Conversion Disorder, Factitious

Disorder And Malingering

Presenter: Yohannes At., Psy R1
Moderator: Dr. Elias Tesfaye, Consultant
Psychiatrist, Associate Professor of
Psychiatry
 Outline
• DSM-5 TR Classification of Somatic
Symptom And Related Disorders
• Conversion disorders
• Factitious disorders
• Malingering
• Category Of Somatic Symptom And Related Disorders in
DSM-5 TR Includes

1. Somatic symptom disorder

2. Illness anxiety disorder
3. Conversion disorder (functional neurological symptom
disorder)
4. Psychological factors affecting other medical conditions
5. Factitious disorder
6. Other specified somatic symptom and related disorder
7. Unspecified somatic symptom and related disorder
 Conversion Disorder
Introduction • Because the onset
• A conversion reaction is frequently coincides
an acute and temporary with psychological
loss or alteration in issues (conflict), early
motor or sensory theorists speculated
function that is that such issues were
incompatible with “converted” to
known neurological neurological symptoms.
disorders.
• The classic syndromes resemble neurological syndromes.

• Conversion motor symptômes mimic syndromes such as

 paralysis,
 ataxia,
 dysphagia, or
 seizure disorder (pseudo seizures/nonepileptic seizures [NESs]),

• the sensory ones mimic neurological deficits such as blindness,

deafness, or anesthesia.
• There also can be disturbances of
consciousness (amnesia, fainting spells).
• Non neurological syndromes such as
pseudocyesis (false pregnancy) or
psychogenic vomiting have also been placed
under the conversion disorder category.
• However, many clinicians continue to reserve
the term conversion reaction for syndromes
mimicking a neurological disease.
History
• The concept of hysteria, derived from the
Greek word for womb or uterus, implied an
unwanted migration of the organ to higher
sites
• In the middle Ages, hysterical symptoms were
attributed to demonic influences, and their
being placed at the moral level retarded the
medical debate
• During the Renaissance, hysteria returned to
medicine, being considered a somatic disorder by
physicians, who implied a connection or pathway
between the uterus and the brain

• By the middle of the 19th century, Briquet

provided a detailed clinical description of a somatic
syndrome affecting young women to which he gave
the name hysteria and whose origin he situated in
the brain.
• Freud and Breuer jointly reported the first
case of hysterical conversion, the case of Anna
O.
• They theorized that symptoms of hysteria
represented unwanted emotional distress or
conflict that was suppressed and kept
unconscious by the individual, only to appear
in the form of medically unexplainable bodily
symptoms.
Comparative Nosology
• In DSM-I (1951), hysteria became conversion
reaction; in DSM-II (1968), hysterical neurosis,
conversion type; and finally, in DSM-III (1980),
conversion disorder, the term that remains to
this date.
• In DSM-IV, conversion disorder is defined as
 the presence of one or more symptoms or deficits
affecting voluntary motor or sensory function, suggesting
a neurological or other medical condition;
 judged to be associated with psychological conflict or
other stressors, not intentionally produced or feigned;
and
 not fully explained by other medical conditions, use of
substances, or cultural nuances.
• DSM-5 made two crucial  Second, it clarifies that the
modifications in diagnosing diagnosis is made when the
this condition. symptom is incompatible
 First, it appended a with known neurological
parenthetical diagnosis disorders.
(“functional neurological
symptom disorder”) in
recognition that this term is
more familiar to neurologists
and arguably more
acceptable to patients.
 Epidemiology
• The epidemiological information on conversion disorder is
limited.

• Estimates vary broadly:

 Less than 1 percent in the general population,
 5 to 14 percent among general hospital medical/surgical
referrals to psychiatry consultation services, and
 5 to 25 percent in treated psychiatric outpatients.
 The disorder appears to be more frequent in females and
can be seen in children as young as 7 or 8 years old.
 It is rare after the age of 35 years.
 Etiology

PERSONALITY FACTORS
• Some of the traditional features of hysteria included a
detached, unemotional, calmed attitude in front of
what appears to be a severe and turbulent illness, a
trait known as “la belle indifference.”
• “Histrionic personality” is currently the term that
summarizes the drama, flair, and flamboyance and
exhibitionism attributed to these patients.
• However, none of these is given any relevance for the
DSM-5 diagnosis of conversion disorder.
BIOLOGICAL FACTORS

• The neurophysiologic conceptualization speaks of an

inherent defect in certain brain functions, especially
those in the dominant hemisphere that may interfere
with verbal associations.

