Deciphering Factitious Disorder vs. Malingering: Key Differences and Diagnostic Challenges

This article will emphasize the importance of accurate differentiation between factitious disorder and malingering in clinical practice.

Have you ever exaggerated how you felt as a child? Maybe you didn’t feel right in your stomach before a big test, but you didn’t know what anxiety was, so you went to the nurse, and she called your mom. You realized that you felt better as soon as you left the classroom, but now your mom was coming to pick you up, and she even bought you ice cream, so you pretended you still had an upset stomach. 

As a child, exaggerating symptoms happens from time to time, especially when there isn’t a fully developed understanding of the different feelings, emotionally or physically.

However, as an adult, this becomes a more serious concern, especially when individuals falsify and exaggerate illnesses and injuries or even cause themselves illness and injury in order to get out of work or get attention from those around them. Factitious disorder is a mental health disorder where an individual does just that, but malingering is a behavioral decision where an individual does similar things but for specific external rewards. There are many similarities in symptom presentation, but it’s important to differentiate between them in clinical practice. 

This article will review the key differences between facetious disorder vs. malingering. 

Understanding the two means understanding their characteristics, treatments, and ethical considerations. 

With factitious disorder vs malingering, there are some differences in terms of diagnostic criteria. 

For example, Factitious disorder presents with:

1. Falsification of psychological or physical symptoms or creating an injury or a disease that an individual perceives to be real.
2. The individual tells others that he or she is ill, injured, or impaired.
3. The behavior happens without any obvious external rewards.
4. The behavior is not better explained by other mental health disorders.

Note: An individual with factitious disorder vs. malingering can also suffer from factitious disorder by proxy, now called “imposed on another,” whereby the same symptoms happen, but instead of themselves, the individual presents someone else as ill or impaired and falsifies symptoms for another. 

Malingering presents with two of the following:

1. An individual has a medical or legal situation that, with a specific diagnosis, could be improved.
2. There are noticeable differences between what a person claims they are feeling and what their physical symptoms are.
3. Individuals will not follow any treatment or receive follow-up care.
4. Individuals have antisocial personality disorder.

With malingering, individuals falsify or exaggerate their psychological or physical problems for a specific external benefit that usually includes things like avoiding any type of responsibility, including work, jury duty, school, or military service. It is also something seen in people who want to avoid trial or reduce a criminal sentence. Some of the biggest factors that indicate malingering are a complete lack of diagnostic criteria to support the claims the individual has and noticeable differences in what someone claims versus what is observed. 

The key difference between malingering disorder vs. factitious disorder is the motivation and intent. 

Someone with a factitious disorder does so for no external reward or gain. they might, by extension, end up with things like extra time and attention from family members or faith leaders as well as emotional support from family or Healthcare professionals but that is not the intended goal.

By comparison, someone with a malingering disorder reports the falsification with the intent of personal gain. This intent could be to gain time off work by exaggerating symptoms so they don’t have to return to work or to get money by exaggerating symptoms so that they can collect on things like disability.

With factitious disorder, the overall motivation is intended simply to get more attention.

With malingering vs factitious disorder, there are several diagnostic challenges. With factitious disorder, for example, patients may very well have legitimate or pre-existing medical conditions. So, it can be difficult to diagnose whether the condition is presenting with abnormal or severe symptoms or whether it is a symptom of a factitious disorder. 

There are several other diagnostic challenges as well. With malingering vs. factitious disorder, a diagnosis for factitious disorder requires that the purposeful falsification cannot be better explained by external rewards; however, these two conditions are not mutually exclusive, which means the motives in a single case might shift based on reactions of other people or circumstances. More importantly, there could be several motives in a single case, which makes it difficult to diagnose malingering vs factitious disorder. 

For factitious disorder vs malingering examples, consider the following:

Patient A has factitious disorder. The patient wakes up with only a slight pain in their head from grinding their teeth at night but now exaggerates the raging migraine they have. They get attention from friends and family, so now they say it is making them dizzy, and they are urinating blood, so they get a medical appointment. The purpose here is to deceive others so that they view them as severely ill. When at the doctor’s office, they regularly falsify their medical tests. For example, when they are asked to give a urine sample, they prick their finger and drip blood into it so that the sample purportedly contains blood. Other times, they wake insulin in order to create an abnormal test result. 

