Chapter 41. Factitious Disorder and Malingering

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James C. Hamilton, Marc D. Feldman: Chapter 41. Factitious Disorder and Malingering, in Gabbard’s Treatments of

Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc.

DOI: 10.1176/appi.books.9781585622986.260630. Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part VII. Somatoform and Factitious Disorders >

Chapter 41. Factitious Disorder and Malingering

INTRODUCTION

Factitious disorder and malingering are characterized by attempts to assume the sick role by

exaggerating, lying about, simulating, aggravating, or inducing illness. Despite the lack of concrete

evidence-based guidance on the care of patients with these behavior patterns, health professionals

are nevertheless expected to protect and promote the patients’ physical and psychological

well-being. In this chapter we attempt to present advice on how to accomplish this goal.

CLINICAL DESCRIPTION

The diagnostic criteria for factitious disorder include intentional feigning or production of illness for

the primary purpose of assuming the sick role. Malingering is differentiated from factitious disorder

because the former is driven by the pursuit of external or instrumental benefits as opposed to

strictly psychological ones. Whereas “legitimate” medical patients generally wish to avoid very

extensive assessment and treatment procedures, patients with factitious disorder are usually

agreeable to these procedures and may even suggest or demand additional ones. In contrast,

malingerers try to minimize medical tests and treatments. The malingerers’ primary motive is to

gain official medical validation of their illness or injury claim; once this is achieved, additional

medical contacts could only undermine their deceptions. Both factitious disorder and malingering

patients might be knowledgeable about medicine and attempt to influence clinical decision making

to an unusual degree, yet they are likely to be elusive and guarded about their medical histories.

For both conditions, diagnosis seldom requires psychological or psychiatric expertise: patients are

caught in the act of hurting themselves or manipulating specimen samples. Improvement is

observed when the patients are denied opportunities to hurt themselves or when past medical

records reveal an unmistakable pattern of disease forgery. Because malingering is not a

psychological disorder, we do not discuss it as a direct target of psychiatric treatment.

MANAGEMENT, TREATMENT, AND PREVENTION

There are no well-tested treatments for factitious disorder. Countless reviews repeat and reinforce

the conventional wisdom that factitious disorder is rare, that patients are not treatable, and that

their resistance and denial preclude even the possibility of conducting treatment research. We can

either keep repeating these orthodoxies or begin to think creatively about different approaches to

the problem. In this chapter we outline several new ways to think about factitious disorder. These

new ideas hold out the immediate hope of more effective management and the promise of effective

prevention and treatment programs in the future.

THREE NEW WORKING ASSUMPTIONS ABOUT FACTITIOUS DISORDER

Assumption 1: Factitious Disorder Is Not Rare and Is Not Always Severe

It is widely assumed that factitious disorder is a rare disorder characterized by extreme forms of

medical deception. However, its apparent rarity and severity are almost certainly artifacts of our

inability to detect more subtle cases. Most persons diagnosed with factitious disorder are those

whose deceptions are so audacious that the patients can somehow be caught in the act, or the act

leaves physical evidence that can be uncovered.

Assumption 2: Factitious Disorder Is Not Categorically Distinct From the

Somatoform Disorders

Since the publication of DSM-III (American Psychiatric Association 1980), factitious disorder and Print: Chapter 41. Factitious Disorder and Malingering http://www.psychiatryonline.com/popup.aspx?aID=260634&print=yes…

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the somatoform disorders have been regarded as two separate categories of psychological

disorders despite their obvious similarities. The distinction is based solely on the assumption that

the excessive illness behavior of patients with factitious disorder is consciously enacted, whereas in

somatoform disorders it is unconsciously enacted. There is actually no empirical support for this

distinction.

Assumption 3: Factitious Disorder Develops Gradually

Surprisingly little attention has been paid to the onset and development of factitious disorder.

Because patients are usually uncooperative with history taking or follow-up, we typically see these

cases as snapshots in time. However, retrospective reviews of the medical histories of these

patients suggest a gradual escalation in the frequency and severity of their medical deceptions,

which sometimes begin after an unexpectedly gratifying hospitalization for an authentic ailment

(Feldman 2004).

