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Exaggerating, mislabeling or simulating obsessive–compulsive symptoms: Case reports of patients claiming to have obsessive–compulsive disorder Leonardo F. Fontenelle a, b, c,⁎, Natália M. Lins-Martins a , Isabela A. Melca a , André Luís C. Lima a , Gabriela B. de Menezes a , Albina R. Torres d , Murat Yücel e , Euripedes C. Miguel f , Mauro V. Mendlowicz c a
Anxiety and Obsessive–Compulsive Disorders Research Program, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil b Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil c Departamento de Psiquiatria e Saúde Mental, Instituto de Saúde da Comunidade, Universidade Federal Fluminense (UFF), Niterói, Brazil d Departmento de Neurologia, Psicologia e Psiquiatria, Universidade Estadual Paulista (UNESP), Botucatu, Brazil e School of Psychological Sciences, Monash University, Melbourne, Australia f Departmento de Psiquiatria, Universidade de São Paulo (USP), São Paulo, Brazil
Abstract Background: There are no reported cases of factitious or simulated obsessive–compulsive disorder (OCD). However, over the last years, our clinic has come across a number of individuals that seem to exaggerate, mislabel or even intentionally “produce” obsessive and/or compulsive symptoms in order to be diagnosed with OCD. Methods: In this study, experienced clinicians working on a university-based OCD clinic were requested to provide clinical vignettes of patients who, despite having a formal diagnosis of OCD, were felt to display non-genuine forms of this condition. Results: Ten non-consecutive patients with a self-proclaimed diagnosis of OCD were identified and described. Although patients were diagnosed with OCD according to various structured interviews, they exhibited diverse combinations of the following features: (i) overly technical and/or doctrinaire description of their symptoms, (ii) mounting irritability, as the interviewer attempts to unveil the underlying nature of these descriptions; (iii) marked shifts in symptom patterns and disease course; (iv) an affirmative “yes” pattern of response to interview questions; (v) multiple Axis I psychiatric disorders; (vi) cluster B features; (vii) an erratic pattern of treatment response; and (viii) excessive or contradictory drug-related side effects. Conclusions: In sum, reliance on overly structured assessments conducted by insufficiently trained or naïve personnel may result in invalid OCD diagnoses, particularly those that leave no room for clinical judgment. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Intentionally simulated illnesses can be classified, on the basis of awareness levels and specific motivations, into factitious disorders and malingering [1]. While factitious disorder result from an unconscious need to assume the sick role, malingering behaviors are deliberately produced to achieve external secondary gains such as economic rewards, ⁎ Corresponding author at: Anxiety and Obsessive–Compulsive Research Program, Institute of Psychiatry, Federal University of Rio de Janeiro, Rua Visconde de Pirajá, 547, 719, Ipanema, Rio de Janeiro, RJ 22410-003, Brazil. Tel./fax: +55 21 2239 4919. E-mail address: [email protected] (L.F. Fontenelle). http://dx.doi.org/10.1016/j.comppsych.2014.03.023 0010-440X/© 2014 Elsevier Inc. All rights reserved.
improved physical well-being, or cleared legal responsibilities [1]. For these reasons, factitious disorders are listed among the psychiatric disorders in the Diagnostic and Statistical ManualIV-Text Revision (DSM-IV-TR) [2], whereas malingering is considered a condition not attributable to a mental illness [1]. The same diagnostic approach was adopted in DSM5, which classified factitious disorders as a somatic symptom related disorder. The literature contains hundreds of cases of individuals with feigned psychosis, post-traumatic stress disorder, bereavement, dissociative identity disorder, and claims of child abuse [3]. However, to the best of our knowledge, there is no published literature that has attempted to address the issue of non-genuine forms of obsessive–compulsive disorder (OCD).
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In recent years, our OCD clinic has come across a number of individuals, either self- or clinician-referred, who held the intention of being diagnosed with OCD, and at the same time manifesting an abnormal symptom pattern or clinical course of OCD symptoms. While most of these patients were apparently motivated by the psychological need of assuming a sick role, it was sometimes difficult to exclude the possibility of concomitant secondary-gain issues (or vice versa). In this report, we describe 10 cases of patients who, despite responding affirmatively to OCD-related questions in structured diagnostic interviews, present with unusual clinical expressions suggestive of exaggerated, mislabeled or even feigned OCD.
2. Methods Experienced clinicians working on a university-based OCD clinic (n = 8) were requested to provide clinical vignettes of patients who, despite having a formal diagnosis of OCD, were felt to display non-genuine forms of this condition. Our OCD clinic, located within the Institute of Psychiatry of the Federal University of Rio de Janeiro (IPUB/UFRJ), is part of the local Anxiety and Obsessive– Compulsive Disorder Research Program and the only specialized public service for the diagnosis and treatment of OCD spectrum disorders in the great metropolitan Rio de Janeiro city area. In general, it receives suspected or confirmed OCD cases screened by the IPUB/UFRJ admission service, sent from other IPUB/UFRJ specialized services, referred by the local OCD support group, or informed about us by word of mouth. The local OCD clinic started on 1998. Currently, it assesses about one new case every week (around 50 potential new patients per year), unless there are specific research protocols requiring the recruitment of a larger number of subjects, in which case the rates of new patients increase. Our clinical staff includes residents under supervision and clinicians with expertise in the assessment and treatment of OCD spectrum patients, including psychiatrists or psychologists doing their PhD thesis, staff psychiatrists with a PhD degree, and medical school faculty members. In general, the diagnosis of OCD is based on a consensus between the resident and a more experienced staff or faculty member. On a practical level, clinicians' diagnostic impression has greater weight as compared to diagnoses generated by structured instruments. Thus, patients with OCD according to clinicians' opinion are always retained, regardless of their SCID or MINI results (based on DSM-IV criteria). That is especially relevant for OCD patients with poor insight who do not endorse clinically significant symptoms on structured interviews. Despite being fully aware of the limitations associated with strict adherence to very rigid diagnostic instruments, our clinic also sometimes retained patients without OCD according to our clinical impressions but who received a diagnosis of OCD when structured interviews
were employed, as there were limited alternatives for referring these patients in the local mental health system. The cases of several of these patients are described in the present study. While a total of 420 medical records from the OCD clinic were reviewed, our clinicians were also allowed to describe patients fitting the description provided in other settings. Eventually, eight patients from the OCD clinic and two patients seen elsewhere (e.g. clinicians' private practice) were identified. Basic socio-demographic and clinical information was collected whenever available, with specific focus on reason for referral, symptoms' description, comorbid axis I and II mental disorders, patterns of treatment responses, and drugrelated side effects. However, since some patients were referred to other specialized services and were not traceable at the moment of our assessment, a few pieces of clinical information were found missing. The local ethics committee approved this research protocol.
