Samenvatting alle hoorcolleges Deception in Clinical Settings
Hoorcollege 1 – Deception in Clinical Settings
Deception is fundamental to survival in the animal kingdom.
Feigning of death to avoid predators is common in many animal species (e.g.
opossum).
Adult birds feign injury to draw predators away from their nest.
Case report
Frank William Abagnale.
Born 1948 in New York, USA.
Cheque con artist, forger and imposter.
Passed bad cheques worth more than 2,5 million in 26 countries.
Committed the majority of his crimes between the ages of 16 and 21.
After being released, he founded a financial fraud consultancy company.
He earned enough money to pay back all those he scammed over his criminal career.
,,,,
Assumption of honesty
Clinicians are trained to believe patients.
Consequently
Often not aware of the potential for deception in the clinical setting.
However
Some patients deliberately produce false or grossly exaggerate symptoms.
to gain external incentives (malingering) or
to assume the sick role (factitious disorders)
Common psychiatric disorders accompanied by deceptive behaviour
Substance abuse and dependence
Part of the disease: denial and other forms of deception in order to minimize
consequences of use.
Ensure continued supply of the substance.
Eating disorders
Clinicians are aware that patients with anorexia and bulimia nervosa use various
common deceptive practices.
Examples:
Dishonesty about bodyweight or food intake.
Hiding food
Secretive use of laxatives or diuretics.
Body weight manipulation (e.g. ingesting water prior to weighting).
Paraphilias
Sexual deviations or perversions with behaviours or sexual urges focusing on
unusual objects, activities, or situations.
Examples:
Fetishism
Exhibitionism
Frotteurism
Voyeurism
Pedophilia
,Personality disorders
Common feature: difficulties with impulse control, including exaggeration or lying.
In particular:
Antisocial personality disorder
Borderline personality disorder
Histrionic and narcissistic personality disorder
Factitious disorders and malingering
Factitious disorder (FD) = a psychiatric condition in which an individual presents with an
illness that is deliberately produced or falsified for the purpose of assuming the sick role.
Voorbeeld video huilend kind.
Internal.
Malingering = the intentional production of false or grossly exaggerated physical or
psychological symptoms motivated by external incentives, such as financial compensation.
Voorbeeld video vrouw die wordt “geslagen” in de rechtzaal.
External.
Both FD and malingering are intentional and conscious.
Differential diagnosis
Differentiation
It can be:
Factitious disorder or malingering
OR
Real medical or mental condition (other than factitious disorder)
, Somatic symptom and related disorder
Prominence of somatic symptoms associated with significant distress and
impairment.
Different forms (e.g. conversion disorder and illness anxiety disorder).
Illness anxiety disorder: preoccupation with fears of having a serious illness.
Conversion disorder: sensory or motor symptoms without and psychological cause.
Sometimes there are reasonable arguments against someones symptoms (voorbeeld hand
is verdeeld in twee zenuwen, als je de buitenste vingers nog wel voelt maar de middelste niet
kan dit anatomisch gezien niet).
Determining existence of an external incentive can be difficult (malingerers usually
do not trumpet their external incentives).
Voluntariness and intentionally are more likely dimensions rather than discrete
entities.
What about the clinicians?
No monopoly on distortion for patients.
Example: Gert postel successfully applied as a medical doctor several times
without ever having received medical training.
It is estimated that around 30% of all sick notes are bogus.
Physicians are prepared to lie in the interest of their patients (e.g. to secure insurance
payment).
Placebo
Why do people malinger?
Explanatory models
Adaptational model
Cost-benefit analysis results in deliberate decision to feign psychological
impairment.
Pathogenic model
Underlying disorders discloses in malingered symptomatology (i.e.
malingerers “can’t control their behaviour”).
Criminological model
Malingering is a sign of antisocial behaviour committed by antisocial persons
(DSM relies on this model, which is questioned by research data).
Hoorcollege 1 – Deception in Clinical Settings
Deception is fundamental to survival in the animal kingdom.
Feigning of death to avoid predators is common in many animal species (e.g.
opossum).
Adult birds feign injury to draw predators away from their nest.
Case report
Frank William Abagnale.
Born 1948 in New York, USA.
Cheque con artist, forger and imposter.
Passed bad cheques worth more than 2,5 million in 26 countries.
Committed the majority of his crimes between the ages of 16 and 21.
After being released, he founded a financial fraud consultancy company.
He earned enough money to pay back all those he scammed over his criminal career.
,,,,
Assumption of honesty
Clinicians are trained to believe patients.
Consequently
Often not aware of the potential for deception in the clinical setting.
However
Some patients deliberately produce false or grossly exaggerate symptoms.
to gain external incentives (malingering) or
to assume the sick role (factitious disorders)
Common psychiatric disorders accompanied by deceptive behaviour
Substance abuse and dependence
Part of the disease: denial and other forms of deception in order to minimize
consequences of use.
Ensure continued supply of the substance.
Eating disorders
Clinicians are aware that patients with anorexia and bulimia nervosa use various
common deceptive practices.
Examples:
Dishonesty about bodyweight or food intake.
Hiding food
Secretive use of laxatives or diuretics.
Body weight manipulation (e.g. ingesting water prior to weighting).
Paraphilias
Sexual deviations or perversions with behaviours or sexual urges focusing on
unusual objects, activities, or situations.
Examples:
Fetishism
Exhibitionism
Frotteurism
Voyeurism
Pedophilia
,Personality disorders
Common feature: difficulties with impulse control, including exaggeration or lying.
In particular:
Antisocial personality disorder
Borderline personality disorder
Histrionic and narcissistic personality disorder
Factitious disorders and malingering
Factitious disorder (FD) = a psychiatric condition in which an individual presents with an
illness that is deliberately produced or falsified for the purpose of assuming the sick role.
Voorbeeld video huilend kind.
Internal.
Malingering = the intentional production of false or grossly exaggerated physical or
psychological symptoms motivated by external incentives, such as financial compensation.
Voorbeeld video vrouw die wordt “geslagen” in de rechtzaal.
External.
Both FD and malingering are intentional and conscious.
Differential diagnosis
Differentiation
It can be:
Factitious disorder or malingering
OR
Real medical or mental condition (other than factitious disorder)
, Somatic symptom and related disorder
Prominence of somatic symptoms associated with significant distress and
impairment.
Different forms (e.g. conversion disorder and illness anxiety disorder).
Illness anxiety disorder: preoccupation with fears of having a serious illness.
Conversion disorder: sensory or motor symptoms without and psychological cause.
Sometimes there are reasonable arguments against someones symptoms (voorbeeld hand
is verdeeld in twee zenuwen, als je de buitenste vingers nog wel voelt maar de middelste niet
kan dit anatomisch gezien niet).
Determining existence of an external incentive can be difficult (malingerers usually
do not trumpet their external incentives).
Voluntariness and intentionally are more likely dimensions rather than discrete
entities.
What about the clinicians?
No monopoly on distortion for patients.
Example: Gert postel successfully applied as a medical doctor several times
without ever having received medical training.
It is estimated that around 30% of all sick notes are bogus.
Physicians are prepared to lie in the interest of their patients (e.g. to secure insurance
payment).
Placebo
Why do people malinger?
Explanatory models
Adaptational model
Cost-benefit analysis results in deliberate decision to feign psychological
impairment.
Pathogenic model
Underlying disorders discloses in malingered symptomatology (i.e.
malingerers “can’t control their behaviour”).
Criminological model
Malingering is a sign of antisocial behaviour committed by antisocial persons
(DSM relies on this model, which is questioned by research data).
