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A Systematic Review On Factitious Disorders Psychopathology and Diagnostic Classification
A Systematic Review On Factitious Disorders Psychopathology and Diagnostic Classification
Abstract
Factitious disorder (FD) is a psychiatric disorder in which sufferers intentionally fabricate phys-
ical or psychological symptoms in order to assume the role of the patient, without any obvious
gain. The clinical and demographic profile of patients with FD has not been sufficiently clari-
fied. The aims of this study are: to outline a demographic and clinical profile of a large sample
of patients with FD, to highlight the psychopathological correlates and to study the evolution
of position of FD in the DSM. A systematic search for all case reports and case series of adult
patients in the databases MEDLINE, Scopus and PsycINFO was conducted. 1636 records were
obtained based on key search terms, after exclusion of duplicate records. 577 articles were
identified as potentially eligible for the study, of which 314 studies were retrieved for full-text
review. These studies included 514 cases. Variables extracted included age, gender, reported
occupation, comorbid psychopathology, clinical presentation and factors leading to the diag-
nosis of FD. 64.5% of patients in the sample were females. Mean age at presentation was 33.5
y.o. A healthcare profession was reported most frequently (n=113). Patients were most likely
to present in psychiatry, neurology, emergency and internal medicine departments. Statistical
analysis has highlighted significant correlations between factitious disorders and depressive
disorders and borderline personality disorder (BPD) and a significant effect of BPD and abuses
in childhood on substance abuse. The survey of socio-demographic profile of the sample has
highlighted some important points for early diagnosis and early psychiatric treatment. The
research also allows deepening the psychopathological correlates of the disorder. The study
showed that patients did not meet DSM-5 diagnostic criteria in the 11.3% of cases.
Keywords
Factitious disorder, Munchausen syndrome, Fabricated illness, Medically unexplained
symptoms
Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Varese, Italy
†
Author for correspondence: Camilla Callegari, Department of Medicine and Surgery, Division of Psychiatry, University of Insubria,
Varese 21100, Italy; E-mail: camilla.callegari@uninsubria.it
10.4172/Neuropsychiatry.1000349 © 2018 Neuropsychiatry (London) (2018) 8(1), 281–292 p- ISSN 1758-2008 281
e- ISSN 1758-2016
Research Camilla Callegari
0.6% and 3 % of referrals from general medicine published to date have been limited to a small
to psychiatryand between 0.02% and 0.9% of number of cases.
cases reviewed in specialist clinics [3].
Thus, the aim of this study is to draft a
Factitious disorders appeared in the Diagnostic comprehensive systematic review of all cases of
and Statistical Manual of Mental Diseases from factitious disorders published in the professional
the third edition (1980). According to DSM- literature.
III-R (1986), factitious disorders should be
Factitious patients are difficult to detect and they
distinguished from malingering in which
have a heavy impact on the healthcare services and
fabrication is motivated by an external reward.
National Health Service. The need for improving
In DSM-IV-TR (2000), FD represents an and speeding up the diagnostic approach and
autonomous diagnostic category. Three subtypes consequently therapeutic treatments is felt.
of distinct fictitious disorder are distinguished by Thus, it is useful to carry out a literature review
predominant symptoms. to characterize the profile of patients with FD.
Purposely, the endpoints are:
With Predominant Psychic Signs and Symptoms
to outline a demographic and clinical profile of a
With Predominant Physical Signs and Symptoms
large sample of patients with factitious disorder;
Combined Psychic and Physical Signs and
to highlight the psychopathological correlates;
Symptoms.
to study the evolution of position of FD in
In DSM-5 FD are part of the largest section of
the Diagnostic and Statistical Manual of Mental
Somatic Symptom and Related Disorders (Table 1).
Disorders
All the disorders of this chapter have in common
the relevance of somatic symptoms associated
with significant discomfort and impairment. This Method
diagnostic formulation is more useful to general
A systematic review of all case report and case
practitioners and non-psychiatric specialists in
series of adult patients which fulfilled DSM-5
the field of general medicine and in other clinical
diagnostic criteria was conducted. The research
areas where individuals who present disorders
involved cases diagnosed according to DSM-III,
with significant somatic symptoms are more
DSM-IV or ICD-10 criteria. A broad keyword
common than in mental healthcare services.
search of the professional literature published
As other somatic symptom disorders, factitious
disorder is characterized by persistent problems in English from January 1950 until November
related to the perception of illness and identity. 2016 was conducted by two couple of raters. The
databases MEDLINE, Scopus and PsycINFO
Early detection of factitious disorder is very were searched using the MeSH terms factitious
important to limit harm to patients and early and munchausen. The terms artefacta, fabricated
management of FD may facilitate improved illness and medically unexplained symptoms were
outcomes for patients with the disorder. included. Exclusion criteria are the following:
However, the clinical and demographic profile cases by proxy
of patients with FD has not been sufficiently
clarified [4,5]. Recommendations and guidelines aged < 18 y.o.
have not been supported by broad evidence articles not in English
on how FD is diagnosed by clinicians or how
methods for early detecting FD may vary among The PRISMA (Preferred Reporting Items for
medical specialties. Systematic Review and Meta-Analyses) flow
chart of the search is reported. A total of 1636
Studies on FD demonstrate the huge impact records were returned based on key search terms,
of unnecessary investigations, treatments and after exclusion of duplicate records. 577 articles
hospital admission on the healthcare system.
were identified as potentially eligible for the
Early detection of FD is in order to limit wastage
study based on title and abstract, of which 314
of healthcare resources and harm to patients
studies were retrieved for full-text review. These
[6,7].
studies included 514 cases. Single cases have
Articles on FD are mostly case reports and been extracted from 74.1% of the studies, while
reviews. Only a limited number of studies 25.9% of the selected articles contained multiple
have been published in the literature and those cases (Figure 1).
