Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

19

Factitious Disorder

D avin K. Q uinn , M.D., D ora W ang , M.D., M.A., S eth P owsner , M.D., and S tuart J. E isendrath , M.D.

cases have inherent limitations, and federally funded investigation is nonexistent. It is likely that every clinician will cross paths with a patient with a factitious disorder at some point in their career. A survey of the literature on factitious disorders may engender conclusions of thera peutic nihilism, given the few descriptions of successful treatment and the many examples of patients with recurrent factitious behav iors over decades. However, Munchausen syndrome , the prototypical factitious disorder and the first to gain wide medical interest, is now understood to be a chronic severe variant that comprises only a small portion of all cases of factitious disorder. Clinicians may do well to remember that deception is a pervasive, normal behavior in human interactions and politics. In medical settings, patients may engage in a wide range of deceptive behaviors for a host of reasons, including as a coping strategy under conditions of stress, as exemplified by a moving first-person description of recovery from factitious disor der published by Bass et al. in 2013. Conceptualizing deception and excessive health care seeking on a spectrum of normal to abnormal behaviors will help clinicians understand that not all factitious ill ness behavior is as refractory or as chronic as that demonstrated by patients with Munchausen syndrome. DEFINITION The main clinical feature of factitious disorder is the falsification of physical or psychological signs or symptoms or the induction, or exaggeration of injury, or disease. It must be associated with iden tified deception and be evident in the absence of obvious external rewards, although at times, this may be difficult to determine. An individual may present oneself as ill, impaired, or injured, in which case the diagnosis is factitious disorder imposed on self . If an indi vidual presents another individual as ill, the diagnosis is factitious disorder imposed on another . Table 19–1 summarizes the definitions in the text revision of the fifth edition of the Diagnostic and Sta tistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases 11th Revision (ICD-11). Factitious disor ders are now considered part of the somatic symptom and related disorders category, given that both disorders involve manifestations of predominantly somatic symptoms and are most often encountered in the medical setting. There are also many areas of overlap between these disorders in comorbidities and treatment. Munchausen syndrome, the eponymous term coined by Richard Asher in his landmark 1951 publication, was known as chronic fac titious disorder with predominantly physical signs and symptoms in the lexicon of DSM-IV. Some practitioners use the term Munchau sen syndrome for a chronic, severe, refractory form of factitious disorder, in which deceptive illness behavior becomes a lifestyle, precluding stable relationships or employment. Munchausen syn drome comprises approximately 10% of all cases of factitious

Patients with factitious disorder simulate, induce, or aggravate illness to receive medical attention, regardless of whether they are ill or not. These patients may inflict painful, deforming, or even life-threatening injury upon themselves, their children, or other dependents. The pri mary motivation is attention and care as a patient . Factitious disorder patients, in contrast to malingerers, lack an obvious external reward, such as avoidance of duties or financial gain. Factitious means “artificial, false,” from the Latin facticius, “made by art.” The art and artifice of patients with factitious disorder often lead to high hospital drama. Clinicians may exclaim in frustra tion, “He’s not really sick! He’s doing it to himself!” and dismiss or refuse to treat patients with factitious disorder. Countertransference can be a major obstacle to the proper treatment of these patients who are at risk and suffering a psychiatric disturbance. Factitious disorders can lead to morbidity or even mortality. Therefore, the medical and psychiatric needs of these patients must be taken seriously, even though presenting complaints are by defini tion falsified. An operating room technician, the daughter of a physician, repet itively injected herself with Pseudomonas, which caused multiple bouts of sepsis, bilateral renal failure, and ultimately her death. Such deaths are not uncommon in severe factitious disorders. In factitious disorder imposed on another, also known as facti tious disorder by proxy, Munchausen syndrome by proxy , and “fab ricated illness in a child,” the patient seeks medical attention for another individual, most commonly their own preverbal infant. Fac titious disorder imposed on another is recognized in all 50 states as child abuse, elder abuse, or abuse of a vulnerable, dependent adult. Clinicians must prioritize the safety of the victim, which may involve notifying government agencies responsible for the protection of these groups. Factitious disorders imposed on self and imposed on another should not be considered diagnoses of exclusion but should be actively pursued, given the potentially high stakes, especially when dependent abuse is suspected. Clinicians should be mindful of mini mizing unnecessary invasive medical procedures and of trying to steer patients toward the psychiatric care they may need in face- saving, nonthreatening ways. Indeed, factitious illness behavior often represents an underlying psychiatric disturbance, such as a person ality disorder, mood disorder, or substance use disorder. Ironically, even patients presenting with factitious psychological complaints, such as feigned bereavement, usually suffer from another psychiatric condition for which they are not seeking help. Limited empirical knowledge is available about the etiology, epidemiology, course, prognosis, and effective treatment of facti tious disorders. Most knowledge comes from case reports, and this information is suspect given that these patients, by definition, fal sify their histories. Methodologic problems are inherent in studying deceptive patients. Systematic studies of reported factitious disorder

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