Factitious and Malingered DID

“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on ... It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”

― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook

Factitious and Malingered DID

It is common for individuals to either assume that all cases of dissociative identity disorder (DID) are iatrogenic or sociocognitive or that all cases of DID are the result of childhood trauma. Even among those who recognize that while the majority of cases of DID are traumagenic, some cases might be iatrogenic or sociocognitive, most hesitate to claim that more than a very rare few individuals are flat out faking their DID. Unfortunately, pseudogenic (non-genuine) DID is more common than many might wish to believe.

Before anything is said about the rates of pseudogenic DID, the overall rates of factitious or malingered disorders should be considered. The rates of malingering have been estimated to range from 7% in non-forensic settings to 17% in forensic settings. Factitious disorders are thought to have a prevalence of 0.5-6% within the overall population (Brand, McNary, Loewenstein, Kolos, & Barr, 2006)1 and affect approximately 1% of individuals within hospital settings (Welburn et. al, 2003)2, though some studies have placed their prevalence in tertiary care settings such as specialized treatment for cancer at 9% (Madrid, 2012).3 Regarding psychiatric health, factitious disorders are thought to account for 0.5% of psychiatric hospital admissions, 6.4% of psychotic disorders in individuals who are inpatient, and 2-10% of dissociative disorders in individuals who are inpatient (Welburn et. al, 2003).2 Overall, factitious dissociative disorders are thought to account for 2-14% of all presentations of dissociative disorders with higher rates being found within specialty dissociative disorder units and within referrals to expert consultants (Brand, McNary, Loewenstein, Kolos, & Barr, 2006).1 One study found that 10% of admissions to a dissociative disorders clinic had either factitious or malingered DID (Coons & Milstein, 1994).4 

Not only are there now more individuals who feign DID than there have been in the past, these feigners are more sophisticated in their presentation because they can make use of publically accessible sources of information regarding the disorder, including personal accounts of life with the disorder, media portrayals, and general information online (Brand, McNary, Loewenstein, Kolos, & Barr, 2006).1 In 1987, Richard Kluft commented that it was fairly easy to distinguish between those who genuinely had DID and those who were simulating DID because the latter group had insufficient knowledge to fully mimic the disorder. By 1991, simulators had become more sophisticated, making recognizing them more difficult and time consuming and requiring more of an expert background. Those with feigned DID and genuine DID are similar in terms of demographics and in many of their claims regarding their symptoms and supposed alters (Coons & Milstein, 1994)4, so to the layperson, they might be almost impossible to casually distinguish. Additionally, factitious disorders in general are thought to be growing increasingly common online, where potential victims to the feigner's story are likely to have little ability to detect feigning and are more likely to suspend their disbelief in the absence of the cues of lying that are present only in face-to-face interactions (Madrid, 2012).3 

However, there are potential red flags that can be noticed across a variety of settings that can indicate that an individual may be faking DID. These red flags regard openness about the disorder and one's traumatic history, continuity of memory, affect tolerance, reporting abuse that is inconsistent with one's medical history, a lack of co-morbid posttraumatic stress disorder (PTSD), trying to prove that one has the desired diagnosis, and dramatic, stereotypical, or bizarre symptoms (Howell, 2011).5 General indicators of factitious disorder and malingering also serve as indications that an individual may be feigning DID. These include la belle indifference, exaggeration, persistent lying, pseudologia fantastica, selective amnesia, lack of consistent work history, refusal of collateral interviews, legal problems, and excessively dramatic behavior as well as lack of prior dissociation and the individual seeking hospitalization or a DID diagnosis. Finally, potential indications that one may be feigning DID include a need to assume a sick role, medico-legal motivation to be labeled as having DID, demanding or depreciating attitudes towards care givers, a lack of previous psychiatric history, inconsistencies within symptoms, numerous hospitalizations, lack of observed symptoms or worsening of symptoms while under observation, or refusing psychological testing (Coons & Milstein, 1994).4 Genuine individuals with DID usually feel ashamed of their diagnosis and genuinely suffer from their symptoms, features that are often absent in stimulators (Thomas, 2001).6 While individuals with pseudogenic DID may not display all of these warning signs and while individuals with genuine DID may display a warning sign or two over time, an individual who displays a large number of these warning signs should be examined very carefully.

Some diagnostic instruments that are used to confirm that an individual has DID contain scales to assess for malingering or other forms of dissimulation. The Structured Clinical Interview (SCID-D) is one such instrument that does well at differentiating between genuine and feigned DID (Thomas, 2001; Welburn et. al, 2003).6, 2 On the other hand, the Dissociative Experiences Scale (DES), which is meant to be more of a screening tool, fails to distinguish between genuine and feigned DID, though inconsistencies between an individual's DES score and their behavior during a structured interview or during therapy can be meaningful (Thomas, 2001).6 In addition, the Multidimensional Inventory of Dissociation (MID) should not generally be used as a measure of malingering because its validity scales seek to highlight response bias, not invalid responding. Its rare symptoms scale can indicate deliberate false endorsement of items, but 8% of individuals with genuine DID will endorse a clinically significant number of rare symptoms, so this scale alone cannot be taken as a sign of pseudogenic DID. Similarly, the factitious behavior scale of the MID is more of a measure of a type of severe borderline pathology than of feigned DID, and 10% of individuals with DID will reach clinically significant levels on it (Dell, 2012).7

Many instruments that are deliberately created to detect feigning are similarly unable to distinguish between genuine and pseudogenic DID. For example, the Minnesota Multiphasic Personality Inventory (MMPI-2) has been shown to be incapable of this task despite its ability to detect malingered PTSD, and the Structured Interview of Reported Symptoms (SIRS) also returns poorer results for DID than it does for other disorders (Brand, McNary, Loewenstein, Kolos, & Barr, 2006).1  

