11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders

Key Takeaways Explain This Topic AI

Schizophrenia and delusional disorders, somatoform disorders, factitious disorders and personality disorders are four separate named blueprint subsections.

Complications of antipsychotic drug therapy are explicitly enumerated under schizophrenia in the blueprint.

Somatic symptom disorder requires disproportionate thoughts and behaviors about symptoms, which may be medically explained or unexplained.

Factitious disorder involves deliberate falsification without external incentive, whereas malingering is motivated by external gain and is not a psychiatric diagnosis.

Clozapine requires absolute neutrophil count monitoring because of agranulocytosis risk and also causes myocarditis and severe constipation.

Last updated: August 2026

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.

• Symptom domain Examples Response to antipsychotics
• Positive Delusions, hallucinations, disorganized speech and behavior Good
• Negative Flat affect, alogia, avolition, anhedonia, asociality Poor
• Cognitive Impaired attention, working memory, executive function Poor

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

Syndrome Onset Features Treatment

Acute dystonia Hours to days Torticollis, oculogyric crisis, laryngospasm Anticholinergic (benztropine) or diphenhydramine, parenterally

Akathisia Days to weeks Inner restlessness, inability to sit still; often misread as agitation or anxiety Reduce dose; propranolol; benzodiazepine

Parkinsonism Weeks to months Bradykinesia, rigidity, tremor Reduce dose or switch agent

Tardive dyskinesia Months to years Choreoathetoid orofacial movements; may be irreversible VMAT2 inhibitor (valbenazine, deutetrabenazine); anticholinergics worsen it

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.

Disorder Core feature

Somatic symptom disorder Distressing somatic symptoms with disproportionate thoughts, feelings and behaviors about them; symptoms may be medically explained

Illness anxiety disorder (hypochondriasis) Preoccupation with having a serious illness with minimal or no somatic symptoms

Conversion disorder (functional neurologic symptom disorder) Neurologic symptoms incompatible with recognized disease , demonstrated by positive signs such as Hoover sign

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

• Factitious disorder Malingering
• Symptom production Deliberate falsification Deliberate falsification
• Motivation Internal — to assume the sick role External — money, drugs, avoiding work or prosecution
• Classification A psychiatric disorder Not a psychiatric disorder

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.

• Cluster Description Disorders
• A Odd, eccentric Paranoid, schizoid, schizotypal
• B Dramatic, emotional, erratic Antisocial, borderline , histrionic, narcissistic
• C Anxious, fearful Avoidant, dependent, obsessive-compulsive

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.