Factitious Disorders and Malingering
Kevin Reeves, MD
Assistant Professor-Clinical, Psychiatry
Wexner Medical Center
The Ohio State University College of Medicine
Learning Objectives
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Approach
Differential Diagnosis
Significance
Diagnostic Criteria
Clinical Features
Epidemiology
Etiology
Treatment
Course and Prognosis
Approach to the Patient
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Review past records and history, if available
Identify your role and establish rapport
Identify any accompanying persons
Attempt to identify reasons for presentation (referral, emergency)
Chief complaint and history of present illness
 Rigorously clarify vague details and chronology while preserving rapport
Physical and Mental Status Examination
Obtain collateral information, if possible
 Consents for Release of Information if the patient is willing
 Emergency settings may not require a release
Confer with colleagues
Present plan, targeting their chief complaint, to the patient, with rationale
Differential Diagnosis
 Will depend on the chief
complaint
 Factitious Disorders and
Malingering may focus on
either physiological or
psychological symptoms
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Differential diagnosis can
encompass any body system
Significance of the Diagnoses
 Patients fitting the criteria for the Factitious Disorders
can undergo lengthy and expensive workups, with hours
of time required for appointments, reviewing results, and
performing procedures
 Patients meeting criteria for Malingering can receive
monetary benefits, freedom from responsibilities or legal
charges, or otherwise utilize resources which may be
appropriate for other patients
 These patterns can continue, un-interrupted, without
proper recognition and management
Factitious Disorder
 DSM-IV-TR Criteria:
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A. Intentional production or feigning of physical or psychological
signs or symptoms.
B. The motivation for the behavior is to assume the sick role.
C. External incentives for the behavior are absent.
 Subtypes: With Predominantly/Combined
Psychological/Physical Signs and Symptoms
Factitious Disorder Not Otherwise Specified
 Disorders with symptoms that do not meet the criteria for
Factitious Disorder.
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Factitious Disorder by proxy.
Clinical Features
 Physician-patient role
disrupted as the physician
must “catch” the patient in a
falsehood
 Patients may tamper with or
contaminate laboratory
samples, wounds or
instruments
 May fabricate physical and/or
psychological symptoms within
the same encounter
The Sick Role
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Described by a medical
sociologist, Parsons in 1951
Being sick confers certain rights
and responsibilities on the patient
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Rights: The patient is not held
responsible for being ill, and the
patient is exempt from “normal role
obligations”
Responsibilities: The patient must
“seek technically competent help”
and must “want to get well”
Patients who assume the sick role
may benefit from relief of duty
toward undesirable responsibilities
and obligations, and from
sympathy generated in the
absence of blame regarding their
condition
Regarding Primary and Secondary Gain
 These concepts were originally described by Freud and again by
Barsky
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Definitions in the following slides
 Appeared, with definitions, as recently as DSM-III-R
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There, both concepts were defined in the setting of Conversion Disorder
 Both sources define primary and secondary gain as
UNCONSCIOUS processes, i.e. the individual is unaware of the
motivation
 It may be more helpful to think of Factitious Disorders and
Malingering as defined in DSM-IV-TR criteria
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Factitious Disorder patients seek to assume the sick role, but have NO
“external incentives” for doing so
Patients who malinger are seeking external incentives
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Economic gain, avoiding legal responsibility or improving physical well being
Primary Gain
 “Reduction in intrapsychic conflict and the partial
gratification accomplished by the defensive operation”
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Defense may be primitive or mature
 Produces “a symptom of the illness”
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I.e. conversion, factitious or somatoform symptom
 Defined most recently in DSM-III-R
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There related specifically to Conversion Disorder
Secondary Gain
 “Acceptable or legitimate interpersonal advantages that
result when one has the symptoms of a disease”
