Factitious disorder

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Photo by:  Ma Spitz

Definition

Factitious disorder (FD) is an umbrella category that covers a group of mental disturbances in which patients intentionally act physically or mentally ill without obvious benefits. According to one estimate, the unnecessary tests and waste of other medical resources caused by FD cost the United States $40 million per year. The name factitious comes from a Latin word that means "artificial" or "contrived."

The Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV-TR , fourth edition) distinguishes factitious disorder from malingering , which is defined as pretending illness when the individual has a clear motive—usually to benefit economically or to avoid legal trouble.

Factitious disorder is sometimes referred to as hospital addiction , pathomimia, or polysurgical addiction. Variant names for individuals with FD include hospital vagrants, hospital hoboes, peregrinating patients, problem patients, and professional patients.

Description

Cases of factitious disorder appear in the medical literature as early as Galen, a famous Roman physician of the second century A.D. The term factitious is derived from a book by an English physician named Gavin, published in 1843, entitled On Feigned and Factitious Diseases . The modern study of factitious disorder, however, began with a 1951 article in Lancet by a British psychiatrist , Richard Asher, who also coined the term Munchausen's syndrome to describe a chronic subtype of FD. The name comes from an eighteenth-century German baron who liked to embellish stories of his military exploits in order to impress his listeners. In 1977, it was Gellengerg who first reported a case of FD with primarily psychological symptoms. Factitious disorder was recognized as a formal diagnostic category by DSM-III in 1980.

DSM-IV-TR defines factitious disorder as having three major subtypes: FD with predominantly psychological signs and symptoms; FD with predominantly physical signs and symptoms; and FD with combined psychological and physical signs and symptoms. A fourth syndrome, known as Ganser syndrome, has been classified in the past as a form of factitious disorder, although DSM-IV-TR groups it with the dissociative disorders.

DSM-IV-TR specifies three criteria for factitious disorder:

• The patient is intentionally producing or pretending to have physical or psychological symptoms or signs of illness.
• The patient's motivation is to assume the role of a sick person.
• There are no external motives (as in malingering) that explain the behavior.

Psychological FD

Factitious disorder with predominantly psychological signs and symptoms is listed by DSM-IV-TR as the first subcategory of the disorder. It is characterized by the individual feigning psychological symptoms.

Some researchers have suggested adding the following criteria for this subtype of FD:

• The symptoms are inconsistent, changing markedly from day to day and from one hospitalization to the next.
• The changes are influenced by the environment (as when the patient feels observed by others) rather than by the treatment.
• The patient's symptoms are unusual or unbelievable.
• The patient has a large number of symptoms that belong to several different psychiatric disorders.

Physical FD

Factitious disorder wih predominantly physical signs and symptoms is the most familiar to medical personnel. Chronic FD of this type is often referred to as Munchausen's syndrome. The most common ways of pretending illness are: presenting a factitious history (claiming to have had a seizure that never happened); combining a factitious history with external agents that mimic the symptoms of disease (adding blood from a finger prick to a urine sample); or combining a factitious history with maneuvers that produce a genuine medical condition (taking a psychoactive drug to produce psychiatric symptoms). In most cases, these patients sign out of the hospital when they are confronted by staff with proof of their pretending, usually in the form of a laboratory report. Many individuals with Munchausen's syndrome move from hospital to hospital, seeking treatment, and thus are known commonly as "hospital hoboes."

FD with mixed symptoms

Factitious disorder in this category is characterized by a mix of psychological and physical signs and symptoms.

FD not otherwise specified

Factitious disorder not otherwise specified is a category that DSM-IV included to cover a bizarre subtype in which one person fabricates misleading information about another's health or induces actual symptoms of illness in the other person. First described in 1977 by an American pediatrician, this syndrome is known as Munchausen syndrome by proxy (MSBP) and almost always involves a parent (usually the mother) and child. MSBP is now understood as a form of child abuse involving premeditation rather than impulsive acting out. Many pediatricians in the United States believe that MSBP is underdiagnosed.

Ganser syndrome

Ganser syndrome is a rare disorder (about a 100 documented cases worldwide) that has been variously categorized as a factitious disorder or a dissociative disorder. It is named for a German psychiatrist named Sigbert Ganser, who first described it in 1898 from an examination of male prisoners who were thought to be psychotic. Ganser syndrome is used to describe dissociative symptoms and the pretending of psychosis that occur in forensic settings.

There are four symptoms regarded as diagnostic of Ganser syndrome:

• Vorbeireden : A German word that means "talking beside the point," it refers to a type of approximate answer to an examiner's questions that may appear silly but usually indicates that the patient understands the question. If examiner asks how many legs a dog has, the patient may answer, "Five."
• Clouding of consciousness: The patient is drowsy or inattentive.
• Conversion symptoms: These are physical symptoms produced by unconscious psychological issues rather than diagnosable medical causes. A common conversion symptom is temporary paralysis of an arm or leg.
• Hallucinations.

