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Factitious disorders 2 Factitious disorders and malingering: challenges for clinical assessment and management Christopher Bass, Peter Halligan Lancet 2014; 383: 1422–32 Published Online March 6, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62186-8 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(13)62640-9 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(13)62183-2 This is the second in a Series of two papers about factitious disorders Department of Psychological Medicine, John Radcliffe Hospital, Oxford, UK (C Bass FRCPsych); and School of Psychology, Cardiff University, Cardiff, UK (Prof P Halligan DSc) Correspondence to: Dr Christopher Bass, Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK christopher.bass@ oxfordhealth.nhs.uk
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.1–4 In this Review, we focus on abnormal healthcare-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. 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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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 www.thelancet.com Vol 383 April 19, 2014
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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.
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 these disorders are described by what they are not, rather than as illnesses in their own right.16 Attempts to relocate factitious disorders into more established psychiatric categories confirm their weak conceptual underpinnings. Some investigators have suggested that factitious disorders should be considered as a variant of somatoform disorders.17 The DSM-5 even includes the suggestion that factitious disorders be recategorised as somatic symptom disorders with two types: factitious disorder imposed on self and factitious disorder imposed on the other (panel 1). Neither revisions acknowledge the contribution of an individual’s consciously mediated choice in the presentation.4 However, in the case of suspected factitious disorder, some have argued that more objective evidence—eg, abnormal pathological findings—should be actively secured.18 The situation with malingering is, if anything, even more unsatisfactory. Although the neuropsychological literature on malingering has expanded in the past 30 years, the section describing malingering in the DSM has barely changed since 1980 and has not been updated in DSM-5.19 This failure to update the criteria in DSM-5 ignores relevant research on the topic,20 and led Berry and Nelson to write that “the evolution of symptom validity and malingering literature in recent decades has culminated in a sophisticated conception of malingering that essentially renders DSM-IV-TR criteria obsolete.”19 This occurrence should come as no surprise to most psychiatrists because neither of the established medical www.thelancet.com Vol 383 April 19, 2014
and psychiatric glossaries5,21 presently consider malingering to be a valid diagnostic term and a legitimate behaviour about which a medical opinion can be expressed, other than by exclusion. Detection of malingering consequently remains difficult, largely because of the late development of an empirical social neuroscience of deception22 and the understandable reticence and absence of confidence of many doctors to consider or explore the possibility that patients could or would use deceptive behaviours to influence their clinical presentation. Well publicised cases have shown how easily the appearance of severe illness is to simulate.23,24 Evidence suggests that psychologists and psychiatrists are often no better at detecting lies than are other professionals or the lay public,25 and that physicians can be easily deceived—eg, by patients with chronic pain.26 Evidence also shows that recognition of the frequency of simulation remains largely a function of experience and predisposing attitudes of the observer.27 For example, findings from a study of simulated presentations showed that neurologists preferentially diagnosed factitious presentations in nurses as hysterical, presumably to avoid the stigma associated with the suggestion that symptoms might have been simulated.28 The disincentives presented to clinicians to establish a diagnosis of malingering are, if anything, more stark than those for factitious disorders.29 In dealing with these clinical presentations, key concepts such as abnormal illness behaviour and the sick role should be understood, as should the contribution of societal and motivational factors.
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
Panel 1: Diagnostic and Statistical Manual, fifth edition, criteria for factitious disorder, code 30019 (International Classification of Diseases-10 code F6810) Factitious disorder imposed on self 1 Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception 2 The individual presents themself to others as ill, impaired, or injured 3 The deceptive behaviour is evident even in the absence of obvious external rewards 4 The behaviour is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder
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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 disorders as acceptable entries into the sick role than they do psychological or emotional disorders, or difficulties coping with and adapting to life’s troubles.32 The determinants of illness behaviour are multifactorial and are dependent on a person’s previous illness history, family influences, developmental factors, and present beliefs about illness and resources.32 A scale for measuring illness behaviour has been devised,33 and evidence shows that the way a patient views his or her illness can have a powerful effect on outcome,34 with organic causal beliefs being associated with a need for diagnostic tests and adverse health outcomes.35
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
Panel 2: Clinical characteristics that might alert a physician to a diagnosis of fabricated illness (adapted and modified from reference 48, by permission of American Psychiatric Press) • The patient has sought treatment at various different hospitals or clinics • The patient is an inconsistent, selective, or misleading informant; he or she resists allowing the treatment team access to outside sources of information • The course of the illness is atypical and does not follow the natural history of the presumed disease—eg, a wound infection does not respond to appropriate antibiotics (self-induced skin lesions often fall into this category, when atypical organisms in the wound might alert the physician) • A remarkable number of tests, consultations, and medical and surgical treatments have been done to little or no avail • The magnitude of symptoms consistently exceeds objective pathology or symptoms have proved to be exaggerated by the patient • Some findings are discovered to have been self-induced or at least worsened through self-manipulation • The patient might eagerly agree to or request invasive medical procedures or surgery • Physical evidence of a factitious cause might be discovered during the course of treatment—eg, a concealed catheter or a ligature applied to a limb to induce oedema • The patient predicts deteriorations or there are exacerbations shortly before their scheduled discharge • A diagnosis of factitious disorder has been explicitly considered by at least one health-care professional • The patient is non-compliant with diagnostic or treatment recommendations or is disruptive on the unit • Evidence from laboratory or other tests disputes information provided by the patient • The patient has a history of work in the health-care field • The patient engages in gratuitous, self-aggrandising lying • The patient has been prescribed (or obtained) opiate drugs, often pethidine or morphine, when this drug is not indicated • While seeking medical or surgical intervention, the patient opposes psychiatric assessment