IMPROVEMENT OF MEDICAL MANAGEMENT

There are few psychological disorders whose management rests so heavily upon nonpsychiatric

physicians. Accordingly, we endorse a proactive approach to psychiatric consultation that

emphasizes primary and continuing medical education about the most effective strategies for

dealing with factitious disorder. The focus of this training should be 1) a review of possible

indicators (as enumerated by Feldman and Eisendrath [1996] and others); 2) an emphasis on the

importance of early acknowledgment of the disorder as a possible explanation for puzzling medical

presentations; and 3) the importance of requesting psychiatric or psychological consultation as

soon as any suspicions arise (Axen 1986; Huffman and Stern 2003).

The primary goal of medical staff must be to protect suspected factitious disorder patients against

the risk associated with self-injurious behavior and the risk of iatrogenic illness resulting from

unnecessary medical procedures. Both risks are drastically reduced the moment the medical

treatment team begins to suspect factitious disorder; careful monitoring of the patient reduces

opportunities for self-harm, and a more conservative medical approach decreases the chances of

iatrogenic harm. Therefore we recommend that physicians maintain a low threshold for developing

suspicions of the disorder. Assumption 1, by suggesting that factitious disorder may be more

prevalent than commonly thought, lowers the threshold of suspicion and should result in improved

medical management of factitious disorder.

Physicians may react to such advice by arguing that premature suspicions could cause

life-threatening delays in the diagnosis and treatment of patients with genuine, but puzzling,

illnesses. However, suspecting a patient of factitious disorder places the patient under no

extraordinary medical risks provided that physicians treat the patient’s medical condition as they

would any other patient with similar signs and symptoms. Clinical experience—our own and that

shared in published case reports—indicates that crucial errors in medical care are most likely to

occur prior to the development of suspicion about factitious disorder (compare Feldman 2001 with

Grenga and Dowden 1987). The most notable errors occur when medical staff allow the patient to

exercise inappropriate influence over decisions that should rest with the physician, such as forgoing

definitive tests or repeating risky tests. These departures from standard practice typically cease the

moment suspicions of factitious disorder arise, and earlier errors are corrected (e.g., definitive

tests are performed despite the patient’s protests; release of past medical records is made a

prerequisite for further care). Thus, even if a difficult or puzzling patient has a genuine illness, his

or her care will either remain the same or improve once a suspicion of factitious disorder arises.

Finally, the failure to consider factitious disorder among the potential explanations for a puzzling

clinical picture is itself a crucial medical error that can have serious medical consequences for the

patient and legal consequences for the provider.

Assumptions 2 and 3 facilitate the development of early suspicions about factitious disorder by

decreasing the accusatory and pejorative connotations associated with it. If psychiatrists and

psychologists promote a view that factitious disorder develops gradually from psychologicalPrint: Chapter 41. Factitious Disorder and Malingering http://www.psychiatryonline.com/popup.aspx?aID=260634&print=yes…

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processes similar to those at work in the somatoform disorders, early suspicions can be framed as

early detection that is in the patient’s interest rather than as a cavalier accusation of intentional

wrongdoing. Early detection might actually permit the application of cognitive-behavioral

treatments that appear to be effective in the somatoform disorders and may be helpful in factitious

disorder (Kroenke and Swindle 2000; Looper and Kirmayer 2002). These same interventions might

be much less effective if the patient has the opportunity to escalate his or her deceptions past the

point where a face-saving retreat from them is no longer possible.

EARLY PSYCHIATRIC OR PSYCHOLOGICAL CONSULTATION

Setting a liberal criterion for suspecting factitious disorder should also have the effect of hastening

the use of psychiatric or psychological consultants. Early interventions with the medical staff should

focus on three important goals. First, the consultant should help the treatment team decide what

sorts of evidence will be needed to satisfy the team that the working hypothesis of factitious

disorder has been sufficiently proved or disproved. Second, the consultant should work to prevent

the staff from developing strong emotional reactions to the patient or to each other (Eisendrath

2001). This is achieved partly by helping the staff arrive at an a priori, mutually acceptable strategy

for testing the hypothesis. Doing this early on can preempt the emotionally charged side-taking that

can develop as a puzzling case drags on without definitive resolution. In addition, the consultant is

in a position to help medical staff understand and minimize feelings of anger, frustration, and

powerlessness that could potentially derail objective clinical management of the case (Feldman and

Smith 1996).

Third, the consultant can begin to help the treatment team address suspicions about the patient.

