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Medscape J Med. 2009; 11(1): 27. Published online 2009 January 27. | PMCID: PMC2654694 |
The A, B, C's of Factitious Disorder: A Response to Turner James C. Hamilton, PhD, Associate Professor, Marc D. Feldman, MD, Clinical Professor, and Jeffrey W. Janata, PhD, Associate Professor The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is being prepared, but little attention has been accorded the category of factitious disorder, despite its presence in the manual for almost 30 years. Among relevant articles that have appeared, Turner's publication advocates retention of the category, but with new criteria. In the current paper, we reject Turner's reformulation but use the identified diagnostic dilemmas to illuminate the phenomenology of factitious disorder. We also offer a reconceptualization of the diagnosis that should better inform the preparations for DSM-V. As revisions to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) are being contemplated, numerous articles on the fate of the somatoform disorder (SD) category have been published. Although the SDs have appeared in the last 4 versions of the DSM [1– 4] and in the last 2 revisions of the International Classification of Diseases, their continued inclusion has been questioned on nosologic, empirical, and practical grounds. [5– 14] However, only one of these analyses has even mentioned factitious disorder (FD) [15] despite the phenotypic resemblance between SD and FD. Some analyses have specifically addressed the fate of the FD category, but they are far fewer in number. [15– 21] As a result, FD as it has historically been conceptualized continues to be a neglected and marginalized medical problem. (For reference, the Table presents the DSM-IV-TR [text revision] [4] criteria for FD.) | TableDSM-IV-TR Diagnostic Criteria for Factitious Disorder* |
Among the published analyses that have specifically addressed logical and nosologic problems with the current status of the FD category, Turner [21] has offered proposals for a revised criteria set to be included in the DSM-V. However, we believe that Turner's suggestions for revising the FD criteria focus on several features of the FD definition that are not widely considered problematic, while disregarding what we believe are some fundamentally flawed assumptions about FD and its relation to the SD category. Following the publication of Turner's paper, Kanaan [22] published a letter that questioned the usefulness of Turner's new proposals, to which Turner responded. In our view, both the original paper and the subsequent exchange of brief letters ignore more fundamental problems with the current conceptualization of FD and its relation to the SDs and malingering. In this article we thoroughly review and critique Turner's provocative analysis, and use it as a springboard for a more wide-ranging discussion of the status of FD in medicine and psychiatry, and of its place in the DSM-V. Before considering Turner's points it is helpful to briefly review the purpose of diagnostic systems and some basic principles of nosology. We use these basic premises to evaluate Turner's arguments and to guide our own analysis of the FD category. Evaluating Psychiatric Diagnoses It is generally agreed that the ultimate purpose of a medical or psychiatric diagnostic system is to provide a simple and effective means by which researchers and clinicians can communicate with one another about important health problems. Ideally, disorders and diseases that make up these systems would have a high degree of reliability across time and among observers. However, even when these reliability conditions are met, a diagnostic system has no value unless the conditions it defines have validity. In the case of psychiatric diagnoses, the evaluation of validity can take at least 2 forms. First, a given category can be regarded as valid if research confirms that it is characterized by epidemiologic or etiologic features that distinguish it from other disorders; this is a type of validity akin to construct validity as converging lines of evidence reveal that a diagnostic entity has distinguishing features (eg, predominance of female patients) and causal mechanisms (eg, high heritability or links to childhood abuse). Second, categories have practical value if the persons who are assigned to them are distinct in clinically meaningful ways from those who are not, for example in their response to treatment, their suicide risk, or their prospects for living independently; this type of validity is akin to predictive validity. It is worth mentioning a third way of evaluating a diagnostic category, although it is not technically an indicator of validity. This is the question of whether a diagnosis is actually used in clinical practice. A diagnosis that is proven to be reliable and valid would typically be welcomed by clinicians, whose use of it would help complete the cycle of understanding by allowing researchers to analyze clinical data generated on the assessment and treatment of people with that diagnosis. In some cases, however, a diagnosis will be eschewed when it creates practical problems, such as alienating patients, or when it does not qualify for reimbursement by healthcare insurance providers. [23] Another disconnect between validity and use