Factitious disorder
A factitious disorder is a condition in which a
person, without a malingering motive, acts as if they have
an illness by deliberately producing, feigning,
or exaggerating symptoms, purely to attain (for themselves or for
another) a patient's role. People with a factitious disorder may
produce symptoms by contaminating urine samples,
taking hallucinogens, injecting fecal material to
produce abscesses, and similar behaviour.
Factitious disorder imposed on self (also called Munchausen
syndrome) was for some time the umbrella term for all such
disorders.[1] Factitious disorder imposed on another (also called
Munchausen syndrome by proxy, Munchausen by proxy, or
factitious disorder by proxy) is a condition in which a person
deliberately produces, feigns, or exaggerates the symptoms of
someone in their care. In either case, the perpetrator's motive is
to perpetrate factitious disorders, either as a patient or by proxy
as a caregiver, in order to attain (for themselves or for another) a
patient's role. Malingering differs fundamentally from factitious
disorders in that the malingerer simulates illness intending to
obtain a material benefit or avoid an obligation or
responsibility. Somatic symptom disorders, though also diagnoses
of exclusion, are characterized by physical complaints that are not
produced intentionally.[2]
Causes[edit]
There are many possible causes for this disorder. One such
possibility is an underlying personality disorder. Individuals with
factitious disorder may be trying to repeat a satisfying childhood
relationship with a doctor. Perhaps also an individual has a desire
to deceive or test authority figures. The underlying desire to
resume the role of a patient and be cared for can also be
considered an underlying personality disorder. Abuse, neglect, or
abandonment during childhood are also probable causes.
These individuals may be trying to reenact unresolved issues with
their parents. A history of frequent illnesses may also contribute to
the development of this disorder. In some cases, individuals
afflicted with factitious disorder are accustomed to actually being
sick, and thus return to their previous state to recapture what they
once considered the "norm". Another cause is a history of close
contact with someone (a friend or family member) who had a
severe or chronic condition. The patients found themselves
subconsciously envious of the attention said relation received,
and felt that they themselves faded into the background. Thus
medical attention makes them feel glamorous and special.
Motives[edit]
For a person with factitious disorder, the primary aim is to obtain
sympathy, nurturance, and attention accompanying the sick
role.[1] This is in contrast to malingering, in which the patient
wishes to obtain external gains such as disability payments or to
avoid an unpleasant situation, such as military duty. Factitious
disorder and malingering cannot be diagnosed in the same
patient, and the diagnosis of factitious disorder depends on the
absence of any other psychiatric disorder.[1] While they are both
listed in the DSM-IV-TR, factitious disorder is considered a mental
disorder, while malingering is not.[3]
Diagnosis[edit]
Criteria for diagnosis includes intentionally fabricating to produce
physical or psychological signs or symptoms and the absence of
any other mental disorder. Motivation for their behavior must be to
assume the "sick" role, and they do not act sick for personal gain
as in the case of malingering sentiments. When the individual
applies this pretended sickness to a dependent, for example a
child, it is often referred to as "factitious disorder by proxy".[citation
needed]
The DSM-5 differentiates among two types:
Factitious disorder imposed on self (Munchausen syndrome)
Factitious disorder imposed on another (Munchausen
syndrome by proxy),[4] defined as: When an individual falsifies
illness in another, whether that be a child, pet, or older adult.[5]
Factitious disorder imposed on self[edit]
Factitious disorder imposed on self, previously called
Munchausen syndrome, or factitious disorder with predominantly
physical signs and symptoms,[6][7] has specified symptoms.
Factitious disorder symptoms may seem exaggerated; individuals
undergo major surgery repeatedly, and they "hospital jump" or
migrate to avoid detection.
Factitious disorder imposed on another[edit]
Main article: Factitious disorder imposed on another
Factitious disorder imposed on another, previously Munchausen
syndrome by proxy, is the involuntary use of another individual to
play the patient role. For example, false symptoms are produced
in children by the caregivers or parents, to produce the
appearance of illness, or they may give misleading medical
histories about their children. The parent may falsify the child's
medical history or tamper with laboratory tests to make the child
appear sick. Occasionally, in Munchausen by proxy, the caregiver
actually injures the child or makes them sick to ensure that the
child is treated. For instance, a father whose son has celiac
disease might knowingly introduce gluten into the diet. Such
parents may be validated by the attention that they receive from
having a sick child. The word "proxy" means "substitute".
