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Comparing Factitious Disorders with Malingering

Posted Aug 31 2010 12:00am

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).

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.

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

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