In which mental health disorder are physical or psychological symptoms or both fabricated to assume the sick role?

Management of Patients With Factitious Disorders

There are neither easy solutions nor uniformly applicable paradigms for dealing with these difficult patients. Most patients with factitious disorders have a need to be injured or disabled, usually without seeking financial gain. Instead, they may have personality disorders or be seeking attention from a parent, spouse, or family member. Others may have a more obvious source of financial gain if disabled.

It is the hand surgeon's responsibility to recognize these patterns of factitious disease and refer or suggest referral for psychiatric evaluation, if possible. The act of referral itself is a delicate matter that requires a level of trust and frequently family support. This is not always the case. Unfortunately, family members are often unwittingly enabling and abetting the factitious illness and are hostile to the suggestion that there is not an operation or test that will cure the problem. Nonetheless, if possible, it is best to refer these patients to a psychiatrist who is willing to help them. Unfortunately, not all psychiatrists are willing to accept these patients, and finding sympathetic treatment may be extremely difficult.7,8

Editor's note (DPG): Some readers may think it inappropriate to have a chapter on factitious disorders in a book on operative surgery. Everyone would agree that the patients described in this brief chapter are clearly those in whom we should want to avoid operative intervention, but an accurate diagnosis in such patients is not always clearly apparent and virtually never easy to prove. It is precisely because these patients do constitute a pitfall for the unsuspecting hand surgeon that the editors deemed it necessary to include the chapter.

5.27.2.2 Practical Differences Between FD in Children and Adults

FD is a performance typically set in a hospital or clinic, and medical providers are the supporting cast. It is mostly a problem of excessive, unnecessary, or disruptive health care encounters. The people most invested in detecting and managing FD are medical providers who are vexed by the patients' persistent and inscrutable medical problems. Because children and adolescents generally do not orchestrate their own healthcare services, FD in children is more likely to be performed for audiences of parents, teachers, or peers, and played out at home or school. Children and adolescents are less likely to possess the knowledge or means to engage in convincing physical simulation or induction of disease (Libow, 2000), so their falsifications are more likely to involve simple lies or exaggerations about subjective complaints, rather than simulation or induction of medical problems, and these types of falsifications do not leave the type of evidence required to diagnose FD. In contrast to adults with FD, children may not want to go to the doctor for fear that they will be found out; they may do so only at the insistence of a concerned (or perhaps suspicious) parent. For these reasons, FD in children may be particularly likely to go unrecognized.

Another complication raised by the fact that children do not independently seek health care services is the ambiguity over who is driving the excessive health care use and specious medical complaints. The clinical management of dubious illness in children is complicated by the question of whether the illness presentations are independently orchestrated by the child, adventitiously reinforced by the parent, the product of a dysfunctional collaboration driven by the needs of both the parent and the child, or exclusively fabrications of the parent (Libow, 2000, 2002; Sanders, 1995). Cases of puzzling medical problems in infants and toddlers always reflect parental influences (in extreme cases, factitious disorder imposed on another, a.k.a Munchausen syndrome by proxy) and in older teenagers, parental influence may be negligible. However, for youth between the ages of 4 and 16, the role of parents is highly variable, may be highly complex, and presents a clinical challenge.

To sum up, FD is a diagnosis that is based on the observation of unexplained or puzzling medical complaints, and, crucially, the conclusion that they are exaggerated, feigned, or induced for the purpose of deceiving others. The requirement for affirmative proof that the complaints are falsified for the purpose of deceiving others, and the practical difficulty of obtaining that proof, creates the impression that FD is a rare and extreme form of psychological disorder, and disinclines clinicians and researchers from considering the possibility that the motivational processes that maintain FD may operate across the broad spectrum of cases of clinically significant unexplained medical complaints. FD and its defining psychological motivations may be particularly hard to detect in children because of the control over healthcare seeking that is exercised by parents. Understanding the contemporaneous family dynamics is vital in the clinical management of FD cases in children.

Nonpharmacologic Therapy

Two approaches may be considered by the primary physician:

Nonpunitive diagnostic disclosure by the primary physician and a psychiatrist in collaboration. This is sometimes called “confrontation,” but it is not adversarial. A supportive stance should be maintained and an offer for ongoing support and follow-up made.Box E3 summarizes consensus opinions on the treatment of factitious disease. Features of supportive “confrontation” are described inBox E4.

