The factitious/malingering continuum and its burden on public health costs: a review and experience in an Italian neurology setting

The factitious disorder is classified by DSM-5 [1] as one of the five aspects of somatic symptom disorders. This is at difference with the DSM IV-TR [2] version, which coded factitious disorder outside of somatoform disorders and edging dissociative disorders. Although the fundamental element of factitious disorder is deception, i.e., pretending to suffer from a medical or psychiatric disorder, the enactment of deception is also considered unconscious. Indeed, the volitional aspect, i.e., perception of deliberate deception, is blurred in patients suffering from factitious disorders. There is no apparent economic purpose in patients with factitious disorder, at difference with malingering, which is considered willed fraudulent behavior [1, 2].

The disorder reached a definite identity only in the DSM III [3]. Therefore, related interpretations are likely biased by the previous insufficient separation from other somatic symptoms disorders and malingering. Before the DSM III, factitious disorder and malingering were considered present mainly in the military (drafted personnel) and criminal world [4, 5]. For some authors, a catalyst of factitious disorder and malingering was the creation of social welfare and the access to financial compensations or unnecessary care [6].

According to the early presentation of the disorder [7], in the DSM IV, factitious disorder was also termed Munchausen syndrome. The DSM-5 now disfavors its use. The reasons to opt for other terms are discussed in detail by Feldman and Yates [6], where attention is focused on the need to highlight the abusive behavior in legal terms.

The core definitions of factitious disorder are that “are conditions in which a patient intentionally produces or feigns physical or psychological symptoms…without obvious secondary gain (ICD-10 definition).” [8] The DSM-5 states that “the motivation for the behavior is to assume the sick role” but, although deception and feigning are the core element for the diagnosis, the manuals also indicate that “assessment of conscious intention is unreliable” and diagnosis is linked to the chance to incur into evidence of feigning [1]. Therefore, guidelines indicate that deception and the absence of external incentives for the behavior are diagnostic criteria. However, paradoxically, the same guidelines state that the intention of feigning cannot be reliably assessed. The DSM IV-TR [2] also provided a detailed guide (red flag, indicating that the presence of specific behaviors should alert the clinics to suspect a factitious origin) for differential diagnosis. “Suspicion that an apparent mental disorder or general medical condition in fact represents factitious disorder should be aroused if any combination of the following is noted in a hospitalized individual: an atypical or dramatic presentation that does not conform to an identifiable general medical condition or mental disorder; pseudologia fantastica (pathological lying); disruptive behavior on the ward (e.g. noncompliance with hospital regulations, arguing excessively with nurses and physicians); extensive knowledge of medical terminology and hospital routines; covert use of substances; evidence of multiple treatment interventions (e.g. repeated surgery); extensive history of traveling; a fluctuating clinical course, with rapid development of “complications” or new “pathology” once the initial workup proves to be negative.”

Factitious disorder may also appear as a “by proxy” behavior, termed as “Munchausen Syndrome by proxy” [9]. In this case, the quest for medical attention is transposed to people (often children) cared for by the person with factitious disorder. Using drugs or physical manipulations or direct poisoning, the perpetrator induces sick conditions to persons of whose care he/she is charged. Recently, a substitution of “Munchausen Syndrome by proxy” with “Medical Child Abuse” has been proposed with the aim, again, to address the legal aspects of the condition [10, 11].

Because pathological lying (pseudologia fantastica) is a critical component of the disorder, it is argued that the clinician should actively seek its identification. Pathological lying is distinguished from “normal” lying by several characteristics, including recurrent, enduring, and compulsive lie presentations as well as fantastic, self-aggrandizing content and the possible ego-dystonic structure with maladaptive or destructive outcomes for the quality of life of the pathological liar [12, 13].