• In addition, functional MRI studies have shown

differences in brain activation between patients with
conversion disorder and controls.
PSYCHOLOGICAL • The psychoanalytic theory,
FACTORS on the other hand,
• The behavioral theory describes symptoms as
compromise formations
attributes conversion
with primary gain of
disorder to faulty
conflict resolution through
childhood learning, with
partial expression of the
the nonadaptive
conflict without conscious
behavioral responses used
awareness of its
for secondary gain and
significance.
control of interpersonal
relationships.
• Some have suggested a strong relationship
between childhood traumatization by sexual
or physical abuse and a later propensity for
conversion disorder.

• Other studies, however, do not confirm such

an association.
 CLINICAL PRESENTATION

• Persons with conversion disorder (also called

functional neurologic symptom disorder)
present with what appears to be a neurologic
condition.

• The symptoms may be motor or sensory but

are incompatible with known neurologic
conditions.
• Often the illness is preceded by conflicts or
other stressors and may seem to be
associated with apparent psychological
factors.

• Individuals with conversion disorder do not

intentionally produce these symptoms or
deficits
 Common Symptoms of Conversion Disorder
Motor Symptoms Sensory Deficits Visceral Symptoms

Involuntary movements Anesthesia, especially of Psychogenic vomiting

extremities
Tics Midline anesthesia Pseudocyesis
Blepharospasm Blindness Globus hystericus
Torticollis Tunnel vision Swooning or syncope
Opisthotonos Deafness Urinary retention
Seizures Diarrhea
Abnormal gait
Falling
Astasia–abasia
Paralysis
Weakness
Aphonia
 Common Symptoms of Conversion
Disorder
Motor Symptoms
• The motor symptoms of conversion disorder include abnormal
movements, gait disturbance, weakness, and paralysis.
• Gross rhythmical tremors, choreiform movements, tics, and jerks
may be present.
• The movements generally worsen when calling attention to them.

• One gait disturbance seen in conversion disorder is astasia–abasia,

which is a wildly ataxic, staggering gait accompanied by gross,
irregular, jerky truncal movements and thrashing and waving arm
movements. Patients with the symptoms rarely fall; if they do, they
are generally not injured.
• Other common motor disturbances are
paralysis and paresis involving one, two, or all
four limbs, although the distribution of the
involved muscles does not conform to the
neural pathways.
 Reflexes remain normal;
 no fasciculations or muscle atrophy (except
after long-standing conversion paralysis);
 electromyography findings are normal.
Seizure Symptoms
• NESs are another symptom of conversion disorder.
• It may be challenging to differentiate NESs from an
actual seizure by clinical observation alone.
• Some patients with NESs also have a coexisting
epileptic disorder, which may complicate the clinical
picture.
• Tongue-biting, urinary incontinence, and injuries
after falling can occur in NESs, although these
symptoms are generally not present.
• Patients with NESs

 retain pupillary and gag reflexes after their

seizure-like activity, and
 have no postseizure increase in prolactin
concentrations.
Sensory Deficits
• In conversion disorder, anesthesia and paresthesia are
common, especially of the extremities.
• All sensory modalities can be involved, and the
distribution of the disturbance is usually inconsistent
with either central or peripheral neurologic disease.

• Thus, clinicians may see the characteristic stocking-

and-glove anesthesia of the hands or feet or the
hemianesthesia of the body beginning precisely along the
midline.
• Conversion disorder symptoms may involve the organs of
special sense and can produce deafness, blindness, and
tunnel vision.

• These symptoms can be unilateral or bilateral, but

neurologic evaluation reveals intact sensory pathways.

• In conversion disorder blindness, for example,

 patients walk around without collisions or self-injury,
 their pupils react to light, and
 their cortical-evoked potentials are normal.
Other Associated Features
• Several psychological symptoms are also
associated with conversion disorder
 Primary gain
 Secondary gain
 La Belle Indifference
 Identification
PRIMARY GAIN
• Patients achieve primary gain by keeping
internal conflicts outside their awareness.
• Symptoms have symbolic value; they
represent an unconscious psychological
conflict.
SECONDARY GAIN
• Patients accrue tangible advantages and
benefits as a result of being sick; for example,

 being excused from obligations and difficult life

situations,
 receiving support and assistance that might not
otherwise be forthcoming, and
 controlling others’ behavior.
LA BELLE INDIFFÉRENCE
 La belle indifférence (“beautiful indifference”)
is a patient’s inappropriately cavalier attitude
toward severe symptoms; that is,