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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 that many are motivated by developmental factors, including a desire to maintain the sick role, to deceive health-care professionals, and to obtain attention.39 In terms of developmental theory, deceptive behaviour becomes evident in non-verbal ways in children younger than 5 years, and children’s capacity to deceive subsequently becomes more complex and better developed. Deception and the development of deception across the lifespan has been studied with use of an information-processing methodology,40–42 and more recently, a social neuroscience approach43 that enables researchers to assess distortions in information processing, and to identify the brain systems engaged by deception. Deliberate or tactical deception is so common in human social interactions that some researchers have suggested that human brains are innately primed to deceive, and that deception happens early in life in a predictable way.6 This view is supported by the developmental psychopathology perspective by which attachment strategies that use deception are adaptive in disorders characterised by complexity.42
Factitious disorders 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 the UK, 8% of 400 patients displayed behaviour that was consistent with illness fabrication.47
Clinical features Clinical features of factitious disorders remain diverse (panel 2).48 Most patients are likely to be socially conforming young women with stable social networks who present to general hospitals in their mid-30s. In some of these women, the self-induced illnesses begin in adolescence,49 and prevalence rates in adolescent consultation-liaison services are similar to those noted for adults.50,51 As many as one half of these patients work in health-related occupations.52 Studies including a heterogeneous case series suggest a typology that includes: (a) a dramatic, deceptive, hostile, sociopathic wandering type, mostly male (Munchausen’s syndrome as described by Asher53), comprising about 10% of cases and becoming increasingly rare;12 (b) self-induced infections, mainly www.thelancet.com Vol 383 April 19, 2014
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chronic or acute on chronic, largely female; (c) wilful interference with chronic wounds and cutaneous ulcers; and (d) a group simulating disorders by falsification of data and fabrication of signs, symptoms, and physiological disturbances.54,55 Many patients have had childhood adversity and have coexisting chronic and complex somatoform disorders.56,57 Fabricated disorders that include the arm and hand have been described,58 and a large series included four clinical categories—psychopathological dystonia, factitious oedema, psychopathological complex regional pain syndrome, and factitious wound creation and manipulation.59 Detailed review of medical notes often identifies the tell-tale signs of simulation in childhood
and adolescence. Close enquiry and careful examination of medical records (table) often shows an unexpectedly large number of childhood illnesses and operations, high rates of substance abuse, mood disorder, and personality disorder that collectively confirm complex histories, which might not be readily disclosed at interview.38 Some patients exploit the internet to misrepresent themselves with various diseases.60 So-called electronic factitious disorder is a term used to describe patients who falsify their electronic medical records to create a factitious report (eg, cancer).61 A further group is encountered in pregnancy, and these cases clearly have great implications for child protection.62 All clinicians
Attendance or referral
Symptoms and precipitants
Tests and investigations
Outcome and plan
Key events
1986 (age 12 years)
Hospital A admission
Right flank pain
Normal laparoscopy
Non-specific abdominal pain
Death of father
1987 (age 13 years)
Hospital A admission
Overdose of analgesics
..
Referred to social worker; patient stealing money from mother
Arguments with mother
1990 (age 16 years)
Hospital B admission
Inhalation of smoke from fire after fire setting
Normal blood tests
Self-discharged
Set fire to house; pregnant
1991 (age 17 years)
Neurology outpatient services (B)
Episodes of loss of consciousness and muscle twitching
Normal EEG and CT scan; normal blood tests
Reassured no organic cause
..
1991 (age 17 years)
Emergency admission to general surgery (A)
Right-sided abdominal pain
Normal radiograph
Admitted for observation; self-discharged against medical advice
..
June,1992 (age 18 years)
Gynaecology outpatient clinic
Claims to be pregnant
Normal pregnancy test
“She lied to the registrar, saying that she had .. a positive pregnancy test when she had been told by the GP [general practitioner (family doctor)] that she was not pregnant”
October, 1992 (age 18 years)
Emergency admission (A)
Overdose of paracetamol in context of excess alcohol
Noted abscess on right breast
Worried about scarring on right breast; dermatologist considered possibility of artifactual skin disorder
1993 (age 19 years)
Ear, nose, and throat outpatient clinic (C)
Episodes of haemoptysis
Normal direct laryngoscopy
Followed up in psychiatric outpatients clinic; .. possibility of personality disorder considered
1993 (age 19 years)
General medicine outpatient clinic (B), with subsequent admission
Unexplained septicaemia
Isolated blood culture of saprophytic organisms not usually associated with the cause of sepsis in the immunocompetent patient
“Given these findings we feel that there has been deliberate introduction into the body of material from an environmental source”
Boyfriend of 2 years has left her
1994 (age 20 years)
Gynaecology outpatient clinic (B)
“Told me she had been sterilised”
Fallopian tubes patent
“When I obtained her notes and showed her this she decided to self-discharge”
..
1995 (age 21 years)
Neurology outpatient clinic on second opinion (C)
Recurrent blackouts and odd movements since age 17 years
All investigations normal (video telemetry)
Diagnosis of psychogenic non-epileptic seizures
..
