FACTITIOUS DISORDER

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2.07 11/03/16

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OUTLINE
 Amnesia, Substance-related disorder, Paraphilias, Hypersomnia
I. Introduction
and Transexualism
II. Epidemiology
III. Etiology CHRONIC FACTITIOUS DISORDER WITH
IV. Factitious Disorder with Predominantly PREDOINANTLY PHYSICAL SSX (MUNCHAUSEN
Psychological Signs and Symptoms SYNDROME)
V. Chronic Factitious Disorder with Predominantly  Also termed as hospital addiction, polysurgical addiction
Physical SSX (Munchausen Syndrome) producing the so-called washboard abdomen and professional
VI. Factitious Disorder with Combined patient syndrome.
Psychological and Physical ssx  Essential feature of patients with the disorder:
VII. Factitious Disorder Not Otherwise Specified  Their ability to present physical symptoms so well that they can
VIII. Differential Diagnosis gain admission to, and stay in, a hospital
IX. Course and Prognosis  Patients may feign symptoms suggesting a disorder involving
X. Treatment any organ system
XI. DSM V CRITERIA  Clinical presentations are myriad and include hematoma,
hemoptysis, abdominal pain, fever, hypoglycemia, lupus-like
syndromes, nausea, vomiting, dizziness, and seizures
FACTITIOUS DISORDER
 Acquire a “gridiron” or washboard-like abdomen from multiple
procedures
 Persons with factitious disorder fake illness.  Complaints of pain especially of renal colic are common with
 They simulate, induce or aggravate illness often inflicting painful, patients wanting narcotics while in some cases, other demand
deforming or even life threatening injury on themselves or those specific medications like analgesics
under their care.  When tests turn out negative, they accuse doctors of being
 Unlike malingerers who have material goals, such as monetary incompetent, threaten litigation and become generally abusive.
gain or avoidance of duties, patients with factitious disorder  Some sign out abruptly before being confronted and go to
undertake these tribulations primarily to gain the emotional care another hospital to begin the same cycle again
and attention that comes with playing the role of the patient.  Predisposing factors are:
 The disorders have a compulsive quality o true physical disorders which occurred in
childhood leading to extensive medical treatment
 Behaviors are considered voluntary in that they are deliberate
o a grudge against the medical profession,
and purposeful, even if they cannot be controlled. employment as a medical paraprofessional and
 Comprise ~ 0.8 to 1.0 %of psychiatry consultation patients an important past relationship with a physician
 Diagnosed in about 1% of patients who are seen in psychiatric
consultation in general hospitals FACTITIOUS DISORDER WITH COMBINED
 Mostly women who outnumber men 3 to 1. With age ranging from PSYCHOLOGICAL AND PHYSICAL SSX
20-40 years old
 With a history of employment or education in nursing or a health  Both psychological and physical symptoms are present but
care occupation neither predominates in the clinical presentation
FACTITIOUS DISORDER
EPIDEMIOLOGY FACTITIOUS DISORDER NOT OTHERWISE SPECIFIED

 Limited studies indicate that patients with factitious disorder
may compromise approximately 0.8-1.0% of psychiatry
consultation patients.
ETIOLOGY
A. PSYCHOSOCIAL FACTORS
 Poorly understood because the patients are difficult to engage
in an exploratory psychotherapy process
 Many of the patients suffered childhood abuse or deprivation,
resulting in frequent hospitalizations during early development
 Many patients have the poor identity formation and disturbed
self-image that is characteristic of someone with borderline
personality disorder
 Significant defense mechanisms are repression, identification
with the aggressor, regression, and symbolization.
B. BIOLOGICAL FACTORS
 Hypothesized that impaired information processing contributes
to the pseudologia fantastica and aberrant behavior of patients
FACTITIOUS DISORDER WITH PREDOMINANTLY
PSYCHOLOGICAL SIGNS AND SYMPTOMS
 Some patients show psychiatric symptoms judged to be feigned
 Feigned symptoms include depression, hallucinations,
dissociative and conversion symptoms, and bizarre behaviour
 Factitious psychological symptoms resemble the phenomenon
of pseudomalingering, conceptualized as a need to maintain an
intact self-image, which would be marred by admitting
psychological problems that are beyond the person’s capacity to
master through conscious effort
 Deception is a transient ego-supporting device
 Patients may appear depressed and may explain the depression
by offering a false history of the recent death of a significant
friend or relative
 Other symptoms which may also appear include pseudologia
fantastica wherein limited factual material is mixed with
extensive and colorful fantasies and imposture which is
commonly related to lying in cases
 Presentations of Factitious disorder with predominantly
psychological signs include Bereavement, Depression,
Posttraumatic Stress disorder, Pain disorders, Psychosis, Bipolar
I disorder, Dissociative Identity Disorder, Eating Disorder,
TRANSCRIBERS: REYES J
 Patients with factitious signs and symptoms who do not meet
the DSM-IV- TR criteria for factitious disorders
 Most notable example is Factitious disorder by Proxy wherein a
mother deceives a medical professional that her child is ill
 The deception may involve a false medical history,
contamination of laboratory samples, alteration of medical
records, or induction of injury and illness to the child
DIFFERENTIAL DIAGNOSIS
1. SOMATOFORM DISORDERS
 Differentiated from somatorform disorders (Briquet’s
syndrome) by the voluntary production of factitious
disorders
 Extreme course of multiple hospitalizations and seeming
willingness of patients with a factitious disorder to undergo
an extraordinary number of mutilating procedures.
2. PERSONALITY DISORDERS
 Because of the attention seeking and occasional flair for
dramatic behaviour of these patients, they may be
classified as having histrionic personality disorder
3. SCHIZOPHRENIA
 Patients do not usually meet the criteria for schizophrenia
unless they have a fixed delusion that they are actually ill
and act on this belief by seeking medical attention

