Chapter 42 - Factitious disorders and malingering in relation to functional neurologic disorders
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
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Cited by (22)
Functional neurological disorder: new subtypes and shared mechanisms
2022, The Lancet NeurologyCitation Excerpt :Feigning is often divided into factitious disorder (wilfully simulating symptoms for medical care) or malingering (simulating symptoms for other gain). Both subtypes of feigning require evidence of conscious deception and action for identification.82 Evidence of feigning primarily involves a major discrepancy between reported and observed activity (ie, what the person says they can do vs what they are seen to do), such as someone claiming they cannot walk who is seen walking their dog.
Concepts and controversies of malingering: A re-look
2020, Asian Journal of PsychiatryCitation Excerpt :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.
Smell status in functional movement disorders: New clues for diagnosis and underlying mechanisms
2019, Clinical Neurology and NeurosurgeryCitation Excerpt :It can be concluded that a normal smell score makes a diagnosis of an IAMOK unlikely and strengthens a diagnosis of FMD when this illness is suspected. Additionally, olfactory testing may aid in differentiating FMD from malingering, which can also be of concern when assessing these patients [6,29]. It is noteworthy that 14% of the FMD patients reported subjective olfactory dysfunction prior to being tested.
Misdiagnosis of functional neurological symptom disorders in paediatrics: Narrative review and relevant case report
2024, Clinical Child Psychology and Psychiatry