the patient seems to be unconcerned about what

appears to be a significant impairment.
 That bland indifference may also occur in
some seriously ill medical patients who
develop a stoic attitude.
 The presence or absence of la belle
indifférence is not pathognomonic of
conversion disorder, but it is often associated
with the condition
IDENTIFICATION
• Patients with conversion disorder may
unconsciously model their symptoms on those of
someone important to them.
• For example, a parent or a person who has
recently died may serve as a model for conversion
disorder.
• During pathologic grief reaction, bereaved persons
commonly have symptoms of the deceased.
 Distinctive Physical Examination Findings in
Conversion Disorder
Condition Test Conversion Findings

Anesthesia Map Sensory loss does not conform

dermatomes to recognized pattern of
distribution
Hemianesthesia Check midline Strict half-body split
Astasia–abasia Walking, With suggestion, those who
dancing cannot walk may still be able
to dance;alteration of sensory
and motor findings with
suggestion
Paralysis, Drop paralyzed hand onto Hand falls next to face,
paresis face not on it
Hoover test Pressure noted in examiner’s
hand under paralyzed leg
when attempting straight leg
raising
Check motor strength Give-away weakness
Condition Test Conversion Findings

Coma Examiner attempts to Resists opening;

open eyes gaze preference is away
from doctor
Ocular cephalic Eyes stare straight ahead,
maneuver do not move from side to
side
Aphonia Request a Essentially normal
cough coughing sound indicates
cords are closing
Intractable Observe Short nasal grunts with
sneezing little or no sneezing on
inspiratory phase;
little or no aerosolization of
secretions: minimal facial
expression;
eyes open; stops when
asleep; abates when alone
Syncope Head-up tilt test Magnitude of changes in
vital signs and venous
pooling do not explain
continuing symptoms
Condition Test
Tunnel vision Visual fields
Profound monocular Swinging flashlight
blindness sign (Marcus Gunn)
Binocular visual fields
Severe bilateral “Wiggle your fingers, I’m
blindness just testing coordination”
Sudden flash of bright light
“Look at your hand”
“Touch your index fingers”
Conversion Findings
Changing pattern on
multiple examinations
Absence of relative afferent
pupillary defect
Sufficient vision in “bad
eye” precludes plotting
normal physiologic blind
spot in good eye
Patient may begin to mimic
new movements before
realizing the slip
Patient flinches
Patient does not look there
Even blind patients can do
this by proprioception
 DIAGNOSIS
• Acute and temporary loss or alteration in
motor or sensory function
that requires substantial discordance between the
symptoms displayed and any neurologic condition,
such that it would be impossible for the patient’s
presentation to be consistent with a neurologic
disease.

• The onset frequently, but not always,

coincides with psychological issues (conflict).
• The classic syndromes represent neurologic
syndromes such as paralysis, seizures, or
blindness.

• In DSM-5, we can indicate the type of

symptom the patient is experiencing.
 DSM-5 Diagnostic Criteria
• Name of the Disorder:
Conversion Disorder
(Functional Neurologic Symptom Disorder)

A. One or more symptoms of altered voluntary motor or

sensory function.

B. Clinical findings provide evidence of incompatibility

between the symptom and recognized neurological or
medical conditions.
C. The symptom or deficit is not better explained
by another medical or mental disorder.

D. The symptom or deficit causes clinically

significant distress or impairment in social,
occupational, or other important areas of
functioning or warrants medical evaluation
Specify symptom type:

• With weakness or paralysis

• With abnormal movement (e.g.,
tremor, dystonia, myoclonus, gait disorder)
• With swallowing symptoms
• With speech symptom (e.g., dysphonia, slurred speech)
• With attacks or seizures
• With anesthesia or sensory loss
• With special sensory symptom (e.g.,
visual, olfactory, or hearing disturbance)
• With mixed symptoms
Specify if:
• Acute episode: Symptoms present for less
than 6 months.
• Persistent: Symptoms occurring for 6 months
or more.
Specify if:
• With psychological stressor (specify stressor)
• Without psychological stressor
• In ICD 10 name of the disorder is:
Dissociative (Conversion) Disorders
Specifiers:
• Dissociative stupor
• Dissociative motor disorder (limb, speech, or gait)
• Dissociative convulsions
• Dissociative anesthesia and sensory loss
• Mixed dissociative (conversion) disorders
 DIFFERENTIAL DIAGNOSIS
• One of the significant problems in diagnosing
conversion disorder is the difficulty in definitively
ruling out a medical disorder.

