Factitious Disorders Defined: What They Are, How They Present, and Their Varieties

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Factitious Disorders Defined: What They Are, How They Present, and Their Varieties

Abnormal Psychology · Chapter 23: Factitious Disorders: Intentional Illness and DeceptionSection 23.1 · lesson 88 of 9716 min · free with a free account

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In this lesson

Intention, incentive - and errors in both directions.

  • Define factitious disorder and its 2 varieties, using the intentionality and incentive framework
  • Distinguish these from somatic presentations, malingering, and undiagnosed conditions
  • Explain why suspicion is not a diagnosis
  • Describe the errors in both directions, and the harm each causes

Transcript

Everything said in the video, section by section (2,165 words). Read along, or search it.

Factitious Disorders: Intentional Illness and Deception

Factitious Disorders Defined

Chapter twenty-three turns to factitious disorders. These are presentations in which signs or symptoms are produced intentionally. This first section defines them, and sets out the framework that organizes the whole chapter. It separates these presentations from somatic symptom presentations, from malingering, and from undiagnosed medical conditions. And it describes the errors that occur in both directions, and the harm each one causes.

Before You Begin

Difficult Judgments, Made by Specialists

This material is educational and clinical. It is not a basis for diagnosing anyone. The determinations described here are difficult. They are made by specialists working together, and they are frequently made wrongly, in both directions. Nothing in this section describes how any symptom is produced, or how any deception is accomplished. And nothing in it equips a reader to detect either.

Where This Chapter Sits

Produced Intentionally - Yet Grouped With Somatic Conditions

Chapter fourteen covered presentations in which physical symptoms are real, distressing, and not produced intentionally. This chapter covers presentations in which signs or symptoms are produced intentionally. Even so, the current classification groups the factitious conditions with the somatic conditions. Given that difference, it looks odd. The reason is shared clinical territory. These presentations come to medical services, they concern the body, and the assessment problems they create fall to the same clinicians. Two things should be said before anything else. First, people with these presentations have a genuine mental health condition, and genuine distress. Producing symptoms intentionally is not the same as being untroubled. The intuition that it is accounts for much of what goes wrong clinically. Second, these presentations reliably provoke hostility in staff. That is understandable, and it is also a clinical problem in its own right, taken up in section twenty-three point two.

The Organizing Concept

2 Independent Dimensions

The organizing concept for this chapter is a distinction along two independent dimensions. Are the symptoms produced intentionally? And is an external incentive present? Crossing the two gives four positions, and confusing any two of them is the most common error in this area. Not intentional, with no external incentive, describes the somatic symptom and functional presentations of chapter fourteen. The symptoms are real, and the person is not producing them. Not intentional, with an external incentive present, describes a person with a genuine condition, who also stands to gain from being unwell. The presence of an incentive does not make a presentation intentional. Treating it as evidence of intent is a serious reasoning error. Intentional, with no obvious external reward, is factitious disorder, the subject of this section. And intentional, with an external incentive present, is malingering. That is not a mental disorder, but it may be a focus of clinical attention.

Figure 23.1.1

4 Positions - Neither Axis Can Be Observed

Here are the four positions, laid out as a grid. Look at the two axis labels before the cells. Neither dimension can be read off a presentation. Both are inferred, from whatever information is available. The highlighted cell is the one most often misread. A genuine condition, in a person who happens to have something to gain. These judgments are made by specialists, and they are frequently wrong in both directions. A person with a genuine undiagnosed condition may be suspected of producing it. And a person producing symptoms may be treated for a condition they do not have. Both errors cause serious harm, and neither is acceptable.

Why Intention Is Hard to Establish

There Is No Test for Intention

There is no test for intention. It cannot be measured, or imaged, or inferred reliably from any single observation. It is established, if at all, by inference from a pattern. And people rarely disclose it. Three consequences follow. The judgment must be made cautiously, by specialists, with a differential that stays open. It must never rest on a clinician's confidence, for reasons we will come to shortly. And the right clinical posture is that suspicion is not a diagnosis. That sounds obvious, and it is routinely lost in practice. Once a suspicion is written down, the next clinician tends to read it as a finding.

Factitious Disorder Imposed on Self

Seeking the Position of Being Ill

Factitious disorder imposed on self involves falsifying physical or psychological signs or symptoms, or inducing injury or disease, with identified deception. The person presents themselves to others as ill or impaired, and no obvious external reward accounts for the behavior. That absence of an external incentive is the defining feature. It is what separates this condition from malingering. What the person is understood to be seeking instead is the position of being ill. The care, attention, and recognition that attach to it, and the structure and identity it provides. Section eight point one described the sick role as a social position, with obligations and exemptions attached. The proposal here is that the role itself is what is being sought, rather than anything it can be exchanged for. Care and attention are psychological needs. A person whose route to them runs through illness is describing a difficulty, not an absence of one.

