By Rawan Abu Nsair

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Title of article: Factitious Disorder.
Author: Rawan Osama Abu-Nsair.
Editors: Ihdaa  Bani Khalaf, Sadeen Eid.
Reviewer: Ethar Hazaimeh

Keywords: factitious disorder, fabricate, Munchausen.

Introduction

Hieronymus Karl Friedrich von Munchausen is a German officer who fought in the Russo-Turkish War. ⁽²⁾ After retirement, he worked as a paid entertainer and was a well-known wartime fabulist in Hanover. ⁽²⁾ Lunar travel, riding a cannonball, and being eaten by a giant fish, are all some of his tales that inspired the German Writer Rudolf Erich Raspe to write a social satire based on von Munchausen’s tales. ⁽³⁾

Years after, in 1951, Richard Asher was the first to link von Munchausen’s falsehoods with the factitious behavior of some patients, calling it “Munchausen’s Syndrome”. ⁽⁴⁾

This eponym was replaced by the new nomenclature: “Factitious Disorder (FD)”. After that, it appeared first in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-3) in 1980. ⁽⁵⁾ In detail, it is now defined as a psychiatric disorder in which sufferers intentionally fabricate illness, injury, impairment, or psychological signs and symptoms to gain hospital admission and undergo medical procedures without any apparent gain. ⁽⁶⁾

FD has two subtypes. The first is “Factitious disorder Imposed on Self”; in which the patient fabricates illness or injury on himself. ⁽⁶⁾ The second is “Factitious disorder Imposed on Another”; which was previously known as “Factitious Disorder by Proxy”. ⁽⁶⁾ In this subtype, the patient presents another person as ill or impaired. ⁽⁶⁾

Figure (1); factitious disorder (1).

Epidemiology

The exact prevalence of Factitious Disorder in hospital settings is currently unknown. ⁽⁷⁾ This could be due to the fact that these patients are usually efficient at hiding their behavior, as well as the involvement of multiple physicians in treating, and the lack of trained healthcare providers in making the diagnosis. ⁽⁸⁾ In addition, the abundance of online medical knowledge may enable patients to present with complex medical problems. ⁽⁹⁾

FD accounts for 0.8%-1%  of psychiatric referrals. ⁽¹⁰⁾ A recent systematic review of 455 cases of FD ⁽⁹⁾ found that 33.8% of patients were males, consistent with many other previous studies that reported a female predominance. ⁽¹¹⁾  Furthermore, the mean age of presentation is 34.2 years. ⁽⁹⁾ Interestingly, 57% of patients have a healthcare-related occupation, with the single most common occupation being nursing. ⁽⁹⁾

Etiology and pathogenesis

According to DSM-5, FD patients tend to intentionally produce symptoms only to assume the sick role. ⁽⁶⁾ It is believed that this motivation is related to psychological deficits rooted in early childhood trauma including physical and mental abuse. ⁽¹²⁾ There are many suggested theories about the psychology that lies behind FD, but none are approved. ⁽⁹⁾

In the meantime, the literature suggests that mothers who have childhood histories of loss, abuse, privation, bereavement, a longstanding history of relational dangers, and disrupted attachment are at a higher risk to fabricate or induce illness in their children. ⁽¹³⁾

Pathological liars showed a strongly activated prefrontal cortex during lying, a 22% increase in its white matter, and a 14% reduction in the grey matter when compared to normal people. ⁽¹⁴⁾ However, it is still controversial whether changes in this area lead to the factitious behavior or the act of lying resulted in these organic changes. ⁽¹⁵⁾

DSM-5 Diagnostic Criteria ⁽⁶⁾

Factitious Disorder Imposed on Self

1. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
2. The individual presents himself or herself to others as ill, impaired, or injured.
3. The deceptive behavior is evident even in the absence of obvious external rewards.
4. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Specify:

Single episode

Recurrent episodes (two or more events of falsification of illness and/or induction of injury)

Factitious Disorder Imposed on Another

(Previously Factitious Disorder by Proxy)

1. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.
2. The individual presents another individual (victim) to others as ill, impaired, or injured.
3. The deceptive behavior is evident even in the absence of obvious external rewards.
4. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

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

Specify:

Single episode

Recurrent episodes (two or more events of falsification of illness and/or induction of injury).