• Concomitant nonpsychiatric medical disorders are

common in hospitalized patients with conversion
disorder, and
 evidence of a current or previous neurologic disorder
or a systemic disease affecting the brain occurs in 18
to 64 percent of such patients.
 DDX cont…
• An estimated 25 to 50 percent of patients classified as
having conversion disorder eventually receive diagnoses
of neurologic or nonpsychiatric medical disorders that
could have caused their earlier symptoms.
• Thus, a thorough medical and neurologic workup is
essential in all cases.

• If the suggestion resolves the symptom, such as with

hypnosis, or parenteral amobarbital or lorazepam, the
symptoms are probably the result of conversion disorder
 DDX cont…
• Neurologic disorders (e.g., dementia and other
degenerative diseases), brain tumors, and basal
ganglia disease are part of the differential diagnosis.

• For example, weakness may be confused with

 myasthenia gravis,
 polymyositis,
 acquired myopathies, or
 multiple sclerosis.
 DDX cont…
• Optic neuritis can resemble conversion disorder
blindness.

• Other diseases that can cause confusing

symptoms are
 Guillain–Barré syndrome,
 Creutzfeldt–Jakob disease,
 periodic paralysis, and
 early neurologic manifestations of AIDS.
 DDX cont…
• Conversion disorder symptoms occur in
schizophrenia, depressive disorders, and
anxiety disorders,

 but these other disorders are associated with

their distinct symptoms that eventually make
differential diagnosis possible.
 DDX cont…
• The demarcation between conversion disorder and
somatic symptom disorder is not that clear, and
conversion symptoms may form part of the
constellation of symptoms seen in somatic symptom
disorder.

 One differentiating feature is that conversion disorder

requires that the presenting symptoms be inconsistent
with neurologic conditions, whereas somatic symptom
disorder does not require this inconsistency.
 DDX cont…
• In both malingering and factitious disorder,
the symptoms are under conscious, voluntary
control.

 A malingerer’s history is usually more

inconsistent and contradictory than that of a
patient with conversion disorder, and
 A malingerer’s fraudulent behavior is
goal-directed.
 COURSE AND PROGNOSIS
• The onset of conversion disorder is usually acute, but a
crescendo of symptomatology may also occur.

• Symptoms or deficits are usually of short duration, and

approximately 95 percent of acute cases remit
spontaneously, usually within 2 weeks in hospitalized
patients.
 If symptoms have been present for 6 months or longer,
the prognosis for symptom resolution is less than 50
percent and diminishes further, the longer that
conversion is present.
 COURSE AND PROGNOSIS Cont…
• Recurrence occurs in one-fifth to one-fourth of
people within 1 year of the first episode.
• Thus, one episode is a predictor for future
episodes.
 COURSE AND PROGNOSIS Cont…
Good prognostic indicators:
 Acute onset,
 presence of clearly identifiable stressors at the time of
onset,
 a short interval between onset and the institution of
treatment, and
 above-average intelligence

• Paralysis, aphonia, and blindness are associated with a good

prognosis, whereas tremor and seizures are poor prognostic
factors.
 TREATMENT
APPROACH TO THE PATIENT
• There should be special attention given to
 history of trauma,
 sexual and physical abuse, and
 family history of conversion symptoms.

• Although psychological etiology is a requisite of DSM-

IV diagnosis, it is often difficult to identify it early in
treatment and may not reveal itself until extensive
additional history is obtained.
• Screening methods for assessing trauma,
dissociative experience, and posttraumatic
stress disorder (PTSD) should be helpful in this
process.
• Physical examination must pay particular
attention to ruling out neurological diseases
such as multiple sclerosis and other peripheral
and central nervous system disorders.

 DSM-5 requires that careful examination

document that the neurological symptom is
incompatible with known neurological
disorders.
Routine laboratory studies are indicated, as
well as electroencephalograms (to distinguish
between epilepsy and pseudo seizures) and
other special studies (e.g., MRI, x-rays, spinal
tap, etc.) to rule out other possible organic
etiologies.
REASSURANCE
• Many conversion syndromes have an acute,
benign course and may remit spontaneously
with understanding and support.

• Early intervention can forestall potential

chronicity and the progression into
a well-entrenched somatization disorder.

