Psychosomatics 47:23-32, February 2006
doi: 10.1176/appi.psy.47.1.23
© 2006 Academy of Psychosomatic Medicine
Factitious Disorders
Reformulating the DSM–IV Criteria
Mark A. Turner, M.B., Ch.B., MRCP, MRCPsych, M.A., M.Sc., M.Phil.
Received October 7, 2004; revised February 3, 2005; accepted March 2, 2005. From the Mental Health Unit, University Hospital of North Tees, Hardwick, Stockton On Tees, UK TS19 8PE. e-mail: mark.turner{at}tney.northy.nhs.uk
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ABSTRACT
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The author criticizes and reformulates the DSM–IV criteria in a clinically and nosologically sensitive way. Criterion A, the intentional production of physical or psychological signs or symptoms, emphasizes symptoms and cannot accommodate pseudologia fantastica, voluntary false confessions, and impersonations. Criterion B, the motivation is to assume the "sick role," has no empirical content and fulfills no diagnostic function. The two criteria need reformulating in terms of lies and self-harm, respectively. Criterion C causes misdiagnosis by pushing factitious disorders into the somatoform and malingering categories and should be abandoned. The author discusses the implications for the etiology of conversion disorders and the classification of factitious disorders.
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INTRODUCTION
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The DSM–IV gives three diagnostic criteria for factitious disorder—A: the intentional production of physical or psychological signs or symptoms; B: the motivation is to assume the sick role; and C: the absence of external incentives.1 Criteria A and C do most of the work, in keeping with the time-honored view that the diagnostic and nosological challenge to factitious disorders comes from two directions. Criterion A supposedly excludes disorders characterized by the unintentional production of symptoms, thereby marking a distinction between factitious disorders and somatoform disorders, especially somatization and conversion disorders and dissociative disorders. Criterion C, on the other hand, excludes the intentional production of symptoms for external gain, thereby supposedly marking a distinction between factitious disorders and those aspects of normal human behavior that constitute malingering.
At a superficial level, the criteria seem to do what they are supposed to, but there are both theoretical and practical problems with them. At the theoretical level, even when we extrapolate from the practical problems applying DSM–IV criteria, there are two reasons for thinking they do not capture the presentations that they intuitively should. First, pseudologia fantastica, voluntary false confessions, and impersonations should arguably be captured by DSM–IV, but are not, because Criterion A is formulated in a medically parochial way. Second, presentations involving deliberate physical self-harm in the absence of suicidal intent satisfy all three of DSM–IV criteria despite being clearly distinguishable from factitious disorder because they do not involving lying about the origin of symptoms. In terms of the usefulness of the criteria in clinical practice, the reliance on "intentions" and "incentives" results in misdiagnosis. More specifically, since the inference of an intention to produce symptoms (Criterion A) is inextricably bound up with finding behavior meaningful, it is inevitable that, in virtue of its meaninglessness, factitious behavior will tend to be wrongly diagnosed as unintentional, and, therefore, as hysterical. Second, the presence of incentives often does little to assuage the feeling that one is in some sense dealing with a factitious disorder. These issues are complicated, but both points raise questions about the viability of Criterion C as a diagnostic criterion.
The upshot is that DSM–IV provides criteria the satisfaction of which is neither necessary nor sufficient for a presentation to be a factitious disorder. The consequence of this is that the most important psychiatric classification system artificially restricts the scope of academic attention by obfuscating the diagnostic issues and excluding, by the front door, what clinical psychiatry has already started to let in through the back. Not surprisingly, therefore, there has been little progress in our understanding of factitious disorders in the 50 years or so since Richard Asher published his original observations on Munchausen’s syndrome.2 This article attempts to improve the situation by exposing DSM–IV’s confusion and reformulating the diagnostic criteria in a more nosologically sensitive way. The article concludes with a brief discussion of the implications of the reformulated criteria for the etiology of conversion, somatization, and dissociation disorders and whether factitious disorders should be classified as somatoform disorders.
