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PubMed2001

A case of pain, factitious disorder and boundary violations.

Although health professionals are usually familiar with factitious disorders, evaluating such cases may be complicated, particularly in the legal arena. This article describes a patient who presented with pain complaints to numerous doctors. Eventually, a malpractice suit was brought against one of the patient's physicians who had diagnosed her condition as multiple personality disorder (dissociative identity disorder). Factitious disorder and the doctor's prescription of pain medications were issues raised during the trial. In view of the issue of harm, physicians' responsibilities and limitations during ongoing medical care are addressed in this case report.

Dissociative Identity Disorder↗
PubMed2003

[A case report of factitious disorder with hallucinations].

Although factitious disorder has been known for a long time, its diagnosis and treatment continue to be a problem. It is an uncommon condition associated with considerable morbidity and health care expenditure. We present a case of factitious disorder with hallucinations. A 37 year-old single woman has had auditory and olfactory hallucinations for six years. She had been diagnosed with schizophrenia, hospitalized for a short term, taking classical antipsychotic drugs for years. She has been performing her job as a teacher and living with her family. A suitable dose of atypical antipsychotic drugs was administered at a convenient time for her illness (Psychotic Disorder NOS) in psychiatric outpatient clinic of Kocaeli University. She was admitted to inpatient clinic twice in order to allow a clear diagnosis to be made. Psychotic disorder and temporal lobe epilepsy were ruled out. Borderline and histrionic personality traits were determined. Her complaints were unchanged over the course of treatment taking three years. She later started to come into the emergency department with anxiety symptoms, conversion like fits and suicide attempts; hospitalized for these complaints in another hospital. She was diagnosed with factitious disorder because of her unchanged complaints, her adding new complaints to the old ones, her complaints unrelated to psychosocial stressors, her ambitions to come to hospital, her increasing hospital dependence and having no prominent secondary gain. This case emphasizes the need for the careful observation of patients to prevent unnecessary investigations at the diagnosis and treatment stage and to establish a specific management strategy for the patients.

Adult↗
PubMed1996

Factitious disorders and the 'professional patient'.

Factitious disorders are fabricated illnesses. Conceptually, these disorders lie in the gray zone between malingering and real diseases. Clinical awareness will prevent unnecessary diagnostic and therapeutic interventions. The author profiles those patients and symptoms that accompany factitious disorders as well as factitious disorders by proxy. In the case of the latter, child abuse may be uncovered as well. Although rare, factitious disorders will be present in a busy primary care practice. Clinical detection based on patient profiles can aide discovery. Early recognition and management may prevent a chronic and debilitating course from culminating into one in which the person becomes a "professional patient."

Adult↗
PubMedDate not supplied

The psychology of factitious disorders. A reconsideration.

Factitious disorder (FD) is a form of somatization that involves apparent deception, simulation of illness, and imposture. This deception may be distinguished from other forms of lying in that patients with FD may suffer from underlying disturbances in the sense of reality and in reality testing. These features may be associated with a poorly consolidated sense of self and with difficulty regarding emotional experience as real. Factitious behavior may serve to stabilize the sense of self by concretizing and legitimizing the subjective experience of distress and by evoking responsiveness of a care-giver in a relatively safe, structured context. A psychotherapeutic stance focused on identifying and validating the patient's subjective experience may lead to a reduction in factitious behavior and to a more authentic and stable sense of self, in which emotional as well as physical experience is regarded as real. However, most patients with FD refuse treatment. Further, psychosis and suicidality are complications that may occur during the course of psychotherapy.

Adult↗
PubMed2003

A case of factitious disorder presenting as alcohol dependence.

Factitious disorders involve the feigning of physical or psychological symptoms in order to assume the patient role. Pseudologia fantastica, which involves the pathological creation of fabrications about one's background, is an associated feature of factitious disorders. Substance abuse disorders are also associated with factitious disorders. However, the manifestation of factitious complaints as substance abuse has yet to be reported in the literature. This case study describes a patient referred to a residential substance abuse treatment program who was discovered to have factitious alcohol dependence and prominent pseudologia fantastica.

Adult↗
PubMed1992

Factitious disorders with psychological symptoms.

BACKGROUND: Factitious disorders with psychological symptoms have been underdiagnosed and hence undertreated. Historically, the literature has focused on factitious disorder with physical symptoms, particularly Munchausen's syndrome. METHOD: The authors report three cases of factitious disorder with psychological symptoms that had diverse clinical presentations. RESULTS: Two of the patients had features of a psychiatric Munchausen's syndrome--being middle-aged, aggressive men who falsified their symptoms, treatments, and backgrounds. The third patient was a younger woman with comorbid substance abuse, dysthymia, and borderline personality disorder. CONCLUSION: The authors feel that there is a need for refinement of diagnostic criteria, greater awareness, and evaluation of treatment approaches for this condition.