PSYCHOTHERAPY
• Once chronicity has
developed, intensive
treatment may use all
treatment modalities,
including
 hospitalization,
 individual or group therapy,
 insight-oriented therapies,
 behavioral techniques,
 hypnosis,
 sodium amytal interview,
 physical therapy,
 biofeedback,
 relaxation training, and
 medication (primarily for
comorbid anxiety,
depression, or other
somatoform disorders).
• Psychological • Any implication to the
interpretations or patient that he or she is
explanations do not work malingering is very
well early in the process, counterproductive.
but reassuring patients
that critical tests are
normal and that
symptoms will eventually
improve may be helpful.
• Behavioral interventions should focus on
improving self-esteem, the capacity for
emotional expression and assertiveness, and
the ability to communicate comfortably with
others.
HYPNOTHERAPY
• This is perhaps the oldest treatment used for
conversion disorder.
• However, there are very few randomized,
controlled trials, and these seem to be
inconclusive because hypnotizability was not
predictive of treatment outcome.
SODIUM AMYTAL
• The use of sodium amytal was for some time a
common approach to the patient with conversion
hysteria for
 diagnosing conversion disorder,
 uncovering traumatic events, and
 providing therapeutic relief.

• However, it is now rarely used because a number of

observations questioned its clinical value
PHARMACOLOGICAL TREATMENT
• Accompanying comorbid depression, anxiety,
and behavior problems may respond to
pharmacologic interventions.

• The use of hypnotic or narcoleptic techniques, if

these are being considered, must be tentatively
offered to patients whose fear of passivity or loss
of control may induce overwhelming anxiety.
PHYSICAL THERAPY
• With chronic conversion, muscle contractures
can occur and physical therapy is necessary.
• Even in the absence of such contractures,
however, many conversion patients find that
physical therapy can be helpful for muscular
symptoms or balance problems.
• The process of slowly progressive exercises and
activity can help restore functioning
 Factitious Disorder
Introduction: • Historically this disorder
• Factitious disorder is was called
the faking of physical “Munchausen
syndrome,” a reference
or psychological signs
to the Baron
and symptoms
Munchausen, legendary
• Symptoms can be imposed
for his outrageously
on self or imposed on
another. exaggerated stories of
his military career.
 EPIDEMIOLOGY
• No comprehensive epidemiologic data on
factitious disorder exist.
• However, it is estimated to comprise
approximately 1 percent of the
healthcare-seeking population.

• Factitious disorder imposed on another

account for less than 0.04 percent of reported
child abuse in the United States each year
 ETIOLOGY
• Etiology is generally not clear, except that
a common denominator is that these
patients tend to be avid medical service
seekers

• The underlying motivations for the

behaviors are likely unconscious
• Two factors may underlie most cases of
factitious disorder:
(1) an affinity for the medical system, and
(2) poor, maladaptive coping skills

• In the case of factitious disorder imposed on

another, psychodynamic theories predominately
view the disorder as an objectification of the
child to serve the parent’s psychological needs
 Predisposing Factors
• Specific predisposing factors are actual
physical disorders during childhood, leading to
extensive medical treatment
• Other factors may include
 a grudge against the medical profession,
 employment in the healthcare industry, or
 a significant relationship with a physician in
the past
 COURSE AND PROGNOSIS
• Factitious disorders typically begin in
early adulthood, although they can
appear during childhood or adolescence

• The onset of the disorder or of discrete

episodes of seeking treatment may
follow a real illness, loss, rejection, or
abandonment
• Usually, the patient or a close relative
had a hospitalization in childhood or
early adolescence for genuine physical
illness.

• After that, a long pattern of successive

hospitalizations begins insidiously and
evolves.
• Factitious disorders are incapacitating to
the patient and often produce severe
trauma or untoward reactions related to
treatment
• A course of repeated or long-term
hospitalization is incompatible with
meaningful vocational work and sustaining
interpersonal relationships
• The prognosis, in most cases, is poor
 CLINICAL PRESENTATION
• Patients with factitious disorder feign,
misrepresent, simulate, cause, induce, or
aggravate illness to receive medical
attention, regardless of whether or not they
are ill

• Thus, they may inflict painful, deforming, or

even life threatening injuries on themselves,
their children, or other dependents .
• The primary motivation is not the
avoidance of duties, financial gain, or
anything concrete.

