Definition, Description, Classification, Clinical Features and Management of Factitious Disorders

1. Dr. Anubhuti Sharma
Psychiatry Resident
JLN Medical College, Ajmer, India
Dr Parth Singh Meena
Associate Professor
JLN Medical College, Ajmer, India
Under Guidance Of

2. INTRODUCTION
 Factitious means “artificial, false,” from the Latin facticius, “made
by art.”
 The main clinical feature of factitious disorder is the falsification of
physical or psychological signs or symptoms, or the induction, or
exaggeration, of injury or disease.
 It must be associated with identified deception and be evident even
in the absence of obvious external rewards.
 An individual may present oneself as ill, impaired, or injured, in
which case the diagnosis is factitious disorder imposed on self.

3.  If an individual presents another individual as ill, the diagnosis is
factitious disorder imposed on another.
 considered part of the Somatic Symptom and Related Disorders
category

4.  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 even 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: single episode Recurrent episode (two or more events of falsification of illness
and/or induction of injury)

5.  term coined by Richard Asher in his landmark 1951 publication, is
known as chronic factitious disorder with predominantly physical
signs and symptoms in the lexicon of DSMIV.
 Some practitioners use the term Munchausen syndrome for a
chronic, severe, refractory form of factitious disorder, in which
deceptive illness behavior becomes a lifestyle, precluding stable
relationships or employment.
 Munchausen syndrome comprises approximately 10 percent of all
cases of factitious disorder.

6.  Constantly seeking medical care and hospitalization, such patients
often assume grandiose false identities, sometimes claiming to be
royalty, relatives of celebrities, or figures in important historical
events
 They travel from hospital to hospital, and when they become well
known in one city, take their deception on the road to begin the
behavior anew elsewhere.
 Previous terms applied to these patients included hospital hoboes,
hospital addicts, and professional patients.

7.  Two distinguishing features of Munchausen syndrome beyond the
simulation of disease are pseudologia fantastica—the telling of
vague, selfaggrandizing, heroic tales often containing a kernel of
truth—and peregrination—the tendency to travel widely.

8.  There is evidence to support a second durable phenotype of
factitious disorder imposed on self, called common factitious
disorder, in which factitious behavior is confined to one locality and
a relatively circumscribed set of complaints.
 The prototypical patient tends to be young, female, socially
connected, employed, and working in health care.

9.  Person intentionally simulates illness in another individual, often
someone who is dependent on the perpetrator for care.
 Most commonly the perpetrator is a mother feigning or producing
illness in her own preverbal infant.
 Factitious disorder imposed on another may also be committed
against an adult, such as an elder or spouse.
 Epidemics of hospital deaths have been attributed to medical
personnel inducing or exacerbating illnesses in patients.

10.  Because factitious disorder imposed on another almost always
constitutes child abuse or criminal abuse, the forensic terms
“perpetrator” and “victim” are used even in the medical literature.
 Subsequent to the DSM-5, factitious disorder imposed on another
replaces the terms factitious disorder by proxy and Munchausen
syndrome by proxy in psychiatric nomenclature.

11.  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 present even 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
Note: the perpetrator, not the victim, receives this diagnosis.

12. HISTORY
 In 1838, the Scottish military physician Hector Gavin published an
essay, “On the Feigned and Factitious Diseases of Soldiers and
Seamen, on the Means Used to Simulate or Produce Them, and on
the Best Modes of Discovering Impostors.”
 Jean-Marie Charcot, around 1890, used the term mania operativa
activa to describe a young girl who continually sought surgery for
pain in a knee joint, until her medical care-seeking resulted in a
surgeon amputating the leg.

13.  In 1901, the Swiss physician Henri Secretan lent his name to a
peculiar syndrome of nonhealing, traumatically induced edema of
the dorsum of the hand. G. Reading, in 1980, confirmed that
Secretan syndrome is factitiously produced.
 In 1934, Karl Menninger described “polysurgical addiction
 “Munchausen syndrome by proxy” was first described in 1977 by
British pediatrician Roy Meadow. He described one mother who
caused salt poisoning in her child and another mother whose
repeated fabrications of urinary tract infections in her daughter

14. NOSOLOGY
 The DSM-III, in 1980, was the first edition of the DSM to recognize
factitious disorder. It focused on Munchausen syndrome, calling it
the “prototype” of all factitious disorders.
 DSM-III-R recognized factitious disorder with physical symptoms
and factitious disorder with psychological symptoms.
 DSM-IV defined a single category, factitious disorder, with three
types:
(1) with predominantly psychological signs and symptoms,
(2) with predominantly physical signs and symptoms, and
(3) with combined psychological and physical signs and symptoms.