3. Case reports Case #1: The former clinician of Mr. A, an 18-year-old medical student, became concerned about the apparent lack of therapeutic response and requested a second opinion from our OCD clinic. The patient complained of “repetitive and obsessive thoughts” that dominated his mental life. Specifically, Mr. A reported seeing disturbing homosexual scenes in his mind during the sexual relations with his girlfriend, leaving him worried about whether or not he was homosexual. Curiously, Mr. A's appearance, body language, mannerisms, voice inflection, and style of clothing were quite effeminate. Our attempts to further clarify the characteristics of the “distressing obsessions” were met with irritability. Mr. A was convinced that he had “sexual-related obsessions,” which were reportedly acknowledged by his former attending psychiatrist and confirmed by his readings in the internet. Assessments with the SCID established the diagnoses of OCD and major depressive disorder. Mr. A also reported several previous suicide attempts, mostly by overdose of his own medications. His symptoms were resistant to different trials of serotonin reuptake inhibitors, employed in maximum tolerated doses for at least 12 weeks each. Case #2: Mr. B, a 20-year-old single biology student, sought treatment for being “severely” worried about contamination issues, especially in relation to tuberculosis, and associated “compulsive” washing. Attempts at clarifying the nature of his symptoms, with questions about time spent, interference in daily activities, resulting anxiety, and other OCD features, were frequently answered with irritability. He reported being offended by these queries and complained that he was disappointed with his clinician who seemed to consider him “untruthful.” Mr. B attributed his symptoms to OCD. They remitted almost completely after only 2 weeks of treatment with paroxetine (20 mg/day). However, Mr. B remained under treatment for several years, due mainly to
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cluster B personality traits, including identity problems. An assessment with the SCID revealed OCD, major depressive disorder, generalized anxiety disorder, and binge eating disorder. Problems with self-image were also prominent. For instance, despite featuring a typical Brazilian multiethnic background, Mr. B recently started wearing blue lenses and donning a kippah, claiming he had just discovered his supposed Jewish origins. Case #3: A local OCD support group referred Mr. C, a 40-year-old Caucasian unemployed man with limited high school education. He reported the recent onset of “repetitive and unwanted thoughts,” whose content, after some persistent and sometimes insistent questioning, turned out to involve insults to his former girlfriend (reported by him as “obsessions with aggressive content”). However, he also felt extremely resentful toward her, especially since she had left him only 3 months earlier. Their relationship was punctuated by frequent disagreements and outbursts of rage. Mr. C insisted that he had OCD and became uncomfortable when told that his symptoms were not consistent with this diagnosis. Facing the prospect of not being accepted in the outpatient clinic for not having OCD as the main diagnosis, Mr. C. somewhat desperately described additional concerns with symmetry and organization. Despite the patients' insistence on the severity of these symptoms, the clinicians felt that they were overstated and too mild to warrant an OCD diagnosis. Mr. C received a diagnosis of a personality disorder not otherwise specified, with prominent cluster B traits. His “repetitive thoughts” symptoms improved after only 2 weeks of sertraline (50 mg/day) but he remained under continuous treatment for several years. His treatment was focused on the resolution of his chronic feelings of abandonment and isolation. Case #4: Mr. D, a 28-year-old single lawyer, sought treatment at our OCD clinic for “repetitive thoughts” and “guilt feelings.” Specifically, he was afraid of looking like or acting as people he regarded as “disgusting.” A diagnosis of OCD was confirmed and Mr. D. was successfully treated with sertraline (up to 200 mg/day). At that point, however, we failed to consider a diagnosis of maladaptive cluster B personality traits. Mr. D was subsequently diagnosed as suffering from severe alcohol abuse and referred to a specialized substance abuse program. At his most recent visit to the OCD clinic, he was scheduled to be discharged from our outpatient program. However, Mr. D became increasingly distraught, angry and verbally abusive, showing unwillingness to accept being treated in an alternate specialized clinic. Despite the fact that Mr. D was not currently showing any significant obsessive–compulsive symptom, he repeatedly visited the OCD clinic, insisting that he suffered from OCD and demanding to be treated for it. Occasionally he would attempt to entice the younger doctors who were less familiar with him, by approaching them on different occasions with different histories on each occasion, and never revealing details of his previous treatments. A careful re-examination of his mental state failed to identify any persistent OCD symptoms.
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Case #5: Mrs. E, a 25-year-old, married artist, sought treatment for an alleged “OCD.” Specifically, she described being “obsessionally jealous.” Because of these “thoughts,” Mrs. E experienced difficulties in controlling herself and began following her husband without his knowledge. She was aware of the possibility of being abandoned by him, who was already very upset by her stalking behavior and frequent attacks of rage. She “admitted” to him being “obsessed” about infidelity themes and decided to seek treatment. During the psychiatric assessment, Mrs. E described her symptoms in a rather dramatic and insincere manner, constantly using psychiatric jargon, and frequently referring to her “OCD.” She also endorsed significant cluster B symptoms, including cruelty to animals during childhood. Following 2 weeks of treatment with citalopram (20 mg/ day), Mrs. E declared that her “OCD” had remitted and soon afterward, dropped out of treatment. Three years later, having once again engaged in stalking behavior toward her husband, Mrs. E decided to resume treatment for her pathological jealousy. Her husband also reported that Mrs. E spent an excessive amount of time checking doorknobs, but appeared to do so only in his presence, and never when she was by herself. “Sometimes I would watch her leaving home to go working but could never notice these checking behaviors,” said Mrs. E's husband. Case #6: A local colleague referred Mr. F, a 60-year-old, single unemployed male with three incomplete university courses. He was the administrator of an OCD-related Web site and had extensive contact with many OCD patients from different parts of the country. Mr. F reported being under regular treatment for OCD, but recently becoming concerned about his alleged “treatment resistance.” Furthermore, Mr. F stated that he was “seriously considering psychosurgery,” to which he requested referral. He also reported “recurrent thoughts” of murdering his family members and committing suicide, which became particularly distressing when he was forced to deal with frustrating situations. His response to all OCD-related questions in structured interviews was stereotypically affirmative. However, after careful assessment, the assisting clinician explained to Mr. F that his symptoms were not consistent with a diagnosis of OCD. Mr. F then pulled a knife from his waist, placed it on the table, and asked why the doctor did not believe that he had OCD. A long and tense conversation between them followed, and soon discussions about his “suicidal obsessions” emerged. In fact, he had chronic suicidality, among several other cluster B symptoms. Fortunately, the psychiatrist was able to manage the situation well and have the patient admitted to a locked psychiatric unit. Case #7: Mrs. G is a 60-year-old, married Caucasian housewife with a bachelor's degree in literature who has been treated in our clinic for several years. She was referred by her assisting clinician who, after several therapeutic attempts, concluded that he was unable to successfully manage her symptoms. Her initial complaint was related to aggressive
