14 factitious disorders and malingering

The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org

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Slide show includes…

Topic Headings

Tables

Key Points

Factitious Disorder and Malingering

Barbara E. McDermott, Ph.D., Martin H. Leamon, M.D.,Marc D. Feldman, M.D., Charles L. Scott, M.D.

The American Psychiatric Publishing

TEXTBOOK OF PSYCHIATRYFifth EditionEdited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.

© 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org

CHAPTER 14


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CHAPTER 14 • Topic Headings

FACTITIOUS DISORDERClassificationDiagnosisEpidemiologyEtiologyTreatment

FACTITIOUS DISORDER BY PROXYClassificationDiagnosisEpidemiologyEtiologyTreatment and Prognosis

MALINGERINGClassificationDetection (“Diagnosis”)Structured Assessments of MalingeringScreening Tools for Malingering

Paper and Pencil TestsInterview FormatComprehensive Assessments of Malingering

EpidemiologyTreatment


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CHAPTER 14 • Tables

Table 14–1. DSM-IV-TR diagnostic criteria for factitious disorder

Table 14–2. DSM-IV-TR diagnostic criteria for factitious disorder not otherwise specified

Table 14–3. DSM-IV-TR research criteria for factitious disorder by proxy

Table 14–4. Warning signs for factitious disorder by proxy

Table 14–5. DSM-IV-TR warning signs for malingering

Table 14–6. Clinical decision model for the assessment of malingering of psychosis

Table 14–7. Threshold model for the assessment of hallucinations and delusions

Table 14–8. Standardized assessments for detecting the malingering of psychiatric disturbances

Summary Key Points


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TABLE 14–1. DSM-IV-TR diagnostic criteria for factitious disorder

DSM-IV-TR (American Psychiatric Association 2000) requires three criteria for the diagnosis of factitious disorder (Table 14–1).


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TABLE 14–2. DSM-IV-TR diagnostic criteria for factitious disorder not otherwise specified

The DSM-IV-TR subtype of factitious disorder not otherwise specified (Table 14–2) should be used for disorders with factitious symptoms that do not meet criteria for one of the other subtypes.

Source. American Psychiatric Association 2000.


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TABLE 14–3. DSM-IV-TR research criteria for factitious disorder by proxy

DSM-IV-TR provides research criteria for factitious disorder by proxy in Appendix B, “Criteria Sets and Axes Provided for Further Study” (American Psychiatric Association 2000). The criteria are similar to those for factitious disorder, with the addition of the “by proxy” specification (Table 14–3).


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TABLE 14–4. Warning signs for factitious disorder by proxy

Certain clusters of warning signs (Table 14–4) can suggest a diagnosis of factitious disorder by proxy.

Source. Data from Bools et al. 1992; Jani et al. 1992; Jureidini 1993; Libow 1995; R. Meadow 1982; Schreier and Libow 1996.


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TABLE 14–5. DSM-IV-TR warning signs for malingering

Table 14–5 provides the DSM-IV-TR guidelines for when to suspect malingering.


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TABLE 14–6. Clinical decision model for the assessment of malingering of psychosis

Table 14–6 provides a suggested clinical decision model for the assessment of malingered psychosis (Resnick 1997). In determining whether reported hallucinations or delusions are fabricated or exaggerated, the factors outlined in Table 14–7 also may prove helpful (Resnick 1997). Note that a bona fide diagnosis of a past psychotic disorder does not necessarily exclude a presentation of manufactured psychotic symptoms.

Source. Resnick 1997.


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TABLE 14–7. Threshold model for the assessment of hallucinations and delusions

In determining whether reported hallucinations or delusions are fabricated or exaggerated, the factors outlined in Table 14–7 also may prove helpful (Resnick 1997). Note that a bona fide diagnosis of a past psychotic disorder does not necessarily exclude a presentation of manufactured psychotic symptoms.

Source. Resnick 1997.


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TABLE 14–8. Standardized assessments for detecting the malingering of psychiatric disturbances

Table 14–8 provides a summary of some assessments commonly used in the detection of malingered psychiatric disturbances.


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CHAPTER 14 • Key Points

The distinction between factitious disorder and malingering lies in the underlying motivation for the production of symptoms.

The motivation for factitious disorder is to assume the sick role and is often presumed to be unconscious.

The motivation for malingering involves the attainment of a tangible reward. Factors suggestive of factitious disorder include discrepancies between

objective findings, inconsistencies between objective findings and clinical history or symptoms, an atypical illness course, and conditions that fail to respond to usual therapies.

Factors suggestive of malingering include inconsistencies between reported versus observed behavior and the reporting of improbable or absurd symptoms in the presence of an understandable motive to malinger.

The treatment/management of both factitious disorder and malingering involves “delicate” confrontation with minimal expectations of confessions.

The treatment for factitious disorder involves focusing on the underlying motivation for the behavior, which often can be psychodynamic in nature.

(continued)


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CHAPTER 14 • Key Points (continued)

The management of malingering involves understanding the secondary gains associated with the production of symptoms in order to address these expectations.

Factitious disorder by proxy involves maltreatment and, when suspected, must be reported to child protection authorities.

14 factitious disorders and malingering

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