Factitious Disorder Not Otherwise Specified
This category is reserved for forms of factitious disorder that do not fit one of the other categories. It includes the Munchausen syndrome by proxy, in which one person surreptitiously induces disease or reports disease in another person. Most commonly, this is the behavior of a mother in reference to a young child.
Factitious illnesses have been known since the Roman era and were described in Galen's textbook of medicine. Modern interest in this surreptitious production of symptoms presented to physicians was spurred by Ashers 1951 description and naming of “The Munchausen Syndrome;” subsequently over 2000 articles in professional journals have described, and tried to explain, this perverse form of illness behavior.
The true incidence of factitious illness behavior is unknown but is probably more common than is recognized. One Canadian study estimated that approximately 1 in 1000 hospital admissions is for factitious disease. However, another investigation of an entirely different type determined that approximately 3.5% of renal stones submitted for chemical analysis were bogus and represented apparent attempts to deceive the physician. A study of patients referred with fever of unknown origin to the National Institutes of Health found that almost 10% had a factitious fever. One can conclude that the incidence of factitious disorder, except in certain specialized clinical settings, is relatively uncommon but may be more frequent than is recognized.
Age and gender distribution varies according to the clinical syndromes described in the next section. Patients with the full-blown Munchausen syndrome are most frequently unmarried middle-aged men who are estranged from their families. Patients with common factitious disorder are most likely to be unmarried women in their 20 s or 30 s who work in health-service jobs such as nursing. Perpetrators of the Munchausen syndrome by proxy are most often mothers of small children who themselves may have previously engaged in factitious disease behavior or meet the criteria for somatization disorder.
Explanations for the apparently nonsensical and bizarre behavior of factitious disorder are largely speculative. Underlying motivations for this behavior are probably heterogeneous and multidetermined. The following explanations have been suggested:
The Search for Nurturance
Individuals in the sick role are characteristically excused from societal obligations and cared for by others. When alternative sources of care, support, and nurturance are lacking, a person may deliberately induce illness as a way of seeking such support. Many patients with factitious disorder are themselves caretakers. Factitious illness behavior allows for a reversal of roles: instead of caring for others, the patient assumes the dependent cared-for role.
Patients with factitious disorders sometimes use illness to obtain disability benefits or release from usual obligations such as working. Their illnesses may elicit from family members attention that might not otherwise be forthcoming. When litigation is involved, the boundary between factitious disorder and malingering becomes blurred or disappears.
The Need for Power & Superiority
A person who successfully perpetuates a ruse may have a feeling of superiority in his or her capacity to fool others. This has been described as “putting one over” or “duping delight.” Thus, the individual can experience a transformation from feeling weak and impotent to feeling clever and powerful over others. Simultaneously the individual may devalue others whom he or she regards as stupid or foolish because they have been deceived.
Some patients have used factitious illness to obtain drugs. Even those patients who have sought controlled substances appear to have done so more for the thrill of fooling the physician than because of addiction.
To Create a Sense of Identity
A patient with severe characterological defects may have a poor sense of self. The creation of the sick role and the associated pseudologia fantastica (pathologic lying) may provide the patient with a role by which his or her personal identity is established. Such a person is no longer faceless but rather the star player in high drama.
To Defend Against Severe Anxiety or Psychosis
A patient with overwhelming anxiety due to fears of abandonment or powerlessness may use a factitious illness to defend against psychological decompensation. Through the perpetuation of a successful fraud and the simultaneous gratification of dependency needs, the patient feels powerful, in control, and cared for.
No information is available regarding a relationship between factitious disorders and heredity.
DSM-IV-TR diagnostic criteria do not adequately describe the different clinical syndromes of persons who present with factitious disorder. Three major syndromes have been identified, although some overlap may exist.