Factitious disorders may appear in association with other mental disorders. The DSM-5 [1] quotes the association with the other four somatic symptoms disorders (i.e., the somatic symptoms disorder-Briquet syndrome, the conversion-functional neurologic disorder, illness anxiety disorder-hypochondria, psychological symptoms occurring during other medical conditions) and with dissociative disorders. The DSM IV-TR [2] includes histrionic, antisocial, borderline, and dependent personality disorders. The DSM-5 goes to the extent of stating that “some aspects of factitious disorders might represent criminal behavior.”

The recent neurologic literature has proposed a clear-cut separation of conversion/functional neurologic disorders (FND) from factitious disorders [14, 15]. However, as mentioned above, the DSM classification system underlines the frequent overlap between different forms of somatic symptom disorders, once termed hysteria and, therefore, a hystero-malingering continuum has been suggested [12, 16].

Studies analyzing the occurrence of somatizations in adopted patients and their biological parents indicated that the somatization disorder was associated with heritable personality traits like predisposition to antisocial behavior and substance abuse [17‐19]. Thus, the antisocial trait (and possible further evolutions to criminal behavior) is an aspect of the factitious/malingering continuum that should not be overlooked.

Factitious disorder is not rare; epidemiological studies show that 1% of referrals to psychiatry liaison services in hospitals exhibit the disorder [20]. Around one-third of the perpetrators of medical child abuse (by proxy disorder) have factitious disorder themselves [21].

Factitious disorder has been extensively studied in the USA and the UK. These studies have highlighted the outrageous costs to the healthcare systems [20, 22]. In Italy, less than 40 single case reports have been published so far, all exclusively reporting “by proxy” cases of medical child abuse [23]. (results of PUBMED search for, Factitious, Munchausen, Italy).

The present study aims to call attention to this disorder and estimate the costs to our healthcare system. The cases reported here are taken from our Neurology Clinic, but factitious disorders have a great impact on the clinical practice of all the other medical disciplines. For instance, factitious disorder commonly overlaps with brittle diabetes, dermatitis factitia, and gastroenterological presentations [18, 24].

Psychodynamic interpretations describe primary gain (i.e., the solution of an intrapsychic conflict) as the origin of factitious disorder. In contrast, secondary gain, which is the practical or economic benefits resulting from the enactment of specific behavior, is typically associated with malingering [25]. Primary gain has been described as keeping an internal conflict or need out of personal insight. Secondary gain is instead associated with avoiding a particular activity that is noxious. Secondary gain also aims at getting support from the environment that otherwise might not be forthcoming. However, the primary gain has also been linked to Conversion disorders, to the point that several studies depict a continuum [10].

Psychodynamic studies highlight that “factitious disorders are famously difficult to treat medically and are highly refractory to psychotherapy.” [25] Only a few reports have successfully described the interaction between the therapist and patient affected by factitious disorder; many authors have concluded that genuine communication is difficult and almost always burdened by deception and opposition. Some authors have also described confrontational management [18] issues once deception is unveiled. Many authors underlined oppositive and defiant responses to attempts to rationalize and explain the behavior to the patient. An unfruitful attempt, constantly resulting in the patient’s question: “what if that’s true?” [8, 20].

An intriguing report, produced from a rare collaborative patient, described herself in a psychotherapy session as “desperate to try and get help” [18]. She wrote: “I despise myself for all the things I have done, and have endlessly tried to stop what it is like an addiction.” Similar descriptions can also be found in a recent book by Feldman and Yates [6].

The unconscious origin of the feigning behavior is interpreted as the hidden drive to be in control of medical conditions that were previously experienced as painful. In this respect, these disorders can also be viewed as repetitive compulsions motivated by the desire to dominate and master (i.e., taking control over) the medical personnel providing care [25]. Feigning, or inflicting damages to a proxy (performed in a state of blurred consciousness), can be interpreted as the expression of unconscious wishes to enact a personal drama and reinforce the strength of a relationship with medical professionals who live in the fantasy of the patient [18, 26]. In the 1978 draft of the DSM III, [3] the underlying motive of factitious disorder was presented as the compulsion to act out a sadomasochistic relationship with physicians who are regarded as parental figures [6].