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Criterion A: From Symptoms to Lies
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Most of the problems with DSM–IV’s approach to factitious disorders can be traced to Criterion A: the intentional production of signs and symptoms. The two elements of this criterion, intentional production and symptoms, were introduced in early descriptions of Munchausen’s syndrome2 and were built directly into Criterion A by DSM–IV. However, because patients with Munchausen’s syndrome typically act upon themselves, to cause what are, ultimately, real physical symptoms, the authors of DSM–IV, like their predecessors, were inadvertently led into drawing an artificial distinction between intentionally produced symptoms, which they regard as "essential feature[s]," and lies, which they regard as a contingent feature. The DSM–IV states that, "individuals with factitious disorder...may engage in lying," thereby betraying the fact that it treats lying as an accoutrement that, aside from entertaining physicians, serves merely to ensure that the essential symptoms get their attention. Now, if Criterion A were intended to capture only factitious disorders associated with physical self-harm, DSM–IV’s confusion may well have escaped attention. But it is not, and if we reflect on the nature of factitious psychological disorders, such as bereavement,3 multiple personality,4 and posttraumatic stress disorder (PTSD),5 the muddled conceptual thinking that underlies Criterion A can be brought into sharp relief.
DSM–IV tries to accommodate the recent emergence of factitious psychological disorders not by altering the original thrust of Criterion A but by appending sub-codes that allow diagnosticians to stipulate whether the symptoms they are referring to in applying Criterion A are physical or psychological. This, however, entirely neglects the fact that in factitious psychological disorders (and indeed factitious physical disorders involving claims about, for example, pain and fatigue) the symptoms are lies. (From now on, we will write "symptoms" to register this fact). The result is that DSM–IV is implicitly committed to, first, a tautological formulation of Criterion A, vis-à-vis the intentional production of intentional productions, and second, to informing its readers that "individuals with [psychological] factitious disorder... may engage in lying," which is, at best, unhelpful, and, at worst, complete nonsense. If these difficulties are to be avoided, the diagnostic criteria will have to reflect the fact that lies, and not symptoms (at least in the sense in which DSM–IV uses the term), are essential to factitious presentations. To achieve this, Criterion A will need to be reformulated as "AR," lying or, even better, deliberate autobiographical falsification. To capture "symptoms," we can then either understand "autobiography" in a broad sense, so that it encompasses "symptoms," or stipulate that falsifications are "about symptoms," where necessary.
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Pseudologia Fantastica, Voluntary False Confessions, and Impersonations
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The reformulation of Criterion A suggests that DSM–IV should really have stated, "individuals with factitious disorder.... may engage in lying about having symptoms." This is borne out by Criterion AR’s clarification of the relationship between factitious disorders and behaviors that are characterized by deliberate autobiographical falsification. The most important of these is pseudologia fantastica, which is regarded by many as a key component of factitious disorder,6 despite the fact that it does not always "produce symptoms." This seeming paradox, which DSM–IV is powerless to explain (Figure 1), disappears when we notice two things. First, that pseudologia satisfies Criterion AR, and, second, that there is now room for it to form part of a factitious disorder on condition that a further diagnostic criterion (which will be arrived at by reformulating Criterion B) is satisfied. This is as it should be, since, unlike cardiopathia fantastica, neurologica diabolica, laparotomaphilia migrans, and hemorrhagica histrionica, pseudologia fantastica is not a rather amusing Latin term for a factitious disorder of a particular bodily system, in this case, the "self," or "autobiography;" it is the process which (can) "produce symptoms" of these other systems. The word "can" is parenthesized, to register the fact that, in many instances of pseudologia, the second criterion we have just referred to will not be satisfied. In these individuals, lying is confined to friends and acquaintances and does not come to medical attention, except perhaps as an incidental finding.
There are several other forms of deliberate autobiographical falsification that arguably ought to be accommodated by DSM–IV diagnostic Criterion A, but are not, on the grounds that they do not give rise to conventional symptoms. Once again, Criterion AR resolves the problems. The presentations in question are voluntary false confessions and impersonations. Voluntary false confessions involve individuals’ intentionally deceiving authorities that they have committed a crime.7 They are currently without nosological status, despite their recognized similarity to psychological factitious disorders.8 Impersonations involve individuals’ pretending to be someone that they are not, and they form an integral part of many factitious presentations2 (indeed, all, if we include "pretending to be a patient" within the definition). They are, however, only singled out for separate attention in military contexts, where lying about rank is a military offense;9,10 but, even there, they are often accompanied by the more conventional "symptoms" of factitious disorder. Baggley11 reported that the majority of patients presenting to military psychiatric services in the United Kingdom with a factitious disorder claim to belong to Special Forces, usually the SAS. However, when there are no conventional "symptoms," and irrespective of the failure of impersonations to satisfy DSM–IV Criterion C, they should not be ignored. Like pseudologia fantastica, they indicate a tendency that is fully expressed as a factitious disorder only when the further necessary condition covered by the second diagnostic criterion is satisfied.
