Factitious DisordersFactitious DisordersFactitious DisordersFactitious DisordersMotivation for Behavior -- sick roleMotivation for Behavior -- sick role

External incentives for behavior -- absentExternal incentives for behavior -- absent

Essential Features• Intentional production of

symptoms • Judgment of

internationality – Direct evidence– Exclusion of other causes

• Behavior:– “voluntary”

• Act is intentional– “not voluntary”

• Usually cannot be controlled/compulsive quality

• Even while knowing dangers

• Presumed goal of behavior– Assume sick role as

opposed to Malingering• Goal of Malingering

– Assume sick role to accomplish externally recognizable goal (compensation, avoid jail or military duty)

• In both disorders “intentionality”

• In Malingering, symptoms stopped when not useful

Other Features• Presence of factitious symptoms

– does not preclude true physical or psychological symptoms

• Diagnosis always implies psychopathology• Frequently with predominately

psychological symptom type– a severe personality disturbance is predisposing

factor

Making A Diagnosis• Core concept is attempt, through

deception, to feign physical or emotional illness in order to assume role of patient

• Any mental disorder better accounting for deceptive behavior takes precedence

Consider the Following:• Many patients elaborate

illness & exaggerate symptoms – but no overt deception with

non-existent illness• Conscious & intentional

faking medical condition– for sole patient role

• No certain method of detecting feigned illness

• Discovery results– by patient mistake or – staff suspicion of

inconsistencies

• Symptoms may disappear– under constant observation or

when no access to personal belongings

• Is there?– excessive knowledge of

symptoms & – suggestions of medical tests

• Are psychiatric symptoms unresponsive to standard treatment?

• Patient is vague or lies about history

• Patient becomes abusive, accusatory of incompetence, or abruptly leaves hospital when suspicion arises.

Other Important Clues• History of previous inconclusive

hospitalizations• Multiple surgical scars especially

on abdomen• History of serious illness as child• Fever present without other

evidence of active disease

Confrontation of Patient

• Team effort needed• Only after a social/psychiatric care

plan can be arranged• Generally direct confrontation

(esp. if premature) is met with– denial, anger & outrage– & a quick departure from medical

setting

Munchausen Syndrome by Proxy (MSP)

• Sick role by proxy– Victim usually child

• Behaviors to get into or stay in hospital

• Describes children whose caretakers (generally mothers) invent false illness

• Substantiated by fabricated evidence

• Usually involves emotional abuse & sometimes severe physical abuse – (usually in 1st 2 yrs. of

child’s life)– Often undetected

form of child abuse

• May indicate intense & symbiotic relationship with mother

Associated Features• With psychological symptoms – severe

character pathology almost always present– Secret use of psychoactive substances may

allow production of mental disorder

• With physical symptoms – psychoactive substance abuse is common– Severe character pathology is invariably

present

Prevalence Course• More common in

males• Relatively rare (1982

– only 100 cases in 80 yrs)

• Factitious by Proxy– Usually females

• May be limited to 1 episodes

• Onset usually early adulthood– often after hospitalization

• Usually short-lived & complete recovery– Often “spontaneous

recovery” • Chronic form of

successive hospitalizations – may become lifelong

pattern

Cost of Factitious Disorder

• Extremely high due to number of tests to rule out & make accurate diagnosis

• Individual my flee hospital without paying

Treatment• No established treatment of choice

– Closed ward to prevent leaving or avoiding treatment

• Patients rarely seen due to lack of motivation– Might appear due to family pressure

• Due to outrage unlikely to engage in meaningful treatment

Treatment Options• Comprehensive diagnostic evaluation

– to identify & treat associated disorders• Concentrate on therapeutic relationship

– to help recognize psychological basis – May motivate healthy mental state vs. sick role status

• May remain in treatment if attention to feigned complaints & dependency needs

• Look at severe external stressors• Behavior modification successful

– with long term (3 yrs) hospitalization• Reality therapy

– demonstrates behavior not meeting needs – development of more rewarding ways to operate

• Medication – no role yet established– Could justify with associated psychiatric disorder– Anticipate non-compliance– Potential for substance abuse

Other Options for Treatment

• Diagnosis of Munchausen’s Syndrome• May facilitate next physician• Publish Blacklist

– Central register or International Rogues Gallery

• Encourage adoption of “pseudo-factitious” behaviors – to satisfy psychological needs while avoiding risky

behaviors as surgery

• Abdominal scars easily removed with soap & water• Imprison for unremitted hospital expenses• Tattoo diagnosis on abdomen to alert next

physician