15.  First, it formally recognized factitious disorder by proxy by dividing
the general category of factitious disorders into two groups:
factitious disorder imposed on self, and factitious disorder imposed
on another. The diagnosis of factitious disorder NOS was eliminated.
 Second, there is no longer a distinction between physical or
psychological presentations. Factitious disorders are now specified
as being a single episode or recurrent episodes.
 Third, the criteria no longer require that illness induction be
conscious or intentional, recognizing the difficulty inherent in
making such a determination. Instead, evidence of deception in the
absence of clear material gain is sufficient to establish
factitiousness.

16.  The tenth revision of the International Statistical Classification of
Diseases and Related Health Problems (ICD-10) lists factitious
disorder (F68.1) under the category “other disorders of adult
personality and behaviour,”
 It emphasize the strong association of personality disorders and
factitious disorders.
 The diagnostic label is “intentional production or feigning of
symptoms or disabilities, either physical or psychological (factitious
disorder).”
 definition emphasizes the lack of obvious external motivation.

17.  “The motivation is obscure and presumably internal with the aim of
adopting the sick role.”
 There are four subtypes:
(1) unspecified;
(2) with predominantly psychological signs and symptoms;
(3) with predominantly physical signs and symptoms; and
(4) with combined psychological and physical signs and symptoms

19. EPIDEMIOLOGY
 Most doctors will encounter at least one patient with FD over the
course of their clinical practice
 FD may account for between 0.6% and 3% of referrals from general
medicine to psychiatry and between 0.02% and 0.9% of cases
reviewed in specialist clinics
 A recent study surveying physicians' own estimates of the presence
of factitious symptoms among their patients reported a higher
prevalence rate of 1.3% .
Gregory P. Yates, et al 2016

20. ETIOLOGY
Factitious Disorder Imposed on Self.
 Unknown,
 Two factors underlie most cases of factitious disorder:
(1)an affinity for the medical system and
(2) poor, maladaptive coping skill
 A majority of factitious disorder patients have medical training,
 Patients seem to come from large families or to have been neglected
as children. grown up without consistent nurturing conducive to the
development of mature coping.

21.  The poor coping skills of these patients are often symptomatic of an
Axis II disorder, such as borderline, narcissistic, dependent, or
antisocial personality disorder.
 Factitious disorder may be the presenting symptom of an Axis I
disorder.
 Many case reports indicate a lessening or alleviation of factitious
illness behavior when major depression is treated.
 Other case reports point to hypochondriasis as an underlying
factor.

22.  Psychodynamic theories have focused on the concepts of mastery,
masochism, and mothering.
 Striving for mastery may especially apply to factitious disorder
patients with predominantly psychological signs and symptoms.
For example, patients with factitious psychosis often progress to
develop a genuine psychotic disorder, which suggests that the feigning of
psychosis may represent a defense or a way of feeling in control of initial
psychotic symptoms.

23.  Many patients with factitious physical symptoms seem to have
suffered traumatic illnesses as children,
 adult factitious illness behavior may represent an attempt to
master and to feel in control of situations in ways in which they
never did as children.
 They demand or refuse procedures and leave the hospital
against medical advice when they feel they are losing control.

24.  Masochism may be a reason that patients repetitively endure
painful or deforming surgeries and procedures, such as amputations
of limbs and fingers, or exploratory abdominal surgeries that result
in extensive scarring.
 The patient relives childhood physical or emotional abuse at the
hands of the medical staff in a repetition compulsion.
 The physician and the medical system at large become symbolic
parents against whom the patient re-enacts dependency,
idealization, and anger.

25.  Behavioral theories postulate that early in life, these patients
received positive reinforcement when sick and perhaps gained
nurturing from the medical community that they did not receive at
home.
 Perhaps they learned to see the medical system as a source of
caring and emotional support.
 Alternatively, many of these patients lived in large, neglectful
households and became the center of focus only when ill.