1995 (age 21 years)
Psychiatric outpatient clinic
Patient denies that non-epileptic seizures are related to emotional problems; attends clinic with crutches
Cognitive behavioural therapy not helping
Demands to be kept on carmazepine despite advice to taper drug
Drinking a bottle of vodka every day
1996 (age 22 years)
Emergency admission orthopaedics
Pain in right forearm after repeatedly punching wall
Substantial soft tissue injury with swelling but no fracture
Currently an inpatient on local psychiatric ward; follow-up by mental health team
Child born
1996 (age 22 years)
Admission orthopaedics (D)
Infection right wrist; demanding oromorph
No positive cultures; “Birefringent particles found consistent with foreign material in a distribution incompatible with wound-care procedures”
Planned supportive confrontation; patient self-discharged; family doctor and psychiatric team informed
..
1996 (age 22 years)
Paediatric outpatient clinic (B)
Worried about 1-year-old son with 3 month history of “shaking episodes”
Investigations unable to detect any relevant organic cause
Patient requesting disability living allowance Case conference convened by social for son; asking how to hire a wheelchair for services at surgery of herself family doctor
Grandfather ill
Data anonymised for patient confidentiality. A, B, C, and D represent four different hospitals.
Table: Chronology of a 22-year-old composite female patient with factitious disorder
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Panel 3: Constructive confrontation—preparation and process (for non-psychiatrists) • Collect firm evidence of fabrication (eg, catheter, syringe, ligature) • Discuss with psychiatrist (or member of hospital legal team if no psychiatrist available) • Arrange meeting to collate the facts, devise strategy, and discuss with primary care doctor • Confrontation with the patient should be non-judgmental and non-punitive, and should include a proposal of ongoing support and follow-up • Discuss the outcome of the confrontation with the primary care doctor • If the patient is a health-care worker the doctor should discuss with a member of their defence organisation • Document a full record of the meeting and its outcome in the patient record
should be alert to the potential onward effect when such a diagnosis is made in women with young children.63
Assessment Medical notes should, ideally, be always read in advance of interview, and any apparent inconsistencies noted for specific enquiry. General practice notes can be crucial, and should be obtained, if possible, and read in detail.64 Longitudinal contemporaneous medical records provide a substantial resource in assessment of such patients, and documentation of a chronology with dates, complaints, and medical outcomes proves invaluable (table), particularly when a team approach is involved.
Management Management of factitious disorders includes acute management in inpatient settings, which could be an emergency room or an inpatient infectious diseases unit, or the longer-term process of attempting to engage the patient in some form of psychotherapy or at least harm reduction.18 The key to successful management in both phases requires negotiation and agreement of the diagnosis with the patient and engagement of that patient with treatment. No robust research evidence is available to support the effectiveness of a management strategy for factitious illness; however, a systematic review recommended the establishment of a central reporting register to aid development of evidence-based guidelines.65 Initial concern about the possible presence of factitious disorders is typically raised by non-psychiatrists, who might wish to involve a psychiatric colleague in a discussion of the diagnosis with the patient, a process sometimes described as supportive confrontation.66 This process needs careful preparation (panel 3). Supportive confrontation should involve at least two members of staff, with an emphasis on the patient being a person who needs help, with the assurance that care will 1426
continue.49 Some patients will interpret confrontation as humiliating and seek care elsewhere, or will lodge complaints or escalate their self-destructive behaviour; as such, a more nuanced approach might be preferable.18 However, saving face and harm minimisation are key management elements. Improved outcomes have been reported with a multidisciplinary team incorporating elements of both medical and psychological support.67 Diagnosis of a factitious disorder in a health-care worker will have important implications for their future employment, and the person’s registering body might need to be contacted. This contact is best made after consultation with the hospital legal department.
Course and prognosis Patients often drop out of follow up, especially after the diagnosis of a factitious disorder has been raised as a possibility. Consequently, prospective studies are rare and the course of the disorder is difficult to ascertain. Evidence from large case series suggests that, typically, patients are first identified in their mid-30s,49,52,54,55 and that the course is variable and can include a chronic and enduring pattern of fabrication or a life punctuated by episodes that might or might not progress to a more chronic pattern.55 These groups might include unfortunate victims of fabricated or induced illness maltreatment in childhood68 who continue their simulations into adult life. Findings from a published series52 showed that three-quarters of the patients were confronted, but only one in six acknowledged that their illness was self-induced; 12% agreed to have psychiatric treatment, but the outcomes were not published. Recovery from chronic factitious disorder is rare69,70 and largely unknown because many patients understandably drop out of follow-up. Furthermore, factitious disorders are associated with substantial morbidity and mortality, and this risk seems to be increased when litigation is involved, whereby the need to obtain judicial endorsement of the presence of an illness might be increased.71 Case reports of suicide have confirmed that deceptive behaviour does not preclude the presence of serious psychopathology.72 The enormous economic burden these patients impose on the health-care system has been extensively documented.73
Ethical and legal matters Obtaining clinical notes is crucial, but if the patient does not sanction this request, doctors are left with a dilemma. Such access difficulties further prevent the optimum management of these patients. Physicians who disclose information to third parties without patient consent might have to justify the decision to their licensing body, and for this reason, doctors should have a low cutoff point for contacting their defence organisations. Evidence has shown that indication of simulation can be identified by doctors using electronic searches of health records.74,75 Although legal and ethical questions www.thelancet.com Vol 383 April 19, 2014