The following quantitative and qualitative The atypical presentation includes the
variables were obtained: age, gender, marital manifestation of symptoms when the patient
status, race and ethnicity, reported occupation, is not under observation, the course of illness
psychopathology, medical diseases, clinical is impossible or highly improbable or does
presentation, multiple surgeries, abuse in not follow the natural history of the presumed
childhood, substance abuse, experience of diagnosis.
illness or long-lasting hospitalization, traumatic
The exclusion of organic causes carries out
experiences, conflicting relationships, premature
from clinical examination and execution
familiar bereavements, grudge towards the
of instrumental diagnostic and laboratory
medical profession, use of para-medical facilities,
investigations. The evidence of fabrication occurs
suicidal behavior, cause of death, psychiatric
through search, surveillance or direct admission
counseling.
by the patient.
Factors leading to the diagnosis of FD were
The patient’s behavior includes unusual medical
extracted using a checklist adapted from two
surveys of clinical information that might raise knowledge or the use of medical and scientific
the suspicion of factitious disorder [5,8]. Starting terms, the extreme eagerness for medical
from the review of Yates and Steel, these items procedures, including invasive ones, attitude of
were considered: past healthcare service use, revenge towards health workers, poor adherence
atypical presentation, exclusion of organic and/ to the proposed treatments, pseudologia fantastica
or psychiatric causes, evidence of fabrication, and opposition to the psychiatric consultation
patient behavior, treatment failure, recurrent instead of medical or surgical procedures. The
disease [3,5]. failure of treatments includes numerous disease
relapses and the appearance of new symptoms in
The past healthcare services use consists in a conjunction to the treatment or worsening of the
history of extensive use of medical services, medical condition.
history of peregrination between healthcare
services and multiple medical examinations In order to collect the elements of the database
request. for the statistical analysis, missing or doubt socio-
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Chronic pain (n=6); Post-surgical pain (n=5); Complications of anesthesia (n=2); Neuropatic
Intensive and Palliative care 14 2.7%
pain (n=1)
Undefined
14 2.7%
physical symptoms
Undefined
5 1.0%
symptoms
Legend:
FUO= fever of unknown origin
ARDS= acute respiratory distress syndrome
GN= glomerulonephritis
UTIs= urinary tract infections
MI= myocardial infarction
DVT= deep vein thrombosis
IBD= inflammatory bowel disease
NOS= not otherwise specificated
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Table 5: Hierarchical multiple linear regression predicting Substance Abuse from Depressive Disorder, Borderline Personality
Disorder, Abuse in childhood, and experiences of Illness and Hospitalization.
Female sample (N = 330) Model 1 Model 2
B SE β B SE β
BPD .29*** 0.07 0.23 .28*** 0.06 0.22
DEPRESSIVE DISORDER .10* 0.04 0.12 0.07 0.04 0.09
CHILDHOOD ABUSE .18*** 0.05 0.21
ILLNESS/HOSPITALIZATION 0.09 0.06 0.08
R2 0.071 0.12
F 12.51*** 11.13***
Male sample (N = 184) Model 1 Model 2
B SE β B SE β
BPD .39* 0.15 0.18 .36* 0.15 0.17
DEPRESSIVE DISORDER 0.1 0.09 0.07 0.05 0.09 0.04
CHILDHOOD ABUSE .20* 0.1 0.15
ILLNESS/HOSPITALIZATION 0.12 0.11 0.08
R2 0.04 0.07
F 3.74* 3.49**
*p < .05; **p < .01; ***p < .001
B coefficients, standard errors and standardized β coefficients for the investigated associations.
Model fit (R2) and F tests are presented for each Model.
Depression instead does not show any significant People affected by FD tend to come to medical
correlation with drug abuse, when the diagnosis of attention in young adult age. This outcome, in
borderline personality disorder is used as a predictor. line with the results of several surveys [3,12,13]
supports the datum that FD patients arrive at
Introducing more other variables as predictors
(child abuse, previous history of illness and/ medical attention in the young adult age.
or hospitalization), model 2 shows a significant A preponderance of patients with employment in
percentage of variance in the dependent variable healthcare emerged. According to a bio-psycho-
(females: R-frame =.12, F(4)=11.13; p<.001; social model and as confirmed by the literature,
males: R-frame =.072, F(4)=3.49; p=.009). this finding, although not an absolute majority in
A statistically significant effect of borderline patients of this study, suggests that a healthcare
personality disorder and early age abuse on work can be a risk factor in the development of
drug abuse can be observed, excluding other factitious disorder if associated to other stressful
independent variables considered (p<0.05). life events [11,14].
