Psychosomatics 49:277-282, July-August
doi: 10.1176/appi.psy.49.4.277
© 2008 Academy of Psychosomatic Medicine
Looking Toward DSM–V: Should Factitious Disorder Become a Subtype of Somatoform Disorder?
Lois E. Krahn, M.D.,
J. Michael Bostwick, M.D., and
Cynthia M. Stonnington, M.D.
Received June 25, 2007; revised December 31, 2007; accepted January 11, 2008. From The Dept. of Psychiatry and Psychology, Mayo Clinic, Scottsdale, AZ (LEK, CMS) and Rochester, MN (JMB). Send correspondence and reprint requests to Lois E. Krahn, M.D., Division of Psychiatry, 13400 East Shea Blvd., Scottsdale, AZ 85259. e-mail: krahn.lois{at}mayo.edu
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: Factitious and somatoform-disorder patients are alike in that they both organize their lives around seeking medical services in spite of having primarily a psychiatric condition. In DSM–IV, the key difference is that factitious-disorder patients feign illness, and somatoform-disorder patients actually believe they are ill. Although patients may not be conscious of their motivation or even their behaviors, deliberately embellishing history or inducing symptoms exemplifies behaviors designed to enhance a self-concept of being ill. CONCLUSION: For DSM–V, we propose reclassifying factitious disorder as a subtype within the somatoform-spectrum disorders or the proposed physical-symptom disorder, premised on our belief that deliberate deceptions serve primarily to portray to treaters the sense of being ill.
Key Words: Factitious Disorder • Somatoform Disorder • DSM–V
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INTRODUCTION
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By placing factitious disorder with physical symptoms in a separate category, DSM–IV asserts that it is truly distinct from other psychiatric disorders. This diagnostic partitioning is problematic because it implies that factitious disorder with physical symptoms has a distinct etiology, symptoms, and treatment. The current criteria specify that patients must intentionally produce an appearance of illness and have no apparent motivation for their deception other than a desire to receive medical care. Thus, DSM–IV separates factitious disorder from somatoform disorders by emphasizing that factitious patients "fake" their symptoms, even as they, in most other respects, resemble somatoform-disorder patients. Both patient types express emotional distress in somatic or physical terms, and the physical symptoms of factitious disorder are frequently comorbid with psychological symptoms.1 Both disorders feature medically unexplained physical symptoms, and it is widely agreed that both are organized around trying to meet emotional needs in maladaptive ways. Psychiatric comorbidity commonly occurs with both. Kroenke has recently proposed a new DSM–V category of physical symptom disorder that could potentially encompass both groups of patients.2
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Somatization Versus Deception: The Challenges of Assessing Beliefs and Motivation
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Factitious patients present themselves as being sick and needing care. The fact that they are manufacturing their ill appearance has supported the mainstream contention that they are not actually somatizing, but are frankly lying. However, the line between lying and embellishment or deliberate enhancement to make physically manifest what is emotionally experienced is not easy to draw.
Deception is hardly unique to factitious disorder. For example, reported base rates of "symptom exaggeration" are 39% in mild head injury, 35% in fibromyalgia and chronic fatigue syndrome, 31% in chronic pain, 15% in depressive disorders, and 11% in dissociative disorders.3 Moreover, the motivation for deception is virtually impossible for the clinician to determine accurately.4 Indeed, the task of determining whether the actions the patient takes in feigning illness are intentional, voluntary, conscious, or unconscious, is problematic in that these behaviors represent an "untestable diagnostic hypothesis for many cases."5 Finally, some authors have found the current DSM–IV diagnostic category for factitious disorder conceptually flawed because of its emphasis on deception, rather than on underlying psychopathology. Thus, given the vagaries of the factitious-disorder diagnosis construct and its similarities with somatoform disorders, which can be challenging to demonstrate objectively, we propose the creation of a factitious-disorder subtype within the somatization-spectrum disorders.