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Malingering 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 Association,82 namely that the disorder involves “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives, such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs”. We have described the shortcomings of this definition above.19,20 One issue with malingering is that despite falling outside the remit of all recognised psychiatric authorities, many clinicians have difficulty avoiding the temptation to medicalise the illness. In an effort to retain medical involvement in the growing number of medically unexplained disorders, new disorders such as compensation neurosis”83 and factitious disorders were introduced into mainstream psychiatric nosologies in the 20th century. Common to both malingering and factitious disorders is the requirement of doctors to ascertain, during a clinical interview, the motivations and level of conscious awareness that accompany symptoms reported by patients.4 As a neuropsychological concept, the assessment of malingering generally involves both exaggeration and poor effort, although it has been claimed to be present with only one of these being accurately detected.80 In recognition that all such disorders are best viewed as existing on a continuum, the conceptual overlaps and potential for confusion are evident when considered in terms of motivation and symptom exaggeration83 or between attributed intention and subject responsibility.8 The figure shows both models. Malingering has been conceptualised in three categories: pure, when nonexistent clinical problems are feigned; partial, when actual symptoms are exaggerated; and false imputation, which refers to the deliberate misattribution of actual symptoms to the compensable event. Exaggeration of symptoms is generally assumed to be more common than outright faking.84 www.thelancet.com Vol 383 April 19, 2014
Epidemiology Prevalence estimates of symptom exaggeration are understandably difficult to estimate and vary according to the setting and criteria adopted.85 In social security disability examinations undertaken in the USA, the prevalence of symptom exaggeration in claimants has been estimated to be between 46% and 60%, with use of symptom validity tests.86 Members of the American Board of Clinical Neuropsychology reported rates of symptom exaggeration in 29% of cases of personal injury, in 30% of disability or workers compensation referrals, in 19% of criminal cases, and in 8% of medical or psychiatric cases (statistically adjusted to remove for the effect of referral source).87 The same rates categorised by diagnosis showed that 39% of cases were for mild head injury, 35% were fibromyalgia and chronic fatigue, 31% were chronic pain, 15% were depressive disorders, and 11% were dissociative disorders. Prevalence of symptom exaggeration is highest in compensation or litigation settings, but notably, most compensation claimants (75–90%) respond well to treatment, recover from illness or injury, and return to work.85
A Choice
Deception
Intentional
Malingering
Exaggeration
Psychiatric or psychosocial disorder Nonintentional Exculpated Responsibility
B Change in motivation going from internal at the bottom to more external at the top
can arise from such searches,76,77 such a search might be warranted to establish a diagnosis of deception when done within the ethical guideline of beneficence (ie, to prevent iatrogenic disease), preferably in conjunction with a colleague from the hospital legal department. Plastic surgeons should be aware that they can be sued for malpractice by patients with factitious disorders.78
Malingering
Conversion disorder (DSM-5 functional neurological disorder)
Compensation neurosis Factitious disorder
Range of level of intentional symptom production increasing from left to right
Figure: Two models of illness deception (A)8 and compensation neurosis (B)83 Reproduced by permission of Sage Publications (A) and American Psychiatric Press (B). Diagrams show the potential roles of patient choice, intentions, and motivation in symptom production and, ultimately, diagnosis. DSM-5=Diagnostic and Statistical Manual of Mental Disorders, fifth edition.
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Assessment The cornerstone of detection as opposed to diagnosis of malingering is the well-prepared clinical interview, having reviewed available documents and, when available, forensic materials. A conclusion of malingering typically needs multiple sources of converging evidence and the systematic ruling out of probable alternative explanations.88 For the interview, plenty of time and a neutral and supportive attitude are essential. A biographical and developmental approach is recommended, starting from childhood and working through the personal history to the index event and thenceforward to the present time. Most UK residents are registered with a primary care doctor, which allows for a longitudinal health record. Medical records potentially constitute an invaluable resource and provide objective evidence of reported complaints and clinic attendances that help to elucidate the association between an accident or injury and any subsequent symptoms attributed by the patient to the putative causal event. For example, doubts could arise if there was a very long gap between an accident and the start of consultations for a health problem (ie, the symptoms did not materialise logically from the incident in question). A chronological summary often pays dividends in the assessment of health documents (table). Special investigations are another method of detection. Probably the most widely encountered technique is video surveillance, which is typically provided by the insurance companies or lawyers. Video surveillance usually provides information about the physical abilities of the claimant. Marked or unexpected differences between the claimant’s observed behaviours and what they claim not to be able to do can raise doubts as to the credibility of their report. Experience and tradition in various specialties have resulted in different clinical techniques being used to help to assess the validity of clinical presentations. Patterns of muscular weakness might be used by neurologists and orthopaedic surgeons and others as indicators of the genuineness or otherwise of clinical presentations.89,90 Several motor tasks have been examined and grip strength measured with a hand dynanometer seems to be a good indicator of poor effort.91 A finger-tapping task has also provided useful information in personal injury claimants.92 In the past two decades, clinical psychology and neuropsychologists have developed psychological tests that have been claimed to provide a more precise assessment of the credibility of verbally claimed symptoms than other assessment methods. In this context symptom validity refers to the accuracy or veracity of a person’s behavioural presentation, self-reported symptoms, or performance on neuropsychological tests.93,94 Symptom validity tests typically comprise a simple memory or recognition task on which a wide range of people with neurological or psychiatric problems can achieve nearperfect performance.95 The basic premise underlying this approach is that a finding of below-chance (ie,
Factitious disorders 2 Factitious disorders and malingering: challenges for clinical assessment and management Christopher Bass, Peter Halligan Lancet 2014; 383: 1422–32 Published Online March 6, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62186-8 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(13)62640-9 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(13)62183-2 This is the second in a Series of two papers about factitious disorders Department of Psychological Medicine, John Radcliffe Hospital, Oxford, UK (C Bass FRCPsych); and School of Psychology, Cardiff University, Cardiff, UK (Prof P Halligan DSc) Correspondence to: Dr Christopher Bass, Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK christopher.bass@ oxfordhealth.nhs.uk
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.1–4 In this Review, we focus on abnormal healthcare-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. 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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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 www.thelancet.com Vol 383 April 19, 2014
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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.
