Facticious Disorder vs. Malingering
A challenge to many physicians, as they are trained to trust patient self-reports, are patients who exaggerate, feign, or induce physical symptoms. Even the most competent physicians may fall prey to these patients, providing official diagnoses and appropriate treatments that enable the factitious patient to become a person with an authentic problem, although it was actually caused by the diagnosis. Oftentimes, persons with factitious disorder or malingering are involved in civil and criminal litigation, as patients may pursue civil damages from their physician for unnecessary treatments. Therefore, a forensic psychiatrist may be called upon to help determine the underlying psychological problems that initially led to the deception.1 The forensic psychiatrist faces two obstacles: first, there is little research regarding factitious disorder and its underlying psychological problems, and second, the DSM-IV-TR lacks a clear-cut classification system for patients who have inauthentic illnesses.1
Legal proceeding decisions often come down to the question of whether or not the person was conscious of their factitiousness or whether it was intentional.1 For example, was the patient aware of what they were doing? Did they intend to do it? Was the motive reasonable? The DSM-IV-TR somatoform disorders category contains five specific disorders for which inauthentic illness behavior is neither conscious or intentional.1 The disorders are as follows: hypochondriasis, conversion disorder, pain disorder, and undifferentiated somatoform disorder.1 The DSM specifies another category, factitious disorder, in which inauthentic illness is consistently and intentionally produced.1 Persons with factitious disorder have motives that reflect sever psychopathology. The DSM also recognizes malingering, which is the inauthentic medical behavior that is conscious, intentional, and reflects upon comprehensible motives, such as faking a fall in a store to obtain medical and emotional compensation for damages.1
The DSM states that psychiatrists should diagnose cases of inauthentic illness behavior as follows:
- When there is the absence of evidence that there has been intentional medical deception, diagnose a somatoform disorder.1
- If there is evidence of intentional medical deception, diagnose malingering or factitious disorder.1
- If there is to be any material benefit from the deception (ex. monetary), diagnose malingering.1
However, these directives are insufficient and oversimplified, as the criteria makes it impossible to diagnose a case as anything other than a somatoform disorder when intentionality cannot be proved.1 There are currently no available psychiatric tests of consciousness; therefore, in disorders where fictitious and conscious complaints such as pain, fatigue, and weakness dominate, it is impossible to diagnose factitious disorder or malingering.1 In fact, few patients with factitious disorder have signs of a thought disorder, disorganized behavior, or psychotic symptoms.1 Therefore, it makes it difficult for forensic experts to state that a sane-looking person personally caused themselves pain.1
Physicians confronted with a patient with factitious disorder may find it difficult to fathom that they induce symptoms without the principal of external gain.1 In fact, playing the role of a sick person allows the person to feel interpersonal benefits.1 Patients with factitious disorder may also have comorbid pseudologia fantastica, which is the telling of tales that are a mixture of fact and fiction. Usually these patients tell flowery stories; however, when questioned further, are very vague in their answers, as well as inconsistent.1 Also, factitious disorder and malingering can also co-occur.1 For example, a patient may begin with factitious disorder and see it necessary to malinger as others often question why they are not pursuing legal remedies for their medical malpractice, which truly resulted from their own self harm. Legally, discovering either disorder may have implications of the patients legal and medical future, and the individual may be prosecuted for false disability claims and inappropriate use of health care.
Overall, the difference between factitious disorder and malingering is the question of motivation.1 Whether the patient is seeking to take the sick role and receive interpersonal benefits or looking for external benefits makes a big difference.1 Evaluations of these patients are challenging, and remains a difficult situation for most physicians.1
 Worley, C.B.; Feldman, M.D.; Hamilton, J.C. (2009, Oct. 30). The Case of Factitious Disorder Versus Malingering. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/print/article/10168/1482349.
 Feldman MD. Factitious disorders and fraud. Psychosomatics. 1995;36:509-510.
 Lipsitt DR. The factitious patient who sues. Am J Psychiatry. 1986;143:1482.
 Feldman MD. Prophylactic bilateral radical mastectomy resulting from factitious disorder. Psychosomatics. 2001;42:519-521.
 Feldman MD. Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York: Brunner-Routledge; 2004.
 Hamilton JC, Feldman MD. Munchausen Syndrome. eMedicine from WebMD. Updated September 16, 2009. http://emedicine.medscape.com/article/295127-overview.
 Ford CV. Ethical and legal issues in factitious disorders: an overview. In: Feldman MD, Eisendrath SJ, eds. The Spectrum of Factitious Disorders. Washington, DC: American Psychiatric Press; 1996.