arises when a distinguishing feature of a disorder, proven through rigorous research, cannot be used because there is no practical way to evaluate that feature clinically. This limitation is exemplified by Alzheimer's disease; we are sure that neurofibrillary tangles and amyloid plaques identify Alzheimer's disease, but they are of no practical use in diagnosing the disease because they can only be detected post mortem. [24]Category systems are ideally based on a single principle of classification. DSM-III through DSM-IV-TR, for example, were supposed to be based on observable clinical features, and not on the presumed etiology, of the disorders they define. In practice this ideal is seldom realized, and in the DSM there are disorders, such as SD, that are defined primarily by their presumed etiology. Another feature of categorical systems like the DSM is the assumption that the included disorders are discrete diseases that one either has or does not have. Many of the conditions included in the DSM seem to be more accurately described as dimensional rather than as discrete entities. [25– 28] In these instances the criterion of impairment or subjective discomfort is used to help draw the line between normal variation and psychological disorder. However, this approach raises a problem for behaviors that professional and nonprofessionals alike would agree reflect serious psychopathology, but are not viewed as problematic by the people who exhibit them. Anorexia nervosa, pedophilia, and many cases of alcohol and drug dependence are good examples. Evaluation of FD as Currently Defined Using the foregoing analysis we can consider 2 questions. First, how well does FD meet the empirical standards for a sound diagnostic entity in terms of its reliability, validity, and usability? Second, to what degree is the FD category consistent with the fundamental nosologic principles upon which the DSM is designed? With regard to the first question, there is almost no empirical evidence on the reliability, validity, or usability of the FD category. Reliability studies of FD would involve a demonstration of high interrater agreement on distinctions between FD patients and truly ill patients, but also between patients with FD and those with SD and between patients with FD and those who are malingering. Case reports also describe a small minority of patients whose abnormal illness behavior is chronic and unremitting, who effect dangerous manipulations of their own physical condition to simulate or create disease or injury, and whose medical deceptions are often accompanied by self-aggrandizing lies (pseudologia fantastica). They are predominantly male, lack stable relationships, and are typically unemployed. This latter group, to whom the label Munchausen syndrome is applied, constitutes roughly 10 percent of patients with FD, and these serious cases can probably be reliably identified. However, at the level of observable descriptive features, most patients with FD are indistinguishable from persons with somatization disorder, conversion disorder, pain disorder, undifferentiated somatoform disorder, and SD not otherwise specified. Like the typical patient with FD, the typical patient with SD is female, has anxiety and depression, and often has cluster B and C personality features. [29] Here again, at the level of informal clinical observation, patients with Munchausen syndrome appear to be distinct from those with SD, but the other 90% of patients with FD do not. As we mentioned above, the most serious cases of FD – those involving blatant self-harm – can probably be reliably identified. The question, then, is whether doing so has clinical utility. Most case reports and case series suggest that one of the most reliable clinical features of these extreme FD cases is that they are not amenable to psychological assessment or psychiatric intervention, and the patients are likely to flee when they are found out. Like disease markers that are available only on autopsy, this sort of information is not very satisfying to the clinician. By the time the FD diagnosis is made, the situation has become clinically unmanageable. Beyond the question of usefulness is the question of actual use. Even though it appears that the most severe cases of self-harm can be detected and diagnosed, there is some question about how often the diagnosis is made. In 2 papers currently under review, Hamilton and colleagues report that in both the Medicare database and a large state hospital database the prevalence of the diagnosis of FD – and SD as well – is hundreds of times lower than would be expected from smaller case series studies of prevalence. Professionals who write about FD seem to agree that there are powerful disincentives to assigning a FD diagnosis, such as the fears of angering patients or making a false accusation. FD also violates the specific nosologic principle of the DSM as well as general assumptions of all category systems. First, it is distinguished from malingering and SD not by observable characteristics, but by the presumed motives and intentions influencing abnormal illness behavior. Second, like many other diagnoses, factitious illness behavior appears to exist on a continuum of severity, and so forcing patients into or out of the FD category is logically problematic. Finally, patients