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 these disorders are described by what they are not, rather than as illnesses in their own right.16 Attempts to relocate factitious disorders into more established psychiatric categories confirm their weak conceptual underpinnings. Some investigators have suggested that factitious disorders should be considered as a variant of somatoform disorders.17 The DSM-5 even includes the suggestion that factitious disorders be recategorised as somatic symptom disorders with two types: factitious disorder imposed on self and factitious disorder imposed on the other (panel 1). Neither revisions acknowledge the contribution of an individual’s consciously mediated choice in the presentation.4 However, in the case of suspected factitious disorder, some have argued that more objective evidence—eg, abnormal pathological findings—should be actively secured.18 The situation with malingering is, if anything, even more unsatisfactory. Although the neuropsychological literature on malingering has expanded in the past 30 years, the section describing malingering in the DSM has barely changed since 1980 and has not been updated in DSM-5.19 This failure to update the criteria in DSM-5 ignores relevant research on the topic,20 and led Berry and Nelson to write that “the evolution of symptom validity and malingering literature in recent decades has culminated in a sophisticated conception of malingering that essentially renders DSM-IV-TR criteria obsolete.”19 This occurrence should come as no surprise to most psychiatrists because neither of the established medical www.thelancet.com Vol 383 April 19, 2014
and psychiatric glossaries5,21 presently consider malingering to be a valid diagnostic term and a legitimate behaviour about which a medical opinion can be expressed, other than by exclusion. Detection of malingering consequently remains difficult, largely because of the late development of an empirical social neuroscience of deception22 and the understandable reticence and absence of confidence of many doctors to consider or explore the possibility that patients could or would use deceptive behaviours to influence their clinical presentation. Well publicised cases have shown how easily the appearance of severe illness is to simulate.23,24 Evidence suggests that psychologists and psychiatrists are often no better at detecting lies than are other professionals or the lay public,25 and that physicians can be easily deceived—eg, by patients with chronic pain.26 Evidence also shows that recognition of the frequency of simulation remains largely a function of experience and predisposing attitudes of the observer.27 For example, findings from a study of simulated presentations showed that neurologists preferentially diagnosed factitious presentations in nurses as hysterical, presumably to avoid the stigma associated with the suggestion that symptoms might have been simulated.28 The disincentives presented to clinicians to establish a diagnosis of malingering are, if anything, more stark than those for factitious disorders.29 In dealing with these clinical presentations, key concepts such as abnormal illness behaviour and the sick role should be understood, as should the contribution of societal and motivational factors.
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
Panel 1: Diagnostic and Statistical Manual, fifth edition, criteria for factitious disorder, code 30019 (International Classification of Diseases-10 code F6810) Factitious disorder imposed on self 1 Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception 2 The individual presents themself to others as ill, impaired, or injured 3 The deceptive behaviour is evident even in the absence of obvious external rewards 4 The behaviour is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder
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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 disorders as acceptable entries into the sick role than they do psychological or emotional disorders, or difficulties coping with and adapting to life’s troubles.32 The determinants of illness behaviour are multifactorial and are dependent on a person’s previous illness history, family influences, developmental factors, and present beliefs about illness and resources.32 A scale for measuring illness behaviour has been devised,33 and evidence shows that the way a patient views his or her illness can have a powerful effect on outcome,34 with organic causal beliefs being associated with a need for diagnostic tests and adverse health outcomes.35
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
Panel 2: Clinical characteristics that might alert a physician to a diagnosis of fabricated illness (adapted and modified from reference 48, by permission of American Psychiatric Press) • The patient has sought treatment at various different hospitals or clinics • The patient is an inconsistent, selective, or misleading informant; he or she resists allowing the treatment team access to outside sources of information • The course of the illness is atypical and does not follow the natural history of the presumed disease—eg, a wound infection does not respond to appropriate antibiotics (self-induced skin lesions often fall into this category, when atypical organisms in the wound might alert the physician) • A remarkable number of tests, consultations, and medical and surgical treatments have been done to little or no avail • The magnitude of symptoms consistently exceeds objective pathology or symptoms have proved to be exaggerated by the patient • Some findings are discovered to have been self-induced or at least worsened through self-manipulation • The patient might eagerly agree to or request invasive medical procedures or surgery • Physical evidence of a factitious cause might be discovered during the course of treatment—eg, a concealed catheter or a ligature applied to a limb to induce oedema • The patient predicts deteriorations or there are exacerbations shortly before their scheduled discharge • A diagnosis of factitious disorder has been explicitly considered by at least one health-care professional • The patient is non-compliant with diagnostic or treatment recommendations or is disruptive on the unit • Evidence from laboratory or other tests disputes information provided by the patient • The patient has a history of work in the health-care field • The patient engages in gratuitous, self-aggrandising lying • The patient has been prescribed (or obtained) opiate drugs, often pethidine or morphine, when this drug is not indicated • While seeking medical or surgical intervention, the patient opposes psychiatric assessment