This is a crucial juncture in the treatment of the patient with factitious disorder. The available

clinical guidance suggests that direct confrontation of the patient seldom will be successful

(Eisendrath 1989; Eisendrath and Feder 1996). Although it might seem like putting an abrupt end

to the patient’s charade will minimize the expense and danger associated with the disorder, it is

likely that the patient will merely relocate to another medical center. Instead, the medical team can

be urged to begin explaining to the patient that having a complicated and puzzling medical

condition is psychologically stressful and that this stress may actually be adversely affecting the

patient’s health (Servan-Schreiber et al. 2000; Stone et al. 2005). This framework allows the

physician to introduce the idea of psychiatric or psychological consultation in a way that does not

threaten the patient’s claim of real physical illness.

PSYCHIATRIC AND PSYCHOLOGICAL INTERVENTIONS

Once the consultant begins seeing the patient, a similarly cautious nonconfrontational approach

should be taken. Early assessment can focus on collecting information about the presence of

comorbid disorders (especially mood and Cluster B personality disorders) and on gathering

information about the patient’s psychosocial assets and weaknesses. A thorough understanding of

the patient’s family and social networks can provide important information about the possibilities

for changing aspects of these systems that might be supporting the patient’s illegitimate sick role

enactments.

PHARMACOTHERAPY

To our knowledge there are as yet no randomized clinical trials of pharmacotherapy for factitious

disorder nor any published case series describing such treatments. There are a few case reports of

patients who have benefited from psychopharmacological treatments. A recent report by Oh et al.

(2005) exemplifies the use of antidepressant medication (mirtazapine) in the early stages of

treatment. In this case, a patient exacerbating her own skin wounds was simultaneously treated

with antidepressants and casting to prevent reinjury. Healing occurred and her self-injury went into

remission. Yanik et al. (2004) reported a similarly positive outcome using fluoxetine. These reports

and at least one other (Earle and Folks 1986) promote the use of antidepressants as part of a

treatment package that includes both behavior therapy or psychotherapy and careful medical

management. We could find only one report of the use of antipsychotic medicine (pimozide) for the

treatment of factitious disorder, and this case seems to have involved an unusually prominentPrint: Chapter 41. Factitious Disorder and Malingering http://www.psychiatryonline.com/popup.aspx?aID=260634&print=yes…

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hypochondriacal fear (Prior and Gordon 1997).

PSYCHOTHERAPY

Most traditional psychotherapy approaches to factitious disorder are based on the idea that

factitious illness behavior is rooted in early developmental problems of the sort described by self

psychologists and object relations theorists (Kupfermann et al. 1998; Mayo and Haggerty 1984;

Plassmann 1994a). This approach is supported by the apparent connections between factitious

disorder and Cluster B personality disorders, which are commonly regarded as a reflection of

failures of early developmental processes such as separation and individuation (Ehlers and

Plassmann 1994). Accordingly, some clinicians have attempted to apply treatment techniques from

self psychology and object relations theory (Plassmann 1994b). One of the most impressive studies

of factitious disorder treatment was based on these models. Plassmann (1994b) reported on the

treatment of 24 patients with factitious disorder. Of the 12 who agreed to treatment, 10 stayed

with treatment long enough (4 years or more) to experience significant progress.

COGNITIVE AND BEHAVIORAL THERAPIES

Although cognitive-behavioral treatments have been successfully employed for patients with

somatoform disorders (Allen et al. 2001; Arnold et al. 2004; Dworkin et al. 2002; Ehlert et al. 1999;

Hiller et al. 2003; Kroenke and Swindle 2000; Looper and Kirmayer 2002), there are only isolated

reports describing their use with factitious disorder patients (Kinsella 2001; Klonoff et al. 1983;

Solyom and Solyom 1990; Teasell and Shapiro 1994). The common theme in all of these reports is a

shift in emphasis away from medical cure and toward improved quality of life. This means engaging

the patient in cognitive restructuring of pain- and disability-related cognitions and changing the

contingencies that control the patient’s behavior in a manner that promotes adaptive functional

behavior and discourages continued disability and other sorts of illness behavior. These general

strategies were developed in the treatment of chronic pain and apply very well to a broad range of

patients with medically unexplained symptoms, functional somatic syndromes, and somatoform

disorders (Looper and Kirmayer 2002).

In treating patients whose medical deceptions are particularly flagrant, a unique challenge is to

find a way for the patients to relinquish the sick role in a manner that does not require them to

admit that they were “faking.” Several authors have suggested face-saving approaches to this

problem (Eisendrath 1989; Solyom and Solyom 1990; Teasell and Shapiro 1994). Klonoff et al.

