Psychology Paper

RUNNING HEAD: FACTITIOUS DISORDER

A Great Deceiver: Patients with Factitious Disorder

In partial fulfillment of

Abnormal Psychology Class (Summer Extended Online)

Instructor

July 12, 2009

According to legend, Baron Karl Friedrich Hieronymus von Munchhausen enjoyed telling larger-than-life war stories pertaining to his time spent fighting for the Russian army (Kaplan and Sadock, 2005). For the purpose of history and classification, Hales and Yudofsky (Eds. 2003) make note of this particular story for two reasons; first, it is an early account of a patient with a strange psychological disorder who has a history of peregrination intertwined with fabricated stories and wounds, and second, factitious disorder was once referred to as Munchausen Syndrome, named after the Baron and his elaborate wartime stories (Hales and Yudofsky, 2003). In 1951, a British physician, Richard Asher, coined the term Munchausen Syndrome (Hales and Yudofsky, 2003). In response to this breakthrough, Dr. Asher stated:

Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always traveled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly, the syndrome is respectfully dedicated to the baron, and named after him (Kaplan and Sadock, 2005, pg. 1830).

Baron von Munchausen played a crucial role in the interest with this particular disorder, but earlier accounts have been noted as well, using various names. Hector Gavin, a Scottish military physician, wrote an essay in 1838 (Kaplan and Sadock, 2005) distinguishing between malingering soldiers, who are attempting to avoid further combat in the Napoleonic Wars, and the soldiers who purpose is “to excite compassion or interest” or “experience an unaccountable gratification in deceiving their officers, comrades, and surgeons” (Kaplan and Sadock, 2005, pg. 1830). In 1890, Jean-Martin Charcot uses the term mania operative active when retelling the account of a young girl in search of a surgeon to attend to her ailing knee. After several attempts, she was able to find a surgeon who would amputate her leg, but the cause of her pain had no organic basis (Kaplan and Sadock, 2005). Although cases of factitious disorder can be traced back to the second century with documented cases by the Greek physician Galen (Kaplan and Sadock, 2005), its true diagnosis is further complicated by comorbid psychological disorders and intentionally produced physical symptoms. These symptoms are mixed with a deceptive representation and medical history. This results in an inaccurate estimation of the prevalence of factitious disorder, no definitive treatment, and difficulty in determining a cure. Altogether, the symptoms lead to a chronic, lifelong cycle of wandering from doctor to doctor, unnecessary medical procedures, and medical conditions unintentionally suggested by these physicians.

According to Barlow and Durand (2005) classify factitious disorder under a broader group, somatoform disorders. The root word soma means body; therefore people with a somatoform disorder include those who have physical symptoms, but no cause of the medical condition can be determined. Somatoform disorders tend to be quite difficult to detect and treat, according to Barlow and Durand (2005), because the physicians and clinicians have three tasks to complete; first, they must rule out the physical complaint, second, mental health professionals rule out other psychological disorders in order to properly label the type of somatoform disorder they are presented with, and third, the clinician must have a thorough understanding of the patient’s culture. With all somatoform disorders similar in presentation, they are set apart by the various motives or rewards; factitious disorder falls somewhere between conversion disorder and malingering (Barlow and Durand, 2005). The DSM-IV-TR (2000), states that “factitious disorders are characterized by physical or psychological symptoms that are intentionally produced or feigned in order to assume the sick role” (pg. 513). They desire to always be the designated patient. There are three subtypes that will be discussed later. According to this definition, factitious disorder is set apart from malingering; with malingering, “the individual also produces the symptoms intentionally, but has a goal that is obviously recognizable when the environmental circumstances are known” (DMS-IV-TR, 2000, pg. 513). Some possible motivations for a malingerer could include financial gain, not returning to combat, avoiding jury duty or other legal matters, or getting out of work (Barlow and Durand, 2005). A person with factitious disorder simply wants to “assume the sick role” and the attention that accompanies it (Barlow and Durand, 2005).