Avoid overt confrontation with patient but provide him or her with a face-saving way to recover. For example, a therapeutic double bind would involve saying, “There are two possibilities here: One is that you have a medical problem that should respond to the next intervention we do, or two, you have a factitious disorder. The outcome will give us the answer.”

Severe cases may be virtually impossible to treat except to avoid further invasive intervention.

BOX E3

Consensus Opinions on the Treatment of Factitious Disease

Achievement of insight should not be the principal early goal of treatment, because it can weaken the patient’s defenses.

One person should have primary responsibility for patient management.

There should be a comprehensive psychiatric evaluation of the patient, including assessment for suicide risk.

All members of a multidisciplinary team should be aware of the psychiatric assessment and treatment plan.

The treatment plan should be individualized.

Comorbid illness should be treated appropriately.

If confrontational techniques are used, they should be nonpunitive and supportive.

BOX E4

Features of Supportive Confrontation

Tell the patient what you suspect without outright accusation.

Support the diagnosis of factitious disease with facts.

Provide empathetic and face-saving comments.∗

Avoid probing to uncover the patient’s underlying feelings and motivations.‡,†

Assure the patient that the physician will not release the diagnosis to others without the patient’s permission unless required to do so by law.‡

Ensure that the staff demonstrates continued acceptance of the patient.

Encourage psychiatric help, but do not force the issue.

Definition

FD is diagnosed in people who consciously and intentionally present themselves as ill or injured when they are not, or who cause themselves to become ill or injured. In the latest version of the Diagnostic and Statistical Manual of Mental Disorders, this disorder is renamed as FD imposed on self (American Psychiatric Association, 2013). According to the DSM, the feigned or induced illnesses or injuries must be produced for psychological reasons. That means there can be no compelling material reward, such as a damage award in a civil suit, or a social security disability claim, that can explain the patient’s sick role enactment.

Principles

Patients may present to the emergency department (ED) with symptoms that are simulated or intentionally produced. The reasons that cause this behavior define two distinct varieties: factitious disorders and malingering.

Factitious disorders are characterized by symptoms or signs that are intentionally produced or feigned by the patient in the absence of apparent external incentives.1,2 Factitious disorders have been present throughout history. In the second century, Galen described Roman patients inducing and feigning vomiting and rectal bleeding.3 Hector Gavin sought to categorize this behavior in 1834.3 These patients constitute approximately 1% of general psychiatric referrals, but this percentage is lower than that seen in emergency medicine because these patients rarely accept psychiatric treatment.1,4 Of patients referred to infectious disease specialists for fever of unknown origin, 9.3% of the disorders are factitious.5 Between 5% and 20% of patients observed in epilepsy clinics have psychogenic seizures, and the number reaches 44% in some primary care settings.6 Among patients submitting kidney stones for analysis, up to 3.5% are fraudulent.7

TheDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies factitious disorders into two types: factitious disorder imposed on self (FDIS) and factitious disorder imposed on another (FDIA).

Munchausen syndrome, the most dramatic and exasperating of the FDIS, was originally described in 1951.8 This fortunately rare syndrome takes its name from Baron Karl F. von Munchausen (1720 to 1797), a revered German military officer and noted raconteur who had his embellished life stories stolen and parodied in a 1785 pamphlet.3 The diagnosis applies to only 10% to 20% of patients with factitious disorders.1,9 Other names applied include the “hospital hobo syndrome” (patients wander from hospital to hospital seeking admission), peregrinating (wandering) problem patients, hospital addict, polysurgical addiction, and hospital vagrant.4,10

FDIA, an especially pernicious variant that involves the simulation or production of factitious disease in children by a parent or caregiver, was first described in 1977.2,11 There are approximately 1200 estimated new cases of FDIA per year in the United States.3 The condition excludes straightforward physical abuse or neglect and simple failure to thrive; mere lying to cover up physical abuse is not FDIA.3,11 The key discriminator is motive: the mother is making the child ill so that she can vicariously assume the sick role with all its benefits. The mortality rate from FDIA is 9% to 31%.12 Children who die are generally younger than 3 years old, and the most frequent causes of death are suffocation and poisoning.13 Permanent disfigurement or permanent impairment of function resulting directly from induced disease or indirectly from invasive procedures, multiple medications, or major surgery occurs in at least 8% of these children.13,14 Other names applied includePolle's syndrome (Polle was a child of Baron Munchausen who died mysteriously),factitious disorder by proxy, pediatric condition falsification, Munchausen syndrome by proxy, andMeadow's syndrome.3,8,10,12

Factitious Disorder with Physical Symptoms

Factitious disorder with physical symptoms involves the intentional production or feigning of physical symptoms. Onset is usually in early adulthood, with successive hospitalizations forming the lifelong pattern. The cause is a psychological need to assume the sick role, and the intentional production of painful symptoms distinguishes factitious disorder from somatoform disorders, in which intention to produce symptoms is absent. Renal colic, orofacial pain, and abdominal pain are three of the common presenting gambits in factitious disorder; of these, abdominal pain and a scarred belly herald the diagnosis most often. Despite the seeming irrationality of the behavior, those with factitious disorder are not psychotic.