These associations are statistically significant
both in male and female gender. A prevalence of married people emerged. Even
though this result is in contrast to some researches
Among the results of this statistical analysis, it in literature [3,15], it can’t be excluded that this
is noticeable the correlation between child abuse data is partly conditioned by the impossibility to
and higher hospital admissions (reported in obtain this information from the whole sample
9.3% of the sample). examined. This aspect deserves a detailed study
in the future.
Discussion The study shows a preponderance of comorbidity
The demographic profile of the sample shows with personality disorders (specifically borderline
a prevalence of female. This data support the personality disorder) and depressive disorders.
hypothesis of several case reports [9] and reviews This outcome is not surprising since the
[3,10] that FD occur mainly in women. However correlation between FD and personality disorders
other studies published in literature show a is frequently described in literature [16,17].
clear prevalence in male gender. This illusory In the group with comorbidity, personality
disagreement finds an explanation in Freyberger’s disorders and depressive disorders are the most
words asserting that there is a prevalence of men represented. There are many studies published
in clinical trials for Munchausen Syndrome in the professional literature that support these
(MS), while the women are most common in the connections [18,19], but the relationship
classic form of FD with a ratio of 3:1 [11]. between these diagnosis is still unclear.
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An atypical presentation is another key issue. drug abuse, depressive disorder and borderline
These patients often use a scientific language personality disorder is supported [43,44].
without having any expertise in the field and they
It is thus confirmed the previously discussed
show a knowledge of the medical procedures
aspect, according to which important traumas
and keep looking for invasive diagnostic
in an individual’s life, among which can be
examinations. Such behavior is also characterized
considered child abuse, could contribute to
by an ambivalent attitude towards the health
determine the psychic fragility typical of patients
workers by alternating a collaborative stance and
affected by a factitious disorder, laying the
an opposition to the therapeutic program, as well
foundations of the pathological behavior itself.
as the use of pseudologia fantastica. In the second
case, there are repeated therapeutic failures that The diagnostic criteria for DSM-5 factitious
do not find an adequate physiological explanation disorders were met in 88.7% of cases. The
as they are often a consequence of the patient’s reason for the percentage of patients who do not
repeated pathological behavior. meet the criteria (11.3%) can be found in the
reclassification that these conditions had in the
The past use of health services has occurred in
modern edition of the manual: some patients
a significant percentage; the difficulty expressed
who first met the criteria of previous editions are
by different authors in trying to reconstruct
now most likely included in another diagnostic
the clinical history of the patients affected by a
category. Medically unexplained symptoms are
factitious disorder is considered.
common and frequent in clinical practice and
Evidence of factitious production has been classifications have often limitations [45]. This
observed in a small number of cases, and this is an intrinsic feature of manuals such as DSM
highlights the difficulties in discovering the act that tend to designate rigid categories to avoid
itself, while avoiding to violate patient’s privacy overlapping, but this inevitably conflicts with the
[11]. clinical practice where flexibility is essential.
According to the results of this study, several
authors have highlighted a frequent comorbidity Conclusions
between factitious disorders and depressive
A systematic review on factitious disorders
disorders [19], as well as a significant correlation
published in the professional literature was
between factitious disorder and borderline
conducted.
personality disorder [17].
With regard to the first endpoint, the survey
Statistical analysis have highlighted significant
of demographic profile of the sample has
correlations between abuses and neglect in
highlighted some important points for early
childhood with depressive spectrum disorders
diagnosis. The research also allows to deepen the
and substance abuse but also between substance
psychopathological correlates of the disorder.
abuse, BPD and depressive disorder in the
female sex. In male gender there are significant The third endpoint of this study is to evaluate
correlations between substance abuse and BPD the evolution of the classification of FD within
as well as between abuse and neglect in childhood the Diagnostic and Statistical Manual of Mental
and substance abuse and past experience of illness Disorders. With regard to this aim, the study
or long-term hospitalization. Many studies in showed that patients did not meet DSM-5
literature report a strong correlation between a diagnostic criteria in the 11.3% of cases; this is
history of physical and/or sexual abuse and the due to the fact that the diagnostic reformulation
development of borderline personality disorder has obviously caused the outplacement of some
[35-41]. disease’s diagnosis in other new additional
sections of the DSM.
Substance abuse disorders are also associated
with factitious disorders [42]. A statistically This study includes some limitations: firstly,
significant effect of BPD and abuses suffered the choice of case reports implies a bias of
in the childhood on substance abuse in both publication and selection: it may happen that
males and females emerged. In the female sex, some authors decide not to publish some cases as
depressive disorders have a significant effect on they are similar to other works in the literature or
use of substances. In literature there are some case because they present already found or less severe
reports that confirm the results of this statistical manifestations. Another possible limitation is
analysis: in particular the relationship between the fact that results of the study are based on case
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