encountered far more frequently in medical than in mental health settings. The majority of individuals with illness anxiety disorder have extensive yet unsatisfactory medical care, though some may be too anxious to seek medical attention. They generally have elevated rates of medical utilization but do not utilize mental health services more than the general population. They often consult multiple physicians for the same problem and obtain repeatedly negative diagnostic test results. At times, medical attention leads to a paradoxical exacerbation of anxiety or to iatrogenic complications from diagnostic tests and procedures. Individuals with the disorder are generally dissatisfied with their medical care and find it unhelpful, often feeling they are not being taken seriously by physicians. At times, these concerns may be justified, since physicians sometimes are dismissive or respond with frustration or hostility. This response can occasionally result in a failure to diagnose a medical condition that is present.
Prevalence estimates of illness anxiety disorder are based on estimates of the DSM-III and DSM-rV diagnosis hypochondriasis. The 1- to 2-year prevalence of health anxiety and/or disease conviction in community surveys and population-based samples ranges fiOm 1.3% to 10%. In ambulatory medical populations, the 6-month/1-year prevalence rates are between 3% and 8%. The prevalence of the disorder is similar in males and females.
Environmental. Illness anxiety disorder may sometimes be precipitated by a major life stress or a serious but ultimately benign threat to the individual's health. A history of childhood abuse or of a serious childhood ilhiess may predispose to development of the disorder in adulthood^ Course modifiers. Approximately one-third to one-half of individuals with illness anxiety disorder have a transient form, which is associated with less psychiatric comorbidity, more medical comorbidity, and less severe illness aiixiety disorder.
The diagnosis should be made with caution in individuals whose ideas about disease are congruent with widely held, culturally sanctioned beliefs. Little is known about the phenomenology of the disorder across cultures, although the prevalence appears to be similar across different countries with diverse cultures.
Illness anxiety disorder causes substantial role impairment and decrements in physical
function and health-related quality of life. Health concerns often interfere with interpersonal
relationships, disrupt family life, and damage occupational performance.
Diagnostic FeaturesMany clinicians use the alternative names of "functional" (referring to abnormal central
nervous system functioning) or "psychogenic" (referring to an assumed etiology) to describe
the symptoms of conversion disorder (functional neurological symptom disorder).
In conversion disorder, there may be one or more symptoms of various types. Motor
symptoms include weakness or paralysis; abnormal movements, such as tremor or dystonie
movements; gait abnormalities; and abnormal limb posturing. Sensory symptoms
include altered, reduced, or absent skin sensation, vision, or hearing. Episodes of abnormal
generalized limb shaking with apparent impaired or loss of consciousness may resemble
epileptic seizures (also called psychogenic or non-epileptic seizures). There may be
episodes of unresponsiveness resembling syncope or coma. Other symptoms include reduced
or absent speech volume (dysphonia/aphonia), altered articulation (dysarthria), a
sensation of a lump in the throat (globus), and diplopia.
Although the diagnosis requires that the symptom is not explained by neurological disease, it should not be made simply because results from investigations are normal or because the symptom is "bizarre." There must be clinical findings that show clear evidence of incompatibility with neurological disease. Internal inconsistency at examination is one way to demonstrate incompatibility (i.e., demonstrating that physical signs elicited through one examination method are no longer positive when tested a different way).
Examples of such examination findings include
• Hoover's sign, in which weakness of hip extension returns to normal strength with contralateral hip flexion against resistance.
• Marked weakness of ankle plantar-flexion when tested on the bed in an individual who is able to walk on tiptoes;
• Positive findings on the tremor entrainment test. On this test, a unilateral tremor may be identified as functional if the tremor changes when the individual is distracted away from it. This may be observed if the individual is asked to copy the examiner in making a rhythmical movement with their unaffected hand and this causes the functional tremor to change such that it copies or "entrains" to the rhythm of the unaffected hand or the functional tremor is suppressed, or no longer makes a simple rhythmical movement.
• In attacks resembling epilepsy or syncope ("psychogenic" non-epileptic attacks), the occurrence of closed eyes with resistance to opening or a normal simultaneous electroencephalogram (although this alone does not exclude all forms of epilepsy or syncope).
• For visual symptoms, a tubular visual field (i.e., tunnel vision). It is important to note that the diagnosis of conversion disorder should be based on the overall clinical picture and not on a single clinical finding.
A number of associated features can support the diagnosis of conversion disorder. There
may be a history of multiple similar somatic symptoms. Onset may be associated with
stress or trauma, either psychological or physical in nature. The potential etiological relevance
of this stress or trauma may be suggested by a close temporal relationship. However,
while assessment for stress and trauma is important, the diagnosis should not be withheld
if none is found.
Conversion disorder is often associated with dissociative symptoms, such as depersonalization, derealization, and dissociative amnesia, particularly at symptom onset or during attacks.
The diagnosis of conversion disorder does not require the judgment that the symptoms are not intentionally produced (i.e., not feigned), as the definite absence of feigning may not be reliably discerned. The phenomenon of la belle indifference (i.e., lack of concern about the nature or implications of the symptom) has been associated with conversion disorder but it is not specific for conversion disorder and should not be used to make the diagnosis. Similarly the concept of secondary gain (i.e., when individuals derive external benefits such as money or release from responsibilities) is also not specific to conversion disorder and particularly in the context of definite evidence for feigning, the diagnoses that should be considered instead would include factitious disorder or malingering (see the section "Differential Diagnosis" for this disorder).
Transient conversion symptoms are common, but the precise prevalence of the disorder is unknown. This is partly because the diagnosis usually requires assessment in secondary care, where it is found in approximately 5% of referrals to neurology clinics. The incidence of individual persistent conversion symptoms is estimated to be 2-5/100,000 per year. disease, and the receipt of disability benefits may be negative prognostic factors.
