Monthly Archives: August 2010

Comparing Factitious Disorders with Malingering


The manifestations of factitious disorder are limited only by human motivation and creativity.  To illustrate this position I would guide the reader to a case study conducted in which a 19 year old female presented to an otolaryngology clinic complaining of bleeding from the mouth, nose, ears, and eyes.  Ultimately Yanik, San, and Alatas (2004) determined that she was smearing her menstrual blood on her face to produce the effect.  Why would someone do such a thing?  Before we can begin to differentiate between factitious disorders and clinical presentations, it is important that we understand the intent of patients of factitious disorder (FD).

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In factitious disorder (FD), patients either intentionally produce or feign signs of medical or psychological disorders, or they misrepresent their histories. The motivation to assume the patient role, rather than to obtain an external reward, distinguishes FD from malingering.  Malingering and FD both differ from somatoform disorders (e.g., somatization disorder, hypochondriasis, persistent somatoform pain disorder) and dissociative/conversion disorders in that the former are marked by active dissimulation, whereas the latter are prompted by unconscious conflicts and symptoms that are not intentionally produced. (Ehrlich, Pfeiffer, Salbach, Lenz, & Lehmkuhl, 2008, p. 392)

The clinical assessment of someone suspected of suffering from a factitious disorder (like most disorders) begins with a careful medical history and comprehensive mental status examination.  Our first consideration is to eliminate investigate the possibilities that the illness is not feigned, but is in fact real.  Typically, the FD case is built through a process of exclusion of actual physical or mental illness, as well as confirmation of intent to assume the “sick role” (thereby differentiating it from malingering).  We as clinicians should carefully document inconsistencies; including inconsistencies among the patient’s account of his or her symptoms (over time), inconsistencies between what we empirically observe and self-reports, and inconsistencies between what is self-reported and what represent typical signs and symptoms of the feigned illness.  (Malone & Lange, 2007)

Possible warning signs of factitious disorders include:

1)      Dramatic but inconsistent medical history

2)      Unclear symptoms that are not controllable and that become more severe or change once treatment has begun

3)      Predictable relapses following improvement in the condition

4)      Extensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illness

5)      Presence of many surgical scars

6)      Appearance of new or additional symptoms following negative test results

7)      Presence of symptoms only when the patient is with others or being observed

8)      Willingness or eagerness to have medical tests, operations, or other procedures

9)      History of seeking treatment at many hospitals, clinics, and doctors offices, possibly even in different cities

10)  Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior doctors (WebMD, n.d.)

Malingering is similar to FD, except that there is an existence of an external reward.  Personal gain is always the motivation; examples might include active duty military personnel seeking medical discharge, or a person attempting to get paid (short-term or long-term) for a nonexistent disability.

Once a legitimate medical condition is eliminated as a possible cause, we are left to attempt to distinguish intent of the client.  Patterns of speech can also be used to detect a potential malingerer.  “Malingerers often sound rehearsed” and, when “led away from these prepared scripts with specific questions,” they tend to “make over-generalized and vague statements.”  When most people lie, they tend to make more negative statements, while using fewer contractions in their speech (e.g., “I do not” instead of the more conversational “I don’t”).  (Malone & Lange, 2007)  The Stroop test has also been found to be effective for detection of malingering of cognitive deficit.  (Osimani, Alon, Berger, & Abarbanel, 1997)

In any event, once the malingering attempt is identified, it must be confronted.  “Approaching the deception as a maladaptive attempt on the patient’s part to resolve a problem or conflict, and drawing analogies to other clinical situations involving more primitive defenses, allows us to use our familiar clinical skills of diagnosis and treatment to resolve our own and the patient’s conflicts in what is often an uncomfortable encounter for both.”  (Malone & Lange, 2007, expression SUMMARY)  Although this will likely be one of the most uncomfortable conversations we can have as clinicians, it can be professionally dealt with and subsequently resolved.

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References

Ehrlich, S., Pfeiffer, E., Salbach, H., Lenz, K., & Lehmkuhl, U. (2008, Sep/Oct). Factitious disorder in children and adolescents: A retrospective study. Psychosomatics, 49(5), 392-399. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1557976921&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Harrison, A. G. (2009, Nov). Clinical assessment of malingering and deception, 3rd edition. Canadian Psychology, 50(4), 294-296. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2003029091&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Malone, R. D., & Lange, C. L. (2007, Spring). A clinical approach to the malingering patient. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 35(1), 13-22. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1256972241&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Osimani, A., Alon, A., Berger, A., & Abarbanel, J. M. (1997, Jun). Use of the Stroop phenomenon as a diagnostic tool for malingering. Journal of Neurology, Neurosurgery and Psychiatry, 62(6), 617-622. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=62&did=13146114&SrchMode=1&sid=2&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272133836&clientId=4683

WebMD. (n.d.). Factitious disorders. Retrieved April 24, 2010, from http://www.webmd.com/mental-health/factitious-disorders?page=2