Table 23.1.2

Patterns That May Raise Concern

How do these presentations come to attention? Only the clinical pattern is described here. No operational detail appears in this course. At this level it has no educational value, and it carries obvious risk. Read the third column carefully. In every row, the pattern is compatible with an entirely different explanation. A presentation that departs from the expected course may mean the working explanation is incomplete. It says nothing about intention, because rare and undiagnosed conditions depart from expected courses too. An inconsistent history needs clarifying. Memory, distress, poor records, and multiple services all produce inconsistency. Contact with many services shows that care is uncoordinated. People with difficult undiagnosed conditions are passed between services precisely because nobody has an answer. And reluctance to allow contact with other services limits assessment. But people who have been disbelieved before decline permission for good reason. One more point. The older labels for these presentations, named after a literary figure, are no longer used. They were sensationalizing, and they encouraged treating a person's condition as a curiosity.

Factitious Disorder Imposed on Another

The Safeguarding Frame Governs Everything

Factitious disorder imposed on another involves falsifying signs or symptoms, or inducing injury or disease, in another person. The perpetrator receives the diagnosis, not the affected person. The affected person is most often a child, or a dependent adult. The safeguarding frame governs everything here. This constitutes abuse of the person affected, and protecting that person is the immediate priority. Suspicion requires specialist multidisciplinary assessment, rather than action by an individual clinician. The legal and reporting framework is covered in chapter twenty-five. No sign, method, or detection content appears anywhere in this course. A student's task is to understand the process, not to be equipped to conduct it.

The Wrongful-Suspicion Problem

Both Errors Are Unacceptable

There is a documented history of harm, when parents and caregivers of children with genuine rare or undiagnosed conditions have been wrongly suspected. Families have been separated. Medical investigation has been stopped, while a genuine condition progressed. And the effects on the people involved have been lasting. So the requirement is extreme caution. But it is held alongside an equally clear statement. Failing to protect a person who is being harmed is also a serious failure. Both errors cause serious harm, and neither is acceptable. Some will conclude from this that the safe course is never to raise a concern. That is the wrong lesson. The safe course is to raise it through a process designed to test it. That process is the subject of section twenty-three point two.

In the Clinic

Once Recorded, a Suspicion Travels

Here is what happens, clinically, when a person who is genuinely unwell is suspected. Once a suspicion is recorded, it travels. The next clinician reads it before meeting the person, and it shapes whether new findings are investigated, or simply attributed. Investigation slows, or stops. The person senses the change, and becomes wary, insistent, or angry. All of which is then read as confirmation. And if a genuine condition is present, it goes untreated while this goes on. The protection is not reluctance to think the thought. It is recording the reasoning rather than the conclusion, and keeping the differential explicitly open in the notes. And it is making sure no single clinician's impression becomes the record.

Malingering and Deception Detection

Not a Disorder - and Not Easy to Spot

Malingering is the intentional production or exaggeration of symptoms, motivated by an identifiable external incentive. It is not a mental disorder. It appears in the classification as a condition that may be a focus of clinical attention, which is a different status entirely. It arises where being unwell carries an external consequence. In forensic settings, in disability and compensation processes, and at work. The framework for assessment in those settings is in chapter twenty-five, including the distinction between clinical and forensic roles. Now a finding worth holding onto. Clinicians and laypeople alike are poor at detecting deception, and confidence does not track accuracy. People who believe they are good at it are no better than people who do not. And experience in a clinical field does not confer the ability. So a clinician's sense that something is wrong is a prompt to gather information, through a governed process. It is not evidence in itself. Any conclusion that rests on finding a person unconvincing rests on a capacity that has been tested, and found wanting.

Differential Reasoning

4 Alternatives to Hold Open

The differential runs in four directions. First, somatic symptom and functional neurological presentations, from section fourteen point one. These are not intentional. The symptoms are real, and they are not produced. This is the boundary that matters most. It runs along the intentionality dimension, not along whether a cause has been found. Second, genuine undiagnosed medical conditions, the most important differential in the whole area. Third, malingering, distinguished by an identifiable external incentive. And fourth, presentations occurring within another mental condition, where that condition better accounts for the behavior.

The Rare-Disease Problem

Surprise Is Not Evidence

Why are undiagnosed conditions the most important differential? Because of base rates. An unusual presentation with negative investigations is far more often a rare or not-yet-identified condition than a factitious one. This is a direct application of the base-rate reasoning from section ten point four. Rare conditions are individually uncommon, but collectively common. Many have unusual courses, and negative early investigations. Factitious presentations are uncommon. So a feature that occurs in both groups discriminates very little, when the underlying frequencies differ that much. The practical rule is that surprise is not evidence. A clinician who has not seen a presentation before has learned something about their own experience, not about the person in front of them.

