Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

imposed on self. Nearly half of them described serious marital prob lems. About half of the perpetrating caregivers had a history of psy chiatric symptoms, and one-third gave histories of emotional neglect or physical abuse. Fathers were generally absent or peripheral. Bass and Jones examined 28 individuals referred for the treatment for factitious disorder imposed on another. Fifty-seven percent had evidence of a DSM-IV somatoform disorder, and 64% had a history of a factitious disorder imposed on self. Thirty-two percent mani fested pseudoseizures and 61% engaged in pseudologia fantastica. Early abuse experiences were seen to lead to pathologic lying and finally to the fabrication of illness in the victim. The etiology of factitious disorder is unknown, and a variety of causes likely explain the wide spectrum of factitious illness behav ior. The underlying motivations for the behaviors are believed to be unconscious, although this aspect of the disease is becoming increas ingly irrelevant for diagnosis. Two factors underlie most cases of fac titious disorder: (1) an affinity for the medical system and (2) poor, maladaptive coping skills. A majority of factitious disorder patients have medical training, such as in nursing. In a review of six case series comprising a total of 165 patients, Reich and Gottfried found that 60% worked in a medical profession. This approximate ratio of two-thirds having medical background has been confirmed in sys tematic reviews by Yates et al. and Caselli et al., as well as single-site case series by Ximenez et al. in 2020. The subjects seemed motivated toward their career choices by genuine lifelong preoccupations with health. Indeed, many with factitious disorder see health care provid ers as allies, not adversaries. In this case series, many patients had personal ties with their physicians, having worked in their offices or having babysat for them. Having a medical background also permits a patient to engage in more sophisticated fabrications of illness and to conceal their deceptions more skillfully. Coping deficits are widely noted. Many factitious disorder patients seem to come from large families or to have been neglected as children. They may have grown up without consistent nurturing conducive to the development of mature coping. The poor coping skills of these patients are often symptomatic of an Axis II disorder, such as borderline, narcissistic, dependent, or antisocial personality disorder. Increasingly, factitious disorder is being placed within the broader concepts of “illness behavior” and the “sick role,” which include conditionally acceptable and socially advantageous behav iors that persons engage in as part of a therapeutic contract between themselves and the health care system (“the doctor tries to heal the patient; the patient tries to get better”). Physical diseases are more readily accepted as entries into the sick role compared to emotional or psychological diseases; thus, factitiousness is seen as a type of adaptive behavior to enter into and maintain a therapeutic contract that confers psychological sustenance, while secretly undermining it in order to prolong it. Factitious disorder may be the presenting symptom of an Axis I disorder. Many case reports indicate a lessening or alleviation of fac titious illness behavior when major depression is treated. Other case reports point to illness anxiety disorder, previously known as hypo chondriasis, as an underlying factor. For example, a 27-year-old phy sician simulated insulinoma by injecting himself with insulin. When insulin and a syringe were found in a toilet tank, he confessed that he was preoccupied with the thought that he had pancreatic cancer and was trying to provoke further investigation. A 15-year-old boy ETIOLOGY Factitious Disorder Imposed on Self

below the expected prevalence estimate. It was theorized that making a factitious disorder diagnosis was likely unpalatable to physicians and could negatively affect insurance reimbursements. However, all psychiatric disorders, including depression and generalized anxiety, were assigned at rates below their expected prevalence, indicating that a factitious disorder diagnosis is not necessarily less acceptable than any other psychiatric diagnosis. In a study of 28 million military health care visits from 2005 to 2011, Lande and Williams found that only a minuscule number (89 patients) were diagnosed with facti tious disorder. However, it is worth noting that in the military, malin gering and self-harm are prosecutable offenses. Profiles of patients with factitious disorder have increased in the last 5 years. Krahn et al. retrospectively reviewed 93 cases of facti tious disorder diagnosed over a span of 21 years in a general hospital. Seventy-two percent were female, with a mean age of 31. Two-thirds of the female factitious disorder patients possessed health care train ing or jobs. Follow-up and treatment engagement were sparse in this group, and only 17% ever acknowledged simulating illness. Reich et al. found a similar profile in their series of 41 cases over 10 years: predominantly female, unmarried, with an average age of 33 years, working in medical jobs, and manifesting emotional and sexual inhibi tion. Yates, in 2016, performed a comprehensive systematic review of 455 adult factitious disorder cases published between 1965 and 2015. Of these, 33% involved males, the mean age was 34.2 years, and in 122 cases, the patient had a health care or laboratory job, most commonly nursing. Of the cases with a history of health care work, 114 of these were female, confirming this particular patient profile known as “common factitious disorder” or “nonperegrinating facti tious disorder” by some groups. In contrast, Munchausen syndrome features peregrination or frequent wide-ranging travel to seek medi cal care and pseudologia fantastica. In the same series described above, the male patients were predominantly middle aged, unem ployed, and unmarried, with antisocial traits or histories, and 61% engaged in peregrination. Factitious Disorder Imposed on Another Factitious disorder imposed on another is most commonly perpe trated by mothers against infants or young children. The estimated incidence is approximately 0.5 to 2.0 cases per 100,000 children under age 16. In the United States, it accounts for less than 0.04%, or 1,000 of 3 million cases of child abuse, although it may well be underrecognized. Of infants brought to an Australian clinic for apparent life-threatening episodes, an estimated 1.5% represented factitious disorder imposed on another. A clinical practice at Great Ormond Street Hospital in England reported that in 20 years, 43 chil dren from 37 families were diagnosed as having induced illnesses. Rosenberg’s review of 117 cases of factitious disorder imposed on another revealed valuable information about the typical perpetra tors and victims. Male and female children were equally victimized. The mean age of a child at diagnosis was 3.3 years, with the onset of symptoms occurring at a mean of 1.24 years earlier. All perpetrators were mothers, with 98% being biologic mothers and 2% adoptive. Paternal collusion was suspected in only 1.5% of the cases. In half of the cases, illness was actively produced in the child, whereas in 25%, illness was simulated without direct infliction on the child. In 25% of the cases, illness was both simulated and produced. In the same review, 10% of perpetrators were thought to have Munchausen syndrome themselves, and an additional 14% showed features of the syndrome. Data collected from the Great Ormand Street Hospital clinic over a 20-year period indicated that about one third of perpetrating mothers also had a history of factitious disorder

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