159 Factitious Disorders (300.19)

DSM-IV-TR criteria

A. The patient is intentionally producing or pretending to have physical or psychological symptoms or signs of illness.

B. The patient’s motivation is to assume the role of a sick person.

C. There are no external motives that explain the behavior.

Associated Features

• Includes intentionally fabricating physical or psychological symptoms without having any actual illnesses. Motivation must lie in assuming the sick role and not for personal gain as in malingering.
• It can have predominantly psychological signs and symptoms, or predominantly physical signs and symptoms or a combination of psychological and physical signs and symptoms.
• Patients may do things to make it look like they are ill and need medical attention such as; contaminating urine sample, ingesting harmful substances like bacteria to invoke some sort of physical proof that they need care, taking hallucinogens, purposefully infecting minor cuts or scrapes to increase the severity and increase the medical attention administered. Can be seen in patient who seeks attention, sympathy, or leniency in some situations.
• Patients may have long medical histories with many hospital admissions. Their records are usually vague and inconsistent.
• The patient may have an unusual knowledge of the supposed disease as if they just had definitions to go off of without any true experience.
• They could be employed in a medical setting.
• Their hospital visits are usually around hospitals and weekends when the experienced staff is not working so they will have a less likely chance of being caught but still get the same treatment.
• The person will probably receive few hospital visits even if they claim to be an important figure.
• The patient may be unusually comfortable with invasive procedures, uncomfortable surgeries, or a drastic diagnosis.
• Their hospital behavior could be classified as controlling, hostile, attention-seeking, or disruptive.
• They may only present symptoms when they think they are being watched or when thought to be under surveillance and may disprove of surveillance.
• They are abusing medications, most commonly pain-killers.
• The illness that is being played out fluctuates, often with rapid progression.
• Self-inflicted wounds are most abundant.

Munshausen

• Munchausen Disorder is another term for Factitious Disorder.
• This is also known as Hospital Addiction Syndrome or Hospital Hopper Syndrome.
• This has the same diagnostic criteria as Factitious Disorder, seeking attention for being sick. Most often seeking sympathy and care. Sometimes multiple surgeries are performed before diagnosing this disorder.

Munchausen Syndrome by proxy

• Referred to in the DSM-IV-TR as Factitious Disorder by proxy, is a disorder in which someone delivers harm to someone else, most often a child, in order to gain attention. Its been described as an extended form of child abuse; it’s only difference is that it’s done for some sort of gain.
• Münchausen syndrome by proxy (MSBP), is a psychiatric disorder, a particular form of child abuse. An impaired emotional relationship exists mainly between the mother and her child. According to the variety of victims’ symptoms, all medicine doctors may deal with this syndrome in every day clinical practice. Still insufficient knowledge about the syndrome and its’ rare consideration in the differential diagnosis result in only severe, potentially lethal cases recognition. For many years the rest remains a source of a long-term physical and mental injuries in victims (Berent, Florkowski, & Galecki, 2010).
• Brief overview of Munchausen by Proxy

Ganser Syndrome

Gasner Syndrome is a separate type of Factitious Disorder. This disorder involves a patient giving absurd or exaggerated responses to simple questions. It can also be when a patient gives approximate answers to simple questions. The symptoms include clouded consciousness, altered reality, confusion, stress, loss of identity, etc.

Epidemiology

• FD often goes undetected therefore making it difficult to accurately determine how many people are afflicted.
• It has been shown that there is a much higher prevalence of physical factitious symptoms than psychological factitious symptoms.
• Only a few select studies have been done to show its prevalence. 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 illnesses by parents were cases of Munchausen syndrome by proxy.

Etiology

• Little is known about the true causes of FD because of poor follow up after hospital visits. There are a few theories; brain imaging has shown some biological associations with FD especially with Gasner Syndrome.
• FD might be attempted to re-enact some unresolved parental issues, or to re-enact a particularly enjoyable hospital visit.
• It also might be a form of masochism.
• It could just be attention seeking behavior or a need for care and nurturance
• It’s been speculated that FD may be an attempt to gain control over an authority figure such as a doctor.
• FD is often common amongst people who received extensive medical treatment as children for real physical disorders, experienced extreme family problems or abuse during childhood,

Treatment

• Medication has yet to prove successful in treating FD, some mood disorder medications have proven effective if they have other personality disorders.
• Most long term treatment is dropped by someone with FD.
• Psychotherapy and Family Therapy are some of the only treatments that have shown benefit, these often require what the patient doesn’t have that caused this disorder, such as a caring family or someone willing to go through long term therapy with them.

DSM5 changes (dsm5.org)

The work group proposed that Factitious Disorder be reclassified to Somatic Symptom Disorders.

Factitious Disorder

To make this diagnosis, all 4 criteria must be met.
1. A pattern of falsification of physical or psychological signs or symptoms, associated with identified deception.

2. A pattern of presenting oneself to others as ill or impaired.
3. The behavior is evident even in the absence of obvious external rewards.
4. The behavior is not better accounted for by another mental disorder such as delusional belief system or acute psychosis.

Major Change #1: Rename somatiform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders

The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism.
Major Change #2: De-emphasize unexplained symptoms

Remove the language concerning medically unexplained symptoms for reasons specified above. The reliability of such judgments is low (Rief, 2007). In addition, it is clear that many of these patients do in fact have considerable medical co-morbidity (Creed, Ng). Medically unexplained symptoms are 3 times as common in patients with general medical illnesses, including cancer, cardiovascular and respiratory disease compared to the general population (OR=3.0 [95%CI: 2.1 to 4.2] (Harter et al 2007). This de-emphasis of medically unexplained symptoms would pertain to somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder. We now focus on the extent to which such symptoms result in subjective distress, disturbance, diminished quality of life, and impaired role functioning.
Minor Change: Factitious Disorders
The work group proposes minor modifications to factitious disorders. Most importantly, it eliminates the distinction between factitious disorders involving physical vs psychological symptoms. It clarifies who is the patient in circumstances previously diagnosed as “factitious disorder by proxy.” This is now termed “factitious disorder on other.”
Additional minor changes in the factitious disorder descriptions were made to emphasize objective identification rather than inference about intentionality or possible underlying motivation. “Intentional production or feigning” was thus removed and replaced with “a pattern of falsification”. The wording “pattern of falsification” attempts to emphasize that the diagnosis should follow an objective characterization of a set of behaviors, without perceived inference about the intentionality or possible underlying motivation for these behaviors. “…associated with identified deception” was inserted to state that the behaviors showed evidence of deception as identified by the observer. Again, this wording emphasizes behaviors being observed, rather than inference about intent. Finally, item A4 was added to clarify that factitious disorder is not diagnosed when it is accounted for by another mental disorder such as an acute psychosis.

Severity:

There are few widely employed measures of severity in factitious disorder or conversion disorder.
For factitious disorder, one might grade severity levels as “1” when symptoms alone are reported (“bright red blood in stool”), as “2” when a lab test was modified (e.g. introducing blood into a urine sample), as “3” when patients make themselves sick or as “4” when patients’ actions lead to life threatening illness.