with FD typically do not complain about their own deceptions, so self-identification is of no help in drawing the line between persons who should and should not be diagnosed with FD. In sum, FD, as it is currently conceptualized and defined in the DSM, fails to meet any of the criteria for a sound nosologic category. It lacks evidence of reliability or validity – either in the empirical sense or by measures of clinical usefulness – and it is assigned at rates many times lower than the most conservative estimates of its prevalence. Finally, its diagnostic criteria do not specify observable characteristics that set FD apart from phenotypically related disorders; the factitious illness behavior at the heart of the FD construct appears to represent a continuum of severity; and patients with FD cannot be counted on to define the point on the continuum at which factitious illness behavior becomes a psychological disorder. Turner's Critique of the FD Category in DSM-IV-TR We now review Turner's suggested revisions and consider whether they might solve some of the problems with the current FD category. Turner [21] believes there are 2 main problems with the FD criteria set. The first is that criterion A, which specifies the intentional feigning or production of signs and symptoms of illness, fails to capture the true nature of the pathology of FD – in Turner's view, that the patient's representations of illness are lies. He argues that this misplaced focus on symptoms has resulted in the neglect of other sorts of chronic lying and imposture that are not included in DSM-IV-TR as formal diagnoses, such as pseudologia fantastica, false confessions, and imposture. He also argues that the failure to emphasize the central role of falsification and imposture leaves the current criteria unable to distinguish the intentional self-harm caused by patients with FD from the intentional self-harm observed in patients who cut themselves or who engage in harmful stereotypies such as head banging. In the current system, the distinction between FD and disorders involving nondeceptive self-harm is achieved by criteria B and C, which together state that the primary motivation for the self-harmful behavior in FD is some type of internal reward associated with playing out the sick role. Turner regards this approach as logically flawed, and thus as unhelpful in distinguishing different varieties of self-harm. Turner's solution is to revise the FD criteria set by modifying criteria A and B, and dropping criterion C. With regard to criterion A, he argues that the current criteria, by emphasizing the intentional production of signs and symptoms of illness while referring only casually to the possible presence of other sorts of lies, obscure the essential fact that the symptoms of FD are lies. To remedy this, he proposes that criterion A be changed to “lying or deliberate autobiographical falsification” (his criterion AR). In addition to clearing up the confusion between symptoms and lies, criterion AR would bring under the umbrella of FD phenomena such as pseudologia fantastica, false confessions, and so on, which are not currently accounted for in the DSM. It would obviate the need for an arbitrary distinction between FD with physical signs and symptoms and FD with psychological signs and symptoms. Finally, by focusing on the lies and autobiographical falsifications of FD, a clear line could be drawn between FD and other disorders in which nondeceptive self-injury occurs. The revision of criterion B is based on a very challenging argument that deserves careful inspection. The argument boils down to the meaning of the terms intention (which figures into the current criterion A) and incentives (which figure into the current criterion C). Turner first invokes a philosophical argument that behavior can be regarded as intentional only if we can imagine reasons for ourselves engaging in a similar act. In this view, the intentionality of FD hinges on whether factitious illness behavior makes sense. To this Turner adds another proposition: behavior that leads to self-harm makes no sense. The logical conclusion is that factitious illness behavior, which leads to self-harm (either directly or indirectly), which, by definition, makes no sense, cannot be intentional. The same reasoning is applied to challenge criterion C. Here, Turner argues that the current criteria B and C combine to suggest that, in the absence of obvious external incentives, FD is assumed to be motivated by internal incentives related to the sick role. On the basis of his belief that factitious illness behavior always constitutes self-harm, he asserts that the DSM criteria amount to a sleight of hand in which an obvious disincentive (self-harm) is transformed into an internal incentive. Thus, Turner arrives at the conclusion that criterion C adds nothing to the criterion set and drops it. Criterion B is revised to reflect what, in Turner's view, is a less inferential, more verifiable, interpretation of sick role behavior: the behavior leads (or is likely to lead) to self-harm. To summarize, Turner advocates for a revised criterion set that defines FD as behavior that meets his 2 new criteria: Criterion AR: Deliberate lies or autobiographical falsification Criterion BR: The behavior leads, or is likely to lead, to self-harm. He argues