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Reformulating Factitious Disorder

TO THE EDITOR: I read Mark Turner’s article "Factitious Disorders: Reformulating DSM-IV Criteria"¹ with great interest and with some agreement as to the problems the criteria face. However, I do not feel his solutions are ultimately helpful. He appears to have been motivated to modify the extension of the criteria to include other forms of pathological deception, and to exclude certain forms of deliberate self-harm; but he also rejects the existing criteria on other grounds. He rightly argues that Criterion C—the absence of external incentives—arbitrarily divides factitious disorders from malingering, and will result in the misdiagnosis of factitious patients. He also feels that the resultant exclusion of external incentives makes Criterion B—motivation by the sick-role—"vacuous," because considering only internal incentives is nothing more than "sleight-of-hand," which "commits DSM-IV to the view that all behavior can be explained in psychological terms."¹ Criterion A, meanwhile—the intentional production of symptoms or signs—is rejected on the grounds that it is tautologous for psychological symptoms. He offers, instead, the revised criteria of lying (Criterion AR), such as is likely to lead to self-harm (Criterion BR). Turner’s argument is an extended one, and any summary will not do it justice, but I hope to make it clear that his revised criteria will not do.

First, it should be clear that the challenges facing the criteria are to distinguish factitious disorders from hysteria, on the one hand (by Criterion A), and malingering, on the other (by Criterion C).² Neither of these distinctions can be made with anything approaching certainty,³ because they rely on assessments of the patient’s self-awareness and motivation, which are inescapably subjective. So much for intension: the extension of the current criteria excludes pathological lying, but includes "routine" deliberate self-harm. Turner is right that the latter is a problem, and an argument could be made that the former is, too, although Turner does not clearly do so. But even if we accept these as problems and accept that his solutions rectify them, his solutions still create problems of their own.

Criterion AR is presented as the means to include pathological lying more generally, and to replace the "intentional production of symptoms," which he finds tautologous. The tautology lies in the fact that "in factitious psychological disorders ... the symptoms are lies"¹ (original italics), so the criterion can be reduced to intentional lying. Lying is ubiquitous, however, so, to prevent Criterion AR from applying to everyone, he says, later in the same paragraph, we should "stipulate that falsifications are ‘about symptoms’ where necessary."¹ It hardly needs pointing out that this would reintroduce precisely the same tautology.

It would seem likely that he noticed this, given that, when explaining the motivations for Criterion BR, he notes, "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...."¹ Turner seems to expect Criterion BR to extend the range of disorders to some not covered by AR, first, and, second, to narrow the scope of AR to prevent all lying being included. But there are problems with both of these. The problem with the first is that the criteria are conjunctive—as shown by his Venn diagram—so that BR cannot extend AR, only restrict it. If he now wishes to make them disjunctive, then criterion BR once again includes generic self-harm, which he rightly wishes to exclude. The problem with the second goal for BR is that it does hot helpfully specify a subgroup of liars. The reason for this is that Turner construes self-harm in a rather broad sense, including "both physical self-injury and the detrimental psychosocial consequences of the forms of lying that satisfy Criterion AR."¹

Attempts to specify the harmfulness of psychiatric disorders run aground in many areas,⁴ including factitious disorders. Although subjecting oneself to unnecessary operations is incontestably harmful, it is far from clear that pretending to experience fatigue, or low mood, or a paralysis is. If the harm Turner has in mind is of the "psychosocial" variant associated with potentially being discovered as a liar (condemnation, public humiliation, shame, etc.), then this clearly applies to all liars, and thus does not restrict the group defined by AR. In particular, it applies strongly to malingerers (which Criterion BR was meant to exclude). If he has something more specific in mind, some particular kind of self-torture experienced by factitious patients, perhaps, then the evidence for this is scanty. Although there are certainly self-reports of regret at the scars of unnecessary operations, such reports are equally clear that the behavior is highly adaptive in meeting the needs of the patient—the love and caring to be gained by being hospitalized⁵—something with which virtually everyone can identify. Furthermore, there are other reports, such as the infamous McIlroy,⁶ where a lifetime of hospital-wandering is regarded with pride. Unfortunately, such is the dedication of factitious patients that we have to conclude that the psychosocial consequences of their behavior are, at best, mixed.

Turner seeks to modify the extension of the factitious criteria and to avoid the vacuities of tautology and motivation-assessment. The problem with his modification is that it extends the criteria to all liars, including malingerers. His attempts to avoid this lead to the reintroduction of the tautology or to reliance on a notion of self-harm that, even when construed according to Davidson’s principle of charity, would seem to do no useful work. What Turner seems to want to get at is the idea of problematic lying, which is highly germane, of course, to factitious disorder; but if he wants to exclude malingering, he will have to reconsider motivation, which would take him right back to the drawing-board.

REFERENCES

1. Turner MA: Factitious disorders: reformulating the DSM-IV criteria. Psychosomatics 2006; 47:23–32[Abstract/Free Full Text]
2. Hyler SE, Spitzer RL: Hysteria split asunder. Am J Psychiatry 1978; 135:1500–154[Abstract/Free Full Text]
3. Freyberger HJ, Schneider W: Diagnosis and classification of factitious disorder with operational diagnostic systems. Psychother Psychosom 1994; 62:27–29[Medline]
4. Cooper R: What is wrong with the DSM? History of Psychiatry 2004; 5-26
5. Feldman MD: Breaking the silence of factitious disorder. South Med J 1998; 91:41–42[Medline]
6. Pallis CA, Bamji AN: McIlroy was here: or was he? BMJ 1979; 1:973–975[Medline]

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