3.14 Malingering and Factitious Disorder: An Approach to Clinical Deception

Dr. Nicholas Kontos, Director of the Consultation-Liaison Psychiatry Fellowship at Massachusetts General Hospital and assistant professor of psychiatry at Harvard Medical School, joins us for a reflective conversation on factitious disorder, malingering, and clinical deception. 

We begin by unpacking the concept of “thinking dirty”—a term used in consultation-liaison psychiatry to describe the delicate and often uncomfortable task of considering deception in clinical care. Dr. Kontos walks us through why patients may deceive providers, including both conscious and unconscious motivations, and shares strategies for approaching these situations with clinical humility, curiosity, and compassion. 

We explore practical interviewing techniques to elicit more accurate histories and review key distinctions between factitious disorder and malingering, including diagnostic criteria, prevalence, and typical management strategies. Dr. Kontos discusses the concept of the “therapeutic discharge,” a framework for ending unproductive hospitalizations while still maintaining a therapeutic posture. 

Throughout the episode, we emphasize the central role of dignity and professionalism in managing deceptive behavior in medical settings, highlighting a model of psychiatry that avoids antagonism and centers patient care, even in the most complex situations. 

1. Teaching Psychiatric Trainees to “Think Dirty”: Addressing Hidden Motivations in the Consultation Setting (Beach, 2017)
2. The Therapeutic Discharge I: An Approach to the Management of Deceptive Suicidality (Kontos, 2017)
3. The Therapeutic Discharge II: An Approach to Documentation in the Setting of Feigned Suicidal Ideation (Kontos, 2018)