Transcript Factitious Disorders

Factitious Disorders
Motivation for Behavior -- sick role
External incentives for behavior -- absent
Essential Features
• Intentional production of
symptoms
• Judgment of internationality
– Direct evidence
– Exclusion of other causes
• Behavior:
– “voluntary”
• Act is intentional
– “not voluntary”
• Usually cannot be
controlled/compulsive
quality
• Even while knowing dangers
• Presumed goal of behavior
– Assume sick role as opposed
to Malingering
• Goal of Malingering
– Assume sick role to
accomplish externally
recognizable goal
(compensation, avoid jail or
military duty)
• In both disorders
“intentionality”
• In Malingering, symptoms
stopped when not useful
Other Features
• Presence of factitious symptoms
– does not preclude true physical or psychological
symptoms
• Diagnosis always implies psychopathology
• Frequently with predominately psychological
symptom type
– a severe personality disturbance is predisposing
factor
Making A Diagnosis
• Core concept is attempt, through
deception, to feign physical or
emotional illness in order to assume
role of patient
• Any mental disorder better
accounting for deceptive behavior
takes precedence
Consider the Following:
•
•
•
•
Many patients elaborate
illness & exaggerate
symptoms
– but no overt deception with
non-existent illness
Conscious & intentional faking
medical condition
– for sole patient role
No certain method of
detecting feigned illness
Discovery results
– by patient mistake or
– staff suspicion of
inconsistencies
•
Symptoms may disappear
•
Is there?
•
Are psychiatric symptoms
unresponsive to standard
treatment?
Patient is vague or lies about
history
Patient becomes abusive,
accusatory of incompetence, or
abruptly leaves hospital when
suspicion arises.
•
•
– under constant observation or
when no access to personal
belongings
–
excessive knowledge of
symptoms &
– suggestions of medical tests
Other Important Clues
• History of previous inconclusive
hospitalizations
• Multiple surgical scars especially on
abdomen
• History of serious illness as child
• Fever present without other evidence
of active disease
Confrontation of Patient
• Team effort needed
• Only after a social/psychiatric care
plan can be arranged
• Generally direct confrontation (esp.
if premature) is met with
– denial, anger & outrage
– & a quick departure from medical
setting
Munchausen Syndrome
by Proxy (MSP)
• Sick role by proxy
– Victim usually child
• Behaviors to get into
or stay in hospital
• Describes children
whose caretakers
(generally mothers)
invent false illness
• Substantiated by
fabricated evidence
• Usually involves
emotional abuse &
sometimes severe
physical abuse
– (usually in 1st 2 yrs. of
child’s life)
– Often undetected form
of child abuse
• May indicate intense &
symbiotic relationship
with mother
Associated Features
• With psychological symptoms – severe
character pathology almost always present
– Secret use of psychoactive substances may
allow production of mental disorder
• With physical symptoms – psychoactive
substance abuse is common
– Severe character pathology is invariably
present
Prevalence
• More common in males
• Relatively rare (1982 –
only 100 cases in 80
yrs)
• Factitious by Proxy
– Usually females
Course
• May be limited to 1
episodes
• Onset usually early
adulthood
– often after hospitalization
• Usually short-lived &
complete recovery
– Often “spontaneous
recovery”
• Chronic form of
successive
hospitalizations
– may become lifelong pattern
Cost of Factitious
Disorder
• Extremely high due to number of
tests to rule out & make accurate
diagnosis
• Individual my flee hospital without
paying
Treatment
• No established treatment of choice
– Closed ward to prevent leaving or avoiding
treatment
• Patients rarely seen due to lack of
motivation
– Might appear due to family pressure
• Due to outrage unlikely to engage in
meaningful treatment
Treatment Options
•
Comprehensive diagnostic evaluation
•
Concentrate on therapeutic relationship
•
•
•
May remain in treatment if attention to feigned complaints & dependency
needs
Look at severe external stressors
Behavior modification successful
•
Reality therapy
•
Medication – no role yet established
– to identify & treat associated disorders
– to help recognize psychological basis
– May motivate healthy mental state vs. sick role status
–
with long term (3 yrs) hospitalization
– demonstrates behavior not meeting needs
– development of more rewarding ways to operate
–
–
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Could justify with associated psychiatric disorder
Anticipate non-compliance
Potential for substance abuse
Other Options for
Treatment
• Diagnosis of Munchausen’s Syndrome
• May facilitate next physician
• Publish Blacklist
– Central register or International Rogues Gallery
• Encourage adoption of “pseudo-factitious” behaviors
– to satisfy psychological needs while avoiding risky behaviors
as surgery
• Abdominal scars easily removed with soap & water
• Imprison for unremitted hospital expenses
• Tattoo diagnosis on abdomen to alert next physician