Table 23.1.3

The Errors and What They Cost

This table sets out the errors, and what each one costs. Suspecting a person with a genuine condition stops investigation, lets a treatable condition progress, and often loses their trust in services for good. For the service, it is a serious clinical failure, and where families are involved, potentially a legal one. Failing to recognize a presentation imposed on another means continued harm, to someone who cannot protect themselves. That is a safeguarding failure, with lasting consequences. Treating suspicion as a diagnosis organizes care around a conclusion the person cannot contest. It leaves an unexaminable record, which shapes every later encounter. And responding with hostility drives the person away from care, and escalates the presentation. For staff, it brings distress, inconsistent responses, and a plan that breaks down. Now read the last column. Recorded reasoning, an open differential, team review, established safeguarding processes, and supervision. Both errors are reduced by the same measures. That is the argument for a governed process, rather than a cautious individual.

The Clinical Relationship

Why Confrontation Typically Fails

Co-occurrence with personality difficulties, depressive conditions, and substance-related conditions is frequently reported. That reporting comes from detected cases, and it carries the sampling caution developed in section twenty-three point two. The clinical relationship characteristically deteriorates once suspicion arises, and the deterioration is mutual. Staff feel deceived, and respond with hostility or withdrawal. The person experiences the change, and responds in kind. The effect on care is direct. Assessment narrows, communication becomes guarded, and decisions get made in irritation. Managing that is a substantial part of managing the presentation. Once a conclusion has formed, the instinct is to put it to the person directly. It does not work. The usual outcome is denial. The person leaves the service and presents elsewhere, where none of the accumulated information is available, and the process begins again. Nothing is achieved, except the loss of any chance to reduce harm. The non-punitive alternative is developed in section twenty-three point two. Confrontation is not the brave option. It is the one that ends the contact.

Summary

Intention, Incentive, and Process

To summarize. Two independent dimensions organize this chapter. Whether symptoms are produced intentionally, and whether an external incentive is present. Somatic and functional presentations are not intentional. Factitious disorder is intentional, without external reward. Malingering is intentional, with an incentive, and is not a mental disorder. Intention cannot be measured. It is inferred cautiously, by specialists, and suspicion is not a diagnosis. Imposed on self, factitious disorder is understood as seeking the sick role itself. Imposed on another, it is abuse. Protection comes first, and action goes through safeguarding processes. Wrongful suspicion has caused documented harm, and so has failure to protect. Neither error is acceptable, and the same governed process reduces both. Deception detection is unreliable. An unusual presentation is far more often a rare condition. And confrontation ends the contact, without achieving anything.

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FAQ

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About Factitious Disorders Defined: What They Are, How They Present, and Their Varieties

What is factitious disorder imposed on self?
Factitious disorder imposed on self involves falsifying physical or psychological signs or symptoms, or inducing injury or disease, with identified deception, while the person presents as ill and no obvious external reward explains the behavior. That absent incentive separates it from malingering. The person is understood to be seeking the position of being ill itself, with its care, attention and recognition. It is a genuine mental health condition with genuine distress.
Why is factitious disorder grouped with somatic symptom disorders?
Factitious disorder is grouped with the somatic symptom conditions because they share clinical territory, not because they work the same way. Both come to medical services, concern the body, and create assessment problems for the same clinicians. The key difference is intention: in somatic symptom and functional presentations the symptoms are real and not produced by the person, while in factitious disorder signs or symptoms are produced or falsified intentionally.
What is factitious disorder imposed on another?
Factitious disorder imposed on another involves falsifying signs or symptoms, or inducing injury or disease, in another person, most often a child or dependent adult. The perpetrator receives the diagnosis, not the affected person. It constitutes abuse, so protecting the affected person comes first, and suspicion calls for specialist multidisciplinary safeguarding assessment rather than action by one clinician. Wrongful suspicion of genuine caregivers also causes serious harm.
Can doctors reliably tell when a patient is faking symptoms?
No, clinicians and laypeople alike are poor at detecting deception, and confidence does not track accuracy. There is no test for intention. An unusual presentation with negative test results is far more often a rare or undiagnosed medical condition than a factitious one, because of base rates. A clinician's sense that something is wrong should prompt careful information gathering, and suspicion alone is not a diagnosis.

About the Abnormal Psychology course

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Abnormal Psychology (Psychology 180) carries a NCCRS credit recommendation for 3 semester credits. ACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities.
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