Just as there is a built-in DSM bias toward somatoform disorder over factitious disorder and malingering, there is a similar bias toward malingering over factitious disorder. Malingering is to be diagnosed when tangible or instrumental benefits accrue from intentional inauthentic illness behavior. In almost every case of genuine illness, benefits are bestowed on the patient. The patient receives extra care and concern, may be placed on paid work leave, is allowed to pass on dinner with the in-laws, and so on. These things happen to virtually everyone who becomes ill or injured, but none of this informs the question of whether inauthentic illness behavior was designed to secure those benefits. There is a difference between a motive and a consequence.8
What are left over for the factitious-disorder category are cases in which patients subject themselves to painful, embarrassing, or debilitating self-harm and medical interventions for no good reason. A malingerer takes a mild fall in a restaurant and gets a half million dollars; a factitious-disorder patient allows both her breasts to be removed so that she can play the role of medical patient for a couple of months.
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.
The behavior of any patient who meets the stringent DSM criteria for factitious disorder strikes the average lay person as truly insane. In fact, clinical experience with dozens of prototypical cases suggests that few patients with factitious disorder—even the extreme Munchausen variant—have any overt signs of thought disorder, disorganized behavior, or psychotic symptoms. Nevertheless, experienced forensic experts who specialize in these types of cases remark that judges and jurors find it hard to believe that such a sane-looking person could have purposefully poisoned himself, or caused his own sepsis, as examples.
There are several implications of the DSM criteria sets for forensic psychiatrists in cases that involve alleged inauthentic illness behavior. First, because of the flaws and biases in DSM, arriving at a DSM diagnosis may not get the examiner or his or her client any closer to the truth of what has transpired in the case at hand. Second, despite its flaws, DSM can and will be used by opposition experts to support the opposition’s theory of the case. Rejoining that there are no data to support the DSM framework is a double-edged sword: there is also no body of evidence to support one’s alterative interpretations.
The differences between factitious disorder and malingering
When confronted with a patient with a factitious disorder, many people find it difficult to fathom someone’s inducing symptoms without the principal objective of external gain. However, for individuals who engage in this behavior, the motivation to play the sick role provides covetous interpersonal benefits. Diagnostic criteria specify that the individual intentionally produces or feigns psychological or physical symptoms without evident external motivations. In assigning this diagnosis, one can specify whether the behavior manifests with predominantly psychological signs and symptoms, predominantly physical signs and symptoms, or a combination of both.9
Factitious disorder is always indicative of psychopathology and may be accompanied by pseudologia fantastica (the telling of tales that are a mélange of fact and fiction).10 Patients who exhibit pseudologia fantastica are usually florid; when questioned, however, these individuals give vague and inconsistent answers regarding the symptoms per se.
DSM-IV-TR suggests that malingering should strongly be considered if one or more of the following contextual factors are present:
• The patient is currently involved in litigation (most often disability claims are in dispute)
• There are noticeable differences between the individual’s claims and objective findings by a health care professional
• The patient is uncooperative in assessment or treatment attempts
The presence of an antisocial personality disorder should also be considered a possible comorbid diagnosis. However, while reasonably sensitive, the findings showing possible comorbidity with antisocial personality disorder have a low specificity.11
Despite the dualism presented in DSM-IV-TR, experience proves that factitious disorder and malingering often co-occur. For instance, a patient starting out with factitious disorder may find it necessary to malinger to “save face” in front of others who question why the patient is not pursuing legal remedies for the apparent medical malpractice that has actually resulted from self-harm.12 Generally, however, the malingerer will attempt to minimize contact with med-ical professionals and testing because each visit or test provides an opportunity for detection; in contrast, the person with factitious disorder welcomes the opportunity to play the role of patient and finds it intrinsically gratifying. Table 1 lists some of the similarities and differences between prototypical presentations of factitious disorder and malingering.
Formal assessments range from clinical guidelines for detecting signs and symptoms that are common to factitious disorder and malingering to formal personality and neuropsychological test batteries.12-17 Although measures built into some tests assist in detecting feigning, these are generally limited to detecting false neurocognitive impairment; such measures do not assess the motivations behind the deceptions. The assessment of internal versus external motivations is often more of an art skill than an objective undertaking. Table 2 presents indicators from patient charts that may point to possible medical deception.13
As suggested, persons with factitious disorder may take their falsification of illnesses and injuries further than is seen in cases of malingering, where the goal is more discrete. The patient’s presentation may not match the diagnostic criteria for the disorder but rather the patient’s conceptualization of how the disorder should manifest.18 Symptom complaints may be unduly numerous or emphatic, or improbable in their combination or severity.14 A survey of neuropsychologists by Slick and colleagues19 found that clinicians often do not use the explicit labels of malingering or factitious disorder but merely indicate that their assessment of the patient’s symptoms was inconsistent with the proposed illness or injury.
There is an inherent uncertainty in differentiating malingering from factitious disorder. Drob and colleagues20 articulated several concerns that psychiatrists may face when evaluating these cases for forensic purposes. They note that there is a specific disadvantage in diagnosing malingering because it depends on the context rather than on the presence or absence of diagnostic criteria. In addition, other pathology comorbid with either malingering or factitious disorder can cloud the diagnostic picture.20
Several case decisions have intensified the standards that forensic psychiatrists must use to detect malingering).21 These decisions have made it necessary for psychiatrists to use measures with accepted reliability in the scientific community more often than their personal expertise and clinical knowledge.22