The factitious/malingering continuum and its burden on public health costs: a review and experience in an Italian neurology setting

Abstract

Factitious disorder is classified as one of the five aspects of somatic symptom disorders. The fundamental element of factitious disorder is deception, i.e., pretending to have a medical or psychiatric disorder, but the enactment of deception is considered unconscious. Indeed, volition, i.e., the perception of deliberate deception, is blurred in patients presenting with factitious disorder. In the USA and the UK, factitious disorder has received constant media attention because of its forensic implications and outrageous costs for the National Health Systems. Unfortunately, a comparable level of attention is not present in Italian National Health System or the Italian mass media. The review analyzes the classifications, disorder mechanisms, costs, and medico-legal implications in the hope of raising awareness on this disturbing issue. Moreover, the review depicts 13 exemplification cases, anonymized and fictionalized by expert writers. Finally, our paper also evaluates the National Health System’s expenditures for each patient, outlandish costs in the range between 50,000 and 1 million euros.

Clinical-Pathological Conference Series from the Medical University of Graz

“…Factitious disorders are an important item on the differential diagnosis list but are often unrecognized and misdiagnosed. As the volitional aspect, i.e., perception of deliberate deception in affected patients is blurred, differentiation from functional, dissociative and somatoform disorders and simulation/aggravation is often challenging [ 3 , 41 ]. The absence of clear external incentives and a strong propensity to self-harm distinguish factitious disease from malingering [ 3 ].…”

Functional Neurologic Disorders, disorders to be managed by neurologists, or are neurologists wandering in a dangerous field with inadequate resources?

“…Several reviews quote the DSM-5 categorization (10), in which factitious disorders are placed in a separate category of somatic symptoms disorders (which, nonetheless, include FND). Many discussions on FND compare this disorder to Malingering (16,17), overlooking or ignoring the complex question posed by the imposing presence of Factitious Disorders.…”

“…The boundaries between the various discussed disorders were therefore considered unclear and a possible continuum was suggested, and the "Hystero-malingering continuum" appears in the literature (10,16,17,48,67,98). For example, it was shown that hysteric patients misinterpret evidence and selectively attend to only a certain part of the overall evidence.…”

“…This is truly a major challenge, as it introduces concepts of self-deception in SSD and the disavowal of intention (15). Some authors, coalescing in 2001 to present a book on contemporary approaches to Hysteria, proposed a continuum encompassing Hysteria, Conversion, and Factitious Disorder, as reformulated in recent publications (16)(17)(18) (Figure 1).…”