• The motivation is simply to receive

medical care and to partake in the
medical system.
• Even if the patients falsify their
presenting complaints,
health professionals must take the
medical and psychiatric needs of these
patients seriously, as their self-induced
symptoms can result in significant harm
or even death.
 DIAGNOSIS
Factitious Disorder Imposed on Self

• We diagnose this condition when an

individual feigns having a medical or
psychiatric illness
in order to achieve the sick role
• Some patients show psychiatric symptoms
judged to be fake
• This determination can be difficult and is often
made only after a prolonged investigation

• The feigned symptoms frequently include

depression, hallucinations, dissociative and
conversion symptoms, and bizarre behavior
• Because the patient’s condition does not
improve after routine therapeutic
measures, he or she may receive large
doses of psychoactive drugs and may
undergo electroconvulsive therapy
• Some patients may use psychoactive
substances to produce symptoms, such
as stimulants to produce restlessness or
insomnia, or hallucinogens to produce
distortions of reality
• Combinations of psychoactive substances
can produce very unusual presentations.
• Other psychological symptoms include
pseudologia fantastica and impostorship

• In pseudologia fantastica, the patient

mixes limited factual material with
extensive and colorful fantasies
• The listener’s interest pleases the patient
and, thus, reinforces the symptom
• In addition to distortions of the history,
patients often give false and conflicting
accounts about other areas of their lives
(e.g., they may claim the death of a
parent, to play on the sympathy of
others)
• Other patients may feign physical
symptoms suggesting a disorder
involving any organ system
• Clinical presentations are myriad and include
hematoma, hemoptysis, abdominal pain,
fever, hypoglycemia, lupus-like syndromes,
nausea, vomiting, dizziness, and seizures
• For example, the patient may contaminate
urine with blood or feces or take
anticoagulants to simulate bleeding disorders,
or insulin to produce hypoglycemia.
• Such patients often insist on surgery and claim
adhesions from previous surgical procedures
 DSM 5 TR Diagnostic Criteria of Factitious
Disorder Imposed On Self
A. Falsification of physical or psychological signs or symptoms, or
induction of injury or disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired,
or injured.
C. The deceptive behavior is evident even in the absence of obvious
external rewards.
D. The behavior is not better explained by another mental disorder,
such as delusional disorder or another psychotic disorder.
Specify:
• Single episode
• Recurrent episodes (two or more events of falsification of illness
and/or induction of injury)
 Clues That Should Trigger Suspicion of
Factitious Disorder
1. The patient has sought treatment at
various different hospitals or clinics
2. The patient is an inconsistent, selective, 5. The magnitude of symptoms
or misleading informant; he or she
resists allowing the treatment team
access to outside sources of
information
3. The course of the illness is atypical and
does not follow the natural history of
the presumed disease
4. A remarkable number of tests,
consultations, and medical and
surgical treatments have been done
to little or no avail
consistently exceeds objective
pathology or symptoms have proved
to be exaggerated by the patient
6. Some findings are discovered to have
been self-induced or at least
worsened through self-manipulation
7. The patient might eagerly agree to or
request invasive medical procedures
or surgery
8. Physical evidence of a factitious cause 12. Evidence from laboratory or other tests
might be discovered during the course disputes information provided by the
of treatment patient

9. The patient predicts deteriorations or 13. The patient has a history of work in the
there are exacerbations shortly before
their scheduled discharge
10. A diagnosis of factitious disorder has
been explicitly considered by at least
one healthcare professional
11. The patient is noncompliant with
diagnostic or treatment
recommendations or is disruptive on
the unit
healthcare field
14. The patient engages in gratuitous, self-
aggrandizing lying
15. The patient has been prescribed (or
obtained) opiate drugs when not
indicated
16. While seeking medical or surgical
intervention, the patient opposes
psychiatric assessment
 Factitious Disorder Imposed on Another
(formerly Factitious Disorder by Proxy)
• In this diagnosis, a person intentionally
produces physical signs or symptoms in
another person who is under the first person’s
care.
• One apparent purpose of the behavior is for
the caretaker to assume the sick role
indirectly; another is to be relieved of the
caretaking role by having the child
hospitalized.
• The most common cause of factitious disorder
imposed on another involves a mother who
deceives medical personnel into believing that
her child is ill.
• The deception may involve a false medical
history, contamination of laboratory samples,
alteration of records, or induction of injury
and illness in the child.
 DSM 5 TR Criteria