Pain may be described as occurring anywhere in the body, and the patient often uses elaborate technical detail to captivate the listener with pseudologia fantastica. Narcotic-seeking behavior, multiple hospitalizations under different names in different cities, inconclusive invasive investigations and surgery, lack of available family, and a suave truculence are characteristic of this disorder. An assiduous inquiry into the exact circumstances of the previous admission and discharge leads to a sudden outraged discharge against medical advice. Typically, there is no effective treatment. If the patient is willing to receive care, however, psychotherapy is the treatment of choice, coupled with addiction treatment when there is underlying opioid abuse or dependence.

FACTITIOUS DISORDERS

Factitious illness is a complicated disorder that is marked by the conscious production of symptoms without clear secondary gain. Unlike malingering, where there is obvious secondary gain, those with factitious disorder are driven to feign illness without obvious direct benefit except to assume the sick role; in fact, they often put their health at considerable risk. They may fake, exaggerate, intentionally worsen, or simply create symptoms. They do not admit to self-harm, but rather hide it from their doctors; herein lies the paradox—those with factitious illness come to health care providers requesting help, but intentionally hide the self-induced cause of their illness. Table 25-1 lists the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for factitious disorder.2 The DSM further describes three subtypes of factitious disorders (depending on predominant signs and symptoms): with predominantly physical signs and symptoms, with predominantly psychological signs and symptoms, and with combined psychological and physical signs and symptoms. Finally, factitious disorders not otherwise specified (NOS) includes the notable example of factitious disorder by proxy (or Münchausen by proxy). Each of these types will be further discussed in the following sections.

Factitious Disorder with Physical Symptoms

Factitious disorder with physical symptoms involves the intentional production or feigning of physical symptoms. Onset is usually in early adulthood with successive hospitalizations forming a life-long pattern. The cause is a psychological need to assume the sick role, and as such, the intentional production of painful symptoms distinguishes factitious disorder from somatoform disorders. Renal colic, orofacial pain, and abdominal pain are three of the common presentations for factitious disorder; of these, abdominal pain and a scarred belly herald the diagnosis most often. Despite the seeming irrationality of the behavior, those with factitious disorder are not psychotic.

Pain may be described as occurring anywhere in the body, and the patient often uses elaborate technical detail to intrigue the listener with pseudologia fantastica. Multiple hospitalizations under different names in different cities, inconclusive invasive investigations and surgery, lack of available family, and a truculent manner are characteristic features of this disorder. Unfortunately, there is no effective treatment.

Malingering and Factitious Disorders

Factitious disorder and malingering are common concerns of clinicians when a diagnosis of FND is being considered [14]. Malingering is where symptoms are feigned for material gain, and factitious disorder is where symptoms are feigned for the purpose of receiving medical attention. These are distinct categories separate from FND. Proving that symptoms are feigned requires evidence of a major discrepancy between reported and observed function (i.e., patients should be able to accurately report what they can and cannot do, even if they are not accurate about reporting how variable their symptoms are). This evidence is rarely obtained and in clinical practice, such patients are likely to be rare. Some clinicians may interpret symptom variability or exaggeration of symptoms as evidence of malingering. Symptom variability can be explained by the amount of attention invested in a movement or action. It may be true that some patients with FND exaggerate symptoms to convince of the need to be taken seriously, but this is different from exaggeration to deceive.

Abstract

The diagnosis of factitious disorder imposed on another (FDIA), popularly known as munchausen syndrome by proxy, describes caregivers who use deceptive tactics to portray and/or induce illness in loved ones. The abuse/neglect associated with FDIA occurs without any obvious external motivation and often goes undetected for years. The effects of FDIA have been known to take an extreme physical and emotional toll on surviving victims. This chapter will shed light on the diagnosis, the ways it can present, how it should be evaluated, and treatment options for caregivers who engage in this most insidious form of child abuse/neglect.