26.  Psychodynamic theories predominately explain objectification of
the child to serve the parent’s psychological needs.
 Schreier and Libow called it as perversion of mothering in which a
child is dehumanized by the mother and instead serves as a
fetishized object through which the mother’s dependency needs are
met.
 Eminson and Postlethwaite argued that two axes are at play: The
desire to consult, and the inability of the parent to distinguish
parental needs from the child’s needs.
 Rosenberg noted a disorder of empathy among perpetrating
mothers, along with pervasive themes of loneliness and isolation,
often under circumstances of uninvolved or absent husbands.

27.  Four factors that suggest a caregiver at risk of fabricating illness in
a child include:
 (1) appearing to need or thrive on attention from physicians;
 (2) insisting the child cannot cope with the caregiver’s ongoing
attention;
 (3) being directly involved in a medical profession or having
expertise or familiarity with medical knowledge and terminology;
and
 (4) having a history of factitious or somatic symptom disorder

28. DIAGNOSIS AND CLINICAL
FEATURESFactitious Disorder Imposed on Self
The diagnosis of factitious disorder should be actively pursued and
not considered a diagnosis of exclusion. This is recommended for the
following reasons:
(1) Satisfactory exclusion of all other possibilities may be difficult to
accomplish or impossible;
(2) early diagnosis can minimize the patient’s self-harm, as well as
harm through iatrogenic complications;
(3) confirmation of deceptive behavior requires positive proof that is
usually not forthcoming without proactive investigation; and
(4) failure to consider the diagnosis is the most common reason for
missing a diagnosis of factitious disorder.

29. Factitious symptoms can be
 (1) fabricated, for example, by giving a false history of cancer,
acquired immune deficiency syndrome (AIDS), or another illness;
 (2) feigned, for example, by faking symptoms such as pain or
seizures;
 (3) induced, by actively producing symptoms through selfinfliction of
injury or through injection or ingestion; or
 (4) aggravated, such as by manipulating a wound so that it will not
heal.

30.  Factitious psychological symptoms are more challenging to diagnose
because of the lack of clear objective markers for psychiatric
symptoms.
 the patient may present with unusual symptoms that fail to
correspond to any recognizable diagnosis.
For example, one patient reported no other psychotic symptoms
except seeing the entire cast of a television show emerge from her
closet.

31.  Other features include worsening of symptoms when the patient is
aware of being observed, inconsistencies in the patient’s story over
time, and the patient’s overeagerness to recount symptoms of the
illness.
 Such patients are often suggestible and readily admit to additional
symptoms on questioning.
 They may refuse to cooperate with obtaining collateral information,
and untraceable prior health care providers are not unusual.
 On admission to the ward, patients may reveal familiarity with
hospital routine while denying previous hospitalizations.

32.  They may exhibit dramatic and unusual reactions to medications.
 They may demonstrate attention-getting tactics by breaking ward
rules.
 Visitors are usually few or absent.
 In contrast to patients with physical factitious disorders, who tend
to avoid psychiatric care, these patients actively seek contact with
the psychiatric system and readily acknowledge the presence of a
psychiatric disorder, even if it may not be the one from which the
patient actually suffers.
 Feigned bereavement and then psychosis appear to be the most
common presenting symptoms.

33.  Covert surveillance, hidden video cameras, or searching the patient’s
belongings for syringes or illness-inducing substances can be
employed after considering the patient’s right to privacy and the
bounds of the patient– doctor relationship.
 Legal counsel is advisable, and in some cases, court orders should be
obtained.
 Consultation from a bioethics team can help weigh the benefits and
risks of violations of privacy versus morbidity from factitious
disorder.

34.  This phase of acquiring information to confirm a diagnosis is often a
time of conflict for staff, who may have split opinions about the
patient and about the means being employed to confirm diagnosis.
 Regular interdisciplinary meetings are helpful.

35. Munchausen Syndrome.
 Diagnosis is often simpler than in other cases of factitious disorder
because of the tendency for dramatic, exaggerated presentations.
 These patients often are new to a particular area, being prone to
peregrination.
 Munchausen syndrome patients often appear eerily comfortable in
hospital settings, immediately talking to nurses, physicians, and
medical staff as peers.

36. They demonstrate pseudologia fantastica, a specific syndrome of
autobiographical lying with four features as defined by King and
Ford:
(1) the stories are not entirely improbable and are built upon a basis
of truth;
(2) (2) the stories are enduring;
(3) (3) the stories are not told purely for personal gain, and have a
self-aggrandizing quality; and
(4) (4) they are not delusions, in that the patient can admit to
falsehoods when confronted with conflicting facts.

