Factitious disorder presenting with mental health symptoms

MiniLop

7+ Year Member
Mar 6, 2012
162
287
Status
  1. Post Doc
I am wondering if anyone has any experience working with clients who appear to be presenting with mental health symptoms that are likely fabricated. I am currently working with a client who claims to have dissociative identity disorder among a host of other mental health issues. Much of their reported symptoms are directly contradicted by objective fact (e.g., reporting agoraphobic symptoms, yet having multiple third parties reporting them as regularly engaging in behaviors contrary to such a diagnosis with no visible distress or avoidance). Further, they also will demonstrate symptoms of specific disorders (often very serious, persistent disorders) that will disappear literally overnight. In practically every session they will discuss having a previously unmentioned mental disorder, and present the symptoms almost as if they were reading them directly of the DSM. This client is very therapized and has been seen by multiple outpatient and inpatient providers throughout the past several years, and notably none of their self-diagnoses have been corroborated by any of their multiple treaters. In fact, when the client receives actual diagnoses from actual mental health professionals (they were recently diagnoses as ASD after relatively thorough testing), they seem completely uninterested in those diagnoses. My read is that these self-reported diagnoses are being reinforced in a number of ways, including getting validation from peers and engaging in online communities for individuals with these diagnoses (particularly DID). That said, it's not clear to me whether (assuming the symptoms are purely fabrication), the malingering is conscious or not.

Curious if anyone has experience with similar presentation, or if there are factors I should be considering.
 
About the Ads

LadyHalcyon

2+ Year Member
Oct 30, 2016
964
599
Status
  1. Psychologist
I thought about that, but there's nothing else in the client's presentation that's consistent with a personality disorder. It's odd.
Are they on the spectrum? What about their Cognitive profile?

Is it possible they have very rigid thinking and they believe they meet criteria for certain diagnoses because of their black and white approach to life? Is this kind of thinking exhibited in other areas of their life? How do they respond when someone points out the contradictions?

These are things I would ask myself. My initial thought is it is very unlikely this person is functioning well in other aspects of their life, although it may not be immediately apparent
 
Last edited:
Jul 13, 2020
150
251
Status
  1. Psychologist
Sounds like someone is spending too much time online. ACT does a good job of getting the person to move away from their “story” a little bit. What are they getting from being so attached to these diagnoses and assuming the “sick” role? You said it was validation - you could bring it up that there are other, more productive ways, to get validation/attention.
 

MiniLop

7+ Year Member
Mar 6, 2012
162
287
Status
  1. Post Doc
Thanks for the ideas, everyone. Just to clarify, client is a teenager, highly intelligent, and was recently diagnosed as being on the spectrum (albeit very high-functioning). I have brought their attention to contradictions between their reported symptoms and other's report, but they refer back to the DID (e.g., "oh, one of my alters has those symptoms so they don't always show up"). This is also where I waver on whether this is intentional malingering or not; their report of their DID is so detailed and fanciful that it seems unlikely that they're just mistaking actual symptoms (like dissociation) for having multiple personalities, though I've also wondered about the role of ASD and legitimate confusion about their inner experience in this.

Factitious disorder (aka the disorder formerly known as Munchausen's) totally exists, though I think that it's a lot more common to see folks presenting with malingered physical (rather than mental health) symptoms for attention/sympathy.
 

ExecutiveDysfunction

2+ Year Member
Feb 17, 2018
91
133
Thanks for the ideas, everyone. Just to clarify, client is a teenager, highly intelligent, and was recently diagnosed as being on the spectrum (albeit very high-functioning). I have brought their attention to contradictions between their reported symptoms and other's report, but they refer back to the DID (e.g., "oh, one of my alters has those symptoms so they don't always show up"). This is also where I waver on whether this is intentional malingering or not; their report of their DID is so detailed and fanciful that it seems unlikely that they're just mistaking actual symptoms (like dissociation) for having multiple personalities, though I've also wondered about the role of ASD and legitimate confusion about their inner experience in this.

Factitious disorder (aka the disorder formerly known as Munchausen's) totally exists, though I think that it's a lot more common to see folks presenting with malingered physical (rather than mental health) symptoms for attention/sympathy.

