Factitious disorder

Lydia Seifu(psych RI)

Moderator: Dr Alemayehu Negash
MD,Phd,Ass’t professor and consltant
psychiatrist
Factitious means “artificial, false,” from the
Latin facticius, “made by art.”
• The main clinical feature of factitious disorder
is the falsification of physical or psychological
signs or symptoms, or the induction, or
exaggeration of injury or disease.
• Jean-Marie Charcot, around 1890, used the term
mania operativa activa to describe a young girl who
continually sought surgery for pain in a knee joint,
until her medical care-seeking resulted in a surgeon
amputating the leg.
• The DSM-III, in 1980, was the first edition of
the DSM to recognize factitious disorder. It
focused on Munchausen syndrome, calling it
the “prototype” of all factitious disorders.
• Subsequent editions of the DSM increasingly
recognized the rarity of Munchausen
syndrome and placed more emphasis on a
greater spectrum of factitious disorders.
 The DSM-III-R recognized factitious disorder with physical
symptoms and factitious disorder with psychological
symptoms.
• The emphasis on Munchausen syndrome was lessened.
Factitious disorder with combined physical and psychological
symptoms made its appearance under the category of
factitious disorder not otherwise specified (NOS).
 In contrast, the DSM-IV defined a single category, factitious
disorder, with three types: (1) with predominantly
psychological signs and symptoms, (2) with predominantly
physical signs and symptoms, and (3) with combined
psychological and physical signs and symptoms.
• DSM-5 in 2014 introduced several changes to the diagnostic category.
 First, it formally recognized factitious disorder by proxy by dividing the
general category of factitious disorders into two groups:
-factitious disorder imposed on self, and factitious disorder imposed
on another.
-The diagnosis of factitious disorder NOS was eliminated.
 Second, there is no longer a distinction between physical or
psychological presentations. Factitious disorders are now specified as
being a single episode or recurrent episodes.
 Third, the criteria no longer require that illness induction be conscious
or intentional, recognizing the difficulty inherent in making such a
determination. Instead, evidence of deception in the absence of clear
material gain is sufficient to establish factitiousness.
• Some practitioners use the term Munchausen
syndrome for a chronic, severe, refractory
form of factitious disorder, in which deceptive
illness behavior becomes a lifestyle,
precluding stable relationships or
employment.
• Munchausen syndrome comprises
approximately 10 percent of all cases of
factitious disorder.
• Two distinguishing features of Munchausen
syndrome beyond the simulation of disease
are:
 Pseudologia fantastica,the telling of vague,
self-aggrandizing, heroic tales often containing
a kernel of truth and
 Peregrination the tendency to travel widely.
• The prevalence of factitious disorder is
estimated to be 0.8%-1.0% of patients seen
for a psychiatric consult.
• Krahn studied 93 hospitalized patients with
factitious disorder and reported 72% of the
patients to be female, with a mean age of 30.7
years; whereas, the mean age of men was 40
years. The mean age at onset was 25 years for
both sexes.
• Factitious disorder is more prevalent in
females, especially those with health care
training, with a mean age at onset of 25 years
for both sexes.
• Symptoms may develop in childhood as a
desire to receive comfort, attention, and
protection from health care providers to
compensate for a neglectful or abusive home
environment.
• The Baron Karl Friedrich
Hieronymus von Munchausen
(1720–1797) was a nobleman
who served in the Russian army
in the war against Turkey (Fig.
19–1). After retirement, he
entertained friends with
embellished stories of his war
adventures. He was turned into
a literary figure by the author
Rudolph Eric Raspe, a friend of
the baron’s, who fled Germany
for England when caught
embezzling from a museum.
• For many providers, patients with factitious disorder can
be a challenge to treat because the etiology of the
disorder remains unclear.
• There are multiple psychological theories that attempt to
explain the motivation and thought process behind the
voluntary production of symptoms.
• Some of these theories have addressed disruptive
attachments during childhood, possible intergenerational
transfer of the disorder, personal identity conflicts,
somatic illness as a form of masochistic activity toward
oneself, and intrapsychic conflicts.
DISRUPTION IN ATTACHMENTS
• If there are problems in relationships, children may
seek to satisfy their innate need for caregiver
attention by exhibiting illness behaviors.
• In this way, children can satisfy their need for comfort
and protection through the attention of health care