37.  Munchausen patients often manifest hostility when their needs are
not met or they are confronted by staff regarding suspicions of
deception, and will then leave the hospital abruptly.
 They present repeatedly under different names to different
hospitals, employing a repertoire of symptoms and presentations to
gain admission and treatment

38. Factitious Disorder Imposed on Another.
 The essential feature is the intentional feigning or production of
physical or psychological symptoms in another individual who is
under the perpetrator’s care.
 Mothers of preverbal infants are the most common perpetrators,
although fathers, other family members, babysitters, and even
medical professionals also have been implicated.
 Victims can also be spouses, elderly parents, hospital patients, or
anyone under the care of a perpetrator

39.  Perpetrating caregivers usually appear to be concerned and
interested in their children’s care.
 They tend to be exemplary in their interactions with medical staff,
enlisting support and sympathy, often crossing professional
boundaries by eating meals with staff or helping nurses with duties.
 They may demonstrate unusual willingness or even excitement at
the prospect of invasive procedures for their children.

40.  The gold standard for confirming factitious disorder imposed on
another is covert video surveillance that may record a perpetrator
causing harm. (after consultation with legal counsel because a court
order may be legally required)
Other means :
 searching a mother’s belongings for illness-inducing agents,
reviewing collateral information and past medical records for
inconsistencies,
 gathering information on siblings,

41.  recording temporal associations between parental visits and a child’s
signs and symptoms.
 observing the child’s well-being when he or she is removed from the
parent’s care,
 and analyzing specimens taken in the presence of the parent
compared to those taken in the parent’s absence.

42. DIFFERENTIAL DIAGNOSIS
 An underlying physical or psychiatric disorder is the main
consideration in the differential diagnosis of suspected factitious
disorder.
For example, a 46-year-old woman with type 2 diabetes
manifested multiple episodes of hypoglycemia despite several
inpatient hospitalizations to optimize her diet and insulin regimen,
and she was suspected of factitious disorder until it was discovered
she had developed antibodies to insulin.
 Cognitive disorders due to cerebral lesions, neurodegenerative
disorders, and delirium may lead to self induced illness and
deceptive behavior.

43.  Munchausen syndrome patients may become addicted to narcotics or
learn to seek disability payments and thereby also demonstrate
substance abuse and malingering.
 In somatic symptom disorder there are one or more physical
symptoms which cause disproportionate distress manifesting in
thoughts, feelings, or behaviors. If the physical symptom does not
have a clear etiology or does not conform to typical clinical
phenomenology, suspicions may be raised for factitious behaviors,
but positive evidence for deceptiveness will be lacking.
 In illness anxiety disorder (formerly hypochondriasis), normal
physiologic sensations are perceived as harbingers of dread disease
despite negative tests and reassurance to the contrary.

44.  If a symptom is neurological and is not consistent with neurologic
pathophysiology, then conversion disorder should be diagnosed.
 Patient with borderline personality disorder may engage in self
destructive, physically injurious, or psychologically damaging
behavior resulting in illness (such as overdosing on acetaminophen
or cutting one’s arm) for the purposes of stress reduction, pain relief,
or conveying distress.
 if deceptive behavior is performed to obtain a material gain such as
to procure disability payments, narcotics, or an excuse from work,
malingering is diagnosed.

45. Factitious Disorder Imposed on Another.
 Hypochondriasis by proxy, a hypochondriac mother preoccupied with
her child’s health may repetitively seek pediatric care leading to
unnecessary procedures and iatrogenic illness for the child.
 In anorexia nervosa by proxy, an anorexic mother may restrict her
child’s food due to fears of excessive weight in her child.
 A mother with malingering by proxy may put her child through
multiple evaluations to maintain disability or welfare payments.
 A paranoid father with a history of psychosis feared that his son was
being

46.  masquerade syndrome (in which illness fabrication results in the
child’s increasing dependency on the mother),
 mothering to death (in which the child is confined to a sick role as if
the child were ill, while avoiding physicians and agencies),
 extreme illness exaggeration (in which a parent exaggerates their
child’s symptoms in an effort to increase a pediatrician’s attention to
the child).