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obsessions toward her family and compulsions to repeat routine activities. Previously, Mrs. G described her symptoms in a didactic and pedantic manner, often employing expressions such as “obsessional thoughts” and “compulsive rituals” and emphasizing the distress and disability experienced by many patients with OCD. However, over the past 12 months, a different pattern of symptoms emerged. Without exception, on each visit, Mrs. G would present a new set of complaints involving previously unreported symptoms, some related to OCD, while others were of a more general nature. For instance, in a recent visit, she unexpectedly described herself as a longtime hoarder, although it soon became entirely obvious that her alleged self-description as a hoarder was “inspired” by recent TV programs on the topic. The initial assessment with a structured clinical interview established the diagnoses of OCD, major depression, panic disorder with agoraphobia, and bulimia nervosa. However, a recent re-assessment with the same instrument identified other previously unidentified conditions, including bipolar II disorder and social phobia. She also had a formal diagnosis of borderline personality disorder (BPD). During the many years this patient has been under the care of this clinic, she had been unable to tolerate any serotonin reuptake inhibitor (SRI), even at minimal doses, and was maintained on a combination of diazepam (40 mg/day) and imipramine (25 mg/day), which according to Mrs. G, “helped her sleep.” Case #8: Ms. H is a 32-year-old, divorced Caucasian public servant, who sought treatment for her allegedly disabling “obsessions” and “compulsions.” She claimed to be already a private patient of a very prominent psychiatrist, with whom she continued to have regular appointments. Despite our advice that she should pursue treatment with only one medical team, she insisted on being followed by two clinicians. Ms. H explained that being treated in a public hospital made it easier for her to claim her social security payments checks. She also explained that, besides financial reasons, being under psychiatric treatment helped keep family problems under control, as this was understood by her parents as an attempt to improve her dysfunctional behaviors. However, every attempt to refer her back to her original doctor ended with her showing up repeatedly at our OCD clinic. In a structured clinical interview, Ms. H responded “yes” to most questions regarding the DSM criteria for mental disorders, resulting in the establishment of multiple diagnoses, namely OCD, major depressive disorder, dysthymia, generalized anxiety disorder, bulimia nervosa and somatization disorder. Ms. H was also diagnosed with a BPD. She was initially medicated with SRIs but developed several bizarre side effects at very low doses and was unable to continue the pharmacological treatment. Repeatedly questioned about the nature of her psychiatric symptoms, Ms. H eventually failed to re-appear for treatment. Case #9: Mr. I, a 36-year-old married physician, was referred by his psychologist, who requested that our team assess him for a possible diagnosis of OCD. He simulta-
neously sought the local OCD support group, which he keeps attending on a regular basis ever since. Specifically, he complained of “obsessional thoughts” which he characterized as “intrusive and not under his personal control,” including images of his wife having sex to former boyfriends and of himself assaulting them in the streets. Mr. I had mixed borderline and narcissistic personality traits and exhibited marked instability and impulsivity across a variety of different contexts. He previously exaggerated his own talents and personal accomplishments and believed that “only very special or high-status people could understand him.” More recently, he started worrying about grammatical errors that his wife was supposedly making during social meetings where several of his co-workers were also present. Due to his increasing anxiety associated with these thoughts, he began questioning people who had attended these meetings as to whether or not they had noticed his wife's presumed mistakes. The content of his symptoms varied widely in response to different life events. According to structured interviews, Mr. I was diagnosed with OCD, major depressive disorder, dysthymia, generalized anxiety disorder and somatization disorder. After being told that his treatment would be carried out in another clinic, Mr. I became indignant and, several weeks later, showed up again at our premises. Against the opinion of several individuals who were close to Mr. I, including his current therapist, he remained convinced of his OCD. Following several failed therapeutic trials with various SRIs at low doses (which he was unable to tolerate for more than few days), Mr. I is now being treated with mirtazapine (30 mg/day) and showing a satisfactory response. Case #10: Mr. J, a 40-year-old single white unemployed man with some limited education, was referred by the local OCD support group for having an “OCD that keeps hammering on the mind 24 hours a day.” He described his thoughts in an overly theatrical and dramatized manner. Mr. J was mostly concerned with his inability to hold down employment, which he described as a reflection of his “perfectionism.” He was unable to provide a detailed account of symptoms in this regard, but he did mention a specific event that took place 10 years prior, while he was in the military. After missing a target in a shooting training session, Mr. J became “obsessed” about his “error.” He only got some relief from this anxiety almost 12 months later, when he got another opportunity to shoot at the target and succeeded in hitting the bulls-eye. Despite these symptoms, to the interviewer, his alleged “perfectionism” appeared to be an attempt to account for the difficulties he faced in different working environments, probably due to some degree of intellectual impairment. As an additional “obsession,” he reported persistent and repetitive thoughts about death and suicide. Specifically, he explained that he would persistently think about “getting a gun to kill myself.” In fact, he reported multiple suicide attempts, the first one “at age 6”. After hearing from his psychiatrist that his disturbing “thoughts” did not correspond to the diagnosis of OCD, Mr. J
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desperately argued that he had this diagnosis since age 16, and had seen several psychiatrists who confirmed this. He also provided the names of the doctors who had allegedly confirmed the diagnosis, however none of them could be identified or contacted. Mr. J was eventually referred to a general outpatient clinic, but continued showing up at the OCD clinic unexpectedly on several occasions. He would pretend being a new patient, avoid being seen by the clinicians who already knew him, and never mentioned his previous visits. In the general outpatient clinic, Mr. J asked nonchalantly for another referral to our OCD center.
4. Discussion In this case series report, we describe 10 cases of patients showing what attending clinicians judged to be non-genuine forms of OCD or, at least, a gross overestimation of the severity of sub-threshold obsessive–compulsive symptoms. The patients were characterized by different combinations of the following features: (i) overly technical and/or pedantic description of their symptoms, (ii) mounting irritability, as the interviewer attempts to unveil what patients meant by these expressions; (iii) marked shifts in symptom patterns; (iv) overly affirmative responses in the diagnostic interviews, (v) multiple Axis I mental disorders, (vi) comorbid BPD or cluster B traits, and (vii) an erratic pattern of treatment response, sometimes with (viii) excessive or inconsistent drug-related side effects. Patients with non-genuine OCD usually employed an unusual style of language to describe their symptoms, which are markedly different from the way regular patients report genuine OCD phenomena. Specifically, these patients often resort to a psychiatric lingo, characterized by an exaggerated use of technical words and of DSM-related terminology, probably based on Internet searches, at the expense of a more personalized and spontaneous description. Characteristically, these individuals become angry when questioned in detail about these technical expressions, which often sound rather cryptic to the interviewer. A pattern of unstable complaints may also be present. For instance, patients may report new obsessive–compulsive symptoms at successive visits to the clinic and then fail to refer to them at all for extended periods, suggesting an inconsistent course, all these against a backdrop of predominant cluster B-related symptoms. Cursory evaluations, particularly by inexperienced clinicians, may fail to identify cases of non-genuine OCD. Reliance on structured interviews conducted by insufficiently trained personnel may also result in false diagnoses [4], particularly with those instruments that may not provide enough room for clinical judgment, such as the MINI [5] or the SCID [6]. Similarly, the overly affirmative pattern of responding may be found in self-report instruments, resulting in the false impression of disproportionally severe symptoms. Some could argue, for instance, that meeting the minimum