Ganser syndrome[edit]
Ganser syndrome was once considered a separate factitious
disorder, but is now considered a dissociative disorder. It is a
disorder of extreme stress or an organic condition. The patient
suffers from approximation or giving absurd answers to simple
questions. The syndrome is sometimes diagnosed as merely
malingering—however, it is more often defined as a factitious
disorder. This has been seen in prisoners following solitary
confinement, and the symptoms are consistent in different
prisons, though the patients do not know one another.
Symptoms include a clouding of consciousness, somatic
conversion symptoms, confusion, stress, loss of personal
identity, echolalia, and echopraxia. Individuals also give
approximate answers to simple questions such as, "How many
legs on a cat?" "Three"; "What's the day after Wednesday?"
"Friday"; and so on. The disorder is extraordinarily rare with fewer
than 100 recorded cases. While individuals of all backgrounds
have been reported with the disorder, there is a higher inclination
towards males (75% or more). The average age of those with
Ganser syndrome is 32, though it stretches from ages 15–62
years old.
Differential diagnosis[edit]
Factitious disorder should be distinguished from somatic symptom
disorder (formerly called somatization disorder), in which the
patient is truly experiencing the symptoms and has no intention to
deceive. In conversion disorder (previously called hysteria), a
neurological deficit appears with no organic cause. The patient,
again, is truly experiencing the symptoms and signs and has no
intention to deceive. The differential also includes body
dysmorphic disorder and pain disorder.
Treatment[edit]
No true psychiatric medications are prescribed for factitious
disorder.[citation needed] However, selective serotonin reuptake
inhibitors (SSRIs) can help manage underlying problems.
Medicines such as SSRIs that are used to treat mood
disorders can be used to treat factitious disorder, as a mood
disorder may be the underlying cause of factitious disorder. Some
authors (such as Prior and Gordon 1997) also report good
responses to antipsychotic drugs such as Pimozide. Family
therapy can also help. In such therapy, families are helped to
better understand patients (the individual in the family with
factitious disorder) and that person's need for attention.
In this therapeutic setting, the family is urged not to condone or
reward the factitious disorder individual's behavior. This form of
treatment can be unsuccessful if the family is uncooperative or
displays signs of denial and/or antisocial disorder. Psychotherapy
is another method used to treat the disorder. These sessions
should focus on the psychiatrist's establishing and maintaining a
relationship with the patient. Such a relationship may help to
contain symptoms of factitious disorder. Monitoring is also a form
that may be indicated for the factitious disorder patient's own
good; factitious disorder (especially proxy) can be detrimental to
an individual's health—if they are, in fact, causing true
physiological illnesses. Even faked illnesses and injuries can be
dangerous, and might be monitored for fear that unnecessary
surgery may subsequently be performed.
Prognosis[edit]
Some individuals experience only a few outbreaks of the disorder.
However, in most cases, factitious disorder is a chronic long-term
condition that is difficult to treat. There are relatively few positive
outcomes for this disorder; in fact, treatment provided a lower
percentage of positive outcomes than did treatment of individuals
with obvious psychotic symptoms such as people
with schizophrenia. In addition, many individuals with factitious
disorder do not present for treatment, often insisting their
symptoms are genuine. Some degree of recovery, however, is
possible. The passage of time seems to help the disorder greatly.
There are many possible explanations for this occurrence,
although none are currently considered definitive. It may be that a
factitious disorder individual has mastered the art of feigning
sickness over so many years of practice that the disorder can no
longer be discerned. Another hypothesis is that many times a
factitious disorder individual is placed in a home, or experiences
health issues that are not self-induced or feigned. In this way, the
problem with obtaining the "patient" status is resolved because
symptoms arise without any effort on the part of the individual.
History[edit]
Previously, the DSM-IV differentiated among three types:
Factitious disorders with predominantly psychological signs
and symptoms: if psychological signs and symptoms
predominate in the clinical presentation
Factitious disorders with predominantly physical signs and
symptoms: if physical signs and symptoms predominate in the
clinical presentation
Factitious disorders with combined psychological and physical
signs and symptoms: if both psychological and physical signs
and symptoms are present and neither predominates in the
clinical presentation[8]
