Practical Strategies Conference Dr. William H. Gnam, PhD, MD, FRCPC Differentiating Somatoform Disorder, Factitious Disorder and Malingering Practical Strategies Conference June 11, 2015 Dr. William H. Gnam, PhD, MD, FRCPC Psychiatrist william.gnam@gmail.com

Outline Malingering and motivation Introduction: The diagnostic methods of psychiatry Clinical Descriptions and Essential Features Diagnostic Criteria: DSM-IV vs. DSM-5 The Changing Conception of Conversion Disorder Factitious Disorder: updated diagnostic criteria Malingering and motivation Practical Strategies for Differentiating Conclusions

Introduction (1) The Diagnostic Manuals for Mental Disorders emphasize standardized, reproducible methods Diagnoses are confirmed on the basis of symptoms (primarily), signs (secondarily) Emphasis on reportable or observable criteria is intended to increase objectivity and reproducibility

Introduction (2) In North America, the dominant diagnostic system is the Diagnostic and Statistical Manual of Mental Disorders (DSM), 1st through 5th editions Diagnoses are defined according to specific diagnostic criteria, with rules for necessary and sufficient criteria The most valuable property of the DSM system is the potential to provide reliable (reproducible) diagnoses

Introduction (3) For many important diagnoses in the DSM-IV, (e.g. Major Depressive Disorder), good reliability has been established scientifically With the DSM-5, less reliability data, some evidence that important diagnoses lack acceptable reliability

Introduction (4) In contrast with the “rational” methods for diagnosis of many mental disorders, confirming the diagnoses of Conversion, Factitious Disorder and Malingering requires: Difficult exclusions (Conversion Disorder) Inferences based upon external data, not exclusively patient self-report Very difficult judgments about motivation

Conversion Disorder (1) Essential features are: The presence of symptoms or deficits affecting voluntary motor or sensory functioning The symptoms or deficits cannot be fully explained by a neurological or general medical condition – and are incompatible with a neurological condition or disease The symptoms/deficits typically do not conform to anatomical pathways or physiological mechanisms, and may not be consistent

Conversion Disorder (2) Estimates of the prevalence of Conversion Disorder: from 11/100,000 to 500/100,000 Onset is generally (but not exclusively) acute Recurrence is common: 25% within the first year Risk factors: maladaptive personality traits, history of childhood abuse/neglect, stressful life events (not always present)

Conversion Disorder (3) There were problems with the diagnosis of Conversion Disorder defined in DSM-IV: Required confirmation that psychological factors contributed, but factors were poorly defined and not always present Required confirmation that feigning / intentional symptom production is excluded, but such exclusions are often not reliable

Conversion Disorder (4) The DSM-5 represents a major revision of the diagnostic criteria for Conversion Disorder

Conversion Disorder(5): Major Changes in Diagnostic Criteria DSM - IV DSM - 5 One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological disorder/general medical condition symptom(s) The symptom cannot be fully explained by a general medical condition One or more symptoms of altered motor or sensory function Evidence of incompatibility between the symptom and recognized neurological conditions

Conversion Disorder(6): Major Changes in Diagnostic Criteria DSM - IV DSM - 5 Psychological factors are judged to be associated with the symptom or deficit The symptom or deficit is not intentionally produced or feigned (This criterion dropped) (Dropped.) The symptom or deficit is not better explained by another medical or mental disorder

Conversion Disorder (7) The revised criteria have major practical implications: More emphasis on eliciting medical evidence of incompatibility with known neurological conditions The onerous requirement to exclude feigning is dropped (but still must consider a better explanation) Dropped requirement for associated psychological factors, consistent with empirical studies

Conversion Disorder (8) Another very important implication/ acknowledgement: “The diagnosis of conversion disorder does not require the judgment that the symptoms are not intentionally produced (i.e., not feigned), as the definitive evidence of feigning may not be reliably discerned” (DSM-5, page 320)

Factitious Disorder (1) Essential Features: Intentional production or feigning of physical or psychological symptoms External incentives (such as economic gain, avoiding legal responsibilities) are absent (The motivation for the behaviour is to assume the sick role.)

