Factitious disorder presenting with mental health symptoms

[MiniLop]

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.

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[LadyHalcyon]

Personality disorder

 

[MiniLop]

Personality disorder

I thought about that, but there's nothing else in the client's presentation that's consistent with a personality disorder. It's odd.

 

[LadyHalcyon]

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

 

[BuckeyeLove]

I would put all of my assets on this being characterological. Without hesitation.

 

[LadyHalcyon]

I would put all of my assets on this being characterological. Without hesitation.

Yeah. I agree. My other thought is ASD and/or borderline intellectual functioning. Also, not mutually exclusive

 

[borne_before]

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.

 

[LadyHalcyon]

Also, does facticious disorder really exist? Isn't it likely almost always better captured by another diagnosis?

I digress

 

[WisNeuro]

Also, does facticious disorder really exist? Isn't it likely almost always better captured by another diagnosis?

I digress

Think of as similar to malingering (which is not a diagnosis) but the person is getting primary vs secondary gain.

 

[MiniLop]

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]

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 🙂

 

[borne_before]

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]

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).

 

[LadyHalcyon]

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]

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]

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)?

 

[WisNeuro]

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?

 

[LadyHalcyon]

Give him the mfast

 

[erg923]

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]

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.

 

[WisNeuro]

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]

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."

 

[LadyHalcyon]

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?

 

[erg923]

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"

 

[MAClinician]

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”

 

[erg923]

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”

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.

 

[MAClinician]

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.

 

[futureapppsy2]

So, bumping this up because I fell down the fascinating hole of reading up on FD by Internet recently. Apparently, saying that you have DID is a TikTok trend for getting attention among teens currently. Honestly, the internet can be bad for this—pro-Ana, tumblr glorifying depression, etc. Apparently, DID is just the current en vogue “diagnosis” for this stuff right now.

 

[WisNeuro]

So, bumping this up because I fell down the fascinating hole of reading up on FD by Internet recently. Apparently, saying that you have DID is a TikTok trend for getting attention among teens currently. Honestly, the internet can be bad for this—pro-Ana, tumblr glorifying depression, etc. Apparently, DID is just the current en vogue “diagnosis” for this stuff right now.

Can't wait for that to start popping up in my IMEs, people claiming DID because of their uncomplicated mTBI.

 

[borne_before]

Everyone on reddit claims to have "dissociation" from what not.

 

[AcronymAllergy]

I've started to see, at least from what I can tell, that it does seem to be a bit in fashion to suggest you have a MH condition and/or have a therapist.

I'd coincidentally had a more substantial series of thoughts on this just the other day, but I can't remember what they were or what prompted them. Sigh.

 

[cara susanna]

I've seen soooo many people on social media say that they have complex PTSD (ugh, you all know how I feel about that diagnosis in general).

 

[DynamicDidactic]

So, bumping this up because I fell down the fascinating hole of reading up on FD by Internet recently. Apparently, saying that you have DID is a TikTok trend for getting attention among teens currently. Honestly, the internet can be bad for this—pro-Ana, tumblr glorifying depression, etc. Apparently, DID is just the current en vogue “diagnosis” for this stuff right now.

What is meant by: FD by Internet?

YouTube is full of people talking about their DID. I get the video recommendations all the time after my DID lecture. I'm actually having a student do some research on this phenomenon. DID seems very hot among the undergrads, more so than even 5 years ago.

 

[futureapppsy2]

What is meant by: FD by Internet?

YouTube is full of people talking about their DID. I get the video recommendations all the time after my DID lecture. I'm actually having a student do some research on this phenomenon. DID seems very hot among the undergrads, more so than even 5 years ago.

Munchausen by Internet: Current Research and Future Directions - PMC

The Internet has revolutionized the health world, enabling self-diagnosis and online support to take place irrespective of time or location. Alongside the positive aspects for an individual’s health from making use of the Internet, debate has ...

www.ncbi.nlm.nih.gov

@MiniLop , any updates on this case?

 

[MiniLop]

Sadly, no good updates. Long story short: Lots of axis 2 stuff in the family, and parents withdrew client from treatment.