Factitious Disorders

Factitious disorder, formerly called Munchausen syndrome, is the intentional falsification of symptoms in order to assume the role of a sick person. Patients may intentionally produce symptoms in someone else (usually a child or elderly patient), which is known as factitious disorder imposed on another (formerly, Munchausen by proxy). Unlike 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, the falsification of symptoms is not associated with an external reward. Diagnosis is clinical, and treatment centers around nonjudgmental confrontation.

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Epidemiology and Etiology

Epidemiology

  • The estimated prevalence is 5% in hospitalized patients. 
  • More common in men than women
  • Prevalence 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
  • Hospitalization and medical attention are thought to provide the safe environment that patients 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 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. 

  • DSM-V diagnostic criteria for factitious disorder imposed on self
    • Fabrication of physical or psychological signs or symptoms, or distortion of injury or disease, associated with identified deception
    • Presents to others as ill, impaired, or injured 
    • Deceptive behavior is evident in the absence of obvious secondary gains. 
    • The behavior does not coexist with another mental disorder.
  • DSM-V diagnostic criteria for factitious disorder imposed on another individual
    • Also known as Munchausen syndrome by proxy 
    • The person fabricates symptoms in another person and then presents that person to others as ill, impaired, or injured. 
    • Deceptive behavior is evident in the absence of obvious secondary gains. 
    • Remember: This diagnosis is made for the person who is fabricating the symptoms, not the person being presented as ill.
Table: Features of factitious disorder compared with important differential diagnoses
Willingness to undergo evaluation Intentional deceptive behavior Evidence of external reward
Illness anxiety disorder Illness Anxiety Disorder Illness anxiety disorder, formerly known as hypochondriasis, is a chronic condition characterized by a prolonged and exaggerated concern about one's health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of a serious medical condition. Illness Anxiety Disorder +
Somatic symptom disorder Somatic symptom disorder Somatic symptom disorder (SSD) is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Somatic Symptom Disorder +
Factitious disorder + +
Malingering + +

Management

  • Management of factitious disorders should be focused on 3 principles: 
    • Reduce risk of morbidity and mortality.
    • 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 may deny their behavior. 
    • Patients 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 or appropriate judicial department!
  • Prognosis 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 or sensory 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. Unlike factitious disorder, there is no evidence of actual disease or deliberate falsification of symptoms.  
  • Borderline personality disorder: 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 may deliberately induce injury as part of attention-seeking behavior. They will not attempt to deceive the provider. 
  • Malingering: a disorder in which patients present with symptoms for secondary gain (e.g., avoiding the police, time off work, disability 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. 

References

  1. Sadock, BJ, Sadock, VA, Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 13, Psychosomatic medicine, pages 465–503. Philadelphia, PA: Lippincott Williams and Wilkins.
  2. Jafferany, M, Khalid, Z, McDonald, KA, Shelley, AJ. (2018). Psychological aspects of factitious disorder. The primary care companion for CNS disorders, 20(1), 17nr02229. https://doi.org/10.4088/PCC.17nr02229

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