Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e


Chapter 19. Factitious Disorder

disorder is the most common comorbid diagnosis. Antisocial personality traits are also common, especially in patients exhib iting pseudologica fantastica and Munchausen syndrome. Phar macologic and psychotherapeutic treatments should be employed according to the diagnosis. Substance abuse and dependence may require intensive outpatient or residential inpatient treatment. Other than targeting comorbid psychiatric disorders, there is no standard pharmacologic treatment for factitious disorder. Once in psychiatric treatment, the greatest challenge is get ting the patient to engage and commit to long-term therapy. Brief regularly scheduled contact on a time-contingent rather than a distress-contingent basis is the mainstay of therapy. Consistent long-term psychotherapy is aimed at enabling patients to express their feelings, gain insight and coping skills, and provide a reliable and supportive outlet for communication. Relapses of factitious behavior should be expected, just as with substance abuse. Clinicians should not despair at relapses but instead, take them as opportunities to further understand the patient. For example, if a patient has a pattern of relapsing under conditions of new romantic involvements or arguments with authority figures, this provides insight into the patient’s vulner abilities and may be addressed in psychotherapy. 3. Managing legal and ethical issues: Early involvement of risk management experts and bioethicists is prudent in the care of factitious disorder patients. Patients’ right to privacy and implicit injunctions against unwarranted searches and seizures are major issues. The once-common practice of alerting all emergency rooms about factitious disorder patients is no longer routinely utilized because of heightened sensitivity about confidential ity rights. Nevertheless, this kind of widespread alerting can be done with the consent of the patient. For example, once a patient acknowledges having factitious disorder, the patient can be asked, “I’d like to minimize harm to you. Can I have your permission to alert emergency rooms and some doctors in the community?” Similarly, the patient’s right to confidentiality should be respected when gathering collateral information in nonemer gent situations. Verbal permission or, preferably, signed releases of information should be obtained prior to contacting collat eral sources, except in emergency situations. Clinicians should be careful about revealing information to the patient’s employ ers, friends, or family. The diagnosis of factitious disorder must never be revealed, even to spouses or significant others, without a patient’s explicit permission, as this will likely lead to accusations of a confidentiality breach. Searching a patient’s hospital room or personal belongings for illness-inducing means may facilitate diagnosis and lessen morbidity, but this should only be done after consulting with risk management or other legal counsel because it goes beyond the contractual and fiduciary bounds of the doctor– patient relationship. Covert surveillance should only be under taken after careful legal consultation. It should also be kept in mind that simply because an action is legal, it is not necessarily ethical. Therefore, the involvement of bioethicists can be helpful. Factitious Disorder Imposed on Another Protection of the victim is the first priority. Active pursuit of the diagnosis and then prompt intervention is essential for minimizing the risk of morbidity and mortality to the victim, who is usually a vulnerable child, as over 50% of reported cases described ongoing induction of illness in the hospital setting. Because young children are the most commonly victimized, Table 19–7 will prioritize the management of pediatric factitious disorder imposed on another.

psychiatric, and dental services: she pled guilty. Laws in several states specifically address this type of action. 2. Addressing psychiatric issues: Allowing the patient to save face is essential toward establishing a therapeutic alliance and toward preventing the patient from simply taking the factitious illness behavior elsewhere. This is especially true because factitious dis order patients usually have immature personalities or personal ity disorders that make them especially sensitive to narcissistic injury. Direct or aggressive confrontation is generally not effec tive. The patient usually responds with anger and denial and may leave the hospital against medical advice, only to perpetuate their factitious illness behavior elsewhere. This kind of confrontation may amplify the patient’s psychological need for mastery through deception. Clinicians should keep in mind that confession is not a necessary aspect of management or treatment. Several behavioral strategies have been successfully used to facilitate the healing of factitiously produced symptoms in face saving ways. Eisendrath advocated a double-bind technique whereby patients are told that if the symptoms are genuine, then they should improve with the treatment administered. If the symp toms do not improve, then they must be factitious. This technique can be used with nonhealing wounds, factitious paralysis, or psy chological factitious symptoms that should improve with medi cations. For example, factitious patients who chronically induce or worsen wounds can be informed, “This treatment should heal your wound. If it doesn’t, we have no choice but to conclude that this is due to a factitious disorder.” Self-hypnosis and biofeedback can allow a patient to relin quish factitious behavior in a face-saving manner. For example, a patient can be told that under self-hypnosis, blood flow to a wound can be increased and healing promoted. In this manner, the patient can take control of healing the wound rather than seek control by worsening symptoms. Positive feedback should be given to patients when their efforts result in healing. Biofeedback can be used in a similar way. Once factitious disorder is confirmed, or evidence is deemed sufficient, the patient should be gently and artfully steered toward ongoing psychiatric treatment in a sympathetic manner acceptable to the patient. For example, the patient can be told that their fac titious illness behavior is an expression of great emotional need or distress. The clinician can make empathic statements about the neglect, abuse, or trauma that the patient may have undergone. The patient should then be engaged in care in a psychiatric setting in which underlying emotional issues can be addressed and where the risk of morbidity and mortality is substantially less than in a medi cal setting. Because these patients may crave to be understood and to have their emotional needs recognized, this type of sympathetic confrontation that focuses on addressing the patient’s genuine rather than factitious needs can be well accepted by patients. Psychiatric treatment should first focus on underlying or comorbid psychiatric disorders or on the emotional distress that might have precipitated the factitious illness behavior. Comorbid mental illnesses must be recognized and treated appropriately. For example, most cases of feigned bereavement are comorbid with major depression. One patient claimed to have feigned bereavement to justify depression. Another falsely claimed to have been recently raped and sought help for post traumatic stress disorder. Although she was not recently raped, she had suffered longstanding childhood sexual abuse. Feigned mental illnesses may express an emotional truth for the patient, if not factual truth. Comorbid personality disorders are more com mon than affective or psychotic disorders. Borderline personality

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