A current revaluation of the majority of psychodynamic interpretations produced before that DSM III [3] often unveils a mixture of somatic symptoms (conversion or functional neurologic disorders (FND)) and factitious disorder exhibited by the same patient (hence the reiterated concept of a continuum) [16, 18, 20].

The psychodynamic model of reference invokes an unconscious mechanism that acts independently of the patient consciousness, thereby favoring the assumption that a disordered unconscious might give rise to a disordered will [25].

From these hypotheses, an unconscious intention to action would rely on a simultaneous (conscious) intention to act. Within this frame, Lacanian interpretations introduced the concept of “failed acts” either as identification with an external will or as “acting in” within a fantasized body space to explain the production of FND motor symptoms or the complex activities enacted in factitious disorder [27].

Further interpretations were focused on self-deception, avowal, and disavowal of action. These suggested that disavowal of action [28] is acted to avoid disturbing the patient’s image of his/herself. Thus, the action becomes not intended as its access to consciousness is barred [28‐30]. The concept of avowal could not separate FND from feigning. Unsurprisingly, the dissection of volition led to discussing moral contents, distinguishing an unconscious, morally neutral deception where it is the self and not the other, whom the deceiver is deceiving, from a deception being a willed act, which should then be pure malingering.

These interpretations blurred the boundaries between FND and factitious disorder, and, again, a possible continuum was suggested, termed “hystero-malingering continuum” [12] (Fig. 1). For example, it was shown that hysteric patients misinterpret evidence and selectively pay attention to only a specific part of the overall evidence. Patients who employ such strategies as positive and negative misinterpretations, selective attention, and selective evidence gathering are biased (driven by primary, secondary, and economic gains) and can become, therefore, self-deceiving [29].

First in philosophy (as in work by Hume) [31], and later in psychology, three main elements of voluntary (willed) actions were considered. These elements are either (a) volition, or will, defined as the power to order the forbearing of an idea; (b) agency, as the perception of being the one who chooses or enacts the action; and (c) intention, as the conscious choice generated by the agent of the action. For example, intention, volition, and agency to act but no motor effects are present in organic paresis. Conversely, in utilization and imitation behaviors (driven by frontal dysfunction), no intention or volition is intended, whereas agency is perceived. In some sensory deafferentation conditions, like the posterior alien hand syndrome, the sense of agency is lost.

Based on these three categories, several attempts have been made to demonstrate structural or functional correlates of feigned acts or motor disorders ascribed to psychogenic causes.

Initially, the focus has been on volition “they say, I cannot; it looks like I will not; but it is I cannot will.” Therefore, manifestations of unconscious actions were interpreted as driven by disordered will (Paget, 1873) [32].

More recently, the focus has shifted on altered agency [15, 33, 34], which was considered the expression of disordered perceptions and altered by insufficient suppression of priors recruited by top-down perception processing [33‐35].

Attention to the motor act, as part of intention, has been also invoked, to explain the distractibility of FND and feigned motor disorders. It must be pointed out that when invoking the concept of attention, a paradox surfaces. The maintenance of unconsciously derived FND symptoms requires in fact conscious attention [36, 37]. The main diagnostic method for dissecting out a functional motor disorder is based on testing the distractibility of the symptom, i.e., if the patient is distracted, the functional or feigned symptom must disappear. However, this finding also indicates that attention is needed to produce the symptom. As attention is part of conscious behavior, the paradox emerges. Indeed, contrary to the construct’s supporting assumption, it is the patient insight and awareness that maintain the symptom’s production. The same interpretation can be applied to the agency of the act of feigning in factitious disorder.

Different reports have suggested dysfunctions in top-down processes. However, the lack of statistically powered studies makes these findings still largely anecdotical [14, 15, 33, 38].

More recent interpretations suggested that factitious disorder should be considered based on the mechanisms of addiction or duress (i.e., like in pathological gambling) [39].

In patients with factitious disorders, the agency of feigning and volition of feigning is denied and erased from consciousness; intention should be consequently unconscious.

