Fake It ‘Til You Break It: Factitious Disorder Imposed on Self

Ahren McGuire
PSY 223: Abnormal Psychology
Dr. Colin Shwartz
March 16, 2023
 The DSM-V (2013) describes Factitious Disorder Imposed on Self (FDIS) as a pattern of

intentionally fabricated symptoms presented by an individual, which are intended to deceive

healthcare providers, in the absence of any external reward (p.325). In this essay, I will first

present a description of FDIS by using the accompanying literature to support and elaborate on

the features and diagnostic criteria of FDIS found in the DSM-V. Secondly, I will describe the

stigmas that have been linked to FDIS that seem to reflect a generally negative misunderstanding

and poor perception of mental disorders that seems to have adversely affected reporting and

diagnoses. The last section will focus on the management strategies and theories for treating

FDIS. While positive outcomes have been rare due to the elusiveness of the afflicted and the

pervasive hindrances surrounding reporting and diagnoses, a robust therapeutic alliance between

healthcare providers and individuals with FDIS has been a central feature towards recovery.

Features of FDIS

Yates and Feldman (2016) have described FDIS as a rare and potentially fatal mental disorder

that has presented a myriad of challenges. The contrived behaviours seem to devour a

disproportionately high amount of resources in the healthcare system and poison therapeutic

alliances (p.20). According to the DSM-V, a diagnosis of FDIS may be warranted if a)

exaggerated, feigned, or induced complaints infer deception; b) there is an overt presentation of

empirically unsubstantiated complaints; c) there are no clear rewards or secondary gains; and d)

there is no other disorder that could provide an appropriate explanation. When there are clear

external rewards, the deceptive behaviour is considered malingering, which is not defined as a

mental disorder in the DSM-V (pp. 324-325).

Yates and Feldman (2016) have gathered common characteristics and factors that have led to

a diagnosis of FDIS. The most prominent factors appear to be an extensive healthcare history,
especially if there are indications that healthcare had been sought out in many different locations.

Furthermore, the information that the individual with FDIS may provide is typically vague and

inconsistent and the individual may attempt to prevent a healthcare provider from substantiating

any of the information with previous healthcare providers or family. How the individual presents

signs and symptoms has typically drawn suspicion, especially involving complaints that follow a

very predictable course. It is common for individuals with FDIS to have strangely specific

medical knowledge and lastly, there is often solid evidence of deception such as foreign material

in a wound. While individuals with FDIS are creative in their deceptions, Yates and Feldman

(2016) assert that they may lack true insight into the consequences of their deceptions, which has

led to deleterious consequences.

Early indicators or FDIS may occur in childhood and have typically been prompted by

childhood trauma, abuse, or neglect. FDIS appears to become a coping strategy and the

presentations gradually become more severe as the disorder progresses (Peng et. al, 2022, 209).

A feature that is crucial in distinguishing FDIS from malingering or other disorders is the

absence of clear rewards, such as financial compensation or to avoid criminal responsibility

(Fasesan & Awokoya, 2022, p.135). Individuals with FDIS may present intentionally falsified

physical symptoms as well as psychological symptoms to assume the “sick role”, to attract

sympathy, or as a coping mechanism. However, studies have revealed that some motivations may

be much darker. Lawlor and Kirakowski (2014) assert that individuals with FDIS may find

pleasure in successfully manipulating healthcare providers and that there is a problematic degree

of premeditation that goes into the overall deception. FDIS that thrives on duping has been

likened to a substance addiction (p.213). The form and perceived motivation of the deceptive
behaviour may be an indicator of the severity and extent of the development of FDIS (Bérar et

al., 2021, p.7).

The prevalence of FDIS is very low, but there are serious issues relating to stigma and

treatment that suggest the prevalence may be much higher. Yates and Feldman (2016) have

recommended that healthcare providers should be especially wary of women in early adulthood

who claim to have experience in healthcare (26). The ambiguity surrounding the prevalence of

FDIS may be due to the similarities between FDIS and other disorders. Malingering is essentially

the same as FDIS, but with rewards. However, it can also be differentiated by the level of

agreeableness towards a complicated medical procedure, in which case malingerers would

typically balk. Another common differential diagnosis has been conversion disorder, which can

be distinguished from FDIS as the symptoms presented in a conversion disorder are unconscious,

while the deception in FDIS is a conscious process. Personality disorders and depression are

common comorbidities, but do not support a differential diagnosis and the level of deception is

insufficient (DSM-V, 2013; Peng et al., 2022).

Stigmas Associated With FDIS

Doyon (1998) asserts that the origin and perceived controllability of a stigma is what

directs the attitudes towards individuals bearing the stigma. According to Doyon (1998), mental

disorders are perceived to have a self-imposed, seemingly voluntary origin, and are perceived to

be controllable. Consequently, the burden of responsibility is assigned to the afflicted. Doyon

(1998) asserts that because of these perceptions, individuals whose stigmas relate to mental

disorder are less likely to receive sympathy and more likely to be judged harshly (p.2). By
applying this logic to FDIS, it appears that stigmas may be a driving factor in the development

and perpetuation of FDIS.

Concerning the origin of FDIS, behaviorists have contended that FDIS is a maladaptive

coping mechanism that is learned (Fasesan & Awokoya, 2022, p.135). This perspective is

supported by Hagglund (2009), whose case study subject admitted to feigning illness at a young

age to avoid life stressors. However, environmental factors must also be considered. The

literature is replete with accounts of childhood abuse, abandonment, and trauma. Hagglund’s

subject was no exception. In her account, the maladaptive nature of the childhood coping

mechanism bloomed into a serious disorder because there was no tolerance for mental disorders.

