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Factitious disorders 2 Factitious disorders and : challenges for clinical assessment and management

Christopher Bass, Peter Halligan

Lancet 2014; 383: 1422–32 Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identifi cation largely dependent Published Online on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient’s March 6, 2014 medical record. Management of such disorders ideally requires a team-based approach and close involvement of the http://dx.doi.org/10.1016/ primary care doctor. As deception is a key defi ning component of factitious disorders, diagnosis has important S0140-6736(13)62186-8 implications for young children, particularly when identifi ed in women and health-care workers. Malingering is See Online/Comment http://dx.doi.org/10.1016/ considered to be rare in clinical practice, whereas simulation of symptoms, motivated by fi nancial rewards, is regarded S0140-6736(13)62640-9 as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can See Online/Series inform the detection of illness deception, such tests need support from converging evidence sources, including detailed http://dx.doi.org/10.1016/ interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of S0140-6736(13)62183-2 abnormal health-care-seeking behaviour is the extent to which a person’s reported symptoms are considered to be a This is the second in a Series of product of choice, or beyond volitional control, or perhaps both. Clinical skills alone are not typically two papers about factitious disorders suffi cient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and deal with patients whose symptoms appear to be Department of Psychological Medicine, John Radcliff e simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs Hospital, Oxford, UK used to provide meaning for both patients and doctors. Future progress in management will benefi t from an increased (C Bass FRCPsych); and School appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical fi ndings of , Cardiff from social neuroscience, occupational health, and clinical psychology. University, Cardiff , UK (Prof P Halligan DSc) Correspondence to: Introduction First, although factitious disorders and malingering are Dr Christopher Bass, Department Abnormal health-care-seeking behaviour covers a both clinically signifi cant, deception is a pervasive, of Psychological Medicine, multitude of clinical and non-clinical behaviours normal, and ubiquitous social behaviour of human John Radcliff e Hospital, ranging from symptom to deliberate nature.6 Second, abundant evidence exists to show that Oxford OX3 9DU, UK 1–4 christopher.bass@ feigning. In this Review, we focus on abnormal health- people (both patients and doctors) frequently engage in a oxfordhealth.nhs.uk care-seeking behaviours that include simulation range of deceptive behaviours outside medical symptom (factitious disorders and malingering) and propose that appraisal and for various reasons.4,7,8 Third, the DSM standard use of these terms in psychiatric classifi cations diagnosis of a has little clinical validity.9 such as the Diagnostic and Statistical Manual of Mental Precisely what impairment to normal mental functioning Disorders (DSM)5 has not kept abreast of conceptual justifi es defi ning the intentional fabrication of illness and psychological advances. In line with our clinical symptoms as a in its own right is unclear. focus, we consider non-medical explanations, in Fourth, evidence that factitious disorders and malingering particular the neglected part that volitional and behaviours tend to be episodic, situation specifi c, and motivational factors can play. As such this Review highly dependent on selective interactions with medical, departs from previous accounts by not explicitly social, or legal professionals suggests that they are not endorsing the standard medical glossary defi nitions of clinical states, but rather discrete “behavior governed by a factitious disorders, and questions the use and cost–benefi t analysis.”10 Fifth, from a clinical and legitimacy of deception as a special form of mental diagnostic perspective, it seems unlikely that most disorder for several reasons. clinicians can reliably and consistently extricate the contributory role of deception and hence distinguish factitious disorder and malingering.11 Sixth, the diagnosis Search strategy and selection criteria of factitious disorders (and compensation ) We searched PsycINFO via Health Databases Advanced Search appear to have been largely created as a way of bridging or on the UK National Health Service evidence website from linking diagnoses between unconsciously mediated Nov 11, 2012, with the terms “FACTITIOUS DISORDERS”, OR psychiatric disorder and consciously mediated malin- 9,12 “MUNCHAUSEN SYNDROME”, OR “MALINGERING”. We gering. Seventh, many existing psychiatric accounts of limited our search to English-language articles published abnormal health-care-seeking behaviour underestimate 13 from 2000. We did a fi nal search of PubMed on May 30, 2013, the contribution of non-medical deception, and without with the terms “factitious disorder” and “malingering”. explicit consideration or exploration of the potential part played by volitional choice, meaningful discussion of

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abnormal health-care-seeking behaviour is always going and psychiatric glossaries5,21 presently consider malin- to be scarce. Eighth, this holistic approach should not gering to be a valid diagnostic term and a legitimate be taken as denying or mitigating the reality or distress behaviour about which a medical opinion can be of illness as subjectively experienced by many patients with expressed, other than by exclusion. medically unexplained disorders, but rather provides a Detection of malingering consequently remains rationale for alternative explanations and treatments. diffi cult, largely because of the late development of an When trying to distinguish between factitious disorders empirical social neuroscience of deception22 and the and malingering, we emphasise the role of context and a understandable reticence and absence of confi dence of well-documented evidence trail. Most research on many doctors to consider or explore the possibility that malingering takes place within specifi c legal contexts or patients could or would use deceptive behaviours to when a patient attempts to evade punishment in the infl uence their clinical presentation. Well publicised criminal justice system, seek damages through personal cases have shown how easily the appearance of severe injury litigation, or gain fi nancial compensation, whereas illness is to simulate.23,24 Evidence suggests that factitious disorders are generally encountered in clinical psychologists and psychiatrists are often no better at settings. detecting lies than are other professionals or the lay public,25 and that physicians can be easily deceived—eg, Controversies and diagnostic dilemmas in by patients with chronic pain.26 psychiatric classifi cations Evidence also shows that recognition of the frequency The biomedical justifi cation underpinning many of simulation remains largely a function of experience psychiatric disorders included in DSM and the and predisposing attitudes of the observer.27 For example, International Classifi cation of still has not been fi ndings from a study of simulated presentations showed established.14 The quest for a medically acceptable that neurologists preferentially diagnosed factitious diagnosis has resulted in the growth and clinical use of presentations in nurses as hysterical, presumably to avoid various aetiologically agnostic, diagnostically ambivalent the stigma associated with the suggestion that symptoms descriptors. However, once a diagnosis has entered might have been simulated.28 The disincentives presented general use it tends to become reifi ed and assumed by to clinicians to establish a diagnosis of malingering are, if many to be a valid entity that need not be questioned.15 In anything, more stark than those for factitious disorders.29 many cases these disorders are described by what they In dealing with these clinical presentations, key concepts are not, rather than as illnesses in their own right.16 such as abnormal illness behaviour and the sick role Attempts to relocate factitious disorders into more should be understood, as should the contribution of established psychiatric categories confi rm their weak societal and motivational factors. conceptual underpinnings. Some investigators have suggested that factitious disorders should be considered Concept of the sick role and abnormal illness as a variant of somatoform disorders.17 The DSM-5 even behaviour includes the suggestion that factitious disorders be A close association exists between illness behaviour in recategorised as somatic symptom disorders with two some patients and the potential benefi ts that society types: factitious disorder imposed on self and factitious provides for the sick role.30 The sick role is a partly and disorder imposed on the other (panel 1). Neither conditionally legitimated state, which might be desirable revisions acknowledge the contribution of an individual’s because of the advantages and potentially socially consciously mediated choice in the presentation.4 mediated secondary gains.31 Notably, “despite a reduction However, in the case of suspected factitious disorder, some have argued that more objective evidence—eg, abnormal pathological fi ndings—should be actively Panel 1: Diagnostic and Statistical Manual, fi fth edition, secured.18 criteria for factitious disorder, code 30019 (International The situation with malingering is, if anything, even Classifi cation of Diseases-10 code F6810) more unsatisfactory. Although the neuropsychological Factitious disorder imposed on self literature on malingering has expanded in the past 1 Falsifi cation of physical or psychological signs or symptoms, 30 years, the section describing malingering in the DSM or induction of injury or , associated with identifi ed has barely changed since 1980 and has not been updated deception 19 in DSM-5. This failure to update the criteria in 2 The individual presents themself to others as ill, impaired, 20 DSM-5 ignores relevant research on the topic, and led or injured Berry and Nelson to write that “the evolution of symptom 3 The deceptive behaviour is evident even in the absence of validity and malingering literature in recent decades has obvious external rewards culminated in a sophisticated conception of malingering 4 The behaviour is not better explained by another mental 19 that essentially renders DSM-IV-TR criteria obsolete.” disorder, such as or another psychotic This occurrence should come as no surprise to most disorder psychiatrists because neither of the established medical www.thelancet.com Vol 383 April 19, 2014 1423 Series