that these criteria successfully classify people who are currently classified as having FD. In addition, he argues that his revised criteria correctly extend the FD category to other forms of self-harmful lies and imposture, such as pseudologia fantastica and false confessions, and at the same time narrow the scope of the disorder to correctly exclude nondeceptive self-injury. And, notably, he argues that his criteria preserve the distinction among FD, SD, and malingering. A Critique of Turner's Reformulation Lies and Imposture Turner makes a good point that the essence of FD is lies about physical and psychological symptoms: the lies are indeed the symptoms. However, we disagree with his implication that the distinction between lying about being ill and lying about other things is specious. There are both psychological and practical reasons to justify a special distinction for lies about being physically or psychologically ill. As Turner points out, it is not easy to understand why people would lie to occupy a role that most people wish to avoid. Unlike lying about credentials to get a good job, on the face of it the sick role appears to be a punishing experience, not a rewarding one. There are exceptions to this rule. Lying about a back injury so that one never has to return to a hot, noisy assembly line job is easy to understand. Lying about a back injury to qualify for multiple back surgeries is not, and so it is not unreasonable to assume that lies of this sort reflect the operation of psychological processes that require extra scientific explanation and clinical attention. On the other hand, we would concede that there are other sorts of lies and imposture that lead to consequences that are generally regarded as undesirable, and that these phenomena might share important psychological features with FD. In false rape accusations, for example, the accuser is subjected to a public airing of personal information that most people would experience as mortifying. However, that does not necessarily invalidate clinical distinctions between FD and these other phenomena. The various anxiety disorders and depression seem to share high levels of trait neuroticism. Nevertheless, there remain valid reasons for regarding the specific anxiety disorders and mood disorders as discrete diagnoses. Similarly, although FD and other false claims of victimization might share underlying processes, there may be other reasons, both scientific and practical, for distinguishing FD. Lies about physical or mental illness, injury, or disability violate a unique and important social contract by which everyone is expected to abide. The sick role provides important privileges and dispensations, and it authorizes access to the resources of the healthcare system. However, we are not supposed to use the sick role gratuitously, and we are obliged to relinquish the sick role as quickly as possible. Although all chronic liars might share similar underlying psychological processes (eg, high levels of sensation seeking or low trait conscientiousness), lies about being ill are situated in this unique psychosocial context that justifies giving them special attention. Doing so is analogous to comparing the way society treats the impersonation of a police officer to the way it treats the impersonation of a gardener. The former is classified as a serious criminal offense because of the important social contract that surrounds the role of the police officer, whose legitimate power is granted in exchange for the protection of society. Perhaps the most crucial reason for regarding lies about the sick role as being of special importance to the medical and mental health communities is that they compromise the effective treatment of authentically ill patients. Were it not for the existence of malingerers and patients with FD, all medical complaints could be regarded as product of a patient's sincere desire to return to good health. Thus, the ability to identify factitious illness behavior, and ultimately to prevent it, has a unique value in the healthcare context. The analogy of impersonating a police officer continues to be useful. In addition to allowing the impostor to usurp powers to which the impostor is not entitled, impersonating a police office is detrimental because it undermines the ability of citizens to trust others who present themselves as police officers. FD undermines the ability of doctors to trust patients who present with unusual or perplexing signs and symptoms. Finally, although there is no shortage of case reports describing a wide variety of patients with FD, we are not aware of any that describe the co-occurrence of FD with other elaborate impersonations. That is, we know of no cases in which a patient with FD previously or subsequently impersonated a police officer, for example, or a doctor. If all forms of imposture were so closely related that they should share the FD category, one would expect these sorts of co-occurrences. There is ample evidence that persons with FD, particularly the extreme Munchausen variant, tell elaborate and self-aggrandizing lies about things unrelated to their alleged health problems. However, these lies almost always appear to be designed to enhance the patient's sick role experience. In short, defining FD within the specific boundaries of illness