Origins, Identification Methods, and Treatment Pathways

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Origins, Identification Methods, and Treatment Pathways

Abnormal Psychology · Chapter 23: Factitious Disorders: Intentional Illness and DeceptionSection 23.2 · lesson 89 of 9716 min · free with a free account

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In this lesson

Governance rather than detection - and goals set at what can be achieved.

  • Describe the proposed origins, and the evidential status of each
  • Describe identification within clinical governance, and its ethical tensions
  • Explain why confrontation fails, and what replaces it
  • Describe realistic management goals, and the support staff need

Transcript

Everything said in the video, section by section (2,118 words). Read along, or search it.

Factitious Disorders: Intentional Illness and Deception

Origins, Identification, and Treatment

This second and final section of chapter twenty-three moves from definition to origins, identification, and treatment. It covers the proposed origins of factitious presentations, and how strong the evidence is for each. It describes how these presentations are identified within clinical governance, and the ethical tensions involved. And it sets out realistic management goals, why confrontation fails, and the support that staff need.

Before You Begin

Principle Only - Never Procedure

This material is educational and clinical. It is not a basis for diagnosing or investigating anyone. These determinations require specialist and multidisciplinary assessment. Nothing here describes how symptoms are produced, how deception is accomplished, or how either might be detected. Identification is discussed only at the level of clinical governance principle.

What Needs Explaining

Real Risk, for Nothing Exchangeable

The framework, the definitions, and the wrongful-suspicion problem were set out in section twenty-three point one. This section begins with the puzzle those definitions leave behind. In malingering, the behavior is intelligible. There is something to be gained, and the person is pursuing it. In factitious presentations there is no such gain. And yet the person accepts real risk, from investigations, procedures, and their complications. They accept it for something that cannot be exchanged for anything. So whatever is being sought must be psychological. The accounts that follow are attempts to say what. Each one is a proposal, rather than an established finding, and that caution is part of the content, not a hedge.

Table 23.2.1

Proposed Contributing Factors

Here are the proposed contributing factors. Read the third column first, because every row rests on the same limited evidence base. Early experience of illness, in oneself or the family, may make illness a familiar context where care and attention were reliably available. That is reported in case series, with no controlled evidence. Adversity and disrupted early attachment may mean needs for care were not met by ordinary routes, so an indirect route was learned. That is inferential, and drawn from detected cases. Exposure to healthcare settings may make the patient position available and familiar. That is a reported association, and no causal reading is supported. The meaning of the sick role, from section eight point one, is that being ill supplies structure, identity, exemption, and recognition. That is conceptually coherent, but not directly tested. And overlap with personality difficulties, in identity and in relating to others, is frequently reported in detected cases. The sampling problem applies in full. One more pattern is often reported, that some people affected have worked in healthcare. Any causal reading is unsupported. And it is exactly the kind of pattern a literature of detected cases would produce, whether or not it is true of the wider group.

The Evidence Problem

A Literature That Selects Twice

The evidence base for these conditions is very limited. Most of it rests on case reports, and confident treatment claims should be treated with skepticism. But the structural reason matters more than the volume. A literature built from case reports selects twice. First, for cases that were detected. Then, for cases unusual enough to be written up. Both selections push in the same direction, toward the elaborate and the extreme. What such a literature describes is the detected and remarkable end of a distribution, whose overall shape is unknown. So generalizing from it, about prevalence, about who is affected, about course, or about what works, is not supportable. Treat every confident statement in this area as provisional, including the ones in this section. That is not true of, say, the treatment evidence in section twenty-two point three.

Identification Within Clinical Governance

4 Principles

Identification is described here only at the level of principle. No detection technique, investigative procedure, surveillance method, or verification strategy appears anywhere in this course. There are four principles. The first is bringing together information already held, across services, with appropriate authorization. Dispersed information is the ordinary situation, and assembling it is the substance of what can properly be done. The second is multidisciplinary review, rather than individual judgment. That is the single most important element, given what section twenty-three point one showed about individual impression. The third is specialist mental health involvement, early, rather than at the point of crisis. And the fourth is documenting reasoning, rather than conclusions. What was observed, what it does and does not establish, and what remains open.

