Conversion Disorder and Factitious Disorder vs Malingering are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.
Conversion Disorder vs Factitious Disorder vs Malingering at a glance
Factitious Disorder vs Malingering: Both involve intentional symptom production; factitious is motivated by the sick role, malingering by external incentive (only factitious is a mental disorder).
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Question 1PsychiatryMedium
A 27-year-old woman is referred for recurrent "seizures" that began after a recent divorce. Episodes involve 5-10 minutes of side-to-side head shaking and asynchronous, thrashing limb movements with the eyes held tightly closed; she has no tongue biting, no incontinence, and recalls the events afterward. Two trials of antiepileptic drugs have not reduced the frequency. Neurologic examination, routine EEG, and MRI of the brain are normal. Which of the following is the most appropriate next diagnostic test?
ASerum prolactin within 20 minutes
BProlonged video EEG monitoring
CContinuous cardiac event monitoring
DLumbar puncture with CSF analysis
Reveal answer & full explanation
Correct answer: B — Prolonged video EEG monitoring
ASerum prolactin within 20 minutes
BProlonged video EEG monitoring✓
CContinuous cardiac event monitoring
DLumbar puncture with CSF analysis
Why Prolonged video EEG monitoring is correct
The semiology — events lasting 5-10 minutes, side-to-side head shaking, asynchronous thrashing limb movements, forced eye closure, retained awareness, no tongue biting or incontinence, and failure of two antiepileptic trials — is classic for psychogenic nonepileptic seizures (PNES), a subtype of conversion (functional neurological symptom) disorder.
Video EEG is the gold standard: it captures a typical event while showing the absence of epileptiform ictal discharge, giving the positive evidence of incompatibility that rules IN PNES.
A confirmed diagnosis stops further antiepileptic exposure and redirects the patient to cognitive behavioral therapy.
Why the others are wrong
Lumbar puncture with CSF analysis — evaluates suspected CNS infection or subarachnoid hemorrhage; nothing in this afebrile, stable patient with normal imaging points to either.
Serum prolactin within 20 minutes — an elevated level 10-20 minutes after an event supports a generalized tonic-clonic or focal impaired-awareness seizure over PNES (specific but insensitive), but a normal level does not exclude epilepsy and it cannot capture the event; it is an adjunct, not the diagnostic standard.
Continuous cardiac event monitoring — targets arrhythmic causes of brief, flaccid loss of consciousness, but these spells last 5-10 minutes with thrashing movements, forced eye closure, and preserved recall, and it records no cerebral activity, so it cannot demonstrate the absent ictal discharge that establishes PNES.
Question 2PsychiatryMedium
A 34-year-old nurse is admitted for the fourth time in six months for episodes of confusion and diaphoresis, and each admission has documented a serum glucose in the 30s mg/dL. She is eager to undergo additional testing and asks repeatedly about exploratory procedures, but becomes evasive and refuses to consent when the team requests records from the three other hospitals where she has been treated. During this admission, a fingerstick glucose is normal whenever a staff member remains in the room. Workup during a hypoglycemic episode shows an elevated serum insulin with a suppressed C-peptide, and a nurse later finds an insulin pen and used syringes in her bag. There is no pending litigation, disability claim, or other external incentive. Which of the following is the most likely diagnosis?
AMalingering of induced hypoglycemia
BFactitious disorder imposed on self
CFactitious disorder imposed on another
DIllness anxiety disorder, care-seeking
Reveal answer & full explanation
Correct answer: B — Factitious disorder imposed on self
AMalingering of induced hypoglycemia
BFactitious disorder imposed on self✓
CFactitious disorder imposed on another
DIllness anxiety disorder, care-seeking
Why Factitious disorder imposed on self is correct
The patient consciously falsifies illness: she self-administers exogenous insulin, proven by the lab pattern of elevated serum insulin with a suppressed C-peptide (an outside insulin source raises measured insulin while shutting off endogenous secretion). The insulin pen and used syringes confirm she is inducing the hypoglycemia.
Classic factitious red flags are all present: a healthcare background, recurrent admissions across multiple institutions, eagerness for invasive procedures, symptoms that normalize when she is observed, and refusal to let the team contact prior caregivers.
The decisive feature is the ABSENCE of any external incentive. Per DSM-5-TR, deception with falsification or induction of illness occurring without an obvious external reward defines factitious disorder; the motive is the intrapsychic need to assume the sick role.
Why the others are wrong
Malingering of induced hypoglycemia is the deliberate production of symptoms for an EXTERNAL incentive (disability, drugs, avoiding work, legal benefit). The stem explicitly states there is no litigation, disability claim, or other external gain, so the watershed feature for malingering is absent.
Factitious disorder imposed on another requires that illness be falsified or induced in a victim, such as a child or a patient under her care, who is then presented for treatment; here she is injecting herself and presenting herself, so the sick role she assumes is her own.
Illness anxiety disorder, care-seeking is preoccupation with having or acquiring a serious illness with minimal or no actual somatic symptoms; there is no fabrication or self-induction of physical findings.
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Neurologic symptoms (motor, sensory, seizure-like) incompatible with recognized neurologic disease.
Both involve intentional symptom production; factitious is motivated by the sick role, malingering by external incentive (only factitious is a mental disorder).
Classic presentation
Motor: limb weakness or paralysis, tremor, abnormal gait, dystonia; Sensory: anesthesia or paresthesia in nonanatomic distribution; Special sensory: blindness, deafness, diplopia; Speech: dysphonia, dysarthria, mutism; Seizure-like: nonepileptic attacks with retained awareness, asynchronous limb movement, eyes closed, side-to-side head…
Dramatic, atypical, or 'textbook' symptom presentations; Symptoms worsen when patient observed; inconsistent with objective findings; Eagerness to undergo invasive procedures; Multiple hospitalizations across institutions, often with feigned identities or addresses; Resistance to letting providers communicate with prior caregivers;…
Workup / key labs
DSM-5-TR: ≥1 altered motor/sensory symptom; clinical findings show incompatibility with known disease (positive signs); not better explained otherwise; impairment/distress. Specify acute (<6 mo) vs persistent (>6 mo); with vs without psychological stressor.; Targeted to exclude mimics — TSH, CMP, glucose, B12, autoimmune panel as…
Factitious: deception with falsification or induction; presents self/other as ill; behavior evident even without external reward; not better explained by another disorder. Malingering: intentional symptom production for external incentive — coded as V65.2 / Z76.5 (not a mental disorder).; Targeted testing based on presentation;…
Imaging
MRI brain/spine if focal neurologic symptoms; Video EEG — gold standard for PNES; captures event and confirms absence of epileptiform discharge; Nerve conduction/EMG if peripheral weakness or sensory loss; Avoid open-ended scanning that prolongs uncertainty
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First-line treatment
Clear, confident communication of the diagnosis using positive signs — explain it as a 'software, not hardware' problem; do NOT frame as 'no disease found'; Physical therapy / occupational therapy for motor symptoms — neurorehabilitation tailored to FND; Cognitive behavioral therapy, especially for PNES; Treat comorbid depression,…
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Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.