Deception in Clinical Settings
Lecture 1: Introduction
Topics covered in the course
• Factitious disorders
• Munchausen syndrome by proxy
• Malingering of cognitive dysfunctions (e.g. amnesia, attention disorders)
• Malingering of psychiatric disorders
• Validity testing in child and adolescent assessment
• Residual effects of feigning
• Polygraph
Deception in animals
• 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, Jr.
o Born 1948 in New York
o Cheque con artist, forger and imposter
o Passed bad cheques worth more than 2.5 million in 26 countries
o Committed the majority of his crimes between the ages of 16 and 21
• Career as attorney
• Career as pilot
• Career as physician
• Career as teacher
• Eventually he was caught in France in 1969
• After being released, he founded a financial fraud consultancy company
Assumption of honesty
• Clinicians 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
o To gain external incentives (malingering) or
o To assume the sick role (factitious disorders)
Common psychiatric disorders accompanied by deceptive behaviour
• Part of the disease: Denial and other forms of deception > in order to >
o Minimize consequences of use
o Ensure continued supply of substance
• Eating disorders
o Clinicians are aware that patients with anorexia nervosa use various common
deceptive practices
• Examples
o Dishonesty about body weight or food intake
o Hiding food
o Secretive use of laxatives or diuretics
o Body weight manipulation (e.g. ingesting water prior to weighing)
, • Paraphilias
o Sexual deviations or perversions with behaviours or sexual urges focusing on unusual
objects, activities or situations
• Examples
o Fetishism
o Exhibitionism
o Frotteurism
o Voyeurism
o Paedophilia
• Personality disorders
o Common feature: difficulties with impulse control, including exaggeration or lying
• In particular
o Antisocial personality disorder
o Borderline personality disorder
o Histrionic and narcissistic personality disorder
Factitious disorder and malingering
Factious disorder = 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
Malingering = The intentional production of
false or grossly exaggerated physical or
psychological symptoms motivated by
external incentives, such as financial
compensation
Differences between factitious disorder and malingering
Differential diagnosis
• Differentiation
o Factitious disorder or malingering
o Real medical or mental condition (other than factitious disorder)
• Somatic symptoms and related disorders
o Prominence or somatic symptoms associated with significant distress and impairment
o Different forms (e.g. conversion disorder and illness anxiety disorder)
o Illness anxiety disorder: preoccupation with fears of having a serious illness
o Conversion disorder: Sensory or motor symptoms without any physiological cause
• Determining existence of an external incentive can be difficult (Malingerers usually do not
trumpet their external incentives)
• Voluntariness and intentionality are more likely dimensions rather than discrete entities
, What about the clinicians?
• Gert Postel
o German imposter (born 1958)
o Successfully applied as a medical doctor several times without ever having received
medical education
• 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)
Why do people malinger?
Explanatory models
• Adaptational model
o Cost-benefit analysis results in deliberate decision to feign psychological impairment
o Rational decision
▪ Substance abuse > Escaping and avoiding responsibilities
• Pathogenic model
o Underlying disorder discloses in malingered symptomatology (i.e. malingerers “can’t
control their behaviour”)
o This model suggests that the person has an underlying psychological disorder, and the
act of malingering is a reflection of that disorder. In other words, the individual may
not entirely be in control of their behavior because of their underlying pathology. This
model implies that the malingering behavior is driven by internal factors, not just an
attempt to manipulate external situations.
o Belief System: The individual may believe they need to behave this way because of
how they see themselves or their condition. I need to do this because it’s just me
▪ Eating disorders: The person may fake or exaggerate symptoms related to an
eating disorder as a way to maintain control or because of a distorted body
image.
▪ Substance abuse: The person may claim psychological problems to self-
medicate and rationalize their behavior.
▪ Paraphilias: Past experiences of abuse may contribute to boundary issues,
leading the individual to justify harmful behavior as a product of their own
abuse history.
• Criminological model
o Malingering is sign of antisocial behaviour committed by antisocial persons (DSM
relies on this model, which is questioned by research data)
▪ Conduct disorder: The individual shows poor impulse control and engages
in deceptive or manipulative behaviors.
▪ Substance abuse: This is linked to secondary antisocial personality traits,
where the person might engage in more criminal behavior to feed their habit.
▪ Paraphilias: The individual may use deception as a way to lure victims or
continue harmful behaviors, using manipulation as a tool to maintain
offending.