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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 that many are motivated by developmental factors, including a desire to maintain the sick role, to deceive health-care professionals, and to obtain attention.39 In terms of developmental theory, deceptive behaviour becomes evident in non-verbal ways in children younger than 5 years, and children’s capacity to deceive subsequently becomes more complex and better developed. Deception and the development of deception across the lifespan has been studied with use of an information-processing methodology,40–42 and more recently, a social neuroscience approach43 that enables researchers to assess distortions in information processing, and to identify the brain systems engaged by deception. Deliberate or tactical deception is so common in human social interactions that some researchers have suggested that human brains are innately primed to deceive, and that deception happens early in life in a predictable way.6 This view is supported by the developmental psychopathology perspective by which attachment strategies that use deception are adaptive in disorders characterised by complexity.42
Factitious disorders 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 the UK, 8% of 400 patients displayed behaviour that was consistent with illness fabrication.47
Clinical features Clinical features of factitious disorders remain diverse (panel 2).48 Most patients are likely to be socially conforming young women with stable social networks who present to general hospitals in their mid-30s. In some of these women, the self-induced illnesses begin in adolescence,49 and prevalence rates in adolescent consultation-liaison services are similar to those noted for adults.50,51 As many as one half of these patients work in health-related occupations.52 Studies including a heterogeneous case series suggest a typology that includes: (a) a dramatic, deceptive, hostile, sociopathic wandering type, mostly male (Munchausen’s syndrome as described by Asher53), comprising about 10% of cases and becoming increasingly rare;12 (b) self-induced infections, mainly www.thelancet.com Vol 383 April 19, 2014
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chronic or acute on chronic, largely female; (c) wilful interference with chronic wounds and cutaneous ulcers; and (d) a group simulating disorders by falsification of data and fabrication of signs, symptoms, and physiological disturbances.54,55 Many patients have had childhood adversity and have coexisting chronic and complex somatoform disorders.56,57 Fabricated disorders that include the arm and hand have been described,58 and a large series included four clinical categories—psychopathological dystonia, factitious oedema, psychopathological complex regional pain syndrome, and factitious wound creation and manipulation.59 Detailed review of medical notes often identifies the tell-tale signs of simulation in childhood
and adolescence. Close enquiry and careful examination of medical records (table) often shows an unexpectedly large number of childhood illnesses and operations, high rates of substance abuse, mood disorder, and personality disorder that collectively confirm complex histories, which might not be readily disclosed at interview.38 Some patients exploit the internet to misrepresent themselves with various diseases.60 So-called electronic factitious disorder is a term used to describe patients who falsify their electronic medical records to create a factitious report (eg, cancer).61 A further group is encountered in pregnancy, and these cases clearly have great implications for child protection.62 All clinicians
Attendance or referral
Symptoms and precipitants
Tests and investigations
Outcome and plan
Key events
1986 (age 12 years)
Hospital A admission
Right flank pain
Normal laparoscopy
Non-specific abdominal pain
Death of father
1987 (age 13 years)
Hospital A admission
Overdose of analgesics
..
Referred to social worker; patient stealing money from mother
Arguments with mother
1990 (age 16 years)
Hospital B admission
Inhalation of smoke from fire after fire setting
Normal blood tests
Self-discharged
Set fire to house; pregnant
1991 (age 17 years)
Neurology outpatient services (B)
Episodes of loss of consciousness and muscle twitching
Normal EEG and CT scan; normal blood tests
Reassured no organic cause
..
1991 (age 17 years)
Emergency admission to general surgery (A)
Right-sided abdominal pain
Normal radiograph
Admitted for observation; self-discharged against medical advice
..
June,1992 (age 18 years)
Gynaecology outpatient clinic
Claims to be pregnant
Normal pregnancy test
“She lied to the registrar, saying that she had .. a positive pregnancy test when she had been told by the GP [general practitioner (family doctor)] that she was not pregnant”
October, 1992 (age 18 years)
Emergency admission (A)
Overdose of paracetamol in context of excess alcohol
Noted abscess on right breast
Worried about scarring on right breast; dermatologist considered possibility of artifactual skin disorder
1993 (age 19 years)
Ear, nose, and throat outpatient clinic (C)
Episodes of haemoptysis
Normal direct laryngoscopy
Followed up in psychiatric outpatients clinic; .. possibility of personality disorder considered
1993 (age 19 years)
General medicine outpatient clinic (B), with subsequent admission
Unexplained septicaemia
Isolated blood culture of saprophytic organisms not usually associated with the cause of sepsis in the immunocompetent patient
“Given these findings we feel that there has been deliberate introduction into the body of material from an environmental source”
Boyfriend of 2 years has left her
1994 (age 20 years)
Gynaecology outpatient clinic (B)
“Told me she had been sterilised”
Fallopian tubes patent
“When I obtained her notes and showed her this she decided to self-discharge”
..
1995 (age 21 years)
Neurology outpatient clinic on second opinion (C)
Recurrent blackouts and odd movements since age 17 years
All investigations normal (video telemetry)
Diagnosis of psychogenic non-epileptic seizures
..
