Motivation and emotion/Book/2019/Factitious disorder and malingering motivation

Overview
Case study

The patient, X was a 22 year old woman, previously already diagnosed with borderline personality disorder and mild depression. Had a history of self-harm and sexual abuse during adolescence.

X had been physically unwell since childhood with asthma and epilepsy and had been admitted to hospital several times. She was studying nursing science before dropping out of university, and also had a poor relationship with her family.

During the last year, X had been admitted to local hospitals several times with reports of symptoms such as chest pains and seizures. The hospital staff eventually noticed her behaviour was unusual and began to suspect she was simulating her illnesses, in which they admitted her to the psychiatric ward, where X was uncooperative with providing any information, and thus a proper diagnosis of factitious disorder could not be met.

Six months before the case study, X attended emergency departments more and more with reports of chest pains, difficulty breathing and urinating, alleged seizures, dizziness, etc. Her mother reported that X only ever left the house to visit the hospital or GP surgery. While in hospital, X would repeatedly ask for invasive treatments, such as intramuscular injections and cannulas. Staff once again noticed that her behaviour was abnormal. X's suicide attempt was what led her to be admitted to the psychiatric ward again, and at this time, X was taking over 30 different medications for her reported ailments, including heavy opioids. From all the evidence the psychiatric team now had, they could then diagnose X with factitious disorder. (Mousailidis, G., Lazzari, C., Bhan‐Kotwal, S., Papanna, B., & Shoka, A., 2019)

Factitious disorder and malingering are both conditions in which a person consciously pretends to have an illness or injury. They can do this by lying about their symptoms, simulating illnesses and conditions, manipulating medical tests and records, or even inducing illness on purpose by taking drugs or harming themselves.

The difference between factitious disorder and malingering is in the motives behind the condition. A malingering person is motivated by external rewards. This can include financial compensation, such as disability payments, or avoidance of responsibilities, such as attending work, military services or jail time. In contrast, someone with factitious disorder has no clear external motive for acting ill.

As one of the main features of these disorders is deception, factitious disorder and malingering are both under-diagnosed, and the true figures of their prevalence are hard to obtain. The estimated prevalence for factitious disorder in the general population ranges widely across different studies, from as little as 0.007% to as high as 8%. A systematic search over 514 cases of factitious disorder reported that 65.4% of cases were female, with a mean age of 33.5. One in five of these patients had some kind of health care profession. In 2002, it was estimated that 29% of personal injury, 30% of disability, 19% of criminal, and 8% of medical cases all were likely to be caused by malingering.

A large concern with these disorders is the cost on the healthcare system. Factitious disorder is estimated to cost the United States $40 million per year, although the true figure is likely to be much higher due to under-diagnosis. Malingering is thought to cost the U.S. insurance industry $150 billion each year.

Factitious disorder is often referred to as Munchausen syndrome, a term created by Richard Asher when he first discovered the disorder. It should be noted that factitious disorder imposed on another (also referred to as factitious disorder by proxy or Munchausen syndrome by proxy) also exists and can be a serious and dangerous problem, though this will not be the focus of this page.

Factitious disorder
The fifth edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-V) states that the main feature of factitious disorder is consciously falsifying medical or psychological symptoms in oneself or in others, in the absence of obvious external rewards. This can include exaggerated or deceptive reports of symptoms, simulating illnesses or disorders, manipulating laboratory tests to induce abnormal results, falsifying medical records to include an illness, or even inducing a real illness or physical injury onto themselves.

DSM-V criteria for factitious disorder
The DSM-V states the following criteria for factitious disorder imposed on the self:
 * 1) Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
 * 2) The individual presents himself or herself to others as ill, impaired, or injured.
 * 3) The deceptive behaviour is evident even in the absence of obvious external rewards
 * 4) The behaviour is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Malingering
Malingering is the conscious falsification of medical or psychological symptoms in oneself with the intent of receiving external rewards. These rewards or incentives can include, but are not limited to, avoidance of duty or work, financial compensation or obtaining medication or drugs. While malingering is referenced multiple times in the DSM-V, unlike factitious disorder, it is not classified as a mental disorder. However, when it is found in patients, malingering is considered a focus of clinical attention, and thus the DSM-V has provided it with it's own V code.

