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 a patient's role. Factitious disorder imposed on another ("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 attain (for themselves or for another) a patient's role. Factitious disorder differs fundamentally from malingering in that the malingerer simulates illness with a view to obtaining a material benefit or avoiding an obligation or responsibility.
Münchausen syndrome, a severe form of factitious disorder, was the first kind identified, and was for a period the umbrella term for all such disorders.
People with this condition may produce symptoms by contaminating urine samples, taking hallucinogens, injecting themselves with fecal material to produce an abscess, and other similar behaviour.
They are motivated to perpetrate factitious disorders, either as a patient or by proxy as a caregiver, in order to attain a patient's role. In contrast, somatic symptom disorders, though also diagnoses of exclusion, are characterized by somatic complaints that are not produced intentionally.
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Types
The DSM-5 differentiates among two types:
- Factitious Disorder Imposed on Self
- Factitious Disorder Imposed on Another, defined as:
- When an individual falsifies illness in another, whether that be a child, pet or older adult.
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Motives
The motives of the patient can vary: for a patient with factitious disorder, the primary aim is to obtain sympathy, nurturance, and attention accompanying the sick role. 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. While they are both listed in the DSM-IV-TR, factitious disorder is considered a mental disorder, while malingering is not.
Differential diagnosis
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.
Criteria
Criteria for diagnosis includes intentionally fabricating (or faking) to produce physical or psychological signs or symptoms and the absence of any other mental disorder. Motivation for their behaviour 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.'
Münchausen syndrome
Münchausen syndrome, or factitious disorder with predominantly physical signs and symptoms has specified symptoms. Factitious disorder symptoms may seem exaggerated; individuals undergo major surgery repeatedly, and they 'hospital jump' or migrate to avoid detection.
Münchausen by proxy
The word 'proxy' means 'substitute'. It is coded in the DSM-IV under Factitious Disorder NOS (not otherwise specified). Münchausen 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 Münchausen by proxy, the caregiver actually injures the child or makes it sick to ensure that the child is treated. For instance, a father whose son is coeliac might knowingly introduce gluten into the diet. Such parents may be validated by the attention that they receive from having a sick child.
Ganser syndrome
Ganser syndrome was once considered a separate factitious 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.
Causes
There are many possible causes for this disorder. One such possibility is an underlying personality disorder. Individuals with FD 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 FD 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.
Treatment
No true psychiatric medications are prescribed for factitious disorder. 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 FD, as a mood disorder may be the underlying cause of FD. 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 FD) and that person's need for attention.
In this therapeutic setting, the family is urged not to condone or reward the FD 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 FD. Monitoring is also a form that may be indicated for the FD patient's own good; FD (especially proxy) can be detrimental to an individual's health--if they are, in fact, causing true physiological illnesses. Even faked illnesses/injuries can be dangerous, and might be monitored for fear that unnecessary surgery may subsequently be performed.
Prognosis
Some individuals experience only a few outbreaks of the disorder. However, in most cases, factitious disorder is a chronic and 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 an FD 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 an FD 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.
Historical classification
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
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