Changes resembling conversion (and dissociative) symptoms are common in certain culturally sanctioned rituals. If the symptoms are fully explained within the particular cultural context and do not result in clinically significant distress or disability, then the diagnosis of conversion disorder is not made.
Conversion disorder is two to three times more common in females.
Individuals with conversion symptoms may have substantial disability. The severity of disability
can be similar to that experienced by individuals with comparable medical diseases.
The essential feature of psychological factors affecting other medical conditions is the
presence of one or more clinically significant psychological or behavioral factors that adversely
affect a medical condition by increasing the risk for suffering, death, or disability
(Criterion B). These factors can adversely affect the medical condition by influencing its
course or treatment, by constituting an additional well-established health risk factor, or by
influencing the underlying pathophysiology to precipitate or exacerbate symptoms or to
necessitate medical attention.
Psychological or behavioral factors include psychological distress, patterns of interpersonal interaction, coping styles, and maladaptive health behaviors, such as denial of symptoms or poor adherence to medical recommendations. Common clinical examples are anxiety-exacerbating asthma, denial of need for treatment for acute chest pain, and manipulation of insulin by an individual v^ith diabetes wishing to lose weight. Many different psychological factors have been demonstrated to adversely influence medical conditions— for example, symptoms of depression or anxiety, stressful life events, relationship style, personality traits, and coping styles. The adverse effects can range from acute, with immediate medical consequences (e.g., Takotsubo cardiomyopathy) to chronic, occurring over a long period of time (e.g., chronic occupational stress increasing risk for hypertension). Affected medical conditions can be those with clear pathophysiology (e.g., diabetes, cancer, coronary disease), functional syndromes (e.g., migraine, irritable bowel syndrome, fibromyalgia), or idiopathic medical symptoms (e.g., pain, fatigue, dizziness).
This diagnosis should be reserved for situations in which the effect of the psychological factor on the medical condition is evident and the psychological factor has clinically significant effects on the course or outcome of the medical condition. Abnormal psychological or behavioral symptoms that develop in response to a medical condition are more properly coded as an adjustment disorder (a clinically significant psychological response to an identifiable stressor). There must be reasonable evidence to suggest an association between the psychological factors and the medical condition, although it may often not be possible to demonstrate direct causality or the mechanisms underlying the relationship.
The prevalence of psychological factors affecting other medical conditions is unclear. In U.S. private insurance billing data, it is a more common diagnosis than somatic symptom disorders.
Many differences between cultures may influence psychological factors and their effects on medical conditions, such as those in language and communication style, explanatory models of illness, patterns of seeking health care, service availability and organization, doctor-patient relationships and other healing practices, family and gender roles, and attitudes toward pain and death. Psychological factors affecting other medical conditions must be differentiated from culturally specific behaviors such as using faith or spiritual healers or other variations in illness management that are acceptable within a culture and represent an attempt to help the medical condition rather than interfere with it. These local practices may complement rather than obstruct evidence-based interventions. If they do not adversely affect outcomes, they should not be pathologized as psychological factors affecting other medical conditions.
Psychological and behavioral factors have been demonstrated to affect the course of many
By definition, the diagnosis of psychological factors affecting other medical conditions entails
a relevant psychological or behavioral syndrome or trait and a comorbid medical condition.
The essential feature of factitious disorder is the falsification of medical or psychological signs and symptoms in oneself or others that are associated with the identified deception. Individuals with factitious disorder can also seek treatment for themselves or another following induction of injury or disease. The diagnosis requires demonstrating that the individual is taking surreptitious actions to misrepresent, simulate, or cause signs or symptoms of illness or injury in the absence of obvious external rewards. Methods of illness falsification can include exaggeration, fabrication, simulation, and induction. While a preexisting medical condition may be present, the deceptive behavior or induction of injury associated with deception causes others to view such individuals (or another) as more ill or impaired, and this can lead to excessive clinical intervention. Individuals with factitious disorder might, for example, report feelings of depression and suicidality following the death of a spouse despite the death not being true or the individual's not having a spouse; deceptively report episodes of neurological symptoms (e.g., seizures, dizziness, or blacking out); manipulate a laboratory test (e.g., by adding blood to urine) to falsely indicate an abnormality; falsify medical records to indicate an illness; ingest a substance (e.g., insulin or warfarin) to induce an abnormal laboratory result or illness; or physically injure themselves or induce illness in themselves or anotiier (e.g., by injecting fecal material to produce an abscess or to induce sepsis).
Individuals with factitious disorder imposed on self or factitious disorder imposed on another are at risk for experiencing great psychological distress or functional impairment by causing harm to themselves and others. Family, friends, and health care professionals are also often adversely affected by their behavior. Factitious disorders have similarities to substance use disorders, eating disorders, impulse-control disorders, pedophilic disorder, and some other established disorders related to both the persistence of the behavior and the intentional efforts to conceal the disordered behavior through deception. Whereas some aspects of factitious disorders might represent criminal behavior (e.g., factitious disorder imposed on another, in which the parent's actions represent abuse and maltreatment of a child), such criminal behavior and mental illness are not mutually exclusive. The diagnosis of factitious disorder emphasizes the objective identification of falsification of signs and symptoms of illness, rather than an inference about intent or possible underlying motivation. Moreover, such behaviors, including the induction of injury or disease, are associated with deception.
The prevalence of factitious disorder is unknown, likely because of the role of deception in this population. Among patients in hospital settings, it is estimated that about 1% of individuals have presentations that meet the criteria for factitious disorder.