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Deliberate Self-Harm
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Before we introduce this second criterion, we need to mention the second major advantage of Criterion AR: that it can be used to distinguish between factitious disorders and deliberate physical self-harm in the absence of suicidal intent. Notice that Axis II criteria for Borderline Personality Disorder cannot be relied upon to perform this function because they may exclude isolated episodes of deliberate self-harm and include some cases of factitious disorder.12 The DSM–IV’s difficulties with deliberate self-harm relate once again to its failure to make lying an explicit part of the diagnostic criteria. More specifically, since the primary theoretical purpose of Criterion A is to differentiate factitious disorder from somatoform disorders on the basis of "intentions," it cannot accommodate the fact that there are two types of "intentionally produced symptoms" that satisfy Criterion C. First, there are factitious "symptoms," and second, there are the symptoms resulting from more conventional deliberate self-harm. The DSM–IV is forced to classify these together (see Figure 1), even though they clearly differ in that only the former involve lying about the origin of symptoms. Notice, however, that once Criterion A is reformulated as AR, deliberate autobiographical falsification, deliberate self-harm no longer qualifies as a factitious disorder because it does not satisfy this criterion. Of course, we are now faced with ensuring, first, that the close association between deliberate self-harm and factitious disorders is not lost, and, second, that factitious disorders involving physical self-harm, rather than overt lying, are correctly classified. These concerns invite us to reformulate DSM–IV’s second diagnostic criterion.
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Criterion B: Intentions and Interpretations
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To understand the difficulties with DSM–IV’s Criterion B, and indeed Criterion C, it is essential that we know something about what it means to characterize behavior as intentional. Let us say, then, that behavior is intentional if it was done for a reason, bearing in mind that reasons are made up of beliefs and desires. The difficulty, which we will see later, exemplified by Criterion B, is that it is possible to specify beliefs and desires in a way that will make any behavior come out as intentional. This suggests that if psychological explanations are to have empirical content, the beliefs and desires that comprise them will need to be identifiable independently of each other and of the behaviors they purport to explain. Hempel,13 who had a considerable influence on the development of DSM, recognized this and suggested that if we "have good grounds for the assumption that that our man is subjectively honest, then his answers may afford a reliable indication of his beliefs."14 Honesty, however, is precisely what we cannot assume when dealing with factitious disorders, and this, coupled with the more general philosophical objections to the empiricist approach to psychology, suggests that deciding on an individual’s beliefs and desires, and therefore his reasons, is a matter of interpretation. The principles of interpretation have been lucidly articulated by the celebrated Berkley philosopher Donald Davidson.15 Davidson accepts that beliefs and desires and actions are conceptually related, so to get around the problem of all behavior being construed as intentional, he introduces the "principle of charity." This is essentially an injunction to interpret the behavior of others by ascribing beliefs and desires, that is, reasons, to them that could, in principle, be reasons for oneself. If one cannot find a way of doing this, then, according to Davidson, one cannot regard behavior as intentional at all.
Certain aspects of the factitious disorders cannot be understood without appreciating the foregoing considerations, so let us try to give a sense of where they will affect the rest of the discussion: 1) Since Criterion C’s "external incentives" are really just reasons, C is no more than DSM–IV’s way of saying that the principle of charity cannot be applied and that behavior is therefore not intentional. (Notice that we are saying "not intentional" because unintentional imputes a hysterical etiological mechanism). This point bears on the validity of Criterion B and will be important in the next section. 2) Behavior that is not intentional (i.e., not performed for a reason) is not necessarily not deliberate, since one can do things deliberately without a reason. This will be important when we discuss DSM–IV’s misdiagnosis of factitious disorders as hysterical. 3) The principle of charity takes into account more than just external incentives. When we say that behavior was performed for a reason, what we really mean is that, all things considered, it makes sense. Arguably the single most important determinant of whether behavior makes sense is whether, overall, it leads, or, on balance, is likely to lead, to self-harm. This point will prove relevant to the reformulation of Criterion B and to DSM–IV’s misdiagnosis of factitious disorders as malingering.