A. Falsification of physical or
psychological signs or D. The behavior is not better
symptoms, or induction of injury explained by another mental
or disease, in another, disorder, such as delusional
associated with identified disorder or another psychotic
deception. disorder.
B. The individual presents another Note: The perpetrator, not the
individual (victim) to others as ill, victim, receives this diagnosis.
impaired, or injured. Specify:
C. The deceptive behavior is evident • Single episode
even in the absence of obvious
• Recurrent episodes (two or more
external rewards.
events of falsification of illness
and/or induction of injury)
 Clues Triggering Suspicion for Factitious
Disorder Imposed on Another Person
1. Diagnosis does not match the 5. Caregiver insists on invasive or
objective findings painful procedures or
2. Signs or symptoms are bizarre hospitalizations
3. Caregiver or suspected 6. Caregiver’s behavior does not
offender does not express match expressed distress or
relief or pleasure when told report
that dependent is improving of symptoms (e.g., unusually
or that dependent does not calm)
have a particular illness 7. Signs and symptoms begin
4. Inconsistent histories of only in the presence of one
symptoms from different caregiver
observers
8. Sibling or another dependent has
or had an unusual or unexplained 12. Extensive unusual illness history
illness or death in the caregiver or caregiver’s
9. Sensitivity to multiple family; caregiver’s history of
environmental substances or somatization disorders
medicines 13. Caregiver seeks other medical
10. Failure of the dependent’s illness opinions when told the dependent
to respond to its normal does not have illness
treatments or unusual intolerance 14. Caregiver perseverates about
to those treatments borderline abnormal results of no
11. Caregiver publicly solicits clinical relevance despite repeated
sympathy or donations or benefits reassurance, or refutes the validity
because of the dependent’s rare of normal results
illness
 TREATMENT
• No specific psychiatric therapy has been effective in
treating factitious disorders.
• It is a clinical paradox that patients with the
disorders simulate severe illness and seek and
submit to unnecessary treatment while they deny
to themselves and others their actual illness and
thus avoid possible treatment for it.
• Ultimately, the patients elude meaningful therapy
by abruptly leaving the hospital or failing to keep
follow-up appointments
• Treatment, thus, is best focused on
management rather than on cure
• The three primary goals in the treatment and
management of factitious disorders are
(1) to reduce the risk of morbidity and
mortality,
(2) to address the underlying emotional needs
or psychiatric diagnosis underlying factitious
illness behavior, and
(3) to be mindful of legal and ethical issues.
• Perhaps the single most crucial factor in
successful management is a physician’s early
recognition of the disorder.
• In this way, physicians can forestall a
multitude of painful and potentially dangerous
diagnostic procedures for these patients.
• There must be a good liaison between
psychiatrists and the medical or surgical staff.
• Although a few cases of individual
psychotherapy exist in the literature, no
consensus exists about the best approach.
• In general, working in concert with the
patient’s primary care physician is more
effective than working with the patient in
isolation.
• The personal reactions of physicians and staff
members are of great significance in treating
and establishing a working alliance with these
patients, who invariably evoke feelings of
futility, bewilderment, betrayal, hostility, and
even contempt
• One appropriate psychiatric intervention is to
suggest to the staff ways of remaining aware
that even though the patient’s illness is
factitious, the patient is ill.
• Physicians should try not to feel resentment
when patients humiliate their diagnostic
prowess, and they should avoid any
unmasking ceremony that sets up the patients
as adversaries and precipitates their flight
from the hospital
• The staff should not perform unnecessary
procedures or discharge patients abruptly,
both of which are manifestations of anger.
 Guidelines for Management and
Treatment of Factitious Disorder
• Keep in mind that active pursuit of a prompt
diagnosis can minimize the risk of morbidity and
mortality.
• Minimize harm. Avoid unnecessary tests and
procedures, especially if they are invasive. Treat
according to clinical judgment, keeping in mind that
subjective complaints may be deceptive.
• Arrange regular interdisciplinary meetings to reduce
conflict and splitting among staff. Manage staff
countertransference.
• Steer the patient toward psychiatric treatment
in an empathic, nonconfrontational, face-
saving manner. Avoid aggressive direct
confrontation.
• Treat underlying psychiatric disturbances. In
psychotherapy, address coping strategies and
emotional conflicts.
• Appoint a primary care provider as a
gatekeeper for all medical and psychiatric
treatment.
• Consider involving risk management and
bioethicists from an early point.
• Consider appointing a guardian for medical and
psychiatric decisions.
• As a behavioral disincentive, consider
prosecution for fraud.
• In cases of factitious disorder imposed on another,
physicians have obtained a legal intervention in
several instances, particularly with children.
• The senselessness of the disorder and the denial of
false action by parents are obstacles to successful
court action and often make conclusive proof
unobtainable.
• In such cases, the treatment team should notify the
child welfare and make arrangements for ongoing
monitoring of the children’s health
 Pediatric Factitious Disorder Imposed on
Another—Basic Principles of Management
• Make sure the child is safe.
• Make sure the child’s future safety is also
assured.
• Allow treatment to occur in the least restrictive
setting possible.
• A pediatrician should serve as “gatekeeper” for
medical care utilization.
• All other physicians should coordinate care with
the gatekeeper.
• Child-protective services should be informed
whenever a child is harmed.
• Family psychotherapy and/or individual
psychotherapy should be instituted for the
perpetrating parent and the child.
• Health insurance companies, school officials, and
other nonmedical sources should be asked to
report possible medical abuse to the physician
gatekeeper. Permission of a parent or of child-
protective services must first be obtained
• The possibility should be considered of admitting
the child to an inpatient or partial hospital setting
to facilitate diagnostic monitoring of symptoms
and to institute a treatment plan.
• The child may require placement in another
family.
• The perpetrating parent may need to be removed
from the child through criminal prosecution and
incarceration.
 Malingering
• Malingering is the deliberate falsification of
physical or psychological symptoms in an
attempt to achieve a secondary gain such as
 avoiding military duty,
 avoiding work,
 obtaining financial compensation,
 evading criminal prosecution, or
 obtaining drugs. Eg Narcotic analgesics
• The clinician should consider possible malingering when
encountering any combination of the following:
(1) medicolegal context of presentation (e.g., the person is
referred by an attorney to the clinician for examination),
(2) evident discrepancy between the individual’s claimed
stress or disability and the objective findings,
(3) lack of cooperation during the diagnostic evaluation
and in complying with the prescribed treatment
regimen, and
(4) the presence of antisocial personality disorder.
 Differential Diagnosis
• The challenge is to differentiate malingering
from an actual physical or psychiatric illness.
• Furthermore, the possibility of partial
malingering, which is an exaggeration of
existing symptoms, must be entertained
• We should also remember that a real
psychiatric disorder and malingering are not
mutually exclusive
• Factitious disorder is distinguished from
malingering by motivation (sick role vs.
tangible pain), whereas the somatoform
disorders involve no conscious volition
• In conversion disorder, as in malingering,
objective signs cannot account for subjective
experience, and differentiation between the
two disorders can be difficult
 Factors Aiding in the Differentiation between
Malingering and Conversion Disorder
1. Malingerers are more likely to be suspicious,
uncooperative, aloof, and unfriendly;
– patients with conversion disorder are likely to be
friendly, cooperative, appealing, dependent, and
clinging.