Seconding the consideration of the pts thinking style. I once saw a teen with ASD for an evaluation. Concerns were raised about auditory hallucinations, but on closer look the patient just described an internal monologue as “hearing voices”. Applied to this case, it’s possible your patient interprets multiple personalities as different mood states. So when I’m sad, this is my alter with depression. When I’m happy, this is my alter with mania. Etc.

As for diagnostics, a dx of factitious disorder requires that this patient is intentionally presenting themselves as mentally ill for primary gain. The above might rule that out, especially with super rigid thinking. However, you would have to identify the primary gain (or at least have a good suspicion). If the rigidity does not explain the presentation, I agree that a cluster B PD is possible.

Treatment-wise, how much is the patient fixated on the diagnosis? If possible, it might be helpful to sidestep that issue and work directly on functional issues. No matter the specific diagnosis, the functional impairment may be modifiable. Even if it’s factitious, you may be able to help them get whatever need is being met by the disorder in a more functional way.

Interesting and tough case.

Edit: to be more clear, my main question remains what the patient is getting from these diagnoses. Figure that out, and you can encourage finding other outlets. I suspect they get attention and support from online groups. How can you support them building friendships not predicated on a diagnosis, and what do they need to get there (social skills training, emotion regulation, etc). Assuming this is a value of theirs - if not, they may be content to stick with the DID support groups :)
 
  • Like
Reactions: 1 user
Jul 13, 2020
150
251
Status
  1. Psychologist
Can you suggest to parents that the kid is spending way too much time online in online spaces that are leading the kid maladaptive beliefs and they should limit or control accesss?
 

MiniLop

7+ Year Member
Mar 6, 2012
162
287
Status
  1. Post Doc
Treatment-wise, how much is the patient fixated on the diagnosis? If possible, it might be helpful to sidestep that issue and work directly on functional issues. No matter the specific diagnosis, the functional impairment may be modifiable. Even if it’s factitious, you may be able to help them get whatever need is being met by the disorder in a more functional way.

The client is very fixated on the diagnosis. I agree about trying to sidestepping it and focus on functionality; I'm doing my best, but the client constantly circles back to the diagnosis. I feel like I'm walking this tightrope of not reinforcing their self-diagnosing while also not invalidating them (which I think would probably do irreparable damage to the therapeutic relationship).
 
About the Ads

LadyHalcyon

2+ Year Member
Oct 30, 2016
964
599
Status
  1. Psychologist
The client is very fixated on the diagnosis. I agree about trying to sidestepping it and focus on functionality; I'm doing my best, but the client constantly circles back to the diagnosis. I feel like I'm walking this tightrope of not reinforcing their self-diagnosing while also not invalidating them (which I think would probably do irreparable damage to the therapeutic relationship).
But he doesn't meet criteria for DID if he is aware he has other personalities... Or am I missing something?
 

CheetahGirl

Clinical Psychologist
10+ Year Member
Feb 15, 2007
1,403
795
formerly from Atlanta, GA
Status
  1. Psychologist
Thanks for the ideas, everyone. Just to clarify, client is a teenager, highly intelligent, and was recently diagnosed as being on the spectrum (albeit very high-functioning). I have brought their attention to contradictions between their reported symptoms and other's report, but they refer back to the DID (e.g., "oh, one of my alters has those symptoms so they don't always show up"). This is also where I waver on whether this is intentional malingering or not; their report of their DID is so detailed and fanciful that it seems unlikely that they're just mistaking actual symptoms (like dissociation) for having multiple personalities, though I've also wondered about the role of ASD and legitimate confusion about their inner experience in this.

Factitious disorder (aka the disorder formerly known as Munchausen's) totally exists, though I think that it's a lot more common to see folks presenting with malingered physical (rather than mental health) symptoms for attention/sympathy.