Much needed research should be invested to identify the neural substrates of deception in factitious disorder, an ambitious target not achieved so far [20, 40, 41].

All cases described here went through anonymization and have been fictionalized by expert writers (age, gender, profession, history, initials, are all fictional. The original observational studies were approved by the local ethical committee (number 16 of 19/Jul/2018 ,emendment 7/May/2020 and number 2098 of 11/Jun/2020).

General agreement concurs that these disorders are mostly untreatable [25], or that psychotherapy is ineffective, other than being mostly refused. This is not unexpected, given the fraudulent nature of some of the enacted behaviors [25].

However, there is a management issue, as patients who are admitted to medical facilities must be confronted with the diagnosis of factitious disorder. Until now, no better approach was devised than the supportive confrontation of the patient by two or more members of the medical staff, and possibly the involvement of a psychiatric colleague, after careful preparation [6, 18, 42]. Anger, hostility, and irritation, which are common among the clinicians involved, as induced by the hostile attitudes of patients, should be tempered by the preparatory meetings [6, 12].

Face saving is considered the key element for the management confrontation, i.e., it is essential for the patient to be able to explain a recovery, or dismission from a medical facility, to themselves and family members, without admitting the psychiatric nature of the problem [6, 12, 43].

When confronted with the evidence of their deception, patients typically react with denial, aggression, or threats of legal actions. The doctor-patient relationship is irreparable [6].

The concept of tertiary gain is also relevant in this context [20, 44, 45]. Tertiary gain occurs when a third subject gains from the perpetuation of the patient’s symptoms. Typical examples include family members who hope to gain financially, physicians who want to recruit patients, and some plaintiff lawyers. Therefore, the confrontation must consider that different sorts of secondary and tertiary gain may be at stake. Even in patients who develop factitious disorder as a defense strategy to get primary gain, a secondary gain may appear as they realize that the illness can bring it. A tertiary gain may follow as part of the surrounding context.

Collecting the evidence for deceit is most often difficult. In the USA and the UK, hidden video recordings (covert video recording, CVR) of patients in their daily life are a common practice and supported by regulatory procedures. In our country, we are unaware of any authorization for video recordings, not even in cases acted with suspected criminal purposes. However, even in the USA and the UK, the attorneys for the accused hospitals or physicians often avoid CVR as they feel that settlements might cost less than a trial, and settlements are frequently reached [46‐48].

In the USA and the UK, collateral tests have been developed to reach evidence of deception. These tests are termed “symptom validity tests” or “effort tests” and focused on the ascertainment of pathological lying. In legal parlance, the evidence of lying calls into question the patient’s credibility [20]. One of the most employed is the “coin-in-the-hand test” for patients with amnesia [49]. All are based on probabilistic natures, assuming that any result in a test, which is inferior to results expected by random answering, indicates that the individual intentionally chooses to get answers wrong. These tests, however, may only show the likelihood of willful non-cooperation but cannot prove it [49]. Although these tests have been used, in the USA and the UK, in forensic medicine, as surrogate evidence of lying, their applicability is far from definite.

The 13 cases provide examples of abnormal behaviors ranging from criminal and fraudulent conduct to unconscious presentations, possibly associated with a grandiose interpretation of oneself and the desire for mastery of medical figures.

The cases also recapitulate the various clinical presentation found in the literature, like “by proxy” behaviors, psychiatric comorbidity, the relevance of previous experiences of compensation, the switch from initial somatic symptom disorder to factitious disorder with belligerent opposition once confrontation was attempted, the overlap/overlay of factitious disorder to coexisting medical (neurologic) diseases, and the blurred borders between factitious and malingering. Of note, it must be considered that unnecessary treatments and investigations may place patients at risk of iatrogenic complications and even death. In American medical literature, cases are reported of patients repeatedly presenting with pseudo-epileptic seizures or status who died because of treatment, as described in a book recently published by the most recognized psychiatric expert of factitious disorder and malingering [6]. For the many cases reported, close similarities with the cases here described are outstanding. The book also provides evidence of cyber-deception [39] or “Munchausen by Internet,” documenting the fraudulent enactment of secondary and tertiary gain, collecting undeserved donations.