Factitious disorders are traditionally viewed as distinct from both somatoform disorders and malingering (Table 1). Patients with somatoform disorders have medically unexplained symptoms into which they are said to lack insight because they reject medical opinions that their complaints are without an organic basis. Even as they complain insistently of their pain, they do not consciously induce symptoms or exacerbate signs.6
Malingering patients, on the other hand, feign medical illness and manipulate the medical setting in order to pursue specific conscious goals. They do not view themselves as ill and do not seek the sick role for its own sake, but, rather, "act sick" only to achieve obvious manifest personal benefit. Although these distinctions appear relatively straightforward, they are frequently not clear-cut. Establishing the factitious-disorder diagnosis with a high degree of diagnostic certainty remains one of the more challenging tasks within psychiatry.
Data from patients’ interviews are bolstered as much as possible by testimony from collateral sources, including family members or friends and involved medical and surgical services, laboratory tests, and outside records. Medical explanations for the signs and symptoms must be excluded. When the patient’s medical presentation is atypical, with suspicious inconsistencies, the primary-care physician or team may question whether the patient has a psychiatric condition. A psychiatric consultation is requested to probe the patient’s emotional functioning and offer insight into psychological difficulties, illness-behavior, and motivation. Efforts are made to detect lying or exaggeration. Highly subjective, the diagnosis hinges on the psychiatrist’s impression of the patient’s beliefs and behaviors; although experienced psychiatrists can develop proficiency in assessing these areas of functioning, the reality is that few do. Most psychiatrists see few of these patients and are thus insufficiently informed to make and document a factitious-disorder diagnosis.1,7
Turner has called for creating a specific DSM–V category for patients with "lying or deliberate autobiographical falsification."8 Such a category would combine malingering and factitious disorders, as well as the phenomenon of pseudologia fantastica. Turner does not, however, define pseudologia fantastica or pathological lying in terms usable by either clinicians or researchers. In previous research, we have found it difficult to define the boundaries between misapprehending, distorting, and lying, let alone standardizing the definition of a lie.1 Medical teams often lack collateral data to determine whether a patient is misrepresenting facts.
Another conundrum also emerges: who defines a lie as a lie? A patient’s subjective, narrative truth may bear little resemblance to the "objective" medical truth perceived by her physicians. Furthermore, even "honest" patients are known to have difficulty accurately and consistently repeating their medical histories because of time, state, or personality factors.9 Physicians themselves are not immune from inadvertently putting distortions into the medical record. Certainly, when patients report apparent false memories or exaggerations of past traumas, it is often difficult to ascertain whether they are doing so deliberately or mistakenly, whether because of unconscious processes or the natural evolution of the story as it is told and retold to different examiners. In sum, patients and physicians may have different conceptions of what constitutes truth. The thinking that doctors are right and their patients are wrong does not, in our opinion, prove to be a workable definition of a lie.
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Obtaining Evidence of Deliberate Self-Harm
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Turner has suggested that factitious-disorder criteria be structured around deliberate self-harm, since patients with this disorder are automatically at risk of self-harm.8 In the most severe cases, patients have intentionally committed such life-threatening acts as massive self-phlebotomy or incurred potentially overwhelming infections. But how is this different from somatoform patients who, in unconscious collusion with their physicians, readily submit to extensive and potentially life-threatening procedures such as unnecessary surgery, in which potential harm would be iatrogenic? We know of patients who, having consented to multiple abdominal procedures, eventually required even more surgery for the iatrogenic complications of those procedures. Even so, for most of these patients—just as for the factitious-disorder patients—only the potential for, not the reality of, serious self-injury exists. This is especially true for patients who fabricate a misleading medical history.
On the other hand, the challenges of developing a clinically useful definition of "deliberate self-harm" is elusive, given the vagaries of measuring intent. Such a factitious category would have to take into account patients as diverse as those whose illness beliefs, voluntary behaviors, desire for engagement with medical providers, or clear secondary gain are perceived as manipulation.
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Establishing the Diagnosis of Factitious Disorder
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The fact that DSM–IV is organized around the criterion of feigning symptoms to achieve the sick role may reflect the realistic difficulty in establishing the psychological underpinnings of factitious disorder. No structured or semistructured interviews exist to identify the roles that psychological processes are hypothesized to play. Standardized objective tests such as the Minnesota Multiphasic Personality Inventory (MMPI) are cumbersome and seldom used in clinical settings to augment the psychiatric interview.