Differential diagnoses


The distinction must be made between the diagnoses of malingering, factitious disorder, and somatization (See Figure 1).

Factitious disorder and malingering
As one might expect, factitious disorder and malingering are both differential diagnoses for each other. The defining difference between the two is the motivation for the deceptive behaviour, which needs to be clearly identified before classifying an individual into either condition.

Somatic symptom disorders
Other somatic symptom and related disorders should also be considered when diagnosing factitious disorder or malingering. These include somatic symptom disorder, illness anxiety disorder and conversion disorder. These disorders all share a common feature of somatic symptoms related to significant distress and impairment without a medical or physiological basis. An individual with one of these disorders may seek an excessive amount of medical attention and therefore be confused with having factitious disorder or malingering, but the key difference is that there is no conscious intent to deceive when experiencing other somatic symptom related disorders. Because of the deception in factitious disorder and malingering, it is obviously difficult to differentiate them from other conditions.

Borderline personality disorder
Some cases of factitious disorder and malingering can involve self harm, such as injuring oneself or inducing health abnormalities. Self harm and self mutilation with the absence of suicidal intent is also a symptom of borderline personality disorder. To differentiate from BPD, the induction of harm needs to be associated with deception.

Other medical and psychological conditions
Maybe the most obvious differential diagnosis for factitious and malingering disorder is the medical or psychological condition that the individual is presenting. Especially in the case of factitious disorder, distinguishing between the actual illness and the feigned condition can be incredibly difficult, as individuals with factitious disorder often have a previous association with the health care field, and thus have the knowledge and experience to fabricate their illness quite effectively. It can often require the collection and scrutiny of many different medical records and tests in order to differentiate the two.

Theories of motivation for factitious disorder and malingering
Using various psychological theories, this page will attempt to answer the problem statement:

What is it that motivates people with factitious disorder and malingering to deceive, simulate and induce illness and injury in themselves?

A continuum of malingering, factitious disorder and other somatic symptom disorders
While the DSM-V classifies all these conditions as separate, some believe that malingering, factitious disorder and other somatic symptom disorders exist on one continuum of deception and motivation.

An example of this is a scale with one end anchored towards unconscious, or 'self-deceptive' motivations, and the other anchored towards conscious, or 'other-deceptive' motivations. Towards the unconscious end of the scale is where disorders such as somatic symptom disorder and conversion disorder would lie. The conscious end of the scale is where factitious disorder and malingering can be found (Boone, 2007).

Some suggest an axis model for these disorders. Bass and Halligan (2007) conceptualise a model where the x axis represents the patients' responsibility, and the y axis represents the level of intention of the patient's choice, with non-intentional at 0 and intentional choice raising towards the top (See Figure 2.)

Hall and Hall (2012) provide a similar but different model, with the x axis representing the range of intentional symptom production, and the y axis representing the change in motivation, with internal motivation towards 0 and external motivation towards the top (See Figure 3.)

These scales and axes can help account for the complex relationship between the conscious and unconscious motivations for these disorders. They also provide insight into the idea that even in cases of malingering, where there is a clear external reward for their behaviour, there may also be unconscious motivations at play (Boone, 2007). In such a case, identifying one's condition as strictly malingering or factitious disorder would be impossible. This theory brings forth more information to underlying motivations behind all of these disorders. However, it also makes diagnosis more complicated and therefore could have implications for treatment.

Self-presentation strategies and supplication
Self-presentation strategies are behaviours that people engage in to communicate and project an image of themselves to other people (Baumesiter & Hutton, 1987). One form of this is supplication. If one is handicapped or injured in some way, whether it be physical or mental, it is the social norm to provide them with care. Supplication is a self-presentation strategy in where one advertises, or even exploits, their weakness and dependence (Jones and Pittman, 1982.)

It has been found that supplication is used by people to gain desired social support (Wong, 2012.) As it incites sympathy and pity, supplication can also bring others to excuse negative traits, such as poor job performance in the workplace.

Potentially, both factitious disorder and malingering could be an extreme form of supplication. By presenting themselves as sick or ill, these people would likely gain sympathy, care, and other benefits. Whilst these behaviours are being rewarded by surrounding people, as supplication is a method of self-presentation, these acts could also become entrenched in their personal identity.