Munchausen Syndrome (Peregrinating Factitious Disorder)
The original Munchausen syndrome, as first described by Asher in 1951, consists of the simulation of disease, pseudologia fantastica, and peregrination (wandering). Some patients with this disorder have achieved great notoriety. These patients typically present to emergency rooms at night or on the weekends when they are more likely to encounter inexperienced clinicians and when insurance offices are more likely to be closed. Their symptoms are often dramatic and indicate the need for immediate hospitalization. Once hospitalized, they become “star patients” because of their dramatic symptoms, the rarity of their apparent diagnosis (e.g., intermittent Mediterranean fever), or because of the stories that they tell about themselves (e.g., tales of being a foreign university president or a former major league baseball player). These patients confuse physicians because of inconsistencies in their physical and laboratory findings and because of their failure to respond to standard therapeutic measures. They rarely receive visitors, and it is difficult to obtain information concerning prior hospitalizations; their frequent use of aliases makes it difficult to track them. When confronted with their factitious illness behavior, they often become angry, threaten to sue, and sign out of the hospital against medical advice. They then travel to another hospital, where they once again perpetuate their ruses.
Personal historical information about Munchausen syndrome patients is limited because they are unreliable historians and are reluctant to divulge accurate personal information. What is known may be somewhat selective in that it is derived from a subgroup of patients who have allowed themselves to be studied. These individuals often come from chaotic, stressful childhood homes. They sometimes report that they were institutionalized or hospitalized during childhood, experiences that were not regarded as frightening but rather were considered a reprieve from stress at home. Childhood neuropathic traits (e.g., lying or fire setting) are often reported. Many of these patients have worked in health-related fields (e.g., as a hospital corpsman in the military). Many have a history of psychiatric hospitalization and legal difficulties.
Common Factitious Disorder (Non-Peregrinating)
The most common form of factitious disorder is common factitious disorder. Disease presentations may involve dermatologic conditions from self-inflicted injuries or infections, blood dyscrasia from the surreptitious use of dicumarol or self-phlebotomy, hypoglycemia from the surreptitious use of insulin, and other diseases. The patient generally has one primary symptom or finding (e.g., anemia) and is characteristically hospitalized on multiple occasions, but the physician or hospital staff never learns the true nature of the underlying “disease.” In the process of their hospitalizations, these patients become the object of considerable concern from physicians, colleagues, and family members, with whom they typically have conflicted relationships.
Patients with common factitious disorder often lie, exaggerate, and distort the truth but not to the same extent, or with the degree of fantasy, as those with the Munchausen syndrome. Patients with common factitious disorder may perpetuate the ruse for years before being discovered. Unmasked, these patients typically react with hostility, eliciting angry disbelief from treating physicians, nurses, and other staff. Even in the face of incontrovertible evidence, these patients often continue to deny the true nature of their problems.
Patients with common factitious disorder typically come from dysfunctional families and exhibit histrionic or borderline personality characteristics.
Munchausen Syndrome by Proxy
This invidious disorder, in which a mother produces disease in her child, was first described in 1978. Subsequently, hundreds of case reports from all over the world have confirmed this form of child abuse. Every major children's hospital will see several cases per year.
In the Munchausen syndrome by proxy, the perpetrator (usually the mother) presents a child (usually an infant) for medical treatment of either simulated or factitiously produced disease. For example, the child may have collapsed after the mother surreptitiously administered laxatives or other medications, or the child may have experienced repeated attacks of apnea secondary to suffocation (e.g., by pinching the nostrils). After the child has been hospitalized, the mother is intensely involved in her child's care and with the ward staff. Interestingly, the mother is surprisingly willing to sign consent forms for invasive diagnostic procedures or treatment. The child may inexplicably improve when the mother is out of the hospital for a period of time. The child's father is usually uninvolved or absent.
When the mother is confronted with suspicions (or proof) that she has caused the child's illness, she often reacts with angry denial and hospital staff may also express disbelief. Reasonable suspicion of Munchausen syndrome by proxy mandates reporting, as a form of child abuse, to the appropriate child protective services. Children who have been victims of Munchausen syndrome by proxy have a high mortality rate (almost 10% die before reaching adulthood). Studies of their siblings show a similarly high mortality rate because this disease-producing behavior may be perpetrated on subsequent children. These children may need to be placed outside the home (e.g., with other relatives or in a foster-care setting).
Psychological test results of Munchausen syndrome patients reflect severe characterological problems often of the sociopathic, narcissistic, or histrionic type. Approximately 30% of Munchausen syndrome patients have some form of cerebral dysfunction. This dysfunction is most commonly demonstrated by the patient's verbal IQ score being significantly greater than his or her performance IQ score, a finding possibly related to pseudologia fantastica.
