Professional Documents
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CH 42
CH 42
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c0210
Chapter 42
st0005 Abstract
Interest in malingering has grown in recent years, and is reflected in the exponential increase in academic
publications since 1990. Although malingering is more commonly detected in medicolegal practice, it is
not an all-or-nothing presentation and moreover can vary in the extent of presentation. As a nonmedical
disorder, the challenge for clinical practice remains that malingering by definition is intentional and delib-
erate. As such, clinical skills alone are often insufficient to detect it and we describe psychometric tests
such as symptom validity tests and relevant nonmedical investigations. Finally, we describe those areas
of neurologic practice where symptom exaggeration and deception are more likely to occur, e.g., postcon-
cussional syndrome, psychogenic nonepileptic seizures, motor weakness and movement disorders, and
chronic pain.
Factitious disorders are rare in clinical practice and their detection depends largely on the level of clin-
ical suspicion supported by the systematic collection of relevant information from a variety of sources. In
this chapter we challenge the accepted DSM-5 definition of factitious disorder and suggest that the tradi-
tional glossaries have neglected the extent to which a person’s reported symptoms can be considered a
product of intentional choice or selective psychopathology largely beyond the subject’s voluntary control,
or more likely, both. We present evidence to suggest that neurologists preferentially diagnose factitious
presentations in healthcare workers as “hysterical,” possibly to avoid the stigma of simulated illness.
A lie is as good as the truth if you can get some- In a study of absenteeism in Canada of hospital workers
body to believe it. who had just returned from a scheduled day off or an
unscheduled day off that had been classified by the
employer as due to sickness absence, 72% admitted
not being sick on their (sick) day off (Haccoun and
s0005 INTRODUCTION DuPont, 1987).
p0090 Controversial, enduring, and ubiquitous, deception The key issue (and source of much controversy) in p0095
describes a common pervasive form of episodic human medicine remains the extent to which a person’s reported
behavior that understandably raises concerns and under- symptoms can be considered a product of conscious
standable prejudices when found or thought to occur in choice, a form of psychopathology (beyond the person’s
medical settings (Conroy and Kwartner, 2006). Consid- volitional making), and/or perhaps both. Notwithstand-
ered by some to be evolutionarily adaptive (Spence, ing recent experimental findings using functional brain
2004), it is important from the outset to locate illness imaging, the diagnosis established is frequently
deception within a wider context of human deception. “influenced by circumstantial factors and the physician’s
*Correspondence to: Dr. Christopher Bass MA MD FRCPsych, Consultant Liaison Psychiatrist, Department of Psychological
Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK, E-mail: c.bass1@btinternet.com
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the current DSM diagnosis of factitious disorder has little siders some current themes and outlines the main areas of
clinical validity (Bass and Halligan, 2007). clinical practice where deception can complicate the clin-
p0110 This is not to argue that medical factors involving ical presentation and its subsequent management, with
deception are not relevant, but that medical education particular reference to neurologic practice.
needs to provide doctors with a broad conceptual, devel-
opmental, and management framework from which to
better understand and manage deception in patient– HISTORIC CONTEXT s0010
doctor interactions. It is equally important to ensure that The practice of illness deception by feigning illness has a p0125
medical disorders are not ignored where symptoms- long history, with illustrative cases from Greek, biblical
and classic literature. Before the 1880s there are several
isolated reports on malingering (e.g., Gavin, 1838), list-
t0005 Table 42.1
ing motives such as the need to “to obtain the ease and
DSM-5* criteria for factitious disorder comfort of a hospital” and the “avoidance of duties.”
1 . A pattern of falsification of physical or psychologic signs or Similar motives were ascribed to the behavior of soldiers
symptoms, associated with identified deception in the American Civil War, including “choosing a career
2. A pattern of presenting oneself to others as ill or impaired diversion as a patient rather than a soldier” (Bartholow,
3. The behavior is evident even in the absence of obvious 1863). But, as Wessely (2003) argues, a key catalyst
external rewards behind the growth in illness deception was the introduc-
4. The behavior is not better accounted for by another mental tion of the social welfare state and in particular the rise in
disorder, such as delusional belief system or acute psychosis workmen’s compensation schemes in the postindustrial
revolution societies of North America and Western
*
Diagnostic and Statistical Manual of Mental Disorders, fifth edition Europe. Fallik (1972) goes so far as to suggest that:
(American Psychiatric Association, 2013).
