Instrumental psychosis: the Good Soldier Svejk syndrome

Abstract

The possession of severe mental illness, mainly schizophrenia and affective psychosis, may be perceived in positive terms. We have identified a group of patients, most of them with a history of previous psychotic disorder, who present with deliberately created symptoms and behaviour, and who are defined as having instrumental psychosis. Because most such patients have had a psychotic disorder in the past the symptoms are very like those of a real psychosis. A parallel is drawn with the fictional anti-hero of the Czech nation, the Good Soldier Svejk, who demonstrated both real and instrumental psychosis. A rating scale, the 'pseudopsychosis inventory', was devised to identify the main components of this disorder and was applied in 15 consecutive patients presenting with putative psychotic disorders in whom assessment could be made by two raters within five days. The inter-rater reliability of the items of the scale was good (intra-class correlation coefficient 0.68). An epidemiological study with this scale in 45 patients with a putative psychotic disorder suggested the presence of instrumental psychosis in 2.

Psicosis instrumental: a propósito de dos probables casos

“…El mismo Peter Tyrer, quien introdujo el concepto de psicosis instrumental, reconoció que la falsedad de los síntomas psiquiátricos simulados en estos casos es difícil de probar, e incluso discernir entre la contribución relativa de motivos conscientes e inconscientes para la simulación, resultaría virtualmente imposible (4). En ese tenor, Tyrer insinuó que su "psicosis instrumental" no debía incorporarse en el grupo de los trastornos facticios sino mantenerse dentro del ámbito original de la esquizofrenia o de la psicosis primaria desde la que emergía (4).…”

“…La variante de trastorno facticio constituida por únicamente síntomas psíquicos, sin embargo, ha sido bastante más descuidada y postergada en la literatura científica (4).…”

“…En esta línea, en el año 2001 Tyrer presentó una serie de casos de pacientes psicóticos que, habiendo sido diagnosticados previamente de psicosis esquizofrénica o afectiva, se presentaron ulteriormente a la consulta fingiendo de manera deliberada síntomas y conductas psicóticas: a estos casos, Tyrer los denominó con el nombre de "psicosis instrumental" (4). La definición exacta de psicosis instrumental enunciada por este autor es: trastorno que se crea deliberadamente con un propósito que no siempre puede ser percibido como ganancia, pero que es independiente de cualquier enfermedad mental concurrente.…”

From the Editor's desk

“…Lastly, we need urgently some independent test of veracity for the diagnosis, either biological or psychological, assuming one exists. As knowledge of mental illness increases, the factitious presentation of all illness for purposes of gain is increasing, and even schizophrenia and other psychoses are not immune (Tyrer et al , 2001), so the danger of real disorders being discredited by phoney presentations is increasing. In reporting both personal disasters (Jones & Craddock, ) and their major equivalents such as the two reported by Carol North and colleagues ( ) and, very shortly, in those following the tsunami tragedy, we do not want the genuine suffering of so many people to be devalued by doubt.…”

Malingered psychosis leading to involuntary psychiatric hospitalization

“…The term 'instrumental psychosis' has been coined to describe patients, most of whom have a history of previous psychosis, who deliberately feign symptoms for purposes such as receiving accommodation or living allowances. 2 Individuals who simulate psychosis may also go on to develop a genuine illness with the passage of time. Hay 3 described a case series of six patients who were thought to be feigning schizophrenia.…”