Adult↗
PubMed1991

Factitious cyclic hypersomnia: a new variant of factitious disorder.

The central goal of patients with factitious disorders is to receive medical care. Unnecessary diagnostic procedures and recurrent hospitalizations often ensue. We saw a 39-year-old man with a novel variation of this disorder: factitious cyclic hypersomnia, or the simulation of recurrent episodes of excessive sleep. This case highlights the observations that patients whose illnesses are simulated may have diverse symptoms, that no syndrome is immune to factitious imitation, and that attempts at treatment, though exceedingly challenging, are always contingent upon appropriate recognition.

Adult↗
PubMed2003

Patients who strive to be ill: factitious disorder with physical symptoms.

OBJECTIVE: Factitious disorder with physical symptoms characterizes patients who strive to appear medically ill and assume the sick role. Clinical suspicion is highest for female health care workers in the fourth decade of life. This study was designed to analyze the diagnosis of factitious disorder, the demographics of affected patients, and intervention and treatment. METHOD: Retrospective examination was of 93 patients diagnosed during 21 years. Two raters agreed on subject eligibility on the basis of DSM-IV criteria and absence of a somatoform disorder and a plausible medical explanation. RESULTS: The group included 67 women (72.0%); mean age was 30.7 years (SD=8.0) for women and 40.0 years (SD=13.3) for men. Mean age at onset was 25.0 years (SD=7.4). Health care training or jobs were more common for women (65.7%) than men (11.5%). Most often, inexplicable laboratory results established the diagnosis. Eighty had psychiatric consultations; 71 were confronted about their role in the illness. Only 16 acknowledged factitious behavior. Follow-up data were available for only 28 patients (30.1%); maximum duration of follow-up was 156 months. Two patients were known to have died. Few patients pursued psychiatric treatment. Eighteen left the hospital against medical advice. CONCLUSIONS: Factitious disorder affects men and women with different demographic profiles. Diagnosis must be based on careful examination of behavior, motivation, and medical history and not on a stereotype. Laboratory data and outside medical records help identify suspicious circumstances and inconsistencies. Confrontation does not appear to lead to patient acknowledgment and should not be considered necessary for management.

Adult↗
PubMed1996

When Munchausen becomes malingering: factitious disorders that penetrate the legal system.

Psychiatrists and other physicians are usually familiar with factitious disorders, but attorneys and judges usually are not. Cases involving factitious disorders may enter the civil legal system in a number of ways and cause incorrect judgements, financial costs, and inappropriate medical care if these disorders are not identified. Psychiatric consultants may play a key role in identifying these cases and educating legal personnel about factitious disorders. This article describes three cases in which persons with factitious disorders entered the civil litigation system. The role of the psychiatrist in these cases is discussed. Clues to the identification of factitious disorders are described. The article also discusses the differentiation of factitious disorders from malingering and other forms of abnormal illness behavior, such as conversion, hypochondriasis, and somatization disorders. The concepts of primary and secondary gain in relationship to illness behaviors are elaborated.

Adult↗
PubMed1986

Chronic factitious disorders. Helping those who hurt themselves.

A chronic factitious disorder is a complex psychiatric illness that generally manifests itself in the medical/surgical setting. The immediate need for psychiatric intervention is generally overshadowed by the need for intense medical treatment. The psychiatric liaison nurse is in a key position to manage emotional nursing care during acute hospitalization. Assisting staff to recognize behavioral manifestations can help to prevent further self-destruction and promote future psychiatric followup. The prevalence of factitious disorders is probably higher than misconceptions about the disorder. The potential to save health care cost as well as needless human misery makes this a professional nursing concern. The high incidence of factitious disorders in the nursing profession may make profession may make it a personal issue for nurses as well.

Adolescent↗
PubMed2000

[Confronting patients about a factitious disorder].

Publications on the technique of confrontation in the treatment of factitious disorder are rare. Two serious cases of factitious disorder are discussed, one of a 25-year-old woman who was admitted after having suffered an epileptic insult in the street. When her general practitioner was contacted it turned out that she had a habit of being admitted to emergency departments presenting with pseudo-insults. The neurologist confronted her rather bluntly with these facts and she disappeared, without proper treatment. The other case was a woman aged 40 who suffered from a leg wound that would not heal. She was encouraged to consult a psychiatrist as well as a surgeon. When it was discovered that she kept the wound open herself, and when a second opinion was to amputate the leg, she was told that in order to give the leg a chance to heal, it needed to be emplastered. She consented but continued to see the psychiatrist and was reassured that the consultations would continue even if the leg had healed, which it did, without recurrence. The technique of the confrontation is of crucial importance for the prognosis of patients with factitious disorder. Factors include ample communication between surgeon and psychiatrist before a psychiatric consultation and confrontation are performed, mild confrontation together with the proposal of a comprehensive treatment plan by the same surgeon and psychiatrist who developed a working relationship with the patient, coordination with the nurses, and so on. The cases suggest that with the right confrontation technique, even serious patients can be treated successfully. Somatic specialists should be aware of the importance of communication with the psychiatrist before they attempt any kind of confrontation in patients with factitious disorder.

