Attention-Seeking Behavior in Therapy: Understanding Factitous Disorder

Factitious disorder (FD) is a complex psychological disorder in which patients either intentionally produce or pretend to have medical or psychological disorders.  The intent is to be in the patient role and to garner sympathy from the medical or psychological practitioner.  This is different from malingering where the patient pretends to have a problem in order to gain some form of external benefit  (e.g., disability payments, Workers Compensation, etc) or to get drugs, like pain killers.

Attention-Seeking Behavior:  Understanding Factitious Disorder

In this blog post, I'll focus on factitious disorder in the psychotherapy office rather than the medical office with the following case example which, as always, is a composite of many different cases and does not identify any one person:

Mary
Mary, who was in her early 40s, had already been in therapy with many therapists in the past.  She rarely remained in therapy for more than a few sessions with most therapists.  She had many complaints about her prior therapists--they didn't understand her, they were shocked by her trauma history, they probably had not dealt with their own trauma history, they said inappropriate and unempathic things to her, and they questioned the authenticity of what she told them.

She told her new therapist in their first session together that she hoped the therapist would be able to handle hearing some horrific things about her early childhood.  She wanted to know, right from the start, if the therapist could deal with hearing about the gruesome details of her childhood sexual and physical abuse.  She was "tired" of having to seek out one therapist after the next in hopes of getting psychological help.

Mary's new therapist, who was an experienced mental health practitioner, listened intently and assured Mary that she had a lot of experience with trauma and she doubted there would be anything that Mary could say that she had not heard before.  The therapist thought to herself that she could form a rapport with Mary in treatment, but Mary's dramatic presentation and the fact that Mary went from one therapist to the next ("therapist hopping") concerned her.  She remained open to listening to Mary in a respectful and empathic way, and she continued to pay attention to her own internal promptings as to what might be going on.

Over the next three sessions, Mary presented her childhood history in a very dramatic way.  She presented everyone in her family (mother, father, siblings, aunts, uncles, grandparents on both sides, cousins, nieces and nephews) in a negative light.  Each one of them had harmed her in some way, either physically, sexually, or emotionally.  Everyone who was in a position to help had been either completely unhelpful, incompetent or somehow aided and abetted in the abuse.  This included teachers, principals, clergy, neighbors, family friends, the police, the court system, and the child welfare system.  Everyone was implicated in some way.

By the fourth session, Mary's therapist, who was following Mary's account very closely and taking notes, began to notice significant inconsistencies in Mary's story from one session to the next.  Mary watched the therapist in a wary sort of way, as if she expected the therapist to say or do something that would upset her.  She needed a lot of assurance that her therapist felt empathic towards her.  When the therapist tactfully asked for clarification about some of the more glaring inconsistencies, Mary exploded. She accused the therapist of being just like all her prior therapists--unempathic and unhelpful.    Then, she said she was ending therapy, she would find another therapist, and she left abruptly.  She was unresponsive to telephone calls from the therapist and, by the next week, she was having her first session with a different therapist.

Factitious disorder is a very difficult disorder to treat.  Aside from it being a complicated diagnosis, people often don't remain in treatment long enough with any one therapist.  They have a tendency to go "therapist hopping," just as people with this disorder tend to do in medical settings.  As soon as they sense that the therapist has doubts about the authenticity of their stories, they're gone.  Their intent is to get as much sympathy as possible and they don't want to be found out.

Attention-Seeking Behavior in Therapy: Understanding Factitous Disorder

Often, people with fictitious disorder do have histories of trauma, but usually not to the extent that they are portraying it.  They also often have a coexisting personality disorder, like borderline personality disorder.

Factitious Disorder:  The Importance of the Therapeutic Alliance
If the client with factitious disorder remains long enough and the therapist has built a therapeutic alliance with the client, broaching the topic of fictitious disorder can be a very delicate but necessary part of the process.  The therapist must have the ability to remain empathic, even while he or she knows the client is not being forthcoming and is trying to manipulate.

The therapist must remain focused on the client's intent--the need to feel cared about.   When the therapist and client have a good enough rapport, the therapist can then bring up the diagnosis of factitious disorder in a tactful, caring, and professional manner.

The goal would be to have the client admit that he or she has been attempting to manipulate and then getting to the underlying psychological issues.   If the client will allow this, there is hope that he or she can overcome this disorder and stop engaging in self sabotaging their treatment and their lives.

About Me

I am a licensed New York City psychotherapist, hypnotherapist, EMDR therapist, and Somatic Experiencing therapist.  I work with individual adults and couples.

To find out more about it, visit my website:  Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (917) 742-2624 during business hours or email me.