Factitious disorder and malingering

Abstract

Abstract Patients with factitious disorder feign or simulate illness, are considered not to be aware of the motives that drive them to carry out this behaviour, and keep their simulation or induction of illness secret. In official psychiatric nomenclature, factitious disorder has replaced the eponym Munchausen syndrome, introduced by Asher to describe patients with chronic factitious behaviour. Asher borrowed the term from Raspe's 1785 fictional German cavalry officer, Baron Karl von Munchausen, who always lied, albeit harmlessly, about his extraordinary military exploits. The criteria for factitious disorder in DSM-IV are (a) the intentional production or feigning of physical or psychological signs or symptoms; (b) motivation to assume the sick role; and (c) lack of external incentives for the behaviour (e.g. economic gain, avoidance of legal responsibility, or improved physical well-being, as in malingering) and lack of a better classification for the disorders. In the last 10 years there has been increased interest in deception in medical practice, with specific focus on pathological lying and the diagnostic dilemmas in this field: specifically, how to differentiate between hysteria, factitious disorders, and malingering. Some of these topics will be discussed in the next section. This chapter concentrates on factitious physical complaints; fabricated psychological symptoms are considered under malingering. The DSM-IV criteria have recently come under attack. Turner has argued that criterion B (motivation to assume the sick role) has no empirical content and fulfils no diagnostic function. He also argues that criterion A, the intentional production of physical or psychological signs or symptoms, emphasizes symptoms and cannot accommodate pseudologia fantastica (PF), voluntary false confessions, and impersonations. He concludes that the two criteria need reformulating in terms of lies and self-harm, respectively. Bass and Halligan have also suggested that because the conceptual justification for factitious disorders is ‘empirically unsubstantiated’ and the motivation for diagnostic purposes (conscious versus unconscious; voluntary versus involuntary) essentially unknowable, it seems reasonable to question the clinical status and legitimacy of factitious disorder. More recently there has been a resurgence of interest in pathological lying, because this is often easier to identify than, for example, the degree of ‘voluntariness’ or ‘motivation’ to attain the sick role (however that is defined).