in disease (pathology) and an improvement in our ability factitious disorders involved in litigation, 12 (60%) had to cure or reduce disease, sickness is rising.”32 In suff ered a childhood illness and more than half a particular, society more readily accepts physical disorders childhood loss.38 Accounts of patients with factitious as acceptable entries into the sick role than they do disorders note that many are motivated by developmental psychological or emotional disorders, or diffi culties factors, including a desire to maintain the sick role, to coping with and adapting to life’s troubles.32 deceive health-care professionals, and to obtain The determinants of illness behaviour are multifactorial attention.39 and are dependent on a person’s previous illness history, In terms of developmental theory, deceptive behaviour family infl uences, developmental factors, and present becomes evident in non-verbal ways in children younger beliefs about illness and resources.32 A scale for than 5 years, and children’s capacity to deceive measuring illness behaviour has been devised,33 and subsequently becomes more complex and better evidence shows that the way a patient views his or her developed. Deception and the development of deception illness can have a powerful eff ect on outcome,34 with across the lifespan has been studied with use of an organic causal beliefs being associated with a need for information-processing methodology,40–42 and more diagnostic tests and adverse health outcomes.35 recently, a social neuroscience approach43 that enables researchers to assess distortions in information Developmental factors processing, and to identify the brain systems engaged by Investigators have argued that chronic somatoform deception. disorders should be regarded as a disorder of Deliberate or tactical deception is so common in development, because of the young age of onset, the human social interactions that some researchers have enduring nature of the syndrome, and the fi nding that suggested that human brains are innately primed to more than two-thirds of patients meet the criteria for a deceive, and that deception happens early in life in a .36,37 In a study of 20 patients with predictable way.6 This view is supported by the developmental psychopathology perspective by which attachment strategies that use deception are adaptive in Panel 2: Clinical characteristics that might alert a physician to a diagnosis of fabricated disorders characterised by complexity.42 illness (adapted and modifi ed from reference 48, by permission of American Psychiatric Press) Factitious disorders • The patient has sought treatment at various diff erent hospitals or clinics Epidemiology • The patient is an inconsistent, selective, or misleading informant; he or she resists As traditionally defi ned, factitious disorders are fairly allowing the treatment team access to outside sources of information uncommon, but likely to be underdiagnosed, with 44,45 • The course of the illness is atypical and does not follow the natural history of the prevalence estimates ranging between 0·5% and 2%. presumed disease—eg, a wound infection does not respond to appropriate antibiotics Evidence shows that US physicians feel more comfortable (self-induced skin lesions often fall into this category, when atypical organisms in the diagnosing conversion disorders than they do other wound might alert the physician) somatoform and factitious disorders, and that as a result, • A remarkable number of tests, consultations, and medical and surgical treatments have the latter disorders are diagnosed far less frequently than 46 been done to little or no avail published prevalence and recognition rates suggest. In • The magnitude of symptoms consistently exceeds objective pathology or symptoms a survey done in an occupational medicine setting in the have proved to be exaggerated by the patient UK, 8% of 400 patients displayed behaviour that was 47 • Some fi ndings are discovered to have been self-induced or at least worsened through consistent with illness fabrication. self-manipulation • The patient might eagerly agree to or request invasive medical procedures or surgery Clinical features • Physical evidence of a factitious cause might be discovered during the course of Clinical features of factitious disorders remain diverse 48 treatment—eg, a concealed catheter or a ligature applied to a limb to induce oedema (panel 2). Most patients are likely to be socially conforming • The patient predicts deteriorations or there are exacerbations shortly before their young women with stable social networks who present to scheduled discharge general hospitals in their mid-30s. In some of these 49 • A diagnosis of factitious disorder has been explicitly considered by at least one women, the self-induced illnesses begin in adolescence, health-care professional and prevalence rates in adolescent consultation-liaison 50,51 • The patient is non-compliant with diagnostic or treatment recommendations or is services are similar to those noted for adults. As many disruptive on the unit as one half of these patients work in health-related 52 • Evidence from laboratory or other tests disputes information provided by the patient occupations. • The patient has a history of work in the health-care fi eld Studies including a heterogeneous case series suggest • The patient engages in gratuitous, self-aggrandising lying a typology that includes: (a) a dramatic, deceptive, • The patient has been prescribed (or obtained) opiate drugs, often pethidine or hostile, sociopathic type, mostly male 53 morphine, when this drug is not indicated (Munchausen’s syndrome as described by Asher ), • While seeking medical or surgical intervention, the patient opposes psychiatric assessment comprising about 10% of cases and becoming increasingly rare;12 (b) self-induced infections, mainly

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chronic or acute on chronic, largely female; (c) wilful and adolescence. Close enquiry and careful examination interference with chronic wounds and cutaneous ulcers; of medical records (table) often shows an unexpectedly and (d) a group simulating disorders by falsifi cation of large number of childhood illnesses and operations, data and fabrication of signs, symptoms, and high rates of , , and physiological disturbances.54,55 Many patients have had personality disorder that collectively confi rm complex childhood adversity and have coexisting chronic and histories, which might not be readily disclosed at complex somatoform disorders.56,57 interview.38 Fabricated disorders that include the arm and hand Some patients exploit the internet to misrepresent have been described,58 and a large series included themselves with various diseases.60 So-called electronic four clinical categories—psychopathological dystonia, factitious disorder is a term used to describe patients who factitious oedema, psychopathological complex regional falsify their electronic medical records to create a pain syn drome, and factitious wound creation and factitious report (eg, cancer).61 A further group is manipulation.59 Detailed review of medical notes often encountered in pregnancy, and these cases clearly have identifi es the tell-tale signs of simulation in childhood great implications for child protection.62 All clinicians