This theory seems like a plausible basis of motivation for factitious disorder and even malingering, as sick or ill people are often more likely to receive external benefits as well. However, it does not provide much information on potential applications for treatments. This theory also only applies to factious  disorder imposed on the self, and cannot explain the motivations for factitious disorder imposed on another.

Factitious disorder as a maladaptive coping mechanism
Many of the behaviours that those with factitious disorder or malingering engage in are abnormal and can be quite intense or grotesque. They may inflict painful injuries or symptoms on themselves in order to simulate an illness, and in extreme circumstances, can even lead to death. As mentioned above, borderline personality disorder is considered a differential diagnosis for factitious disorder and malingering, as they both can include self-harm and self-mutilation.

If some cases of factitious disorder and malingering can be seen as a form of self-harm, one should consider the motivations for self-harm as well. Self-injury is considered to be a maladaptive coping mechanism for psychological stress (Walsh, 2006). To read more about self-injury and its motivations, go to See Also.

This suggests that a potential motivation for factitious disorder, and maybe even an underlying motivation for malingering, is to cope with stress or trauma. Evidence that supports this theory shows that high levels of emotional deprivation, physical abuse, sexual abuse, and neglect are often found in those with factitious disorder.

This theory provides good information not just about potential motivations for factious disorder, but also for its treatments, as treatments for self-injury could potentially cross over to help those with the disorder. It may even help with some underlying motivations of malingering, under the assumption that it is not just the external motivations feeding the condition. However, this theory can only be applied to those who harm themselves to simulate their illnesses. There are plenty of patients with both factitious disorder and malingering that do not engage in these harmful behaviours, and instead use deception, manipulation of medical test results, etc., to simulate their medical conditions. And once again, this theory cannot be applied to those with factitious disorder imposed on another.

Operant conditioning theory
Operant conditioning is the widely accepted phenomenon that one is likely to increase performing a behaviour that is rewarded, and decrease a behaviour that is being punished.

In the most basic sense, the behaviours of factitious disorder and malingering can be seen as being motivated by rewards. For malingering, these rewards are external, such as financial compensation, and for factitious disorder, they are most likely internal, such as care or sympathy. They are both also negatively reinforced as duties and responsibilities are often removed because of their illness. As these behaviours continue to be rewarded, the patient is encouraged, and learns to repeat them. Therefore, factitious disorder and malingering could be the result of social learning.

This theory can be applied to malingering and both forms of factitious disorder, both 'imposed on the self' and 'imposed on another'. It also provides opportunities for treatments. If one takes away these rewards, or replaces them with punishments, according to operant conditioning, these behaviours should cease. However, this theory may appear too simplistic for such a complicated set of disorders.

Current research on motives for factitious disorder and malingering
Much of the research on factitious disorder and malingering focuses on detection, diagnosis and treatment. This is most likely for multiple reasons. As these conditions are centred around medicine, factitious disorder and malingering are usually discovered by medical professionals of some kind. These people do not necessarily have in-depth training in psychology, and therefore do not have the knowledge or resources to consider why these patients simulate illnesses. The more important questions to them are how to determine if a patient is deceiving them, how does one stop this behaviour, and how does one prevent others from developing these conditions.

But in order to answer these, a deeper understanding of the motivations behind factitious disorder and malingering is necessary. These motives are often unclear, but even so, in the pursuit to simulate illness, patients with factitious disorder are often strongly motivated. As mentioned before, they will often inflict painful symptoms upon themselves, endure uncomfortable operations and investigations, and conduct intensive medical research. In the worst cases, their behaviours may even result in death.

Motives for factitious disorder
Many medical professionals who encounter patients with factitious disorder report that they desire to obtain and maintain a sick role and receive attention. By remaining in this sick role, they may be attempting to meet underlying needs of dependency, or compensate for a psychological deficit they have, such as a need for identity. Factitious disorder being a learnt behaviour, an act of internalised masochism, and a psychological coping mechanism, among many others, are theorised. It has been commonly assumed that the motivations for factitious disorder are unconscious processes, however, that may not be the case.