4. MALINGERING
 Malingerers have an obvious, recognizable environmental
goal in producing signs and symptoms
 Seek hospitalizations due to financial gains, evade the
police, free bed and board for the night
5. SUBSTANCE ABUSE
 Although patients with factitious disorders may have a
complicating history of substance abuse, they should be
considered not merely as substance abusers but as having
co existing diagnoses.
6. GANSER’S SYNDROME
 A controversial syndrome associated with prison inmates
characterized by the use of approximate answers.
 They respond to questions with astonishingly incorrect
answers e.g. when asked about the color of a blue car,
they would answer red
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son 2, Person 3
 PSYCHIATRY 2
FACTITIOUS DISORDER

COURSE AND PROGNOSIS

 Begin in early adulthood, though may appear during childhood
or adolescence
 Onset of disorder or discrete episodes of seeking treatment may
follow real illness, loss, rejection or abandonment and as the
disorder progresses, patients become knowledgeable of
medicines and hospitals
 It is incapacitating to the patient and often produces severe
trauma or untoward reaction related to treatment.
 Prognosis is poor with patients ending up in prison due to minor
crimes like burglary, vagrancy and disorderly conduct
 Features of a favourable prognosis include: presence of a
depressive-masochistic personality, functioning at a borderline,
not a continuously psychotic level and attributes of an anti-
social personality disorder with minimal symptoms

TREATMENT (kAPLAN)

 The major goal is to reduce the risk of morbidity and mortality

 Also to address the underlying emotional needs or psychiatric
diagnosis underlying factitious illness behaviour
 To be mindful of legal and ethical issues
 The single most important factor in successful management is a
physician’s early recognition of the behaviour
 Working in concert with the patient’s primary care physician is
more effective than working with the patient in isolation
 Guidelines for management and treatment include:
o Active pursuit of a prompt diagnosis can minimize
the risk of morbidity and mortality
o Minimize harm. Avoid unnecessary tests and
procedures especially if invasive. Treat according
to clinical judgment, keeping in mind the
subjective complaints may be deceptive
o Regular interdisciplinary meetings to reduce
conflict and splitting among staff. Manage staff
countertransference
 Consider facilitating healing by using the double-bind technique
or face-saving behavioral strategies such as self-hypnosis or
biofeedback
 Steer the patient toward psychiatric treatment use an empathic
nonconfrontational, face-saving manner. Avoid aggressive
direct confrontation
 Treat underlying psychiatric disturbances such as Axis I and II
disorders. In psychotherapy, address a coping strategies and
emotional conflicts
 Appoint a primary care provider as gatekeeper for all medical
and psychiatric treatment
 Consider involving risk management professionals and
bioethicists from an early point
 Consider prosecution for fraud, as a behavioral disincentive

DSM V CRITERIA
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 himself or herself to others as
ill, impaired or injured.
C. The deceptive behavior is evident 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

Specify if:
Single Episode
Recurrent Episodes (> or = 2 events of falsification of illness
and/or induction of injury.
FACTITIOUS DISODER IMPOSED ON ANOTHER
(PREVIOUSLY FCTITIOUS DISORDER BY PROXY)
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 metal
disorder, such as delusional disorder or another
psychotic disorder.

Note: The perpetrator, not the victim, received this diagnosis.

Specify if:
Single Episode
Recurrent Episodes (> or = 2 events of falsification of illness
and/or induction of injury.

TRANSCRIBERS: REYES J Page 2 of 2