Figure 23.2.2

The Governance Pathway

This figure shows the governance pathway. Read the questions beneath each stage, rather than the boxes. The boxes only say who is involved. The questions say what has to be answered before anything proceeds. Is there a lawful basis for assembling the information, and is it recorded? What does the information establish, and what does it not? Has specialist input come early, rather than at a crisis? And is the differential still open? The threshold for action follows from this. Suspicion is not a diagnosis. The differential must stay open throughout, including an undiagnosed medical condition. And the base-rate reasoning from section ten point four applies at every stage, not only at the start.

Ethical Tensions

Where Duties Compete

Identification involves real ethical tensions. The first is confidentiality. Bringing information together across services engages the person's confidentiality. It requires a lawful basis, and a record of that basis. The framework is in chapter twenty-five. The second is the person's right to know what is recorded about them. A suspicion that is recorded but not disclosed shapes the person's care, while remaining impossible for them to contest. That is difficult to justify. And the third is the duty of care, set against the risk of wrongful suspicion. These are the two errors from section twenty-three point one, in their live form.

Ethical Tensions: Covert Methods

Serious Ethical and Legal Matters

The fourth tension concerns covert methods. Covert surveillance and covert record-sharing are serious ethical and legal matters. They require institutional and legal authorization, and are never an individual or team decision. The argument in favor is that where a dependent person may be being harmed, less intrusive means may be inadequate to protect them. The argument against is that covert methods breach the relationship on which all later care depends. They may also be legally impermissible, and they produce evidence obtained in a way that is itself contestable. No operational content appears here. The legal framework is in chapter twenty-five.

Why Confrontation Fails

Confess, or Leave

Direct confrontation is generally unhelpful. It typically leads to the person leaving the service, and it is not supported. The mechanism is straightforward. A demand for an admission gives the person a choice. Confess to something with serious consequences, or leave. Leaving is the lower-cost option. What follows is re-presentation elsewhere, where none of the assembled information exists. The alternative is a non-punitive approach, which offers a psychological formulation without demanding an admission. It is sometimes described as an inexact, or face-saving, interpretation. It involves naming the distress and the difficulty in a way the person can accept without conceding anything, and offering support on that basis. It is described here at the level of principle only. Whether it works is not well established. What is better established is that the alternative does not.

Table 23.2.3

2 Responses Compared

This table compares the two responses. Read the final row first, because the evidential position is asymmetric. Confrontation asks for an admission of deception, with all its consequences. The non-punitive response asks for nothing. A formulation is offered, rather than a charge. The likely outcome of confrontation is denial, departure, and re-presentation elsewhere. With the non-punitive response, contact is kept, though engagement remains uncommon. Confrontation ends the relationship, usually for good. The non-punitive response keeps the possibility of a plan. Confrontation reduces no harm, since investigation simply resumes elsewhere. The non-punitive response lets unnecessary investigation be limited, which is a measurable gain. And so, one response has evidence against it. The other has an argument for it, with limited direct evidence.

Table 23.2.4 - Management Goals

Realism Is a Requirement, Not Pessimism

Realism about goals is a requirement here, not pessimism. Engagement in psychological treatment is uncommon, and a realistic goal is often harm reduction, rather than resolution. Limiting unnecessary investigation and intervention is achievable through service coordination alone, without the person's agreement. It is measured by the number and invasiveness of procedures over time. Coordinating care through one identified clinician is an administrative decision. It is measured by whether a named clinician holds the plan, and others route through them. A shared plan across services needs organization, rather than engagement. Does a written plan exist, and do services follow it? Co-occurring conditions are treatable in their own right, whatever else is unresolved. And psychological support can be offered even where it is declined, with the door left open. Notice the third column. Each goal can be judged from the record, without the person's agreement or disclosure. That is what makes these goals clinical, rather than aspirational.

In the Clinic

Limiting Iatrogenic Harm Is a Real Goal

These presentations carry real medical risk to the person. And a substantial part of that risk is generated by the healthcare system, rather than by the condition. Every unnecessary investigation carries its own hazard, and the build-up across services can be considerable. Reducing it is achievable and measurable. And it does not depend on the person agreeing to anything, or admitting to anything. A clinician who ends a year having prevented a series of unnecessary procedures has achieved something real, even where nothing about the underlying condition has changed. This is worth saying explicitly. Teams working with these presentations frequently conclude that nothing they do makes any difference.

