Overview
Factitious Disorder, also known as Munchausen’s Syndrome, is a disorder characterized by feigned, exaggerated, or self-inflicted symptoms presented to healthcare providers in order to seek diagnosis and treatment.
Patients of Factitious Disorder may be present in various medical and mental health settings, with internal motives such as gaining attention, coping with stress, or perplexing healthcare workers. They can pose a significant threat to themselves by self-inflicting symptoms and undergoing unnecessary diagnostic procedures and treatments, as well as over-utilize limited healthcare resources.
Two forms of Factitious Disorder are commonly recognized: Factitious Disorder imposed on self, wherein the symptoms are presented by the patient, and Factitious Disorder imposed on another (also known as Factitious Disorder by proxy or Munchausen’s syndrome by proxy).
The latter refers to the condition wherein the patient falsifies signs or symptoms of a usually terminal or life-threatening illness in a victim, most often a child or dependent. This serves a deep-seated psychological need, most often the desire to be seen as a good parent, to receive attention or care from others, or to be seen as a martyr.
The mean onset of Factitious Disorder is considered to be 25 years, with women with healthcare training being more susceptible than men. However, due to the secretive nature based in deception, the disorder is extremely difficult to diagnose, and is likely underrepresented in epidemiological surveys.
Signs and Symptoms
Factitious Disorder must be diagnosed by a clinical psychologist or psychiatrist, and is one of the toughest disorders to diagnose. Patients may usually present themselves with symptoms that are simple but serious enough to warrant hospital admission. These symptoms tend to be feigned, exaggerated or self-induced.
Signs that may point towards Factitious Disorder include:
- Inconsistencies in the information provided by the patient
- Symptoms whose effect is disproportionately exaggerated in comparison to probable diagnosis
- Inconsistencies in symptoms and exam results
- Anatomically or physiologically inconsistent symptoms
- Patient resists releasing medical records or undergoing medical examination
- Extensive workups without definite diagnosis
- Refusing psychological evaluation
Risk Factors
Due to the lack of large-scale testing related to the disorder, the aetiology of Factitious Disorder has a largely speculative basis. It is considered largely to be a developmental disorder, with the presented behavior thought to be maladaptive responses to life events, mainly childhood trauma.
Observed similarities among patients of Factitious Disorder include the likelihood of having suffered a major childhood illness, coupled with early experience of the healthcare system. There has also been establishment of an association between patients with personality disorders and Factitious Disorder.
Factitious Disorder is more prevalent in females, especially those involved in healthcare who have received prior training. The diathesis of the disorder has also been ascertained to the factor of being unmarried. The mean age of onset is 25 years, regardless of sex.
While the exact prevalence of the disorder is unknown due to it being deceptive in nature, it is estimated that around 1% of patients in hospital settings present criteria for diagnosis. Furthermore, it was estimated that up to 5% of patient/physician encounters may be due to factitious production of symptoms, with a reported 2.2%-9.3% of fevers being reported as self-induced or factitious in those presenting with fever of unknown origin.
Those with chronic disabilities may be at a higher risk of being victims of Factitious Disorder imposed on another. Some abusers get their own psychological needs met by continuing engagement with medical or mental health professionals, as well as playing the part of the caregiver. In such cases, underlying medical causes cannot be ruled out, as victims of the disorder may have other confirmed illnesses that are being exacerbated by abusers.
Diagnosis
The diagnosis of Factitious Disorder proves to be extremely difficult, owing to a lack of objective screening measures and definitive tests as well as the absence of clinical differentiation between conscious deception and unconscious manifestation of symptoms.
In cases like these, it is up to the healthcare provider to carefully navigate through evidence and investigate the possibility of the disorder. Some new diagnostic results such as low C-peptide results in suspected external insulin use can be helpful.
The DSM-5 states the following diagnostic criteria for Factitious Disorder:
Factitious Disorder imposed on self
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
B. The individual presents themselves to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
Factitious Disorder imposed on another
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.
B. The individual presents another individual (victim) to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
The diagnosis of Factitious Disorder imposed on another is received by the perpetrator and not the victim.
Factitious Disorder may be determined through an extensive process:
1. Identifying inconsistencies between presented symptoms and clinical findings: Vague or contradictory information given by the patient may be a clue that they are consciously or unconsciously misleading the healthcare providers. Additionally, when the patient’s condition does not improve following the appropriate treatment, it may be a sign of factitious behavior.
2. Exclusion of major differential diagnoses: It is important to rule out any possible differential diagnoses, including underlying mental and physical conditions.
3. Observing signs: dramatic and inconsistent medical history, being evasive with the history taker, changing biographical evidence such as name or date of birth, barriers in obtaining corroborative accounts (absence of next of kin or previous medical providers), patients having substantial information about medical procedures and treatments, occurrence of symptoms when the patient is not being monitored, eagerness towards diagnostic and treatment procedures, multiple inconclusive test results followed by development of new symptoms, can be signs of factitious behavior.
4. Identification of incriminating evidence of deception: Cases where patients are witnessed tampering with tests, or inflicting illness or injury.
5. Confirmation of evidence through second opinion from peers: Upon identification of incriminatory evidence, it should be presented to (ideally several) senior colleagues to discuss and rule out other possible causes for the behavior.