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Intrapsychic Needs and Internal Incentives
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The question that causes most consternation in relation to factitious disorders is not which symptoms should be regarded as lies, but which lies should be regarded as symptoms.16 The answer is complicated because the main types of nonfactitious lying, namely malingering and pseudologia fantastica (which satisfies Criterion AR only) each raise slightly different issues. In this section, we can start to disentangle these issues by reformulating Criterion B: the motivation in factitious disorders is to assume the sick role, because of concerns about its empirical validity. The main concern about Criterion B arises from the fact that the "sick role" is associated with malingering (and, indeed, hysterical disorders) and not just factitious disorders. If we allow the sick role to function as motivation in the absence of external incentives, how we will ever know that it is not so functioning in their presence? In other words, because DSM–IV malingering occurs in the presence of both external and intrapsychic motivation (or internal incentives), how, when faced with a malingerer, will we ever know that he is not actually motivated by a desire to assume the sick role? It is important to realize that this dilemma cannot be resolved by invoking the sick role only in cases in which external incentives do not satisfactorily explain behavior, since this amounts to refining Criterion C in order to "define in" previously misclassified factitious disorders and leaves genuine malingering, which still results in the adoption of the sick role, untouched.
To resolve this problem, we need to recall that interpreting behavior is about finding a reason that is a reason for the interpreter. What constitutes an incentive or disincentive is therefore fixed by an interpreter’s standard, which in this case is DSM–IV’s standard. Since, by definition, malingering can be understood in terms of incentives, the sick role can only function as a disincentive by DSM–IV standards. This, however, creates a problem when it comes to explaining factitious disorders where there are only disincentives. To address it, DSM–IV turns disincentives into incentives, which it then makes "intrapsychic," or internal, primarily because if the sick role were allowed to be an external incentive, factitious disorders would fail to satisfy Criterion C and would qualify as malingering. This maneuver is conveniently supported by patients’ own ignorance of their motivation, but it commits DSM–IV to the view that all behavior can be explained in psychological terms.17 In other words, when a given behavior cannot be explained by external incentives, DSM–IV can simply take ordinary disincentives and turn them into internal incentives. This is no more than a sleight of hand, and, once it is exposed, it becomes clear that the most psychiatry can meaningfully say about factitious disorders is either that they occur in the presence of disincentives (thereby dropping the motivational component of Criterion B and making it a descriptive criterion), or that disincentives act as external incentives for unusual individuals. The latter option may well be correct. However, because these "factitious" external incentives are not external incentives by DSM–IV’s standards, it is forced to rely on Criterion C’s absence of conventional external incentives to determine whether Criterion B is satisfied. Therefore, not only is Criterion B vacuous, but it contributes nothing over and above Criterion C to the diagnosis of factitious disorder. This is why it is not represented in Figure 1.
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From the "Sick Role" to Self-Harm
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Even in the absence of external incentives, the sick role has to remain what it is in malingering, that is, a disincentive, something to be avoided, a form of psychosocial self-harm.18 This suggests that if DSM–IV wanted a "motivational" criterion, then B should have been the motivation to self-harm. However, in view of the problems identified in the last section, Criterion B can only go as far as the descriptive criterion, the behavior leads (or is likely to lead) to self-harm. Let us call this Criterion BR, bearing in mind that the parenthesized "likely to lead to self-harm" is included because the diagnosis of factitious disorder cannot be made to depend on whether lies go undiscovered. It is also worth adding that a Criterion B that drops motivation while retaining the sick role, faces difficulties resulting from the reformulation of Criterion A. The problem is that the adverse psychosocial consequences that we will shortly suggest convert pseudologia fantastica, voluntary false confessions, and impersonations into factitious disorders, only amount to the "sick role" in a very loose sense. This problem is particularly pressing in voluntary false confessions. Incarceration in prison is clearly related to being detained under mental health legislation and can therefore be construed as a form of the sick role. However, this view, which is related to DSM–IV’s inadvertent symptomatization of lies, leads ultimately to an unhelpful obfuscation of the distinction between illness and deviance.