Yanik, M., San, I., & Alatas, N. (2004). A case of factitious disorder involving menstrual blood smeared on the face. International Journal of Psychiatry in Medicine, 34(1), 97-102. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=4&did=692035021&SrchMode=2&sid=3&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272135912&clientId=4683

Nature, nurture, and the effect of theory on personal development


The adoption of one or more developmental theories could have significant implications on implementation of real world therapy practices. Our theoretical worldview has the potential to bias our views of developmental change and the antecedents that drive that change. Will the therapist sitting across from you attribute your current situation to biological antecedents? Is nature responsible for (insert any psychological condition here)? Or, instead, will your therapist choose to focus on the environmental and societal factors that have influenced your personal developmental trajectory? Before any of us engage a therapist, or any of us engage in the practice of therapy, we should consider the theoretical underpinnings that form the foundation of our helping professionals’ worldview. Obviously there’s a good reason why individual therapists choose the theories they do… conscious consumers should not be afraid to ask for the reason.

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When change occurs in my personal life, I usually attribute it to entropy. The illusion of being able to control my environment is tempting to say the least, but I believe self realization comes as a result of accepting that you have little or no control over the sequence and timing of developmental change. For me, clinical counseling represents a vehicle by which individuals learn to control reactions to a constantly changing chaotic world. My goal for all of my clients, and for myself, is to be able to embrace change and employ it as a springboard to drive structural, functional, and behavioral growth. To me, it’s almost irrelevant as to whether it is “governed by nature (i.e., genetics, maturation or biological structures) or nurture (i.e., child rearing methods, cultural values, planned learning experiences, unplanned life events).” (Bergen, 2008, p. 3) Regardless of the governance, the reality is that we have the opportunity to change tomorrow by acting today.

As I continue to process and refine my own theoretical perspective on human development, my expectation is that the theory provides individuals I serve with an outcome that can be predicted with reasonable certainty. For example, if we engage dialectical behavior therapy (DBT) I should be able to predict with reasonable certainty that you will experience an increase in mindfulness. If DBT fails to produce that result, I am content to attribute that failure to individual variability… to me, it doesn’t much matter if it’s nature or nurture… so long as we identify the point of failure and try again (this time modified to fit the individualized participant). Perhaps we could integrate religious and metaphysical concepts into the effort to increase the traction of our DBT efforts. Or, perhaps we will go in a parallel direction and focus more on interpersonal effectiveness or emotion regulation since they are contributing factors to the overall efficacy of DBT? Maybe we abandon DBT altogether and take another angle? The options are endless… but a theory some provide some direction, some purpose, to the decisions that are made in that process.

Applied Behavior Analysis (ABA) meets all of my expectations for a theoretical construct. ABA is committed to resolving real world issues not theoretical quandaries. Practical importance is at the forefront of my interest. ABA focuses on the behavior that needs improvement, not just any behavior. Good results must be measurable, conceptually systematic, and able to be replicated. Finally, a good theory must possess generality of the in the respect that it lasts over time and it appears in environments other than the one in which… it was implemented. (Cooper, Heron, & Heward, 2007, p. 18)

As a sidebar…

Does anyone out there have any real world examples of entrainment? (juxtaposition of one or more systems to form new combinations)

What strategies do you use to ensure you are employing “activated knowledge” as defined by Bergen (2008) on page 33?

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References

Bergen, D. (2008). Human development: Traditional and contemporary theories. Upper Saddle River, NJ: Pearson Prentice Hall.

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Response to: Growing up bipolar: ‘Nobody was on my side’ (CNN)


CNN published an insightful piece on Bipolar Disorder today (see link below) that hit a few significant points that have been under expressed here of late…  I have to credit the author (Elizabeth Landau) because she acknowledged that the spike in bipolar disorder diagnosis rates could be attributed to our collective focus on the disorder.

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I would also like to demonstrate support for the ‘mind over meds’ concept that is purveyed when the author suggests “as a first line of defense, family support and therapy would be given to the child and problematic environments — be it home or school — would be improved, and then medication would be given as needed.”  Medication should be a last resort, especially when it comes to psychotropic drugs.  It is widely acknowledged that there is no psychotropic drug that comes without significant potential for side effects.  Regardless of our theoretical perspective… Cognitive Behavioral – Dialectical Behavioral – Gestalt – Group – Psychoanalytic – Talk… or the other variations of therapy… I would submit that the best case scenario for medication is as an adjunct treatment… adjunct to traditional therapy services.  What’s not to like about no side effects?

Last, but certainly not lest, CNN provides another voice to the growing crowd of providers who are frustrated by a general lack of access when it comes to individuals without insurance.  All men are created equal. Those five words used to mean something.  Unfortunately, those of us who are wading through the fragmented mess we call a mental health system in the United States know… it’s exactly what the author of the article purports it to be…

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Link to the original article:

http://www.cnn.com/2010/HEALTH/08/30/bipolar.kids/index.html?hpt=C2