Have you had any collateral visits with the parents (or primary caregivers)?
 

erg923

Regional Clinical Officer, Centene Corporation
10+ Year Member
Apr 6, 2007
10,231
4,358
Status
  1. Psychologist
I am wondering if anyone has any experience working with clients who appear to be presenting with mental health symptoms that are likely fabricated. I am currently working with a client who claims to have dissociative identity disorder among a host of other mental health issues. Much of their reported symptoms are directly contradicted by objective fact (e.g., reporting agoraphobic symptoms, yet having multiple third parties reporting them as regularly engaging in behaviors contrary to such a diagnosis with no visible distress or avoidance). Further, they also will demonstrate symptoms of specific disorders (often very serious, persistent disorders) that will disappear literally overnight. In practically every session they will discuss having a previously unmentioned mental disorder, and present the symptoms almost as if they were reading them directly of the DSM. This client is very therapized and has been seen by multiple outpatient and inpatient providers throughout the past several years, and notably none of their self-diagnoses have been corroborated by any of their multiple treaters. In fact, when the client receives actual diagnoses from actual mental health professionals (they were recently diagnoses as ASD after relatively thorough testing), they seem completely uninterested in those diagnoses. My read is that these self-reported diagnoses are being reinforced in a number of ways, including getting validation from peers and engaging in online communities for individuals with these diagnoses (particularly DID). That said, it's not clear to me whether (assuming the symptoms are purely fabrication), the malingering is conscious or not.

Curious if anyone has experience with similar presentation, or if there are factors I should be considering.

Ok. So You probably don't have the full picture here? Is that fair to say? Nor do we, right? If you are the one doing any kind of therapy with this patient...I would press pause now.

When the last time this patient had a thorough psychiatric evaluation with a psychiatrist or something similar? And I do mean a through and structured interview (e.g., SCID, SADS, etc) rather than the more willy nilly stuff...collateral information included. And MMPI validify scales? Specifically F(p)?
 
Last edited:
  • Like
Reactions: 2 users

WisNeuro

Board Certified Neuropsychologist
10+ Year Member
Feb 15, 2009
12,593
13,216
Somewhere
Status
  1. Psychologist
Ok. So You probably don't have the full picture here? Nor do we, right? If you are the one doing any kind of therapy with this patient...I would press pause now.

When the last time this patient had a thorough psychiatric evaluation with a psychiatrist or something similar? And I do mean a through and structured interview (e.g., SCID, SADS, etc) rather than the more willy nilly stuff...collateral information included. And MMPI validify scales? Specifically F(p)?

In what world are psychiatrists doing structured clinical interviews or MMPIs?
 
  • Like
  • Haha
Reactions: 6 users

erg923

Regional Clinical Officer, Centene Corporation
10+ Year Member
Apr 6, 2007
10,231
4,358
Status
  1. Psychologist
In what world are psychiatrists doing structured clinical interviews or MMPIs?

Oh. I don't know. I would hope that cases that have multiple treatment failures and/or are more recalcitrant would warrant engaging diagnostic best practices by...someone???
 

MiniLop

7+ Year Member
Mar 6, 2012
162
287
Status
  1. Post Doc
But he doesn't meet criteria for DID if he is aware he has other personalities... Or am I missing something?

To put all my biases out there, I am highly suspicious of DID as a diagnosis in general, and particularly in regards to this client. They have also apparently been assessed (though god knows how) for DID by a psychiatrist, who determined they did not have it. I've been trying to get in touch with the psychiatrist for collateral, but have not been successful so far.

I've spoken with the parents, who also don't agree with a DID diagnosis (and are largely dismissive of client's experience in general).

The only evaluations that I have currently have access to is the client's ASD report (ABS-3, ASRS, BASC-3, CARS2-HF). I believe more was done by their psychiatrist, but again, I am having trouble getting in contact with them.
 
  • Like
Reactions: 1 user

WisNeuro

Board Certified Neuropsychologist
10+ Year Member
Feb 15, 2009
12,593
13,216
Somewhere
Status
  1. Psychologist
I would hope that cases that have multiple treatment failures and/or are more recalcitrant would warrant engaging diagnostic best practices by...someone?

Maybe in a MH clinic by a psychologist, but I have never seen a SCID/SADS/etc ever referenced in a psychiatry note.
 

erg923

Regional Clinical Officer, Centene Corporation
10+ Year Member
Apr 6, 2007
10,231
4,358
Status
  1. Psychologist
Maybe in a MH clinic by a psychologist, but I have never seen a SCID/SADS/etc ever referenced in a psychiatry note.

That's a choice on their part? It is there for all to use....