There are, in any case, enormous advantages to introducing a criterion based on self-harm. These will become clear if we remind ourselves of the main reasons for reformulating Criterion B: First, because Criterion AR does not refer to symptoms, there is a requirement to ensure that the self-injurious factitious disorders, which may not involve overt lying, are captured; second, we need to resolve which of the lies that satisfy Criterion AR should be regarded as symptoms; third, we need to ensure that the criteria acknowledge the close relationship between deliberate self-harm and factitious disorders. Because Criterion BR is formulated in terms of generic self-harm, it covers both physical self-injury and the detrimental psychosocial consequences of the forms of lying that satisfy Criterion AR. It can therefore capture self-injurious factitious disorders and answer the question about why some of the lies associated with pseudologia fantastica, voluntary false confessions, and impersonations and not others, should be considered symptomatic of a factitious disorder. Basically, it is those that result in a tangible amount of psychosocial damage to the individual. (Incidentally, we can accommodate the distinction between physical and psychological factitious disorders by specifying whether Criterion BR involves physical or psychosocial harm). In relation to the third motivation, Criterion BR makes room for deliberate self-harm and thereby works with Criterion AR to prevent either its exclusion or its collapse with factitious disorder. We will return to the nosological implications of this later, but it is worth making the related point that, in addition to the logical and theoretical advantages, Criteria AR and BR explain Fink and Jensen’s observation that Munchausen’s syndrome can be separated into pseudologic and self-harming subtypes.19 This is because all factitious presentations have two components corresponding to Criteria AR and BR, but any individual case will inevitably lean in one direction or the other.
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Criterion C: "Unintentional" Misdiagnosis
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In the next four sections, we will explain how, in practice, Criterion C leads to the misdiagnosis of factitious disorders. We will suggest that Criteria AR and BR can perform the diagnostic function that DSM–IV assigns to Criterion C without the adverse consequences. Criterion C has a hidden but crucial role in DSM–IV’s attempt to distinguish factitious disorders from related disorders, especially somatization, conversion, and dissociation disorders (in some of what follows, we will use "hysterical disorders" to avoid differentiating between physical and psychological symptoms). Since DSM–IV implicitly takes the view that hysterical disorders involve unintentionally-produced symptoms, it seems natural to assume that A does the work of distinguishing between these and the intentionally-produced symptoms of factitious disorders. Unfortunately, it is only when factitious symptoms are deliberately induced by physical interference that Criterion A can get any purchase (Figure 2). In most factitious disorders, it is simply impossible to know whether symptoms are intentional (it should be clear by now that DSM–IV would have done better to use the term "deliberate"), and this indicates that factitious disorders will have to be distinguished from hysterical disorders on the basis of other considerations.
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FIGURE 2. Misdiagnosis Resulting From Applying DSM–IV Criteria A and C
Note: FD1 represent factitious disorders misdiagnosed as somatoform disorders. FD2 represent factitious disorders misdiagnosed as malingering. FD3 represent factitious disorders mixed with cases of deliberate self-harm (DSH). Notice that all misdiagnosis is resolved by the reformulated Criteria AR and BR.
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The most important of these, in terms of the logic of the diagnostic decision-making process, is whether there is an intention to obtain external gain (which is, effectively, DSM–IV Criterion C), since this is the first port-of-call in trying to decide whether symptoms are deliberate. However, as our philosophical digression earlier illustrated, satisfying Criterion C indicates that behavior is not intentional, rather than not deliberate. Indeed, Criterion C is only an indicator of deliberateness; what it really addresses is whether behavior is intentional. Fortunately for DSM–IV, since most deliberate behavior is intentional, and vice versa, Criterion C manages to correctly categorize much of what it is deployed to deal with. But, contrary to what DSM–IV assumes, this is not due to the application of Criterion C, but instead, to the latter’s effect being fortuitously overridden by the presence of physical self-interference, which provides a window onto "deliberateness." The reason for the confusion is that factitious disorders fit into a small conceptual gap between, first—deliberate, intentional, and second—not-deliberate, not-intentional behavior, about which Criterion C is, strictly speaking, silent. It is, therefore, inevitable that factitious disorders not accompanied by physical interference (or perhaps significant psychosocial harm) will get carried along with other non-intentional behavior and end up being misdiagnosed as hysterical disorders (Figure 2).
