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SUMMARY OF CASES OF FACTITIOUS ILLNESSES
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Six cases of factitious disease and malingering in pediatric patients referred to an infectious diseases practice in a tertiary care children's hospital are described, and implications for general clinical practice are reviewed. All patients were girls aged 9-15 years. Two patients were malingering with the secondary gain of avoiding attendance at...
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Citations
... This is particularly true from a semeiological standpoint, where functional and simulated movement disorders can be impossible to differentiate, even if several functional magnetic resonance imaging (fMRI) studies have shown differences in regions of activation (Hassa et al., 2016;Perez et al., 2021). Additionally, an accurate psychosocial history must be taken when evaluating these conditions, as both functional and factitious disorders often have experienced traumatic adverse events in childhood (Hausteiner-Wiehle & Hungerer, 2020;Peebles et al., 2005;Steffen-Klatt et al., 2019). ...
Functional neurological symptom disorders (FNSD) pose a common challenge in clinical practice, particularly in pediatric cases where the clinical phenotypes can be intricate and easily confused with structural disturbances. The frequent coexistence of FNSDs with other medical disorders often results in misdiagnosis. In this review, we highlight the distinctions between FNSD and various psychiatric and neurological conditions. Contrary to the misconception that FNSD is a diagnosis of exclusion, we underscore its nature as a diagnosis of inclusion, contingent upon recognizing specific clinical features. However, our focus is on a critical learning point illustrated by the case of a 14-year-old male initially diagnosed with FNSD, but subsequently found to have a rare primary monogenic movement disorder (paroxysmal kinesigenic dyskinesia, PKD). The crucial takeaway from this case is the importance of avoiding an FNSD diagnosis based solely on psychiatric comorbidity and suppressible symptoms. Instead, clinicians should diligently assess for specific features indicative of FNSD, which were absent in this case. This emphasizes the importance of making a diagnosis of inclusion. Extended follow-up and clinical-oriented genetic testing might help identify comorbidities, prevent misdiagnosis, and guide interventions in complex cases, which cannot be simply classified as “functional” solely because other conditions can be excluded.
... Journal of Psychology and Behavioral Science, Vol. 9, No. 1, June 2021 According to McCaffrey and Lynch (2009, p. 377) -In addition to having the capability for deceptive behavior, children have been found to use this skill to fabricate symptoms during medical, psychological, and neuropsychological examinations.‖ Peebles et al. (2005) reported two cases of malingering in adolescent girls to avoid attendance at school. In the first case, a 14-year-old girl presented with fatigue, reduced appetite, nausea, and a facial rash. ...
... As noted in DSM-5, malingering may in some cases represent adaptive behavior (e.g., feigning illness while captive during wartime), and this was also added to the description of incentives. More common examples also include feigning illness to avoid school and thus evade bullying or feigning illness to avoid being discharged from hospital to an abusive home, or to stop a parental separation (e.g., Kirkwood, Kirk, Blaha, & Wilson, 2010;Peebles, Sabella, Franco, & Goldfarb, 2005). ...
Objectives:
Empirically informed neuropsychological opinion is critical for determining whether cognitive deficits and symptoms are legitimate, particularly in settings where there are significant external incentives for successful malingering. The Slick, Sherman, and Iversion (1999) criteria for malingered neurocognitive dysfunction (MND) for malingered neurocognitive dysfunction (MND) are considered a major milestone in the field's operationalization of neurocognitive malingering and have strongly influenced the development of malingering detection methods, including serving as the criterion of malingering in the validation of several performance validity tests (PVTs) and symptom validity tests (SVTs) (Slick, D.J., Sherman, E.M., & Iverson, G. L. (1999). Diagnostic criteria for malingered neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist, 13(4), 545-561). However, the MND criteria are long overdue for revision to address advances in the field of malingering research and to address limitations identified by experts in the field.
Method:
The MND criteria were critically reviewed, updated with reference to research on malingering, and expanded to address other forms of malingering pertinent to neuropsychological evaluation such as exaggeration of self-reported somatic and psychiatric symptoms.
Results:
The new proposed criteria simplify diagnostic categories, expand and clarify external incentives, more clearly define the role of compelling inconsistencies, address issues concerning PVTs and SVTs (i.e., number administered, false positives, and redundancy), better define the role of SVTs and of marked discrepancies indicative of malingering, and most importantly, clearly define exclusionary criteria based on the last two decades of research on malingering in neuropsychology. Lastly, the new criteria provide specifiers to better describe clinical presentations for use in neuropsychological assessment.
