Tag Archives: Pain Disorder

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

Somatoform Disorders


 

 

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Somatoform Disorders could be summed up in the following statement… “there are more questions than answers.”  (Blaney & Millon, 2009, p. 499)  As a collection of disorders, it appears as though they don’t belong under the same heading or classification.  Many have more in common with Obsessive-Compulsive Disorder (OCD) than they have with each other.

“The common feature of the somatoform disorders is the presence of physical symptoms that suggest a general medical condition and are not fully explained by a general medical condition, nor by the direct effects of substance, or by another mental disorder.”  (Blaney & Millon, 2009, p. 483)  Somatoform can only be diagnosed by the process of exclusion… which seems odd to me.  It represents a “curve ball” for medical and mental health professionals, because the underlying consensus is that the client “believes they have an ailment, but they don’t.”  I don’t use “very, very” very often, but this has to make it very, very difficult to diagnose.  It might give some explanation to the very low prevalence rates.

I would have expected a greater degree of stress or anxiety in a patient that presents with this disorder, as would be typical of someone who presents with symptoms that can’t be explained.  “Patients with these disorders typically experience little or no anxiety, whereas those with so-called preoccupation disorders are excessively concerned or anxious about the notion that there is something physically wrong with their bodies.”  (Blaney & Millon, 2009, p. 483)  Can we use this lack of anxiety as a “flag” for diagnosis?

The “sick role” seems to be an underlying sociological construct among all the somatoform disorders.  Sick role implies granted privileges (staying home from work) and avoidance of obligations because one has to comply with medical instructions.

I was particularly interested and enthralled with the cultural differences in the presentation of Conversion Disorder (CD).  Not only is it more prevalent among rural residents from low socioeconomic backgrounds, but there is remarkable differences between geographical areas.  The text cited frequent cases of “burning hands” in Asia, which are typically never reported in the Western world.  (Blaney & Millon, 2009, p. 487)

Pain disorder is another anomaly.  What surprised me is that typical clients don’t come to treatment because of the degree or intensity of the perceived pain, but are more likely to come seeking respite from the psychological costs of pain management.  I could anticipate that this would be one of the most debilitating somatoform disorders because of its ability to disconnect clients from family, friends, work, and recreation.  (Blaney & Millon, 2009, p. 487)

I was relatively familiar with the concept of hypochondriasis before reading the text, but I was wholly unaware of the underlying theoretical etiology.  The concept of increased sensitivity to innocuous bodily sensations is new to me.  I was aware that some clients have formed selective attention to illness formation, risk perception, and misinterpretation of benign symptoms.  The suggestion that it is triggered by critical incidents, and is predispositioned by parental attitudes rings true to me.  I was also suitably surprised by the transient nature of the disorder, since it can apparently go into full remission and then appear again when a stressor appears.

Body Dysmorphic Disorder (BDD) is fascinating, quite honestly I have never heard of it.  I think this probably has more to do with societal views of “what is beautiful” than we think.  I was not at all surprised by the suggestion that some believe it to be delusional in nature.  I am a “perfectionist type” myself, but I never in my life would have dreamed this could be one of the results of that predisposition.  The text suggests that it may be compounded by being teased or bullied as a teenager (during puberty), leading to a general lack of social skills and self conscious maladaptive behavior.

Factitious Disorder is when “physical symptoms are produced or feigned intentionally to assume the sick role.”  (Blaney & Millon, 2009, p. 492)  The concept of “hospital hopping” in effort to undergo medical procedures, even surgery, is amazing.  The fact that these patients frequently lie about the nature of their symptoms, and life circumstance in general, probably contribute to the difficulty of diagnosing and treating this disorder.  I mean, how can you believe them?  I would question everything that came out of their mouth, it might be increasingly difficult to sort out “real issues” from “fake ones.”

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.