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Step 2

Rule Out Malingering and Factitious Disorder

    The first step is to rule out Malingering and Factitious Disorder (which involve the intentional production of false or grossly exaggerated physical or psychological symptoms), because if the patient is not being honest regarding the nature or severity of their symptoms, all bets are off regarding the clinician’s ability to arrive at an accurate psychiatric diagnosis. Most psychiatric work depends on a good-faith collaborative effort between the clinician and the patient to uncover the nature and cause of the presenting symptoms. There are times, however, when everything may not be as it seems. Some patients may elect to deceive the clinician by producing or feigning the presenting symptoms. Two conditions in DSM-5-TR are characterized by feigning: Malingering and Factitious Disorder. These two conditions are differentiated based on the motivation for the deception. When the motivation is the achievement of a clearly recognizable goal (e.g., insurance compensation, avoiding legal or military responsibilities, obtaining drugs), the patient is considered to be Malingering. When the deceptive behavior is present even in the absence of obvious external rewards, the diagnosis is Factitious Disorder. Although the motivation for many individuals with Factitious Disorder is to assume the sick role, this requirement was dropped in DSM-5 because of the inherent difficulty in determining an individual’s underlying motivation for their observed behavior.

 

    The intent is certainly not to advocate that every patient be treated as a hostile witness nor that every clinician become a cynical district attorney. Rather, the clinician’s index of suspicion should be raised 1) when there are clear external incentives to the patient for a psychiatric diagnosis (e.g., disability determinations, forensic evaluations in criminal or civil cases, prison settings), 2) when the patient presents with a cluster of psychiatric symptoms that conforms more to a lay perception of mental illness than to a recognized clinical entity, 3) when the nature of the symptoms shifts radically from one clinical encounter to another, 4) when the patient has a presentation that mimics that of a role model (e.g., another patient on the unit, a mentally ill close family member), and 5) when the patient is characteristically manipulative or suggestible. Finally, it is useful for clinicians to become mindful of tendencies they might have toward being either excessively skeptical or excessively gullible.

Ruling Out Malingering and Factitious Disorder

Diagnostic Readout

Definition
Factitious Disorder is characterized by falsification of physical or psychological signs or symptoms or induction of injury or disease in oneself or another person, associated with identified deception.
 
ICD-10-CM Coding
___.__ Factitious Disorder - Specify: Single episode, Recurrent episodes
F68.10 – Factitious Disorder Imposed on Self
F68.A – Factitious Disorder Imposed on Another
 
Differential Diagnosis
Differential Diagnosis for Factitious Disorder
Differentiating Characteristics
A Factitious Disorder comes in two forms: Factitious Disorder Imposed on Self, in which an individual feigns medical or psychiatric symptoms; and Factitious Disorder Imposed on Another, in which an individual falsifies a disease or injury in another, usually a dependent child or elder.

Somatic Symptom Disorder: May be characterized by excessive attention and treatment seeking for perceived medical concerns, but there is no evidence that the individual is providing false information or behaving deceptively.
 
Malingering: Is characterized by the intentional reporting or feigning of symptoms for personal gain (e.g., money, time off work), whereas the diagnosis of Factitious Disorder requires that the feigning behaviors persists even in the absence of obvious external incentives.
 
Functional Neurological Symptom Disorder (Conversion Disorder): Is characterized by neurological symptoms that are inconsistent with neurological pathophysiology. Factitious Disorder with neurological symptoms is distinguished from Functional Neurological Symptom Disorder by evidence of deceptive falsification of symptoms.
 
Borderline Personality Disorder: May be characterized by deliberate physical self-harm in the absence of suicidal intent. Factitious Disorder requires that the induction of injury occurs in association with deception.
 
Child or elder abuse (as distinguished from Factitious Disorder Imposed on Another): Is characterized by lying about abuse injuries in dependents solely to protect oneself from liability. Such individuals are not diagnosed with Factitious Disorder Imposed on Another because the deceptive behavior is motivated by an obvious external incentive (i.e., protection from criminal liability). Caregivers who are found to lie more extensively than needed for immediate self-protection may be diagnosed with Factitious Disorder Imposed on Another.
 
Related Decision Trees

  • Memory Loss or Memory Impairment

  • Self Injurious Behavior

  • Somatic Complaints or Illness/Appearance Disorder

  • Suicidal Ideation or Behavior

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