Factitious Disorders Motivation for Behavior -- sick role External incentives for behavior -- absent

Essential Features Intentional production of symptoms Judgment of internationality –Direct evidence –Exclusion of other causes Behavior: –“voluntary” Act is intentional –“not voluntary” Usually cannot be controlled/compulsive quality Even while knowing dangers Presumed goal of behavior –Assume sick role as opposed to Malingering Goal of Malingering –Assume sick role to accomplish externally recognizable goal (compensation, avoid jail or military duty) In both disorders “intentionality” In Malingering, symptoms stopped when not useful

Other Features Presence of factitious symptoms – does not preclude true physical or psychological symptoms Diagnosis always implies psychopathology Frequently with predominately psychological symptom type – a severe personality disturbance is predisposing factor

Making A Diagnosis Core concept is attempt, through deception, to feign physical or emotional illness in order to assume role of patient Any mental disorder better accounting for deceptive behavior takes precedence

Consider the Following: Many patients elaborate illness & exaggerate symptoms –but no overt deception with non-existent illness Conscious & intentional faking medical condition –for sole patient role No certain method of detecting feigned illness Discovery results – by patient mistake or –staff suspicion of inconsistencies Symptoms may disappear –under constant observation or when no access to personal belongings Is there? – excessive knowledge of symptoms & –suggestions of medical tests Are psychiatric symptoms unresponsive to standard treatment? Patient is vague or lies about history Patient becomes abusive, accusatory of incompetence, or abruptly leaves hospital when suspicion arises.

Other Important Clues History of previous inconclusive hospitalizations Multiple surgical scars especially on abdomen History of serious illness as child Fever present without other evidence of active disease

Confrontation of Patient Team effort needed Only after a social/psychiatric care plan can be arranged Generally direct confrontation (esp. if premature) is met with –denial, anger & outrage –& a quick departure from medical setting

Munchausen Syndrome by Proxy (MSP) Sick role by proxy –Victim usually child Behaviors to get into or stay in hospital Describes children whose caretakers (generally mothers) invent false illness Substantiated by fabricated evidence Usually involves emotional abuse & sometimes severe physical abuse –(usually in 1 st 2 yrs. of child’s life) –Often undetected form of child abuse May indicate intense & symbiotic relationship with mother

Associated Features With psychological symptoms – severe character pathology almost always present –Secret use of psychoactive substances may allow production of mental disorder With physical symptoms – psychoactive substance abuse is common –Severe character pathology is invariably present

PrevalenceCourse More common in males Relatively rare (1982 – only 100 cases in 80 yrs) Factitious by Proxy –Usually females May be limited to 1 episodes Onset usually early adulthood –often after hospitalization Usually short-lived & complete recovery –Often “spontaneous recovery” Chronic form of successive hospitalizations –may become lifelong pattern

Cost of Factitious Disorder Extremely high due to number of tests to rule out & make accurate diagnosis Individual my flee hospital without paying

Treatment No established treatment of choice –Closed ward to prevent leaving or avoiding treatment Patients rarely seen due to lack of motivation –Might appear due to family pressure Due to outrage unlikely to engage in meaningful treatment

Treatment Options Comprehensive diagnostic evaluation –to identify & treat associated disorders Concentrate on therapeutic relationship – to help recognize psychological basis –May motivate healthy mental state vs. sick role status May remain in treatment if attention to feigned complaints & dependency needs Look at severe external stressors Behavior modification successful – with long term (3 yrs) hospitalization Reality therapy –demonstrates behavior not meeting needs –development of more rewarding ways to operate Medication – no role yet established – Could justify with associated psychiatric disorder – Anticipate non-compliance – Potential for substance abuse

Other Options for Treatment Diagnosis of Munchausen’s Syndrome May facilitate next physician Publish Blacklist –Central register or International Rogues Gallery Encourage adoption of “pseudo-factitious” behaviors –to satisfy psychological needs while avoiding risky behaviors as surgery Abdominal scars easily removed with soap & water Imprison for unremitted hospital expenses Tattoo diagnosis on abdomen to alert next physician