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Chapter 14. Factitious Disorder and Malingering

Barbara E. McDermott, Ph.D.; Martin H. Leamon, M.D.; Marc D. Feldman, M.D.; Charles L. Scott, M.D.
DOI: 10.1176/appi.books.9781585623402.297514

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Excerpt

Factitious disorder and malingering are often linked, because both involve the feigning or production of physical and/or psychological symptoms absent any underlying pathology. The distinction between the two is the motivation for the production of symptoms. In factitious disorder, the motivation is presumed to be unconscious and is related to the desire to assume the sick role. In contrast, malingering is viewed as the intentional production (or reporting) of symptoms for a specific purpose associated with some secondary gain, such as evading criminal prosecution or receiving financial compensation. Thus, in distinguishing the two, the treater is left to determine the underlying motivation for symptom production. Although there has been argument about the veracity of this taxonomy (Cunnien 1997; Rogers et al. 2005), reliable discrimination is important for a variety of reasons. Of primary importance is that the two conditions call for very different treatment or management approaches. The following discussion of both disorders will aid the clinician in making this crucial determination.

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TABLE 14–1. DSM-IV-TR diagnostic criteria for factitious disorder
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TABLE 14–2. DSM-IV-TR diagnostic criteria for factitious disorder not otherwise specified
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TABLE 14–3. DSM-IV-TR research criteria for factitious disorder by proxy
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TABLE 14–4. Warning signs for factitious disorder by proxy
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TABLE 14–5. DSM-IV-TR warning signs for malingering
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TABLE 14–6. Clinical decision model for the assessment of malingering of psychosis
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TABLE 14–7. Threshold model for the assessment of hallucinations and delusions
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TABLE 14–8. Standardized assessments for detecting the malingering of psychiatric disturbances
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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.

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.

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CME Activity

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Sample questions:
1.
Which of the following criteria is not necessary in order to diagnose factitious disorder?
2.
Which of the following descriptors characterizes the Munchausen subtype of factitious disorder?
3.
Which of the following is a warning sign for factitious disorder by proxy?
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
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