Conclusions:
The proposed multidimensional malingering criteria that define cognitive, somatic, and psychiatric malingering for use in neuropsychological assessment are presented.
... In dissociative disorders, on the other hand, the person is not aware of the unreal nature of the symptoms but truly believes that they have the reported ailments. [2][3][4]7 A clear documentation and proper evaluation will promote a safe and supportive relationship to assist in eliciting possible underlying motivations. 8,9 The client's knowledge of psychotic symptoms must be explored. ...
There are few reported cases of malingering in children in developed countries, but none has been reported among Nigerian children. This could be because of missed diagnosis, thus creating the impression that malingering is rare in children. Ability to clearly establish that a client has a primary motive behind feigning the illness is a major to look for in malingering. We present a case of a 5-year-old boy with a history of recurrent abnormal body movement and shaking of his body which on detailed evaluation revealed the intention behind his presentation.
... Pattern of symptom presentation is varied and may involve multiple organ systems. Patients described here had Gastrointestinal and Genitourinary system related complaints [10,11]. A brief summary of both the case scenarios is presented in table 1. ...
Literature on illness falsification by caregivers is in abundance. There remains an
invisible group, where the symptoms can be intentionally feigned by child and adolescent
patients. Recognizing this group is essential and a high index of suspicion is necessary to
arrive at a diagnosis. In this group, it is not only difficult to identify the mechanism of
symptom production but also to delineate if it is feigned by the adolescent or they
participate in the fabrication of symptoms along with their perpetrator. Motivation
remains another challenging area of debate in this group. As in other pediatric somatic
symptom disorders, pediatric factitious disorder also has a better prognosis with a nonconfrontational
approach, the focus being symptom reduction, uncovering the conflict
area, assessing family dynamics and behavioral approaches as and when necessary. Here
we present two adolescent patients diagnosed with factitious disorder based on their
symptom presentation and family psychopathology. Management principles employed
for both the patients are also discussed.
... Feigning psychiatric symptoms and/or cognitive deficits is a behavior that transcends a variety of clinical, cultural, and linguistic contexts. Feigning has been identified across genders (Rogers, Salekin, Sewell, Goldstein, & Leonard, 1998), ages (Peebles, Sabella, Franco, & Goldfarb, 2005), and cultures (Salazar, Lu, Wen, & Boone, 2007). Depending on the clinical and evaluation context, prevalence rates of malingering in the United States have been estimated to be as low as 1% in clinical practice or 5% in military settings, but higher in medico-legal contexts where financial gain or legal responsibility are of a concern (Singh, Avasthi, & Grover, 2007). ...
The cross-cultural validity of feigning instruments and cut-scores is a critical concern for forensic mental health clinicians. This systematic review evaluated feigning classification accuracy and effect sizes across instruments and languages by summarizing 45 published peer-reviewed articles and unpublished doctoral dissertations conducted in Europe, Asia, and North America using linguistically, ethnically, and culturally diverse samples. The most common psychiatric symptom measures used with linguistically, ethnically, and culturally diverse samples included the Structured Inventory of Malingered Symptomatology, the Miller Forensic Assessment of Symptoms Test, and the Minnesota Multiphasic Personality Inventory (MMPI). The most frequently studied cognitive effort measures included the Word Recognition Test, the Test of Memory Malingering, and the Rey 15-item Memory test. The classification accuracy of these measures is compared and the implications of this research literature are discussed. (PsycINFO Database Record
... • Predisposing factors and personality traits: Mr. S possessed predisposing factors typically seen in patients with factitious disorder, including family history of psychiatric illness (mother with depression; father with alcoholism), and history of physical abuse or emotional neglect (corporal punishment and emotional neglect by his father) (21). Furthermore, there are high rates of substance abuse with onset in the early adult years, as well as mood disorders and personality disorders in individuals diagnosed with factitious disorder (16). ...
Factitious disorder involves the conscious simulation of psychological or physiological symptoms of illness, for the purpose of fulfilling the unconscious desire to be taken care of or to assume the “sick role.” Typically patients with factitious disorder simulate conditions that are designed to arouse feelings of empathy in care providers with the intention to engage them in caretaking. However, patients might also simulate conditions that arouse revulsion or rejection and still meet full diagnostic criteria for factitious disorder. In this case report, we present a patient who fabricated an elaborate history of being a sexually sadistic serial killer with homicidal ideation with the intention of obtaining personal attention, nurturance, and empathy from his psychotherapist. However, given the nature of his feigned condition, the patient frightened the very person whom he sought to engage in caretaking.