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Differentiating Factitious From Hysterical Disorders
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The question, then, is how, in practice, we differentiate factitious from hysterical disorders, in view of the fact that Criterion A is ineffective, Criterion B is vacuous and can be invoked as an explanation for both disorders, and Criterion C pushes disorders into the hysterical category. The answer lies in deciding whether a given presentation satisfies Criteria AR and BR (Figure 2). When there is evidence of autobiographical falsification and significant self-harm, a diagnosis of factitious disorder will be difficult to resist. More specifically, Criterion AR is broader than Criterion A, and it therefore allows a clinician to infer that symptoms are deliberate on the basis of more general evidence of deliberate autobiographical falsification. This is entirely consistent with what happens in clinical practice. In terms of Criterion BR, the behavior leads or is likely to lead to self-harm, in cases of chronic or unusual medically unexplained symptoms (even without evidence of autobiographical falsification), the more a patient acquiesces in the sick role and seeks out potentially damaging interventions, the more this suggests that a diagnosis of factitious disorder should be considered. These, of course, constitute the most difficult diagnoses of all, but there has to be some limit to the amount of physical, psychological, and social harm that a patient will subject himself to if he has a genuine hysterical disorder. It is worth adding that the more harm the patient incurs as a result of his or her lies, the less chance there is of their being inadvertently misdiagnosed as having a hysterical disorder, because it will be clearer that they satisfy BR from the outset.
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Why Factitious Disorders Cannot Be Malingered
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A more obvious consequence of DSM–IV’s Criterion C is that factitious disorders cannot be malingered. Unfortunately, this has unacceptable implications for the nosological status of factitious disorders, since all genuine disorders can be malingered.
In other words, for every DSM–IV disorder (excluding factitious disorder), it is possible to imagine a scenario in which pretending to have the disorder in question could, for example, bring about financial reward. Criterion C is formulated exclusively in terms of the presence of external incentives, and this means that to include it in the diagnostic criteria for a disorder is to rule out, by definition, that one can both have the disorder and make money from it. This is clearly untenable for genuine mental disorders and is the main reason why Criterion C has no place in their diagnostic criteria. Fortunately, DSM–IV confines Criterion C to factitious disorder, but its inclusion there suggests that DSM–IV views this disorder as in some sense different from all other mental disorders.
The origins of this inconsistency can be understood by returning to Criterion A. The reason that, for example, schizophrenia can be malingered is that its diagnostic criteria correspond to symptoms that it is possible to pretend to have and get wrong because the "pretend" symptoms do not resemble real ones. However, with factitious disorders, Criterion A is also a "criterion" for malingering, and this means that, in the case of factitious disorders, there is no gap between "having symptoms" and pretending to have them. This, of course, is because "having them" is pretending to have them. The upshot is that DSM–IV is forced to introduce Criterion C to decide what is disorder and what is not. This has the consequence that a factitious disorder can only be diagnosed in an artificially restricted set of circumstances—namely, when external incentives are absent. In order to bring the diagnosis of factitious disorder in line with that of other mental disorders, we need to allow it a degree of independence from DSM–IV’s external incentives.
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Differentiating Factitious Disorders From Malingering
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We can the search for this independence by returning to the issue of misdiagnosis. In clinical practice, it is not uncommon to feel that what is ostensibly malingering has more in common with a factitious disorder. Sharpe16 recently asked, "if a person malingered persistently but unsuccessfully—that is, their behavior was manifestly dysfunctional, would they then be awarded psychiatric disorder status?" Sharpe’s point is, how do we decide when an individual who is lying about illness in the presence of external incentives (a DSM–IV malingerer) has a factitious disorder, and this amounts to an implicit acknowledgment that DSM–IV Criterion C results in the misdiagnosis of factitious disorders as malingering (Figure 2). It would not be surprising if Criterion BR, which has a role in distinguishing which cases of pseudologic fantastica deserve a diagnosis of factitious disorder, could help resolve this issue. With this in mind, recall from our discussion of philosophy that, although malingering is lying about illness for a reason, deciding whether the behavior has a reason behind it is more complicated than simply assessing the presence of external incentives, as DSM–IV assumes. It involves judgments about intelligibility that take into account a range of variables, including the nature of autobiographical falsification, and, especially, whether the behavior leads to overall self-harm, or is likely to do so.