Attendance or referral Symptoms and precipitants Tests and investigations Outcome and plan Key events 1986 Hospital A admission Right fl ank pain Normal laparoscopy Non-specifi c abdominal pain Death of father (age 12 years) 1987 Hospital A admission Overdose of analgesics .. Referred to social worker; patient stealing Arguments with (age 13 years) money from mother mother 1990 Hospital B admission Inhalation of smoke from fi re Normal blood tests Self-discharged Set fi re to house; (age 16 years) after fi re setting pregnant 1991 Neurology outpatient Episodes of loss of consciousness Normal EEG and CT scan; Reassured no organic cause .. (age 17 years) services (B) and muscle twitching normal blood tests 1991 Emergency admission to Right-sided abdominal pain Normal radiograph Admitted for observation; self-discharged .. (age 17 years) general surgery (A) against medical advice June,1992 Gynaecology outpatient Claims to be pregnant Normal pregnancy test “She lied to the registrar, saying that she had .. (age 18 years) clinic a positive pregnancy test when she had been told by the GP [general practitioner (family doctor)] that she was not pregnant” October, 1992 Emergency admission (A) Overdose of paracetamol in Noted on right breast Worried about scarring on right breast; Grandfather ill (age 18 years) context of excess alcohol dermatologist considered possibility of artifactual skin disorder 1993 Ear, nose, and throat Episodes of haemoptysis Normal direct laryngoscopy Followed up in psychiatric outpatients clinic; .. (age 19 years) outpatient clinic (C) possibility of personality disorder considered 1993 General medicine outpatient Unexplained septicaemia Isolated blood culture of “Given these fi ndings we feel that there has Boyfriend of 2 years (age 19 years) clinic (B), with subsequent saprophytic organisms not usually been deliberate introduction into the body has left her admission associated with the cause of sepsis of material from an environmental source” in the immunocompetent patient 1994 Gynaecology outpatient “Told me she had been sterilised” Fallopian tubes patent “When I obtained her notes and showed .. (age 20 years) clinic (B) her this she decided to self-discharge” 1995 Neurology outpatient clinic Recurrent blackouts and odd All investigations normal Diagnosis of psychogenic non-epileptic .. (age 21 years) on second opinion (C) movements since age 17 years (video telemetry) seizures 1995 Psychiatric outpatient clinic Patient denies that non-epileptic Cognitive behavioural therapy Demands to be kept on carmazepine despite Drinking a bottle of (age 21 years) seizures are related to emotional not helping advice to taper drug vodka every day problems; attends clinic with crutches 1996 Emergency admission Pain in right forearm after Substantial soft tissue injury with Currently an inpatient on local psychiatric Child born (age 22 years) orthopaedics repeatedly punching wall swelling but no fracture ward; follow-up by team 1996 Admission orthopaedics (D) Infection right wrist; demanding No positive cultures; “Birefringent Planned supportive confrontation; patient .. (age 22 years) oromorph particles found consistent with self-discharged; family doctor and psychiatric foreign material in a distribution team informed incompatible with wound-care procedures” 1996 Paediatric outpatient Worried about 1-year-old son Investigations unable to detect Patient requesting disability living allowance Case conference (age 22 years) clinic (B) with 3 month history of any relevant organic cause for son; asking how to hire a wheelchair for convened by social “shaking episodes” herself services at surgery of family doctor

Data anonymised for patient confi dentiality. A, B, C, and D represent four diff erent hospitals.

Table: Chronology of a 22-year-old composite female patient with factitious disorder

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continue.49 Some patients will interpret confrontation as Panel 3: Constructive confrontation—preparation and humiliating and seek care elsewhere, or will lodge process (for non-psychiatrists) complaints or escalate their self-destructive behaviour; as • Collect fi rm evidence of fabrication (eg, catheter, syringe, such, a more nuanced approach might be preferable.18 ligature) However, saving face and harm minimisation are key • Discuss with psychiatrist (or member of hospital legal team management elements. Improved outcomes have been if no psychiatrist available) reported with a multidisciplinary team incorporating • Arrange meeting to collate the facts, devise strategy, and elements of both medical and psychological support.67 discuss with primary care doctor Diagnosis of a factitious disorder in a health-care worker • Confrontation with the patient should be non-judgmental will have important implications for their future and non-punitive, and should include a proposal of ongoing employment, and the person’s registering body might support and follow-up need to be contacted. This contact is best made after • Discuss the outcome of the confrontation with the primary consultation with the hospital legal department. care doctor • If the patient is a health-care worker the doctor should Course and prognosis discuss with a member of their defence organisation Patients often drop out of follow up, especially after the • Document a full record of the meeting and its outcome in diagnosis of a factitious disorder has been raised as a the patient record possibility. Consequently, prospective studies are rare and the course of the disorder is diffi cult to ascertain. Evidence from large case series suggests that, typically, patients are should be alert to the potential onward eff ect when such a fi rst identifi ed in their mid-30s,49,52,54,55 and that the course diagnosis is made in women with young children.63 is variable and can include a chronic and enduring pattern of fabrication or a life punctuated by episodes that Assessment might or might not progress to a more chronic pattern.55 Medical notes should, ideally, be always read in advance These groups might include unfortunate victims of of interview, and any apparent inconsistencies noted for fabricated or induced illness maltreatment in childhood68 specifi c enquiry. General practice notes can be crucial, who continue their simulations into adult life. Findings and should be obtained, if possible, and read in detail.64 from a published series52 showed that three-quarters of Longitudinal contemporaneous medical records provide the patients were confronted, but only one in six acknow- a substantial resource in assessment of such patients, ledged that their illness was self-induced; 12% agreed to and documentation of a chronology with dates, have psychiatric treatment, but the outcomes were not complaints, and medical outcomes proves invaluable published. (table), particularly when a team approach is involved. Recovery from chronic factitious disorder is rare69,70 and largely unknown because many patients understandably Management drop out of follow-up. Furthermore, factitious disorders Ma nagement of factitious disorders includes acute are associated with substantial morbidity and mortality, management in inpatient settings, which could be an and this risk seems to be increased when litigation is emergency room or an inpatient infectious diseases unit, involved, whereby the need to obtain judicial or the longer-term process of attempting to engage the endorsement of the presence of an illness might be patient in some form of psychotherapy or at least harm increased.71 Case reports of suicide have confi rmed that reduction.18 The key to successful management in both deceptive behaviour does not preclude the presence of phases requires negotiation and agreement of the serious psychopathology.72 The enormous economic diagnosis with the patient and engagement of that patient burden these patients impose on the health-care system with treatment. No robust research evidence is available to has been extensively documented.73 support the eff ectiveness of a management strategy for factitious illness; however, a systematic review recom- Ethical and legal matters mended the establishment of a central reporting register Obtaining clinical notes is crucial, but if the patient does to aid development of evidence-based guidelines.65 not sanction this request, doctors are left with a dilemma. Initial concern about the possible presence of factitious Such access diffi culties further prevent the optimum disorders is typically raised by non-psychiatrists, who management of these patients. Physicians who disclose might wish to involve a psychiatric colleague in a information to third parties without patient consent might discussion of the diagnosis with the patient, a process have to justify the decision to their licensing body, and for sometimes described as supportive confrontation.66 This this reason, doctors should have a low cutoff point for process needs careful preparation (panel 3). Supportive contacting their defence organisations. confrontation should involve at least two members of Evidence has shown that indication of simulation can staff , with an emphasis on the patient being a person be identifi ed by doctors using electronic searches of who needs help, with the assurance that care will health records.74,75 Although legal and ethical questions