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severity requirements for OCD (e.g. at least 1 hour per day spent with obsessions and/or compulsions) may not be that particularly difficult, so that individuals with subclinical OCD symptoms would not need too much effort to maximize the importance of their experiences and thus be diagnosed with OCD. Some patients described by us were also diagnosed with multiple Axis I disorders according to structured interviews [7]. However, whether these associated conditions are valid entities is a matter of debate. Although we acknowledge that increased comorbidity rates have been widely documented in the OCD literature both in clinical (e.g. Ref. [8]) and nonclinical samples (e.g. Ref. [9]), our point is that everyone, including OCD patients, has a limited amount of “mental space” that can be dedicated to different themes, complaints and, ultimately, genuine clinical symptoms. That been said, we believe that sometimes, as the number of “comorbid conditions” increase in guided or very structured interviews, so does the likelihood that the patient is describing conditions that do not meet minimum severity requirements for the diagnoses. The fact that the presence of multiples symptoms can be frequently attributed to personality problems has been reported by researchers from different backgrounds [10,11]. Obsessive–compulsive disorder is traditionally known to be associated with low rate of response to placebo [12], besides delayed and usually only partial responses even to high doses of SRIs. Therefore, impressive clinical improvements in response to low doses of anti-obsessional medication early in the treatment cast doubt on the accuracy of a diagnosis of OCD. Another noteworthy feature of these patients is the frequent reporting of intolerable side effects with different anti-OCD drugs, even in very low doses, thus hindering the treatment at its initial stages. It is conceivable that patients with non-genuine OCD intentionally produce or exaggerate them, a phenomenon that may be closely related to the so-called nocebo effects (i.e. non-pharmacodynamic, harmful, unpleasant, or undesirable effects that a person may experience after receiving an inactive treatment) [13]. Indeed, it has already been shown that maladaptive personality traits mediate the nocebo response and increase the risks of adverse event reporting [13]. One of the most frequent diagnoses among patients with feigned illness (particularly factitious) disorders is BPD, a condition characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and earlyonset impulsivity present in a variety of contexts [2]. This association is not surprising, as identity problems represent a key feature of BPD, portrayed by markedly and persistently unstable self-image or sense of self [2]. Experienced clinicians frequently see patients with BPD or related cluster B traits “desperately” looking for alternate identities, which may include, as in our cases, the “OCD patient.” Support groups serve as a vehicle to decrease the social isolation experienced by individuals with OCD [14]. They provide information related to OCD through campaigns,
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conferences, Web sites, and the general press, thus educating patients, family, and friends about OCD symptoms and their treatment. They also motivate a significant proportion of community individuals with OCD, who may eventually start or re-enter treatment for their symptoms and disabilities. These organizations are also increasingly employed in the recruitment of volunteers for research. Unfortunately, though, support groups, as well as the widespread availability of OCD-related information in the media, also offer a convenient opportunity for patients with personality issues to adopt a new identity and to receive emotional support. Patients with BPD often identify themselves with “real” OCD patients attending support groups, individuals making dramatic public confessions about OCD, and subjects reporting disabling “compulsions,” as well as with popular figures, actors, celebrities, entertainers, or athletes who describe themselves as OCD patients. It is noteworthy that one of the cases (#6) had even created a Web site for OCD sufferers. To individuals with BPD or related traits, a diagnosis of OCD may provide a convenient justification for their personal shortcomings and failures, ultimately attributable to personality issues rather than to OCD itself, which, when indeed present, is much milder than reported. It could be argued that the patients we have described here were not well informed about OCD and sincerely believed they were suffering from this disorder. However, their dramatic insistence on having a self-made diagnosis of OCD to the point of feigning or intentionally producing its symptoms is noteworthy. As we have pointed out, differentiating factitious disorders from malingering in this context can be problematic since the motivation underlying factitious disorder can sometimes operate contemporaneously with that typically associated with malingering [3]. In fact, much like the level of insight regarding OCD symptoms, the degree of awareness regarding these feigned manifestations is probably not a black and white phenomenon, and levels may vary amply among individuals and even in the same person, according on the situation experienced. However, we believe that most of our patients can be diagnosed with factitious disorders, since no financial or legal motivation was clearly identified among them. It is also likely that some of our patients are not actively producing but rather mislabeling as OCD symptoms different phenomena that could otherwise be attributed to personality issues (e.g. BPD) or be regarded as entirely nonpathological occurrences. By doing this, they are adopting a sick role that may help them avoid taking responsibility for any personal contribution for their misgivings, but rather seeing themselves as helpless victims (e.g. “it is not me, but a medical condition that is causing all these problems”). Thus, the motivations are obviously very similar to the ones reported in factitious disorder. Finally, it must be stressed that our clinic is the only public service providing treatment for OCD in the state of Rio de Janeiro, Brazil. Clearly, there is a shortage of services for patients with BPD issues, even in university setting.
Our institute also provides a range of medications (including some SRI, such as fluoxetine) for free, thus looking potentially attractive to patients who, despite not having OCD, may present conditions that benefit from other types of medications. Nevertheless, the issue of provision of drugs did not emerge as a significant motivation during patients' assessments, nor did a marked preference for our clinic as a universal phenomenon among all patients. We have listed below a series of signs that may alert clinicians to the possibility of non-genuine OCD (Table 1). After the clinical suspicion is confirmed, management of countertransference reactions and long-term psychotherapy (beyond the traditional exposure and response prevention techniques) are often useful. We suggest adopting an initially non-confrontational, mostly observational approach, followed by a gradual deepening of discussion on the BPD-related issues, which usually constitute the core problem for these patients. Admittedly, the interpretation of our case reports has a number of drawbacks. No patient acknowledged a voluntary control of obsessions or compulsions, disclosed deceit, or exhibited bizarre or absurd symptoms. Therefore, we cannot fully exclude the possibility that some of them have a “true” comorbidity between BPD and OCD. It might be, for instance, that cluster B personality traits are merely coloring the clinical picture presented by some of our OCD patients. Although a structured assessment of personality disorders was not conducted, it is interesting that all patients described above caused the same clinical impression in the assisting clinicians that were able to interview them in our center. Also, by analogy, one needs to consider that requiring a full self-disclosure to detect these cases is actually an error of logic and that, by not reporting absurd or bizarre OCD symptoms, our patients might have learned fairly well what they have been studying lately. Independently from being “real” or non-genuine OCD, patients who exhibit the features described in Table 1 seem to have a different course and response to treatment, thus deserving a distinctive therapeutic approach.
Table 1 Warning signs to feigned obsessive–compulsive disorder. (i) Stereotypical description of their OCD symptoms, often using pedantic terminology or DSM-IV-TR technical terms (such as “obsessions” and “compulsions”) (ii) Mounting irritability, as the interviewer attempts to unveil the underlying nature of these descriptions; (iii) Unusually marked shifts in symptom patterns, as a consequence of exposure to different sources of information; (iv) An affirmative “yes” pattern of response to diagnostic interview questions; (v) Multiple comorbid psychiatric disorders; (vi) Comorbid cluster B features; (vii) An erratic pattern of treatment response, with either therapeutic resistance or, alternatively, with a spectacular responses to low dose medications early in treatment, (viii) Inconsistent drug-related side effects. OCD, obsessive–compulsive disorder.
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References [1] McCullumsmith CB, Ford CV. Simulated illness: the factitious disorders and malingering. Psychiatr Clin North Am 2011;34:621-41. [2] APA. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition: DSM-IV-TR: American Psychiatric Association; 2000. [3] Hamilton JC, Feldman MD, Cunnien AJ. Factitious disorder in medical and psychiatric practice. In: & Rogers R, editor. Clinical Assessment of Malingering and Deception. New York: Guilford Publications; 2008. p. 128-44. [4] Nordgaard J, Sass LA, Parnas J. The psychiatric interview: validity, structure, and subjectivity. Eur Arch Psychiatry Clin Neurosci 2013;263:353-64. [5] Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 (Suppl 20):22-33 [quiz 4-57]. [6] First MB, Spitzer RL. Structured Clinical Interview for Dsm-IV Axis I Disorders: Scoresheet/Prepack of 5: Amer Psychiatric Pub Incorporated; 1997.
