The Case of Factitious Disorder Versus Malingering

Patients who exaggerate, feign, or induce physical illness are a great challenge to their physicians. Trained to trust their patients’ self-reports, even competent and conscientious physicians can fall victim to these deceptions. In doing so, the treating physician may unwittingly provide support for specious claims of illness or injury by conferring official diagnoses, or by delivering treatments that transform the patient from a pretender into a person with a genuine, although iatrogenic, medical problem (eg, via adrenalectomy, pancreatectomy, serial amputation).^1-3

Forensic psychiatrists may be called on during civil or criminal litigation to help determine the authenticity of a patient’s apparent medical illnesses or injuries. Even when a patient’s medical deceptions are proved beyond any doubt, the forensic psychiatrist may be asked to help determine the underlying psychological processes that led to the deception. In other cases, the patient may pursue civil damages from the treating physician for performing unnecessary interventions, and the forensic psychiatrist is asked to weigh in on the culpability of a colleague for failing to detect the deception.^4-6

The forensic psychiatrist faces 2 synergistically related obstacles. First, in contrast to malingering, there is little empirical research on the nature of factitious disorder, its underlying psychological processes, or ways to assess it. Second, despite the aforementioned lack of scientific evidence, DSM-IV-TR provides an artificially definitive classification system for patients with inauthentic illness behavior, to which the examiner’s conclusions are expected to correspond.

Consciousness, intentionality, and insanity in DSM

Many decisions in legal proceedings boil down to the question of consciousness and intention. Was the defendant aware of what he or she was doing, did he intend to do it, and was the motive for doing it reasonable? Conveniently, DSM-IV-TR categories dealing with inauthentic illness behavior (ie, behaving as if one is sick when one really is not) neatly address these questions.

The DSM somatoform disorders category specifies 5 disorders for which inauthentic illness behavior presumably is neither conscious nor intentional. These are somatization disorder, hypochondriasis, conversion disorder, pain disorder, and undifferentiated somatoform disorder. It specifies another category-factitious disorder-in which inauthentic illness behavior is consciously and intentionally produced. This category is reserved for people whose motives appear to reflect severe psycho-pathology (eg, a person who would agree to prophylactic double mastectomy just to get attention from medical personnel, friends, and coworkers).⁷DSM also recognizes cases of malingering (as a “V” code, not a true psychiatric diagnosis) in which the inauthentic medical behavior is conscious, intentional, and reflects more comprehensible motives (eg, faking a fall in a retail store to get millions of dollars in compensation for medical and emotional damages).

Without detailing the full DSM diagnostic criteria sets for these disorders and their relations, the following is a summary of how DSM instructs psychiatrists to diagnose cases of inauthentic illness behavior:

1. In the absence of overwhelming affirmative evidence of intentional medical deception (eg, caught on video, evidence from a room search), diagnose a somatoform disorder.

2. If there is traditional forensic evidence of overt medical deception, diagnose malingering or factitious disorder.

3. If there is any significant material or instrumental benefit from the intentional medical deception (eg, financial settlement, disability determination, access to narcotic medicine), diagnose malingering.

These 3 categories are mutually exclusive, and there is no hedging.

Anyone with even minimal experience in dealing with patients with complex and suspicious medical histories recognizes how inadequate and oversimplified DSM directives are. The criteria make it virtually impossible to diagnose a case as anything other than a somatoform disorder when intentionality cannot be proved with traditional forensic evidence. There are no psychological tests of consciousness, and even strong evidence of a relationship between the occurrence of inauthentic illness behavior and tangible benefits would not suffice to overrule a somatoform diagnosis. Thus, in cases dominated by subjective complaints like pain, fatigue, and weakness, it is virtually impossible to definitively diagnose factitious disorder or malingering.

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 mlange 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

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