In our case descriptions, what was not reported is the amount of time devoted by medical doctors to unnecessary care. It should be a reminder that, in Italy, the National Healthcare system is based on a coding system that categorizes all the diseases divided for each medical specialty (DRG, diagnosis related group) [50]. The coding is key to regulate the amount that the Ministry of Health reimburses to the hospital for any given disease. The DRG does not recognize factitious disorder (nor any somatic symptom disorder) with the neurology category. Therefore, any care provided to patients with factitious disorder is not reimbursed, resulting in a net economic loss. Finally, what is overlooked is the amount of time wasted by medical doctors to defend themselves from illogical or fraudulent allegations, a hidden economic cost neglected by legal litigations.

Our report documents the costs of factitious disorders, which are not adequately recognized by the legal system. It also discusses the immaterial costs driven by inadequate recognition of the disorder or supporting feigned complaints. The inadequate appreciation of the unethical background of factitious disorder forces many medical doctors to shy away from documenting and reporting cases, fearing being left alone and defenseless against aggressive legal prosecutions.

The current cultural climate of the legal system is largely outbalanced in favor of the “victim” role play. Furthermore, threats of legal actions are not discouraged and not prosecuted as the reasoning goes that they cause no harm unless legal action is actually pursued. This interpretation does not take into account the disruption of medical activities that these behaviors cause. This disruption has direct costs, encompassing unjustified procedures, indirect costs for the emotional burden, and the waste of time devoted to providing a shield against fraudulent behaviors.

A revision of attitudes toward factitious disorder must rely on the unethical and anti-economic outcomes of this disrupted behavior, that is to gain undeserved benefits, no matter which the motivation is.

Undoubtedly, as shown by psychodynamic studies, in factitious disorder, borders between volition and insight are dubious and blurred [1, 25]. Still, focusing the attention on practical outcomes rather than dynamics [1] leads to the notion that any complacency with the disordered behavior results in the provision of undeserved gain and outrageous costs and waste of public services and money.

The unethical pretense for an undeserved gain enacted by patients with factitious disorders should be adequately recognized as part of antisocial behavior.

When public health systems’ sustainability is on the brink of collapse, it seems fitting to ask for a shift of the cultural climate of legal systems toward an increased engagement of the medical professions and a proper consideration of immediate and long-term costs of these disorders.

In the USA, it was calculated that the prevalence of factitious disorder/malingering is 10 to 30% of patients seeking compensation, with an estimated cost of $20 billion [20] per year.

As pointed out in the book by Feldman and Yates [6], the legal principles involved in disclosing factitious disorder are equivocal. The Hippocratic principles make no explicit references to medical deception, despite the “How to detect those who feign diseases” was written by Galen of Pergamon almost 1900 years ago [51]. The issue revolves around the authorization to breach patients’ confidentiality in cases of factitious illness. The authors of the book advise seeking legal consultation when danger is predictable and hope for a statement by medical associations, like “In terms of our code of ethics, there are certain circumstances in which confidentiality no longer holds. These include situations in which patients or their caregivers have been fraudulent in producing information and/or have produced the diseases for which they seek treatment.” [6] Legislators must need to develop similar statutory language and judges to affirm its legality. Historically, however, every medical or legal issue has taken priority over consideration of factitious disorders [52].

As a concluding remark, we want to point out that the legal implications of factitious disorder may reach unforeseeable dimensions. Recently, patients with factitious disorder have successfully produced allegations against physicians claiming that by not providing a definite diagnosis, they were responsible for unnecessary medical procedures.

We encourage a shift in attitude and a better understanding of the disorder and its outrageous financial and emotional costs. We also urge raising legal figures  [53] to protect doctors against fraudulent behaviors clearly intertwined with compensation aims as well as against futile allegations presented by plaintiff lawyers.

As a final note, we like to stress that the cases originating our fictionalization were not prosecuted.