25: Factitious Disorders and Malingering

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CHAPTER 25 Factitious Disorders and Malingering

OVERVIEW

Factitious disorders and malingering both involve voluntary symptom production and deception of medical providers. In this light, Ford has combined these two disorders under the heading of deception syndromes.1 The deceptive nature often angers medical providers, making these patients some of the most memorable seen in our careers. The thought of a patient with an infection that requires multiple diagnostic studies and broad-spectrum antibiotics, only to be seen self-injecting feces into various body parts, seems incredulous to most. The motivation is often difficult to comprehend, but it separates the two diagnoses. In factitious disorder the motivation centers around assuming the sick role. Malingerers, on the other hand, are motivated by a clear external secondary gain (often legal or financial). The deceptive nature and the difficulty confirming the diagnosis make each of these difficult to study; thus, prevalence rates are less than reliable. The potential subjective nature of determining the motivation (which is often murky at best) further complicates matters. It seems clear, however, that the disruption caused by these patients to themselves and to the larger medical system is significant and merits further discussion in this chapter.

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.

Table 25-1 DSM-IV-TR Criteria for Factitious Disorder

Criterion A Intentional production of physical or psychological signs or symptoms:
  Fabrication of subjective complaints (e.g., acute abdominal pain)
  Falsification of objective signs (e.g., manipulating a thermometer)
  Self-inflicted conditions (e.g., production of an abscess by injecting saliva)
  Exaggeration or exacerbation of preexisting condition (e.g., feigning grand mal seizures by an individual with a seizure disorder)
  Any combination of the above
Criterion B Motivation for this behavior is to assume the sick role
Criterion C External incentives (e.g., economic, legal, and drug seeking) are absent

FACTITIOUS DISORDER WITH PHYSICAL SIGNS AND SYMPTOMS

In factitious disorder with predominantly physical signs and symptoms, the common presentation is that of a general medical condition. Examples of faked clinical problems run the gamut from fever, bleeding, hypoglycemia, and seizures to more elaborate productions, including cancers and infection with the human immunodeficiency virus (HIV).36 While the term Münchausen syndrome is often used interchangeably with the physical type of factitious disorder, the classic Münchausen syndrome is reserved for the most severe and chronic form of the disorder, which is marked by the following three components: recurrent hospitalizations, travel from hospital to hospital (peregrination), and pseudologia fantastica.7 Pseudologia fantastica is the production of intricate and colorful stories or fantasies associated with the patient’s presentation. It is a form of pathological lying characterized by overlapping fact and fiction, with a repetitive quality, and often with grandiosity or assumption of the victim role by the storyteller.1 In some cases, it may be difficult to determine whether these lies are actually delusions or conscious deceptions. Münchausen patients often make a career out of their illness. Serial hospitalizations make employment or sustained interpersonal relationships impossible. Moreover, patients who produce significant self-trauma or develop untoward complications from medical or surgical interventions become further incapacitated. The prognosis is generally poor in these cases, and patients may die prematurely from complications of their own self-injurious behavior or from iatrogenesis.

Clinical Features

While Münchausen syndrome is the most dramatic form of factitious illness, common factitious disorder is more frequently encountered.1 As opposed to those with Münchausen syndrome, these patients do not typically use aliases or travel from hospital to hospital, but rather frequent the same physician. They are well known in their health care system due to numerous hospitalizations. They still misrepresent symptoms and feign illness, but are not as prone to pseudologia fantastica. Although conflicting data exist with regard to whether factitious disorders are more common in males or females, some suggest that common factitious disorder is more prevalent in women. Other risk factors include being unmarried, an age in the thirties, experience in the health care profession, and having a cluster B personality disorder. Münchausen syndrome, on the other hand, may be more frequently seen in men in their forties who are single and have antisocial traits.1 The co-morbidity with personality disorders may be a result of rigid defensive structure, poor identity formation, and prominent dependency needs.8

A typical hospitalization for those who feign medical illness has a number of common characteristics. First, the patient often comes to the emergency department after hours (at night or on the weekend) when it is less likely that medical staff who know him or her are available. The patient uses medical jargon and generally knows what diagnoses or conditions will merit hospitalization. The history is often quite dramatic and convincing, and the patient persuades the physician to provide care by appealing to narcissistic qualities, such as omnipotence. Once hospitalized, the treatment is marked by demands for specific interventions (e.g., surgery or particular medications) and by an increasing need for attention. When these are not delivered, the patient becomes angry and may accuse staff of mistreatment or misdiagnosis. If medical personnel uncover the deception, strong countertransference feelings of hatred ensue—the patient is then rapidly discharged or elopes from the hospital only to seek “treatment” at another facility soon thereafter.

The types of physical symptoms and diseases that have been faked are limited only by the imagination of those who feign them. Table 25-2 lists some common categories. Modern-day laboratory tests and diagnostic modalities may be particularly useful in distinguishing factitious symptoms from true medical illness. For example, in the case of suspicious infection, polymicrobial culture results that indicate an uncommon source (e.g., from urine or feces) is highly suggestive. Those who inject insulin to produce hypoglycemia will have a low C-peptide on laboratory analysis, while glyburide can be measured in the urine of those suspected of taking oral hypoglycemics. Laxative abuse to cause ongoing diarrhea is confirmed by testing for phenolphthalein in the stool.9 Finally, diagnostic studies in cases of suspected thyrotoxicosis (from surreptitious ingestion of thyroid hormone) reveal elevated serum total or free thyroid hormone levels, undetectable serum thyrotropin levels, low serum thyroglobulin concentration, normal urinary iodine excretion, suppressed thyroidal radioactive iodine uptake (RAIU), absence of goiter, and absence of circulating antithyroid antibodies.10

Table 25-2 Typical Clinical Presentations of Factitious Disorder

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Type Clinical Findings or Symptoms
Acute abdominal type (laparotomaphilia migrans) Abdominal pain—multiple surgeries may result in true adhesions and subsequent bowel obstruction
Neurological type (neurologica diabolica) Headache, loss of consciousness, or seizure
Hematological type