Patient B also has factitious disorder. They report feelings of suicidal ideations after their spouse passes away, even though they were never married, so no spouse passed away. They report neurological symptoms that are not true, like seizures or blacking out. 

Patient C has malingering. The patient wants to avoid work so they do things like raise the temperature on a lamp and then put it over their forehead so that they present as warm and clammy. They also complain of subsequent injuries so that they can get a prescription from their doctor.

Patient D also has malingering. They exaggerate their mental health symptoms so that they won’t be punished for a criminal activity for which they were recently convicted. In order to change the chemistry of things like urine samples, they add contaminants to their sample when at the doctor’s office. In other cases, they inject themselves with feces so that they get sick and don’t have to go to jury duty. 

With malingering disorder vs factitious disorder, treatment approaches can be equally challenging. The primary treatment is psychotherapy, and the goal is to help people manage the motivation for attention or personal gain in a healthy way and, in so doing, reduce how much they abuse medical resources and decrease those behaviors. Similarly, therapy helps individuals tackle any underlying mental health disorders.

With malingering disorder, it’s not a mental health condition. It’s just a deliberate behavior designed to create personal gain. Therefore there’s no therapy or medication used to treat it. Those who have malingering have to be detected early and managed. Unfortunately, the burden falls on medical professionals to evaluate things like medical conditions and symptoms and then rule out genuine illnesses, after which indirect confrontation or no longer providing services can be a solution. 

The prevalence of factitious disorder is estimated to account for almost 1% of the presentations for those at inpatient hospitals across the United states. However, the role of deception complicates any effort to determine how prevalent this condition is and therefore what extent or impact it has on the healthcare system.

What is known is that people with factitious disorders misuse and overuse medical resources. By lying to medical personnel and tampering with tests, inducing illness or injury, individuals with this condition are abusing limited resources, taking away medical attention and treatment from people who have legitimate concerns. 

Similarly, malingering, though not a medical condition, has a similar impact on the healthcare system because individuals will falsify symptoms that end up wasting time and resources that could otherwise be dedicated to those in legitimate need. 

There are a lot of considerations for future directions in factitious disorder treatment. As of late, those who are seeking treatment should avoid invasive or risky treatment options. Given the fact that factitious disorder symptoms can potentially relate to childhood trauma, there might be opportunities for future research to center on trauma-based therapies like EMDR, which could potentially help resolve trauma contributing to ongoing symptoms.

Factitious disorder often presents with intermittent episodes. While there are no gender-related diagnostic differences or race-related diagnostic differences, individuals can experience the onset of symptoms in early adulthood, usually after they have been hospitalized for a mental health disorder or medical condition. This leads to questions about the role of hospitalization in bringing forth symptoms of factitious disorder.

Similarly, individuals who struggle with recurrent episodes are at risk for a lifelong pattern of successful deceptive contact with their medical staff, including lifelong hospitalizations. Given the fact that the symptoms tend to initiate following a hospitalization, it stands to reason that there are complicated psychological dynamics behind each subsequent hospitalization that contribute to the lifelong prevalence. 

If discovered, malingerers will provide several excuses for their behavior, but at some point, they might give up because they are no longer being attended to or getting the external reward that they are looking for. 

There are several ethical considerations with factitious disorder vs malingering examples for psychiatrists and medical practitioners alike. If a professional suspects that a client or patient is struggling with malingering or factitious disorder, it’s up to them to carefully assess the symptoms, medical history, and any genuine medical illnesses and from there determine when it’s appropriate to confront them directly or indirectly.

Aas mentioned, malingers will provide several excuses for their behavior if confronted but at some point they will run out of excuses and no longer falsify their condition because they aren’t achieving their end goal. But it’s up to medical professionals and mental health professionals to decide when they should stop providing services if they suspect malingering.

When looking at factitious disorder vs malingering, the biggest difference is that malingering is a deliberate behavior where an individual falsifies symptoms, illnesses, or injuries for personal gain, whereas factitious disorder is a mental health disorder that can be treated with things like therapy. It is important to get an accurate diagnosis and individualized treatment approaches for individuals struggling with either.