Patients with factitious psychological symptoms present a diagnostic challenge to psychiatrists. These individuals may feign psychological symptoms of any psychiatric disorder. Snowdon et al. (1978) described a series of patients with factitious mourning. Feldman-Schorrig (1996) described factitious sexual harassment. Pathe et al. (1999) studied individuals claiming traumatization with false claims of being stalked. Sparr and Pankratz (1983) described individuals being treated in the Department of Veterans Affairs system who feigned posttraumatic stress disorder (PTSD). In these cases, veterans claimed to have had traumatic experiences in Vietnam when they had never been in combat and, in some cases, had never been to Vietnam. On a research ward for psychotic disorders, Pope et al. (1982) identified 9 patients with factitious disorders among 219 consecutive admissions. Bhugra (1988) reported the prevalence of factitious psychological disorders to be 0.5% among 775 admissions to a psychiatric hospital.
Patients with these disorders appear to be primarily motivated by wanting to assume the psychiatric patient role. This differentiates them from malingering patients, who are attempting to achieve some external gain. However, differentiating between malingering for an external gain that may have unconscious motivational underpinnings and a factitious psychiatric disorder is not always easy. In other words, there is a continuum between conscious and unconscious motivations that makes discrete separations into malingering and factitious disorder diagnoses difficult. Identification of factitious psychological disorders also may be more difficult than identification of factitious physical disorders because verification of the etiology rests primarily with the patient. Often the patient’s history of psychological symptoms is revealing; the symptoms may suggest a layperson’s view of a psychiatric disorder rather than a genuine description. In some cases, psychological testing or collateral history from family or prior caregivers may aid in reaching the correct diagnosis.
The literature on factitious psychological disorders consists primarily of individual and multiple case reports. Of striking notice in these reports is the severity of psychological dysfunction that is present in the patients. Several reports have indicated a high rate of suicide in this population. Although the patients feign psychiatric symptoms of the major Axis I disorders, almost all of the patients have marked personality dysfunction, often associated with substance abuse. In fact, Bustamante and Ford (1977) raised the idea that feigning a psychosis may be a defense against the emergence of a genuine psychosis. Indeed, the limited outcome studies that have been described suggest that a factitious psychological disorder has a worse prognosis than most other Axis I disorders.
Little is known about the treatment of factitious psychological disorders; there are few, if any, reports of successful treatment. Many of these patients abruptly leave the psychiatric hospital once confrontation occurs and are lost to follow-up. In the few reports in which more detailed information is available, the patient’s factitious behavior may serve as a reflection of genuine psychological suffering. For example, in Snowdon et al.‘s (1978) cases of factitious bereavement, the patients often appeared to have significant and genuine depressive elements. The factitious bereavement may have served as a means to obtain help for a genuine loss that may have occurred in the past but was incompletely mourned. The factitious component also may serve as a way for patients to feel in control of their situation by the construction of a deceit scripted by themselves. The irony, therefore, is that these patients may actually have a genuine psychiatric disorder underlying their factitious one. This consideration raises the idea that appropriate psychiatric interventions of either a psychotherapeutic or a pharmacological nature may be effective. Unfortunately, this idea is predominantly theoretical.
Merrin et al. (1986) and Parker (1993) noted that certain patients oscillated between factitious physical and psychological disorders. For example, when confronted about the factitious nature of his PTSD, one individual switched to complaints of physical symptoms. Some individuals may concurrently present with both factitious physical and factitious psychological symptoms. The DSM-IV category for patients with combined psychological and physical signs and symptoms highlights the reality that the classifications “with primarily physical signs and symptoms,” “with primarily psychological signs and symptoms,” or with both types of signs and symptoms are actually bound by permeable membranes. Indeed, all of the abnormal illness-affirming behaviors may occur in the same individual at overlapping points in time, making precise diagnosis difficult. Awareness of the fluidity of diagnosis will alert the psychotherapists of factitious disorder patients to the substitutions in symptoms these patients frequently create.
Revision date: July 7, 2011
Last revised: by Sebastian Scheller, MD, ScD