Factitious Disorder Criteria Need Review for DSM-V

Lying to gain medical attention may be as old as the medical profession, but there has been little or no increase in understanding factitious disorders over the last three or four decades despite nearly 2,000 publications on the subject, Charles Ford, M.D., a professor of psychiatry at the University of Alabama, Birmingham, told listeners at APA's 2007 annual meeting in San Diego.

However, the time may have come to rethink the entire category of factitious disorders, said Ford. “The current DSM-IV diagnostic category of factitious disorders is conceptually flawed and creates clinical problems,” he said at a session on legal issues at the interface of psychiatry and medicine.

DSM-IV says that the essential feature of factitious disorders is the “intentional production of physical or psychological signs or symptoms,” which is motivated by a desire to assume the sick role. Malingering, which involves greed or avoidance of work, has an external motivation, so Ford did not include it in his discussion.

“People who tell untruths about their medical conditions are motivated not by material gain but express their desire for care because they want attention or to be cared for,” said Thomas Wise, M.D., chair of the Department of Psychiatry at Fairfax Hospital in Falls Church, Va., and a professor of psychiatry at Johns Hopkins, in an interview.

Some lying is a normal part of human development, said Ford, a professor of psychiatry at the University of Alabama, Birmingham, and the author of Lies! Lies! Lies!: The Psychology of Deceit (American Psychiatric Publishing Inc., 1999). Parents may tell children not to lie, but they may also say, “Don't tell Aunt Fanny you didn't like the present she gave you for your birthday.” Lying permits individuation, facilitates social relationships, and keeps personal behavior personal, said Ford.

Lying has evolutionary advantages, too. Primate studies have found that the bigger the neocortex, the greater the capacity to lie, which allows more sophisticated and elaborate social manipulations. Functional MRI and positron emission tomography studies also show increased brain activation—mainly in the prefrontal and anterior cingulate cortices—in liars compared with truth-tellers.

“You could say that lying requires more mental activity than telling the truth,” said Ford.

There may be other biological differences, too. One study found that pathological liars had more prefrontal white matter and a lower gray-to-white-matter ratio compared with either normal or antisocial controls.

However, most lying is not benign. “The bigger the lie, the bigger the problems,” said Wise.

Specialists define types of lying by reference to the liars' intent and the relative mixture of truth and falsity in their statements.

Pathological lying happens when there is no external motivation to lie and when telling the truth might actually serve the speaker better, said Ford. Habitual lying starts in childhood and is associated with other delinquent behavior and with less parental involvement. Compulsive liars lie about meaningless issues as a means to assert autonomy in the face of intrusive, controlling parents.

Pseudologia fantastica is a mixture of fact and fiction involving fantasized events and self-aggrandizing personal roles. For instance, such persons may repeatedly tell untrue stories of heroics in wartime or on the athletic field. These are not delusions, said Ford. “They almost believe [what they are saying], but if confronted, they will admit the falsehood.”

Imposture carries such falsity one step further, providing an entirely new identity to the subject. Highly successful imposters enjoy their mastery in fooling others. “Look how smart I am and what I got away with,” they seem to say.

Munchausen's syndrome by proxy is a form of child abuse, a medicalization of criminal activity, said Ford.

There's a fundamental philosophical problem with all these behavioral patterns because so much of psychiatry is dependent on subjective reports from patients about their conditions, said Wise. There is no biomarker that reveals whether a patient is telling the truth. Reflecting the phrasing of psychoanalyst Donald Spence, Ph.D., Wise said that there is a line between historical truth and narrative truth, between recounting events and interpreting them. That boundary probably marks the borders between denial and deception.

Lately, critics, including Ford, have found fault with DSM's criteria for factitious disorders. For instance, he referred to a recent discussion by Christopher Bass and Peter Halligan in the February Journal of the Royal Society of Medicine.

“Factitious disorder as a distinct type of psychiatric disorder is conceptually flawed, diagnostically impractical, and clinically unhelpful and should be dropped from existing nosologies,” they wrote. They argue that if the behavior is involuntary, then it is not deception. If it is voluntary, then it amounts to malingering.

Hence, motivation is the key to understanding this phenomenon, not deception as such.

All three DSM criteria are flawed because they place the lie rather than the symptoms at the core of the diagnosis and assume the absence of external motivations, said Ford. “Deception syndromes are really a form of misbehavior rather than discrete diagnostic entities. They are the common symptomatic outcomes of varying etiologies. We should study the underlying personality problems that lead to the need for deceit.”

Wise is not ready to throw the DSM-IV definition out with the bath water yet, however. Some aspects of factitious disorders clearly overlap with mental illness, he said. Deep-seated fears can induce denial of the truth and an inability to report it. He recalled a fellow physician who denied symptoms of colon cancer until the disease metastasized, because his mother had died of the disease and he was frightened by its appearance in his own body. Wise also believes that the unconscious reasons for selecting a particular illness to lie about and be treated for reflect an underlying psychiatric illness.“ Anybody who wants unneeded surgery clearly has a problem,” he said.

Physicians should have a higher index of suspicion when they see inconsistent lab results, he said. He has seen minimal evidence of effective treatment for factitious disorders and has found that these patients are not remorseful and never apologize when they are exposed.

“Future research might be better focused on underlying mechanisms of personality disorders that may facilitate deceit,” said Ford.

Regardless of whether standards for factitious disorders are changed for DSM-V, psychiatrists must still find ways to care for these patients, commented Gary Rodin, M.D., of the University of Toronto and the Ontario Cancer Institute, who spoke at the same session as Ford.

“Our organization principle—that the patient lies but should tell the truth—is our view,” he said, speaking of physicians.“ We must move from an individual psychiatric point of view to a social interaction point of view. The most important thing is the formation of a therapeutic relationship—which is what they are seeking and which is what stops them from lying.” ▪