falsification is justified on 3 grounds. First, these impersonations uniquely involve the abuse of the sick role. They reflect a willingness to participate in a role that entails the sorts of pain, discomforts, inconvenience, and indignities that most people strive to avoid. They also show a willingness to take unfair advantage of family, friends, and medical personnel who are obliged by their part in the social contract to accept a patient's claims of illness. Second, the falsification uniquely affects the healthcare system whereas other forms of imposture do not. And third, there is no empirical or clinical evidence of a close family resemblance between FD and other types of imposture. Self-Harm We are troubled by Turner's interpretation of factitious illness behavior as self-harm and his use of self-harm as a criterion for FD. We suspect that this maneuver will exclude prototypic cases, which, under the current definition of FD, would certainly be regarded as FD. These include cases in which an illness, such as AIDS or cancer, is feigned through lies and manipulations of the patient's appearance, and in which no medical or surgical interventions imperil the physical health of the patient. More generally, the self-harm criterion would tend to exclude persons whose illegitimate sick role behavior is enacted primarily outside of the medical setting, such as at work or at home. Turner does allow for indirect self-harm to satisfy his criterion BR. However, just as a strict self-harm criterion would exclude prototypic cases of FD, the looser criterion of indirect self-harm would include such a vast array of nonprototypic cases so as to render the diagnosis practically useless. Sixteen-year-olds who lie about their age to secure and abuse alcoholic beverages would meet the dual criteria of imposture and self-harm. So would a middle-aged man who loses his retirement savings at a gambling casino trying to convince a pretty woman that he is wealthy, as would a job applicant who pads her resume to attain a job at which she is destined to fail because she is not properly trained. Even cases in which the patient does expose himself or herself to medical risks, calling this self-harm reflects a medical parochialism that is a bit out of step with modern biopsychosocial perspectives on health and illness, and which Turner expressly wishes to avoid (page 23 of his article). By Turner's definition, almost every elective medical procedure, from rhinoplasty to bariatric surgery to orthodontic manipulation, could be regarded as self-harm. They are not considered as such because we accept that the patient has decided, through a complex equation that includes psychological and social terms, as well as medical ones, that the pain and dysfunction are worth the benefits of looking prettier, or being thinner, or having a nice smile. There is no less reason to take psychological and social considerations into account when evaluating the reasonableness of factitious illness behavior. Although Turner seems to find it hard to make sense out of factitious illness behavior, almost anyone who has experienced even a moderately serious illness or injury has experienced the psychosocial benefits of the sick role first hand. These benefits include tangible displays of friendship and love that may not be offered under the more routine conditions of life; respite from the demands and expectations of work and family life; and, at very least, a little drama and excitement. For someone who is genuinely ill these benefits are rarely adequate compensation for the pain, fear, and disability associated with illness or injury. But in the case of a patient who is not really ill, and for whom the psychological rewards of day-to-day life are few, the sick role may yield psychosocial benefits that exceed the physical costs. Even if one were to accept Turner's requirement for determining intentionality (ie, one can imagine why one might engage in the act), it is not at all difficult to imagine why someone would engage in factitious illness behavior. Thus, the problems of intentionality and incentive need not, and cannot, be dismissed by labeling factitious illness behavior as senseless self-harm. We must be clear, however, that the ability to grasp the reasons for engaging in factitious illness behavior is not incompatible with the view that chronic factitious illness behavior may reflect a psychological disorder. We can similarly imagine why a person with obsessive-compulsive disorder engages in relentless cleaning rituals and at the same time regard the behavior as a form of psychopathology. Our response to Turner's concern with the distinction between internal and external incentives is closely tied to our defense of the intentionality of factitious illness behavior. The possible reasons for factitious illness behavior, to elicit expressions of kindness and forbearance, not only support the intentionality of factitious illness behavior, they constitute the likely psychological incentives for it. We agree with Turner that the presence of internal incentives must be verified in some way other than the apparent absence of external rewards. Clinically, this can often be achieved by comparing the effects of medical validation on malingerers vs patients with FD. For malingerers, the sick role is a means to an end, and