Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

Table 19–2 lists reported presentations of factitious disorders along with means used to simulate illness, features suggestive of fabrication, and possible means of detection. The list is a testament to the creativ ity and resourcefulness of these patients, as well as to their willingness to undergo pain, injury, and inconvenience. Diseases of every organ system have been simulated, limited only by the patient’s creativity, knowledge, and access to technologic means. Often, the factitious patient’s knowledge of disease exceeds that of the evaluating physi cian, given the tendency of the patient to be medically trained, as well as the tendency to present to emergency rooms or clinics during eve nings or weekends when less experienced resident physicians and staff are on duty. It has been noted by Sinha et al. that factitious patients may emphasize signs and symptoms leading to protocol-driven or “fast-track” admission workups and may be attracted to specialties with more complex disorders and overlapping differential diagnoses. Factitious symptoms can be (1) fabricated, for example, by giv ing a false history of cancer, acquired immune deficiency syndrome (AIDS), or another illness; (2) feigned, for example, by faking symp toms such as pain or seizures; (3) induced, by actively producing symptoms through self-infliction of injury or through injection or ingestion; or (4) aggravated, such as by manipulating a wound so that it will not heal.

and (4) having a history of factitious or somatic symptom disorder. It should be noted that these characteristics overlap with those of care givers who are advocates for children with genuine illnesses and that a caregiver with factitious disorder imposed on another may manifest none of these traits. DIAGNOSIS AND CLINICAL FEATURES Table 19–1 summarizes the definitions in the text revision of the DSM-5 and the ICD-11. Factitious Disorder Imposed on Self The diagnosis of factitious disorder should be actively pursued and not considered a diagnosis of exclusion. This is recommended for the following reasons: (1) satisfactory exclusion of all other possibilities may be difficult to accomplish or impossible; (2) early diagnosis can minimize the patient’s self-harm, as well as harm through iatrogenic complications; (3) confirmation of deceptive behavior requires posi tive proof that is usually not forthcoming without proactive investi gation, and (4) failure to consider the diagnosis is the most common reason for missing a diagnosis of factitious disorder.

Table 19–2. Methods of Factitious Symptom Production, Suggestive Signs, and Confirmatory Tests by Systems

Method of Factitious Symptom Manufacture

Symptom

Signs Suggestive of Factitiousness

Test for Factitious Method

Infectious Disease Fever

Higher than 41 ° C

Injecting infectious material into vein/intravenous line Ingesting thyroid hormone

Monitoring while temperature taken

Not accompanied by other vital sign abnormalities Does not follow diurnal pattern

Using electronic thermometers reading skin surface Recording oral and rectal temperatures simultaneously Measuring fresh urine specimen temperature Culture, whole-genome sequencing to establish reinfection vs. relapse

Drinking hot fluids

Manipulating thermometers with lightbulb or heating pad Substituting another thermometer Warm wax/wet cotton in ears

No diaphoresis with rapid defervescence Noting thermometer brand names/serial numbers

Bacteremia

Injection of contaminated substance

Polymicrobial bacteremia

Absence of urologic/biliary/GI obstruction Stool flora/pet flora noted Normal CD4 count/undetectable viral load/Antibody negative

HIV/AIDS

False history/reports

Repeat HIV ELISA, western blot, viral load Confirm test results with laboratory

Gastrointestinal Diarrhea

Laxative abuse (magnesium, castor oil, phenolphthalein)

Metabolic alkalosis

Detection of laxative in urine or stool (usually need multiple tests)

Acute hyperchloremic metabolic acidosis with normal anion gap Decreased serum bicarbonate with metabolic acidosis Melanosis coli on sigmoidoscopy Cathartic colon on barium enema Low urine potassium concentration High fecal fluid potassium concentration Fecal fluid osmolality < 290 mOsm/kg High stool osmolar gap > 125 mOsmol/kg High urine potassium concentration Low urine chloride concentration Metabolic alkalosis with increased serum bicarbonate High daily stool volume Hypokalemia

3-day stool collection

Urine screen for phenolphthaleins, anthraquinones, bisacodyl Stool screen for magnesium > 45 mmol/L, phosphate

Adding water to stool sample Ipecac/cathartic abuse

Vomiting

Detection of ipecac in stool by chromatography Serum/urine emetine levels EKG with abnormalities c/w ipecac toxicity

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