Series Factitious disorders 2 Factitious disorders and malingering: 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 psychopathology 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 Psychology, 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 exaggeration 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 factitious disorder 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 mental disorder 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 neurosis) 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 con tribution 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 1422 www.thelancet.com Vol 383 April 19, 2014 Series 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 Diseases 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