6. Exclude somatization and malingering: Medically unexplained symptoms can have multiple explanations. In case of somatic symptoms, there may be a valid presence of symptoms without any explainable physical cause. It is safest to presume this is the case unless absolute proof of deception is present. In such cases, possible motives should be considered.
It is rare for physicians to consider Factitious Disorder in primary differential diagnoses in the absence of incriminating evidence. Inappropriately confronting patients about their role in inducing an illness can be distressing for the patient.
In cases of Factitious Disorder imposed on another
The above measures of diagnosis can be applied in altered forms to the case of Factitious Disorder imposed on another. The same signs should be looked for, and incriminating evidence must be gathered. General warning signs include inconsistencies in the patient’s presented symptoms and tests and the caregiver’s reports, unusual clinical presentation, and a lack of improvement despite efficacious treatment.
Treatment
While there is no concrete treatment plan for Factitious Disorder, a therapeutic approach is the standard treatment considered. Due to the deceptive nature of the disorder, it is not entirely unlikely for there to be a possibility of ethical concern. It is important to remember that patients presenting suspected factitious behavior have the same right to privacy, confidentiality, and informed consent as all other patients do.
An extensive treatment process may involve the following measures:
1. Gathering records: Putting together all information pertaining to the case, including notes and corroborative accounts, description of incriminating evidence and records of colleagues agreeing with the diagnosis.
2. Psychiatric Consultation: When cases are being handled by general practitioners, it is important to involve psychiatrists for their expertise and advice on moral, legal and interpersonal issues.
3. Confronting the patient: The patient must be spoken to ethically, preferably with a present witness while maintaining detailed records of the account. The patient should be informed of all the tests conducted and why deliberate deception on their part is the only possible conclusion, and given a chance to confess or “come clean”. Accusatory tones should not be used, and the patient should not be treated in a way that would cause further distress.
4. Re-evaluating the doctor-patient relationship: In conditions where the patient confesses and apologises, the doctor may consider deferring the patient to a psychiatrist while providing consults. However, in most cases, it is likely that the patient will deny any allegations of deception. In such scenarios, it is important to reiterate the role of trust in the doctor/patient relationship, and lay down the consequence as discontinuation of treatment and consultation altogether.
5. Termination or reduction of medical association: There is an inherent likelihood for patients of Factitious Disorder to sabotage medical treatment or any other form of intervention. Thus, medical involvement should be kept to a minimum.
Therapeutic approaches can range from persistent confrontations to supportive but firm treatments, with a preference of the latter. A firm psychotherapeutic approach works best with collaboration between the physician and psychiatrist. While a small fraction of patients accept treatment, it is important to keep up regular examinations with the primary physician even while consulting with a psychotherapy provider.
Similar approaches are taken with perpetrators of Factitious Disorder imposed on another. The first step is usually to remove the victim from the home, away from the abuser. The therapeutic process with the patient often consists of various goals that begin with getting them to acknowledge their own deception and harmful behavior.
Following this, the psychotherapist may work with them on coping, empathy, parenting, and taking charge. In cases of Factitious Disorder imposed on another, it is necessary to provide therapeutic support to the victim as well as other family members or friends. Co-parenting therapy and family therapy are also important considerations.
Medication is of no significant help with respect to Factitious Disorder, although in cases of comorbid disorders such as psychotic disorders or depression, medication may be employed to treat symptoms of these causes.
Differential Diagnosis
1. Somatic symptom disorder: In somatic symptom disorder, there may be excessive attention and treatment seeking for perceived medical concerns, but there is no evidence that the individual is providing false information or behaving deceptively.
2. Malingering: Malingering is differentiated from factitious disorder by the intentional reporting of symptoms for personal gain (e.g., money, time off work). In contrast, the diagnosis of factitious disorder requires the absence of obvious rewards.
3. Conversion disorder: Conversion disorder is characterized by neurological symptoms that are inconsistent with neurological pathophysiology. Factitious disorder with neurological symptoms is distinguished from conversion disorder by evidence of deceptive falsification of symptoms.
4. Borderline personality disorder: Deliberate physical self-harm in the absence of suicidal intent can also occur in association with other mental disorders such as borderline personality disorder. Factitious disorder requires that the induction of injury occur in association with deception.
5. Medical condition or mental disorder not associated with intentional symptom falsification: Presentation of signs and symptoms of illness that do not conform to an identifiable medical condition or mental disorder increases the likelihood of the presence of a factitious disorder.
Specialist
Due to the involvement of Factitious Disorder with manifestation of medical symptoms, the specialists of interest in this case are usually primary physicians working together with psychiatrists. It is vital to enlist the expertise of multiple professionals with extensive knowledge regarding Factitious Disorder during diagnosis as well as treatment.
In Conclusion
A person with a factitious disorder deceives others by pretending to be ill, intentionally getting unwell, or inflicting harm on oneself. When family members or caregivers misrepresent others, such as children, as being unwell, damaged, or impaired, factitious disorder can also result.
The symptoms of a factitious disease might be modest (a slight exaggeration of symptoms) or severe (previously called Munchausen syndrome). To persuade others that therapy, such as high-risk surgery, is necessary, the person may fabricate symptoms or even tamper with medical examinations.
Factitious disorders are difficult to diagnose and cure. The self-harm that is typical of this illness must be prevented, though, and medical and psychological assistance is essential.
Early diagnosis and treatment of factitious disorder may help prevent needless testing and treatments that could be harmful.
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