Chapter 42 - Factitious disorders and malingering in relation to functional neurologic disorders

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Abstract

Interest in malingering has grown in recent years, and is reflected in the exponential increase in academic publications since 1990. Although malingering is more commonly detected in medicolegal practice, it is not an all-or-nothing presentation and moreover can vary in the extent of presentation. As a nonmedical disorder, the challenge for clinical practice remains that malingering by definition is intentional and deliberate. As such, clinical skills alone are often insufficient to detect it and we describe psychometric tests such as symptom validity tests and relevant nonmedical investigations. Finally, we describe those areas of neurologic practice where symptom exaggeration and deception are more likely to occur, e.g., postconcussional syndrome, psychogenic nonepileptic seizures, motor weakness and movement disorders, and chronic pain.

Factitious disorders are rare in clinical practice and their detection depends largely on the level of clinical suspicion supported by the systematic collection of relevant information from a variety of sources. In this chapter we challenge the accepted DSM-5 definition of factitious disorder and suggest that the traditional glossaries have neglected the extent to which a person's reported symptoms can be considered a product of intentional choice or selective psychopathology largely beyond the subject's voluntary control, or more likely, both. We present evidence to suggest that neurologists preferentially diagnose factitious presentations in healthcare workers as “hysterical,” possibly to avoid the stigma of simulated illness.

Introduction

Controversial and ubiquitous, deception describes a common pervasive form of episodic human behavior that understandably raises concerns and prejudices when found and/or thought to occur in medical settings (Conroy and Kwartner, 2006). Considered by some to be evolutionarily adaptive (Spence, 2004), it is important from the outset to locate illness deception within a wider context of human deception. In a study of absenteeism in Canada of hospital workers who had just returned from a scheduled day off or an unscheduled day off classified by the employer as due to sickness absence, 72% admitted not being sick on their (sick) day off (Haccoun and DuPont, 1987).

The key issue (and source of much controversy) in medicine remains the extent to which a person's reported symptoms can be considered a product of conscious choice, a form of psychopathology (beyond the person's volitional making), and/or perhaps both. Notwithstanding recent experimental findings using functional brain imaging, the diagnosis established is frequently “influenced by circumstantial factors and the physician's opinion of the patient's personality or background” (Spence, 2004).

According to Rogers (1997):

If we never investigate dissimulation [e.g., deceit subterfuge, falsification], then we may never find it. I believe that our working assumption in clinical practice should be that an appreciable minority of evaluatees engage, at some time, in a dissimulate response style. If we accept this working assumption, then we also accept the responsibility to screen all referrals and activity to consider the possibility of malingering and other forms of deception.

We have argued elsewhere (Halligan et al., 2003b, Bass and Halligan, 2014) that illness deception (e.g., factitious disorder and malingering as defined in DSM-5) is probably underestimated and is better understood within a wider biopsychosocial model. At the heart of the DSM-5 definition is falsification of symptoms and/or signs associated with deception, in the absence of external rewards. The behavior is not accounted for by another mental disorder such as delusional disorder.

We suggest that the medicalization of illness deception (such as factitious disorders and compensation neurosis) arose largely as an attempt to create a way of bridging or linking diagnoses between unconsciously mediated psychiatric disorder and consciously mediated malingering (Bass and Halligan, 2014). Moreover, we believe that the current DSM diagnosis of factitious disorder has little clinical validity (Bass and Halligan, 2007).

This is not to argue that medical factors involving deception are not relevant, but that medical education needs to provide doctors with a broad conceptual, developmental, and management framework from which to better understand and manage deception in patient–doctor interactions. It is equally important however, to ensure that medical disorders are not ignored where symptoms-based illness behavior provides for an alternative working hypothesis. A study in the Israeli military showed that two dozen conscripts repeatedly considered to be malingering were in fact suffering from serious psychiatric disorders (Witztum et al., 1996).

A growing challenge for dealing with illness deception is the increasing acceptance that many medical illnesses cannot be exclusively diagnosed or validated on the basis of the biomedical model. Medically unexplained symptoms (MUS) continue to form one of the most expensive diagnostic categories in Europe and are the fifth most common reason for visiting doctors in the USA (Creed et al., 2011). Interest in functional neurologic disorders has also grown steadily over the last decade, and recent conferences on conversion disorders and psychogenic movement disorders (PMD) have led to the publication of a number of books (Halligan et al., 2001, Hallett et al., 2011) and in the UK the formation of an interdisciplinary Functional Neurology Group (Carson et al., 2011a). In tandem, there has been a growing neuropsychologic interest in illness deception and malingering (e.g., Halligan et al., 2003a, Rogers, 2008, Bass and Halligan, 2014, Young, 2014), with neuropsychologists and clinicians introducing and refining novel methods of assessment in patients suspected of simulating illness.