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can arise from such searches,76,77 such a search might be Epidemiology warranted to establish a diagnosis of deception when Prevalence estimates of symptom exaggeration are done within the ethical guideline of benefi cence (ie, to understandably diffi cult to estimate and vary according prevent iatrogenic disease), preferably in conjunction to the setting and criteria adopted.85 In social security with a colleague from the hospital legal department. disability examinations undertaken in the USA, the Plastic surgeons should be aware that they can be sued prevalence of symptom exaggeration in claimants has for malpractice by patients with factitious disorders.78 been estimated to be between 46% and 60%, with use of symptom validity tests.86 Members of the American Malingering Board of Clinical Neuropsychology reported rates of Defi nition and conceptual issues symptom exaggeration in 29% of cases of personal injury, Malingering is not a formal medical diagnosis and there in 30% of disability or workers compensation referrals, continues to be little agreement about its defi nition.79 in 19% of criminal cases, and in 8% of medical or Additionally, many neuropsychologists conceptualise psychiatric cases (statistically adjusted to remove for the malingering in probabilistic rather than dichotomous eff ect of referral source).87 The same rates categorised by terms,80 and perceive feigning of physical symptoms as diagnosis showed that 39% of cases were for mild head dimensional and episodic rather than categorical.81 injury, 35% were fi bromyalgia and chronic fatigue, 31% Although the DSM makes clear that malingering is not a were chronic pain, 15% were depressive disorders, and psychiatric disorder, the most commonly quoted 11% were dissociative disorders. Prevalence of symptom defi nition of malingering is probably from the American exaggeration is highest in compensation or litigation Psychiatric Association,82 namely that the disorder settings, but notably, most compensation claimants involves “the intentional production of false or grossly (75–90%) respond well to treatment, recover from illness exaggerated physical or psychological symptoms, or injury, and return to work.85 motivated by external incentives, such as avoiding military duty, avoiding work, obtaining fi nancial compensation, evading criminal prosecution, or A obtaining drugs”. We have described the shortcomings of Choice 19,20 Deception this defi nition above. Intentional Malingering One issue with malingering is that despite falling outside the remit of all recognised psychiatric authorities, many clinicians have diffi culty avoiding the temptation to medicalise the illness. In an eff ort to retain medical involvement in the growing number of Exaggeration medically unexplained disorders, new disorders such as compen sation neurosis”83 and factitious disorders were Psychiatric or introduced into mainstream psychiatric nosologies in psychosocial disorder the 20th century. Common to both malingering and Non- factitious disorders is the requirement of doctors to intentional ascertain, during a clinical interview, the motivations Exculpated and level of conscious awareness that accompany Responsibility 4 symptoms reported by patients. As a neuropsychological B concept, the assessment of malingering generally involves both exaggeration and poor eff ort, although it has been claimed to be present with only one of these being accurately detected.80 In recognition that all such disorders are best viewed as Malingering existing on a continuum, the conceptual overlaps and potential for confusion are evident when considered in 83 Compensation terms of motivation and symptom exaggeration or neurosis 8 between attributed intention and subject responsibility. (DSM-5 functional Factitious disorder The fi gure shows both models. Malingering has been ) conceptualised in three categories: pure, when non- Change in motivation going from internal at the bottom to more external top existent clinical problems are feigned; partial, when Range of level of intentional symptom production increasing from left to right actual symptoms are exaggerated; and false imputation, which refers to the deliberate misattribution of actual Figure: Two models of illness deception (A)8 and compensation neurosis (B)83 symptoms to the compensable event. Exaggeration of Reproduced by permission of Sage Publications (A) and American Psychiatric Press (B). Diagrams show the symptoms is generally assumed to be more common potential roles of patient choice, intentions, and motivation in symptom production and, ultimately, diagnosis. than outright faking.84 DSM-5=Diagnostic and Statistical Manual of Mental Disorders, fi fth edition. www.thelancet.com Vol 383 April 19, 2014 1427 Series

Assessment performance in a forced-choice test suggests a voluntary The cornerstone of detection as opposed to diagnosis of endorsement of incorrect answers,96 and considered by malingering is the well-prepared clinical interview, having some as tantamount to confession of malingering.97 The reviewed available documents and, when available, importance of these tests has been stressed by professional forensic materials. A conclusion of malingering typically bodies and guidelines.98 needs multiple sources of converging evidence and the Among the best-studied self-reported symptom validity systematic ruling out of probable alternative explanations.88 tests used in chronic pain populations is the test of For the interview, plenty of time and a neutral and memory malingering,99 the word memory test,100 and the supportive attitude are essential. A biographical and Portland digit recognition test.79 When several symptom developmental approach is recommended, starting from validity tests are used in combination, the likelihood that a childhood and working through the personal history to malingerer will go undetected is greatly reduced.101 Other the index event and thenceforward to the present time. techniques that allow for the objective detection of feigned Most UK residents are registered with a primary care symptoms include validity scales from the Minnesota doctor, which allows for a longitudinal health record. Multiphasic Personality Inventory-2,79 the Personality Medical records potentially constitute an invaluable Assessment Inventory,98 and the Psychological Screening resource and provide objective evidence of reported Inventory.19 The structured interview of reported complaints and clinic attendances that help to elucidate symptoms has been used in samples of patients with the association between an accident or injury and any mental disorders.102 Investigators have persuasively argued subsequent symptoms attributed by the patient to the that no evidence exists to support the view that psychiatric putative causal event. For example, doubts could arise if disorders, such as somatoform and dissociative disorders, there was a very long gap between an accident and the lead to failure on symptom validity tests per se, and in start of consultations for a health problem (ie, the view of this point, the patient’s self-reported symptoms symptoms did not materialise logically from the incident and life history can no longer be accepted at face value.103 in question). A chronological summary often pays dividends in the assessment of health documents (table). Types of clinical presentations Special investigations are another method of detection. Post-traumatic disorder Probably the most widely encountered technique is video Many clinical disorders can be simulated,4 but in this surveillance, which is typically provided by the insurance section, we discuss three of the more common disorders: companies or lawyers. Video surveillance usually post-traumatic stress disorder, brain injury, and chronic provides information about the physical abilities of the pain. Well attested examples of non-genuine post- claimant. Marked or unexpected diff erences between the traumatic stress disorder have been published,104–106 claimant’s observed behaviours and what they claim not possibly because the diagnosis is based almost entirely on to be able to do can raise doubts as to the credibility of the individual’s subjective report of symptoms.107 Striking their report. Experience and tradition in various positive symptoms such as and fl ashbacks are specialties have resulted in diff erent clinical techniques more readily elaborated than are more subtle features, being used to help to assess the validity of clinical such as .108 Evidence from the USA suggests presentations. Patterns of muscular weakness might be that malingering of post-traumatic stress disorder in the used by neurologists and orthopaedic surgeons and military is a huge problem.104 others as indicators of the genuineness or otherwise of Comprehensive assessment is crucial. In a prospective clinical presentations.89,90 Several motor tasks have been study of patients claiming post-traumatic stress disorder, examined and grip strength measured with a hand 70% showed negative response bias on at least one dynanometer seems to be a good indicator of poor eff ort.91 symptom validity test, and 25% did in all three tests.109 A fi nger-tapping task has also provided useful Neuropsychologists stress the importance of use of information in personal injury claimants.92 various methods for assessment of possible response In the past two decades, clinical psychology and distortion, and of the establishment of whether the neuropsychologists have developed psychological tests trauma reported satisfi es a proportional reaction.110 that have been claimed to provide a more precise assessment of the credibility of verbally claimed symptoms Brain injury than other assessment methods. In this context symptom Brain injury is a common subject in personal injury validity refers to the accuracy or veracity of a person’s litigation, and 15–30% of patients with mild traumatic behavioural presentation, self-reported symptoms, or brain injury report the presence of continuing non- performance on neuropsychological tests.93,94 Symptom specifi c symptoms such as distress, headache, and validity tests typically comprise a simple memory or cognitive problems, collectively described as post- recognition task on which a wide range of people with concussional syndrome.111 There is also the complication neurological or psychiatric problems can achieve near- of an association between patient concern (ie, expectations) perfect performance.95 The basic premise underlying this that symptoms will have adverse consequences, and the approach is that a fi nding of below-chance (ie, <50%) reporting of major and enduring complaints.112,113