Psychological testing may be difficult to obtain because of limited time or absent reimbursement. More importantly, patients resist attempts to explore their presentation in psychological terms and fail to cooperate with testing. In any scenario in which the disorder’s key features are identified by clinical interview alone, however, the reliability and validity of the diagnostic process varies and depends on the examiner’s skills. Diagnosing factitious disorder is further complicated because this disorder—despite its notoriety—is rare enough that a typical psychiatrist seldom encounters such a patient and thus has little opportunity to develop specific interview techniques.10 We assert that current scientific understanding of the disorder remains descriptive, rather than etiologic.
As with somatoform disorders, establishing an accurate diagnosis of factitious disorder is compounded by specific patient factors. This subset of patients classically resists psychological explanations. The attention and care they desire from medical teams, a key tenet of the condition, does not include psychiatric care, particularly when psychiatrists engage with patients more as detectives than caregivers. Lacking insight into their desperate search for the patient role, they are typically unable to identify relevant emotional issues. If no source of information exists other than a resistant, even hostile, patient, conducting a truly comprehensive biopsychosocial evaluation is impossible. Even so, the diagnosis requires the examiner to assess illness beliefs, emotional issues, degree of insight, and the patient’s desire to assume the sick role.
Once factitious-disorder patients have denied the role—or even the presence—of emotional factors in their presentations, psychiatrists are often asked by the referring physicians to continue the investigation into the simulation or production of physical symptoms. Confronted patients seldom acknowledge any role in creating the impression of illness.1 Psychiatrists and primary services thus take a forensic stance, trying to catch a patient "in the act." A wide range of factitious behaviors are recognized, ranging from simulating illness by falsifying history to manipulating the body to create signs of disease.11 The only limiting factor is the patient’s cleverness and creativity. Presumably, much factitious activity goes undetected in patients—accepted as "real" and deserving of care. In the case of an exaggerated history, for example, a patient who feigns cancer, little proof exists of the fabrications other than inconsistent or implausible assertions, unless family members come forward with conflicting testimony or data from contradictory medical records are available. Even with factitious symptom production, clinicians must remain humble. Even when a series of laboratory tests, imaging studies, and biopsies are negative, disease can seldom be definitively excluded.
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Factitious Disorder Versus Somatoform Disorder
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Fabrications aside, a key question is whether patients actually view themselves to be ill. Clearly, malingerers do not view themselves as ill, even as they are motivated to appear ill for secondary gain. Indeed, unlike factitious disorder, the general consensus among physicians and psychiatrists is that malingerers are not psychiatrically ill, but instead display "a single-minded interest in an obvious goal,"12 even if achieving that goal requires deliberate self-injury. Somatoform patients see themselves as medically ill, but often resist interpretations that their physical symptoms are psychologically-based. As previously outlined, both somatoform and factitious-disorder patients also have difficulty acknowledging painful feelings or being fully emotionally aware and thus may not see themselves as mentally ill.
If—like somatoform patients—factitious-disorder patients do see themselves as fundamentally ill, they may embellish a story of fabricate illness-signs to get care they truly believe they need. In the process of collecting our large case series, a difficult task was to discriminate between factitious and somatoform disorders, as opposed to bona fide medical disorders.1 Presenting with a variety of actual illnesses to a tertiary-care medical center, many of these patients were labeled with exaggerated symptoms out of proportion to what would have been expected with their known medical condition.
Like somatoform-disorder patients, they had high incidences of chronic pain, unusual spells, muscle weakness, fatigue, and gastrointestinal complaints. A large number of patients were excluded from the case series because data were lacking that they were "caught" deliberately acting to create the impression of illness. For those who met the eligibility criteria (some form or proof that they were inducing or perpetuating medical signs), the majority of the patients acted-out only intermittently or transiently with behaviors simulating a medical condition. Had these patients been examined at a different point, most would have been indistinguishable from somatoform-disorder patients. This observation underpins our assertion that factitious disorder is a subcategory of somatoform disorder. In some fashion, patients view themselves to be ill and intermittently act-out so as to prove this point and receive the medical care they desire.