providers who through completing the duties of their
jobs act as substitute caregivers.
• These abnormal illness behaviors may extend into
adolescence and adulthood.
INTERGENERATIONAL TRANSFER
• It is well established that adults who experienced abuse or
neglect as children are more likely to become abusers
themselves.
• Therefore, individuals who develop factitious disorder in
childhood to cope with abuse or neglect may be more likely to
become abusers as adults.
• Through this process of the abused becoming abusers, the
offspring of adults who coped with childhood abuse through
factitious disorder may be at higher risk of becoming victims of
factitious disorder imposed on another (also called
Munchausen syndrome by proxy)
PERSONAL IDENTITY
• Patients with a diagnosis of factitious disorder commonly have
a history of abuse, neglect, and unstable childhood
environments.
• Due to these factors, patients often do not develop a strong
sense of self and suffer from low self-esteem.
• The instability of their childhood results in these patients
experiencing a lack of control over their lives. Hence, patients
fabricate symptoms and their medical histories, which allows
them to feel a sense of control over an aspect of their lives.
• The role of an ill patient also provides these individuals an
identity.
• MASOCHISTIC ATTEMPTS
• Undergoing multiple invasive and possibly
painful diagnostic tests, procedures, and
treatment can be viewed as masochistic
attempts.
• Patients may use these painful measures to
punish themselves in order to cope with guilt
that may exist as part of their psychiatric
comorbidities or history of abuse.
INTRAPSYCHIC DEFENSE
• A psychodynamic approach to factitious disorder is to view it as an
intrapsychic defense, wherein patients feel a sense of importance
when receiving close care for their somatic complaints that can
counter their low self-esteem.
• When patients experience anger or aggression toward others, they
mobilize somatic complaints as a pathway to obtain their attention.
Once help for their somatic complaints is offered by others, these
patients are able to decline it, and in this process, also reduce any
intrapsychic conflict that was caused by the anger. Being ill is also an
effective shield that protects the patient’s ego from guilt that may
arise from not being able to meet expectations at work, in his or her
personal life, or in any other setting.
• Coping deficits are widely noted.
• Many factitious disorder patients seem to come
from large families or to have been neglected as
children. They may have grown up without
consistent nurturing conducive to the development
of mature coping.
• The poor coping skills of these patients are often
symptomatic of an Axis II disorder, such as
borderline, narcissistic, dependent, or antisocial
personality disorder
• Factitious illness behavior often occurs when a
patient experiences a loss such as the death of
a relative or an occupational loss.
• Securing the attention of medical clinicians,
family, and friends may be a way of obtaining
emotional solace without directly confronting
the loss. Dependency and narcissistic needs
are fulfilled.
• Warning signs for health care providers
include:
 patients seeking treatment and testing at
multiple sites
 inconsistent histories, and discrepancies
between patient behavior, symptoms, and
history.
• Factitious symptoms can be
(1) fabricated, for example, by giving a false history of
cancer, acquired immune deficiency syndrome (AIDS),
or another illness
(2) feigned, for example, by faking symptoms such as
pain or seizures
(3) induced, by actively producing symptoms through
selfinfliction of injury or through injection or ingestion
(4) aggravated, such as by manipulating a wound so
that it will not heal.
• Factitious disorders imposed on self and
imposed on another should not be considered
diagnoses of exclusion but should be actively
pursued, given the potentially high stakes,
especially when dependent abuse is suspected.
• Treatment initiation and maintenance are
challenging; however, psychotherapy remains
the first-line treatment for patients with
factitious disorder.
 Treatment and Management

• Three major goals should guide the treatment

and management of factitious disorders:
 To reduce the risk of morbidity and mortality
 To address the underlying emotional needs or
psychiatric diagnosis that may be driving
factitious illness behavior
 To be mindful of legal and ethical issues.
Management of countertransference is a
priority to reduce risk, because a clinician’s
negative feelings can interfere with
appropriate patient care.
Comorbid mental illnesses must be recognized
and treated appropriately.
Comorbid personality disorders are more
common than affective or psychotic disorders.
Borderline personality disorder is the most
common comorbid diagnosis.