Tag Archives: Factitious Disorders

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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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

Factitious Disorders | Factitious Disorder by Proxy | Munchausen Syndrome

Factitious Disorders and Factitious Disorder by Proxy covers the disorders formerly known as Munchausen Syndrome.  By definition, factitious disorders are a condition in which symptoms are feigned or created by the patient.  This might manifest in by someone complaining about a pain that doesn’t exist, or it might result in the client drinking a pint of Drain-o to get sick.  Generally speaking, the goal or objective is to assume the “sick role,” and subsequently obtain the benefits that are generally imbued on them as a result.

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Do kids start lying as early as age 2?  It would appear that they learn to lie about the same time they learn how to talk.

“As children, many of these patients experienced rejection, mistreatment, and parental loss.  For them, the hospital provides a haven or refuge.”  (Netherton, Holmes, & Walker, 1999, p. 305-306)  I have trouble identifying with this… you couldn’t pay me to go to a hospital; I avoid them like I avoid the plague.  I don’t know if most “normal” people feel like that, but it’s about the last place I would consider a refuge…

Factitious disorders are best differentiated from malingering by accessing the goal.  “Only when the sick role becomes part of the child’s life can the diagnosis of factitious disorder be considered.”  (Netherton et al., 1999, p. 306)  So, factitious disorders represent more than malingering in a sense that they are persistent efforts to appear sick, without any apparent short term goal other than to obtain the sick role status.  If that means the client has to lie, they often do.  The symptoms are intentionally produced, and the patient can voluntarily make them appear or disappear.  In that respect, they differ from somatoform disorders because they are voluntary, not involuntary.  Where malingerers pretend to be sick, somatoform sufferers feel doomed to be sick, and sufferers of factitious disorder creating symptoms that to ensure that status.  (Netherton et al., 1999, p. 307)

Treatment begins with confrontation.  A “normal” person (I am not sure I can ever write the word normal again without the “”) would probably stop lying right there and the problem would be solved.  Unfortunately, that confrontation does not typically resolve the issue with factitious disorders.  I was surprised to see that the relationship typically improves after that process occurs though… I wonder if there is a sense of relief on the part of the client that they have been caught.

The “by proxy” version of Factitious Disorder is fascinating.    Check out this video… I couldn’t believe my eyes! http://www.youtube.com/watch?v=UVLqADEdrig&feature=related People who suffer from this disorder make their kids sick, or engage in deceptive behavior to make them appear sick… ultimately in an effort to gain attention or sympathy.  The average time taken to uncover the proxy diagnosis was estimated to be 14.9 months!  (Netherton et al., 1999, p. 310)  Although the text makes a case for more widespread general knowledge, that process has unfortunately led to many false identifications and misdiagnosis.  One surefire way to identify the proxy diagnosis is to remove the child from the care of the parent or caregiver and see if their issues persist.  Another (more controversial, if that’s even possible) method is to covertly attempt to videotape the act of child abuse.  Imagine the legal ramifications if you were wrong!  It’s a pretty hefty gamble; we could potentially lose a license over a misdiagnosis like that.

How does mandatory reporting play into this “by proxy” diagnosis.  I mean, if you even suspect this as a possible diagnosis, don’t you have to report it?

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Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.