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Malingering, factitious disorders and somatoform disorders: Pathology review

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Malingering, factitious disorders and somatoform disorders: Pathology review

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USMLE® Step 1 style questions USMLE

8 questions
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A 17-year-old girl presents to her primary care physician to evaluate right leg weakness for two weeks. The patient states, “I can’t lift my right leg, and it feels numb too. I haven’t been able to walk or go to school because of my symptoms.” The patient's parent states, “I don’t know what’s wrong. I know school has been hard this year with her applying to college, but all of this just came out of the blue.” The patient is otherwise healthy and neither uses illicit substances nor consumes alcohol. Vital signs are within normal limits. The patient has 2+ symmetric reflexes in the bilateral lower extremities on physical examination. Plantar reflex testing results in flexion of the big toe bilaterally. While the patient lies supine, the physician places a hand under the right heel; when asked to lift the left leg against resistance, the patient exerts downward pressure with the right heel. Further history gathering is most likely to reveal which of the following?  

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Transcript

Content Reviewers:

Antonella Melani, MD

A 5 year old girl named Celia is brought to the emergency department by her mother due to a sudden episode of loss of consciousness.

You decide to run some blood tests, which reveal low glucose levels.

After glucose administration, Celia fully recovers.

You admit her to the hospital to do exhaustive studies to start looking for a cause of her hypoglycemia.

The tests all come back normal, so you decide to discharge Celia.

The next morning, Celia has another unexplained episode of hypoglycemia, so you decide to check her blood insulin levels, which are found high, while her C-peptide levels are slightly low.

Some days later, 32 year old Sofia presents to the emergency department.

Sofia is complaining of severe chest pain that has been going on for the past couple hours, and she is certain that she is having a heart attack.

According to the hospital records, she has presented to the emergency department with similar symptoms 7 times within the past 12 months.

And each time, cardiac evaluation was normal.

Upon examination, both cardiac auscultation and ECG are normal.

Sofia becomes frustrated and storms out of the hospital demanding a second opinion.

Based on the initial presentation, both Celia and Sofia have some form of malingering, factitious, or somatic symptom and related disorders.

What all these have in common is that the affected individual claims to have physical or psychological symptoms that aren’t explained by any known physical or mental disorder.

Okay, starting with malingering, this is when individuals are intentionally faking or exaggerating their symptoms in order to achieve some secondary gain or external goal.

This may include getting money, housing, time off from work, access to medications, or even escaping jail time.

In other words, they’re conscious or aware of their specific motivation.

For your exams, remember that these individuals are typically uncooperative, meaning that they demand an extensive workup, but are not satisfied with negative results and don’t adhere to the diagnostic follow-up or treatment plan.

Another clue is that symptoms stop once they achieve their goal.

On the other hand, in factitious disorder, the individuals are intentionally faking or inducing symptoms, but the goal here is to get the attention and sympathy that is often given to someone who’s sick.

And remember that these individuals are usually unconscious or unaware of their motivation, which means that individuals often don’t even realize why they fabricate their symptoms.

Now, there’s factitious disorder imposed on self, and factitious disorder imposed on another.

In factitious disorder imposed on self, formerly known as Munchausen syndrome, individuals mainly pretend to have physical signs and symptoms of a disease.

This is most common in those with healthcare experience, such as healthcare workers or those somehow related to one, which makes them very knowledgeable about the symptoms they are trying to pass off as real.

And that’s an extremely high yield fact!

For your exams, keep in mind that these individuals typically have a medical record of recurrent hospitalizations, and are overeager to go through invasive interventions, like surgical procedures.

But an important difference with malingering is that, in factitious disorder imposed on self, the pretend symptoms persist even after they get the attention, sympathy, or even medical care.

In contrast, there’s factitious disorder imposed on another, formerly known as Munchausen syndrome by proxy.

In this case, the person deliberately makes a second person ill without that person’s knowledge.

Often, this second person is someone they’re responsible for, like a child, an elder, or even a pet.

Remember that this is considered a type of child or elder abuse.

And if that is suspected, it’s the healthcare provider’s responsibility to contact child or elder protective services.

Oftentimes a social worker should be involved to help decide on the best next steps to ensure the individual’s safety, like separating them from the abuser and helping the family cope.

Now, make sure you don’t confuse this with vulnerable child syndrome, which is when a parent believes that their child is unrealistically prone to getting ill or injured.

For your exams, keep in mind that vulnerable child syndrome classically starts after the child goes through a serious disease or life-threatening event.

And it may lead to repeated absences from school or exaggerated use of healthcare services.

Now, remember that these (pause) are all intentional.

So switching gears, there’s somatic symptom and related disorders, where individuals are unintentionally experiencing symptoms that can’t be explained by any physical or mental disorder.

In other words, affected individuals truly believe their symptoms are real, which are often made worse because they can’t be medically explained or treated.

Sources
  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Excessive Illness Behavior" Psychiatric Care of the Medical Patient (2015)
  4. "Essentials of Psychiatry" Wiley (2006)
  5. "The diagnosis and treatment of Munchausen’s syndrome" General Hospital Psychiatry (2003)
  6. "Kaplan & Sadock's Comprehensive Textbook of Psychiatry" NA (2000)
  7. "Diagnostic and Statistical Manual of Mental Disorders" Amer Psychiatric Pub Incorporated (2000)
  8. "Multisomatoform Disorder" Archives of General Psychiatry (1997)