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[7] Zimmerman M, Mattia JI. Axis I diagnostic comorbidity and borderline personality disorder. Compr Psychiatry 1999;40:245-52. [8] Hofmeijer-Sevink MK, van Oppen P, van Megen HJ, Batelaan NM, Cath DC, van der Wee NJ, et al. Clinical relevance of comorbidity in obsessive compulsive disorder: the Netherlands OCD Association study. J Affect Disord 2013;150:847-54. [9] Ruscio AM, Stein DJ, Chiu WT, Kessler RC. The epidemiology of obsessive–compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry 2010;15:53-63. [10] Paris J. The nature of borderline personality disorder: multiple dimensions, multiple symptoms, but one category. J Pers Disord 2007;21:457-73. [11] Millon T. Disorders of personality: introducing a DSM/ICD spectrum from normal to abnormal. Wiley; 2011. [12] Clomipramine in the treatment of patients with obsessive–compulsive disorder. The Clomipramine Collaborative Study Group. Arch Gen Psychiatry 1991;48:730-8. [13] Data-Franco J, Berk M. The nocebo effect: a clinicians guide. Aust N Z J Psychiatry 2013;47:617-23. [14] Broatch JW. Obsessive–compulsive disorder: adding value to treatment through patient support groups. Int Clin Psychopharmacol 1996;11(Suppl 5):89-94.
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Exaggerating, mislabeling or simulating obsessive–compulsive symptoms: Case reports of patients claiming to have obsessive–compulsive disorder Leonardo F. Fontenelle a, b, c,⁎, Natália M. Lins-Martins a , Isabela A. Melca a , André Luís C. Lima a , Gabriela B. de Menezes a , Albina R. Torres d , Murat Yücel e , Euripedes C. Miguel f , Mauro V. Mendlowicz c a
Anxiety and Obsessive–Compulsive Disorders Research Program, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil b Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil c Departamento de Psiquiatria e Saúde Mental, Instituto de Saúde da Comunidade, Universidade Federal Fluminense (UFF), Niterói, Brazil d Departmento de Neurologia, Psicologia e Psiquiatria, Universidade Estadual Paulista (UNESP), Botucatu, Brazil e School of Psychological Sciences, Monash University, Melbourne, Australia f Departmento de Psiquiatria, Universidade de São Paulo (USP), São Paulo, Brazil
Abstract Background: There are no reported cases of factitious or simulated obsessive–compulsive disorder (OCD). However, over the last years, our clinic has come across a number of individuals that seem to exaggerate, mislabel or even intentionally “produce” obsessive and/or compulsive symptoms in order to be diagnosed with OCD. Methods: In this study, experienced clinicians working on a university-based OCD clinic were requested to provide clinical vignettes of patients who, despite having a formal diagnosis of OCD, were felt to display non-genuine forms of this condition. Results: Ten non-consecutive patients with a self-proclaimed diagnosis of OCD were identified and described. Although patients were diagnosed with OCD according to various structured interviews, they exhibited diverse combinations of the following features: (i) overly technical and/or doctrinaire description of their symptoms, (ii) mounting irritability, as the interviewer attempts to unveil the underlying nature of these descriptions; (iii) marked shifts in symptom patterns and disease course; (iv) an affirmative “yes” pattern of response to interview questions; (v) multiple Axis I psychiatric disorders; (vi) cluster B features; (vii) an erratic pattern of treatment response; and (viii) excessive or contradictory drug-related side effects. Conclusions: In sum, reliance on overly structured assessments conducted by insufficiently trained or naïve personnel may result in invalid OCD diagnoses, particularly those that leave no room for clinical judgment. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Intentionally simulated illnesses can be classified, on the basis of awareness levels and specific motivations, into factitious disorders and malingering [1]. While factitious disorder result from an unconscious need to assume the sick role, malingering behaviors are deliberately produced to achieve external secondary gains such as economic rewards, ⁎ Corresponding author at: Anxiety and Obsessive–Compulsive Research Program, Institute of Psychiatry, Federal University of Rio de Janeiro, Rua Visconde de Pirajá, 547, 719, Ipanema, Rio de Janeiro, RJ 22410-003, Brazil. Tel./fax: +55 21 2239 4919. E-mail address: [email protected] (L.F. Fontenelle). http://dx.doi.org/10.1016/j.comppsych.2014.03.023 0010-440X/© 2014 Elsevier Inc. All rights reserved.
improved physical well-being, or cleared legal responsibilities [1]. For these reasons, factitious disorders are listed among the psychiatric disorders in the Diagnostic and Statistical ManualIV-Text Revision (DSM-IV-TR) [2], whereas malingering is considered a condition not attributable to a mental illness [1]. The same diagnostic approach was adopted in DSM5, which classified factitious disorders as a somatic symptom related disorder. The literature contains hundreds of cases of individuals with feigned psychosis, post-traumatic stress disorder, bereavement, dissociative identity disorder, and claims of child abuse [3]. However, to the best of our knowledge, there is no published literature that has attempted to address the issue of non-genuine forms of obsessive–compulsive disorder (OCD).
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In recent years, our OCD clinic has come across a number of individuals, either self- or clinician-referred, who held the intention of being diagnosed with OCD, and at the same time manifesting an abnormal symptom pattern or clinical course of OCD symptoms. While most of these patients were apparently motivated by the psychological need of assuming a sick role, it was sometimes difficult to exclude the possibility of concomitant secondary-gain issues (or vice versa). In this report, we describe 10 cases of patients who, despite responding affirmatively to OCD-related questions in structured diagnostic interviews, present with unusual clinical expressions suggestive of exaggerated, mislabeled or even feigned OCD.
2. Methods Experienced clinicians working on a university-based OCD clinic (n = 8) were requested to provide clinical vignettes of patients who, despite having a formal diagnosis of OCD, were felt to display non-genuine forms of this condition. Our OCD clinic, located within the Institute of Psychiatry of the Federal University of Rio de Janeiro (IPUB/UFRJ), is part of the local Anxiety and Obsessive– Compulsive Disorder Research Program and the only specialized public service for the diagnosis and treatment of OCD spectrum disorders in the great metropolitan Rio de Janeiro city area. In general, it receives suspected or confirmed OCD cases screened by the IPUB/UFRJ admission service, sent from other IPUB/UFRJ specialized services, referred by the local OCD support group, or informed about us by word of mouth. The local OCD clinic started on 1998. Currently, it assesses about one new case every week (around 50 potential new patients per year), unless there are specific research protocols requiring the recruitment of a larger number of subjects, in which case the rates of new patients increase. Our clinical staff includes residents under supervision and clinicians with expertise in the assessment and treatment of OCD spectrum patients, including psychiatrists or psychologists doing their PhD thesis, staff psychiatrists with a PhD degree, and medical school faculty members. In general, the diagnosis of OCD is based on a consensus between the resident and a more experienced staff or faculty member. On a practical level, clinicians' diagnostic impression has greater weight as compared to diagnoses generated by structured instruments. Thus, patients with OCD according to clinicians' opinion are always retained, regardless of their SCID or MINI results (based on DSM-IV criteria). That is especially relevant for OCD patients with poor insight who do not endorse clinically significant symptoms on structured interviews. Despite being fully aware of the limitations associated with strict adherence to very rigid diagnostic instruments, our clinic also sometimes retained patients without OCD according to our clinical impressions but who received a diagnosis of OCD when structured interviews
were employed, as there were limited alternatives for referring these patients in the local mental health system. The cases of several of these patients are described in the present study. While a total of 420 medical records from the OCD clinic were reviewed, our clinicians were also allowed to describe patients fitting the description provided in other settings. Eventually, eight patients from the OCD clinic and two patients seen elsewhere (e.g. clinicians' private practice) were identified. Basic socio-demographic and clinical information was collected whenever available, with specific focus on reason for referral, symptoms' description, comorbid axis I and II mental disorders, patterns of treatment responses, and drugrelated side effects. However, since some patients were referred to other specialized services and were not traceable at the moment of our assessment, a few pieces of clinical information were found missing. The local ethics committee approved this research protocol.