once their alleged illnesses have been authenticated with a doctor's report, they avoid further medical contacts that might jeopardize their scheme. For patients with FD, on the other hand, the rewards of the sick role are somehow inherent in the role itself, and medical validation will either increase sick role behaviors or leave them unchanged. These different patterns of response suggest that the prototypic case of FD reflects a different set of motives and psychological processes than the prototypic case of malingering. It is noteworthy that Turner includes in the category of indirect self-harm various psychosocial costs. It is logically inconsistent to disallow the notion of psychosocial benefits (incentives). Differentiating FD From SD and Malingering The crucial test of any definition of FD is the way it construes the relation between FD phenomena on the one hand and SD and malingering on the other. We agree with Turner that the current DSM criteria seem to be biased against the diagnosis of FD in favor of SD and malingering. However, we disagree about how to correct this bias. With regard to malingering, we agree that the sick role often leads to tangible rewards, and that the mere presence of these rewards does not prove that the patient's sick role behavior is controlled by them. However, Turner's solution, which is to evaluate the magnitude of the self-harm suffered against the degree of external rewards, is problematic. First, it exacerbates the current bias toward diagnosing FD only in cases involving gross physical self-harm. Direct self-harm is easier to appraise and more compelling than psychosocial indirect self-harm. In addition, large and conspicuous external incentives exist in only a small number of cases, whereas small to moderate rewards (eg, a fruit basket or 2 days of paid sick leave) occur in almost every case. The combined effect of these 2 trends will inevitably be a greater bias toward diagnosing malingering in mild self-harm cases than in severe ones, and consequently a biased view of FD as restricted to cases involving severe and direct self-harm. A second, more fundamental, problem with Turner's approach is that malingering and FD are differentiated on only a single criterion, reasonableness, which is dimensional, and which requires the clinician to impose his or her own standards of reasonableness on the patient to decide whether an act could qualify as reasonable (eg, “I suppose I'd give my left arm for a million dollars”). But there is a large inferential gap between the conclusion that an external reward could render a certain degree of self-harm reasonable, and the conclusion that the reward actually figured into the patient's calculations. This gap means that prototypic malingerers who accidentally overdo a self-injury would be misdiagnosed with FD, and prototypic FD patients who win an unexpectedly large personal injury settlement would be misdiagnosed as malingerers. Turner's approach to differentiating FD and SD relies on a peculiar twist on how FD and SD have traditionally been understood. He asserts that “there must be some limit to the amount of physical, psychological, and social harm that a [SD] patient will subject himself [sic] to if he [sic] has a genuine hysterical disorder” (page 28). The implication is that patients with SD know that they are not really ill and so there is a limit to how far they will push their sick role enactments. And by further implication, patients with FD, who Turner believes are acting without reason, cannot modulate the degree of harm to which they subject themselves. This is exactly the opposite of how clinicians usually think about FD and SD. To the extent that we accept that the patients with SD believe they are genuinely ill, we must conclude that they will put themselves through whatever physical, psychological, or social harm that a genuinely ill patient would endure to get well. It is patients with FD, who, presumably, are aware that they are not really ill, who should be able control their deceptions to avoid excessive self-harm. In the end, Turner acknowledges that his revised criteria shift the distinction between FD and SD from the matter of intention to the matter of truthfulness. The clinician must determine whether the patient is trying to deceive others by offering misinformation, creating the appearance of medical signs, or making themselves sick. Like the proof of intention, which amounts to detective work rather than psychological assessment, tests of truthfulness will similarly rely on eyewitnesses or physical evidence of medical deception. Similarly, this approach will perpetuate the bias toward diagnosing FD in only the severe cases. In other words, nothing would change. Finally, Turner's approach implicitly supports the idea that cases of medical deception can be categorically classified as malingered, factitious, or unconsciously produced. No evidence supports this idea, and it might seriously impede efforts to arrive at a comprehensive understanding of cases of unexplained medical complaints. Failure to change the current DSM approach to FD will perpetuate the scientific and clinical neglect of FD, and inhibit research into the motivational factors that affect other types of unexplained medical problems. 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