Treatment, and Presentations Imposed on Another

Honest About Evidence - and About Who Is Owed Care

The approaches described in the literature are psychodynamic, cognitive-behavioral, and supportive models. They are named here only as model types. None has an adequate evidence base, and engagement is uncommon. That is the honest position, and it should not be dressed up. Medication is described by class only. It is directed at co-occurring conditions, not the presentation itself, and any prescribing decision rests with a prescriber. For presentations imposed on another, the safeguarding frame from section twenty-three point one governs, in full. Protecting the affected person is the immediate priority. Action goes through established safeguarding processes, not an individual clinician. And both failure to protect and wrongful accusation cause serious harm. One point is easily overlooked. The affected person has needs of their own. Where harm has occurred, they need their own assessment, and psychological support. Where a child is involved, the disruption of the family is itself a significant event for them, whatever caused it. Planning that addresses only the investigation has not addressed the person it was undertaken for.

The Effect on Staff

Supporting Staff Is Part of the Management

These presentations commonly produce anger, a sense of betrayal, and demoralization in staff. Those feelings are neither unprofessional nor avoidable. What matters is what happens to them next. Unacknowledged, they show up in the person's care. In curt notes, in inconsistent responses, in reluctance to assess a new complaint, and in decisions made in irritation. So supporting staff is part of managing the presentation, not something separate from it. A team that has nowhere to put its frustration will put it somewhere worse. Saying the feeling is legitimate is the starting point. A team told that its anger is unprofessional will stop reporting it, and carry on having it. What helps is naming it in supervision, separating the feeling from the decision, and returning to the shared plan, rather than whoever is on duty. And it helps to say two things the team most needs to hear. The person has a genuine condition and genuine distress. And limiting harm is an achievement, even when nothing else changes.

Service-Level Responses and Prognosis

Consistency Works; the Ad Hoc Fails

At service level, what works is consistency. A single agreed multidisciplinary plan, and a single point of contact. Agreed limits on investigation, with explicit criteria for revisiting them. And documented reasoning. What fails is the individual, ad hoc response. And it fails for a structural reason. Each clinician meets the presentation fresh, without the accumulated information. Each responds reasonably in isolation, to a situation that can only be managed collectively. On prognosis, the honest statement is that long-term outcome is poorly documented. The available reports are biased toward severe and detected cases. Anyone quoting an outcome figure in this area is quoting something the literature cannot support.

Table 23.2.5 - Chapter 23 Synthesis

Process, Not Paralysis

Here is chapter twenty-three in summary. Intentional production and external incentive are independent, so never infer one from the other. Factitious presentations involve genuine distress, so treat the person as having a condition, not as an adversary. Wrongful suspicion and failure to protect are both serious, so raise concerns through a process designed to test them. Identify through governance, not detection. Assemble information lawfully, review it as a team, and document reasoning. Manage toward harm reduction, and offer support without demanding an admission. And hold every claim in this area as provisional, including these. This is an area where the clinician's own conviction is the least reliable instrument available, and where the literature cannot settle the questions it is asked. The response is not paralysis, but process. Decisions made by teams, reasoning recorded rather than conclusions, differentials held open, and goals set at what can actually be achieved.

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FAQ

Questions students ask us

About Origins, Identification Methods, and Treatment Pathways

What causes factitious disorder?
The causes of factitious disorder are not established, and proposed factors rest on limited evidence. Suggestions include early experience of illness, adversity and disrupted attachment, familiarity with healthcare settings, the structure and recognition that the sick role supplies, and overlap with personality difficulties. Most of this comes from case series of detected cases, so these are proposals rather than findings, and no causal reading is supported.
Why does confronting someone with factitious disorder usually fail?
Direct confrontation usually fails because a demand for an admission leaves the person a choice between confessing to something with serious consequences or leaving, and leaving costs less. The person typically denies it, leaves the service, and presents elsewhere, where none of the gathered information exists. A non-punitive approach instead offers a psychological formulation and support without demanding an admission, though its effectiveness is not well established.
What are realistic treatment goals for factitious disorder?
Realistic goals usually center on harm reduction rather than cure, since engagement in psychological treatment is uncommon. Services can limit unnecessary investigations and procedures, coordinate care through one named clinician, keep a shared plan across services, treat co-occurring conditions, and leave the door open to psychological support. These goals can be measured from the record without the person agreeing or admitting anything, and reducing iatrogenic harm is a real achievement.
Why is research on factitious disorder considered unreliable?
Most research on factitious disorder comes from case reports, which select twice: first for cases that were detected, then for cases unusual enough to publish. Both filters push toward the elaborate and extreme, so the literature describes only one end of a distribution whose overall shape is unknown. Claims about prevalence, who is affected, long-term course or what works should therefore be treated as provisional.

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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