Differences Between A Simulation, A Factitious Disorder And A Somatic Disorder

Simulation, factitious disorder, and somatic disorder present unique challenges in evaluation, diagnosis, and treatment. In all three tables there are symptoms that are excessive, nonexistent, or exaggerated beyond the available medical evidence.

This characteristic is usually a central issue in all three disorders; a common root that makes differential diagnosis difficult. In the very nature of simulation, factitious disorders, and somatic disorders is distrust of the patient’s personal report at first glance.

In many cases, the treatment approaches of simulation, 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 rather a condition that can be a focus of clinical attention. Simulation is defined as an 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 low 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 feigned or greatly exaggerated.
• The excessive production of symptoms 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 the simulation “should be strongly suspected.” These include the medico-legal 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 such as unreliability or unusual 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 feigning of symptoms is suspected. Despite these similarities, the two conditions differ in terms of patients’ motivation to cheat.

The simulation requires that the deception be motivated by an external incentive. A diagnosis of factitious disorder requires that deception occur even in the absence of an outside incentive. On the contrary, in a factitious disorder the patient does not know what leads him, for example, to injure himself or to produce a disease.

The principles of factitious disorder remain quite similar in DSM-IV-TR and DSM-5. However, the motivation for the behavior to be deceptive must be to “take on the sick role” is now absent from 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 the need to make inferences regarding a patient’s internal motivation to cheat, provided there is no external incentive and cheating has been ruled out as a cause.

Factitious disorder imposed on another

Factitious disorder imposed on another (formerly factitious disorder by proxy); it occurs when one volitionally falsifies the psychological or physical signs or symptoms of another person in the absence of an external incentive. This can take the form of one individual falsely reporting or exaggerating the symptoms of another in order to receive 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 may cause medical problems in a child (such as poisoning the child to the point of illness) and then repeatedly take the child to the pediatrician for symptom evaluation. In this way, indirectly, you get professional care.

Certainly, ethical and legal issues 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 simulation and fictional from somatic disorders

In DSM-5 there are a number of substantial changes in the labels and diagnostic criteria for somatoform disorders. These disorders are now known as somatic symptoms and related disorders. It includes factitious disorder, as well as conditions such as somatic symptom disorder, illness anxiety disorder, and conversion disorder.

The latter disorders can be difficult to differentiate from sham and fictional disorders. Patients with these disorders also report symptoms that are not correlated with medical tests performed on the patient.

Somatic Symptom Disorder more closely resembles the condition formerly known as Somatization Disorder. Patients may express concern, report a disruption to daily life, or seek medical intervention for their somatic symptoms to an excessive degree.

However, these somatized patients differ from those with sham or fictional disorder in that they do not intentionally exaggerate or falsify their symptoms with direct or indirect motivation. In contrast, Somatic Symptom Disorder patients actually suffer from the symptoms they report. They are really distressed and often lack an idea of ​​the psychological processes underlying their symptoms.