Factitious Disorders

Epidemiology and Etiology

Epidemiology

• The estimated prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency is 5% in hospitalized patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship. 
• More common in men than women
• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency is higher in healthcare workers and those with higher intelligence.
• Many people with factitious disorders have underlying comorbid psychiatric disorders such as personality, mood, or substance use disorders.

Etiology

• Unknown 
• May be associated with a history of abuse or neglect Neglect Child Abuse
• Hospitalization Hospitalization The confinement of a patient in a hospital. Delirium and medical attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment are thought to provide the safe environment that patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have lacked.

Clinical Presentation and Diagnosis

Clinical presentation

• Symptoms are widely variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables and depend on the mechanism of falsification.  
• Usually presents with dramatic and bizarre clinical presentation that cannot be explained by conventional medical understanding
• No response to usually effective medical or psychological interventions 
• Common scenarios:
  • Recurrent episodes of hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia from auto-injection of insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin 
  • Recurrent infections Recurrent infections Common Variable Immunodeficiency (CVID) of wounds
• If missed, factitious disorders may lead to unintentional death.

Diagnosis

The psychiatric interview must include collateral or external sources of information whenever possible. 

• Diagnostic criteria for factitious disorder imposed on self: 
  • Purposefully falsified or exaggerated symptoms of physical or psychological disease processes
  • Purposeful misrepresentation of injury, impairment, or chronic sickness 
  • Obvious acts of deception with no clear motive of secondary gain 
  • Behavior not well accounted for by another psychiatric or medical diagnosis
• Diagnostic criteria for factitious disorder imposed on another individual: 
  • Formerly referred to as Munchausen syndrome by proxy
  • Purposefully falsified or exaggerated symptoms of physical or psychological disease processes reported in another individual by an unaffected individual 
  • Obvious acts of deception with no clear motive of secondary gain 
  • Note: The diagnosis of factitious disorder imposed on another individual is specific to the individual reporting the falsified symptoms, not the person for whom they are reporting the symptoms.

Management

• Management of factitious disorders should be focused on 3 principles: 
  • Reduce risk of morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status and mortality Mortality All deaths reported in a given population. Measures of Health Status.
  • Address underlying psychiatric illness.
  • Beware of legal/ethical implications. 
• Confront the patient in a nonthreatening manner:
  • Videographic evidence of devious behavior may assist in facilitating conversation, as patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may deny their behavior. 
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship should be referred for psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy.
  • Caution must be exercised during confrontation, as therapeutic rapport may be lost and the patient may seek another provider. 
• Avoid unnecessary procedures.
• Factitious disorder imposed on another person warrants a referral to child protective services Child protective services Local governmental offices which investigate reports of abuse and neglect of children, and act to assure a safe environment for minors. Child Abuse or appropriate judicial department!
• Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas is poor and treatment should be focused on managing rather than curing the disorder.

Differential Diagnosis

• Conversion disorder Conversion disorder Conversion disorder (CD), also called functional neurological symptom disorder, is a psychiatric disorder with prominent motor or sensory impairment which is not compatible with any known neurologic medical condition. The deficits are not consciously produced. Conversion Disorder: the presence of symptoms or deficits that affect voluntary motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology or sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology function in a way that suggests a neurological condition but is not explained by medical findings. Diagnosis is clinical, and management includes psychological and physical therapy Physical Therapy Becker Muscular Dystrophy. Unlike factitious disorder, there is no evidence of actual disease or deliberate falsification of symptoms.  
• Borderline personality disorder Borderline Personality Disorder A personality disorder marked by a pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. Cluster B Personality Disorders: the most commonly recognized personality disorder. Characterized by emotional instability, impulsiveness, distorted patterns of thinking, and intense yet unstable relationships. Diagnosis is clinical and management includes psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, notably dialectical behavior therapy (DBT). A patient with borderline personality disorder Borderline Personality Disorder A personality disorder marked by a pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. Cluster B Personality Disorders may deliberately induce injury as part of attention-seeking behavior. They will not attempt to deceive the provider. 
• Malingering Malingering Malingering is not a medical disorder, but a behavior of an individual. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients may either invent new ailments or exaggerate current symptoms. Malingering: a disorder in which patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with symptoms for secondary gain (e.g., avoiding the police, time off work, disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment benefits). Determination of the external incentive distinguishes malingering Malingering Malingering is not a medical disorder, but a behavior of an individual. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients may either invent new ailments or exaggerate current symptoms. Malingering from factitious disorder.