11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders

1. Schizophrenia and Delusional Disorders

Schizophrenia requires at least six months of disturbance with at least one month of active symptoms, including at least one of delusions, hallucinations or disorganized speech, plus functional decline.

Negative and cognitive symptoms are the main determinants of long-term function, and they respond least to medication — a point worth remembering when a vignette implies that a stable patient with residual flat affect is inadequately treated.

Delusional disorder features one or more delusions for at least a month without the other features of schizophrenia and with otherwise preserved function. The somatic type — a fixed false belief of infestation, malodor or deformity — is the one internists meet, typically after multiple dermatologic or infectious disease referrals. Confrontation is counterproductive; maintaining the therapeutic relationship and referring for psychiatric care is more effective.

Before diagnosing a primary psychotic disorder, exclude medical causes: delirium, substance intoxication or withdrawal (stimulants, cannabis, alcohol, corticosteroids), temporal lobe epilepsy, neurosyphilis, HIV, autoimmune encephalitis (notably anti-NMDA receptor encephalitis in a young person with psychosis, seizures and dyskinesias), thyroid disease, vitamin B12 deficiency and Wilson disease. New psychosis after age 40 is medical until proven otherwise.

2. Complications of Antipsychotic Therapy

The blueprint lists complications of drug therapy explicitly under this subsection, and these are the items an internist is most likely to face.

Metabolic effects

Second-generation antipsychotics cause weight gain, dyslipidemia and type 2 diabetes, contributing substantially to the reduced life expectancy in serious mental illness. Olanzapine and clozapine carry the highest metabolic burden; aripiprazole, ziprasidone and lurasidone the lowest.

Monitoring is a quality standard: weight and body mass index at baseline and regularly, waist circumference, fasting glucose or hemoglobin A1c, lipids, and blood pressure.

Movement disorders

Two traps: akathisia is frequently mistaken for worsening psychosis, and increasing the antipsychotic dose makes it worse. And anticholinergics help acute dystonia but worsen tardive dyskinesia — the correct drug depends entirely on which syndrome is present.

Other adverse effects

• Hyperprolactinemia — galactorrhea, amenorrhea, gynecomastia, sexual dysfunction, bone loss; worst with risperidone and first-generation agents.
• QT prolongation — greatest with ziprasidone, haloperidol (especially intravenous) and thioridazine.
• Neuroleptic malignant syndrome — covered separately.
• Clozapine, reserved for treatment-resistant schizophrenia and for reducing suicidality, requires mandatory absolute neutrophil count monitoring for agranulocytosis, and also causes myocarditis (early, with chest pain, tachycardia and elevated troponin), seizures, severe constipation progressing to ileus, sialorrhea and orthostasis.

3. Somatic Symptom and Related Disorders

The blueprint lists somatoform disorders with subtopics somatic symptom disorder, hypochondriasis and conversion disorder.

A crucial conceptual update: somatic symptom disorder is no longer defined by the absence of a medical explanation. It is defined by the disproportionate psychological and behavioral response. A patient may have both genuine coronary disease and somatic symptom disorder.

Conversion disorder is a positive diagnosis, not a diagnosis of exclusion. Hoover sign — weak voluntary hip extension that normalizes with contralateral hip flexion against resistance — demonstrates internal inconsistency. The symptoms are not feigned; the patient is not producing them deliberately.

Management principles across this group:

• Regularly scheduled visits with one primary clinician, not visits driven by symptom escalation
• Limit new diagnostic testing, which reinforces illness behavior and generates false positives
• Acknowledge that the suffering is real; avoid framing the problem as nothing wrong
• Shift the goal from cure to function
• Treat comorbid depression and anxiety; cognitive behavioral therapy has the best evidence

4. Factitious Disorder and Malingering

Both involve conscious deception, which distinguishes them from somatic symptom and conversion disorders. Motivation is the discriminator.

Clues to factitious disorder: extensive medical knowledge, numerous hospitalizations at different institutions, symptoms that appear only when observed, willingness to undergo painful procedures, resistance to release of outside records, and objective findings that are physiologically inconsistent — such as hypoglycemia with high insulin and suppressed C-peptide (exogenous insulin), unexplained infections with mixed enteric organisms, or covert diuretic or laxative use.

Factitious disorder imposed on another (formerly Munchausen syndrome by proxy) is child abuse and requires mandatory reporting.

Management avoids direct confrontation, which usually causes the patient to leave and seek care elsewhere. Better approaches involve minimizing further invasive testing, a face-saving framing that permits recovery, and psychiatric involvement.

5. Personality Disorders

A named blueprint subsection. Enduring, inflexible patterns of inner experience and behavior deviating from cultural expectation, beginning by early adulthood and causing impairment.

Borderline personality disorder is the one internists encounter most consequentially: affective instability, unstable relationships alternating between idealization and devaluation, identity disturbance, impulsivity, chronic emptiness, frantic efforts to avoid abandonment, and recurrent self-harm and suicidal behavior. Lifetime suicide risk is substantial and self-harm must not be dismissed as merely attention-seeking.

Treatment is psychotherapy — dialectical behavior therapy has the strongest evidence. No medication treats the disorder itself; medications target comorbid depression, anxiety or transient psychotic symptoms, and polypharmacy is a common harm.

Practical management in medical settings:

• Maintain consistent, clearly stated boundaries that are the same across the team
• Communicate as a team to prevent splitting, in which staff are divided into all-good and all-bad
• Validate distress without capitulating to demands that are not clinically appropriate
• Recognize countertransference — strong feelings of anger, rescue fantasies or dread are diagnostic information, not personal failures

Obsessive-compulsive personality disorder must be distinguished from obsessive-compulsive disorder. The personality disorder involves ego-syntonic perfectionism, rigidity and control — the patient sees these traits as correct and does not want to change them. Obsessive-compulsive disorder involves ego-dystonic intrusive obsessions and compulsions that the patient recognizes as excessive and finds distressing.

6. Eating Disorders in Brief

Covered in detail with sleep and sexual disorders, but noted here because anorexia nervosa carries the highest mortality of any psychiatric disorder apart from opioid use disorder, from both medical complications and suicide.

7. The Interface with Medical Care

Serious mental illness reduces life expectancy by roughly 10 to 20 years, and most of that gap is from cardiovascular disease, not suicide. The mechanisms are actionable by internists:

• Metabolic effects of antipsychotics — see above
• Very high smoking prevalence — cessation treatment is effective in this population and does not destabilize psychiatric illness
• Diagnostic overshadowing — attributing new physical symptoms to the psychiatric illness and therefore under-investigating them
• Reduced access to preventive care — lower rates of cancer screening, immunization and lipid and diabetes screening

Diagnostic overshadowing is the exam-relevant error. A patient with schizophrenia who reports abdominal pain deserves the same evaluation as anyone else; assuming a somatic delusion is how perforations and malignancies are missed.