In addition to a brief historic review, this chapter considers some current themes and outlines the main areas of clinical practice where deception can complicate the clinical presentation and its subsequent management, with particular reference to neurologic practice.

Section snippets

Historic context

The practice of illness deception by feigning illness has a long history, with illustrative cases from Greek, biblical and classic literature. Before the 1880s there are several isolated reports on malingering (e.g., Gavin, 1838), listing motives such as the need to “to obtain the ease and comfort of a hospital” and the “avoidance of duties.” Similar motives were ascribed to the behavior of soldiers in the American Civil War, including “choosing a career diversion as a patient rather than a

Diagnosis of simulated illness

Despite general acceptance that malingering is not a medical diagnosis “it is clear from medical literature and the examination of law reports that many doctors consider detection of malingering as an integral part of the medical enterprise” (Mendelson, 1995). From a clinical and diagnostic perspective, however, there is also evidence that most people, including clinicians, are unable to reliably and consistently detect the contributory role of deception (Ekman, 1985, Rosen et al., 2004).

Growing interest in illness deception

After World War II medical efforts to detect deception moved from clinical “intuition” to the more active search for new techniques to detect it. Understanding deception in the medical context was further facilitated by the introduction of concepts such as abnormal illness behavior (Pilowsky, 1969, Mechanic, 1978). The introduction of quantitative testing by clinical psychologists however arrived relatively late, with the first modern textbook on malingering published as late as 1988 (Rogers,

Psychosocial context

The clinical dilemmas presented by patients with illnesses without definable biomedical causes are well established (Hatcher and Arroll, 2008, Sharpe, 2013). In general practice, one-fifth of consultations constitute medical unexplained symptoms (MUS) (Burton, 2003) and estimates of those without confirmed disease seen in hospital outpatient clinics range from 35% to 53% (Stone et al., 2010, Creed et al., 2011). These figures are likely to be an underestimate, as many doctors understandably

Definition

It was recently suggested that factitious disorders should be considered a variant of somatoform disorders (Krahn et al., 2008), as both conditions provide patients with the opportunity to “organize their lives around seeking medical services in spite of having primarily a psychiatric condition.” This latter model has been adopted by DSM-5, with factitious disorders recategorized as somatic symptom disorders with two types: factitious disorder imposed on self and factitious disorder imposed on

Conceptual and definitional problems

Rogers (1990) considers malingering to be a behavior governed by a cost–benefit analysis. Psychiatric glossaries have struggled to define malingering, and the shortcomings of the DSM-5 definition have been described elsewhere (Bass and Halligan, 2014). In essence, the diagnostic glossary presents malingering as a categoric condition (“the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives” and where this external gain may

Malingered cognitive deficit (e.g., postconcussional syndrome)

A significant proportion (15–30%) of patients with mild traumatic brain injury seem at risk of developing postconcussional syndrome, with symptoms such as headache, distress, cognitive problems, and dizziness (Hou et al., 2012). It has also been shown that there is an association between patient concern (i.e., expectations) that symptoms will have adverse consequences, and the reporting of major and enduring complaints (Whittaker et al., 2007, Ferrari, 2011).

In their influential paper, Miller

Conclusions

Sensitivities surrounding the nature of illness deception will no doubt continue to be a challenging issue for modern medicine given the growing recognition that many medical illnesses are not exclusively diagnosed or validated on the basis of the biomedical model. Given the personal, financial, and social benefits provided by sick role and the low risk of detection (Halligan et al., 2003b), it seems reasonable that illness deception is more prevalent than previously presumed or detected. Much

References (105)

  • J. Libow

    Munchausen by proxy victims in adulthood: a first look

    Paediatrics

    (1995)
  • C. McCullumsmith et al.

    Simulated illness: the factious disorders and malingering

    Psychiatr Clin North Am

    (2011)
  • G. Mendelson

    Compensation neurosis revisited: outcome studies of the effects of litigation

    J Psychosom Res

    (1995)
  • H. Miller et al.

    Simulation and malingering after injuries to the brain and spinal cord

    Lancet

    (1972)
  • H. Singh et al.

    The effect of short term dependency and immobility on skin temperature and colour in the hand

    J Hand Surg [Br]

    (2006)
  • J. Stone

    Effort testing in patients with neurological symptoms unexplained by disease

    J Psychosom Res

    (2008)
  • A.J. Sutherland et al.

