Factitious Disorders With Predominantly Psychological Signs and Symptoms

Clinical Findings
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.

Etiology
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.