1995 (age 21 years)
Psychiatric outpatient clinic
Patient denies that non-epileptic seizures are related to emotional problems; attends clinic with crutches
Cognitive behavioural therapy not helping
Demands to be kept on carmazepine despite advice to taper drug
Drinking a bottle of vodka every day
1996 (age 22 years)
Emergency admission orthopaedics
Pain in right forearm after repeatedly punching wall
Substantial soft tissue injury with swelling but no fracture
Currently an inpatient on local psychiatric ward; follow-up by mental health team
Child born
1996 (age 22 years)
Admission orthopaedics (D)
Infection right wrist; demanding oromorph
No positive cultures; “Birefringent particles found consistent with foreign material in a distribution incompatible with wound-care procedures”
Planned supportive confrontation; patient self-discharged; family doctor and psychiatric team informed
..
1996 (age 22 years)
Paediatric outpatient clinic (B)
Worried about 1-year-old son with 3 month history of “shaking episodes”
Investigations unable to detect any relevant organic cause
Patient requesting disability living allowance Case conference convened by social for son; asking how to hire a wheelchair for services at surgery of herself family doctor
Grandfather ill
Data anonymised for patient confidentiality. A, B, C, and D represent four different hospitals.
Table: Chronology of a 22-year-old composite female patient with factitious disorder
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Panel 3: Constructive confrontation—preparation and process (for non-psychiatrists) • Collect firm evidence of fabrication (eg, catheter, syringe, ligature) • Discuss with psychiatrist (or member of hospital legal team if no psychiatrist available) • Arrange meeting to collate the facts, devise strategy, and discuss with primary care doctor • Confrontation with the patient should be non-judgmental and non-punitive, and should include a proposal of ongoing support and follow-up • Discuss the outcome of the confrontation with the primary care doctor • If the patient is a health-care worker the doctor should discuss with a member of their defence organisation • Document a full record of the meeting and its outcome in the patient record
should be alert to the potential onward effect when such a diagnosis is made in women with young children.63
Assessment Medical notes should, ideally, be always read in advance of interview, and any apparent inconsistencies noted for specific enquiry. General practice notes can be crucial, and should be obtained, if possible, and read in detail.64 Longitudinal contemporaneous medical records provide a substantial resource in assessment of such patients, and documentation of a chronology with dates, complaints, and medical outcomes proves invaluable (table), particularly when a team approach is involved.
Management Management of factitious disorders includes acute management in inpatient settings, which could be an emergency room or an inpatient infectious diseases unit, or the longer-term process of attempting to engage the patient in some form of psychotherapy or at least harm reduction.18 The key to successful management in both phases requires negotiation and agreement of the diagnosis with the patient and engagement of that patient with treatment. No robust research evidence is available to support the effectiveness of a management strategy for factitious illness; however, a systematic review recommended the establishment of a central reporting register to aid development of evidence-based guidelines.65 Initial concern about the possible presence of factitious disorders is typically raised by non-psychiatrists, who might wish to involve a psychiatric colleague in a discussion of the diagnosis with the patient, a process sometimes described as supportive confrontation.66 This process needs careful preparation (panel 3). Supportive confrontation should involve at least two members of staff, with an emphasis on the patient being a person who needs help, with the assurance that care will 1426
continue.49 Some patients will interpret confrontation as humiliating and seek care elsewhere, or will lodge complaints or escalate their self-destructive behaviour; as such, a more nuanced approach might be preferable.18 However, saving face and harm minimisation are key management elements. Improved outcomes have been reported with a multidisciplinary team incorporating elements of both medical and psychological support.67 Diagnosis of a factitious disorder in a health-care worker will have important implications for their future employment, and the person’s registering body might need to be contacted. This contact is best made after consultation with the hospital legal department.
Course and prognosis Patients often drop out of follow up, especially after the diagnosis of a factitious disorder has been raised as a possibility. Consequently, prospective studies are rare and the course of the disorder is difficult to ascertain. Evidence from large case series suggests that, typically, patients are first identified in their mid-30s,49,52,54,55 and that the course is variable and can include a chronic and enduring pattern of fabrication or a life punctuated by episodes that might or might not progress to a more chronic pattern.55 These groups might include unfortunate victims of fabricated or induced illness maltreatment in childhood68 who continue their simulations into adult life. Findings from a published series52 showed that three-quarters of the patients were confronted, but only one in six acknowledged that their illness was self-induced; 12% agreed to have psychiatric treatment, but the outcomes were not published. Recovery from chronic factitious disorder is rare69,70 and largely unknown because many patients understandably drop out of follow-up. Furthermore, factitious disorders are associated with substantial morbidity and mortality, and this risk seems to be increased when litigation is involved, whereby the need to obtain judicial endorsement of the presence of an illness might be increased.71 Case reports of suicide have confirmed that deceptive behaviour does not preclude the presence of serious psychopathology.72 The enormous economic burden these patients impose on the health-care system has been extensively documented.73
Ethical and legal matters Obtaining clinical notes is crucial, but if the patient does not sanction this request, doctors are left with a dilemma. Such access difficulties further prevent the optimum management of these patients. Physicians who disclose information to third parties without patient consent might have to justify the decision to their licensing body, and for this reason, doctors should have a low cutoff point for contacting their defence organisations. Evidence has shown that indication of simulation can be identified by doctors using electronic searches of health records.74,75 Although legal and ethical questions www.thelancet.com Vol 383 April 19, 2014
