Riverview Psychiatric Center

Psychology Articles by Dr. Arthur Dingley - It’s All In Your Head

Dr. Art Dingley

When a patient complains of physical ailments, and her doctor can’t find anything wrong, the physician may tactfully raise the possibility that the problem is psychological. Psychiatrists often see patients with undiagnosable complaints such as fatigue, chronic pain, stomach upset, and headaches. Mental health professionals classify these problems into several distinct types.

Malingering is unique because the malingering patient is just plain making it up. Malingering is lying about one’s physical or psychiatric condition in order to get something. Usually, the malingerer wants money, like disability benefits or an insurance settlement, or she may want a prescription for abusable drugs. Malingering is not a form of mental illness.

In Facitious Disorder, like Malingering, the person fakes symptoms of physical or psychiatric illness. With Factitious Disorder, however, there is an interesting twist. The motivation for Malingering is some external incentive. The motivation in Factitious Disorder is to get medical treatment. In addition to simply faking symptoms, some people with Factitious Disorder will actually make themselves sick in order to get medical treatment. Many people with Factitious Disorder are health care workers who can divert medicines and know how to cause signs of disease. A classic example would be a nurse who steals needles and injects insulin, thyroid hormone, or infectious matter in order to cause an apparent illness. Again, his motive would not be to get insurance money, or time off from work, but to get medical care.

More concerning are people who make their children ill in order to get medical treatment for the child. One example involved a mother who repeatedly smothered her infant with a pillow, then frantically reported that the baby had “stopped breathing”. She was eventually caught by a camera hidden in the child’s hospital room. Unlike malingerers, people with Factitious Disorder have a psychiatric illness. Usually, Factitious Disorder is seen in people with other kinds of psychiatric conditions, such as personality disorders. More men than women have Factitious Disorder.

Hypochondriasis is a preoccupation with the idea that one has a serious disease. The idea is based on misinterpreting or catastrophizing some bodily sign or sensation. The hypochondriac can acknowledge the possibility that she may be exaggerating. This separates the hypochondriac from someone who is delusional. Even so, a person with Hypochondriasis persists with her fear of dread disease even after medical assurance that she is not ill. A person with Hypochondriasis is so preoccupied with the idea that she is seriously ill that it begins to interfere with her life. She will begin “doctor shopping” after becoming angry at her family physician for “not taking her seriously” or “telling her that it’s all in her head.” She demands to have expensive, unwarranted tests and procedures. She may demand special treatment or consideration from family and friends because of her perceived condition. Time lost from work may result in unemployment and then a protracted, and unsuccessful, battle to be declared disabled. Hypochondriasis is equally common in men and women.

Somatoform Disorder is a persistent set of physical complaints that can’t be fully explained by any known medical condition. The most common are complaints of chronic fatigue, weakness, loss of appetite, gastrointestinal problems, and urinary problems. A person with Somatoform Disorder will consult his family doctor, but he is not making up symptoms to get medical attention (Factitious Disorder). He wants to feel better, but is not convinced that he is dying of some terrible disease (Hypochondriasis). Unexplained physical complaints are most common in young, poor, women.

Somatization Disorder is pattern of many physical complaints, beginning before the age of thirty, which cannot be explained by any known medical condition. The complaints must come from each of four areas: First, the person must have pain in at least four places. Second, she must have two gastrointestinal complaints, such as bloating, nausea, diarrhea, or food intolerance. Third, he must have at least one sexual or reproductive symptom. Finally, he must have one neurological complaint, such as numbness, localized weakness, dizziness, difficulty swallowing, seizures, or loss of consciousness. People with Somatization Disorder often describe their symptoms with drama, but in a vague and impressionistic way. Their descriptions of symptoms tend to be inconsistent. Although the person may seek medical attention, she is not faking symptoms in order to get medical treatment (Factitious Disorder), nor is she determined that she has some undiagnosed dread disease (Hypochondriasis). Even so, these folks are often seeing several doctors at the same time, undergoing many tests, and taking multiple medicines. They often have real side effects from their long lists of medicines and complications from multiple diagnostic procedures. Many people with Somatization Disorder have chaotic lives, fraught with interpersonal conflict. They commonly have depression, anxiety, personality disorders, and substance abuse disorders. In the United States, Somatization Disorder is rare in men.

Conversion Disorder is a condition in which psychic distress is “converted” into a physical symptom, usually some type of paralysis or sensory difficulty. A person with Conversion Disorder may develop impaired balance or coordination, weakness, paralysis of the legs, or inability to speak. She may appear to be blind, or deaf, or to have seizures. It is interesting to note that the deficits do not follow any actual neurological pathways but, instead, follow the person’s own ideas about how his nervous system works. This means that the less medical knowledge the person has, the less plausible his complaints will be. People with Conversion Disorder may present their symptoms with great drama. More often, however, they seem oddly unconcerned with their sudden blindness or paralysis – things the average person would find extremely alarming. This separates these folks from people with Hypochondriasis. People with conversion disorder are not faking their symptoms the way people do when malingering or when they have Factitious Disorder. Conversion Disorder is uncommon but is seen much more often in women.

How do you get better when “it’s all in your head”? Each of these conditions creates its own challenge for healthcare providers. Malingerers, though infuriating, go away once they get what they want, or give up when they find they can’t. They must be dealt with firmly and clearly. Fortunately, Factitious Disorder is rare. The patient must be confronted directly when his fakery is uncovered. People with Factitious Disorder often benefit from treatment of other problems such as personality disorders. Conversion Disorder often gets better on its own or responds to brief psychotherapy aimed at resolving the underlying psychic distress. Somatization Disorder may respond to a combination of psychotherapy and medicine aimed at the underlying anxiety and negative thinking which keep people tuned in to their symptoms. Office visits should be focused and brief. Medicine should be prescribed sparingly. Diagnostic tests must be kept to the bare minimum. Patients with Hypochondriasis are often resistant to psychiatric treatment because they fear that they will die of some terrible disease in the meantime. Cognitive psychotherapy aimed at the thinking errors which perpetuate Hypochondriasis may be very helpful if the person can stop doctor-shopping long enough.

Dr. Dingley is a psychiatrist at Evergreen Behavioral Services in Farmington. He may be contacted at adingley@fchn.org

Agency information

Riverview Psychiatric Center

Psychology Articles by Dr. Arthur Dingley - It’s All In Your Head

Featured links

RPC news