Factitious Disorder (2) There is very limited evidence on prevalence, but factitious disorders are very rare In large general hospitals, about 1% of inpatients for whom there is psychiatric consultation are diagnosed are diagnosed with Factitious Disorder Onset usually in early adulthood, course characterized by (repeated) intermittent episodes, often after hospitalization for a general medical condition or psychiatric disorder

Factitious Disorder (3) Published case series suggest a strong association with severe dysfunctional personality characteristics The intentional production of symptoms or feigning can mimic a wide range of medical conditions or psychological symptoms, not just motor or sensory symptoms/deficits

Factitious Disorder (4) What limited data that exists suggests that persons with Factitious Disorder do not experience their motive to be the need to assume the sick role The DSM-5 contains a significant revision of the diagnostic criteria for Factitious Disorder:

Factitious Disorder(5): Changes in Diagnostic Criteria DSM - IV DSM - 5 Intentional production or feigning of physical or psychological signs or symptoms The motivation for the behaviour is to assume the sick role Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception (Dropped as a criterion: but stipulates that behaviour is not better explained by another mental disorder)

Factitious Disorder(6): Changes in Diagnostic Criteria DSM - IV DSM - 5 External incentives for the behaviour (such as economic gain, etc.) are absent (Not explicitly stated) The deceptive behaviour is evident even in the absence of obvious external incentives The individual presents himself or herself to others as ill, impaired, or injured

Factitious Disorder (7) The revised criteria have some practical implications: More emphasis on the objective identification of falsification of signs and symptoms of illness, rather than inference about intent or possible underlying motivation. The revised criteria do not imply that factitious disorder behaviours could never occur in the presence of external incentives, but does stipulate that they persist even when obvious external rewards/incentives are absent.

Malingering (1) Malingering is a massive topic and not the focus of the current presentation Malingering has never been considered to be a mental disorder The essential feature of Malingering definitions is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives

Malingering (2) The limited data on Malingering indicates that the prevalence is not high, but from a societal perspective the prevalence is nonetheless significant The definition of Malingering has not changed significantly between the DSM-IV and DSM-5.

Malingering (3) Despite the attempts of the DSM-5 to remove criteria that require inference about motivation, the DSM-5 description of Malingering emphasizes that the motivation for the symptom production is an external incentive The difficulties in determining motives acknowledged in other disorders are no easier in Malingering

Malingering (4) There are difficulties with the DSM and other discussions of Malingering: Failure to distinguish between other motivation for conscious symptom production/exaggeration (e.g., “cry for help”) Lack of acknowledgement of the difficulties in determining motivation clinically

Differentiating: Practical Strategies (1) The changes in diagnostic criteria correctly imply that clinical assessment should focus on accurately identifying behaviours, and gathering evidence about incompatibility with medical conditions, and not should not speculate/infer motive This change does not imply that differentiating between Conversion, Factitious Disorder and Malingering (or other conscious symptom production) is not possible in many cases

Differentiating: Practical Strategies (2) Factitious Disorder can be excluded in most cases involving disability after acute traumatic injury (MVAs, work accidents), because Factitious Disorders are very rare They can involve behaviours that produce non- conversion symptoms They become manifest mostly in inpatient settings The natural history is repeated episodes over time, usually established before a traumatic event They do not occur repeatedly or predominantly with obvious external incentives

Differentiation: Practical Strategies (3) Distinguishing between “Malingering” and Conversion Disorder based upon a single clinical encounter is difficult or impossible, but this should not preclude a “working” diagnosis of Conversion Disorder in cases of genuine uncertainty Malingering vs. Conversion cannot be reliably distinguished by minor inconsistencies in the symptom/deficit, as such inconsistencies are common to both

Differentiation: Practical Strategies (4) Distinguishing between Conversion vs. “Malingering” cannot be reliably accomplished by identification of external incentives or risk factors, as none are sensitive or specific enough to discriminate reliably

Differentiation: Practical Strategies (5) Distinguishing between Conversion vs. “Malingering” is best accomplished with longitudinal clinical data provided by extensive documentation review, by collateral examination for symptom production (such as neuropsychological testing), and by repeated observations However, in some cases uncertainty is inevitable and may persist for years or indefinitely

Summary (1) The diagnoses of Factitious Disorder, Conversion and Malingering have often been unreliable due to inference / speculation about motive Major changes in the diagnostic criteria for Conversion Disorder and Factitious Disorder improve the practical procedures to make these diagnoses by removing reference to motivation

Summary (2) Excluding Factitious Disorder is usually straightforward in cases involving acute injury, especially when external incentives are persistently present, or when a history of repeated disturbance while in hospital is absent There is no straightforward clinical method to distinguish between Conversion Disorder and Malingering, which is acknowledged for the first time in the DSM-5.

Summary (3) While in many cases Conversion Disorder vs. Malingering can be differentiated by the consistency of evidence and presentation over time, in some (rare) cases the uncertainty will persist. The DSM and other discussions of Malingering often involve unwarranted assumptions regarding motivation that are likely simplistic