Factitious Disorders, Conversion Reaction, and Malingering in Children

Abstract

Somatic disorders and malingering are often frustrating for patients, their families, and physicians. The presentation is widely variable but often includes exaggeration of physical symptoms, self-inflicted wounds, and tampering with lab results. Somatic disorder is a mental illness that is not associated with conscious secondary gain. In contrast, malingering is a feigned illness or disability in which there is an identifiable motive. Children and adolescents can falsify subjective and objective symptoms. Many physicians do not consider that their pediatric patients could be deceiving them, and thus a high percentage of these patients undergo extensive diagnostic testing before a diagnosis of somatic disorder is reached. The etiology of factitious disorder is unclear. It is more common in females and is hypothesized to be a coping mechanism to early exposure to traumatic events. No objective testing exists to confirm the diagnosis, and many patients refuse psychiatric therapy. A thorough physical and mental status exam is essential when evaluating these patients; however, no finding has been shown to be pathognomonic. Patients that present with a history of multiple diagnostic testing and evaluation from numerous physicians and hospital systems without a clearly defined diagnosis should raise a concern. The DSM-IV defines criteria for a diagnosis of factitious disorder and should be used as a reference. Once a diagnosis is reached, treatment is difficult. Psychiatric consultation is crucial and mental health intervention is imperative. Once confronted with a diagnosis, many adolescents, in contrast to adults, will be responsive to psychiatric therapy. Although many physicians are reluctant to suspect deception by their pediatric patients, early detection is critical to prevent treatment of a nonexistent disease and to break the cycle of behavior at an early age.