Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

considered criminal abuse and is mandated to be reported to govern ment authorities. In an unusual case of adult factitious disorder imposed on another, a 34-year-old man drugged his wife with sleeping pills in her coffee, then injected gasoline into her skin to cause lesions from which she eventually died. Subsequently, he hired a female babysit ter to care for his children and repeated his actions with her. In each case, he assumed the role of the concerned caretaker in the center of medical drama. He was finally arrested for murder, and in prison, he sought to work in the infirmary. Factitious disorder imposed on another has also been cited as the etiology for epidemics of death at hospitals and nursing homes. Perpetrators have largely been nurses and aides who produced ill ness through various means, such as injection of insulin, lidocaine, digoxin, or other substances. In Great Britain in 1993, pediatric nurse Beverly Allitt was convicted of killing four children under her care and was given 13 life sentences. Florida registered nurse Bobbie Sue Terrell was accused of a rash of murders at a nursing home where she worked, and in 1988, she plead guilty to reduced charges of second-degree murder. Apparently, after learning of her infertility, she began demonstrating self-injurious behavior and factitious disorder. Kristen Gilbert, a nurse at the Veterans Affairs Medical Center in Northampton, Massachusetts, from 1989 to 1996, was found guilty of having induced cardiac arrest in at least four patients by injecting epinephrine into their intravenous fluids and was suspected of potentially having sickened or killed hun dreds of patients. Known as the “Angel of Death” because of the anecdotal increase in deaths during the shifts she worked, Gilbert was reported to have a history of pathologic lying in childhood, including faking a suicide note. During the investigation into the deaths, Gilbert called in a bomb threat to the hospital. Most reported cases involve mothers and their children. The chal lenges of recognizing this condition are illustrated by unfortunate examples. Nancy Reagan presented a Mother of the Year award in 1988 to foster mother Yvonne Eldridge for her valorous care of ill children. Eldridge was later recognized as a factitious disorder imposed on another perpetrator and was convicted of child abuse in 1996. Hillary Rodham Clinton publicly recognized Kathy Bush’s dedication to her daughter. Bush was later recognized as a perpetra tor of factitious disorder imposed on another and was sent to prison in 2002 for child abuse that had resulted in 200 hospitalizations, 40 surgeries, and 15 bouts of sepsis for her daughter. Sudden infant death syndrome (SIDS) was initially thought to have a strong genetic component because it often occurred in sib lings. Today, when siblings die of SIDS, infanticide is suspected. Indeed, a study of 81 children who died of SIDS or natural causes and who later were found to have died at the hands of their parents showed that half of the perpetrating parents had factitious disorder or another somatic symptom disorder. The comorbidity of factitious disorder and factitious disorder by proxy is estimated to be from 10% to 30%. When one child is victimized, there is a high likelihood a sibling will also be victimized, usually serially. Table 19–4 lists clues that should trigger suspicion of factitious disorder imposed on another. The variety of medical presentations of factitious disorder imposed on another is impressive. In the first comprehensive review of the disorder, published in 1987, Rosenberg described 68 induced or fabricated signs or symptoms. The most common presentations among 117 cases were bleeding (44%), seizures (42%), central ner vous system depression (19%), apnea (15%), diarrhea (11%), vomit ing (10%), fever (10%), and rash (9%). Many children had more than one presentation. Twenty-five percent of cases involved simulation

medical records exchanges outside of a health care system rep resent a powerful modern tool to identify evidence of factitious disorder, and should also be informed by consultation with legal counsel. 3. Stigma: Careful workup for genuine organic causes, judicious use of indicated testing, and application of evidence-based treatment must be performed even in circumstances where a factitious dis order is heavily suspected. Devising tests for factitious illness and obtaining a resistant patient’s consent for such tests requires a skillful approach that is nonconfrontational but truthful. There is no role for deceptiveness on the part of the provider in the diag nosis of factitious disorder, such as misrepresenting the reasons for tests or giving placebos disguised as active treatment. The intense negative countertransference on the part of health care staff deceived by patients with factitious disorder is formidable and can result in distortions of usual care, violations of protocols and regulations, and even malpractice. If a patient becomes pejo ratively labeled as a “faker” or “somatizer,” it is very possible that a condition that has a genuine organic basis may go undetected or untreated. Munchausen Syndrome Diagnosis of Munchausen syndrome is often simpler than in other cases of factitious disorder because of the tendency for dramatic, exaggerated presentations. Treatment and management, however, are usually far more challenging. These patients often are new to a particular area, being prone to peregrination. Munchausen syn drome patients may appear eerily comfortable in hospital settings, immediately talking to nurses, physicians, and medical staff as peers. Some show up for hospital admission wearing surgical scrubs. They demonstrate pseudologia fantastica, a specific syndrome of auto biographical lying with four features as defined by King and Ford: (1) the stories are not entirely improbable and are built upon a basis of truth; (2) the stories are enduring; (3) the stories are not told purely for personal gain, and have a self-aggrandizing quality; and (4) they are not delusions, in that the patient can admit to falsehoods when confronted with conflicting facts. Munchausen patients often mani fest hostility when their needs are not met, or they are confronted by staff regarding suspicions of deception and will then leave the hospital abruptly. They repeatedly present under different names to different hospitals, employing a repertoire of symptoms and presen tations to gain admission and treatment. The cost of this disorder can be tremendous, as illustrated by the British report of a “million-dollar man” who, over a 13-year period, spent 1,300 days in psychiatric units, 556 days in prison, and 354 days in medical care for 261 hospi tal admissions. All diagnostic considerations that apply to factitious disorder also apply here. Because the risk of morbidity and mortality may be higher in these patients, it may be prudent to involve bioeth ics consultations and hospital legal counsel early. Factitious Disorder Imposed on Another Previously called Munchausen syndrome by proxy, the essential feature of this disorder is the intentional feigning or production of physical or psychological symptoms in another individual who is under the perpetrator’s care. The perpetrator’s motive is to assume the sick role by proxy. Mothers of preverbal infants are the most common perpetrators, although fathers, other family members, baby sitters, and even medical professionals also have been implicated. Victims can also be spouses, older adult parents, hospital patients, or anyone under the care of a perpetrator. In all cases, this behavior is

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