Clinical presentation

Most patients are presented to general hospitals in their mid-30s. ⁽¹⁶⁾ In any case, FD patients are attracted more to presentations that are associated with fast-track admission. ⁽⁹⁾ Moreover, a recent study found that 58.7% of patients induce injury or illness on themselves, 22.2% falsely report a medical problem, and 19.1% attempt only to simulate a medical problem. ⁽⁹⁾

The variety of possible presentations depends on the patient’s imagination and medical knowledge. ⁽¹⁷⁾ However, this is limited by the nature of the fabricated medical problem. ⁽⁹⁾ For example, most are presented with dermatological or endocrinological problems, respectively. ⁽⁹⁾ This could be also attributed to the increased awareness of physicians in these specialties in FD and the commonly fabricated symptoms. ⁽⁹⁾

All in all, those patients usually have a medical history full of multiple investigations and treatments. ⁽¹⁸⁾ Also, they tend to show a lack of concern for the medical problem. ⁽¹⁹⁾ Moreover, their behavior is characterized by disobedience to hospital rules and excessive arguing with medical care providers. ⁽²⁰⁾ Interestingly, when hospitalized they receive few or no visits at all. ⁽²⁰⁾ When confronted, they tend to aggressively deny or leave without a formal discharge. ⁽²⁰⁾  However, the diagnosis is mostly made by a passing physician or nurse who recognizes the patient. ⁽²¹⁾

Differential diagnosis

To begin with, motivation plays an essential role in differentiating FD from other similar disorders. For example, external incentives like avoiding military duty, work, or obtaining financial compensation, are associated with Malingering. ⁽²²⁾ In contrast, FD patients have no clear external rewards, and the motivation is almost always obscure. ⁽²³⁾ A recent case report suggested that there could be an overlap between the two diagnoses, as some degree of gain in the form of free accommodation and food was present. ⁽²⁴⁾ In somatic symptom disorder, although there are excessive medical concerns and visits, there is no evidence of deception. ⁽⁶⁾ This is also true with Conversion disorder (functional neurological symptoms disorder), which is characterized by neurological symptoms that are inconsistent with neurological pathophysiology. ⁽⁶⁾

As aforementioned, early-life trauma which could predispose to FD, ⁽¹²⁾ is also associated with Personality disorders, especially Borderline personality disorder. ⁽²⁵⁾ Moreover, this suggests a strong co-morbidity between the two disorders. ⁽²⁵⁾ Also, a recent study found that Depression is the most common co-morbid psychiatric disorder. ⁽⁹⁾ In addition, other common comorbid disorders include anxiety, substance abuse, conversion disorder, and eating disorders. ⁽⁹⁾

Management

Initially, management of these patients includes acute management and long-term management like engaging the patient in psychotherapy. ⁽²⁶⁾ Additionally, it is necessary to avoid direct confrontation in the acute or inpatient setting as this could be counter-therapeutic. ⁽²²⁾ This led to the emergence of  “Supportive confrontation”, in which the confrontation process involves at least two of the caregivers, highlighting the patient’s need for help, and reassuring them that care will continue. ⁽²⁷⁾ In spite of this, some could interrupt confrontations, or even escalate their self-destruction behavior, and seek care elsewhere. ⁽²⁶⁾ After all, only 17.2% of the confronted patients acknowledged their fictitious behavior. ⁽¹¹⁾

In long-term management, there are many suggested treatments; including psychotherapy, behavioral therapy, medication treatment, and multidisciplinary approaches. ⁽²⁸⁾ Unfortunately, FD treatment is not based on controlled and randomized trials. ⁽²⁸⁾ Also, a systematic review reported no difference in effectiveness between any of the suggested treatments of FD. ⁽²⁸⁾ 

Prognosis and effect on life

In general, FD is a chronic disease, although it can be limited to one or more brief episodes ⁽²⁹⁾  and recovery is rare. ⁽³⁰⁾

This disorder carries significant morbidity and mortality, and legal issues could arise in some cases. ⁽³¹⁾ Besides, the multiple unnecessary investigations, medical procedures, and hospitalizations form a huge economic burden and strain the medical care system. ⁽²¹⁾ A six-year follow-up of one patient revealed four hospitalizations with a total cost of 47,487.14 $. ⁽²¹⁾

A recent systematic review reported that 14.1% of patients have current suicidal ideation or previous suicidal attempts. ⁽⁹⁾ Judicial issues could arise also in FD imposed on another, as it may be consistent with abuse, especially if the victim is a child, a vulnerable adult, or an elder. ⁽³²⁾

Munchausen by Internet

This term emerged first in 2000, to describe cases of virtual FD, in which patients show factitious behaviors but on online platforms. ⁽³³⁾ They may use chat rooms or online support groups to falsely represent a serious illness that could negatively affect real patients.⁽³⁴⁾

The continuous invasion of social media in our lives could make it an increasing issue. ⁽³³⁾ Literature about this pattern is not enough. More research should be done to evaluate the prevalence and the potential harm.

References...

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