Elsevier

The Lancet

Volume 383, Issue 9926, 19–25 April 2014, Pages 1422-1432
The Lancet

Series
Factitious disorders and malingering: challenges for clinical assessment and management

https://doi.org/10.1016/S0140-6736(13)62186-8Get rights and content

Summary

Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identification largely dependent on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient's medical record. Management of such disorders ideally requires a team-based approach and close involvement of the primary care doctor. As deception is a key defining component of factitious disorders, diagnosis has important implications for young children, particularly when identified in women and health-care workers. Malingering is considered to be rare in clinical practice, whereas simulation of symptoms, motivated by financial rewards, is regarded as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can inform the detection of illness deception, such tests need support from converging evidence sources, including detailed interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of abnormal health-care-seeking behaviour is the extent to which a person's reported symptoms are considered to be a product of choice, or psychopathology beyond volitional control, or perhaps both. Clinical skills alone are not typically sufficient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and deal with patients whose symptoms appear to be simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors. Future progress in management will benefit from an increased appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical findings from social neuroscience, occupational health, and clinical psychology.

Introduction

Abnormal health-care-seeking behaviour covers a multitude of clinical and non-clinical behaviours ranging from symptom exaggeration to deliberate feigning.1, 2, 3, 4 In this Review, we focus on abnormal health-care-seeking behaviours that include simulation (factitious disorders and malingering) and propose that standard use of these terms in psychiatric classifications such as the Diagnostic and Statistical Manual of Mental Disorders (DSM)5 has not kept abreast of conceptual and psychological advances. In line with our clinical focus, we consider non-medical explanations, in particular the neglected part that volitional and motivational factors can play. As such this Review departs from previous accounts by not explicitly endorsing the standard medical glossary definitions of factitious disorders, and questions the use and legitimacy of deception as a special form of mental disorder for several reasons.

First, although factitious disorders and malingering are both clinically significant, deception is a pervasive, normal, and ubiquitous social behaviour of human nature.6 Second, abundant evidence exists to show that people (both patients and doctors) frequently engage in a range of deceptive behaviours outside medical symptom appraisal and for various reasons.4, 7, 8 Third, the DSM diagnosis of a factitious disorder has little clinical validity.9 Precisely what impairment to normal mental functioning justifies defining the intentional fabrication of illness symptoms as a mental disorder in its own right is unclear. Fourth, evidence that factitious disorders and malingering behaviours tend to be episodic, situation specific, and highly dependent on selective interactions with medical, social, or legal professionals suggests that they are not clinical states, but rather discrete “behavior governed by a cost–benefit analysis.”10 Fifth, from a clinical and diagnostic perspective, it seems unlikely that most clinicians can reliably and consistently extricate the contributory role of deception and hence distinguish factitious disorder and malingering.11 Sixth, the diagnosis of factitious disorders (and compensation neurosis) appear to have been largely created as a way of bridging or linking diagnoses between unconsciously mediated psychiatric disorder and consciously mediated malingering.9, 12 Seventh, many existing psychiatric accounts of abnormal health-care-seeking behaviour underestimate the contribution of non-medical deception,13 and without explicit consideration or exploration of the potential part played by volitional choice, meaningful discussion of abnormal health-care-seeking behaviour is always going to be scarce. Eighth, this holistic approach should not be taken as denying or mitigating the reality or distress of illness as subjectively experienced by many patients with medically unexplained disorders, but rather provides a rationale for alternative explanations and treatments.

When trying to distinguish between factitious disorders and malingering, we emphasise the role of context and a well-documented evidence trail. Most research on malingering takes place within specific legal contexts or when a patient attempts to evade punishment in the criminal justice system, seek damages through personal injury litigation, or gain financial compensation, whereas factitious disorders are generally encountered in clinical settings.

