Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

1916

Chapter 19. Factitious Disorder

response bias, unusual patterns of deficits, poor levels of effort, or overreporting of symptoms in a manner that suggests a motivation to appear ill. As in the assessment of malingering, these tests may come in the form of embedded tests or stand-alone symptom validity tests and have been extensively reviewed and approved for this use by the American Academy of Clinical Neuropsychologists. Examples of embedded tests include subscales and indices within the Person ality Assessment Inventory (PAI); the Meyers index, which uses seven subscales of the Minnesota Multiphasic Personality Inventory (MMPI); the Fake Bad Scale, drawn from 43 questions on the MMPI that correlate with simulation; reliable digit span tests of memory. Stand-alone tests for simulating symptoms include the Structured Inventory of Malingered Symptomatology (SIMS), the Structured Interview of Reported Symptoms (SIRS), and the Miller Forensic Assessment of Symptoms Test (M-FAST), and the Test of Memory Malingering (TOMM). Important in the use of neuropsychological testing to supplement the diagnosis of factitious disorder is an under standing of its limitations: While a set of given tests can detect a pattern suggestive of simulation, it cannot ascertain motivation or etiology of the pattern. In other words, neuropsychological testing cannot make a diagnosis of factitious disorder—assessment by the clinician is required. Conclusive confirmation of factitious disorder can be difficult. Covert surveillance, hidden video cameras, or searching the patient’s belongings for syringes or illness-inducing substances can be employed after considering the patient’s right to privacy and the bounds of the patient–doctor relationship. Internet searches and scans of social media may uncover pictures, text, news articles, or legal records that contradict the patient’s history or presentation. Legal counsel is advisable, and in some cases, court orders should be obtained. Consultation from a bioethics team can help weigh the benefits and risks of violations of privacy versus morbidity from factitious disorder. This phase of acquiring information to confirm a diagnosis is often a time of conflict for staff, who may have split opinions about the patient and about the means being employed to confirm the diagnosis. Regular interdisciplinary meetings are helpful. However, the obtaining of this collateral and confirmatory infor mation to aid in the diagnosis of a factitious disorder brings up several ethical dilemmas: 1. Privacy: Patients have a right to privacy concerning their per sonal health information and activities, and providers are bound by biomedical ethical principles such as nonmaleficence (doing no harm) and patient autonomy. On the other hand, providers must also consider ethical principles of beneficence (doing what is good for the patient) and justice (doing what is right for soci ety), and patients are expected to participate in their health care in good faith. When the risk of harm from suspected self-induced behavior becomes great enough, decisions to override patient preferences and seek information from covert searches or video taping may be made, typically in consultation with legal counsel. 2. Confidentiality: Patients with factitious disorder will frequently refuse to release medical records to their providers, hampering the ability to diagnose and manage factitious behaviors. The U.S. Health Insurance Portability and Accountability Act (HIPAA) allows health care providers to release medical records to one another for treatment purposes without an individual patient’s consent, as long as both health care providers had a relationship with the patient and the records pertain to that relationship. Unau thorized disclosing of information to third parties that are not covered entities under the HIPAA law will need legal vetting to ensure compliance. Searching pharmacy databases and electronic

Factitious psychological symptoms are more challenging to diag nose because of the lack of clear objective markers for psychiatric symptoms. Methods of confirmation applicable with factitious phys ical disorders, such as contradictory laboratory results or findings on room searches, are difficult to apply here. Nevertheless, certain features of the patient’s presentation can alert the psychiatrist that the patient may be simulating illness. As with physical factitious dis orders, the patient may present with unusual symptoms that fail to correspond to any recognizable diagnosis. For example, one patient reported no other psychotic symptoms except seeing the entire cast of a television show emerge from her closet. Other features include worsening of symptoms when the patient is aware of being observed, inconsistencies in the patient’s story over time, and the patient’s overeagerness to recount symptoms of the illness. Such patients are often suggestible and readily admit to additional symptoms on questioning. They may refuse to cooperate with obtaining collat eral information, and untraceable prior health care providers are not unusual. On admission to the ward, patients may reveal familiarity with hospital routine while denying previous hospitalizations. They may exhibit dramatic and unusual reactions to medications. They may demonstrate attention-getting tactics by breaking ward rules. Visitors are usually few or absent. Symptoms may acutely worsen when discharge is imminent. In contrast to patients with physical factitious disorders, who tend to avoid psychiatric care, patients with factitious psychologi cal symptoms actively seek contact with the psychiatric system and readily acknowledge the presence of a psychiatric disorder, even if it may not be the one from which the patient actually suffers. Feigned bereavement and then psychosis appears to be the most common presenting symptoms. Ironically, one patient sought psychiatric admission for his Munchausen syndrome, claiming that he feigned physical illness when in fact, there was no evidence of this. In a series of 20 patients who presented with factitious bereave ment, 15 also exhibited a history of factitious physical symptoms. A majority of them met the criteria for other psychiatric disorders. They typically reported recent, dramatic, violent, and often multiple deaths of loved ones, whereas collateral information showed that, in fact, no deaths had occurred. Another series of 12 cases of facti tious bereavement yielded similar findings of complaints of violent, dramatic deaths and referral from medical wards for supposed physi cal illness. Although the complaints of bereavement were factitious, these patients exhibited prominent symptoms of depression. A the ory about factitious bereavement is that patients are expressing the underlying truth of their emotional state, if not the factual truth. In contrast to the stigma associated with psychiatric illness, sympathy and care are usually offered to those in mourning. This may be why factitious bereavement is the most commonly seen factitious psycho logical disorder. One patient stated that she fabricated the complaint of bereavement to rationalize her depression. In a series of 219 consecutive cases of psychosis, 9 (0.04%) met the criteria for factitious disorder. All nine patients demonstrated severe personality disorder. These patients were doing poorly when followed up 4 to 7 years later, with multiple hospitalizations and poor quality of life. Their outcome was no better than for schizophren ics concurrently followed. In another study of six patients who pre sented with feigned psychosis, five of the six were diagnosed with schizophrenia on follow-up 3 months to 10 years later. Consistent with psychodynamic theories about factitious disorders represent ing an attempt to feel mastery, feigning psychosis may have been an attempt to feel control over early psychotic symptoms.

Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of this content is prohibited. In patients who complain of neuropsychiatric or cognitive symp toms, neuropsychological testing can be useful in establishing