3. Case reports Case #1: The former clinician of Mr. A, an 18-year-old medical student, became concerned about the apparent lack of therapeutic response and requested a second opinion from our OCD clinic. The patient complained of “repetitive and obsessive thoughts” that dominated his mental life. Specifically, Mr. A reported seeing disturbing homosexual scenes in his mind during the sexual relations with his girlfriend, leaving him worried about whether or not he was homosexual. Curiously, Mr. A's appearance, body language, mannerisms, voice inflection, and style of clothing were quite effeminate. Our attempts to further clarify the characteristics of the “distressing obsessions” were met with irritability. Mr. A was convinced that he had “sexual-related obsessions,” which were reportedly acknowledged by his former attending psychiatrist and confirmed by his readings in the internet. Assessments with the SCID established the diagnoses of OCD and major depressive disorder. Mr. A also reported several previous suicide attempts, mostly by overdose of his own medications. His symptoms were resistant to different trials of serotonin reuptake inhibitors, employed in maximum tolerated doses for at least 12 weeks each. Case #2: Mr. B, a 20-year-old single biology student, sought treatment for being “severely” worried about contamination issues, especially in relation to tuberculosis, and associated “compulsive” washing. Attempts at clarifying the nature of his symptoms, with questions about time spent, interference in daily activities, resulting anxiety, and other OCD features, were frequently answered with irritability. He reported being offended by these queries and complained that he was disappointed with his clinician who seemed to consider him “untruthful.” Mr. B attributed his symptoms to OCD. They remitted almost completely after only 2 weeks of treatment with paroxetine (20 mg/day). However, Mr. B remained under treatment for several years, due mainly to
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cluster B personality traits, including identity problems. An assessment with the SCID revealed OCD, major depressive disorder, generalized anxiety disorder, and binge eating disorder. Problems with self-image were also prominent. For instance, despite featuring a typical Brazilian multiethnic background, Mr. B recently started wearing blue lenses and donning a kippah, claiming he had just discovered his supposed Jewish origins. Case #3: A local OCD support group referred Mr. C, a 40-year-old Caucasian unemployed man with limited high school education. He reported the recent onset of “repetitive and unwanted thoughts,” whose content, after some persistent and sometimes insistent questioning, turned out to involve insults to his former girlfriend (reported by him as “obsessions with aggressive content”). However, he also felt extremely resentful toward her, especially since she had left him only 3 months earlier. Their relationship was punctuated by frequent disagreements and outbursts of rage. Mr. C insisted that he had OCD and became uncomfortable when told that his symptoms were not consistent with this diagnosis. Facing the prospect of not being accepted in the outpatient clinic for not having OCD as the main diagnosis, Mr. C. somewhat desperately described additional concerns with symmetry and organization. Despite the patients' insistence on the severity of these symptoms, the clinicians felt that they were overstated and too mild to warrant an OCD diagnosis. Mr. C received a diagnosis of a personality disorder not otherwise specified, with prominent cluster B traits. His “repetitive thoughts” symptoms improved after only 2 weeks of sertraline (50 mg/day) but he remained under continuous treatment for several years. His treatment was focused on the resolution of his chronic feelings of abandonment and isolation. Case #4: Mr. D, a 28-year-old single lawyer, sought treatment at our OCD clinic for “repetitive thoughts” and “guilt feelings.” Specifically, he was afraid of looking like or acting as people he regarded as “disgusting.” A diagnosis of OCD was confirmed and Mr. D. was successfully treated with sertraline (up to 200 mg/day). At that point, however, we failed to consider a diagnosis of maladaptive cluster B personality traits. Mr. D was subsequently diagnosed as suffering from severe alcohol abuse and referred to a specialized substance abuse program. At his most recent visit to the OCD clinic, he was scheduled to be discharged from our outpatient program. However, Mr. D became increasingly distraught, angry and verbally abusive, showing unwillingness to accept being treated in an alternate specialized clinic. Despite the fact that Mr. D was not currently showing any significant obsessive–compulsive symptom, he repeatedly visited the OCD clinic, insisting that he suffered from OCD and demanding to be treated for it. Occasionally he would attempt to entice the younger doctors who were less familiar with him, by approaching them on different occasions with different histories on each occasion, and never revealing details of his previous treatments. A careful re-examination of his mental state failed to identify any persistent OCD symptoms.
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Case #5: Mrs. E, a 25-year-old, married artist, sought treatment for an alleged “OCD.” Specifically, she described being “obsessionally jealous.” Because of these “thoughts,” Mrs. E experienced difficulties in controlling herself and began following her husband without his knowledge. She was aware of the possibility of being abandoned by him, who was already very upset by her stalking behavior and frequent attacks of rage. She “admitted” to him being “obsessed” about infidelity themes and decided to seek treatment. During the psychiatric assessment, Mrs. E described her symptoms in a rather dramatic and insincere manner, constantly using psychiatric jargon, and frequently referring to her “OCD.” She also endorsed significant cluster B symptoms, including cruelty to animals during childhood. Following 2 weeks of treatment with citalopram (20 mg/ day), Mrs. E declared that her “OCD” had remitted and soon afterward, dropped out of treatment. Three years later, having once again engaged in stalking behavior toward her husband, Mrs. E decided to resume treatment for her pathological jealousy. Her husband also reported that Mrs. E spent an excessive amount of time checking doorknobs, but appeared to do so only in his presence, and never when she was by herself. “Sometimes I would watch her leaving home to go working but could never notice these checking behaviors,” said Mrs. E's husband. Case #6: A local colleague referred Mr. F, a 60-year-old, single unemployed male with three incomplete university courses. He was the administrator of an OCD-related Web site and had extensive contact with many OCD patients from different parts of the country. Mr. F reported being under regular treatment for OCD, but recently becoming concerned about his alleged “treatment resistance.” Furthermore, Mr. F stated that he was “seriously considering psychosurgery,” to which he requested referral. He also reported “recurrent thoughts” of murdering his family members and committing suicide, which became particularly distressing when he was forced to deal with frustrating situations. His response to all OCD-related questions in structured interviews was stereotypically affirmative. However, after careful assessment, the assisting clinician explained to Mr. F that his symptoms were not consistent with a diagnosis of OCD. Mr. F then pulled a knife from his waist, placed it on the table, and asked why the doctor did not believe that he had OCD. A long and tense conversation between them followed, and soon discussions about his “suicidal obsessions” emerged. In fact, he had chronic suicidality, among several other cluster B symptoms. Fortunately, the psychiatrist was able to manage the situation well and have the patient admitted to a locked psychiatric unit. Case #7: Mrs. G is a 60-year-old, married Caucasian housewife with a bachelor's degree in literature who has been treated in our clinic for several years. She was referred by her assisting clinician who, after several therapeutic attempts, concluded that he was unable to successfully manage her symptoms. Her initial complaint was related to aggressive