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Malingering 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 Association,82 namely that the disorder involves “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives, such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs”. We have described the shortcomings of this definition above.19,20 One issue with malingering is that despite falling outside the remit of all recognised psychiatric authorities, many clinicians have difficulty avoiding the temptation to medicalise the illness. In an effort to retain medical involvement in the growing number of medically unexplained disorders, new disorders such as compensation neurosis”83 and factitious disorders were introduced into mainstream psychiatric nosologies in the 20th century. Common to both malingering and factitious disorders is the requirement of doctors to ascertain, during a clinical interview, the motivations and level of conscious awareness that accompany symptoms reported by patients.4 As a neuropsychological concept, the assessment of malingering generally involves both exaggeration and poor effort, although it has been claimed to be present with only one of these being accurately detected.80 In recognition that all such disorders are best viewed as existing on a continuum, the conceptual overlaps and potential for confusion are evident when considered in terms of motivation and symptom exaggeration83 or between attributed intention and subject responsibility.8 The figure shows both models. Malingering has been conceptualised in three categories: pure, when nonexistent clinical problems are feigned; partial, when actual symptoms are exaggerated; and false imputation, which refers to the deliberate misattribution of actual symptoms to the compensable event. Exaggeration of symptoms is generally assumed to be more common than outright faking.84 www.thelancet.com Vol 383 April 19, 2014
Epidemiology Prevalence estimates of symptom exaggeration are understandably difficult to estimate and vary according to the setting and criteria adopted.85 In social security disability examinations undertaken in the USA, the prevalence of symptom exaggeration in claimants has been estimated to be between 46% and 60%, with use of symptom validity tests.86 Members of the American Board of Clinical Neuropsychology reported rates of symptom exaggeration in 29% of cases of personal injury, in 30% of disability or workers compensation referrals, in 19% of criminal cases, and in 8% of medical or psychiatric cases (statistically adjusted to remove for the effect of referral source).87 The same rates categorised by diagnosis showed that 39% of cases were for mild head injury, 35% were fibromyalgia and chronic fatigue, 31% were chronic pain, 15% were depressive disorders, and 11% were dissociative disorders. Prevalence of symptom exaggeration is highest in compensation or litigation settings, but notably, most compensation claimants (75–90%) respond well to treatment, recover from illness or injury, and return to work.85
A Choice
Deception
Intentional
Malingering
Exaggeration
Psychiatric or psychosocial disorder Nonintentional Exculpated Responsibility
B Change in motivation going from internal at the bottom to more external at the top
can arise from such searches,76,77 such a search might be warranted to establish a diagnosis of deception when done within the ethical guideline of beneficence (ie, to prevent iatrogenic disease), preferably in conjunction with a colleague from the hospital legal department. Plastic surgeons should be aware that they can be sued for malpractice by patients with factitious disorders.78
Malingering
Conversion disorder (DSM-5 functional neurological disorder)
Compensation neurosis Factitious disorder
Range of level of intentional symptom production increasing from left to right
Figure: Two models of illness deception (A)8 and compensation neurosis (B)83 Reproduced by permission of Sage Publications (A) and American Psychiatric Press (B). Diagrams show the potential roles of patient choice, intentions, and motivation in symptom production and, ultimately, diagnosis. DSM-5=Diagnostic and Statistical Manual of Mental Disorders, fifth edition.
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Assessment The cornerstone of detection as opposed to diagnosis of malingering is the well-prepared clinical interview, having reviewed available documents and, when available, forensic materials. A conclusion of malingering typically needs multiple sources of converging evidence and the systematic ruling out of probable alternative explanations.88 For the interview, plenty of time and a neutral and supportive attitude are essential. A biographical and developmental approach is recommended, starting from childhood and working through the personal history to the index event and thenceforward to the present time. Most UK residents are registered with a primary care doctor, which allows for a longitudinal health record. Medical records potentially constitute an invaluable resource and provide objective evidence of reported complaints and clinic attendances that help to elucidate the association between an accident or injury and any subsequent symptoms attributed by the patient to the putative causal event. For example, doubts could arise if there was a very long gap between an accident and the start of consultations for a health problem (ie, the symptoms did not materialise logically from the incident in question). A chronological summary often pays dividends in the assessment of health documents (table). Special investigations are another method of detection. Probably the most widely encountered technique is video surveillance, which is typically provided by the insurance companies or lawyers. Video surveillance usually provides information about the physical abilities of the claimant. Marked or unexpected differences between the claimant’s observed behaviours and what they claim not to be able to do can raise doubts as to the credibility of their report. Experience and tradition in various specialties have resulted in different clinical techniques being used to help to assess the validity of clinical presentations. Patterns of muscular weakness might be used by neurologists and orthopaedic surgeons and others as indicators of the genuineness or otherwise of clinical presentations.89,90 Several motor tasks have been examined and grip strength measured with a hand dynanometer seems to be a good indicator of poor effort.91 A finger-tapping task has also provided useful information in personal injury claimants.92 In the past two decades, clinical psychology and neuropsychologists have developed psychological tests that have been claimed to provide a more precise assessment of the credibility of verbally claimed symptoms than other assessment methods. In this context symptom validity refers to the accuracy or veracity of a person’s behavioural presentation, self-reported symptoms, or performance on neuropsychological tests.93,94 Symptom validity tests typically comprise a simple memory or recognition task on which a wide range of people with neurological or psychiatric problems can achieve nearperfect performance.95 The basic premise underlying this approach is that a finding of below-chance (ie,