Section snippets

Controversies and diagnostic dilemmas in psychiatric classifications

The biomedical justification underpinning many psychiatric disorders included in DSM and the International Classification of Diseases still has not been established.14 The quest for a medically acceptable diagnosis has resulted in the growth and clinical use of various aetiologically agnostic, diagnostically ambivalent descriptors. However, once a diagnosis has entered general use it tends to become reified and assumed by many to be a valid entity that need not be questioned.15 In many cases

Concept of the sick role and abnormal illness behaviour

A close association exists between illness behaviour in some patients and the potential benefits that society provides for the sick role.30 The sick role is a partly and conditionally legitimated state, which might be desirable because of the advantages and potentially socially mediated secondary gains.31 Notably, “despite a reduction in disease (pathology) and an improvement in our ability to cure or reduce disease, sickness is rising.”32 In particular, society more readily accepts physical

Developmental factors

Investigators have argued that chronic somatoform disorders should be regarded as a disorder of development, because of the young age of onset, the enduring nature of the syndrome, and the finding that more than two-thirds of patients meet the criteria for a personality disorder.36, 37 In a study of 20 patients with factitious disorders involved in litigation, 12 (60%) had suffered a childhood illness and more than half a childhood loss.38 Accounts of patients with factitious disorders note

Epidemiology

As traditionally defined, factitious disorders are fairly uncommon, but likely to be underdiagnosed, with prevalence estimates ranging between 0·5% and 2%.44, 45 Evidence shows that US physicians feel more comfortable diagnosing conversion disorders than they do other somatoform and factitious disorders, and that as a result, the latter disorders are diagnosed far less frequently than published prevalence and recognition rates suggest.46 In a survey done in an occupational medicine setting in

Definition and conceptual issues

Malingering is not a formal medical diagnosis and there continues to be little agreement about its definition.79 Additionally, many neuropsychologists conceptualise malingering in probabilistic rather than dichotomous terms,80 and perceive feigning of physical symptoms as dimensional and episodic rather than categorical.81 Although the DSM makes clear that malingering is not a psychiatric disorder, the most commonly quoted definition of malingering is probably from the American Psychiatric

Post-traumatic stress disorder

Many clinical disorders can be simulated,4 but in this section, we discuss three of the more common disorders: post-traumatic stress disorder, brain injury, and chronic pain. Well attested examples of non-genuine post-traumatic stress disorder have been published,104, 105, 106 possibly because the diagnosis is based almost entirely on the individual's subjective report of symptoms.107 Striking positive symptoms such as nightmares and flashbacks are more readily elaborated than are more subtle

Management

Patients with mild traumatic brain injury are most likely to present with symptom validity failure, exaggeration, or malingering, or all three,87 and feedback of test results has been most systematically studied in this group.133 A feedback model has been described that involves building of rapport with the patient, exploring of the reasons for poor effort and acknowledgment of possible task disengagement, establishment of the potential reasons for exaggeration, and discussion of other factors

Prognosis and outcome

The prognosis for malingering in personal injury litigants is unknown, but clinical experience suggests that patients with longstanding disability, even if partly or wholly non-organic, do not always recover after settlement.135 Improvement after settlement can take place for many reasons, including less stress and uncertainty in the litigant's life because they are no longer involved in an adversarial system in which their reputation is under scrutiny and they have to prove their injury.82

Conclusions

Although specialists generally agree that malingering and factitious disorders describe a cluster of illness-related symptoms that include differential degrees of simulation, controversy and debate continue about the best way to frame, explain, and manage these behaviours.4 Central to this debate is the model of illness adopted.137 Unlike the traditional biomedical model, the expanded WHO International Classification of Functioning model should be considered in view of its focus on the person

Search strategy and selection criteria

We searched PsycINFO via Health Databases Advanced Search on the UK National Health Service evidence website from Nov 11, 2012, with the terms “FACTITIOUS DISORDERS”, OR “MUNCHAUSEN SYNDROME”, OR “MALINGERING”. We limited our search to English-language articles published from 2000. We did a final search of PubMed on May 30, 2013, with the terms “factitious disorder” and “malingering”.

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