(Malingering is differentiated from factitious disorder by the inten- laws of social welfare and work insurance were
tional reporting of symptoms for personal gain. In contrast, the diag- made mostly for law-abiding people who really
nosis of factitious disorder requires the absence of obvious rewards.) are in need. Therefore it is not the individual
The shortcomings of this definition are described in the text. who causes the problem of simulation and
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Documents by year
175
150
125
100
Documents
75
50
25
0
1871 1889 1913 1926 1938 1947 1953 1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013
f0005 Fig. 42.1. Number of published papers on malingering, factitious disorder, and Munchausen’s syndrome (Scopus
December 2014).
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with a “psychogenic,” less than definitive diagnosis conditions largely based on patient feedback, probably
(Espay et al., 2009). remain underdiagnosed. A survey of referrals to a psychi-
p0200 Whereas disease is typically dependent on objective atric liaison service in a North American general hospital
abnormalities of physical structure or function, illness found that 0.8% had factitious disorder (Sutherland and
relates to the patient’s experience, including what the Rodin, 1990). Surveys of physicians have demonstrated
individual perceives to be involuntary behaviors. This, a wide range of prevalence estimates, with a mean esti-
in turn, has led to a growing acceptance of a number mated prevalence of 1.3%, with dermatologists and neu-
of illness-based conditions such as “functional somatic rologists giving the highest estimations (Fliege
symptoms/syndromes,” particularly within psychiatry, et al., 2007).
where many of the mental disorders already described Recognizing simulation remains largely a function of p0225
by DSM-5 remain biomedically unexplained. experience and the predisposing attitudes of the observer,
p0205 In response to the perceived and growing need to con- especially among neurologists (Miller and Cartilidge,
sider more complex, interactional, and contextual para- 1972). In a review of factitious disorders in neurology,
digms, “biopsychosocial models” applied to health Kanaan and Wessely (2010b) found that neurology
sciences emerged in the 1970s (Engel, 1977; White, patients were strikingly different from those in other spe-
2005). These biopsychologic models, however, were cialties in terms of their demographics. Considering
not specifically etiologic but rather argued for a process 90 patients from a total of 45 published reports, they
model of illness (Halligan and Aylward, 2006), where found a wide range of neurologic presentations, the most
the person, and not the disease, became the central common of which was functional motor symptoms/sim-
focus when defining ill health. Acute and chronic ulated strokes, and seizures/blackouts. They found that
symptoms originating from benign or mild forms of proportionately more of the patients were male (56%)
physical or mental impairment were considered to be and only 17% were healthcare workers, which was sur-
re-experienced as amplified perceptions with accompa- prising, given that the majority of patients with factitious
nying distress which, when filtered through the present- disorders are women and many are involved in the
ing patient’s attitudes, beliefs, coping skills, and healthcare professions. The authors speculated that
occupational or cultural social context, can affect “factitious nurses” (or, more properly, nurses presenting
patients’ perceptions of their impairment and associated with factitious disorders) are typically diagnosed with
disability (Petrie and Weinman, 2006). conversion disorder. They also speculated that there
was evidence that neurologists preferentially diagnosed
factitious presentations in nurses as “hysterical,” pre-
s0030 FACTITIOUS DISORDERS
sumably to avoid the stigma of simulated illness.
