Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

may represent an attempt to master and to feel in control of situations in ways in which they never did as children. They demand or refuse procedures and leave the hospital against medical advice when they feel they are losing control. Masochism may be a reason that patients repetitively endure painful or deforming surgeries and procedures, such as amputa tions of limbs and fingers or exploratory abdominal surgeries that result in extensive scarring. The patient relives childhood physical or emotional abuse at the hands of the medical staff in a repetition compulsion. The physician and the medical system at large become symbolic parents against whom the patient re-enacts dependency, idealization, and anger. The system responds with caring, but also with ostensible physical (e.g., surgery) and emotional (e.g., caregiver anger) abuse and, too often, ultimately with rejection and abandon ment. Indeed, for those with chronic factitious disorder, the medical system becomes the main object relation. Factitious illness behavior often occurs when a patient experi ences a loss, such as the death of a relative or an occupational loss. Securing the attention of medical clinicians, family, and friends may be a way of obtaining emotional solace without directly confront ing the loss. Dependency and narcissistic needs are fulfilled. Facti tious illness behavior may also serve the function of providing some patients a role, identity, or purpose. In the role of a patient, they are masterful orchestrators of medical drama. In practicing pseudologica fantastica, they often construct desirable and interesting identities. Behavioral theories postulate that early in life, these patients received positive reinforcement when sick and perhaps gained nurtur ing from the medical community that they did not receive at home. Per haps they learned to see the medical system as a source of caring and emotional support. Alternatively, many of these patients lived in large, neglectful households and became the center of focus only when ill. Factitious Disorder Imposed on Another Psychodynamic theories predominately explain factitious disor der imposed on another as objectification of the child to serve the parent’s psychological needs. Schreier and Libow called factitious disorder imposed on another a perversion of mothering in which a child is dehumanized by the mother and instead serves as a fetishized object through which the mother’s dependency needs are met. Emin son and Postlethwaite argued that two axes are at play: the desire to consult and the inability of the parent to distinguish parental needs from the child’s needs. Rosenberg noted a disorder of empathy among perpetrating moth ers, along with pervasive themes of loneliness and isolation, often under circumstances of uninvolved or absent husbands. The mother seeks a relationship with the physician, who substitutes for the unin volved husband. The relationship with the physician is often ambiva lent, characterized by idealization and belittling. The more severe the child’s alleged illness, the more the mother fulfills her own need for caretaking, both vicariously through the child and more directly in her relationship with the physician. A common view is that those who impose factitious disorder on another have suffered a loss, such as spousal abandonment or loss of contact with another child. Whether perpetrating mothers tend to have suffered abuse is controversial because many such reports of abuse have subsequently been disqualified by collateral sources. Four factors that suggest a caregiver at risk of fabricating illness in a child include (1) appearing to need or thrive on attention from physicians; (2) insisting the child cannot cope without the caregiver’s ongoing attention; (3) being directly involved in a medical profession or hav ing expertise or familiarity with medical knowledge and terminology;

who was convinced he had a lesion in his urogenital system simu lated hematuria to encourage investigation. These vignettes highlight how factitious behavior may be deployed in the service of getting the attention of medical professionals to focus on a perceived con cern. Substance abuse, and to a lesser degree psychotic disorders, and developmental disorders have also been implicated in factitious illness behavior. No genetic or familial inheritance pattern has been shown. Inter generational transmission of susceptibility to factitious disorder is possible, as cases and reviews highlight how families in which a child of a parent with factitious disorder goes on to develop factitious disorder as an adult. While intact neurologic and cognitive functioning is observed in most factitious disorder patients, a neurobiologic basis of some facti tious behaviors is suggested by reports of abnormal brain scans and deficits in neuropsychological testing in several studies. Pankratz and Lezak, in 1988, reviewed 25 cases of factitious disorder in which neuropsychological testing was obtained. Approximately one-third of those patients manifested significant neuropsychological defi cits. Lawrie et al. in 1993 described a case of a 34-year-old woman who developed personality change and a full-blown Munchausen syndrome after a cholecystectomy. Electroencephalogram demon strated focal slowing in the right temporal lobe, and testing revealed attentional and memory deficits with a significant visuospatial con structional apraxia. Single-photon emission computed tomogra phy (SPECT) demonstrated reduced uptake in bilateral frontal and left temporal cortices. Mountz et al. in 1995 reported the results of a SPECT scan in a woman with severe Munchausen syndrome. Regional cerebral blood flow in the right hemithalamus was mark edly increased, in line with a theory of right hemisphere abnormali ties in factitious disorder put forth by Pankratz. There is one case report of fMRI performed by Spence et al. in a woman convicted of child abuse as a result of factitious disorder imposed on another. She was scanned both while endorsing her ver sion of events in which she is innocent and while she endorsed the account of her accusers. Longer response times and greater acti vation of ventrolateral prefrontal areas were observed on repeated scans when she endorsed her accusers’ version of events, indicating a change in brain state depending on “truthful” versus “false” endorse ment. While this, of course, cannot be considered a biomarker for innocence or guilt, this finding confirms what has been found in stud ies using neuroimaging to study simulation. Zheltyakova found regions such as the bilateral temporoparietal junction, right superior temporal sulcus, and left precuneus to have increased blood oxygen level–dependent signal during actions with deceptive intentions, Different and more complex patterns of activa tion were observed by Stone et al. in bilateral frontal and subcortical areas when patients with conversion weakness attempt to move the paretic limb versus when healthy controls are asked to simulate a weak limb. This line of research suggests that while clinical assess ment and treatment of somatic symptom disorders and factitious disorders are converging, deception may involve different brain func tions than somatic symptom disorders. Psychodynamic theories have focused on the concepts of mas tery, masochism, and mothering. Striving for mastery may especially apply to factitious disorder patients with predominantly psychologi cal signs and symptoms. For example, patients with factitious psy chosis often progress to develop a genuine psychotic disorder, which suggests that the feigning of psychosis may represent a defense or a way of feeling in control of initial psychotic symptoms. Because many patients with factitious physical symptoms seem to have suf fered traumatic illnesses as children, adult factitious illness behavior

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