Somatic symptom and related disorders — branching viva

Stem

The examiner will test whether you can run a validating, function-first somatic-symptom pathway under pressure — refusing both over-investigation and dismissal — and pivot correctly when a safeguarding concern appears. [1] [2]

Branch 1 — First presentation and validation

Examiner: A 13-year-old has eight months of daily abdominal pain and headache, normal bloods and three normal scans, and now attends school two days a week. Her mother is convinced something is being missed. What do you do first? [1]

Strong answer: See the young person alone, state conditional confidentiality with its lawful limits, and validate that the symptoms are real and not her fault. Take a focused symptom history and the family's explanatory model, then a HEEADSSS-tailored psychosocial history (mood, sleep, school, peers, family, adversity, bullying), screen for suicidality, and examine including a neurological screen. Screen once for red flags — weight loss, growth failure, systemic features, new neurological deficit, nocturnal symptoms — and, with normal tests already in hand, avoid a further cascade. Quantify disability with the Functional Disability Inventory. [1] [4]

Branch 2 — The DSM-5 principle

Examiner: The mother asks, "If all the tests are normal, how can this be a real illness?" What is the diagnostic principle here? [2]

Strong answer: Explain the pivotal DSM-5 / DSM-5-TR point: a somatic symptom disorder is diagnosed on positive grounds — distressing somatic symptoms plus disproportionate thoughts, feelings and behaviours — and the symptoms need not be medically unexplained. The symptoms are genuine; the treatable problem is the amplifying pattern of attention, fear and avoidance around them. Reframe the normal tests as "reassuring because her body is healthy, not because nothing is wrong." Avoid "it's all in her head." [2] [1]

Branch 3 — The symptom-amplification reframe

Examiner: Explain to the family, in language they can use, why the symptom persists. [3]

Strong answer: Use the symptom-amplification loop: a real bodily signal is picked up by selective attention and catastrophising ("this means damage"), which drives anxiety and arousal, sensitising the nervous system so the signal is amplified; avoidance and deconditioning then lock in disability and school absence. Explain that sleep loss, inactivity, repeated "normal" results and family worry all feed the loop. Then say how we break it — validation, CBT/ACT, graded activity, a sleep reset and return to school. The explanation is itself a treatment. [3] [1]

Branch 4 — The function-first interdisciplinary plan

Examiner: Walk me through your management plan. [4]

Strong answer: Set shared FUNCTION goals — school, sleep, movement, friends — not a symptom-elimination target. Coordinate psychology (CBT or ACT), physiotherapy (graded activity), a sleep reset, and a graded school-led return-to-school plan with education liaison. Treat comorbid mood, with SSRI therapy considered only for a comorbid anxiety/depressive disorder under specialist guidance and monitoring. State that opioids have no routine place in a paediatric somatic presentation; simple analgesia within local guidance is at most adjunctive. Name a coordinator and a relapse (flare) plan. [4] [5]

Branch 5 — Conversion disorder on the ward

Examiner: A 12-year-old on the ward has functional left-leg weakness with a positive Hoover sign; structural disease is excluded. How do you establish the diagnosis and manage her? [7]

Strong answer: Conversion disorder (functional neurological symptom disorder) is diagnosed on positive grounds — symptoms clinically incompatible with recognised neurological disease, such as a Hoover sign and internally consistent functional weakness — after a targeted exclusion of mimics, not by piling up normal scans. Validate that the symptoms are real. Management is interdisciplinary: neurology confirms the diagnosis, functional physiotherapy delivers graded motor/sensory retraining, and psychology addresses thoughts and mood. Comorbid anxiety and depression are common and must be treated. Childhood conversion generally has a good prognosis with timely functional intervention. [7] [2]

Branch 6 — Safeguarding challenge: fabricated or induced illness

Examiner: A 7-year-old has inexplicable collapse episodes and abnormal results that happen only when the mother is present; the parents' histories are discordant and the mother wants more invasive tests. What is your concern and your immediate action? [2]

Strong answer: The concern is fabricated or induced illness — a safeguarding presentation, not a psychiatric referral, and distinct from somatic symptom disorder (which is unconscious and without deception). Document the history, examination and test discrepancies objectively and contemporaneously; refer to the local child-protection / multi-agency pathway (in ANZ the statutory child-protection authority and paediatric child-protection team); do not confront the mother alone, which may endanger the child or compromise the investigation; and continue all clinically necessary treatment and monitoring while the process runs. [2] [1]

Examiner extras

• State the DSM-5 principle early and unprompted — symptoms need not be medically unexplained. [2]
• Function is the goal, not symptom elimination — say it first. [4]
• The single word "intentionality" separates factitious disorder from the rest of the family. [2]
• Guard against diagnostic overshadowing, especially in disabled and neurodivergent children. [1]