... This required differentiating MSBP from Münchausen's syndrome (chronic FD) [3]. Libow et al. described as much as 42 cases, and Peebles et al. described 6 cases of children fabricating their diseases [5,17]. ...
Münchausen syndrome by proxy (MSBP) describes a pattern in which a caregiver induces a disease in a child. The symptoms may manifest in the oral cavity.
PubMed was researched for articles between 1990-2014, presenting manifestations of MSPB, following PRISMA 2009 guidelines, and an in-house case of MSBP with oral manifestations was presented.
Among 66 articles presenting MSBP symptoms, four included descriptions of oral lesions in five children. They included: tooth loss, ulcerations and ulcers on oral mucosa, scars due to old, healed lesions, bleeding, black tongue, polysialia, and discolouration and swelling in the lips. Münchausen syndrome by proxy with participation of the mother was diagnosed in four cases.
A 13-year-old girl was hospitalised because of a non-healing ulcer of the septum, loose and lost mandibular teeth, skin lesions, and suspected immunodeficiency. She had been hospitalised numerous times at other facilities. Consultations and diagnostic tests did not confirm an organic disease. The patient and her mother agreed to undergo all examinations, and some symptoms 'went away' during the examinations. The behaviour of the patient and her mother during hospital stays, ambulatory care, and the psychiatric observations all pointed towards MPSB. They refused further treatment at the present facility.
A dentist should take into account the potential 'fabrication' of symptoms in a child by the latter or by a caregiver. Consultations with a paediatrician or psychiatrist enable a diagnosis and treatment.
... [34][35][36][37] Outright malingering is apt to occur less frequently in children, although multiple case reports and case series have documented that children provide noncredible responses at least occasionally during health care examinations. [38][39][40][41][42][43][44][45][46][47][48][49][50] Only 1 identified study has focused on how frequently noncredible responding occurs after pediatric mTBI specifically. A consecutive neuropsychological case series of ours consisting of 193 school-aged children found that 17% of the sample failed a performance validity test (PVT). ...
A minority of pediatric patients who have mild traumatic brain injury (mTBI) report persistent postconcussive symptoms. In adults, failure on validity tests, which help to detect exaggerated or feigned problems, is associated with symptom complaints. No pediatric studies have examined the relationship between validity test performance and symptom report. We hypothesized that children failing a validity test would report significantly more postconcussive symptoms than those passing.
Using a consecutive clinical case series design, we examined 191 patients aged 8 to 17 years seen for neuropsychological evaluation after mTBI. Participants were administered a validity test (Medical Symptom Validity Test; MSVT) and completed a graded symptom scale as part of a neuropsychological battery.
A total of 23 participants (12%) failed the MSVT. The Fail group endorsed significantly more postconcussive symptoms than the Pass group, with a large effect size (P < .001; d = 1.1). MSVT performance remained a robust unique predictor of symptom report even after controlling for other influential factors (eg, female gender, premorbid psychiatric problems).
A subset of children who had persistent complaints after mTBI may be exaggerating or feigning symptoms. If such negative response bias remains undetected, errors in etiologic statements and less than optimal treatment may occur. Because the detection of invalid responding is well established in neuropsychology, clinical neuropsychologists should be incorporated routinely into clinical care for patients who have persistent complaints. To better control for noninjury effects in future pediatric mTBI studies, researchers should add validity tests to neurobehavioral outcome batteries.
... In some of these women, the self-induced illnesses begin in adolescence, 49 and prevalence rates in adolescent consultation-liaison services are similar to those noted for adults. 50,51 As many as one half of these patients work in health-related occupations. 52 Studies including a heterogeneous case series suggest a typology that includes: (a) a dramatic, deceptive, hostile, sociopathic wandering type, mostly male (Munchausen's syndrome as described by Asher 53 ), comprising about 10% of cases and becoming increasingly rare; 12 ...
Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identification largely dependent on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient's medical record. Management of such disorders ideally requires a team-based approach and close involvement of the primary care doctor. As deception is a key defining component of factitious disorders, diagnosis has important implications for young children, particularly when identified in women and health-care workers. Malingering is considered to be rare in clinical practice, whereas simulation of symptoms, motivated by financial rewards, is regarded as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can inform the detection of illness deception, such tests need support from converging evidence sources, including detailed interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of abnormal health-care-seeking behaviour is the extent to which a person's reported symptoms are considered to be a product of choice, or psychopathology beyond volitional control, or perhaps both. Clinical skills alone are not typically sufficient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and deal with patients whose symptoms appear to be simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors. Future progress in management will benefit from an increased appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical findings from social neuroscience, occupational health, and clinical psychology.
