Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

categorizes malingering as a “condition that may be a focus of clini cal attention,” defining it as the production of grossly exaggerated or feigned symptoms motivated by an external incentive. DSM-5 lists four conditions under which malingering should be strongly suspected, including medicolegal context, a discrepancy between self-report and medical findings, poor patient cooperation, and antisocial personality disorder; however, these are considered neither sensitive nor specific. Ganser syndrome, also known as “prison psychosis,” presents a related challenge. It was first described in 1897, consisting of twilight states, memory disturbances, and vorbeireden, a German term loosely trans lated as “talking at cross purposes.” Ganser syndrome is also known as the “syndrome of approximate answers,” in which answers to simple questions are erroneous in a manner that implies knowledge of the correct answer. An example would be answering “3” to the question of “How many legs does a horse have?” Ganser syndrome may be due to dissociation, malingering, or organic causes. In actuality, whether a behavior arises from external or internal origins can be difficult to discern. A clinician may be unaware of a patient’s upcoming court date and thus potential gain from being sick. For these reasons, Feldman and coworkers argued that these dis orders fall along a continuum: “there is little to be gained, and much to be lost, by the use of the current practice of viewing the somato form disorders, factitious disorder, and malingering as discrete and distinct clinical entities.” Conscious versus unconscious production of symptoms can be especially difficult to discern for psychological signs and symptoms, as there are few objective tests of mental status. It is for this reason that the DSM-5 no longer requires clinicians to determine that patients are explicitly aware of their deceptive behav ior, only that there is deception, and not for evident secondary gain. Mr. J, a 60-year-old man, presented to his local emergency department com plaining of nausea, vomiting, and dizziness. He was admitted for possible bleeding peptic ulcer and was also found to have a skin rash and depression. His rash was diagnosed as scabies, but Mr. J refused to shower or change out of his dirty garments. He then requested to be discharged. Psychiatric consultation was requested for evaluation of depression. Mr. J stated that he was grieving the deaths of his younger daughter and wife in a car accident 2 and a half years ago and that his life had been dis integrating since then. He was staying at friends’ houses after leaving his home with his older daughter, as he “couldn’t stand being there” any longer because of the grief. He had not sought treatment or professional help, he said, because “I don’t want to bother my family or doctors with anything.” However, he did endorse having “snapped” and having two “breakdowns” during which he could not remember where he was or who he was, and was hospitalized at a psychiatric unit in another state, but could not recall any details of this incident. He refused to give any contact information for fam ily or friends, citing concerns about bothering them too much and refused treatment for depression. His social history included employment as a chemical engineer in his own laboratory for the nearby military base, a PhD in parapsychology and forensic psychology, training as a paramedic, a father who was a fighter pilot, and a mother who was a physician. He wistfully recalled his family being stationed overseas. He related that his daughters both held advanced degrees, and his younger daughter was on her way to start a position at a prestigious university hospital when she was killed in the accident. Inconsistencies between his presentation and his history prompted a search for records in the wider hospital system. Records filed under the same name and date of birth at another facility detailed a significantly different history. When he was approached with these disparate facts, he angrily denied them. He was discharged the next day after it was deter mined he was not a danger to himself or others. Two weeks later, Mr. J presented with worsening altered mental sta tus, shortness of breath, abdominal pain, nausea, cough, dysphagia, and

vertigo. He was found to have pneumonia, a posterior inferior cerebellar artery (PICA) stroke, a pulmonary embolus, bilateral lower extremity venous thromboses, and esophagitis causing gastrointestinal bleeding. He was treated with antibiotics, anticoagulation, inferior vena cava filter placement, and gastric tube placement. Magnetic resonance brain imag ing revealed an old left temporal lobe infarct with encephalomalacia and gliosis, in addition to the PICA infarct. Psychiatric evaluation after Mr. J’s stroke revealed significantly impaired cognition (12/25 on the Montreal Cognitive Assessment) with deficits in short-term memory, attention, and executive function. He could not recall what he was being told by hospital staff about his con dition and needed frequent repetition of information. He then revealed that he could not recall any remote memories about his early life, such as schooling, family possessions, or even where he was born. He con tinued to refuse to speak with family or friends. However, hospital staff had to contact his daughter so that someone could serve as a surrogate decision-maker. Over several weeks, Mr. J became more attentive and his short-term memory improved. He revealed that, in fact, his wife and daughter had not died in a car accident 2 years ago, that this was a story lifted from the life of his friend “Bill.” He could offer no explanation for why he had given this as his life history. He also recounted that he was interested in parapsychology but denied having an advanced degree or practicing in this field. He seemed surprised by the details of his life that were obtained from outside hospital records. Interestingly, he complained that the hospital staff was “keeping secrets” from him. He was transferred to the outside hospital, familiar with his history, for longer-term care. Three months later, Mr. J presented to the local hospital with a supra therapeutic level of anticoagulation and pain in his lower extremities. It was discovered that when Mr. J had been transferred to the subacute facility 3 months prior, the facility received a telephone call from a hos pital in another state, stating that Mr. J was in fact not Mr. J, because the “real” Mr. J was admitted at their facility—family positively confirmed that their relative was the person at the other hospital. The patient who had suffered scabies, cerebellar stroke, and pulmo nary emboli was not the person he said he was, nor was he the person the outside hospital thought he was—he was Mr. R. When Mr. R was interviewed about his identity, he could not recall any episodic history of his life prior to his hospitalizations, nor could he recall his parents’ names, wife’s name, whether he had children, where he hailed from, or his employment history. He did not recall his previ ous deceptive stories. When presented with pictures of famous persons and allusions to famous world events, he denied knowing anyone named Hitler, Marilyn Monroe, or Ronald Reagan. He stated that he recognized Jesus from having read the Bible at the outside hospital and also knew of Martin Luther of the Reformation from reading. His short-term memory, attention, praxis, and executive function seemed very intact. He was able to recall numerous accurate details about his recent hospitalizations. He refused to give details of where he had been living and who had been helping him, always out of a concern to “not bother them.” Mr. R was hospitalized on a psychiatric ward out of concern that his amnesia, whether factitious or organic, was interfering with his abil ity to manage his medical issues, in particular the anticoagulation. He refused to engage in formal cognitive testing but accepted treatment for depression and aftercare planning and was discharged with appropriate appointments and services in place. After discharge, Mr. R regularly attended an anticoagulation clinic, physical therapy, wound clinic, and psychiatric appointments. During his mental health appointments, he endorsed that parts of his remote memory were coming back, including how his family lived overseas, his father served in the military, and his mother was a physician. How ever, he could not call to mind any memory of his family’s appearances or names. He later claimed that at his living situation (a group home, but what he termed “someone’s garage”), he fixed computers that others brought to him, that others said he was “trained as a paramedic” and that he was “head of an Information Technology department.”

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