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obsessions toward her family and compulsions to repeat routine activities. Previously, Mrs. G described her symptoms in a didactic and pedantic manner, often employing expressions such as “obsessional thoughts” and “compulsive rituals” and emphasizing the distress and disability experienced by many patients with OCD. However, over the past 12 months, a different pattern of symptoms emerged. Without exception, on each visit, Mrs. G would present a new set of complaints involving previously unreported symptoms, some related to OCD, while others were of a more general nature. For instance, in a recent visit, she unexpectedly described herself as a longtime hoarder, although it soon became entirely obvious that her alleged self-description as a hoarder was “inspired” by recent TV programs on the topic. The initial assessment with a structured clinical interview established the diagnoses of OCD, major depression, panic disorder with agoraphobia, and bulimia nervosa. However, a recent re-assessment with the same instrument identified other previously unidentified conditions, including bipolar II disorder and social phobia. She also had a formal diagnosis of borderline personality disorder (BPD). During the many years this patient has been under the care of this clinic, she had been unable to tolerate any serotonin reuptake inhibitor (SRI), even at minimal doses, and was maintained on a combination of diazepam (40 mg/day) and imipramine (25 mg/day), which according to Mrs. G, “helped her sleep.” Case #8: Ms. H is a 32-year-old, divorced Caucasian public servant, who sought treatment for her allegedly disabling “obsessions” and “compulsions.” She claimed to be already a private patient of a very prominent psychiatrist, with whom she continued to have regular appointments. Despite our advice that she should pursue treatment with only one medical team, she insisted on being followed by two clinicians. Ms. H explained that being treated in a public hospital made it easier for her to claim her social security payments checks. She also explained that, besides financial reasons, being under psychiatric treatment helped keep family problems under control, as this was understood by her parents as an attempt to improve her dysfunctional behaviors. However, every attempt to refer her back to her original doctor ended with her showing up repeatedly at our OCD clinic. In a structured clinical interview, Ms. H responded “yes” to most questions regarding the DSM criteria for mental disorders, resulting in the establishment of multiple diagnoses, namely OCD, major depressive disorder, dysthymia, generalized anxiety disorder, bulimia nervosa and somatization disorder. Ms. H was also diagnosed with a BPD. She was initially medicated with SRIs but developed several bizarre side effects at very low doses and was unable to continue the pharmacological treatment. Repeatedly questioned about the nature of her psychiatric symptoms, Ms. H eventually failed to re-appear for treatment. Case #9: Mr. I, a 36-year-old married physician, was referred by his psychologist, who requested that our team assess him for a possible diagnosis of OCD. He simulta-
neously sought the local OCD support group, which he keeps attending on a regular basis ever since. Specifically, he complained of “obsessional thoughts” which he characterized as “intrusive and not under his personal control,” including images of his wife having sex to former boyfriends and of himself assaulting them in the streets. Mr. I had mixed borderline and narcissistic personality traits and exhibited marked instability and impulsivity across a variety of different contexts. He previously exaggerated his own talents and personal accomplishments and believed that “only very special or high-status people could understand him.” More recently, he started worrying about grammatical errors that his wife was supposedly making during social meetings where several of his co-workers were also present. Due to his increasing anxiety associated with these thoughts, he began questioning people who had attended these meetings as to whether or not they had noticed his wife's presumed mistakes. The content of his symptoms varied widely in response to different life events. According to structured interviews, Mr. I was diagnosed with OCD, major depressive disorder, dysthymia, generalized anxiety disorder and somatization disorder. After being told that his treatment would be carried out in another clinic, Mr. I became indignant and, several weeks later, showed up again at our premises. Against the opinion of several individuals who were close to Mr. I, including his current therapist, he remained convinced of his OCD. Following several failed therapeutic trials with various SRIs at low doses (which he was unable to tolerate for more than few days), Mr. I is now being treated with mirtazapine (30 mg/day) and showing a satisfactory response. Case #10: Mr. J, a 40-year-old single white unemployed man with some limited education, was referred by the local OCD support group for having an “OCD that keeps hammering on the mind 24 hours a day.” He described his thoughts in an overly theatrical and dramatized manner. Mr. J was mostly concerned with his inability to hold down employment, which he described as a reflection of his “perfectionism.” He was unable to provide a detailed account of symptoms in this regard, but he did mention a specific event that took place 10 years prior, while he was in the military. After missing a target in a shooting training session, Mr. J became “obsessed” about his “error.” He only got some relief from this anxiety almost 12 months later, when he got another opportunity to shoot at the target and succeeded in hitting the bulls-eye. Despite these symptoms, to the interviewer, his alleged “perfectionism” appeared to be an attempt to account for the difficulties he faced in different working environments, probably due to some degree of intellectual impairment. As an additional “obsession,” he reported persistent and repetitive thoughts about death and suicide. Specifically, he explained that he would persistently think about “getting a gun to kill myself.” In fact, he reported multiple suicide attempts, the first one “at age 6”. After hearing from his psychiatrist that his disturbing “thoughts” did not correspond to the diagnosis of OCD, Mr. J
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desperately argued that he had this diagnosis since age 16, and had seen several psychiatrists who confirmed this. He also provided the names of the doctors who had allegedly confirmed the diagnosis, however none of them could be identified or contacted. Mr. J was eventually referred to a general outpatient clinic, but continued showing up at the OCD clinic unexpectedly on several occasions. He would pretend being a new patient, avoid being seen by the clinicians who already knew him, and never mentioned his previous visits. In the general outpatient clinic, Mr. J asked nonchalantly for another referral to our OCD center.