There are three subtypes of factitious disorder, according to the criteria in the DSM-IV-TR (2000); first, with predominantly psychological signs and symptoms, second, with predominantly physical signs and symptoms, and the third, with combined psychological and physical signs and symptoms (pg. 514-515). Factitious disorder with predominantly psychological signs and symptoms is simply when a patient presents with a mental disorder, such as “depression, suicide, memory loss, hallucinations or delusions, PTSD (post-traumatic stress syndrome), or a dissociative disorder” (DMS-IV-TR, 2000, pg. 514). When predominantly physical signs and symptoms are associated with the disorder, common medical conditions can include “feigning/intentionally producing, exaggerating, or fabricating infection (e.g. abscesses), aggravating an existing wound from healing, pain (e.g. abdominal), hypoglycemia, anemia (e.g. bloodletting), rashes, seizures, dizziness, blacking out, vomiting, diarrhea, fevers, or symptoms related to an autoimmune/connective tissue disease” (DSM-IV-TR, 2000, pg. 514-515). The third subtype is simple; both psychological and physical signs and symptoms are present with neither of the two dominating (DSM-IV-TR, 2000). Defining factitious disorder is an easy task, but the difficulty begins when diagnosing a patient, determining the treatment, and providing history of the disorder.

Before being able to address appropriate diagnosis and treatments, it is best for people to have sufficient knowledge of the history of this deceptive psychological disorder. Because of the deceptive nature of this disorder, accurate estimates of epidemiology and prevalence are difficult to calculate (Kaplan and Sadock, 2005). Factitious disorder patients have a tendency to leave the hospital once their medical problems are determined to be fabricated or there is supporting evidence that the symptoms were intentionally produced, leaving the patient feeling embarrassed or humiliated (Pasic, Combs, and Romm, 2009). Not only does the patient fleeing the scene lead to no help and a greater chance of no cure for their problem, it causes another issue for researchers who are trying to determine the prevalence. It is thought that with their repeated roaming from one physician or medical facility to another as a common characteristic, some patients may be counted more than once in a location which may lead to an overestimation. Factitious disorder may be underestimated because the patients are fleeing when found out rather than seeking the help they need (Hales and Yudofsky, 2003, Epidemiology).

Of the known cases, the prevalence differs with each hospital, various studies, and depending on the specialty of the physician (Hales and Yudofsky, 2003). As mentioned by Pasic, Combs, and Romm (2009), the majority of patients tend to be women between the ages of 20-40 and are “often employed in the medical field as nurses, medical technicians, or other health-related jobs” (pg. 63). Several different studies have been performed in order to calculate a potential prevalence rate; they can be found in Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, Eight Edition, Vol. I, on page 1831-1832 or Hales and Yudofsky’s Textbook of Psychiatry. However, according to the DSM-IV-TR (2000), “the best data indicate that, within large general hospitals, Factitious Disorder is diagnosed for about 1 % of the patients on whom mental health professionals consult” and is “greater in highly specialized treatment settings.” (pg. 516). Not only is this a rare disorder, it can be very puzzling to researchers and clinicians.

Now that the complicated task of determining prevalence has been addressed, one can focus on the information that is available to clinicians and physicians. Before discussing the complicated issues of diagnosing a patient with factitious disorder, understanding potential causes may be helpful in narrowing the affected population. Of the documented cases, a common factor is present in a majority of the patients. After much research, Kaplan and Sadock (2005) note that “the etiology of factitious disorder is not known” but they can associate a list of possible childhood events that may be a contributing factor to the development of this disorder later in life (pg. 1832). Stated earlier that the motivation is to “assume the sick role” (which it is thought to be a conscious action), the authors point out that the underlying motive may actually be unconscious (Kaplan and Sadock, 2005, pg. 1832), with two common factors in most cases; (1) “an affinity to the medical system” and (2) “poor, maladaptive coping skills.” Many of the patients with factitious disorder share a similar childhood history, to include physical and/or sexual abuse, “emotional deprivation”, early illness with lengthy hospitalizations, poor relationships with parents, and the tendency to activate another psychological disorder (Hales and Yudofsky, 2003, Etiology). Being a child from a large family could have resulted in neglect, leading to the development of “immature coping skills” and a preoccupation with the healthcare field (which would explain why many factitious disorder patients enter the healthcare field) (Kaplan and Sadock, 2005, pg. 1832). With a potential precursor from their childhood, typically a stressful event later in life will trigger the onset of the disorder, to include loss of a loved one, divorce, or loss of a job (Kaplan and Sadock, 2005, pg. 1833). Their “dependency and narcissistic needs are fulfilled” by family, friends, and medical staff. It is said that physical manipulation, in response to the “extreme anxiety” and stress, are a way of relief for the patient (Hales and Yudofsky, 2003, Etiology). Positive reinforcement during childhood illness may also be a reason why patients “assume the sick role” in order to find “emotional relief” through the attention they get from loved ones (Kaplan and Sadock, 2005, pg. 1833). With a short list of possible childhood factors contributing to factitious disorder, there is “no genetic or familial inheritance pattern” to date (Kaplan and Sadock, 2005, pg. 1832).