Test results of patients with common factitious disorder are consistent with histrionic or borderline personality traits, somatic preoccupation, and conflicts about sexuality.
Test results of the perpetrators of Munchausen syndrome by proxy may reflect personality disorders (e.g., narcissistic) and concurrent Axis I disorders (e.g., major depression). Frequently they demonstrate no clear-cut abnormality.
Laboratory testing may disclose inconsistent findings, not typical of known physical diseases (e.g., the pattern of hypokalemia that occurs with surreptitious ingestion of diuretics). The presence of toxins or medications, the use of which the patient denies, may establish the diagnosis of factitious disease behavior. For example, phenolphthalein may be present in the stool of a baby who is experiencing diarrhea as a result of Munchausen syndrome by proxy.
No neuroimaging studies have been reported specifically for factitious disorder. However, in view of the extensive lying in which these persons engage and some similarities to malingering, it would be reasonable to expect similarities to findings with lying/malingering (see below).
The deceptive nature of persons with factitious illness behavior precludes good data concerning either the course of the disease or the prognosis. We do know that some patients with common factitious disorder may persist in their symptom production for years. They may give it up spontaneous or perhaps after being “caught” and confronted. Persons with Munchausen syndrome may perpetrate their simulation of disease for decades, often traveling widely and using aliases to make tracking more difficult. Some patients die as a result of miscalculations in their illness productions. Other patients trade the drama of the hospital for the drama of the courtroom and sue physicians for causing the very disease that the patient him/herself created (e.g., suing a surgeon for postoperative infections that were self-induced).
Differential Diagnosis (Including Comorbidity)
As with all somatizing disorders, the diagnosis of factitious disorders involves ruling out the presence of a genuine disease process. Patients with factitious disorder often have physical disease, but the disease is the result of deliberate and surreptitious behavior such as self-phlebotomy. Occasionally, a patient with a genuine physical disease (e.g., diabetes mellitus) will learn how to manipulate symptoms and findings in such a way as to create a combination of physical disease and factitious disorder. In such cases, both the disease process and the behavior will require therapeutic attention.
Factitious disorder must also be distinguished from malingering; the difference here is one of motivation. The person with malingering has a definable external goal that motivates the behavior, such as disability payments from an insurance company, whereas with factitious disorders, the patient's goal is to seek the sick role for the psychological needs it fulfills. Malingering and factitious disorders often overlap.
Patients with factitious disorders may also meet the criteria for other somatoform disorders, particularly somatization disorder or other Axis I disorders such as major depression or, more rarely, schizophrenia. Most patients with factitious disorders are comorbid for one of the cluster B personality disorders (i.e., antisocial, borderline, histrionic, narcissistic).
Therapeutic approaches to factitious disorder must be different from those used to treat specific disease states. A factitious disorder represents disordered behavior that is determined by widely varied and often multiple motivations. The clinician must evaluate and develop a separate treatment plan for each patient. Further, because factitious behavior is often associated with severe personality disorders the clinician must avoid splitting and other manipulative behaviors by the patient. Thus, a multidisciplinary management strategy involving attorneys, nurses, social workers, and other professionals is essential. Unfortunately, for many patients with factitious disorder, the goal must be to contain symptoms and avoid unnecessary and expensive medical care rather than to effect a cure.
There are no pharmacologic treatments that are specific for factitious diseases.
The overwhelming majority of patients with factitious illness have severe underlying personality disorders. Despite their superficial confidence and, at times, braggadocio, these patients are fragile. They are not candidates for confrontative insight-oriented psychotherapy and may decompensate in such treatment. The techniques described in this section are suggested for use by either psychiatrists or other members of the medical treatment team as indicated. Many patients completely reject any psychiatric treatment, and therapeutic efforts must be made by nonpsychiatric personnel.
Psychotherapy needs to be supportive, empathic, and nonconfrontative. At times just “being there” and allowing the patient to talk, even if much of the talk consists of pseudologia fantastica, provides sufficient support for the patient to no longer have the immediate need to engage in factitious illness behavior. Such treatment is not curative but helps prevent further iatrogenic complications and high medical utilization.
