Chapter 23. Factitious Disorders and Malingering

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Intentional production or feigning of physical or psychological signs or symptoms.

2. The motivation for the behavior is to assume the sick role.

3. External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington DC: American Psychiatric Association, 2000.)

Factitious disorders are consciously determined surreptitious simulations or productions of diseases. Factitious illness behavior is relatively uncommon, but when present it consumes large amounts of professional time and medical costs. The Munchausen syndrome by proxy is a particularly malignant form of child abuse that physicians must identify and manage in order to save the health or lives of children.

DSM-IV-TR lists the following four diagnostic subtypes of factitious disorder:

Factitious Disorder with Predominantly Psychological Signs & Symptoms

Patients with factitious disorders may simulate psychological conditions and psychiatric disorders. For example, a patient may feign bereavement by reporting that someone to whom he or she was close has died or been killed in an accident. Patients may simulate symptoms of posttraumatic stress disorder or provide false reports of previous trauma (e.g., a civilian accident or combat experience). Closely related to factitious posttraumatic stress disorder is the false victimization syndrome, in which the patient falsely claims some type of abuse. For example, a woman may falsely report that she had been raped. Other simulated psychological disorders include various forms of dementia, amnesia, or fugue; multiple personality disorder; and more rarely, schizophrenia.

Factitious Disorder with Predominantly Physical Signs & Symptoms

The production of physical symptoms or disease is probably the most common form of factitious disorder. Essentially all medical diseases and symptoms have been either simulated or artificially produced at one time or another. Among the most common of these disorders are factitious hypoglycemia, factitious anemia, factitious gastrointestinal bleeding, pseudoseizures, simulation of brain tumors, simulation of renal colic, and more recently, simulation of AIDS.

Factitious Disorder with Combined Psychological & Physical Signs & Symptoms

A patient may be admitted to the hospital with factitious physical symptoms and, in the course of hospitalization, perhaps in an attempt to obtain more sympathy or interest, may report or simulate a variety of psychological symptoms such as having experienced the recent loss of a close relative or friend or having been raped in the past.

Factitious Disorder Not Otherwise Specified

This category is reserved for forms of factitious disorder that do not fit one of the other categories. It includes the Munchausen syndrome by proxy, in which one person surreptitiously induces disease or reports disease in another person. Most commonly, this is the behavior of a mother in reference to ...