Psychosomatics 47:453-454, October 2006
doi: 10.1176/appi.psy.47.5.453
© 2006 Academy of Psychosomatic Medicine
Dr. Turner Replies:
Dr. Mark A. Turner, Consultant Psychiatrist, Newcastle Upon Tyne, UK
TO THE EDITOR: I am grateful to Dr. Kanaan for giving me the opportunity to clarify some of the issues relating to my revision of the diagnostic criteria for factitious disorder. Kanaan’s main concern is quite a pressing one about the usefulness of my Criterion BR (self-harm); but first let me deal with several of the subsidiary issues he raises by conceding one point, and then outlining why Kanaan has misunderstood another. Kanaan is quite right to point out that my Criterion BR cannot extend the scope of Criterion AR (lying), as I implied with my claim that a self-harm criterion was necessary to capture presentations that do not involve "overt lying."1 My Criterion BR was intended to constrain Criterion AR, and the ambiguity arose because I rather hastily placed a linguistic constraint on what is to count as lying. A simple extension of the concept of lying to capture non-verbal forms of deceit, such as when a patient presents in self-induced coma, should rectify the problem to Kanaan’s satisfaction.
This brings me to Kanaan’s misunderstanding of the arguments about DSM-IV’s Criterion A being tautological. Kanaan starts by correctly reiterating my central claim that because symptoms are lies in psychological factitious disorders, Criterion A is reduced to the tautological "intentional production of lies" and should be replaced simply by "lies." However, he then wrongly assumes that my caveat that "we can stipulate that lying is about symptoms where necessary" is an attempt to get around the fact that lying is ubiquitous and re-introduces the original tautology. In fact, my reason for adding the caveat about symptoms was simply that since I was developing the claim that factitious disorders do not necessarily involve lies about symptoms, I wanted to acknowledge that it may be useful to stipulate when they do. Kanaan has not followed my arguments and has consequently missed the difference between DSM-IV’s "intentional production of symptoms" and my "lying about symptoms," a difference that even DSM-IV implicitly acknowledges when it comments that individuals with factitious disorder "may engage in lying."2
It should now be clear that my Criterion AR does not re-introduce the original tautology and, if I might make some comments about what I was trying to achieve with my revision of the DSM-IV criteria, the advantages of making lying an explicit part of diagnosis will become even more apparent. With this in mind, among the most noticeable difficulties with the current criteria is the fact that they give us no sense either of the etiology of factitious disorders or why they are of interest to psychiatry. Since future psychiatric classifications will inevitably be more etiologically driven and less tolerant of nosological anomalies than DSM-IV, factitious disorders may be at risk of being relegated to the V categories. Because my Criterion AR clarifies that lying is a crucial feature of factitious disorders, and lying is both related to confabulation and is the subject of a growing body of neuroscientific research,3 my revision gives factitious disorder a degree of scientific respectability that is not strictly available under DSM-IV criteria. This should reassure Kanaan, since he concedes that "problematic lying" is "highly germane... to factitious disorders," but instead he emphasizes that my Criterion AR "extends...to all liars."
One would not expect neuroscience to "specify a subgroup of [problematic] liars," so the question is, can my self-harm criterion (BR) help in this regard? Kanaan thinks not and retreats to DSM-IV’s motivational approach. However, since motivation is, by Kanaan’s own admission, "inescapably subjective," a motivational criterion can only address the presence or absence of motivating factors. Kanaan’s difficulty is that deciding this is just as complicated as deciding what constitutes self-harm. It is worth adding that self-harm has the other advantages of, first, being a recognized clinical entity with which factitious disorder has a demonstrable empirical relationship, and second, providing arguably the most important justification for psychiatric intervention in these cases. Kanaan, however, is concerned about the vagueness of the notion of self-harm, and he points out that "attempts to specify the harmfulness of psychiatric disorders run aground in many areas, including factitious disorders." To my mind, this is not evidence that a self-harm criterion should be abandoned but evidence of the intractable nature of the distinction it is designed to address. Indeed, the problem distinguishing between lying that is relevant to psychiatry and that which is not is one manifestation of the problem distinguishing illness from deviance, and this, Kanaan will realize, only becomes tractable in circumstances where one would not expect to find a copy of DSM.
REFERENCES
- Turner MA: Factitious disorders: reformulating the DSM-IV diagnostic criteria. Psychosomatics 2006; 47:23–32[Abstract/Free Full Text]
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994, pp 471-472
- Yang Y, Raine A, Lencz T, et al: Prefrontal white matter in pathological liars. Br J Psychiatry 2005; 187:320–325[Abstract/Free Full Text]
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