Once a physician has a better understanding of a patient’s medical history (such as seeing an extensive list of previous medical procedures or surgical scars) and the conclusion that all or most of the diagnostic tests fail to confirm a positive diagnosis, diagnosing by exclusion seems to be a good approach. Mental health professionals have been able to educate physicians and other medical staff in regard to the typical behavior of a factitious disorder patient. Some red-flag signs to observe, especially in the emergency room setting, include: “dramatic presentation” of symptoms that do not point to or pinpoint a condition exactly (as in a textbook case), symptoms and signs only present when the patient is aware that he/she is being observed, pseudologia fantastica, disruptive behavior towards medical staff, good understanding of medical terminology and hospital routine, covert use of surgical tools, supplies and substances, extensive medical procedures/scars, peregrination (frequent traveling or moving), few visitors when patient is finally hospitalized, an acute onset of symptoms or “complications”, and new symptoms/signs once the initial ones were proven negative are a common theme (DSM-IV-TR, 2000, pg. 516). The types of symptoms feigned are generally limited only by the patient’s creativity and medical knowledge (Kaplan and Sadock, 2005, pg. 1833).

Diagnosis by exclusion is not as simple as it may appear. With no set diagnostic testing, “accurate diagnosis is difficult” which leaves the physicians puzzled and forced to eliminate all possible etiologies (Pasic, Combs, and Romm, 2009, pg. 63). They must continue to treat the intentionally produced medical condition, providing “adequate care” in response to the “physician’s ethical duty” (pg. 65). Pasic, Combs, and Romm (2009) later go on to conclude that despite the frustration and anger aroused in the medical staff because of erroneous and careless attention-getting tactics, the ethical issue is addressed again, “An individual suspected of factitious disorder has the same rights as any patient, i.e., the right to reasonable care, respect, privacy, safety, and confidentiality” (pg. 65). This “ethical duty” can prove to be harmful because treating the patient can further damage the psychological disorder by falsely providing a positive reinforcement of their behavior. All cases that involve a potential diagnosis of factitious disorder should include a legal committee (Kaplan and Sadock, 2005), because covert tactics may be required once the patient is suspected of feigning and he/she has denied allegations. Diagnosis may not be confirmed on many patients due to the nature of the patient to flee when confronted. Once confronted, they may check out against medical advice and flee to the next hospital, where new physicians spend valuable time and money to care for the patient before they too discover their past. It is against confidentiality agreements between hospital and patient for the previous hospital staff to call and warn other hospital staff members of a potential case, therefore, diagnosis is more often suspected than it is actually confirmed (Hales and Yudofsky, 2003).

After the tedious process of diagnosing a patient with factitious disorder, the even more difficult process of treatment and prognosis must be determined. In order to properly treat a patient with factitious disorder, the “diagnosis must be confirmed” and the physical symptoms need to be cared for (Hales and Yudofsky, 2003). The easiest facet in treating a factitious disorder patient is caring for the physical symptoms, but the underlying psychological problem is the difficult part of treating this disorder. After the diagnosis is made, any underlying psychological problem needs to be either determined or ruled out, such as depression or an anxiety disorder. Kaplan and Sadock (2005) mention that treating a psychological disorder may provide the patient with a better prognosis, resulting in a decrease or absence of the symptoms of factitious disorder.

