1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

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

11. 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

12. 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

13. 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

14. 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)

15. 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.)

16. 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

17. 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

18. 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:

19. 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)

20. 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

21. 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.

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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.

33. 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