Lying to gain medical attention may be as old as the medical profession,
but there has been little or no increase in understanding factitious disorders
over the last three or four decades despite nearly 2,000 publications on the
subject, Charles Ford, M.D., a professor of psychiatry at the University of
Alabama, Birmingham, told listeners at APA's 2007 annual meeting in San
However, the time may have come to rethink the entire category of
factitious disorders, said Ford. "The current DSM-IV diagnostic
category of factitious disorders is conceptually flawed and creates clinical
problems," he said at a session on legal issues at the interface of
psychiatry and medicine.
DSM-IV says that the essential feature of factitious disorders is
the "intentional production of physical or psychological signs or
symptoms," which is motivated by a desire to assume the sick role.
Malingering, which involves greed or avoidance of work, has an external
motivation, so Ford did not include it in his discussion.
"People who tell untruths about their medical conditions are
motivated not by material gain but express their desire for care because they
want attention or to be cared for," said Thomas Wise, M.D., chair of the
Department of Psychiatry at Fairfax Hospital in Falls Church, Va., and a
professor of psychiatry at Johns Hopkins, in an interview.
Some lying is a normal part of human development, said Ford, a professor of
psychiatry at the University of Alabama, Birmingham, and the author of
Lies! Lies! Lies!: The Psychology of Deceit (American Psychiatric
Publishing Inc., 1999). Parents may tell children not to lie, but they may
also say, "Don't tell Aunt Fanny you didn't like the present she gave
you for your birthday." Lying permits individuation, facilitates social
relationships, and keeps personal behavior personal, said Ford.
Lying has evolutionary advantages, too. Primate studies have found that the
bigger the neocortex, the greater the capacity to lie, which allows more
sophisticated and elaborate social manipulations. Functional MRI and positron
emission tomography studies also show increased brain activation—mainly
in the prefrontal and anterior cingulate cortices—in liars compared with
"You could say that lying requires more mental activity than telling
the truth," said Ford.
There may be other biological differences, too. One study found that
pathological liars had more prefrontal white matter and a lower
gray-to-white-matter ratio compared with either normal or antisocial
However, most lying is not benign. "The bigger the lie, the bigger
the problems," said Wise.
Specialists define types of lying by reference to the liars' intent and the
relative mixture of truth and falsity in their statements.
Pathological lying happens when there is no external motivation to lie and
when telling the truth might actually serve the speaker better, said Ford.
Habitual lying starts in childhood and is associated with other delinquent
behavior and with less parental involvement. Compulsive liars lie about
meaningless issues as a means to assert autonomy in the face of intrusive,
Pseudologia fantastica is a mixture of fact and fiction involving
fantasized events and self-aggrandizing personal roles. For instance, such
persons may repeatedly tell untrue stories of heroics in wartime or on the
athletic field. These are not delusions, said Ford. "They almost believe
[what they are saying], but if confronted, they will admit the
Imposture carries such falsity one step further, providing an entirely new
identity to the subject. Highly successful imposters enjoy their mastery in
fooling others. "Look how smart I am and what I got away with,"
they seem to say.
Munchausen's syndrome by proxy is a form of child abuse, a medicalization
of criminal activity, said Ford.
There's a fundamental philosophical problem with all these behavioral
patterns because so much of psychiatry is dependent on subjective reports from
patients about their conditions, said Wise. There is no biomarker that reveals
whether a patient is telling the truth. Reflecting the phrasing of
psychoanalyst Donald Spence, Ph.D., Wise said that there is a line between
historical truth and narrative truth, between recounting events and
interpreting them. That boundary probably marks the borders between denial and
Lately, critics, including Ford, have found fault with DSM's
criteria for factitious disorders. For instance, he referred to a recent
discussion by Christopher Bass and Peter Halligan in the February Journal
of the Royal Society of Medicine.
"Factitious disorder as a distinct type of psychiatric disorder is
conceptually flawed, diagnostically impractical, and clinically unhelpful and
should be dropped from existing nosologies," they wrote. They argue that
if the behavior is involuntary, then it is not deception. If it is voluntary,
then it amounts to malingering.
Hence, motivation is the key to understanding this phenomenon, not
deception as such.
All three DSM criteria are flawed because they place the lie
rather than the symptoms at the core of the diagnosis and assume the absence
of external motivations, said Ford. "Deception syndromes are really a
form of misbehavior rather than discrete diagnostic entities. They are the
common symptomatic outcomes of varying etiologies. We should study the
underlying personality problems that lead to the need for deceit."
Wise is not ready to throw the DSM-IV definition out with the bath
water yet, however. Some aspects of factitious disorders clearly overlap with
mental illness, he said. Deep-seated fears can induce denial of the truth and
an inability to report it. He recalled a fellow physician who denied symptoms
of colon cancer until the disease metastasized, because his mother had died of
the disease and he was frightened by its appearance in his own body. Wise also
believes that the unconscious reasons for selecting a particular illness to
lie about and be treated for reflect an underlying psychiatric illness."
Anybody who wants unneeded surgery clearly has a problem," he
Physicians should have a higher index of suspicion when they see
inconsistent lab results, he said. He has seen minimal evidence of effective
treatment for factitious disorders and has found that these patients are not
remorseful and never apologize when they are exposed.
"Future research might be better focused on underlying mechanisms of
personality disorders that may facilitate deceit," said Ford.
Regardless of whether standards for factitious disorders are changed for
DSM-V, psychiatrists must still find ways to care for these patients,
commented Gary Rodin, M.D., of the University of Toronto and the Ontario
Cancer Institute, who spoke at the same session as Ford.
"Our organization principle—that the patient lies but should
tell the truth—is our view," he said, speaking of physicians."
We must move from an individual psychiatric point of view to a social
interaction point of view. The most important thing is the formation of a
therapeutic relationship—which is what they are seeking and which is
what stops them from lying." ▪