s0035 Definition
Factitious disorders: clinical features s0045
p0210 The DSM-5 definition for factitious disorders is shown in
Table 42.1. Clinical features remain diverse, but the majority of p0230
p0215 It was recently suggested that factitious disorders patients with factitious disorders are nonperipatetic,
should be considered a variant of somatoform disorders socially conforming young women with relatively stable
(Krahn et al., 2008), as both conditions provide patients social networks (Krahn et al., 2003). Evidence of
with the opportunity to “organize their lives around seek- fabrication can be derived from multiple sources,
ing medical services in spite of having primarily a e.g., inexplicable laboratory results, an inconsistent or
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case reports of suicide suggest that deceptive behavior effectiveness of any management strategy for factitious
does not preclude the presence of serious psychopathol- illness (Eastwood and Bisson, 2008). Despite this, the
ogy (Binder and Grieffenstein, 2012). authors of this chapter recommend supportive confronta-
p0240 There is a suggestion that factitious behavior can be tion, which should always involve at least two members
“communicated” from one generation to another of staff, with an emphasis on the patient being a sick per-
(Libow, 1995). For example, of children with illnesses son in need of help. For some patients a more nuanced
induced by their carers (often the mothers), a proportion approach may be preferred, with nonconfrontational
present with pseudoneurologic symptoms such as anoxic approaches. Face saving is a key element, and it is impor-
episodes and epilepsy. Examination of their mother’s tant for patients to subsequently explain their disclosures
medical records reveals that pseudoseizures are often a to other people as “recoveries,” without admitting that
key component of their somatoform presentation (Bass their original problems were fabricated.
and Jones, 2011). This is an important observation,
and neurologists should be alert to it, especially as sei-
Course and prognosis s0055
zures have been reported to be the most common presen-
tations of fabricated and induced illness in children Recovery from factitious disorder is extremely rare and p0260
(Barber and Davis, 2002). few patients agree to comply with treatment. In the
93 patients described by Krahn et al. (2003), three-
quarters were confronted with their diagnosis; however,
s0050 Management
only 17% acknowledged that their illness was self-
p0245 Management of simulated disorders can be divided into induced or simulated, and a small number agreed to have
two phases: the acute management in the hospital, which psychiatric treatment, but the outcomes were not pub-
could be an emergency room or an inpatient infectious lished. Despite this, recent accounts of patients wishing
diseases unit, or the chronic process of engaging the to engage in treatment have demonstrated that, with
patient in outpatient management with some form of psy- appropriate management, these individuals can be
chotherapy (McCullumsmith and Ford, 2011). Manage- helped (Avignal and Hall, 2012; Bass and Taylor,
ment in both phases must focus on negotiating the 2013). In a fascinating study using a novel method of
diagnosis with the patient and then engaging the patient accessing first-hand experiences of an online community
into treatment. of factitious disorder sufferers, Lawlor and Kirakowski
p0250 The initial diagnosis of factitious disorder (in hospi- (2014) found that members were aware of their motiva-
tal) is nearly always made by a nonpsychiatrist, who tions, were upset by their behavior, and claimed to want
may wish to involve a psychiatric college in a supportive to recover, but were deterred by fear. The enormous cost
confrontation of the patient. This process requires careful to the healthcare system has been extensively documen-
preparation (Table 42.2). ted (Hoertel et al., 2012).
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the view that it is a dimensional construct. As Lipman to diagnosis of malingering is the well-prepared clinical
(1962) has pointed out, the behavior is not a binary char- interview, having reviewed available documents and
acteristic of being “present” or “absent”: an individual incorporating available forensic materials. Further evi-
might, for example, be exaggerating genuine difficulties dence includes lying from differing accounts to people,
(Table 42.3). evidence of tampering with wounds, and avoiding inves-
tigations that might confirm their stated diagnosis. Typ-
ically, diagnosis requires collating evidence from
s0070 Epidemiology multiple sources, including both structured and unstruc-
p0270 A frequently cited study (Mittenberg et al., 2002) found tured clinical interviews, psychometric testing, and infor-
that experienced neuropsychologists estimate the preva- mation collected from third parties (Iverson, 2007).
lence of malingering in patient referrals from civil (i.e., A longitudinal health record is invaluable, as medical p0280
personal injury cases) and criminal legal settings to be records provide objective evidence of reported com-
in the 10–30% range. Further evidence to support the plaints and clinic attendances that help illuminate the
nontrivial prevalence of malingering comes from studies relationship between an accident/injury/life event and
that have administered symptom validity tests (SVTs) to any subsequent symptoms attributed by the patient to
patients involved in litigation or disability-related evalu- the putative causal event. A chronologic summary or
ation (discussed further below). Many of these studies “chronology” often pays dividends in the assessment
of health documents.