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In medicolegal settings, clinical neuropsychologists regional pain syndrome type 1 is controversial, in view have been encouraged to assess motivation and eff ort of claims of overdiagnosis in medicolegal settings,127 with use of both separate and embedded eff ort measures and in the UK this disorder seems to have displaced throughout an assessment of a patient with a mild another non-specifi c disorder—repetitive strain traumatic brain injury.96,98,114 A frequent fi nding in the injury.128 Iatrogenic complications129 and self-induced scientifi c literature on symptom validly tests is that symptoms have been reported,130 and in a survey of patients with mild traumatic brain injury (especially 73 patients with complex regional pain syndrome those seeking compensation) do worse on cognitive tests type 1, incentivised by disability-seeking contexts, at than do those with moderate or severe brain injury.115 least three-quarters failed one performance validity This fi nding confi rms Miller’s formative fi nding that indicator.131 Doctors need to be especially cautious when many patients’ fabricated memory and other cognitive they encounter this diagnosis.132 symptoms are in inverse proportion to injury severity and only resolve with receipt of compensation.27 Management Patients with mild traumatic brain injury are most likely Somatoform disorders, chronic pain, and whiplash to present with symptom validity failure, exaggeration, neck injury or malingering, or all three,87 and feedback of test results Chronic pain is common and 10% of people surveyed has been most systematically studied in this group.133 A report some disability associated with chronic pain.116 In feedback model has been described that involves the UK, whiplash neck injury is regarded as a public building of rapport with the patient, exploring of the health problem, accounting for double the proportion of reasons for poor eff ort and acknowledgment of possible personal injury claims as other countries in Europe.117 task disengagement, establishment of the potential Research in whiplash has shown the importance of reasons for exaggeration, and discussion of other factors patient beliefs and expectations,118 and the role of that can underlie symptom persistence. Evidence has perceived injustice in the establishment of occupational shown that after confrontation two-thirds of patients disability,119 suggesting that a patient’s expectations about from a non-forensic sample produced valid scores on getting better and negative psychological outlook are just subsequent re-examination, suggesting that this inter- as important as the physical symptoms.120 vention can be helpful.134 In medicolegal settings the proportion of patients with a diagnosis of somatoform, dissociative, or pain disorders Prognosis and outcome who show negative response bias is substantial and can The prognosis for malingering in personal injury amount to at least a third.87 The clinical practice of litigants is unknown, but clinical experience suggests diagnosis of medically unexplained symptoms or that patients with longstanding disability, even if partly dissociative disorders without attempts to exclude or wholly non-organic, do not always recover after malingering (or factitious disorders) as alternative settlement.135 Improvement after settlement can take explanations could result in gross overdiagnosis, place for many reasons, including less stress and especially in litigating populations and in patients uncertainty in the litigant’s life because they are no seeking other forms of external gain.103 longer involved in an adversarial system in which their The challenge of pain assessment in contexts of reputation is under scrutiny and they have to prove their secondary gain is formidable, and malingered pain-related injury.82 However, convincing evidence exists to show disability has been described.101,121 Fibromyalgia and individuals involved in litigation for fi nancial rewards to chronic regional pain syndrome type 1 have attracted compensate pain and suff ering after a road traffi c attention in the past few years, especially because accident do not recover as quickly as those with similar psychological factors or so-called yellow fl ags122 have been injuries who are not litigating.136 shown to be key determinants of pain intensity and disability. Many patients with fi bromyalgia who seek Conclusions disability benefi ts fail eff ort tests.123 Moreover, performance Although specialists generally agree that malingering on validity testing and disability status is associated with and factitious disorders describe a cluster of illness- exaggeration of non-cognitive symptoms such as pain, related symptoms that include diff erential degrees of sleep, and fatigue in people with fi bromyalgia.124 simulation, controversy and debate continue about the The phenomenon of complex regional pain syndrome best way to frame, explain, and manage these behaviours.4 type 1, once known as refl ex sympathetic dystrophy, can Central to this debate is the model of illness adopted.137 arise after injury to a limb.125 The disorder is diagnosed Unlike the traditional biomedical model, the expanded on the basis of non-specifi c, often subjective, criteria, WHO International Classifi cation of Functioning model some of which, including skin temperature, weakness, should be considered in view of its focus on the person and colour diff erences between limbs, can be produced and not the disorder as central to defi ning health and ill and maintained by short-term immobilisation and health.138 Consequently, if illness as an experience is dependency of the limb.126 Diagnosis of complex attributable to the person, and not just to their body, then www.thelancet.com Vol 383 April 19, 2014 1429 Series