Though rarely used for this purpose, there are tests that explicitly highlight malingered amnesia and so could potentially be used to indicate pseudogenic DID. These include the Portland Digit Recognition Test (PDRT), a two-alternative test based on what is known regarding a crime committed by an individual who claims to be amnesiac of it (possibly because of alter activity), the Test of Malingered Memory (TOMM), the Rey 15-item Memory Test (Conroy & Kwartner, 2006)8, and the Rey Auditory Verbal Learning Test (Adetunji et al., 2006).9 It should be noted that these tests could not be used to test inter-identity amnesia because it's known that some memory transfer occurs between alters. Instead, these tests measure respondents' attempts to give a profile of amnesia within the tests that does not actually match the profiles of individuals with genuine amnesia. In other words, they do not measure genuine amnesia but only attempts to feign amnesia.

Some of the difficulties of distinguishing feigned from genuine DID exist because some individuals with DID do present in a highly dramatic manner that would usually be taken as an indication of faking. Individuals with DID might also exhibit "antisocial features, factitious histories, factitious alternate identities, malingering, and factitious medical symptoms," and those in forensic settings may "exaggerate symptoms in the hopes of being exculpated on psychiatric grounds" (Brand, McNary, Loewenstein, Kolos, & Barr, 2006).1

DID may be malingered for the same reasons that PTSD is malingered, including disability benefits, financial settlements, and being found not guilty of crimes by reasons of insanity (Brand, McNary, Loewenstein, Kolos, & Barr, 2006)1, or for more specific reasons such as having an excuse to behave aggressively, erratically, or selfishly, as a way to justify a pathological relationship, or as a way to claim entitlement (Howell, 2011).5 Individuals who simulate DID may attempt to use their "alters" to avoid negative repercussions for their actions and may appear to be compensating for a feeling of not being seen (Thomas, 2001).6 Factitious disorder may be associated with characteristics of borderline personality disorder (BPD), with a poorly developed sense of self, and with re-enactment of childhood trauma (Welburn et. al, 2003).2 In some cases, individuals with factitious or malingered DID may have been influenced by outside individuals. For example, they may be consciously trying to please a therapist or mimicking an individual that they know who has DID. Individuals who feign DID may be especially likely to attend self help groups, may treat their DID "diagnosis" as a vital part of their identity, or may have the majority of their social network be DID related (Thomas, 2001).6

It is important that clinicians be able to distinguish genuine from pseudogenic DID because treatment will be very different for non-traumagenic presentations of DID. Additionally, a clinician who falsely diagnoses an individual with DID may be risking law suits or allegations of inappropriate treatment. On the other hand, if an individual does have DID and is not appropriately diagnosed, their suffering will be prolonged by and may worsen because of the absence of appropriate treatment (Thomas, 2001).6 Similarly, an individual who has a factitious disorder but is not recognized as such will have a very poor prognosis, making accurate diagnosis vital (Welburn et. al, 2003).2 

It should be noted that not all individuals who falsely assume a label of DID are consciously feigning the disorder. "Imitative DID," or a phenomena in which individuals with "cluster B personality disorder profiles [assume] the social role of a DID trauma survivor," is not uncommon. Individuals with imitative DID truly believe that they have DID and may have had this false belief reinforced by therapists or other concerned individuals. They may genuinely suffer from dissociative symptoms, though their overall profiles fail to match those of actual DID individuals, particularly in regards to more subtle symptoms. As with deliberate feigners, those with imitative DID often show less shame or conflict regarding their supposed DID diagnosis (Brand, McNary, Loewenstein, Kolos, & Barr, 2006).1 Diagnostic instruments such as the SCID-D and MID are capable of distinguishing between genuine and imitative DID when correctly used.

1 Brand, B. L., McNary, S. W., Loewenstein, R. J., Kolos, A. C., & Barr, S. R. (2006). Assessment of genuine and simulated dissociative identity disorder on the Structured Interview of Reported Symptoms. Journal of Trauma & Dissociation, 7(1), 63-85. doi:10.1300/j229v07n01_06

2 Welburn, K. R., Fraser, G. A., Jordan, S. A., Cameron, C., Webb, L. M., & Raine, D. (2003). Discriminating dissociative identity disorder from schizophrenia and feigned dissociation on psychological tests and structured Interview. Journal of Trauma & Dissociation, 4(2), 109-130. doi:10.1300/j229v04n02_07

3 Madrid, C. (2012, November 21). The lying disease: Why would someone want to fake a serious illness on the internet? Retrieved May 24, 2015, from http://www.thestranger.com/seattle/the-lying-disease/Content?oid=15337239

4 Coons, P. M., & Milstein, V. (1994). Factitious or malingered multiple personality disorder: Eleven cases. Dissociation, 7(2).

5 Howell, E. F. (2011). Understanding and treating dissociative identity disorder: A relational approach. New York: Routledge/Taylor & Francis Group.

6 Thomas, A. (2001). Factitious and malingered dissociative identity disorder: Clinical features observed in 18 cases. Journal of Trauma & Dissociation, 2(4), 59-77. doi: 10.1300/J229v02n04_04

7 Dell, P. F. (2012). An interpretive mini-manual for the Multidimensional Inventory of Dissociation (MID). 1-22.

8 Conroy, M. A., & Kwartner, P. P. (2006). Malingering. Applied Psychology in Criminal Justice, 2(3), 29-51.

9 Adetunji, B. A., Basil, B., Mathews, M., Williams, A., Osinowo, T., & Oladinni, O. (2006). Detection and management of malingering in a clinical setting. Primary Psychiatry, 13(1), 61-69.