Lipowski identified a feature common to all somatoform patients:13 their somatic symptoms are a manifestation of emotional distress. Subric-Wrana and colleagues14 suggest that this somatic presentation of emotional distress may arise from an endophenotype with deficient mental representations of emotional distress. With somatizing patients less able to describe emotional experiences or attribute emotional significance than non-somatizing patients, a deficit in emotional awareness and processing of emotions is likely a central etiological component of somatoform disorder.14 Mental experiences are often communicated in ways other than through a verbal expression of one’s subjective experience.15 Numerous examples exist of mental experiences communicated in ways other than through a verbal expression of subjective experience.15 Although the studies remain to be done, we believe it is likely that factitious and somatoform disorder share this deficit in emotional awareness and emotional processing.
Barsky has proposed several criteria central to somatoform disorder. These features include somatic symptoms, difficulty coping with these symptoms, disease conviction, "illness as a way of life," maladaptive use of medical care, and refractoriness to palliative and symptomatic treatment.16 Of these proposed criteria, all except "disease conviction" would fit what we presently know about the physical symptoms of factitious-disorder patients with physical symptoms. Whether they are convinced they are ill is key. Certainly many medical providers are convinced that they are not, and the physician’s perspective often carries the day.
Factitious-disorder patients present to medical providers seeking engagement. At some point, they have embellished or induced their symptoms. Do they engage in these behaviors while they believe themselves healthy? Alternately, do they perceive themselves as ill and engage in behaviors that reflect their beliefs to highlight their needs and get the medical attention they crave? Suspecting that behaviors are deliberately produced does not exclude the possibility that the patient feels unwell. Do behaviors, which, in some cases, are transient in an episode of illness, merit an entirely different diagnostic category, with the implication that these conditions differ markedly in terms of etiology, prognosis, and treatment? Furthermore, in the case of both somatoform and factitious disorder, the patient may in fact have verifiable illness of an organ system and still meet Barsky’s criteria.
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Proposed Reclassification: Factitious Behavior as a Subcategory of Somatoform Disorder
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The evidence-base for our arguments is admittedly very limited. Despite thousands of reports describing the case histories of patients with factitious disorders, barriers exist to more in-depth studies of biological mechanisms, epidemiology or treatment response. Until they are exposed, factitious patients are elusive to the point of fading into the "legitimate" background of daily medical business, with most not admitting their illness-inducing activities, even when confronted with irrefutable evidence. It is exceedingly unlikely that they would consent to being studied for a syndrome they deny having. Perhaps the imperfections of the current DSM–IV classification system for factitious disorder are partly responsible for this absence of research. For reasons that are unclear, no published study compares factitious-disorder patients with other categories of patients whose disorders include medically unexplained symptoms.
In the absence of empirical data, we challenge DSM–IV on epistemological grounds. The categorical system of the DSM requires three standards: 1) mutually exclusive categories; 2) clear boundaries between them; and 3) largely homogenous cases within a category. None of these three standards are satisfied by factious disorder. Factitious disorder is heterogeneous, with overlap and indistinct boundaries between the somatoform disorders and malingering. The variability of beliefs and behaviors of patients with factitious disorder with physical symptoms or psychological features is striking, despite the common feature of desire for medical engagement.
Rather than giving factitious disorder a separate diagnostic category in DSM–V, psychiatrists, nonpsychiatric physicians, and patients alike will be better served by addressing its overlap with somatoform disorder. "Factitious disorder with physical symptoms" could naturally be grouped with other psychiatric conditions, with physical symptoms in its own subcategory of "factitious behavior disorder" (Table 2). This would place it in the company of undifferentiated somatoform disorder and chronic pain, among others. Ideally, this reorganization would facilitate study of the similarities and differences among these conditions; for example: "Factitious disorder with psychological symptoms," that are inherently subjective (factitious disorder with physical symptoms that are described without actually manufacturing physical signs). Both of these factitious-disorder variants, plus somatoform and chronic-pain disorder, would be linked under the rubric of conditions with a central feature of seeking medical engagement. Factitious disorder by proxy, inherently different because one individual induces the physical symptoms in another, is beyond the scope of this discussion.