The determination of whether behavior constitutes a factitious disorder is therefore more closely tied to self-harm, and whether or not this is present, is informed, but not exhausted by, considerations about external incentives. Diagnostic criteria like DSM–IV’s, which fail to respect this, will inevitably result in the misdiagnosis of some cases of factitious disorder; that is, those involving self-harm in the presence of external incentives. Criterion BR, on other hand, can be satisfied even if DSM–IV’s Criterion C is not, and this allows a disorder to be a factitious disorder without, pace Sharpe, satisfying DSM–IV’s criteria for one (Figure 3). Furthermore, and returning to the concerns of the last section, Criterion BR creates the conceptual space for an individual to "DSM–IV malinger" a factitious disorder. It is admittedly difficult to imagine that an individual who did not have factitious "tendencies" would be willing to satisfy Criterion BR in pursuit of the external incentives covered by DSM–IV’s Criterion C. This point bears on the complicated matter of why criminals and others use impersonation as their modus operandi. In other words, impersonation may be a way of pursuing external incentives, but it is, even by most criminal standards, a rather unusual way.
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Further Implications: Conversion, Somatization, and Dissociation
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The introduction of autobiographical falsifications in Criterion AR disturbs the intentional/ unintentional symptom dichotomy. If we want to continue to maintain that there is a close relationship between factitious and hysterical disorders, we will need to reevaluate to what extent the latter involve symptoms. With this in mind, because the etiology of these disorders is obscure, there is a tendency for their symptoms to be interpreted as either factitious or as genuinely physical. In conversion presentations, recent research20 has led to the factitious interpretation displacing that implied by Slater’s findings,21 but, in somatization presentations, the debate is at an earlier stage, and many want to treat symptoms as genuinely physical. This last view entails either that there are two types of genuine physical symptoms, or that somatization symptoms are medically unexplained physical symptoms. Since the first option requires the existence of something like "nonorganic physical symptoms,"22 those with less psychodynamic inclination prefer to embrace the second. White,23 for example, recently suggested that "somatization is a process.... which can.... be applied to a patient with any medical condition."23 However, since this requires that genuine physical symptoms have two etiologies, it is more or less an invitation to reintroduce the concept of conversion.
Conversion is not "a viable concept,"24 but that is not to say that some patients diagnosed with conversion and somatization disorders do not have genuine physical symptoms. As with factitious "symptoms," some misclassification is inevitable. But to accord too much nosological significance to these diagnostic problems amounts to a contemporary failure to heed Lewis’ warning that "hysteria ...tends to outlive its obiturists"25 by ignoring the gap between having physical symptoms and lying about having them. If conversion and somatization disorders are to earn their inclusion in DSM–IV, they will have to fit into this gap by being neither genuine physical symptoms nor lies, but by having some of the characteristics of both. Understanding how this is possible has enormous implications for the direction of future research in this area, since, although genuine physical symptoms need splitting into systemic syndromes,23 distinguishing between, say, laparotomaphilia migrans and neurologica diabolica only obfuscates the issues. This requirement to resemble both symptoms and lies therefore acts as a constraint on theorizing about conversion and somatization disorders. Arguably, the only way of fulfilling it is by adopting a two-component approach, according to which symptoms are misinterpretations (or misattributions) of ambiguous information.26,27
The "misattributional approach" allows that the informational components, which can include sensory information, resemble genuine physical symptoms. However, since the information cannot amount to genuine physical symptoms, most of the responsibility for creating symptoms must lie elsewhere. It is therefore misinterpretation that explains how patients go from receiving information to believing something false about themselves, in this case, that they have genuine physical symptoms. This brings out 1) the close relationship between conversion and somatization disorders and other somatoform disorders, such as hypochondriasis and body dysmorphic disorder; and 2) the idea that since the etiological process essentially involves distortion of the truth, the "symptoms" in question have more in common with lies (factitious "symptoms") than with genuine physical symptoms. Indeed, the phrase "unintentional falsification," which is closely related to Criterion AR, seems apt to describe the phenomena. Furthermore, because any type of information can be misinterpreted, the theory potentially clarifies the etiology of "dissociative disorders." Here, concerns about whether symptoms are genuine are less conspicuous, and it is difficult to resist the claim that, for example, "dissociative identity disorder" and "false memories" involve unintentional autobiographical falsifications. From this, we can only conclude that DSM–IV’s separation of psychological and physical presentations is once again the result of seeing symptoms where there are only "symptoms." Progress in understanding this area, like that in relation to factitious disorders, can only be hindered by this.
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A Hybrid Disorder: Factitious Disorders, Somatoform Disorders, and DSM–IV
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ABSTRACT
INTRODUCTION