At times the patient will discard the symptom if he or she does not need to admit the behavior. For example, the patient may be told that the problem will resolve with physical therapy, medications, or other treatment techniques. The patient may use such an opportunity to discard symptoms in a face-saving manner and behavior without ever overtly acknowledging culpability for factitious illness behavior.
Insight-oriented psychotherapy is almost always contraindicated. However, it may be useful to make interpretations without direct confrontation. For example, a patient whose factitious illness behavior is tied to losses or separation might be told in a very general way that it seems that he or she has difficulty in dealing with disappointments in life.
The patient who is suspected of factitious illness behavior might be told that such suspicions exist—and that if symptoms fail to respond to a proposed treatment then such a failure would be confirmation of factitious illness. Although this technique may be symptomatically effective, there are obvious questions as to its ethical appropriateness. For example, is it ethical to lie to a lying patient in order to effect change?
Patients with simple factitious disorder often come from dysfunctional families and are experiencing current conflicted interpersonal relationships. The patient's factitious illness behavior may be a way of controlling or manipulating the family in order to obtain a sense of power or gratification of dependency needs. Family therapy may be one way to address distorted communications in the family and provide for the more appropriate expression of needs.
When factitious disorder is suspected, the treating physician must recruit a multidisciplinary task force to assist with ethics and management. Such a task force, and associated staff meetings, educate all health care personnel as to the nature of the disorder, facilitate communication in such a manner as to defuse attempts by the patient to split staff, and ensure a united front for treatment. The multidisciplinary task force might include hospital administrators, the hospital attorney, a chaplain or ethicist, the patient's primary physician, a psychiatrist, and representatives from the nursing staff. Although this degree of involvement may seem like overkill, it is necessary in order to anticipate medicolegal complications.
When factitious disorder is suspected or has been confirmed, the medical staff must confront the patient. Such confrontation is generally best accomplished with several of the multidisciplinary staff members present. The staff should communicate to the patient that they know he or she has been surreptitiously producing or simulating the disease and that such behavior is indicative of internal distress. The staff should suggest to the patient that it is time to reformulate the illness from a physical disease to a psychological disorder. The patient should be told that the treatment team is concerned and that appropriate help and treatment can be made available. Despite such a supportive approach, many patients will continue to deny that they have contributed to their illness and will angrily reject any referral for psychological help.
Treatment of Comorbid Disorders
Patients must be evaluated carefully for comorbid psychiatric disorders such as major depression or schizophrenia. The presence of another Axis I disorder is relatively uncommon but when present must be treated before proceeding with psychotherapy and other management.
Treatment Issues in Munchausen Syndrome by Proxy
When the victim of Munchausen syndrome by proxy is a child, it may be necessary to place the child in foster care in order to protect his or her health and life. The child will require supportive psychological assistance to deal with separation from the parent and changes in his or her environment.
Perpetrators of Munchausen syndrome by proxy, usually mothers, generally have severe personality disorders, which are very difficult to treat. This is especially true when the perpetrator continues to deny her behavior. Many psychiatrists believe that return of the child to the mother must depend on the mother's acknowledgment of her behavior, the requirement that she stop it, and her recognition of the needs and rights of the child. These mothers may have severe narcissistic personality disorder. They may view others merely as objects to be manipulated rather than as separate persons with feelings, needs, and rights. When there is a history of an unexplained death of a sibling, extra care must be taken to ensure the safety of the child.
Ethical & Medicolegal Issues
Many ethical and medicolegal issues are raised in treating factitious disorders. Some physicians may believe that because patients with these disorders are liars, they can treat them in a cavalier manner. The following discussion demonstrates that this is not the case.
Because a patient with factitious disorder has presented himself or herself to the physician fraudulently, violating the traditional doctor-patient relationship, a legitimate question can be raised as to whether this invalidates the physician's obligation of confidentiality. To what extent should such an individual be allowed to perpetuate fraud, as it may affect family members, friends, and other physicians? This question is not easily answered, but from a medicolegal standpoint any violation of confidentiality must be in the interest of protecting the patient's health or significantly reducing the damage to others. Such violations should not occur capriciously but only after careful consideration and consultation with the multidisciplinary task force.