(1983), for example, used electroencephalographic biofeedback training as a means for a patient

with nonepileptic seizures to achieve a “cure.” Other behavioral treatment approaches could be

employed for the same purpose, including self-hypnosis and relaxation training, as well as low-risk

treatments from complementary and alternative medicine. Shapiro and Teasell (2004) used

patients’ desire to save face as a therapeutic tool. They tested a therapeutic double-bind strategy in

the context of a crossover design. Patients with nonorganic motor problems who did not respond to

standard cognitive-behavioral therapy were told that a favorable response to treatment would

confirm that they did indeed have a genuine medical illness, whereas nonresponse would indicate

that the patients had a psychiatric illness. This double-bind strategy appears to have been

successful in 17 of 21 cases that failed to respond to other forms of CBT, and results were seen in a

matter of weeks.

The second important element in behavioral treatments of factitious disorder is the management of

contingencies in order to reduce the reinforcement of factitious illness behavior. It is medically

risky to simply ignore the patient’s claims to be ill. However, some physicians have taken the

approach of providing medical attention that is not contingent upon a medical crisis; that is, the

patient is seen regularly regardless of whether he or she has an active medical complaint (Smith et

1. 1986a, 1986b). Schwarz et al. (1993) used this approach with a patient who was allowed to

admit herself whenever she felt the need to be in the hospital. By allowing her to enact the sick role

without having to hurt herself, the treatment team was able to reduce the medical risks to the

patient, and they also succeeded in reducing hospitalization days over time. Solyom and Solyom

(1990) reported on two cases of factitious paraplegia in which the focus of treatment was reducingPrint: Chapter 41. Factitious Disorder and Malingering http://www.psychiatryonline.com/popup.aspx?aID=260634&print=yes…

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positive reinforcement for excessive sick role behavior. Their treatment included a negative

reinforcement procedure whereby the patients received regular mildly painful electrical stimulation

treatments that (the patients were told) would continue to escalate in intensity until their

functioning improved. Both patients were able to walk within days following the beginning of these

treatments. Despite this dramatic treatment response, any treatments using aversive stimuli should

not be undertaken without the close consultation of a behaviorally trained psychologist and

appropriate ethical and legal oversight.

NOVEL APPROACHES

Some patients who conceptualize their factitious illness behavior as an addiction have profited from

developing and taking part in 12-Step approaches. Although conventional group activities to

implement 12-Step programs for factitious disorder are not practical, some patients have turned to

Internet-based support groups for this purpose. Finally, some patients have reduced or abandoned

their illness deceptions due to gratifying life changes, such as marriage or spiritual fulfillment

(Feldman 2004).

PREVENTION

It is likely that factitious disorder begins with relatively benign forms of excessive sick role

behavior that progress to more consequential forms of medical deception (Assumption 3). If this is

the case, then prevention efforts can be focused on detecting mildly excessive illness behavior and

intervening before more life-impairing patterns of sick role enactments have a chance to develop.

Although credible research on the epidemiology and etiology of the disorder is practically

nonexistent, clinical evidence suggests two key features in its development: 1) direct or vicarious

exposure to the benefits that the sick role provides; and 2) problems in personality or social

development that leave the patient susceptible to the unconditional interpersonal acceptance that

accompanies the sick role. To address these risk factors, primary care physicians, especially

pediatricians, should be attentive to patterns of illness behavior encouragement that can develop in

their patients’ families and social environments. Patients and their families should be assisted with

the difficult task of setting reasonable expectations about the patients’ physical and mental

capabilities during recovery and beyond and should be educated about the risks of becoming overly

dependent on the sick role. When excessive illness behavior is suspected, families should be

provided with effective behavioral management techniques for minimizing sick role behavior and

maximizing developmentally appropriate, growth-promoting activities at work, at school, and at

home. Not only will these measures help to prevent factitious disorder, we believe they will also

help to prevent disorders such as somatization, conversion, and pain disorder.

Psychologists and psychiatrists can contribute to these prevention efforts by advocating for the

inclusion of these issues in primary and continuing medical education. Mental health professionals

can be more directly involved by making assessment of illness behavior encouragement a routine

part of their consultation-liaison work.

CONCLUSION

Factitious disorder is poorly understood by scientists and poorly managed by practitioners. We have

suggested new working assumptions about the disorder that promote the importance of early

identification and early intervention in suspected cases and in all cases in which excessive illness

behavior develops. As with other diseases that are difficult to cure but preventable, our best chance

of controlling factitious disorder may be through effective education of physicians and patients.

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