Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

1923

Chapter 19. Factitious Disorder

Factitious Disorder Imposed on Another Victims of factitious disorder imposed on another are at very high risk. Mortality rate estimates of victims range from 6% to 22%, with deaths commonly occurring through suffocation or poisoning. In Rosenberg’s 1987 review, 10 of 117 children died, yielding a mortal ity rate of 9%, with the youngest children being the most vulnerable to death. A sobering statistic is that in 20% of the deaths, caretakers were confronted with the diagnosis of factitious disorder imposed on another, but the children were not removed from their custody. Of the survivors, 8% suffered long-term morbidity, including destructive joint changes, limp, cerebral palsy, cortical blindness, and psychiat ric problems. Approximately 75% of the morbidity was precipitated by caregivers’ behaviors occurring while the child was hospitalized. In 25% of the cases, morbidity was solely iatrogenic, caused by medical procedures and investigations. Factitious disorder imposed on another is often recurrent. In a 1998 follow-up study by Davis et al., 17% of victims who returned home without restrictions were abused again. In cases where the child was poisoned or suffocated, repeat abuse rates were as high as 50%, in some cases leading to death. These statistics reinforce the importance of prompt diagnosis, proper intervention, and protection. Siblings of victims are at great risk. Studies indicate that 9% to 29% of siblings die, underscoring the importance of checking and protecting all children of a given perpetrator. Siblings tend to be the focus serially rather than simultaneously, and so clinicians should always be alert for past and future victims. In 1990, Meadow studied 27 young children suffocated by their mothers. Over 13 years, nine died, and one suffered severe brain damage. These 27 children had 18 siblings who had died “suddenly and unexpectedly in early life.” In another study of 32 children presenting with factitious epilepsy, 21% of siblings (7 of 33) had died of SIDS. In a study of suffocation cases, 21% of siblings (3 of 14) had died unexpectedly. In another study of 56 victims of factitious disorder imposed on another, 39% of siblings were subjected to illness fabrication. Among Rosenberg’s review of 117 cases, 10 siblings had died under “unusual circumstances.” TREATMENT AND MANAGEMENT Guidelines for the treatment and management of factitious disorder are given in Table 19–6. Factitious Disorder Imposed on Self Three major goals should guide the treatment and management of factitious disorders: (1) to reduce the risk of morbidity and mortality, (2) to address the underlying emotional needs or psychiatric diag nosis that may be driving factitious illness behavior, and (3) to be mindful of legal and ethical issues. 1. Risk reduction: The Hippocratic doctrine of “first do no harm” should be foremost. Prompt recognition of factitious disorder can reduce morbidity or mortality. Active pursuit of the diagnosis and timely management are essential. For example, in the case of a woman who reported an extensive family history of breast cancer and sought prophylactic mastectomy, early suspicion of factitious disorder may have prevented the unnecessary bilateral mastec tomies that were performed. Recognition of factitious asthma or arthritis prevents the administration of steroid medications, which pose significant side effects. Invasive, potentially harmful tests, procedures, and treatments can be minimized. Once symptoms are confirmed as factitious, clinicians should administer medi cal treatment according to their clinical judgment, considering

objective evidence and keeping in mind that the patient’s com plaints and requests can be deceptive. Management of countertransference is a priority to reduce risk because a clinician’s negative feelings can interfere with appro priate patient care. If possible, psychiatric consultation should be promptly obtained. Good communication among all involved is essential because these patients are prone to cause confusion and splitting of caretakers. Regular interdisciplinary meetings are helpful. Psychiatrists should be aware of their own countertransfer ence reactions and help medical clinicians cope with their own reactions to these patients who falsify symptoms but who also have genuine needs. Negative countertransference can lead to therapeutic nihilism, breaches of confidentiality, inappropri ate treatment, or denial of care. Countertransference feelings of frustration and anger can more constructively be understood as projective identification and, thus, a window toward understand ing the patient’s longstanding feelings. It is essential to preserve good staff communication and to formulate a clear management plan involving the whole team to minimize splitting. Allowing staff to express negative views and emotions at team meetings while providing empathic support and helpful formulations of the patient can reduce unintended retribution against the patient. The psychiatrist or psychotherapist may also be prone to nega tive countertransference arising from feelings of being “duped” or manipulated and should seek appropriate supervision. On an outpatient basis, all medical care should be directed through a single primary care physician through whom all care is coordinated. This gatekeeper can minimize the unnecessary rep etition of tests and treatments. However, it should be remembered that the patient may seek care from clinicians in another system, in another city, or even in another state or country. Appointments with the gatekeeper primary care physician should be regular and frequent and not dependent on medical crises. This fosters object constancy while minimizing the patient’s need to induce illness to seek medical attention. As a means of last resort, legal disin centives might be pursued. In Arizona, a woman with factitious disorder was prosecuted for fraudulent procurement of medical, Treat underlying psychiatric disturbances such as Axis I disorders and Axis II disorders. In psychotherapy, address coping strategies and emotional conflicts. Appoint a primary care provider as a gatekeeper for all medical and psychiatric treatment. Consider involving risk management and bioethicists from an early point. Consider appointing a guardian for medical and psychiatric decisions. As a behavioral disincentive, consider prosecution for fraud. Table 19–6. Guidelines for Management and Treatment of Factitious Disorder Keep in mind that active pursuit of a prompt diagnosis can minimize the risk of morbidity and mortality. Minimize harm. Avoid unnecessary tests and procedures, especially if they are invasive. Treat according to clinical judgment, keeping in mind that subjective complaints may be deceptive. Arrange regular interdisciplinary meetings to reduce conflict and splitting among staff. Manage staff countertransference. Consider facilitating healing by using the double-bind technique or face-saving behavioral strategies such as self-hypnosis or biofeedback. Steer the patient toward psychiatric treatment in an empathic, nonconfrontational, face-saving manner. Avoid aggressive direct confrontation.

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