People would malinger if it gives them a clear advantage
Lecture 2: Factitious Disorders and Munchausen Syndrome
Factitious Disorder (FD)
• Refers to the psychiatric condition
• In which an individual presents with an illness
• That is deliberately produced or falsified
• Usually for the purpose of assuming the sick role
Lecture 1: Introduction
Topics covered in the course
• Factitious disorders
• Munchausen syndrome by proxy
• Malingering of cognitive dysfunctions (e.g. amnesia, attention disorders)
• Malingering of psychiatric disorders
• Validity testing in child and adolescent assessment
• Residual effects of feigning
• Polygraph
Deception in animals
• 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, Jr.
o Born 1948 in New York
o Cheque con artist, forger and imposter
o Passed bad cheques worth more than 2.5 million in 26 countries
o Committed the majority of his crimes between the ages of 16 and 21
• Career as attorney
• Career as pilot
• Career as physician
• Career as teacher
• Eventually he was caught in France in 1969
• After being released, he founded a financial fraud consultancy company
Assumption of honesty
• Clinicians 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
o To gain external incentives (malingering) or
o To assume the sick role (factitious disorders)
Common psychiatric disorders accompanied by deceptive behaviour
• Part of the disease: Denial and other forms of deception > in order to >
o Minimize consequences of use
o Ensure continued supply of substance
• Eating disorders
o Clinicians are aware that patients with anorexia nervosa use various common
deceptive practices
• Examples
o Dishonesty about body weight or food intake
o Hiding food
o Secretive use of laxatives or diuretics
o Body weight manipulation (e.g. ingesting water prior to weighing)
, • Paraphilias
o Sexual deviations or perversions with behaviours or sexual urges focusing on unusual
objects, activities or situations
• Examples
o Fetishism
o Exhibitionism
o Frotteurism
o Voyeurism
o Paedophilia
• Personality disorders
o Common feature: difficulties with impulse control, including exaggeration or lying
• In particular
o Antisocial personality disorder
o Borderline personality disorder
o Histrionic and narcissistic personality disorder
Factitious disorder and malingering
Factious disorder = 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
Malingering = The intentional production of
false or grossly exaggerated physical or
psychological symptoms motivated by
external incentives, such as financial
compensation
Differences between factitious disorder and malingering
Differential diagnosis
• Differentiation
o Factitious disorder or malingering
o Real medical or mental condition (other than factitious disorder)
• Somatic symptoms and related disorders
o Prominence or somatic symptoms associated with significant distress and impairment
o Different forms (e.g. conversion disorder and illness anxiety disorder)
o Illness anxiety disorder: preoccupation with fears of having a serious illness
o Conversion disorder: Sensory or motor symptoms without any physiological cause
• Determining existence of an external incentive can be difficult (Malingerers usually do not
trumpet their external incentives)
• Voluntariness and intentionality are more likely dimensions rather than discrete entities
, What about the clinicians?
• Gert Postel
o German imposter (born 1958)
o Successfully applied as a medical doctor several times without ever having received
medical education
• 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)
Why do people malinger?
Explanatory models
• Adaptational model
o Cost-benefit analysis results in deliberate decision to feign psychological impairment
o Rational decision
▪ Substance abuse > Escaping and avoiding responsibilities
• Pathogenic model
o Underlying disorder discloses in malingered symptomatology (i.e. malingerers “can’t
control their behaviour”)
o This model suggests that the person has an underlying psychological disorder, and the
act of malingering is a reflection of that disorder. In other words, the individual may
not entirely be in control of their behavior because of their underlying pathology. This
model implies that the malingering behavior is driven by internal factors, not just an
attempt to manipulate external situations.
o Belief System: The individual may believe they need to behave this way because of
how they see themselves or their condition. I need to do this because it’s just me
▪ Eating disorders: The person may fake or exaggerate symptoms related to an
eating disorder as a way to maintain control or because of a distorted body
image.
▪ Substance abuse: The person may claim psychological problems to self-
medicate and rationalize their behavior.
▪ Paraphilias: Past experiences of abuse may contribute to boundary issues,
leading the individual to justify harmful behavior as a product of their own
abuse history.
• Criminological model
o Malingering is sign of antisocial behaviour committed by antisocial persons (DSM
relies on this model, which is questioned by research data)
▪ Conduct disorder: The individual shows poor impulse control and engages
in deceptive or manipulative behaviors.
▪ Substance abuse: This is linked to secondary antisocial personality traits,
where the person might engage in more criminal behavior to feed their habit.
▪ Paraphilias: The individual may use deception as a way to lure victims or
continue harmful behaviors, using manipulation as a tool to maintain
offending.
People would malinger if it gives them a clear advantage
Lecture 2: Factitious Disorders and Munchausen Syndrome
Factitious Disorder (FD)
• Refers to the psychiatric condition
• In which an individual presents with an illness
• That is deliberately produced or falsified
• Usually for the purpose of assuming the sick role