4. Discussion In this case series report, we describe 10 cases of patients showing what attending clinicians judged to be non-genuine forms of OCD or, at least, a gross overestimation of the severity of sub-threshold obsessive–compulsive symptoms. The patients were characterized by different combinations of the following features: (i) overly technical and/or pedantic description of their symptoms, (ii) mounting irritability, as the interviewer attempts to unveil what patients meant by these expressions; (iii) marked shifts in symptom patterns; (iv) overly affirmative responses in the diagnostic interviews, (v) multiple Axis I mental disorders, (vi) comorbid BPD or cluster B traits, and (vii) an erratic pattern of treatment response, sometimes with (viii) excessive or inconsistent drug-related side effects. Patients with non-genuine OCD usually employed an unusual style of language to describe their symptoms, which are markedly different from the way regular patients report genuine OCD phenomena. Specifically, these patients often resort to a psychiatric lingo, characterized by an exaggerated use of technical words and of DSM-related terminology, probably based on Internet searches, at the expense of a more personalized and spontaneous description. Characteristically, these individuals become angry when questioned in detail about these technical expressions, which often sound rather cryptic to the interviewer. A pattern of unstable complaints may also be present. For instance, patients may report new obsessive–compulsive symptoms at successive visits to the clinic and then fail to refer to them at all for extended periods, suggesting an inconsistent course, all these against a backdrop of predominant cluster B-related symptoms. Cursory evaluations, particularly by inexperienced clinicians, may fail to identify cases of non-genuine OCD. Reliance on structured interviews conducted by insufficiently trained personnel may also result in false diagnoses [4], particularly with those instruments that may not provide enough room for clinical judgment, such as the MINI [5] or the SCID [6]. Similarly, the overly affirmative pattern of responding may be found in self-report instruments, resulting in the false impression of disproportionally severe symptoms. Some could argue, for instance, that meeting the minimum
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severity requirements for OCD (e.g. at least 1 hour per day spent with obsessions and/or compulsions) may not be that particularly difficult, so that individuals with subclinical OCD symptoms would not need too much effort to maximize the importance of their experiences and thus be diagnosed with OCD. Some patients described by us were also diagnosed with multiple Axis I disorders according to structured interviews [7]. However, whether these associated conditions are valid entities is a matter of debate. Although we acknowledge that increased comorbidity rates have been widely documented in the OCD literature both in clinical (e.g. Ref. [8]) and nonclinical samples (e.g. Ref. [9]), our point is that everyone, including OCD patients, has a limited amount of “mental space” that can be dedicated to different themes, complaints and, ultimately, genuine clinical symptoms. That been said, we believe that sometimes, as the number of “comorbid conditions” increase in guided or very structured interviews, so does the likelihood that the patient is describing conditions that do not meet minimum severity requirements for the diagnoses. The fact that the presence of multiples symptoms can be frequently attributed to personality problems has been reported by researchers from different backgrounds [10,11]. Obsessive–compulsive disorder is traditionally known to be associated with low rate of response to placebo [12], besides delayed and usually only partial responses even to high doses of SRIs. Therefore, impressive clinical improvements in response to low doses of anti-obsessional medication early in the treatment cast doubt on the accuracy of a diagnosis of OCD. Another noteworthy feature of these patients is the frequent reporting of intolerable side effects with different anti-OCD drugs, even in very low doses, thus hindering the treatment at its initial stages. It is conceivable that patients with non-genuine OCD intentionally produce or exaggerate them, a phenomenon that may be closely related to the so-called nocebo effects (i.e. non-pharmacodynamic, harmful, unpleasant, or undesirable effects that a person may experience after receiving an inactive treatment) [13]. Indeed, it has already been shown that maladaptive personality traits mediate the nocebo response and increase the risks of adverse event reporting [13]. One of the most frequent diagnoses among patients with feigned illness (particularly factitious) disorders is BPD, a condition characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and earlyonset impulsivity present in a variety of contexts [2]. This association is not surprising, as identity problems represent a key feature of BPD, portrayed by markedly and persistently unstable self-image or sense of self [2]. Experienced clinicians frequently see patients with BPD or related cluster B traits “desperately” looking for alternate identities, which may include, as in our cases, the “OCD patient.” Support groups serve as a vehicle to decrease the social isolation experienced by individuals with OCD [14]. They provide information related to OCD through campaigns,
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conferences, Web sites, and the general press, thus educating patients, family, and friends about OCD symptoms and their treatment. They also motivate a significant proportion of community individuals with OCD, who may eventually start or re-enter treatment for their symptoms and disabilities. These organizations are also increasingly employed in the recruitment of volunteers for research. Unfortunately, though, support groups, as well as the widespread availability of OCD-related information in the media, also offer a convenient opportunity for patients with personality issues to adopt a new identity and to receive emotional support. Patients with BPD often identify themselves with “real” OCD patients attending support groups, individuals making dramatic public confessions about OCD, and subjects reporting disabling “compulsions,” as well as with popular figures, actors, celebrities, entertainers, or athletes who describe themselves as OCD patients. It is noteworthy that one of the cases (#6) had even created a Web site for OCD sufferers. To individuals with BPD or related traits, a diagnosis of OCD may provide a convenient justification for their personal shortcomings and failures, ultimately attributable to personality issues rather than to OCD itself, which, when indeed present, is much milder than reported. It could be argued that the patients we have described here were not well informed about OCD and sincerely believed they were suffering from this disorder. However, their dramatic insistence on having a self-made diagnosis of OCD to the point of feigning or intentionally producing its symptoms is noteworthy. As we have pointed out, differentiating factitious disorders from malingering in this context can be problematic since the motivation underlying factitious disorder can sometimes operate contemporaneously with that typically associated with malingering [3]. In fact, much like the level of insight regarding OCD symptoms, the degree of awareness regarding these feigned manifestations is probably not a black and white phenomenon, and levels may vary amply among individuals and even in the same person, according on the situation experienced. However, we believe that most of our patients can be diagnosed with factitious disorders, since no financial or legal motivation was clearly identified among them. It is also likely that some of our patients are not actively producing but rather mislabeling as OCD symptoms different phenomena that could otherwise be attributed to personality issues (e.g. BPD) or be regarded as entirely nonpathological occurrences. By doing this, they are adopting a sick role that may help them avoid taking responsibility for any personal contribution for their misgivings, but rather seeing themselves as helpless victims (e.g. “it is not me, but a medical condition that is causing all these problems”). Thus, the motivations are obviously very similar to the ones reported in factitious disorder. Finally, it must be stressed that our clinic is the only public service providing treatment for OCD in the state of Rio de Janeiro, Brazil. Clearly, there is a shortage of services for patients with BPD issues, even in university setting.
Our institute also provides a range of medications (including some SRI, such as fluoxetine) for free, thus looking potentially attractive to patients who, despite not having OCD, may present conditions that benefit from other types of medications. Nevertheless, the issue of provision of drugs did not emerge as a significant motivation during patients' assessments, nor did a marked preference for our clinic as a universal phenomenon among all patients. We have listed below a series of signs that may alert clinicians to the possibility of non-genuine OCD (Table 1). After the clinical suspicion is confirmed, management of countertransference reactions and long-term psychotherapy (beyond the traditional exposure and response prevention techniques) are often useful. We suggest adopting an initially non-confrontational, mostly observational approach, followed by a gradual deepening of discussion on the BPD-related issues, which usually constitute the core problem for these patients. Admittedly, the interpretation of our case reports has a number of drawbacks. No patient acknowledged a voluntary control of obsessions or compulsions, disclosed deceit, or exhibited bizarre or absurd symptoms. Therefore, we cannot fully exclude the possibility that some of them have a “true” comorbidity between BPD and OCD. It might be, for instance, that cluster B personality traits are merely coloring the clinical picture presented by some of our OCD patients. Although a structured assessment of personality disorders was not conducted, it is interesting that all patients described above caused the same clinical impression in the assisting clinicians that were able to interview them in our center. Also, by analogy, one needs to consider that requiring a full self-disclosure to detect these cases is actually an error of logic and that, by not reporting absurd or bizarre OCD symptoms, our patients might have learned fairly well what they have been studying lately. Independently from being “real” or non-genuine OCD, patients who exhibit the features described in Table 1 seem to have a different course and response to treatment, thus deserving a distinctive therapeutic approach.
Table 1 Warning signs to feigned obsessive–compulsive disorder. (i) Stereotypical description of their OCD symptoms, often using pedantic terminology or DSM-IV-TR technical terms (such as “obsessions” and “compulsions”) (ii) Mounting irritability, as the interviewer attempts to unveil the underlying nature of these descriptions; (iii) Unusually marked shifts in symptom patterns, as a consequence of exposure to different sources of information; (iv) An affirmative “yes” pattern of response to diagnostic interview questions; (v) Multiple comorbid psychiatric disorders; (vi) Comorbid cluster B features; (vii) An erratic pattern of treatment response, with either therapeutic resistance or, alternatively, with a spectacular responses to low dose medications early in treatment, (viii) Inconsistent drug-related side effects. OCD, obsessive–compulsive disorder.
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