 May be tangible or intangible rewards:
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Money, desired working conditions
Sympathy and concern from friends or family
 Popularly used to describe specific financial benefits
from intentional symptom production
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This is inconsistent with the original definition
Tertiary Gain
 Gain realized by a separate party due to the patient’s
illness
 Similar to secondary gain, tertiary may be tangible or
intangible
 As with primary and secondary gain, tertiary gain should
be considered to be an unconscious goal
Epidemiology
 Female predominance
 Young age
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Psychologically “immature”
 Many have health care experience, professionally or
through interactions with others, and some medical
knowledge- self taught or formal
 Generally, complaints are confined to a single hospital
system
 Patients are more likely to be living within the
surrounding community
Münchausen’s Syndrome
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10% of Factitious Disorders
Male predominance
Multiple, frequent presentations to
hospitals with provocative or
fantastic complaints (pseudologia
fantasica)
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Can be life-threatening symptoms
Often seek invasive testing or
involved treatments
Peregrination: Serially visiting
hospitals over a wide area
Name taken from fantastic
account of the exploits of Baron
Karl Friedrich Hieronymous von
Münchausen, a real life German
cavalry officer in the Russian army
during the 1700s
Treatment
 Establish rapport with a single provider
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Prior knowledge of past complaints allows current complaints to
be examined in perspective
 Continuity of care across providers also minimizes
unnecessary diagnostic and treatment costs
 Psychotherapy to address underlying conflicts and
stressors
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Nearly always outpatient level of care
Course and Prognosis
 Outcomes largely dependent on patient engagement in
treatment and rapport with providers
 Range from no improvement with continued dysfunction
to remission of symptoms without expected recurrence
Malingering
 No firm criteria given in DSM-IV-TR
 Strongly suspect if any combination of the following:
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Medicolegal context of presentation.
Marked discrepancy between the person’s claimed stress or
disability and the objective findings.
Lack of cooperation during diagnostic evaluation and in
complying with the prescribed treatment regimen.
The presence of Antisocial Personality Disorder.
Malingering
 DSM-IV-TR provides a concept of this diagnosis, stating:
“The essential feature of Malingering is the intentional
production of false or grossly exaggerated physical or
psychological symptoms, motivated by external
incentives…”
Clinical Features
 Malingering is a diagnosis based on a specific symptom
at a specific time
 A person may malinger some or all of their symptoms
 Mental health providers (psychiatrists and psychologists)
were not superior to lay persons in detecting malingering
Epidemiology
 One review of 33,000 cases
seen by neuropsychologists
(usually Ph.D. or Psy.D. level
providers who do
neuropsychometric testing)
reported rates between 8% of
medical and psychiatric
“cases” and up to 30% of
disability or worker’s comp
evaluations
Management
 Obtain collateral information from parties who know the
patient, if possible
 Neuropsychological testing can aid in clarifying
symptoms and contains an internal metric for poor effort
 In an emergency situation, prioritize patient safety above
suspicion of validity of symptoms
Course and Prognosis
 Patients are intentionally manufacturing symptoms with
an intentional goal, and can be difficult to engage or
collaborate with
 This diagnosis is not due to a mental disorder, therefore
there is no treatment, per se
 Patients who have malingered in the past may do so
again if they feel the risks and benefits are favorable to
them
References
 Hales RB, Yudofsky SC, eds. Essentials of Clinical Psychiatry. 2nd
ed. Arlington, VA: American Psychiatric Publishing; 2004.
 Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text
Revision. Arlington, VA: American Psychiatric Association; 2000.
 David A. Fishbain. Secondary Gain Concept- Definition, Problems
and Its Abuse in Medical Practice. APS Journal. 1994; 3: 264-273.
 Simon J. Williams. Parsons revisited: from the sick role to…?
Health. 2005; 9: 123-144.
 McCullumsmith CB, Ford CV. Simulated Illness: The Factitious
Disorders and Malingering. Psychiatr Clin N Am. 2011; 34: 621-641.
Thank you
Do not hesitate to contact me.
Email with questions/comments:
Kevin.Reeves@osumc.edu
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