This document discusses differentiating between somatoform disorder, factitious disorder, and malingering. It outlines the clinical descriptions, diagnostic criteria changes between DSM-IV and DSM-5, and practical strategies for differentiating between the conditions. Key points include revisions to the diagnostic criteria for conversion disorder and factitious disorder in DSM-5, acknowledging difficulties determining motivation, and emphasizing accurate identification of behaviors over inferring motive in clinical assessments.
This document discusses differentiating between somatoform disorder, factitious disorder, and malingering. It outlines the clinical descriptions, diagnostic criteria changes between DSM-IV and DSM-5, and practical strategies for differentiating between the conditions. Key points include revisions to the diagnostic criteria for conversion disorder and factitious disorder in DSM-5, acknowledging difficulties determining motivation, and emphasizing accurate identification of behaviors over inferring motive in clinical assessments.
This document discusses differentiating between somatoform disorder, factitious disorder, and malingering. It outlines the clinical descriptions, diagnostic criteria changes between DSM-IV and DSM-5, and practical strategies for differentiating between the conditions. Key points include revisions to the diagnostic criteria for conversion disorder and factitious disorder in DSM-5, acknowledging difficulties determining motivation, and emphasizing accurate identification of behaviors over inferring motive in clinical assessments.
Psychiatrist william.gnam@gmail.com Outline • Introduction: The diagnostic methods of psychiatry • Clinical Descriptions and Essential Features • Diagnostic Criteria: DSM-IV vs. DSM-5 • The Changing Conception of Conversion Disorder • Factitious Disorder: updated diagnostic criteria • Malingering and motivation • Practical Strategies for Differentiating • Conclusions Introduction (1) • The Diagnostic Manuals for Mental Disorders emphasize standardized, reproducible methods
• Diagnoses are confirmed on the basis of
symptoms (primarily), signs (secondarily)
• Emphasis on reportable or observable criteria is
intended to increase objectivity and reproducibility Introduction (2) • In North America, the dominant diagnostic system is the Diagnostic and Statistical Manual of Mental Disorders (DSM), 1st through 5th editions
• Diagnoses are defined according to specific
diagnostic criteria, with rules for necessary and sufficient criteria
• The most valuable property of the DSM system is
the potential to provide reliable (reproducible) diagnoses Introduction (3) • For many important diagnoses in the DSM-IV, (e.g. Major Depressive Disorder), good reliability has been established scientifically
• With the DSM-5, less reliability data, some
evidence that important diagnoses lack acceptable reliability Introduction (4) • In contrast with the “rational” methods for diagnosis of many mental disorders, confirming the diagnoses of Conversion, Factitious Disorder and Malingering requires:
– Difficult exclusions (Conversion Disorder)
– Inferences based upon external data, not exclusively patient self-report – Very difficult judgments about motivation Conversion Disorder (1) • Essential features are: – The presence of symptoms or deficits affecting voluntary motor or sensory functioning
– The symptoms or deficits cannot be fully explained by a
neurological or general medical condition – and are incompatible with a neurological condition or disease
– The symptoms/deficits typically do not conform to anatomical
pathways or physiological mechanisms, and may not be consistent Conversion Disorder (2) • Estimates of the prevalence of Conversion Disorder: from 11/100,000 to 500/100,000
• Onset is generally (but not exclusively) acute
• Recurrence is common: 25% within the first year
• Risk factors: maladaptive personality traits,
history of childhood abuse/neglect, stressful life events (not always present) Conversion Disorder (3) • There were problems with the diagnosis of Conversion Disorder defined in DSM-IV:
– Required confirmation that psychological factors
contributed, but factors were poorly defined and not always present
– Required confirmation that feigning / intentional
symptom production is excluded, but such exclusions are often not reliable Conversion Disorder (4)
• The DSM-5 represents a major revision of the
diagnostic criteria for Conversion Disorder Conversion Disorder(5): Major Changes in Diagnostic Criteria DSM - IV DSM - 5 • One or more symptoms or • One or more symptoms of deficits affecting voluntary altered motor or sensory motor or sensory function function that suggest a neurological disorder/general medical condition symptom(s) • Evidence of incompatibility • The symptom cannot be between the symptom and recognized neurological fully explained by a general conditions medical condition Conversion Disorder(6): Major Changes in Diagnostic Criteria DSM - IV DSM - 5 • Psychological factors are • (This criterion dropped) judged to be associated with the symptom or deficit
• The symptom or deficit is • (Dropped.) The symptom or
not intentionally produced deficit is not better or feigned explained by another medical or mental disorder Conversion Disorder (7) • The revised criteria have major practical implications:
– More emphasis on eliciting medical evidence of
incompatibility with known neurological conditions
– The onerous requirement to exclude feigning is dropped
(but still must consider a better explanation)
– Dropped requirement for associated psychological factors,
consistent with empirical studies Conversion Disorder (8) • Another very important implication/ acknowledgement:
– “The diagnosis of conversion disorder does not
require the judgment that the symptoms are not intentionally produced (i.e., not feigned), as the definitive evidence of feigning may not be reliably discerned” (DSM-5, page 320) Factitious Disorder (1) • Essential Features:
– Intentional production or feigning of physical or
psychological symptoms
– External incentives (such as economic gain, avoiding
legal responsibilities) are absent
– (The motivation for the behaviour is to assume the
sick role.) Factitious Disorder (2) • There is very limited evidence on prevalence, but factitious disorders are very rare
• In large general hospitals, about 1% of inpatients