And yes, I understand that not every minute of what we (or a psychiatrist) does gets "payed."
 
Last edited:

LadyHalcyon

2+ Year Member
Oct 30, 2016
964
599
Status
  1. Psychologist
To put all my biases out there, I am highly suspicious of DID as a diagnosis in general, and particularly in regards to this client. They have also apparently been assessed (though god knows how) for DID by a psychiatrist, who determined they did not have it. I've been trying to get in touch with the psychiatrist for collateral, but have not been successful so far.

I've spoken with the parents, who also don't agree with a DID diagnosis (and are largely dismissive of client's experience in general).

The only evaluations that I have currently have access to is the client's ASD report (ABS-3, ASRS, BASC-3, CARS2-HF). I believe more was done by their psychiatrist, but again, I am having trouble getting in contact with them.
Why is he in therapy? What are his goals? Is he being forced to attend?
 
  • Like
Reactions: 2 users

erg923

Regional Clinical Officer, Centene Corporation
10+ Year Member
Apr 6, 2007
10,231
4,358
Status
  1. Psychologist
To put all my biases out there, I am highly suspicious of DID as a diagnosis in general, and particularly in regards to this client. They have also apparently been assessed (though god knows how) for DID by a psychiatrist, who determined they did not have it. I've been trying to get in touch with the psychiatrist for collateral, but have not been successful so far.

I've spoken with the parents, who also don't agree with a DID diagnosis (and are largely dismissive of client's experience in general).

The only evaluations that I have currently have access to is the client's ASD report (ABS-3, ASRS, BASC-3, CARS2-HF). I believe more was done by their psychiatrist, but again, I am having trouble getting in contact with them.

Do the SCID-5....and with the parents. And maybe another collateral source too? Maybe it takes an hour. Maybe it takes 3? Either way, I would think that would be more than sufficient to say they are full of ****...or to recommend something or someone who could actually help them. Again, I think F(p) from the MMPI might help here too. But that may be more "academic" than anything else at the of the day...

I would rid yourself of the notion that "patient-centered care"="patient directed care"
 
Last edited:
  • Like
Reactions: 3 users

MAClinician

Masters level clinician
2+ Year Member
Mar 19, 2016
332
339
Status
  1. Non-Student
I've spoken with the parents, who also don't agree with a DID diagnosis (and are largely dismissive of client's experience in general).
Why are the parents bringing client to treatment, especially if they are dismissive in general? What are they hoping to achieve? How does that line up with what the client wants for treatment? What does the home environment look like? I’ve worked with a few youth where “presenting” as unstable/ill/whatever you want to call it is the only way to get any attention from the caregiver. Just a thought.
Maybe in a MH clinic by a psychologist, but I have never seen a SCID/SADS/etc ever referenced in a psychiatry note.
At my current employer there was one psychiatrist who administered the SCID (or portions of) during the initial assessment appointment. It was odd sitting in the appointment with the family listening to the questions and realizing “holy **** an actual structured interview in a community setting” :laugh:
 
  • Like
Reactions: 1 user

erg923

Regional Clinical Officer, Centene Corporation
10+ Year Member
Apr 6, 2007
10,231
4,358
Status
  1. Psychologist
At my current employer there was one psychiatrist who administered the SCID (or portions of) during the initial assessment appointment. It was odd sitting in the appointment with the family listening to the questions and realizing “holy **** an actual structured interview in a community setting” :laugh:

The SCID is there for all to use. It exists for a good reason, and I do not think it to be particularly cumbersome or time-intensive if one has done has done it once or twice and/or knows what they are doing. I believe it is underutilize and under-valued.
 
Last edited:
  • Like
Reactions: 1 users

MAClinician

Masters level clinician
2+ Year Member
Mar 19, 2016
332
339
Status
  1. Non-Student
Agreed. But the only time (besides that one appointment) I had seen it used was during training in grad school. It is not the norm at my employer (though we are required to use other measures during treatment) and fairly confident several other community mental health agencies don’t use it either. This of course is probably regional /state dependent.
 

Your message may be considered spam for the following reasons:

  1. Your new thread title is very short, and likely is unhelpful.
  2. Your reply is very short and likely does not add anything to the thread.
  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.
About the Ads