Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

“Munchausen syndrome by proxy” was first described in 1977 by British pediatrician Roy Meadow. He described one mother who caused salt poisoning in her child and another mother whose repeated fabrications of urinary tract infections in her daughter resulted in 12 hospitalizations, more than 150 urine cultures, six examinations under anesthesia, five cystoscopies, and seven major x-ray proce dures—all by the age of 6 years. When the girl was admitted for observation, the diagnosis of Munchausen syndrome by proxy was made based on urine samples that were bloody whenever collected by the mother but normal when collected by the nurse. Of note, the mother had also sought medical treatment for factitiously induced urinary tract infections in herself, an early indication of the intergen erational transmission of illness behavior that is often seen in facti tious disorders. COMPARATIVE NOSOLOGY The DSM-III, in 1980, was the first edition of the DSM to recognize factitious disorder. It focused on Munchausen syndrome, calling it the “prototype” of all factitious disorders. Factitious disorder with psychological symptoms was also recognized, as well as a category called atypical factitious disorder that included what later was termed factitious disorder with predominantly physical signs and symptoms. Subsequent editions of the DSM increasingly recognized the rarity of Munchausen syndrome and placed more emphasis on a greater spectrum of factitious disorders. The DSM-III-R recognized factitious disorder with physical symptoms and factitious disorder with psychological symptoms. The emphasis on Munchausen syn drome was lessened. Factitious disorder with combined physical and psychological symptoms made its appearance under the category of factitious disorder not otherwise specified (NOS). In contrast, the DSM-IV defined a single category, factitious dis order, with three types: (1) with predominantly psychological signs and symptoms, (2) with predominantly physical signs and symptoms, and (3) with combined psychological and physical signs and symp toms. Factitious disorder NOS was exemplified by factitious disorder by proxy, a disorder cited as a category deserving of more research, with research criteria listed. The DSM-IV-TR criteria for factitious disorders were unchanged from the DSM-IV criteria. DSM-5 in 2014 introduced several changes to the diagnostic cat egory. First, it formally recognized factitious disorder by proxy by dividing the general category of factitious disorders into two groups: factitious disorder imposed on self and factitious disorder imposed on another. The diagnosis of factitious disorder NOS was eliminated. Second, there was no distinction made between physical or psycho logical presentations. Factitious disorders are specified as being a single episode or recurrent episodes. Third, the criteria no longer required that illness induction be conscious or intentional, recogniz ing the difficulty inherent in making such a determination. Instead, evidence of deception in the absence of clear material gain (also known as “secondary gain”) is sufficient to establish factitiousness. If secondary gain is present, such as financial remuneration, relief from duties or legal responsibility, or receipt of controlled substances or narcotics, the deceptive behavior is considered malingering, which is not considered a psychiatric disorder. The ICD-11 is closely aligned with DSM-5. It lists factitious dis order under the category of “mental, behavioral, or neurodevelop mental disorders” and has subtypes of factitious disorder imposed on self (6D50), factitious disorder imposed on another (6D51), and factitious disorder, unspecified (6D5Z). Falsified illness manifesta tions are also listed separately under specific medical disorders, such as factitious hypoglycemia, urticaria, cheilitis, purpura, panniculitis,

multiple identities and sought care at multiple hospitals. In prefacing the case reports, he wrote: Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always traveled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly, the syndrome is respectfully dedicated to the Baron and named after him. Hieronymus Carl Friedrich Freiherr von Münchhausen (1720– 1797) was a nobleman who served in the Russian army in the war against Turkey (Fig. 19–1). After retirement, he entertained friends with embellished stories of his war adventures. He was turned into a literary figure by the author Rudolph Eric Raspe, a friend of the Baron, who fled Germany for England when caught embezzling from a museum. To pay off debts, Raspe published an account of the baron’s tales in 1785. The spelling of the Baron’s name has evolved over time to its current most commonly used but likely misspelled form, Munchausen. In 1968, Spiro noted that of the 38 cases of Munchausen syndrome then published, none involved a detailed psychiatric workup, and less than half were evaluated by a psychiatrist. He advocated a greater understanding of these patients and presented the first detailed psy chiatric case study, confirming information with collateral sources. He criticized the “Munchausen” label and recommended the less pejorative term chronic factitious symptomatology. Factitious disorder with psychological symptoms was first described by Alan Gelenberg in 1977, who mused that whereas other factitious disorder patients avoided psychiatrists, his patient, a war veteran, gained admission to more than 30 psychiatric hospitals within a few years, usually feigning depression and suicidality under various pseudonyms.

FIGURE 19–1. Hieronymus Carl Friedrich Freiherr von Münchhausen (1720–1797). Left: The baron wears military armor in this 1750 portrait by G. Bruckner. A nobleman who served the Russian army in the war against the Turks, the Baron entertained friends with embellished stories of his war adventures in his retirement. His tales gained fame when pub lished by Rudolph E. Raspe. Right: The baron appears as a caricature in this drawing by 19th-century artist Gustave Doré. The Latin inscription running diagonally across the shield says “mendace veritas” (ambiva lence between lie and truth). Like the Baron, patients with factitious disorders are real persons deserving of respect, even though they often present themselves as caricatures. (Portrait courtesy of Bernhard Wiebel, http://www.Muenchhausen.ch. The actual portrait was lost in World War II. Caricature from Gustave Doré. The Adventures of Baron Munchau sen, One Hundred and Sixty Illustrations by Gustave Doré. New York: Pantheon Books; 1944.)

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