Adult↗
PubMed2002

Forensic assessment of illness falsification, Munchausen by proxy, and factitious disorder, NOS.

The purpose of this article is to propose guidelines for the evaluation of possible Munchausen by proxy child abuse for the court systems. These assessments require the evaluator to have an understanding of the complexity involved when this type of abuse is alleged. The evaluator should have an appreciation of how falsification of illness may or may not occur, recognize the need for careful analysis of medical records, and understand the problems associated with the use of a profile in determining the validity of an abuse allegation. This article presents guidelines for gathering pertinent data, analyzing records, and evaluating psychological testing for forensic evaluations when the questions for the evaluation are the following: (a) Is there evidence that child abuse did occur? (b) Does the alleged perpetrator meet criteria forfactitious disorder, NOS (or factitious disorder by proxy)? and (c) What management and treatment recommendations should be made?

Child↗
PubMed1994

Countertransference in factitious disorder.

In the treatment of patients with factitious disorder it is important to realize that at various levels of their experience these patients are more intimate with death than with life. This requires a particular awareness of resistance mechanisms to countertransference as well as of the importance of clinical procedures, in particular with regard to superego analysis. A requirement for establishing a psychotherapeutic alliance with patients suffering from factitious disorder is a high degree of 'therapeutic eros', hope and trust in one's own capabilities. The emphasis on a 'biophile attitude' does, however, involve the danger that the destructive potential, fantasies of death or killing, but above all feelings of guilt and shame are euphemistically interpreted and played down. A supportive superego analysis is viewed by the patient as playing down her or his 'terror of conscience' and a sense of being left alone. The therapist can be of greater help to the patient by focusing on his or her need and by escorting him or her. This requires that the therapist accept the feelings of relentlessness and hopelessness experienced by the patients in her- or himself. By relinquishing the denial of death-directed tendencies, the therapist is able to establish normality, reality and structure, and is thus in a position to exert a stabilizing effect, initially on her- or himself, but frequently also on the patient, for whom new horizons open.

Adult↗
PubMed1995

Factitious disorder presenting as bacteremia. Case report and literature review.

A factitious disorder is typically a chronic illness that can be frustrating for the clinical team because it often eludes early diagnosis. Case reports in the literature show that patients can simulate almost any illness or disease state with some resorting to injecting themselves with contaminated substances to produce infection. A case is reported of a patient with self-induced bacteremia who presented with multiple episodes of polymicrobial bloodstream infections. The various types of factitious disorders and a review of treatment options are discussed. The current criteria for factitious disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 4th edition are reviewed.

Adult↗
PubMed1998

Identification and classification of factitious disorders: an analysis of cases reported during a ten year period.

OBJECTIVE: The current article offers a new conceptualization of factitious disorders based on cases reported in the literature. METHOD: The current analysis examines twenty-nine cases of factitious disorder patients over the course of ten years (1986-1996). Cases were found through PSYCHLIT and MEDLINE searches. Patient variables examined include: demographics, occupational status, marital status, childhood history, extent of medical history, the presence of a borderline personality disorder, and presence of a psychosocial stressor prior to the onset of the factitious disorder. RESULTS: An examination of the cases found demographic patterns of illness presentation consistent with previous reviews of the disorder. From the examination emerged two distinct types of factitious presentations-one acute, one chronic. A two-dimensional approach is introduced in an attempt to understand various disease presentations. Cases were classified based on proposed Current Life Stress and Chronic Life Pattern dimensions. These dimensions are measures of the extent to which the patient's factitious presentation is in response to an immediate psychosocial stressor, or an action consistent with a long-term maladaptive behavior pattern resulting from an underlying character pathology. Three patient groups were identified based on estimated patient levels of each dimension. The three groups are: Stress Response, Life Response, and Mixed Response. CONCLUSION: Recommendations are made to increase the role of physicians in the detection of factitious patients, as well as to move toward a more uniform reporting of cases of factitious disorders in the literature.

Adolescent↗
PubMed2006

Factitious disorder on an inpatient psychiatry ward.

The authors present 6 cases of factitious disorder seen on a general adult inpatient psychiatry unit of a university hospital. They review the clinical features of this disorder and suggest that factitious disorder is much more prevalent among psychiatric inpatients than is commonly recognized. Strategies to assist in the diagnosis and management this disorder are detailed.

Adult↗