for whom there is psychiatric consultation are diagnosed are diagnosed with Factitious Disorder
• Onset usually in early adulthood, course
characterized by (repeated) intermittent episodes, often after hospitalization for a general medical condition or psychiatric disorder Factitious Disorder (3) • Published case series suggest a strong association with severe dysfunctional personality characteristics
• The intentional production of symptoms or
feigning can mimic a wide range of medical conditions or psychological symptoms, not just motor or sensory symptoms/deficits Factitious Disorder (4) • What limited data that exists suggests that persons with Factitious Disorder do not experience their motive to be the need to assume the sick role
• The DSM-5 contains a significant revision of
the diagnostic criteria for Factitious Disorder: Factitious Disorder(5): Changes in Diagnostic Criteria DSM - IV DSM - 5 • Intentional production or • Falsification of physical or feigning of physical or psychological signs or psychological signs or symptoms, or induction of symptoms injury or disease, associated with identified deception
• The motivation for the • (Dropped as a criterion: but
behaviour is to assume the stipulates that behaviour is sick role not better explained by another mental disorder) Factitious Disorder(6): Changes in Diagnostic Criteria DSM - IV DSM - 5 • External incentives for the • The deceptive behaviour is behaviour (such as evident even in the absence economic gain, etc.) are of obvious external absent incentives
• (Not explicitly stated) • The individual presents
himself or herself to others as ill, impaired, or injured Factitious Disorder (7) • The revised criteria have some practical implications:
– More emphasis on the objective identification of
falsification of signs and symptoms of illness, rather than inference about intent or possible underlying motivation.
– The revised criteria do not imply that factitious disorder
behaviours could never occur in the presence of external incentives, but does stipulate that they persist even when obvious external rewards/incentives are absent. Malingering (1) • Malingering is a massive topic and not the focus of the current presentation
• Malingering has never been considered to be a
mental disorder
• The essential feature of Malingering definitions is
the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives Malingering (2)
• The limited data on Malingering indicates that
the prevalence is not high, but from a societal perspective the prevalence is nonetheless significant
• The definition of Malingering has not changed
significantly between the DSM-IV and DSM-5. Malingering (3) • Despite the attempts of the DSM-5 to remove criteria that require inference about motivation, the DSM-5 description of Malingering emphasizes that the motivation for the symptom production is an external incentive
• The difficulties in determining motives
acknowledged in other disorders are no easier in Malingering Malingering (4) • There are difficulties with the DSM and other discussions of Malingering:
• Failure to distinguish between other
motivation for conscious symptom production/exaggeration (e.g., “cry for help”)
• Lack of acknowledgement of the difficulties in
determining motivation clinically Differentiating: Practical Strategies (1) • The changes in diagnostic criteria correctly imply that clinical assessment should focus on accurately identifying behaviours, and gathering evidence about incompatibility with medical conditions, and not should not speculate/infer motive
• This change does not imply that differentiating
between Conversion, Factitious Disorder and Malingering (or other conscious symptom production) is not possible in many cases Differentiating: Practical Strategies (2) • Factitious Disorder can be excluded in most cases involving disability after acute traumatic injury (MVAs, work accidents), because – Factitious Disorders are very rare – They can involve behaviours that produce non- conversion symptoms – They become manifest mostly in inpatient settings – The natural history is repeated episodes over time, usually established before a traumatic event – They do not occur repeatedly or predominantly with obvious external incentives Differentiation: Practical Strategies (3) • Distinguishing between “Malingering” and Conversion Disorder based upon a single clinical encounter is difficult or impossible, but this should not preclude a “working” diagnosis of Conversion Disorder in cases of genuine uncertainty
• Malingering vs. Conversion cannot be reliably
distinguished by minor inconsistencies in the symptom/deficit, as such inconsistencies are common to both Differentiation: Practical Strategies (4)
• Distinguishing between Conversion vs.
“Malingering” cannot be reliably accomplished by identification of external incentives or risk factors, as none are sensitive or specific enough to discriminate reliably Differentiation: Practical Strategies (5) • Distinguishing between Conversion vs. “Malingering” is best accomplished with longitudinal clinical data provided by extensive documentation review, by collateral examination for symptom production (such as neuropsychological testing), and by repeated observations
• However, in some cases uncertainty is inevitable
and may persist for years or indefinitely Summary (1) • The diagnoses of Factitious Disorder, Conversion and Malingering have often been unreliable due to inference / speculation about motive
• Major changes in the diagnostic criteria for
Conversion Disorder and Factitious Disorder improve the practical procedures to make these diagnoses by removing reference to motivation Summary (2) • Excluding Factitious Disorder is usually straightforward in cases involving acute injury, especially when external incentives are persistently present, or when a history of repeated disturbance while in hospital is absent
• There is no straightforward clinical method to
distinguish between Conversion Disorder and Malingering, which is acknowledged for the first time in the DSM-5. Summary (3) • While in many cases Conversion Disorder vs. Malingering can be differentiated by the consistency of evidence and presentation over time, in some (rare) cases the uncertainty will persist.
• The DSM and other discussions of Malingering
often involve unwarranted assumptions regarding motivation that are likely simplistic