    Factitious disorders in a general hospital setting: clinical features and review of the literature

    Psychosomatics

    (1990)
  • R. Ahrenfeldt

    Psychiatry in the British army in the Second World War

    (1958)
  • American Psychiatric Association

    Diagnostic and Statistical manual of mental Disorders

    (1980)
  • A. Avignal et al.

    Secrets unraveled. Overcoming Munchausen syndrome (ebook)

    (2012)
  • M. Barber et al.

    Fits, faints, or fatal fantasy? Fabricated seizures and child abuse

    Arch Dis Child

    (2002)
  • H. Barrow

    Simulated patients

    (1971)
  • R. Bartholow

    A Manual of Instructions for Enlisting and Discharging Soldiers

    (1863)
  • C. Bass

    Complex regional pain syndrome medicalises limb pain

    Br Med J

    (2014)
  • C. Bass et al.

    Illness related deception: social or psychiatric problem?

    J R Soc Med

    (2007)
  • C. Bass et al.

    Psychopathology of perpetrators of fabricated or induced illness: a case series

    Br J Psychiatr

    (2011)
  • C. Bass et al.

    Recovery from chronic factitious disorder (Munchausen's syndrome): a personal account

    Pers Ment Health

    (2013)
  • S. Bender et al.

    PCS, iatrogenic symptoms, and malingering following concussion

    Psychol Inj Law

    (2013)
  • D. Berry et al.

    DSM-5 and malingering: a modest proposal

    Psychol Inj Law

    (2010)
  • L. Binder et al.

    Deceptive examinees who committed suicide: report of two cases

    Clin Neuropsychol

    (2012)
  • C. Burton

    Beyond somatization: a review of the understanding and treatment of patients with medically unexplained physical symptoms (MUPS)

    Br J Gen Pract

    (2003)
  • A. Carson et al.

    Functional (conversion) neurological symptoms: research since the millennium

    J Neurol Neurosurg Psychiatry

    (2011)
  • A. Carson et al.

    Disability, distress and unemployment in neurology outpatients with symptoms “unexplained by organic disease”

    J Neurol Neurosurg Psychiatry

    (2011)
  • M. Chafetz et al.

    Estimated costs of malingered disability

    Arch Clin Neuropsychol

    (2013)
  • J. Collie

    Malingering and Feigned Sickness

    (1913)
  • M.A. Conroy et al.

    Malingering

    Appl Psychol Crim Justice

    (2006)
  • D. Cragar et al.

    Performance of patients with epilepsy or psychogenic non-epileptic seizures on four measures of effort

    Clin Neuropsychol

    (2006)
  • F. Creed et al.

    Epidemiology: prevalence, causes and consequences

  • B. Crick et al.

    Lawsuit verdicts and settlements involving reflex sympathetic dystrophy and complex regional pain syndrome

    J Surg Orthop Adv

    (2011)
  • M. Crocq et al.

    From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology

    Dialogues Clin Neurosci

    (2000)
  • R. de Asla

    Complex regional pain syndrome type 1: disease or illness construction?

    J Bone Surg Am

    (2011)
  • M. de Mos et al.

    Outcome of the complex regional pain syndrome

    Clin J Pain

    (2009)
  • C. Dodrill

    Do patients with psychogenic nonepileptic seizures produce trustworthy findings on neuropsychological tests?

    Epilepsia

    (2008)
  • D. Drane et al.

    Cognitive impairment is not equal in patients with epileptic and psychogenic nonepileptic seizures

    Epilepsia

    (2006)
  • J. Eagles et al.

    Simulated patients in undergraduate education in psychiatry

    Psychiatr Bull

    (2007)
  • S. Eastwood et al.

    Management of factitious disorders: a systematic review

    Psychother Psychosom

    (2008)
  • P. Ekman

    Telling Lies: Clues to Deceit in the Marketplace, Politics, and Marriage

    (1985)
  • G. Engel

    The need for a new medical model: a challenge for biomedicine

    Science

    (1977)
  • A. Espay et al.

    Opinions and clinical practices related to diagnosing and managing patients with psychogenic movement disorders: an international survey of movement disorder society members

    Mov Disorders

    (2009)
  • R. Ferrari

    Minor head injury: do you get what you expect?

    J Neurol Neurosurg Psychiatry

    (2011)
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      Both ICD-10 and ICD-11 have denoted malingering as a condition (not a mental disorder) that may be a focus of clinical attention. Recent opinion about malingering is that it can be best viewed as a continuum disorder ranging from exaggeration to dissimulation/concealment to symptom feigning only to misattribution of cause to invention/creating symptoms and signs when none exist (Bass and Halligan, 2016; Bass and Wade, 2019). Ever since the concept of malingering had been introduced to the it had invited more controversies among the medical professionals.

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