Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

1919

Chapter 19. Factitious Disorder

See Table 19–2 for laboratory tests that can be helpful in deter mining that a given sign or symptom has been artificially induced.

workup, including electromyography, could not discern any neurologic disorder. There was no evidence of deception or material gain in this patient, but when a random loud noise startled him, the patient leaped off the examination table quite nimbly and was diagnosed with FND.

DIFFERENTIAL DIAGNOSIS The lynchpin of diagnosis of factitious disorder imposed on self or another is the confirmation of deceptive behavior perpetrated by the patient in the service of simulating or exacerbating a disease. An underlying physical or psychiatric disorder is the main consid eration in the differential diagnosis of suspected factitious disorder. Unusual, inconsistent, or poorly characterized symptoms must still be explored for nonfactitious etiologies according to best practices, evidence-based guidelines, and clinical indications.

The use of video electroencephalographic monitoring allows for the rapid capturing and diagnosis of nonresponsive episodes mimick ing absence seizures, complex partial seizures, or syncope. Dissociative disorders such as dissociative amnesia or dissociative identity disorder may involve episodes of inability to recall important personal information too extensive to be due to ordinary forgetful ness. These episodes can resemble psychological presentations of fac titious disorders in which amnesia or cognitive impairment features prominently. However, they do not involve deceptive behaviors. The second area of diagnostic differentiation concerns self inflicted harm. A patient with borderline personality disorder may engage in self-destructive, physically injurious, or psychologically damaging behavior resulting in illness (such as overdosing on acet aminophen or cutting one’s arm) for the purposes of stress reduc tion, pain relief, or conveying distress. If the induction of injury is associated with deception, then factitious disorder may be diagnosed. However, patients who have attempted suicide and caused physical harm may lie about their suicidal ideation, intent, plan, or the after math of the attempt. This may be in the service of avoiding detection or hospitalization and carrying out another attempt successfully. This is not factitious disorder nor malingering per se, but the expectable behavior of a person bent on suicide and must be screened for with a high level of suspicion. If a patient’s habitual behaviors contribute to worsening health, such as overeating leading to type 2 diabetes, work-related stress exacerbating hypertension, or cigarette smoking contributing to emphysema, and there is no overt deception in the patient’s presenta tion for care, then the appropriate diagnosis is psychological factors affecting other medical conditions. This is a new somatic symptom disorder in DSM-5 and is meant to capture psychological states which complicate the course of a physical disease, interfere with its treatment, and represent a well-established health risk. When assess ing whether deception is involved, it is important to remember that patients commonly minimize reporting of behaviors that they expect health care providers to criticize or that are not socially, culturally, or legally sanctioned. This should not automatically trigger a diagnosis of factitious disorder without a full exploration of the reasons for min imization. Likewise, ostensibly deceptive behavior may be a result of a lack of cultural understanding on the part of the health care provider, a language barrier between provider and patient, or due to violence or the threat of violence in the patient’s life. As Bass and others have rec ommended, diagnosing a patient’s deceptive behavior as a disorder is less important than understanding the underpinnings of the behavior. A 48-year-old woman with intractable hypertensive urgency endorsed taking her medications faithfully to her primary care physician. How ever, with intensive case management involvement, it became clear she did not take her medications as prescribed. The team discovered that she was being forced into prostitution by her husband under threat of death, something that she never volunteered to her providers.

A 46-year-old woman with type 2 diabetes manifested multiple episodes of hypoglycemia despite several inpatient hospitalizations to optimize her diet and insulin regimen. She was suspected of factitious disorder until it was discovered she had developed antibodies to insulin.

Underlying or prodromal psychiatric/neurologic illnesses may initially be mistaken for psychological factitious disorders. Several case reports document the development of full-blown psychotic dis order following the emergence of factitious illness behavior. Cogni tive disorders due to cerebral lesions, neurodegenerative disorders, and delirium may lead to self-induced illness and deceptive behavior. In cases of frontotemporal dementia, the deceptions are usually unso phisticated, and the attempts to obfuscate inept. Neuropsychological and functional testing may help to delineate the cognitive deficits in such cases. Even when deception is present, genuine comorbid illness is more often the rule than the exception in factitious disorders. Factitious disorder patients frequently aggravate an actual physical illness. Many patients who feign pseudoseizures also have true seizures. Many who manipulate blood sugars to produce symptoms are also diabetic. Munchausen syndrome patients may become addicted to narcotics or learn to seek disability payments and thereby also dem onstrate substance abuse and malingering. One area of diagnostic differentiation concerns psychiatric disorders, which can present similarly to factitious disorder with unusual or inconsistent physical or psychological symptoms and may even be comorbid when decep tive behavior is positively confirmed. In somatic symptom disorder, there are one or more physi cal symptoms that cause disproportionate distress manifesting in thoughts, feelings, or behaviors. If the physical symptom does not have a clear etiology or does not conform to typical clinical phe nomenology, suspicions may be raised for factitious behaviors, but positive evidence for deceptiveness will be lacking. In illness anxiety disorder (formerly hypochondriasis), normal physiologic sensations are perceived as harbingers of dread disease despite negative tests and reassurance to the contrary. It is important to remember that a presentation that does not conform to an identifiable medical or men tal disorder, or the diagnosis of factitious disorder, does not necessar ily rule out the presence of a true medical condition not associated with intentional symptom falsification. If a symptom is neurologic and is not consistent with neuro logic pathophysiology, then functional neurologic symptom disorder (FND) should be diagnosed.

Once confirmed, if deceptive behavior is performed to obtain a material gain such as to procure disability payments, narcotics, or an excuse from work, malingering is the appropriate label. DSM-5

A 35-year-old man presented to emergency care with rapidly progressive lower extremity flaccid paralysis following a mild head injury. Medical

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