A common method of factitious disorder research is the use of case studies. Syed, Khan and Hossain (2017) investigated a 45 year old woman who met the criteria for factitious disorder imposed on the self. She had scratches and cuts on her body, which she claimed happened by accident during the night while she was asleep. Eventually, when acknowledging that she had performed the injuries on herself, she claimed that her motivation was to "assume the sick role, and get the attention of her children." However, a case study, while in-depth, cannot be generalised across all accounts of those with factitious disorder, as one person's motivations for simulating illness and injury may not be another's.

In a case study by Hagglund, a patient discussed that their motivation to assume the sick role was to avoid emotionally uncomfortable situations and certain responsibilities in a socially acceptable manner. This is a variation of operant conditioning, in where avoiding a punishing situation becomes a learnt behaviour over time. However, as it seems this patient was motivated by external factors, the argument that they did not have factitious disorder, but instead malingering, should be considered.

Lawlor and Kirakowski reported the long-term motivations of 57 individuals in two online support groups for factitious disorder. The most cited motivation was the desire to receive affection. Users reported feelings of being unloved, wanting to be cared for, to feel special and to be 'rescued'. Acting ill was a way to for isolated individuals to make social contact with other people, whether it was for family and friends, or even just medical professionals. Some users of these forums described this attention as insatiable and that they were always wanting more. In this way, their actions could be explained by operant learning, in that they were always rewarded and were taught to seek more attention.

The majority of forum members also reported some form of childhood abuse, usually mental, including lack of emotional support, bullying, and harsh criticism, from parents. Physical abuse and sexual abuse were also reported, as well as other familial problems such as feeling estranged from family members, history of familial mental illness, familial chronic illness and childhood illness. Many also recognised that their factitious disorder was an unhealthy coping mechanism for their previous traumas.

Some also identified with being sick, to the point where not being in the 'sick role' felt uncomfortable to them, supporting the idea that supplication may play a role in the motivations of factitious disorder.

Many more long-term motivations were reported, as well as the triggers that would set off their episodes of simulating illness.

While this study provides a large amount of information on these individual's motivations, it is important to consider its limitations. The forum members were largely self-diagnosed, and thus it cannot be reliably said that all of them had a diagnosable case of factitious disorder. As these people were seeking support for their condition, there is also potential that they are the exception, and not the norm, of factitious disorder patients, by having a more conscious understanding of their motivations.

Even so, this study provides a rare insight into the motivations behind people with factitious disorder, as it is often quite difficult to confront them directly.

Motives for malingering
At first, the motives for malingering may seem obvious compared to factitious disorder, in that they are external rewards, such as financial compensation, or avoidance of certain responsibilities. However, research shows that the relationship between malingering behaviours and their rewards is more complex.

Evidence shows that an increase in reward can show an increase in simulating illness behaviours. This supports the idea that malingering is a form of operant learning, as a larger reward can produce a larger behavioural response.

The use of supplication has also been found to deter negative performance reviews in work environments, showing that malingerers could effectively use supplication presentation strategies in the workplace.

Research by Rogers suggests that in some individuals, malingering is an individual's attempt to cope with extreme life stressors. The malingerer sees no other alternative to reaching their goal than to deceive, for example, a person who is in desperate need of money may act ill to receive compensation. As theorised earlier, it may also be an indication of poor coping skills.

Conclusion
The motivations behind factitious disorder, and even the potential underlying motivations of malingering, are still not entirely well understood. While it has not been the main focus for research as of yet, it is a vital piece of the puzzle in order to help those with the conditions or those who are at risk of developing them. As well as this, knowledge of the motives for factitious disorder and malingering can benefit many societal institutions, such as the healthcare system, insurance companies, workplace environments, the military and even criminal detention services. A stronger understanding of the prevalence of these conditions, while difficult to obtain, would be a great first step. More case studies of those with factitious disorder could provide more in-depth information about their motives for staying in their sick role. Malingering as a behaviour is likely to always exist, but with a greater understanding in the fields where it is likely to occur could minimise the financial damage it can cause. Overall, much development is needed in the research behind factitious disorder and malingering in order to help its prevention, detection and treatment.