Caveats for forensic psychiatrists
In the legal realm, the distinction between factitious disorder and malingering may have important implications. In a forensic evaluation, the recognition of either phenomenon has implications for the patient’s future, both legally and medically. In the legal context, not only are symptom presentations being called into question, but individuals who feign a medical disorder can also face criminal charges. These individuals may be prosecuted for false disability claims or charged with inappropriate use of health care resources by hospitals or their insurance companies.23 Furthermore, they themselves may bring charges against medical professionals for claims of malpractice that include explicit recognition of deception.
In interacting with these patients in medical practice, there are concerns about ethical obligations for treatment. Hamilton and Feldman12 question whether the doctor-patient relationship persists after the patient enacts medical deception, and question what responsibility the physician has once feigning is discovered. If the relationship is broken, does the physician have a responsibility to notify other professionals whom the patient may see so that they are not misled into providing unwarranted treatment? When individuals are “exposed,” an additional complication includes medical professionals’ bringing legal action for the misdirected, and often unreimbursed, medical services.3,23
One side or the other may use the existence of factitious disorder to advance the claim that the accused patient was legally insane and therefore not legally responsible for his actions. Each case must be considered individually. However, patients with factitious disorder rarely meet the criteria for legal insanity. In this respect, there is little practical significance to distinguishing between factitious disorder and malingering. However, it is reasonable to argue that the illness deceptions in factitious disorder bear a close relationship to compulsions and may represent a legitimate mitigating condition that is generally not present in malingering.
It is a mistake to assume that all malingerers are driven by shameless greed. There are countless scenarios in which malingering might be the product of financial desperation, a desire to escape physical or emotional abuse, or other causes. A fair and thorough evaluation of medical deception should include sufficient psychosocial history gathering to understand the context of medical deception.
Psychiatric reports of medical deception, particularly of cases involving factitious disorder, often make the curious assumption that a patient’s self-reported history about past abuse or another significant psychiatric event is somehow more trustworthy than all the lies, simulations, and obfuscations that are used to deceive doctors.
Professionals sometimes mistakenly assume that uncovering medical deception is sufficient proof that the patient is not really physically ill or injured. Medical deception does not ameliorate the risk of authentic disease or injury, however. In some cases, intentional exaggeration of symptoms might reflect a desperate attempt to get attention for a medi-cal problem that the patient actually has.
Andrea, a 32-year-old part-time athletic coach, was a passenger in a van operated by the Police Athletic League of a major city. During an outing, the van and a car sideswiped each other. No injuries were evident among the riders in either vehicle, and no one requested or required medical intervention. Six months later, Andrea filed a lawsuit alleging that the incident had in fact caused a head injury that resulted in progressive paresis. By the time a psychiatric expert was retained by the defense, Andrea was ostensibly quadriplegic.
After completing a review of the extensive medical records, the expert found it incontrovertible that the patient was feigning her paralysis. Among other factors, he noted that it was unusual that a motor vehicle accident for which on-site medical evaluation and treatment were refused—one in which no head injury was initially reported—had culminated in ostensibly permanent disability.
Although the patient had seen an extraordinary number of medical providers, she reported that no intervention had ever helped her. However, her symptoms were disconfirmed by objective testing. Andrea’s statements were deemed inconsistent and misleading, and she was found to have lied floridly and gratuitously about her education and career. The medical records showed that she had had more than 60 hospitalizations after the accident for ailments that typically eluded formal diagnosis. In addition, she had generally signed out against medical advice after the recommendation of a psychiatric consultation or the opposition of the staff to her escalating demands for potentially abusable drugs.
Before the accident, Andrea was living in poverty. Following the accident, she received full-time home health care, maid services, workers’ compensation payments, and Medicaid. Weighing the potential motivations for Andrea’s behavior, the psychiatric expert opined that malingering was primary, with factitious disorder secondary. Noting that the patient had obtained at least 30 prescriptions for diazepam(Drug information on diazepam) and meperidine during an 18-month period, he indicated that the goals of the malingering included acquisition of abusable drugs, the disability entitlements and, most important, the potential financial windfall from the litigation. Factitious disorder was indicated by the severe and chronic nature of her falsified signs and symptoms, her pseudologia fantastica, and her itinerancy (ie, the triad for the diagnosis of Munchausen syndrome).
Because of the breadth and duration of the symptoms, the associated litigation, and the inappropriate procurement of resources that had already taken place, the psychiatric expert predicted that resolution of the malingering was all but impossible. Although the defendant denied culpability, they were induced to settle the case for $500,000. Their reasons included the complexity of the case, the likelihood of a prolonged trial, and the difficulty a jury might have in believing that an ostensibly ill, wheelchair-bound woman would fake her own ailments and, in the process, successfully mislead so many physicians.
The primary difference between malingering and factitious disorder is the question of motivation. Is the patient seeking to take the sick role and receive interpersonal benefits from this illness behavior or are there external incentives for his behavior? Although evaluations of these patients are complicated, several protocols have been developed for assessment, and supplemental guidelines written by professionals in the field can aid in evaluation.12-17 Forensic psychologists are presented with a challenge when asked to evaluate these individuals in medical or legal settings. Specific concerns for the professional include ethical obligations for treatment of the individual, and financial and legal concerns related to factitious disorder and malingering.