Factitious disorder and malingering are two variations on a similar theme. Both involve people who exaggerate or make up symptoms of an illness. But in malingering vs. factitious disorder, the reasons why are very different. This also means that treatment is different, too.
What Is Factitious Disorder?
Factitious disorder is a mental illness, classified as a somatic symptom disorder (also called a somatoform disorder). People with factitious disorders exaggerate or lie about having medical or psychiatric symptoms. There are two kinds of factitious disorder:
- Factitious disorder imposed on self (FDIS): The person lies about their own health. Also called Munchausen syndrome.
- Factitious disorder imposed on another (FDIA): The person lies about someone else’s health. The victim is typically a child or other person who can’t take care of themselves. Also called Munchausen syndrome by proxy (MSBP).
People with these disorders often present themselves, or another person, to a doctor or in a hospital or clinic. They claim symptoms of a nonexistent illness and may injure themselves (or another) or make themselves (or another) ill. They may also try to fake diagnostic test results. For instance, they might falsify a urine test by adding blood to their urine sample. In factitious disorder, people engage in this behavior without any clear motive. It may be about seeking attention and sympathy. Or it might simply be a strong attachment to the idea of being ill or being the caretaker of someone who is ill.
What Is Malingering?
Malingerers engage in many of the same activities as people with factitious disorder. They exaggerate or make up symptoms of an illness, either physical or psychiatric. Whereas factitious disorder is a mental health condition with no clear cause, malingerers do it for personal gain. They have clear external motivations that drive their behavior. Some reasons why people malinger include:
- Insurance fraud or other form of financial gain
- To get time off work
- To get prescriptions for controlled medications
- Shirking obligations for military service
- Reducing work obligations
- An attempt to avoid prison time
Malingering itself is not a mental illness. In some cases, however, people who adopt malingering behavior do have a mental illness. One example is antisocial personality disorder. Individuals with this disorder often exploit people and laws for personal or financial gain. This can include malingering behavior.
Diagnosis of Malingering vs. Factitious Disorder
It can be hard to tell the difference between malingering and factitious disorder. It can also be hard to distinguish these from a real illness. At least initially, it can seem that the patient is ill. However, there are signs that point toward someone faking or exaggerating an illness. These signs may not be seen right away, but can be noticed as a pattern over time. In the current Diagnostic and Statistical Manual (DSM-5), medical symptoms are de-emphasized for diagnosing factitious disorder. Diagnosing a mental illness based on atypical medical symptoms is now considered inappropriate. Another issue is that it may lead to misdiagnosis. Instead, there’s a new focus on how people think, feel and behave in response to the symptoms they have. Some signs of factitious disorder include:
- A medical history that includes one or more previous serious or dramatic illnesses
- A history of seeking treatment with many different doctors and/or at many hospitals or clinics
- Having an extensive knowledge of medical terminology
- Knowing textbook descriptions of illnesses and symptoms
- Being willing or eager to have medical tests, be hospitalized or have surgery
- New symptoms appear after receiving negative test results or after a diagnosis is ruled out
- The patient doesn’t get better, even after having appropriate treatment
Signs of malingering can include:
- A previous diagnosis of antisocial personality disorder
- A significant difference between a person’s stated injury or illness and the findings of a professional
- Refusal of the appropriate treatment for the illness they claim to have
- Someone is referred for treatment by a lawyer or involves a lawyer early in the diagnostic process, which can indicate a financial motive
How Is Diagnosis Made? To be diagnosed with factitious disorder, the following criteria must apply:
- The person has deliberately falsified symptoms of physical or psychological illness or injury in themselves (FDIS) or another (FDIA)
- The person has presented themselves (or another) to others as ill, impaired or injured
- The person’s deceptive behavior is carried out without any expectation of an external reward (for instance, financial gain)
If someone is a malingerer:
- The person has deliberately falsified symptoms of physical or psychological illness or injury in themselves
- The person has presented themselves to others as ill, impaired or injured
- The person’s deceptive behavior is carried out with the expectation of an external reward (e.g. time off work or financial gain)
How Factitious Disorder and Malingering Are Different
Differences in Presentation Factitious disorder and malingering can look similar. However, some signs are more likely to appear in one case or the other. For instance:
- Someone with a history of seeking treatment at multiple places is more likely to have factitious disorder.
- People with a long and/or dramatic medical history are more likely to have factitious disorder.
- Someone with antisocial personality disorder is more likely a malingerer.
- If a lawyer is involved early in the diagnostic process, the person is likely malingering.
Differences in Motivation and Control The motivations are different for people with factitious disorder versus malingerers. For people with factitious disorder, there’s no expectation of an external reward. Their motivations are often unknown even to themselves. Malingerers fake illness for financial or personal gain. Another difference is that people with factitious disorder can’t control their behavior. Even if they know the risks, they can’t stop themselves. In contrast, the behavior of the malingerer is both intentional and voluntary. They don’t feel a compulsion but rather choose to behave this way.
The Importance of Getting the Right Diagnosis
For people with these disorders, a correct diagnosis is important. This is especially so for people with factitious disorder. It’s only with an accurate diagnosis that they can get the right treatment. Without treatment they risk harming themselves or others, depending on the kind of factitious disorder they have. Some people self-harm to fake disease symptoms. For instance, they may make themselves sick by ingesting or injecting harmful substances. They might injure themselves or take medications they haven’t been prescribed. This is often dangerous, but people with factitious disorder can’t stop themselves, even if they know the risks. Malingerers also risk harm to themselves, for similar reasons. Malingerers tend not to go to the same lengths to fake symptoms. However, they still face the risk of unnecessary medical treatment or medication. Conversion Disorder Sometimes, a person has genuine symptoms that can’t be explained by a medical diagnosis. Some common “mystery” symptoms include blindness, paralysis and other nervous system issues. This is called conversion disorder. These symptoms often appear due to a psychological issue. Conversion disorder can be triggered by an illness or intense psychological distress. However, the symptoms aren’t made up or exaggerated. They just happen to have a psychological cause. Treatment includes psychotherapy, stress management and sometimes physical therapy.
Treatment Options for Factitious Disorder and Malingering
The motivations that drive malingering vs. factitious disorder are very different. This means that treatment is, by necessity, also very different. Treatment for Factitious Disorder Treatment focuses on symptom management, as factitious disorder is considered incurable. Treatment is a multi-pronged approach, which includes:
- Having a single primary doctor. This helps to reduce or prevent duplicate visits to multiple doctors or specialists.
- Psychotherapy to learn healthy coping skills. This helps the person reduce their need to lie about their health. Addressing any co-occurring disorders can help too.
- Medication can treat co-occurring problems such as anxiety or depression.
- Hospitalization may be needed in some situations. If the person is a danger to themselves, inpatient psychiatric care can help keep them safe.
Treatment for Malingering Malingering isn’t a true mental illness. The behavior a malingerer engages in is intentional, with a clear motive. Treatment isn’t necessary, unless they’ve caused themselves real harm. However, malingering can have other results. For instance, someone might lose their job if they fake an illness to avoid work.
How Can You Get Help?
If you think a loved one is hurting themselves, getting help is vital no matter the reason. If you suspect factitious disorder, it’s also important to know that they can’t control their behavior. They need specialized treatment, whether in an inpatient program or elsewhere.