Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

Table 19–4. Clues Triggering Suspicion for Factitious Disorder Imposed on Self

Table 19–5. Diagnostic Principles and Tools for Factitious Disorder Imposed on Another

1. Diagnosis does not match the objective findings 2. Signs or symptoms are bizarre

parent. An institutional protocol should be in place regarding covert taping, including plans for monitoring and interventions, if the child is found to be at risk. Other means of confirming factitious disorder imposed on another include searching a mother’s belongings for illness-inducing agents, reviewing collateral information and past medical records for incon sistencies, gathering information on siblings, recording temporal associations between parental visits and a child’s signs and symp toms, observing the child’s well-being when they are removed from the parent’s care, and analyzing specimens taken in the presence of the parent compared to those taken in the parent’s absence. The international literature on factitious disorder imposed on another indicates that signs and symptoms appear to be consistent across the world. Perpetrators are usually mothers, and serial abuse of children is common. This does not appear to be a phenomenon exclusive to medicalized societies. Pathology and Laboratory Reports No laboratory or pathology tests are diagnostic of factitious disor ders, although they may help to confirm the diagnosis by demonstrat ing deception. In many cases, a laboratory finding may be the only objective sign that factitious behavior is taking place. 13. Interview the child separately from the caregiver, if verbal, for their recollection of any symptoms, including when and where they occurred 14. Take a careful social and family history, including for any unusual or frequent illnesses in the extended family and siblings 15. Perform diagnostic testing for fabricated illness alongside tests for organic etiologies 16. Separate the child from the suspected caregiver and observe for improvement 17. Employ covert video surveillance while the child is hospitalized, with legal and ethical consultation 1. Ask: Are the history, signs, and symptoms of disease credible? 2. Ask: Is the child receiving unnecessary and harmful or potentially harmful medical care? 3. Ask: If so, who is instigating the evaluations and treatment? 4. Multidisciplinary evaluation involving medical, psychosocial, child protective, and legal professionals 5. Consultation with a specialist in child abuse pediatrics/elder abuse 6. Complete review of the medical record 7. Construction of a chronologic summary of medical contacts with attention to: ▶ use of multiple medical facilities ▶ excessive or inappropriate pattern of utilization ▶ pattern of missed appointments and discharge against medical advice ▶ pattern of misrepresentation of opinions of physicians about the child’s medical problems 8. Attribution of all medical information to its source (e.g., Did the nurse observe apnea or did the caretaker inform the nurse of it?) 9. Creation of a table with the following elements for each health contact: Name; date; location; reason for contact; reported symptoms as stated by caregiver; objective signs documented by physician; conclusions/diagnoses made; treatment provided; efficacy of treatment 10. Ask: Does the history provided by the caregiver match the history in the medical record and/or the diagnosis made by the physician? 11. Contact involved physicians and solicit concerns about possible fabrication of illness 12. Have all involved staff meet and develop a consensus management plan

of illness, 50% involved production of illness, and in the remaining 25%, simulation and illness production were concurrent. Perpetrating caregivers usually appear to be concerned and inter ested in their children’s care. They tend to be exemplary in their interactions with medical staff, enlisting support and sympathy, often crossing professional boundaries by eating meals with staff or helping nurses with duties. They may demonstrate unusual willingness or even excitement at the prospect of invasive procedures for their children. However, analyses of reported cases indicate that factitious behavior continued during hospitalization in 54.4% of cases and that the death of the victim was caused in 7.4% of cases, indicating the potentially fatal consequences if the perpetrator is not stopped in their abuse. Factitious disorder imposed on another should not be a diagnosis of exclusion, but confirmatory evidence should be actively pursued with the goal of lessening the risk to the victim and assuring the victim’s safety. The recommended steps for diagnosing a suspected factitious disorder imposed on another by the American Academy of Pediatrics are outlined in Table 19–5. The gold standard for confirming factitious disorder imposed on another is covert video surveillance that may record a perpetrator caus ing harm. Examples of documented harms include caregivers suffocat ing children, causing fractures, and administering poisons, or injecting harmful substances into intravenous lines. Such videos have also shown mothers appearing concerned in the presence of staff but behav ing indifferently toward their children when unaware of being watched. Despite the benefits of objective documentation of abuse, the use of covert video surveillance is not without risk: (1) damage may be done to the child prior to health care intervention; (2) it may inter rupt a potential therapeutic alliance; (3) some consider covert tap ing to violate the parents’ right to privacy or represent entrapment; (4) video footage can be difficult to interpret and may result in false accusations; and (5) covert taping can be costly and require constant real-time monitoring to prevent harm. Covert video should only be undertaken after consultation with legal counsel because a court order may be legally required. A bioethics consultation can help weigh the potential benefits to the child versus compromises of privacy for the 3. Caregiver or suspected offender does not express relief or pleasure when told that dependent is improving or that dependent does not have a particular illness 4. Inconsistent histories of symptoms from different observers 5. Caregiver insists on invasive or painful procedures or hospitalizations 6. Caregiver’s behavior does not match expressed distress or report of symptoms (e.g., unusually calm) 7. Signs and symptoms begin only in the presence of one caregiver 8. Sibling or another dependent has or had an unusual or unexplained illness or death 9. Sensitivity to multiple environmental substances or medicines 10. Failure of the dependent’s illness to respond to its normal treatments or unusual intolerance to those treatments 11. Caregiver publicly solicits sympathy or donations or benefits because of the dependent’s rare illness 12. Extensive unusual illness history in the caregiver or caregiver’s family; caregiver’s history of somatization disorders 13. Caregiver seeks other medical opinions when told the dependent does not have illness 14. Caregiver perseverates about borderline abnormal results of no clinical relevance despite repeated reassurance, or refutes the validity of normal results

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