Deception in Clinical Settings Summary (incl. material from readings)
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Course
Deception in clinical settings (PSB3EM13)
Institution
Rijksuniversiteit Groningen (RuG)
I combine the information on the slides with the information in the articles assigned. The summary is complete, structured, and easy to follow. Hope it helps!
Week 1: Introduction to deception in clinical settings
Deception in animals
- Feigning of death to avoid predators is common in many animal Many common psychiatric disorders are accompanied by
species (e.g. opossum) deceptive behaviour:
• Substance abuse and dependence
Assumption of honesty Part of the disease: denial and the forms of deception
• Clinicians are trained to believe patients In order to: minimise consequences and ensure continued supply of
• Consequently, often not aware of the potential for deception in the substance
the clinical setting
• However, some patients deliberately produce false or grossly • Eating disorders
exaggerate symptoms Body weight manipulation, secretive use of laxatives or diuretics,
- To gain external incentives (malingering) or hiding food, dishonesty about weight or food intake
- To assume the sick role (factitious disorders)
• Paraphilia
Sexual deviances or perversions (fetishism, voyeurism, pedophilia,
exhibitionism etc)
Factitious disorders and malingering
• Personality disorders (difficulties with impulse control, incl.
Factitious disorders: A psychiatric condition in which an exaggeration or lying)
individual presents wit an illness that is deliberately produced or
falsified for the purpose of assuming the sick role
Malingering: The intentional production of false or grossly
exaggerated physical or psychological symptoms motivated by
external incentives, such as financial compensation(and will
generally seek to minimise medical contact to maintain deceit)
Categories of malingering (Resnick, 1984)
• Pure malingering — entirely fabricating a psychological or
medical condition that doe snot and has never existed.
• Partial malingering — exaggerating symptoms of a
condition that actual exists.
• False imputation —- ascribing symptoms to an unrelated
cause.
Differential diagnosis
If a physician or psychologists raise stem issue of malingering as a clinical consideration, five conditions should first be considered
in the differential diagnosis:
1. Undetected physical pathology
2. Somatisation disorder
3. Hypochondriasis
4. Pain disorder
5. Factitious disorder with predominantly physical signs and symptoms What about clinicians?
Somatic symptoms and related disorders: Many physicians are prepared to lie in the
• Prominence of somatic symptoms associated with significant distress and impairment
interest of their patients (e.g. incentive
• Different forms (e.g. conversion disorder an illness anxiety disorder)
• Illness anxiety disorder: preoccupation with fears of having a serious illness could be securing insurance payment)
• Conversion disorder: sensory or motor symptoms without any psychological cause
Explanatory Models: Why do people malinger?
Adaptational Model Pathogenic Model Criminological Model
Cost-benefit analysis results in deliberate Underlying disorders discloses in Malingering is sign of antisocial
decision to feign psychological malingered symptomatology (i.e. behaviour committed by antisocial
impairment malingerers “can’t control their persons (DSM relies on this model,
behaviour”) which is questioned by research data)
E.g. In substance abuse: escaping and
avoiding responsibilities • E.g. Eating disorder: rigidity, distorted • E.g. Conduct disorder: Poor impulse
body image, maintaining control control
• E.g. Substance abuse: self-medicating • E.g. Substance abuse: Secondary to
• E.g. Paraphilia: own abuse history leads antisocial personality disorder
to poor boundaries • E.g. paraphilia: Luring victims/
maintaining offending
, Week 2: Factitious Disorder Case report: Bethany Storro
Factitious disorders refer to the psychiatric condition in which an individual presents
with an illness that is deliberately produced or falsified, usually for the purpose of Falsified severe acid burns in her face, while
assuming the sick role claiming her eyesight was saved by a pair of
FD can be imposed on self (FDIOS) or imposed on another (FDIOA) glasses she had bought that day before being
attacked by a black woman who allegedly
Modern history of FD:
threw acid in her face
Asher (1951) introduced term Munchausen’s syndrome: patients who habitually migrate
form hospital to hospital, seeking admission through feigned symptoms, while
embellishing their personal history During a police interview, she admitted that the
Then Meadow (1977) coined the term Munchausen’s syndrome by proxy (nowadays injuries were self-inflicted
termed “FD imposed on other")
Classification: DSM5 criteria
A. Falsification of physical or psychological signs or symptoms, or induction of Case report: Factitious transsexualism
injury or disease, associated with identified deception
B. The individual presents himself or herself to others as ill, impaired, or injured A 68 year old patient resorted to a ruse of
C. The deceptive behaviour is evident even in the absence of obvious external transsexualism because he thought to would
rewards
D. The behaviour is better explained by another mental disorder, such as delusional bring him security and special care
disorder or another psychotic disorder He repeatedly came to a psychiatrists asking to
Criteria change in DSM-5 Ed.: Motivation to assume the sick role has been removed as be changed into a woman
a requirement for FD diagnosis. He even showed the psychiatrist photos of
himself dresses as a woman and wearing a wig
Three types of FD: The psychiatrist never believed him, and finally
1. FD with predominantly psychological signs and symptoms one day te patient confessed the real reason for
2. FD with predominantly physical signs and symptoms wanting the operation: “nobody cares about old
3. FD with combined psychological and physical signs and symptoms men, but they take care of old women”
Pseudologia fantastica or compulsive lying or pathological lying
• Perpetration appears to be designed in order to bolster self-esteem and promote
admiration by others
• Falsifies a substantial amount of information and understand the difference between Case report: Pseudologia Fantastica
fact and fiction
• Patients tend to forget some of their lies or details they provide - lead to A 41 year old divorced woman went to a
inconsistencies which result in the discovery of their lies hospital complaining of joint pain and fever.
Comorbid disorders Claiming to have been an active freedom
The sole diagnosis of FD is rare… fighter in the Israeli War for Independence in
Overlap with 1948, she became a star in the hospital.
• Personality disorders She was later discovered for lying about her
• Mood disorders
• Substance abuse disorders life.
• Adjustment disorders
• Eating disorders
Mortality & morbidity Prevalence
Four features of FD that are particularly prominent in Munchausen syndrome significantly
increase the morbidity and mortality risks
• Only cases in which deception has
1. Dangerous manipulations of the patient’s own body (e.g. ingestion of chemical toxins, been unsuccessful are being reported,
self-infection, aggravation of wounds) so the condition is probably under-
2. Patients with FD frequently provide incomplete or false medical history information — diagnosed because it involves wilful
intentionally or accidentally cause increase of risk of morbidity or mortality (e.g.
deception
dangerous adverse medication effects)
3. For genuinely ill patients with a known history of factitious medical complaints —
medical staff may withhold or delay necessary tests and treatments • Conversely, the prevalence of chronic
4. Patients place themselves at risk by repeatedly engaging in deceptions that cause medical FD may be over-diagnosed in some
care providers to undertake risky diagnostic and treatment procedures cases because the same patients with
FD may migrate from hospital to
hospital
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