Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

1907

Chapter 19. Factitious Disorder

Table 19–1. Factitious Disorder Imposed on Self

DSM-5

ICD-11

Name

Factitious disorder

Factitious disorder

Duration Symptoms

Factitious disorder imposed on self: ▶ Act of falsifying symptoms and clinical findings in one’s self ▶ Presenting one’s self to others as ill ▶ Deceptive behaviors present outside of identifiable external reward or motivation Factitious disorder imposed on another: ▶ Act of falsifying symptoms/injury/disease and clini cal findings in another individual ▶ Presenting individual in whom symptoms have been falsified to others as being ill ▶ Deceptive behaviors present outside of identifiable external reward or motivation

Factitious disorder imposed on self: ▶ Feigning, falsifying, or inducing signs, symptoms, or injuries ▶ Deceptive behaviors present ▶ If pre-existing disorder present, aggravates signs or symptoms or injuries associated ▶ Seeks treatment and presents as ill/impaired

Factitious disorder imposed on another: ▶ As above, but enacted on another person

# Symptoms needed Exclusion (not the result of) Psychosocial impact Symptom specifiers

Another mental disorder

Excoriation disorder Malingering

Severity specifiers Course specifiers

Single episode Recurrent episodes (2 or more discrete events) Note: In factitious disorder imposed on another, the perpetrator receives the diagnosis, not the victim.

Comments

consistent with the approach to diagnosing other forms of child maltreatment.

disorder. Constantly seeking medical care and hospitalization, such patients often assume grandiose false identities, sometimes claiming to be royalty, relatives of celebrities, or figures in important his torical events. They travel from hospital to hospital, and when they become well known in one city, take their deception on the road to begin the behavior anew elsewhere. Previous terms applied to these patients included hospital hoboes, hospital addicts, and professional patients. Two distinguishing features of Munchausen syndrome beyond the simulation of disease are pseudologia fantastica— the telling of vague, self-aggrandizing, heroic tales often containing a kernel of truth—and peregrination —the tendency to travel widely. There is evidence to support a second durable phenotype of facti tious disorder imposed on self, called common factitious disorder, in which factitious behavior is confined to one locality and a relatively circumscribed set of complaints. The prototypical patient tends to be young, female, socially connected, employed, and working in health care. In factitious disorder imposed on another, a person intention ally simulates illness in another individual, often someone who is dependent on the perpetrator for care. In 95% of all reported cases, the perpetrator is a mother feigning or producing illness in her own child. Factitious disorder imposed on another may also be committed against an adult, such as an elder or spouse. Epidemics of hospital deaths have been attributed to medical personnel inducing or exac erbating illnesses in patients. Because factitious disorder imposed on another almost always constitutes child abuse or criminal abuse, the forensic terms “perpetrator” and “victim” are used even in the medical literature. Subsequent to the DSM-5, factitious disorder imposed on another replaces the terms factitious disorder by proxy and Munchausen syndrome by proxy in psychiatric nomenclature. There is an ongoing debate in the pediatric literature about the appro priate terminology for the condition. Caregiver-fabricated illness in a child is the term used by the American Academy of Pediatrics Committee on Child Abuse and Neglect, as it focuses attention on the harm caused to a child and less on the motivations of the perpetrator,

HISTORY In the second century of the Common Era, the Greek-born physi cian Galen wrote of patients inducing or simulating symptoms such as vomiting or rectal bleeding. The Bible relates accounts of self-inflicted injury. In the Middle Ages, “hysterics” reportedly put leeches in their mouths to simulate hemoptysis and abraded their skin to reproduce skin conditions. However, judging historical accounts through contemporary mindsets is often problematic, and it is difficult to say whether these accounts actually represent facti tious disorder. In 1838, the Scottish military physician Hector Gavin published an essay, “On the Feigned and Factitious Diseases of Soldiers and Seamen, on the Means Used to Simulate or Produce Them, and on the Best Modes of Discovering Impostors.” Although most of Gavin’s subjects were malingering to escape duty in the high-casualty Napo leonic Wars, he also noted that the motive of some was simply “to excite compassion or interest” and that “some soldiers, indeed, with out any ulterior object, seem to experience an unaccountable gratifi cation in deceiving their officers, comrades, and surgeon.” Jean-Marie Charcot, around 1890, used the term mania operativa activa to describe a young girl who continually sought surgery for pain in a knee joint until her medical care seeking resulted in a sur geon amputating the leg. No pathology was ever found in the leg. In 1901, the Swiss physician Henri Secretan lent his name to a peculiar syndrome of nonhealing, traumatically induced edema of the dorsum of the hand. G. Reading, in 1980, confirmed that Secretan syndrome is factitiously produced. In 1934, Karl Menninger described “poly surgical addiction.” Interest in factitious disorder increased markedly when the term Munchausen syndrome was coined by Asher in 1951 to describe three patients with false abdominal complaints, all of whom used

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