2. Malingerers may try to avoid diagnostic

evaluations and refuse recommended treatment;
– patients with conversion disorder likely welcome
evaluation and treatment, “searching for an answer.”
3. Malingerers likely refuse employment opportunities
designed to circumvent their disability;
– patients with conversion disorder likely accept such
opportunities.

4. Malingerers are more likely to provide extremely

detailed and exacting descriptions of events
precipitating their “illness”;
– patients with conversion disorder are more likely to
report historical gaps, inaccuracies, and vagaries.
 Course and Prognosis
• Malingering persists as long as the malingerer
believes it will likely produce the desired
rewards.
• In the absence of concurrent diagnoses, after
the individual has attained the goal, the
feigned symptoms disappear.
• In children, malingering is most likely
associated with a predisposing anxiety or
conduct disorder;
• proper attention to this developing problem
may alleviate the child’s propensity to
malinger
 Treatment
• The appropriate stance for the psychiatrist is
clinical neutrality.
• If malingering is suspected, a careful
differential investigation should ensue
• If, after the diagnostic evaluation, malingering
seems most likely, the clinician should tactfully
but firmly confront the patient with the
apparent outcome.
• The clinician should also try to understand the
underlying reasons for the ruse, and explore
alternative, more acceptable pathways to the
desired outcome.
• Coexisting psychiatric disorders should be
thoroughly assessed
• Only if the patient is utterly unwilling to
interact with the physician undern any terms
other than manipulation should the physician
abandon the interaction
THANK YOU !!!