There is no cure for factitious disorder, but it is thought that management and treatment of this particular disorder may reduce “self-harm” or “self-created disease” (Pasic, Combs, and Romm, 2009, pg. 65), and “reduce risk of morbidity and mortality” (Kaplan and Sadock, 2005, pg. 1841) by addressing the psychological and emotional problems. Due to the “wide spectrum” of physical and psychological symptoms involved, it is important to keep this in mind when determining treatment; each patient’s treatment plan and prognosis more than likely will be individualized according to the current medical complications, childhood history, and underlying psychological problems (Kaplan and Sadock, 2005). Some common psychological disorders that are associated with factitious disorder include: mood disorders, anxiety, substance abuse, and personality disorders. Each of the above mentioned have their own unique criteria and treatment plans, all of which can be found in the DSM-IV-TR (2000).

Some psychological problems are easier to manage than others, so those which are associated with factitious disorder patients will help determine the prognosis of that patient. Some personality disorders prove to be more difficult to treat, whereas mood, anxiety, and substance abuse prove to be easier (Kaplan and Sadock, 2005, pg. 1840), but it is noted that many patients will “experience remission at approximately 40 years of age.”

A variation of this disorder is factitious disorder by proxy (more commonly known as Munchausen Syndrome by Proxy). This is defined by Frye (2009) as “a psychological diagnosis applied to mothers (and other care givers) who intentionally induce illness or injury in a child to get attention from physicians and medical personnel.” (pg. 14). The intentionally induced, fabricated, or exaggerated problems are not limited to physical symptoms or illness, but rather include psychological symptoms as well, such as learning disabilities, which require school districts to spend countless amounts of tax payer dollars on unnecessary testing (Frye, 2009). “Perpetrator”, referring to any caregiver, such as a babysitter, grandparent, or stepparent, is more commonly seen with a mother and small child, and the perpetrator is indirectly gaining attention or sympathy through the child (Frye, 2009, pg. 15). Factitious disorder by proxy is classified in the DSM-IV-TR (2000) as ‘Factitious Disorder Not Otherwise Specified’ but it is suggested for further research (pg. 517).

According to Frye (2009), the caregiver appears to be very interested in the well-being of the child, showing “normal” “good” characteristics, often welcoming invasive medical procedures (pg. 15). When it appears no one is watching, the caregiver is often inattentive to the sick child or out of the room, comforting other parents who have sick children in the hospital (Frye, 2009).

With a deceptive nature, similar to factitious disorder, the prevalence is difficult to calculate, according to Kaplan and Sadock (2005), but once it is correctly diagnosed, hospital staff is required by law to report it to CPS (child protective services) because factitious disorder by proxy is treated as a form of child abuse. The treatment of the perpetrator differs from a typical factitious disorder patient because the victim must be cared for and separated from the mother, while the mother needs to receive her treatment for the underlying psychological disorder(s) she may have. It is extremely important to remove the child from the situation and get the caregiver help because, according to statistics, there is a high rate of mortality and morbidity among the victims (Kaplan and Sadock, 2005). There are other cases of by proxy where the perpetrator (caregiver) has a victim other than a child, such as the elderly or a spouse (Kaplan and Sadock, 2005), but little information regarding diagnosis, treatment, and prognosis is available at this time.

Factitious disorder and factitious disorder by proxy are complicated, puzzling psychological disorders deep within, but have physical symptoms and signs masking the true problem. There is good information available, but still there are many areas left with large question marks. The diagnosis of factitious disorder is made difficult because patients are deceptive in nature and ethical issues linger over the physician’s head when confronted with how to approach the patient. Treatment is even more difficult, because often the patient disappears before treatment can be given, and if treatment is available, there may be a comorbidity of psychological disorders, making it difficult to treat them all and put factitious disorder into remission. Although a number of factitious disorder cases are speculated, few cases are confirmed and even fewer are treated, resulting in limited treatment information available for mental health clinicians and an extremely low percentage of patients who overcome this chronic disorder. More research would be beneficial in order to track this disorder and develop a treatment plan. While treating these patients may be extremely frustrating, it is necessary to treat the obvious physical symptoms so that further complications do not occur, but by treating the patient or trying to help them by referring to a mental health clinician our society can gain better insight into this deceptive disorder, and hopefully end the patient’s cycle of deception and destruction and develop better guidelines for diagnosis, prognosis, and treatment.

References

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