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CONCLUSIONS
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Advancing the theory that factitious disorder is a somatoform disorder subcategory would enhance the utility of DSM–V calls for research data. The descriptive data we have mustered here support better definition of how these two broad illness categories relate to one another. Carefully diagnosed patients with a factitious component would be compared with somatoform-disorder patients without this element. Unfortunately, a sample of reasonable size would be predictably hard to recruit and retain until study measures or interventions were complete. Multiple centers would need to collaborate to amass a large enough database that might include MMPI profiles for both, including Conversion and Denial scales. Actual data would guide the decision about whether to continue to segregate factitious disorder, a misunderstood and maligned condition, into its own DSM–V category or to reclassify it as a somatoform-disorder variant.
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REFERENCES
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- Krahn LE, Li H, O’Connor MK: Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry 2003; 160:1163–118[Abstract/Free Full Text]
- Kroenke K: Physical symptom disorder: a simpler diagnostic category for somatization-spectrum conditions. J Psychosom Res 2006; 60:335–339[CrossRef][Medline]
- Mittenberg W, Patton C, Canyock EM, et al: Base rates of malingering and symptom exaggeration. J Clin Exp Neuropsychol 2002; 24:1094–1102[Medline]
- Bass C, Halligan PW: Illness-related deception: social or psychiatric problem? J Royal Soc Med 2007; 100:81–84[Abstract/Free Full Text]
- Delis DC, Wetter SR: Cogniform disorder and cogniform condition: proposed diagnoses for excessive cognitive symptoms. Arch Clin Neuropsychol 2007; 22:589–604
- Starcevic V: Somatoform disorders and DSM-V: conceptual and political issues in the debate. Psychosomatics 2006; 47:277–281[Abstract/Free Full Text]
- Fliege H, Grimm A, Eckhardt-Henn A, et al: Frequency of ICD-10 factitious disorder: survey of senior hospital consultants and physicians in private practice. Psychosomatics 2007; 48:60–64[Abstract/Free Full Text]
- Turner MA: Factitious disorders: reformulating the DSM-IV criteria. Psychosomatics 2006; 47:23–32[Abstract/Free Full Text]
- Barsky AJ: Forgetting, fabricating, and telescoping: the instability of the medical history. Arch Intern Med 2002; 162:981–984[Abstract/Free Full Text]
- Sutherland AJ, Rodin GM: Factitious disorders in a general hospital setting: clinical features and a review of the literature. Psychosomatics 1990; 31:392–399[Abstract/Free Full Text]
- Feldman MD, Hamilton JC, Deemer HA: Factitious disorder, in Somatoform and Factitious Disorders (Review of Psychiatry). Edited by Phillips KA. Washington, DC, American Psychiatric Press, Inc., 2001, pp 129-159
- Andrews TC, Cull DL, Pelton JJ, et al: Self-mutilation and malingering among Cuban migrants detained at Guantanamo Bay. New Engl J Med 1997; 336:1251–1253[Free Full Text]
- Lipowski ZJ: Somatization: the concept and its clinical application. Am J Psychiatry 1988; 145:1358–1368[Abstract/Free Full Text]
- Subic-Wrana C, Bruder S, Thomas W, et al: Emotional-awareness deficits in inpatients of a psychosomatic ward: a comparison of two different measures of alexithymia. Psychosom Med 2005; 67:483–489[Abstract/Free Full Text]
- Frith C, Perry R, Lumer E: The neural correlates of conscious experience: an experimental framework. Trends Cogn Sci 1999; 3:105–114[CrossRef][Medline]
- Barsky AJ: The somatoform disorders: a nosological conundrum. (Workshop presentation at the 53rd Annual Meeting of the Academy of Psychosomatic Medicine, Tucson, AZ, Nov. 18, 2006)
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ABSTRACT
INTRODUCTION
