DSM-IV

Diagnostic Criteria

A. Intentional production of feigning of physical or psychological signs or symptoms.

B. The motivation for the behavior is to assume the rick role.

C. External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in Malingering) are absent.

Record based on type:

  • With Predominantly Psychological Signs and Symptoms: if psychological signs and symptoms predominate in the clinical presentation
  • With Predominantly Physical Signs and Symptoms: if physical signs and symptoms predominate in the clinical presentation
  • With Combined Psychological and Physical Signs and Symptoms: if both psychological and physical signs and symptoms are present but neither predominates in the clinical presentation

Subtypes

With Predominantly Psychological Signs and Symptoms

This subtype describes a clinical presentation in which psychological signs and symptoms predominate. It is characterized b the intentional production or feigning of psychological (often psychotic) symptoms that are suggestive of a mental disorder. The individual's goal is apparently to assume the "patient" role and is not otherwise understandable in light of environmental circumstances (in contrast to the case in Malingering). This subtype may be suggested by a wide-ranging symptomatology that often does not correspond to a typical syndromal pattern, an unusual course and response to treatment, and the worsening of symptoms when the individual is aware of being observed. Individuals with this subtype of Factitious Disorder may claim depression and suicidal ideation following the death of a spouse (the death not being confirmed by other informants), memory loss (recent and remote), hallucinations (auditory and visual), and dissociative symptoms. These individuals may be extremely suggestible and may endorse many of the symptoms brought up during a review of symptoms. Conversely, they may be extremely negativistic and uncooperative when questioned. The presentation usually represents the individual's concept of mental disorder and may not conform to any recognized diagnostic category.

With Predominantly Physical Signs and Symptoms

This subtype describes a clinical presentation in which signs and symptoms of an apparent general medical condition predominate. The individual's entire life may consist of trying to get admitted to, or stay in, hospitals (known as "Munchausen syndrome"). Common clinical pictures include severe right-lower-wuadrant pain associated with nausea and vomiting, dizziness and blacking out, massive hemoptysis, generalized rashes and abscesses, fevers of undetermined origin, bleeding secondary to ingestion of anticoagulants, and "lupus-like" syndromes. All organ systems are potential targets, and the symptoms presented are limited only by the individual's medical knowledge, sophistication, and imagination.

With Combined Psychological and Physical Signs and Symptoms

This subtype describes a clinical presentation in which both psychological and physical signs and symptoms are present, but neither predominates.

Differential Diagnosis

True general medical condition or mental disorder

A Factitious Disorder must be distinguished from a true general medical condition and from a true mental disorder. Suspicion that an apparent mental disorder or general medical condition in fact represents Factitious Disorder should be aroused if any combination of the following is noted in a hospitalized individual: an atypical or dramatic presentation that does not conform to an identifiable general medical condition or mental disorder; symptoms or behaviors that are present only when the individual is being observed; pseudologia fantastica; disruptive behavior on the ward (e.g., noncompliance with hospital regulations, arguing excessively with nurses and physicians); extensive knowledge of medical terminology and hospital routines; covert use of substances; evidence of multiple treatment interventions (e.g., repeated surgery, repeated courses of electroconvulsive therapy); extensive history of traveling; few, if any, visitors while hospitalized, and a fluctuating clinical course, with rapid development of "complications" or new "pathology" once the initial workup proves to be negative.

Somatoform Disorders

In Somatoform Disorders, physical complaints that are not fully attributable to a true general medical condition are also present, but the symptoms are not intentionally produced.

Malingering

Malingering differs from Factitious Disorder in that the motivation for the symptom production in Malingering is an external incentive, whereas in Factitious Disorder external incentives are absent. Individuals with Malingering may seek hospitalization by producing symptoms in attempts to obtain compensation, evade the police, or simply "get a bed for the night." However, the goal is usually apparent, and they can "stop" the symptoms when the symptoms are no longer useful to them.

DSM-5

Diagnostic Criteria

Factitious Disorder Imposed on Self

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

B. The individual presents himself or herself to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Specify:

  • Single episode
  • Recurrent episodes (two or more events of falsification of illness and/or induction of injury)

Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy)

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.

B. The individual presents another individual (victim) to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Note: The perpetrator, not the victim, received this diagnosis.

Specify:

  • Single episode
  • Recurrent episodes (two or more events of falsification of illness and/or induction of injury)

Recording Procedures

When an individual falsified illness in another (e.g., children, adults, pet), the diagnosis is factitious disorder imposed on another. The perpetrator, not the victim, is given the diagnosis. The victim may be given an abuse diagnosis.

Differential Diagnosis

Caregivers who lie about abuse injuries in dependents solely to protect themselves from liability are not diagnosed with factitious disorder imposed on another because protection from liability is an external reward (Criterion C, the deceptive behavior is evident even in the absence of obvious external rewards). Such caregivers who, upon observation, analysis of medical records, and/or interviews with others, are found to lie more extensively than needed for immediate self-protection are diagnosed with factitious disorder imposed on another.

Somatic symptom disorder

In somatic symptom disorder, there may be excessive attention and treatment seeking for perceiving medical concerns, but there is no evidence that the individual is providing false information or behaving deceptively.

Malingering

Malingering is differentiated from factitious disorder by the intentional reporting of symptoms for personal gain (e.g., money, time off work). In contrast, the diagnosis of factitious disorder requires the absence of obvious rewards.

Conversion disorder (functional neurological symptom disorder)

Conversion disorder is characterized by neurological symptoms that are inconsistent with neurological pathophysiology. Factitious disorder with neurological symptoms is distinguished from conversion disorder by evidence of deceptive falsification of symptoms.

Borderline personality disorder

Deliberate physical self-harm in the absence of suicidal intent can also occur in association with other mental disorders such as borderline personality disorder. Factitious disorder required that the induction of injury occur in association with deception.

Medical condition or mental disorder not associated with intentional symptom falsification

Presentation of signs and symptoms of illness that do not conform to an identifiable medical condition or medical disorder increases the likelihood of the presence of a factitious disorder. However, the diagnosis of factitious disorder does not exclude the presence of true medical condition or mental disorder, as comorbid illness often occurs in the individual with factitious disorder. For example, individuals who might manipulate blood sugar levels to produce symptoms may also have diabetes.

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