Virtual FD

Although virtual factitious disorder does not appear as a heading in any present diagnostic manual, it is a phenomenon that has appeared with increasing frequency with the spread of the Internet. The growing use of the personal computer has affected presentations of factitious disorder in two important ways. First, computers allow people with sufficient technical skills to access medical records from hospital databases and cut-and-paste changes into their own records in order to falsify their medical histories. Second, computers allow people to enter Internet chat rooms for persons with serious illnesses and pretend to be a patient with that illness in order to obtain attention and sympathy. "Munchausen by Internet" can have devastating effects on chat groups, destroying trust when the hoax is exposed.

Causes and symptoms

Causes

The causes of factitious disorder, whether physical or psychiatric, are difficult to determine because these patients are often lost to follow-up when they sign out of the hospital. Magnetic resonance imaging (MRI) has detected abnormalities in the brain structure of some patients with chronic FD, suggesting that there may be biological or genetic factors in the disorder. PET scans of patients diagnosed with Ganser syndrome have also revealed brain abnormalities. The results of EEG ( electroencephalography ) studies of these patients are nonspecific.

Several different psychodynamic explanations have been proposed for factitious disorder. These include:

• Patients with FD are trying to re-enact unresolved childhood issues with parents.
• They have underlying problems with masochism.
• They need to be the center of attention and feel important.
• They need to receive care and nurturance.
• They are bothered by feelings of vulnerability.
• Deceiving a physician allows them to feel superior to an authority figure.

There are several known risk factors for factitious disorder, including:

• The presence of other mental or physical disorders in childhood that resulted in the patient's getting considerable medical attention.
• A history of significant past relationships with doctors, or of grudges against them.
• Present diagnosis of borderline, narcissistic, or antisocial personality disorder.

Symptoms

SYMPTOMS OF FACTITIOUS DISORDER IN ADULTS OR ADOLESCENTS. Reasons for suspecting factitious disorder include:

• The individual's history is vague and inconsistent; or the individual has a long medical record with many admissions at different hospitals in different cities.
• The patient has an unusual knowledge of medical terminology or describes the illness as if they are reciting a textbook description of it.
• The patient is employed in a medical or hospital-related occupation.
• Pseudologia fantastica , a Latin phrase for "uncontrollable lying," is a condition in which the individual provides fantastic descriptions of events that never took place.
• The patient visits emergency rooms at times such as holidays or late Friday afternoons when experienced staff are not usually present and obtaining old medical records is difficult.
• The patient has few visitors even though he or she claims to be an important person.
• The patient is unusually accepting of surgery or uncomfortable diagnostic procedures.
• The patient's behavior is controlling, attention-seeking, hostile, or disruptive.
• The symptoms are present only when the patient thinks he or she is being watched.
• The patient is abusing substances, particularly prescription pain-killers or tranquilizers.
• The course of the "illness" fluctuates, or complications develop with unusual speed.
• The patient has multiple surgical scars, a so-called "gridiron abdomen," or evidence of self-inflicted wounds or injuries.

SYMPTOMS OF MUNCHAUSEN SYNDROME BY PROXY. Factors that suggest MSBP include:

• The victim is a young child; the average age of MSBP victims is 40 months.
• There is a history of long hospitalizations and frequent emergency room visits.
• Siblings have histories of MSBP, failure to thrive, or death in early childhood from an unexplained illness.
• The mother is employed in a health care profession.
• The mother has been diagnosed with depression or histrionic or borderline personality disorder.
• There is significant dysfunction in the family.

Demographics

The demographics of factitious disorder vary considerably across the different subtypes. Most individuals with the predominantly psychological subtype of FD are males with a history of hospitalizations beginning in late adolescence; few of these people, however, are older than 45. For non-chronic factitious disorder with predominantly physical symptoms, women outnumber men by a 3:1 ratio. Most of these women are between 20 and 40 years of age. Individuals with Munchausen syndrome are mostly middle-aged males who are unmarried and estranged from their families. Mothers involved in MSBP are usually married, educated, middle-class women in their early 20s.

Little is known about the rates of various subcategories of factitious disorder in different racial or ethnic groups.

The prevalence of factitious disorder worldwide is not known. In the United States, some experts think that FD is underdiagnosed because hospital personnel often fail to spot the deceptions that are symptomatic of the disorder. It is also not clear which subtypes of factitious disorders are most common. Most observers in developed countries agree, however, that the prevalence of factitious physical symptoms is much higher than the prevalence of factitious psychological symptoms. A large teaching hospital in Toronto reported that 10 of 1,288 patients referred to a consultation service had FD (0.8%). The National Institute for Allergy and Infectious Disease reported that 9.3% of patients referred for fevers of unknown origin had factitious disorder. A clinic in Australia found that 1.5% of infants brought in for serious illness by parents were cases of Munchausen syndrome by proxy.

Diagnosis

Diagnosis of factitious disorder is usually based on a combination of laboratory findings and the gradual exclusion of other possible diagnoses. In the case of MSBP, the abuse is often discovered through covert video surveillance.

The most important differential diagnoses, when factitious disorder is suspected, are malingering, conversion disorder , or another genuine psychiatric disorder.

