14 Factitious Disorders and Malingering

The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRY
Fifth Edition
Edited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.
© 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 14
Factitious Disorder and Malingering

Barbara E. McDermott, Ph.D., Martin H. Leamon, M.D.,
Marc D. Feldman, M.D., Charles L. Scott, M.D.
Slide show includes…

Topic Headings
Tables
Key Points
The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, 1
Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 14 • Topic Headings
FACTITIOUS DISORDER
Classification
Diagnosis
Epidemiology
Etiology
Treatment
FACTITIOUS DISORDER BY PROXY
Classification
Diagnosis
Epidemiology
Etiology
Treatment and Prognosis
MALINGERING
Classification
Detection (“Diagnosis”)
Structured Assessments of Malingering
Screening Tools for Malingering
Paper and Pencil Tests
Interview Format
Comprehensive Assessments of Malingering
Epidemiology
Treatment
CHAPTER 14 • Tables
Table 14–1. DSM-IV-TR diagnostic criteria for factitious disorder

Table 14–2. DSM-IV-TR diagnostic criteria for factitious disorder not otherwise specified
Table 14–3. DSM-IV-TR research criteria for factitious disorder by proxy
Table 14–4. Warning signs for factitious disorder by proxy
Table 14–5. DSM-IV-TR warning signs for malingering
Table 14–6. Clinical decision model for the assessment of malingering of psychosis
Table 14–7. Threshold model for the assessment of hallucinations and delusions
Table 14–8. Standardized assessments for detecting the malingering of psychiatric disturbances
Summary Key Points
DSM-IV-TR (American Psychiatric
Association 2000) requires three criteria
for the diagnosis of factitious disorder
(Table 14–1).
TABLE 14–1. DSM-IV-TR

diagnostic criteria for
factitious disorder
The DSM-IV-TR subtype of factitious disorder not otherwise specified (Table 14–2) should be used
for disorders with factitious symptoms that do not meet criteria for one of the other subtypes.
TABLE 14–2. DSM-IV-TR diagnostic criteria for factitious disorder not otherwise
specified
Source. American Psychiatric Association 2000.
DSM-IV-TR provides research criteria for factitious disorder by proxy in Appendix B, “Criteria Sets
and Axes Provided for Further Study” (American Psychiatric Association 2000). The criteria are
similar to those for factitious disorder, with the addition of the “by proxy” specification (Table 14–3).
TABLE 14–3. DSM-IV-TR research criteria for factitious disorder by proxy
Certain clusters of warning signs
(Table 14–4) can suggest a diagnosis
of factitious disorder by proxy.
TABLE 14–4. Warning signs for

factitious disorder by proxy
Source. Data from Bools et al. 1992; Jani et al. 1992; Jureidini 1993;
Libow 1995; R. Meadow 1982; Schreier and Libow 1996.
Table 14–5 provides the DSM-IV-TR guidelines for when to suspect malingering.
TABLE 14–5. DSM-IV-TR warning signs for malingering
Table 14–6 provides a suggested clinical decision
model for the assessment of malingered
psychosis (Resnick 1997). In determining whether
reported hallucinations or delusions are
fabricated or exaggerated, the factors outlined in
Table 14–7 also may prove helpful (Resnick
1997). Note that a bona fide diagnosis of a past
psychotic disorder does not necessarily exclude
a presentation of manufactured psychotic
symptoms.
TABLE 14–6. Clinical decision model for the

assessment of malingering of psychosis
Source. Resnick 1997.
In determining whether reported hallucinations or delusions are fabricated or exaggerated, the factors
outlined in Table 14–7 also may prove helpful (Resnick 1997). Note that a bona fide diagnosis of a past
psychotic disorder does not necessarily exclude a presentation of manufactured psychotic
symptoms.
TABLE 14–7. Threshold model for

the assessment of hallucinations
and delusions
Source. Resnick 1997.
Table 14–8 provides a summary of some assessments commonly used in the detection of malingered
psychiatric disturbances.
TABLE 14–8. Standardized assessments

for detecting the malingering of
psychiatric disturbances
CHAPTER 14 • Key Points
 The distinction between factitious disorder and malingering lies in the

underlying motivation for the production of symptoms.
 The motivation for factitious disorder is to assume the sick role and is often
presumed to be unconscious.
 The motivation for malingering involves the attainment of a tangible reward.
 Factors suggestive of factitious disorder include discrepancies between
objective findings, inconsistencies between objective findings and clinical
history or symptoms, an atypical illness course, and conditions that fail to
respond to usual therapies.
 Factors suggestive of malingering include inconsistencies between reported
versus observed behavior and the reporting of improbable or absurd
symptoms in the presence of an understandable motive to malinger.
 The treatment/management of both factitious disorder and malingering
involves “delicate” confrontation with minimal expectations of confessions.
 The treatment for factitious disorder involves focusing on the underlying
motivation for the behavior, which often can be psychodynamic in nature.
(continued)
CHAPTER 14 • Key Points (continued)
 The management of malingering involves understanding the secondary gains

associated with the production of symptoms in order to address these
expectations.
 Factitious disorder by proxy involves maltreatment and, when suspected,
must be reported to child protection authorities.

14 Factitious Disorders and Malingering

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Factitious Disorder and Malingering

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Table 14–1. DSM-IV-TR diagnostic criteria for factitious disorder

TABLE 14–1. DSM-IV-TR

Source. American Psychiatric Association 2000.

TABLE 14–3. DSM-IV-TR research criteria for factitious disorder by proxy

TABLE 14–4. Warning signs for

TABLE 14–5. DSM-IV-TR warning signs for malingering

TABLE 14–6. Clinical decision model for the

Source. Resnick 1997.

TABLE 14–7. Threshold model for

Source. Resnick 1997.

TABLE 14–8. Standardized assessments

 The distinction between factitious disorder and malingering lies in the

 The management of malingering involves understanding the secondary gains

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