t0015 Table 42.3
SPECIAL INVESTIGATIONS s0080
Malingering – a continuum disorder
Probably the most widely encountered is video surveil- p0285
1 . Exaggeration: symptoms and/or disabilities are magnified
lance and evidence from social media sites, typically
or embellished
provided by the insurance companies/lawyers. Usually
2. Dissimulation (concealment): patient denies the existence of
problems that would account for the symptoms (e.g., this provides information about both the reported and
presenting to doctors repeatedly with gastric bleeding whilst observed physical abilities of the claimant. Marked or
deliberately withholding the fact that he/she is prescribed unexpected differences between the claimant’s reported/
nonsteroidal anti-inflammatory drugs) observed behaviors and what he/she claims not to be able
3. Symptom feignings only (subjective states, e.g., abdominal to do can understandably raise serious doubts as to the
pain) credibility of a claimant’s report.
4. Misattribution/false imputation of cause: attributing real
symptoms to a false cause (e.g., patient reports symptoms
PSYCHOLOGIC APPROACHES s0085
that were formerly present and ceased, but are alleged to
continue; alternatively, genuine symptoms are fraudulently Clinical psychologists and neuropsychologists have p0290
attributed to a particular injury) developed psychologic tests that claim to provide for a
5. Invention: creating symptoms and signs when none exist more precise assessment of the credibility of verbally
(e.g., smash fist on wall and present to Accident and claimed symptoms. In this context symptom validity
Emergency, stating that hand was damaged in a road traffic
refers to the accuracy or veracity of a person’s behavioral
accident)
presentation, self-reported symptoms, or performance on
neuropsychologic tests (Larrabee, 2012; Tracy, 2014).
Adapted and extended from Lipman (1962). SVTs typically comprise a simple memory or recognition
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response might help to differentiate PMD from other The levels of physical disability and psychologic comor- p0350
movement disorders. bidity in follow-up studies of patients with functional
motor symptoms (weakness and movement disorder)
are generally high (Gelauff et al., 2014). The prognosis
s0105 Psychogenic nonepileptic seizures for malingered neurologic disorders, however, is
unknown, but clinical experience suggests that patients
p0335 Drane et al. (2006) first raised the possibility that patients with longstanding disability, even if partly or wholly
with PNES performed poorly on effort tests, especially nonorganic, do not always recover after settlement
when compared to patients with epilepsy. These findings (Mendelson, 1995). Outcomes following the completion
were not replicated by Dodrill (2008), whose patients of litigation require more systematic evaluation.
were recruited over a consecutive period, none of whom
had received epilepsy surgery. In keeping with the find-
CONCLUSIONS s0120
ings of Cragar et al. (2006), these authors founds a high
failure rate on effort test scores for the epilepsy patients, Sensitivities surrounding the nature of illness deception p0355
and point out that the failure rate in unselected epilepsy will continue to be a challenging issue for modern med-
patient samples may be much higher than is commonly icine given the growing recognition that many medical
believed. illnesses are not exclusively diagnosed or validated on
p0340 In a recent study of 91 participants with PNES, the basis of the biomedical model. Given the personal,
Williamson et al. (2012) found a relationship between financial, and social benefits of the sick role and the
failure rates on SVTs and reported histories of abuse, low risk of detection (Halligan et al., 2003b), it seems
but, contrary to expectation, was not associated with reasonable that illness deception is more prevalent than
the presence of financial incentives or severity of previously presumed or detected. Much of the contro-
reported psychopathology. This finding was unexpected, versy surrounding illness deception reflects the conflict
and the extent to which SVT failure is related to reports of of strongly held beliefs regarding human nature. Unlike
abuse in other groups of patients with MUS is unclear. It the traditional biomedical model, the expanded World
has been argued that large-scale studies that dissect Health Organization International Classification of
incentive, motivation, and effort (as opposed to effort Functioning model, which highlights the role of the per-
tests) are needed to answer these questions (Bender son when defining illness (Wade and Halligan, 2003),
and Matusewicz, 2013). provides a more comprehensive model that includes
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