key characteristics of being a person might contribute to 11 Hallett M. Physiology of psychogenic movement disorders. the emergence and adoption of a sick role.138 J Clin Neurosci 2010; 17: 959–65. 12 Hamilton JC, Feldman MD, Janata JW. The A, B, C’s of factitious Doctors should consider competing explanatory models disorder: a response to Turner. Medscape J Med 2009; 11: 27. to help them and their patients to better understand the 13 Pearce S, Pickard H. Finding the will to recover: philosophical interaction of potential psychological causes and reasons, perspectives on agency and the sick role. J Med Ethics 2010; and should appreciate the capacity of individuals to 36: 831–33. 139,140 14 Angell M. The illusions of . New York Rev Books 2011; 58: 14. infl uence and control their own actions. Consideration 15 Kendell R, Jablensky A. Distinguishing between the validity and of non-medical aspects moves the discussion from the utility of psychiatric diagnoses. Am J Psychiatry 2003; 160: 4–12. traditional reliance on medical or psychological causes to a 16 Halligan P. Psychogenic movement disorders: illness in search of consideration of the reasons, psychosocial determinants, disease? In: Hallett M, Lang A, Jankovic J, et al, eds. Psychogenic movement disorders and other conversion disorders. Cambridge: and potential incentives that help explain why some people Cambridge University Press, 2011: 120–33. engage in these socially deviant behaviours.4 Even in 17 Krahn LE, Bostwick JM, Stonnington CM. Looking toward DSM-V: patients with established and well recognised psychiatric should factitious disorder become a subtype of somatoform disorder? Psychosomatics 2008; 49: 277–82. and neurological illnesses, it might be unclear whether all 18 McCullumsmith C, Ford C. Simulated illness: the factious disorders the abnormal illness behaviour is exclusively derived from and malingering. Psychiatr Clin North Am 2011; 34: 621–41. their medical disorder. Many patients with medically 19 Berry D, Nelson N. DSM-5 and malingering: a modest proposal. unexplained physical symptoms do not have psychiatric Psychol Inj Law 2010; 3: 295–303. 20 Merckelbach H, Merten T. A note on cognitive dissonance and disorders; rather, the symptoms might be the consequence malingering. Clin Neuropsychol 2012; 26: 1217–29. of minor pathological changes, physiological perceptions, 21 WHO. The ICD-10 Classifi cation of Mental and Behavioural and factors such as the previous experience of illness.141 Disorders. Geneva: World Health Organisation, 1992. 22 Ganis G, Keenan JP. The cognitive neuroscience of deception. Finally, there is clearly scope for increased inter- Soc Neurosci 2009; 4: 465–72. disciplinary collaboration between social neuroscience and 23 Ronson G. Leading from the front. Edinburgh: Mainstream, 2009. neuropsychology, as well as clinicians involved in the 24 Raab S. Mafi a leader who feigned insanity dies. Dec 19, 2005. assessment of patients with somatoform disorders,142 in http://www.nytimes.com/2005/12/19/obituaries/19cnd-gigante. html?pagewanted=all&_r=0 (accessed Jan 14, 2014). particular liaison psychiatrists, clinical psychologists, 25 Drob SL, Meehan KB, Waxman SE. Clinical and conceptual neuropsychiatrists, neurologists, pain clinicians, and problems in the attribution of malingering in forensic evaluations. occupational health physicians. J Am Acad Psychiatry Law 2009; 37: 98–106. 26 Jung B, Reidenberg MM. Physicians being deceived. Pain Med 2007; Contributors 8: 433–37. CB did the literature search, wrote the fi rst draft of the Review, 27 Miller H, Cartlidge N. Simulation and malingering after injuries to and coordinated subsequent revisions. PH reviewed the relevant the brain and spinal cord. Lancet 1972; 1: 580–85. neuropsychological literature and contributed to later refi nements 28 Kanaan RA, Wessely SC. Factitious disorders in neurology: and additions to the fi nal draft. Both authors contributed fi gures and an analysis of reported cases. Psychosomatics 2010; 51: 47–54. approved the fi nal submitted version. 29 Green P, Merten T. Noncredible explanations on noncredible Confl icts of interest performance on SVTs In: Carone D, Bush S, eds. Mild traumatic We declare that we have no confl icts of interest. brain injury: symptom validity assessment and malingering. New York: Springer, 2013: 73–99. Acknowledgments 30 Mechanic D, Volkart E. Stress, illness behaviour, and the sick role. David Gill commented on an earlier draft of the section about Am Sociol Rev 1961; 26: 51–58. malingering, but did not contribute to parts about fabricated illness. 31 Barsky AJ, Klerman GL. Overview: , bodily References complaints, and somatic styles. Am J Psychiatry 1983; 140: 273–83. 1 Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling 32 Wade DT, Halligan PW. Social roles and long-term illness: is it time musculoskeletal pain. J Bone Joint Surg Am 2009; 91: 2014–18. to rehabilitate convalescence? Clin Rehabil 2007; 21: 291–98. 2 Vranceanu AM, Barsky A, Ring D. Less specifi c arm illnesses. 33 Rief W, Ihle D, Pilger F. A new approach to assess illness behaviour. J Hand Ther 2011; 24: 118–22. J Psychosom Res 2003; 54: 405–14. 3 Creed F, Barsky A, Leinkes A. Epidemiology: prevalence, causes and 34 Petrie K, Weinman J. Patients’ perceptions of their illness: the consequences. In: Creed F, Henningsen P, Fink P, eds. Medically dynamo of volition in health care. Curr Dir Psychol Sci 2012; unexplained symptoms, somatoform disorders and bodily distress: 21: 60–65. developing better clinical services. Cambridge: Cambridge 35 Rief W, Nanke A, Emmerich J, Bender A, Zech T. Causal illness University Press, 2011: 1–42. attributions in somatoform disorders: associations with comorbidity 4 Halligan P, Bass C, Oakley D. Wilful deception as illness behaviour. and illness behavior. J Psychosom Res 2004; 57: 367–71. In: Halligan P, Bass C, Oakley D, eds. Malingering and illness 36 Bass C, Murphy M. Somatoform and personality disorders: deception. Oxford: Oxford University Press, 2003: 3–28. syndromal comorbidity and overlapping developmental pathways. 5 American Psychiatric Association (APA). Diagnostic and Statistical J Psychosom Res 1995; 39: 403–27. Manual of Mental Disorders, 5th edn. DSM-5. Washington DC: 37 Tyrer P, Seivewright N, Seivewright H. Long-term outcome of APA, 2013. hypochondriacal personality disorder. J Psychosom Res 1999; 6 Vrij A. Detecting lies and deceit. Pitfalls and opportunities, 2nd 46: 177–85. edn. Chichester: John Wiley, 2008. 38 Eisendrath SJ, McNiel DE. Factitious disorders in civil litigation: 7 Trivers R. Deceit and self-deception. London: Allen Lane, 2011. twenty cases illustrating the spectrum of abnormal illness-affi rming 8 Bass C, Halligan PW. Illness related deception: social or psychiatric behavior. J Am Acad Psychiatry Law 2002; 30: 391–99. problem? J R Soc Med 2007; 100: 81–84. 39 Pankratz L. Patients who deceive: assessment and risk in providing 9 Kanaan RA, Wessely SC. The origins of factitious disorder. health care and fi nancial benefi ts. Springfi eld, IL: Charles Thomas, Hist Human Sci 2010; 23: 68–85. 1998. 10 Rogers R. Development of a new classifi catory model of 40 Kozlowska K. The developmental origins of conversion disorders. malingering. Am Acad Psychiatry Law 1990; 18: 323–33. Clin Child Psychol Psychiatry 2007; 12: 487–510.