As a result, feigning physical complaints was seen as a socially accepted method of reacting to

stigmatized emotional issues (p.61). This aligns with Doyon’s (1998) assertion that stigmas

involving mental illness are treated far less favorably than physical stigmas. In these instances,

the origin does not seem self inflicted, and it appears that controllability of the stigma may be

lost to social expectations.

Peng et al. (2022) provide a list of derisive terms for FDIS that have been taken from

medical literature, which speaks to the ingrained perceptions about FDIS that fuel negative

stigmas even in healthcare settings. To refer to individuals with FDIS, terms like ‘black hole

patients’, ‘hospital hoboes’, ‘scalpel addicts’, and ‘peregrinating problem patients’ were deemed

to be acceptable enough to publish. Hagglund (2009) indicates that stigmatization has been a

factor that has dissuaded healthcare providers from assigning a diagnosis of FDIS. A rationale

behind the reluctance to diagnose FDIS has been to protect patients from the stigma that is

attached to FDIS, which could potentially interfere with any treatment of future genuine
complaints (p.60). However, this strategy may perpetuate the stigma and would naturally reduce

the opportunity for early detection of FDIS.

Treating FDIS

A notable challenge in treating FDIS has been to maintain a strong and nurturing

therapeutic alliance between healthcare practitioners and individuals with FDIS, which has been

a determining factor in positive treatment outcome (Fasesan & Awokoya, 2022, 137).

Unfortunately, most of the features of FDIS have the potential to threaten the alliance. Before a

diagnosis has been assigned, healthcare providers must first arrive at the conclusion that the

diagnostic criteria have been met. At which point, it would also be evident that they had been

deceived and manipulated. Peng et al. (2022) indicate that it is important for healthcare providers

to reconcile any negative products of countertransference to protect the alliance (p.210). With a

strong therapeutic alliance in place, healthcare providers are then in a better position to diagnose

FDIS.

Subsequently, formally assigning a diagnosis of FDIS has presented further challenges to

treatment. Bérar et al. (2021) assert that individuals with FDIS are unlikely accept a diagnosis as

it would equate to an admission that their complaints were fabricated. Even when faced with

evidence that directly contradicts the veracity of any symptoms or complaints, individuals with

FDIS have rejected any suggestion that would infer deception. Deception may be a cardinal

feature of FDIS, but the inability to accept a diagnosis may also be linked to a fear of

humiliation. It has even been suggested that a barrier to treatment is the fear of recovery as

feigned illnesses would no longer serve as a coping mechanism (Lawlor & Kirakowski, 2014,

p.210).
 A strong therapeutic relationship appears to provide a stable foundation for healthcare

providers to apply additional treatment strategies. Peng et al. (2022) suggest that psychotherapy

may be useful in helping individuals with FDIS recognize the maladaptive and deleterious nature

of their affliction. If individuals with FDIS are open to the process, healthcare providers have

been advised to maintain a narrative that promotes validation and acceptance for the individual

(p.211). Furthermore, Bérar et al. (2021) contend that there have been reductions in the severity

of FDIS when treatment has been directed at the comorbid conditions, which may be responsive

to medication (7). While personality disorders have been considered the most common comorbid

condition (Peng et al., 2022, p.212), Yates (2016) has indicated that depression has a higher rate

of comorbidity with FDIS than personality disorders (p.25). In cases where the underlying

condition has been depression, Fasesan and Awokoya (2022) have indicated that the prognosis is

very positive if the appropriate medications are supported by consistent psychotherapy sessions

(p.136).

Despite the careful considerations and delicate treatment efforts, many individuals with

FDIS resume the harmful behavioural patterns. In such circumstances, Peng et al. (2022) have

mentioned a legal pathway to treatment as a viable option. When there is a high likelihood that a

mental disorder will cause harm, involuntary commitment to a psychiatric institution would

allow healthcare providers to provide treatment and supervise the effect of the treatment. This is

a controversial approach that has ethical implications, but FDIS has proven to be fatal and

extremely resistant to other forms of treatment, which may support an involuntary commitment

(212). A final option that can deter individuals with FDIS is a by keeping a “black list” that

would allow healthcare providers to identify individuals who have met the criteria for FDIS. The
inability to assume a sick role may deter individuals with FDIS and fewer resources would be

lost with unnecessary medical procedures (Fasesan & Awokoya, 2022, p. 7).

Conclusion

Although the first step in the process of DSM-5 Differential Diagnosis Handbook (2014) is to

exclude the possibility of factitious disorder or malingering, FDIS is rarely detected in its early

stages. This has often been attributed to a lack of understanding or familiarity with the

symptoms, which has resulted in imprecise diagnoses. Lawlor and Kirakowski (2014) assert that

the inherent unwillingness of individuals with FDIS to accept treatment may be responsible for

the scarcity of understanding. However, it may also be possible that the lack of understanding is

connected to label avoidance and the fear of stigmatization. This may discourage diagnoses of

FDIS, which reduces the demand for treatment of FDIS and may prevent a more complete

understanding of the disorder. Recent literature continues to promote early recognition as key

component to a positive outcome, which might imply that once the severity of FDIS increases,

the challenges are beyond present capabilities.

 References

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