Treatments

Medications

Medications have not proved helpful in treating factitious disorder by itself, although they may be prescribed for symptoms of anxiety or depression if the individual also meets criteria for an anxiety or mood disorder.

Psychotherapy

As of 2002, knowledge of the comparative effectiveness of different psychotherapeutic approaches is limited by the fact that few people diagnosed with FD remain in long-term treatment. In many cases, however, the factitious disorder improves or resolves if the individual receives appropriate therapy for a co-morbid psychiatric disorder. Ganser syndrome usually resolves completely with supportive psychotherapy .

One approach that has proven helpful in confronting patients with an examiner's suspicions is a supportive manner that focuses on the individual's emotional distress as the source of the illness rather than on the anger or righteous indignation of hospital staff. Although most individuals with FD refuse psychiatric treatment when it is offered, those who accept it appear to benefit most from supportive rather than insight-oriented therapy.

Family therapy is often beneficial in helping family members understand the individual's behavior and their need for attention.

Legal considerations

In dealing with cases of Munchausen syndrome by proxy, physicians and hospitals should seek appropriate legal advice. Although covert video surveillance of parents suspected of MSBP is highly effective (between 56% and 92%) in exposing the fraud, it may also be considered grounds for a lawsuit by the parents on grounds of entrapment. Hospitals can usually satisfy legal concerns by posting signs stating that they use hidden video monitoring.

All 50 states presently require hospitals and physicians to notify law enforcement authorities when MSBP is suspected, and to take steps to protect the child. Protection usually includes removing the child from the home, but it should also include an evaluation of the child's sibling(s) and long-term monitoring of the family. Criminal prosecution of one or both parents may also be necessary.

Prognosis

The prognosis of factitious disorder varies by subcategory. Males diagnosed with the psychological subtype of FD are generally considered to have the worst prognosis. Self-mutilation and suicide attempts are common in these individuals. The prognosis for Munchausen's syndrome is also poor; the statistics for recurrent episodes and successful suicides range between 30% and 70%. These individuals do not usually respond to psychotherapy. The prognosis for non-chronic FD in women is variable; some of these patients accept treatment and do quite well. This subcategory of FD, however, often resolves itself after the patient turns 40. MSBP involves considerable risks for the child; 9–10% of these cases end in the child's death.

Ganser syndrome is the one subtype of factitious disorder with a good prognosis. Almost all patients recover within days of the diagnosis, especially if the stress that precipitated the syndrome is resolved.

Prevention

As of 2002, factitious disorder is not sufficiently well understood to allow for effective preventive strategies—apart from protection of child patients and their siblings in cases of MSBP.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Eisendrath, Stuart J., MD. "Psychiatric Disorders." In Current Medical Diagnosis & Treatment 2000, edited by Lawrence M. Tierney, Jr., MD, and others. Stamford, CT: Appleton and Lange, 2000.

"Psychiatry in Medicine," Section 15, Chapter 185 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2000.

PERIODICALS

Andersen, H. S., D. Sestoft, and T. Lillebaek. "Ganser Syndrome After Solitary Confinement in Prison: A Short Review and a Case Report." Norwegian Journal of Psychiatry 55 (2001): 199-201.

Daly, Robert C., MPH, and Can M. Savasman, MD. "Ganser Syndrome." eMedicine Journal 3, no. 1 (January 14, 2002).

Elwyn, Todd S., MD, and Iqbal Ahmed, MD. "Factitious Disorder." eMedicine Journal 2, no. 11 (November 5, 2001).

Feldman, Marc D., and Charles V. Ford. "Liejacking." Journal of the American Medical Association 271 (May 25, 1994): 574.

Gordon, Leo A. "Munchausen Patients Have Found the Computer." Medical Economics 74 (September 8, 1997): 118-122.

Libow, Judith A., MD. "Child and Adolescent Illness Falsification." Pediatrics 105 (February 2000): 58-64.

McEwen, Donna R., BSN. "Recognizing Munchausen's Syndrome." AORN Journal 67 (February 1998): 206-211.

Paulk, David. "Munchausen Syndrome by Proxy." Clinician Reviews 11 (August 2001): 783-791.

Snyder, S. L., M. S. Buchsbaum, and R. C. Krishna. "Unusual Visual Symptoms and Ganser-Like State Due to Cerebral Injury: A Case Study Using (18)F-Deoxyglucose Positron Emission Tomography." Behavioral Neurology 11 (1998): 51-54.

Stephenson, Joan. "Patient Pretenders Weave Tangled 'Web' of Deceit." Journal of the American Medical Association 280 (October 21, 1998): 1297.

Stern, Theodore A. "How to Spot the Patient Who's Faking It." Medical Economics Journal 76 (May 24, 1999): 54-56.

Szoke, Andrei, MD, and Didier Boillet, MD. "Factitious Disorder with Psychological Signs and Symptoms: Case Reports and Proposals for Improving Diagnosis." Psychiatry On-Line , 1999.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. <www.aacap.org> .

Munchausen by Proxy Survivors Network. P. O. Box 806177, Saint Clair Shores, MI 48080. <www.mbpsnetwork.com> .

Rebecca J. Frey, Ph.D.