1430 www.thelancet.com Vol 383 April 19, 2014 Series

41 Farnfi eld S, Hautamäki A, Nørbech P, Sahhar N. DMM 68 Libow JA. Munchausen by proxy victims in adulthood: a fi rst look. assessments of attachment and adaptation: Procedures, validity and Child Abuse Negl 1995; 19: 1131–42. utility. Clin Child Psychol Psychiatry 2010; 15: 313–28. 69 Fehnel CR, Brewer EJ. Munchausen’s syndrome with 20-year 42 Crittenden PM, Landini A. Assessing adult attachment: a follow-up. Am J Psychiatry 2006; 163: 547. dynamic-maturational approach to discourse analysis. New York: 70 Bass C, Taylor M. Recovery from chronic factitious disorder Norton, 2011. (Munchausen’s syndrome); a personal account. Pers Ment Health 43 Spence SA, Hunter MD, Farrow TF, et al. A cognitive neurobiological 2013; 7: 80–83. account of deception: evidence from functional neuroimaging. 71 Eisendrath SJ, McNiel DE. Factitious physical disorders, litigation, Philos Trans R Soc Lond B Biol Sci 2004; 359: 1755–62. and mortality. Psychosomatics 2004; 45: 350–53. 44 Gieler U, Eckhardt-Henn A. Factitious disorders. 72 Binder LM, Greiff enstein MF. Deceptive examinees who committed Dermatol Psychosom 2004; 5: 93–98. suicide: report of two cases. Clin Neuropsychol 2012; 26: 116–28. 45 Fliege H, A, Eckhardt-Henn A, Gieler U, Martin K, 73 Hoertel N, Lavaud P, Le Strat Y, Gorwood P. Estimated cost of a Klapp BF. Frequency of ICD-10 factitious disorder: survey of senior factitious disorder with 6-year follow-up. Psychiatry Res 2012; hospital consultants and physicians in private practice. 200: 1077–78. Psychosomatics 2007; 48: 60–64. 74 Van Dinter TG Jr, Welch BJ. Diagnosis of Munchausen’s syndrome 46 Hamilton JC, Eger M, Razzak S, Feldman MD, Hallmark N, by an electronic health record search. Am J Med 2009; 122: e3. Cheek S. Somatoform, factitious, and related diagnoses in the 75 DeWitt DE, Ward SA, Prabhu S, Warton B. Patient privacy versus national hospital discharge survey: addressing the proposed protecting the patient and the health system from harm: a case DSM-5 revision. Psychosomatics 2013; 54: 142–48. study. Med J Aust 2009; 191: 213–16. 47 Poole CJ. Illness deception and work: incidence, manifestations and 76 Robertson MD, Kerridge IH. “Through a glass, darkly”: the clinical detection. Occup Med 2010; 60: 127–32. and ethical implications of Munchausen syndrome. Med J Aust 48 Eisendrath S, Rand D, Feldman M. Factitious disorders and litigation. 2009; 191: 217–19. In: Feldman M, Eisendrath S, eds. The spectrum of factitious 77 Dewitt DE, Bhat R, Ward S. “Through a glass, darkly”: the clinical disorders. Washington, DC: American Psychiatric Press, 1996: 65–81. and ethical implications of Munchausen syndrome. Med J Aust 49 Reich P, Gottfried LA. Factitious disorders in a teaching hospital. 2010; 192: 55. Ann Intern Med 1983; 99: 240–47. 78 Eisendrath SJ, Telischak KS. Factitious disorders: potential 50 Ehrlich S, Pfeiff er E, Salbach H, Lenz K, Lehmkuhl U. Factitious litigation risks for plastic surgeons. Ann Plast Surg 2008; disorder in children and adolescents: a retrospective study. 60: 64–69. Psychosomatics 2008; 49: 392–98. 79 Aronoff GM, Mandel S, Genovese E, et al. Evaluating malingering 51 Peebles R, Sabella C, Franco K, Goldfarb J. Factitious disorder and in contested injury or illness. Pain Pract 2007; 7: 178–204. malingering in adolescent girls: case series and literature review. 80 Iverson GL. Ethical issues associated with the assessment of Clin Pediatr 2005; 44: 237–43. exaggeration, poor eff ort, and malingering. Appl Neuropsychol 2006; 52 Krahn LE, Li H, O’Connor MK. Patients who strive to be ill: factitious 13: 77–90. disorder with physical symptoms. Am J Psychiatry 2003; 160: 1163–68. 81 Walters GD, Berry DT, Rogers R, Payne JW, Granacher RP Jr. 53 Asher R. Munchausen’s syndrome. Lancet 1951; 1: 339–41. Feigned neurocognitive defi cit: taxon or dimension? 54 Goldstein AB. Identifi cation and classifi cation of factitious J Clin Exp Neuropsychol 2009; 31: 584–93. disorders: an analysis of cases reported during a ten year period. 82 American Psychiatric Association. Diagnostic and Statistical Int J Psychiatry Med 1998; 28: 221–41. Manual of Mental Disorders, 4th edn. Washington, DC: American 55 Kapfhammer H, Rothenhausler H, Dietrich E, Dobmeier P, Psychiatric Association, 2000. Mayer C. Artifactual disorders–between deception and self- 83 Hall RC, Hall RC. Compensation neurosis: a too quickly forgotten mutilation: experiences in consultation psychiatry at a university concept? J Am Acad Psychiatry Law 2012; 40: 390–98. clinic. Nervenartz 1998; 69: 401–09. 84 Resnick P, West S, Payne J. Malingering of posttraumatic stress 56 Fink P. Physical complaints and symptoms of somatising patients. disorders. In: Rogers, R, ed. Clinical assessment of deception and J Psychosom Res 1992; 32: 125–36. malingering, 3rd edn. New York: Guilford Press, 2008: 109–127. 57 Bass C, Jones D. Psychopathology of perpetrators of fabricated or 85 Sullivan K. Methods of detecting malingering and estimated induced illness in children: case series. Br J Psychiatry 2011; symptom exaggeration base rates in Australia. 199: 113–18. J Forensic Neuropsychol 2007; 4: 49–70. 58 Burke FD. Factitious disorders of the upper limb. 86 Chafetz M, Underhill J. Estimated costs of malingered disability. J Hand Surg Eur Vol 2008; 33: 103–09. Arch Clin Neuropsychol 2013; 28: 633–39. 59 O’Connor EA, Grunert BK, Matloub HS, Eldridge MP. Factitious 87 Mittenberg W, Patton C, Canyock EM, Condit DC. Base rates of hand disorders: review of 29 years of multidisciplinary care. malingering and symptom exaggeration. J Clin Exp Neuropsychol J Hand Surg Am 2013; 38: 1590–98. 2002; 24: 1094–102. 60 Cunningham JM, Feldman MD. Munchausen by Internet: current 88 Iverson GL. Identifying exaggeration and malingering. Pain Pract perspectives and three new cases. Psychosomatics 2011; 52: 185–89. 2007; 7: 94–102. 61 Hadeed V, Trump DL, Mies C. Electronic cancer Munchausen 89 Granacher R, Berry D. Feigned medical presentations. In: Rogers R, syndrome. Ann Intern Med 1998; 129: 73. ed. Clinical assessment of malingering and deception, 3rd edn. 62 Feldman MD, Hamilton JC. Serial factitious disorder and New York: Guilford Press, 2008: 145–56. Munchausen by proxy in pregnancy. Int J Clin Prac 2006; 60: 1675–78. 90 Main CJ, Waddell G. Behavioral responses to examination. 63 Bass C, Glaser D. Fabricated and induced illness in children: early A reappraisal of the interpretation of “nonorganic signs”. Spine recognition and management. Lancet 2014; published online 1998; 23: 2367–71. March 6. http://dx.doi.org/10.1016/S0140-6736(13)62183-2. 91 Greve K, Bianchini K. The psychological assessment of pain-related 64 Bass C, Gill D. Factitious disorder and malingering. In; Gelder M, disability. In: Faust D, ed. Coping with psychiatric and psychological Andreason N, Lopez-Ibor J, Geddes J, eds. New Oxford Textbook of testimony, 6th edn. New York: Oxford University Press, 2012: 587–609. Psychiatry. Oxford: Oxford University Press, 2009: 1049–59. 92 Larrabee GJ. Detection of malingering using atypical performance 65 Eastwood S, Bisson JI. Management of factitious disorders: patterns on standard neuropsychological tests. Clin Neuropsychol a systematic review. Psychother Psychosom 2008; 77: 209–18. 2003; 17: 410–25. 66 Eisendrath SJ, Feder A. Management of factitious disorders. 93 British Psychological Society (BPS). Assessment of eff ort in clinical In: Feldman M, Eisendrath S, eds. The spectrum of factitious testing of cognitive functioning for adults. Leicester: BPS, 2009. disorders. Washington, DC: American Psychiatric Press, 94 Larrabee GJ. Performance validity and symptom validity in 1996: 195–213. neuropsychological assessment. J Int Neuropsychol Soc 2012; 67 Mahondas P, Bewley A, Taylor R. Dermatitis artefacta and artefactual 18: 625–30. skin disease: the need for a psycho dermatology multi-disciplinary 95 Sweet J, Guidotti Breting L. Symptom validity test research. Status team to treat a diffi cult condition. Br J Dermatol 2013; 169: 600–06. and clinical implications. J Exp Psychopathol 2013; 4: 6–19.

