It is difficult for many health professionals to differentiate between simulation, factitious disorder, and somatic symptom disorder. All three display exaggerated symptom manifestations and behavior that may appear pretended. In this article we explain the main differences.
Simulation, factitious disorder, and somatic disorder present unique challenges in assessment, diagnosis, and treatment. Symptoms that are excessive, non-existent, or exaggerated beyond the available medical evidence appear in all three tables .
This characteristic is usually a central question of the three disorders; a common root that makes differential diagnosis difficult. In the very nature of simulation, factitious disorders and somatic disorders is mistrust of the patient's personal report at first sight.
In many cases, simulation treatment approaches, factitious disorders, and somatic disorders leave the underlying problem unattended beyond the symptoms reported by the patient. Intervention with these patients is a difficult task, so much so that many professionals prefer to refer these cases. In any case, to properly treat each disorder, the first thing is to know how to differentiate them properly.
Simulation
As documented in DSM-5, simulation is not a mental disorder, but a condition that can be a focus of clinical attention. Simulation is defined as the intentional production of exaggerated or feigned symptoms motivated by an external incentive , such as obtaining financial compensation or evading criminal prosecution.
Attempts to obstruct evaluation or treatment due to poor participation or non-compliance are not sufficient to determine the presence of simulation. To determine that a patient is simulating, the following conditions must be met :
- The symptoms are faked or greatly exaggerated.
- Excessive symptom production must be intentional.
- The production of symptoms is motivated by an external incentive (for example, avoiding work or military service or criminal prosecution).
Both the DSM-IV-TR and DSM-5 provide four conditions under which simulation "must be strongly suspected." These include the legal medical context, the discrepancy between self-report and medical findings, poor patient cooperation, and antisocial personality disorder . It is important to note that these supporting characteristics are neither necessary nor sufficient to determine the simulation.
In cases where the simulation is unclear, it may be more appropriate to describe the patient's behavior . For example, using terms like unreliability or atypical behavior.
Factitious disorder: how to differentiate it from simulation
In the diagnosis of factitious disorder, there is also a conscious and intentional falsification of physical or psychological symptoms . Therefore, both etiologies should be considered when a voluntary attempt to deceive through exaggeration or pretense of symptoms is suspected. Despite these similarities, the two conditions differ in terms of patients' motivation to cheat.
Simulation requires that the deception be motivated by an external incentive. A factitious disorder diagnosis requires cheating to occur even in the absence of an external incentive. In contrast, in a factitious disorder the patient does not know what leads, for example, to injury or illness.
The principles of factitious disorder remain quite similar in DSM-IV-TR and DSM-5. However, the motivation for the behavior to be misleading must be to "take the role of the sick" is now absent from the DSM-5 . This change is likely to reflect the challenges in determining the presence or absence of specific internal incentives.
Currently, the diagnosis can be made without making inferences regarding a patient's internal motivation to cheat, provided there is no external incentive and cheating has been excluded as the cause.
Factitious disorder imposed on another
Factitious disorder imposed on another (formerly factitious disorder by proxy); It occurs when one willfully falsifies another person's psychological or physical signs or symptoms in the absence of an external incentive . This can take the form of an individual falsely reporting or exaggerating another's symptoms for sympathy or attention. In more harmful cases, individuals can induce physical or psychological harm to others.
For example, in Munchausen syndrome by proxy, a parent can cause medical problems in a child (such as poisoning the child to the point of illness) and then repeatedly taking the child to the pediatrician for evaluation of symptoms. In this way, indirectly, you get professional attention.
Certainly, ethical and legal problems can arise due to this type of behavior. When the victim is a child, mandatory reporting laws are likely to apply; in these cases, it is essential to protect the child from the person with the disorder .
Differentiate between simulation and fiction of somatic disorders
A series of substantial changes in the labels and diagnostic criteria for somatoform disorders appear in DSM-5. These disorders are now known as somatic symptoms and related disorders . It includes factitious disorder, as well as conditions such as somatic symptom disorder, disease anxiety disorder, and conversion disorder .
The latter disorders can be difficult to differentiate from mock and fictional disorder . Patients with these disorders also report symptoms that do not find a correlation in the medical tests performed on the patient.
Somatic symptom disorder is more like the condition formerly known as somatization disorder . Patients may express concern , report an interruption of daily life, or seek medical intervention for their somatic symptoms to an excessive degree.
However, these somatization patients differ from those with simulated or dummy disorder in that they do not intentionally exaggerate or falsify their symptoms with direct or indirect motivation . In contrast, patients with somatic symptom disorder actually suffer from the symptoms they report. They are truly distressed and often lack insight into the psychological processes underlying their symptoms.