Surreptitious Room Searches
The medical literature on factitious disorders contains multiple descriptions of searches of patients' rooms after they have been sent off for testing or for other reasons. Syringes and other paraphernalia may have been found, thereby confirming the diagnosis. Such searches, however, violate patients' civil rights and should be undertaken only after careful consideration and consultation with the multidisciplinary task force.
Withdrawal of Medical Care
The physician who finds that he or she has been the object of the fraudulent seeking of medical care is likely to react with anger and possibly rejection. The expenditure of professional time and the use of scarce medical supplies for patients with factitious disorders may be questioned. However, an analogy can be drawn to the question of whether medical care should be withdrawn from a patient with liver cirrhosis who continues to drink alcohol or from a patient with emphysema who continues to smoke cigarettes. The point at which one starts to enter the “slippery slope” is always an issue for debate. Medical care should be withdrawn only after careful consideration of the medicolegal ramifications.
Involuntary Psychiatric Treatment
Many patients with factitious disorder engage in self-injurious behavior that could permanently affect body function or cause death. Involuntary psychiatric treatment has been suggested but is generally rejected by the courts. In one case, a judge provided an “outpatient commitment” for a patient and ordered that all of her (publicly funded) medical care be coordinated by a guardian. Such an approach seems eminently reasonable, but it may be difficult to effect in many states, especially if the patient is covered by private insurance.
On the surface, one might ask how or why a patient might ever initiate a malpractice lawsuit against a physician when the patient is responsible for the medical illness. Such lawsuits, however, have occurred and can emerge in one of two different forms. One form of lawsuit can occur because many of these patients have severe borderline personality disorder. Such individuals are likely to idealize a physician initially and then later devalue him or her. With such devaluation comes rage and a resort to malpractice suits as a way of inflicting injury. The lay people who comprise juries are not knowledgeable about factitious disorders and may side with the patient.
Another form of lawsuit can occur when the patient admits factitious disorder and sues the physician for failure to recognize it. In other words, “I was lying to you, but this is a recognized medical illness, and you were incompetent not to have recognized my fraudulent behavior.” One such lawsuit was settled out of court with a payment to the patient.
If the health of another individual is involved (particularly that of a child), the clinician is legally required to report his or her suspicions to the appropriate authorities. In the case of children, this is a legal requirement equivalent to that of reporting any suspected child abuse. Insofar as the report is made in good faith, the physician is exempt from prosecution for the violation of confidentiality.
Complications/Adverse Outcomes of Treatment
Patients with factitious disorder have a remarkable ability to obtain hospitalization and to be treated with invasive procedures. As a result, these patients often experience unnecessary operations such as nephrectomies and even pancreatectomies. They are at risk for a number of iatrogenic complications, and physicians may contribute to drug dependence. Hundreds of thousands of dollars, millions in some cases, may be spent in the diagnosis and treatment of surreptitious and self-induced illness. The physician is also at risk. When angered, patients with these disorders may initiate lawsuits and, at the very least, will generally create disarray and dissension among their medical caretakers.
For the victim of the Munchausen syndrome by proxy, the clinician's failure to recognize the disorder or to take decisive action may result in continued medical treatment, medical complications, or even death.
Relatively little is known about the long-term outcome of factitious disorder. Some patients die as a result of their factitious illness behavior, and others experience severe medical complications including the loss of organs (e.g., pancreas or kidney) or limbs. If the factitious disorder is the outgrowth of, for example, a psychotic depression, the prognosis is better than if the factitious illness results from severe personality disorder, as is usually the case. Although there are reports of successful psychotherapeutic intervention with some patients, there is no evidence of continued remission on follow-up. Munchausen syndrome appears to be relatively refractory to treatment, although the ultimate outcome for most of these patients is unknown. When confronted, some patients with common factitious disorder enter psychotherapy and appear to improve and demonstrate fewer symptoms. Some patients deny their illness and merely change physicians, continuing their factitious illness behavior elsewhere; other patients deny their illness but apparently cease their behavior after being confronted with it.
The long-term prognosis of Munchausen syndrome by proxy is not encouraging. Victims have a high mortality rate during childhood, and those who survive childhood may develop somatoform disorders or factitious disorders upon reaching adulthood. Because this is a recently recognized disorder, long-term follow-up information is not yet available.
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