**Background:** The disease burden from somatoform disorders and medically unexplained symptoms is high, with a meta-analysis of 32 studies reporting a prevalence of at least one somatoform disorder at 34.8% in high-quality primary care studies, a mean lifetime prevalence of 41%, and 40–49% of primary care patients having at least one medically unexplained symptom. Factitious disorders, where patients intentionally fabricate illness, are underdiagnosed due to their secretive nature, with prevalence estimates ranging from 1.3% to 6%. Differentiating somatoform disorders (actual suffering with unconscious symptoms) from factitious disorders (deliberate symptom production) is crucial for disability benefit decisions, as factitious disorder can lead to income suspension. This case report illustrates the impact of misdiagnosis between these conditions on disability benefits and psychosocial outcomes.
**Methods:** The patient was evaluated in a multidisciplinary medical expertise service, including a general practitioner, psychiatrists, and a neuro-ophthalmologist. Data were collected from medical records, psychiatric interviews, and comprehensive ophthalmological and neurological assessments. The evaluation aimed to review a disability income decision after a prior diagnosis of factitious disorder.
**Key Results:** A 42-year-old Caucasian woman, a former fiduciary accountant, developed persistent trigeminal neuralgia at age 32, leading to 100% disability benefits. Despite multiple interventions (glycerolization, microvascular decompression, radiosurgery, subcutaneous electrodes), pain persisted. At age 36, she developed progressive visual loss, becoming completely blind by age 39. At age 42, neuro-ophthalmological examination showed total absence of light perception subjectively, but objective findings were normal: fundus examination revealed normal macula, peripheral retina, retinal vessels, and optic nerve in both eyes; Optical Coherence Tomography (OCT) was normal; electrophysiological testing (multifocal ERG, full-field ERG, pattern visual evoked potentials) was normal. Only left neurotrophic keratitis from prior trigeminal therapies was found, insufficient to explain total blindness. Vitamin B12 deficiency (99 pmol/L; norm 145–569 pmol/L) was treated but did not improve vision. Psychiatric history revealed childhood sexual abuse at age 7, repeated abuse by a teacher at age 14 (including being blindfolded during abuse and a forced abortion while blindfolded), and a traumatic relationship breakup at age 30. Visual symptoms emerged during exposure therapy for trauma. A prior psychiatric expert diagnosed factitious disorder at age 39, leading to disability income suspension and family conflict. Our psychiatric examination concluded diagnoses of pain disorder related to psychological factors and dissociative neurological symptom disorder with visual disturbance (ICD-11 6B60.0), ruling out factitious disorder or simulation. The patient showed no premeditated intentionality; symptoms were linked to unconscious psychic conflicts and trauma reactivation (e.g., blindness associated with being blindfolded during abuse).
**Clinical Implications:** This case underscores that functional non-organic blindness can accompany trauma and psychological distress, and misdiagnosis as factitious disorder can have severe consequences, including disability income loss and family conflict. Differentiating somatoform/dissociative disorders from factitious disorders is essential in insurance medicine. The ICD-11 diagnosis of dissociative neurological symptom disorder with visual disturbance (6B60.0) provides a more precise classification. Psychotherapy, biopsychosocial approaches, and transparent explanation of visual ability within a strong doctor-patient relationship are therapeutic. Early and accurate diagnosis can prevent unnecessary interventions and improve outcomes.