www.thelancet.com Vol 383 April 19, 2014 1431 Series

96 Bush SS, Ruff RM, Tröster AI, et al. Symptom validity assessment: 120 Holm LW, Carroll LJ, Cassidy JD, Skillgate E, Ahlbom A. practice issues and medical necessity NAN policy & planning Expectations for recovery important in the prognosis of whiplash committee. Arch Clin Neuropsychol 2005; 20: 419–26. injuries. PLoS Med 2008; 5: e105. 97 Larrabee G. 2004. Diff erential diagnosis of mild head injury. 121 Greve KW, Ord JS, Bianchini KJ, Curtis KL. Prevalence of In: Ricker J, ed. Diff erential diagnosis in adult neuropsychological malingering in patients with chronic pain referred for psychologic assessment. New York: Springer, 2004: 243–75. evaluation in a medico-legal context. Arch Phys Med Rehabil 2009; 98 Heilbronner RL, Sweet JJ, Morgan JE, Larrabee GJ, Millis SR, and 90: 1117–26. the Conference Participants. American Academy of Clinical 122 Nicholas MK, Linton SJ, Watson PJ, Main CJ, and the “Decade of Neuropsychology Consensus Conference Statement on the the Flags” Working Group. Early identifi cation and management of neuropsychological assessment of eff ort, response bias, and psychological risk factors (“yellow fl ags”) in patients with low back malingering. Clin Neuropsychol 2009; 23: 1093–129. pain: a reappraisal. Phys Ther 2011; 91: 737–53. 99 Tombaugh TN. The test of memory malingering. Toronto: 123 Gervais RO, Russell AS, Green P, Allen LM 3rd, Ferrari R, Multi-Health Systems, 1996. Pieschl SD. Eff ort testing in patients with fi bromyalgia and 100 Green P. Green’s word memory test for Windows: user’s manual. disability incentives. J Rheumatol 2001; 28: 1892–99. Edmonton: Green’s Publishing, 2005. 124 Johnson-Greene D, Brooks L, Ference T. Relationship between 101 Greve KW, Bianchini KJ, Brewer ST. The assessment of performance validity testing, disability status, and somatic performance and self-report validity in persons claiming complaints in patients with fi bromyalgia. Clin Neuropsychol 2013; pain-related disability. Clin Neuropsychol 2013; 27: 108–37. 27: 148–58. 102 Rogers R, Payne JW, Berry DT, Granacher RP Jr. Use of the SIRS in 125 Goebel RA, Barker C. Turner-Stokes L, et al. Complex regional pain compensation cases: an examination of its validity and syndrome in adults. UK guidelines for diagnosis, referral, and generalizability. Law Hum Behav 2009; 33: 213–24. management in primary and secondary care. London: RCP, 2012. 103 Merten T, Merckelbach H. Symptom validity testing in somatoform 126 Singh HP, Davis TR. The eff ect of short-term dependency and and dissociative disorders: a critical review. Psychol Inj Law 2013; immobility on skin temperature and colour in the hand. 6: 122–37. J Hand Surg [Br] 2006; 31: 611–15. 104 Morel K. Diff erential diagnosis of malingering versus PTSD. New 127 Pearce JM. Chronic regional pain and chronic pain syndromes. York: Nova Science, 2010. Spinal Cord 2005; 43: 263–68. 105 R Burkett B, Whitley G. Stolen Valor: how the Vietnam Generation 128 Lucire Y. Constructing RSI. Belief and desire. Sydney: University of was robbed of its heroes and its history. Dallas: Verity Press, 1998. South Wales Press, 2003. 106 Rosen GM, Taylor S. Pseudo-PTSD. J Anxiety Disord 2007; 21: 201–10. 129 de Asla R. Complex regional pain syndrome type1: disease or illness 107 Hall RC, Hall RC. Malingering of PTSD: forensic and diagnostic construction? J Bone Jt Surg Am 2011; 93: e116. considerations, characteristics of malingerers and clinical 130 Mailis-Gagnon A, Nicholson K, Blumberger D, Zurowski M. presentations. Gen Hosp Psychiatry 2006; 28: 525–35. Characteristics and period prevalence of self-induced disorder in 108 Hall RC, Hall RC. Detection of malingered PTSD: an overview of patients referred to a pain clinic with the diagnosis of complex clinical, psychometric, and physiological assessment: where do we regional pain syndrome. Clin J Pain 2008; 24: 176–85. stand? J Forensic Sci 2007; 52: 717–25. 131 Greiff enstein M, Gervais R, Baker WJ, Artiola L, Smith H. 109 Merten T, Thies E, Schneider K, Stevens A. Symptom validity Symptom validity testing in medically unexplained pain: a chronic testing in claimants with alleged posttraumatic stress disorder: regional pain syndrome type 1 case series. Clin Neuropsychol 2013; comparing the Morel emotional numbing test, the structure 27: 138–47. inventory of malingered symptomatology, and the word memory 132 Ochoa JL, Verdugo RJ. Neuropathic pain syndrome displayed by test. Psychol Inj Law 2009; 2: 284–93. malingerers. J Neuropsychiatry Clin Neurosci 2010; 22: 278–86. 110 Torres L, Skidmore S, Gross N. Asssessment of post traumatic 133 Carone D, Bush S, Iverson G. Providing feedback on symptom stress disorder: diff erences in standards and practice between validity, mental health, and treatment in mild traumatic brain licensed and board-certifi ed psychologists. Psychol Inj Law 2012; injury. In: Carone D, Bush S, eds. Mild traumatic brain injury, 5: 1–11. symptom validity assessment and malingering. New York: Springer, 111 Hou R, Moss-Morris R, Peveler R, Mogg K, Bradley BP, Belli A. 2013: 101–18. When a minor head injury results in enduring symptoms: a 134 Suchy Y, Chelune G, Franchow EI, Thorgusen SR. Confronting prospective investigation of risk factors for postconcussional patients about insuffi cient eff ort: the impact on subsequent syndrome after mild traumatic brain injury. symptom validity and memory performance. Clin Neuropsychol J Neurol Neurosurg Psychiatry 2012; 83: 217–23. 2012; 26: 1296–311. 112 Whittaker R, Kemp S, House A. Illness perceptions and outcome in 135 Mendelson G. ‘Compensation neurosis’ revisited: outcome studies mild head injury: a longitudinal study. J Neurol Neurosurg Psychiatry of the eff ects of litigation. J Psychosom Res 1995; 39: 695–706. 2007; 78: 644–46. 136 Cassidy JD, Bendix T, Rasmussen C, Carroll L, Côté P. Re: Spearing 113 Ferrari R. Minor head injury: do you get what you expect? and Connelly. Is compensation bad for your health? A systematic J Neurol Neurosurg Psychiatry 2011; 82: 826. meta-review. Injury 2011;42:15–24. Injury 2011; 42: 428–29. 114 Guidotti Breting L, Sweet J. Freestanding cognitive symptom validity 137 Wade DT, Halligan PW. Do biomedical models of illness make for tests: use and selection in mild traumatic brain injury. In: Carone D, good healthcare systems? BMJ 2004; 329: 1398–401. Bush S, eds. Mild traumatic brain injury, symptom validity 138 Wade DT, Halligan P. New wine in old bottles: the WHO ICF as an assessment and malingering. New York: Springer, 2013: 145–58. explanatory model of human behaviour. Clin Rehabil 2003; 115 Greiff enstein M, Baker J. Miller was (mostly) right: head injury 17: 349–54. severity inversely related to simulation. Leg Criminol Psychol 2005; 139 Salmon P. Confl ict, collusion or collaboration in consultations 10: 1–16. about medically unexplained symptoms: the need for a curriculum 116 Croft P, Blyth F, van der Wint D. The global occurrence of chronic of medical explanation. Patient Educ Couns 2007; 67: 246–54. pain: an introduction. In: Croft P, Blyth F, van der Wint D, eds. 140 Stone J, Warlow C, Sharpe M. Functional weakness: clues to Chronic pain epidemiology. From aetiology to public health. Oxford: mechanism from the nature of onset. J Neurol Neurosurg Psychiatry Oxford University Press, 2010: 3–8. 2012; 83: 67–69. 117 Dyer C. Ministers consider measures to reduce UK’s 1500 daily 141 Nimnuan C, Hotopf M, Wessely S. Medically unexplained claims for whiplash. BMJ 2012; 344: e3226. symptoms: how often and why are they missed? Q JM 2000; 118 Ferrari R, Russell AS. Whiplash: nothing to lose sleep over. 93: 21–28. J Rheumatol 2012; 39: 655. 142 Lamberty G. Understanding somatisation in the practice of clinical 119 Sullivan MJ, Scott W, Trost Z. Perceived injustice: a risk factor for neuropsychology. New York: Oxford University Press, 2008. problematic pain outcomes. Clin J Pain 2012; 28: 484–88.

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