47. COURSE AND PROGNOSIS
Factitious Disorder Imposed on Self
 Difficult to determine
 Wide spectrum
 At one end factitious illness behavior could be considered within
normal range,
as when a patient magnifies his symptoms to seek reassurance from a
physician, or when a patient lies about completing her antibiotic course
for cellulitis in order to win attention.
 Further along the spectrum, factitious illness behavior becomes a
maladaptive coping mechanism but not a chronic pattern of
deception.

48.  Less pernicious cases may respond to a clinician’s sensitive inquiry
into the precipitants to factitious behavior, and coaching the patient
to find more adaptive solutions
 Concurrent mood, anxiety, or substance abuse disorders bode a
better prognosis;
 comorbid personality disorders, especially antisocial personality
disorder, bode a poorer prognosis.
 Munchausen syndrome tends to have an unremitting, refractory
course, and is associated with substantial morbidity and mortality.
 After efforts to engage a patient in treatment fail, management
should be directed toward harm reduction rather than cure.

49. Factitious Disorder Imposed on Another.
 Victims of factitious disorder imposed on another are at very high
risk.
 Mortality rate estimates of victims range from 6 to 22 percent, with
deaths commonly occurring through suffocation or poisoning.
 Siblings of victims are at great risk.
 Studies indicate that 9 to 29 percent of siblings die, underscoring
the importance of checking and protecting all children of a given
perpetrator.

50. TREATMENT AND
MANAGEMENT
Factitious Disorder Imposed on Self.
Three major goals should guide the treatment and management of
factitious disorders:
(1)to reduce the risk of morbidity and mortality,
(2) to address the underlying emotional needs or psychiatric diagnosis
that may be driving factitious illness behavior, and
(3) to be mindful of legal and ethical issues.

51. 1. Risk Reduction:
 The Hippocratic doctrine of “first do no harm” should be foremost.
 Active pursuit of the diagnosis and timely management are
essential.
 For example, in the case of a woman who reported an extensive
family history of breast cancer and sought prophylactic
mastectomy, early suspicion of factitious disorder may have
prevented the unnecessary bilateral mastectomies

52.  Once symptoms are confirmed as factitious, clinicians should
administer medical treatment according to their clinical judgment,
considering objective evidence and keeping in mind that the
patient’s complaints and requests can be deceptive.
 Good communication among all involved is essential because these
patients are prone to cause confusion and splitting of caretakers.
 Regular interdisciplinary meetings are helpful.
 Negative countertransference can lead to therapeutic nihilism,
breaches of confidentiality, inappropriate treatment, or denial of
care.

53.  On an outpatient basis, all medical care should be directed through
a single primary care physician through whom all care is
coordinated.
 As a means of last resort, legal disincentives might be pursued.

54. Addressing Psychiatric Issues
 Allowing the patient to save face is essential toward establishing a
therapeutic alliance and toward preventing the patient from simply
taking the factitious illness behavior elsewhere.
 patients usually have immature personalities or personality
disorders that make them especially sensitive to narcissistic injury.
 Direct or aggressive confrontation is generally not effective.
 confrontation may amplify the patient’s psychological need for
mastery through deception

55.  Eisendrath advocated a double-bind technique whereby patients are
told that if the symptoms are genuine, then they should improve
with the treatment administered. If the symptoms do not improve,
then they must be factitious.
 Self-hypnosis and biofeedback can allow a patient to relinquish
factitious behavior in a face-saving manner.
 For example, a patient can be told that under self-hypnosis, blood
flow to a wound can be increased and healing promoted. In this
manner, the patient can take control of healing the wound, rather
than seek control by worsening symptoms. Positive feedback
should be given to patients when their efforts result in healing.

56.  Factitious disorder is confirmed, the patient should be gently and
artfully steered toward ongoing psychiatric treatment in a
sympathetic manner acceptable to the patient.
 For example, the patient can be told that his or her factitious
illness behavior is an expression of great emotional need or
distress.
 Psychiatric treatment should first focus on underlying or comorbid
psychiatric disorders or on the emotional distress that might have
precipitated the factitious illness behavior
 For example, most cases of feigned bereavement are comorbid
with major depression.

57.  Comorbid personality disorders are more common than affective or
psychotic disorders.
 Borderline personality disorder is the most common comorbid
diagnosis.
 Antisocial personality traits are also common, especially in patients
exhibiting pseudologica fantastica and Munchausen syndrome.
 Pharmacologic and psychotherapeutic treatments should be
employed according to the diagnosis.

58.  Substance abuse and dependence may require intensive outpatient
or residential inpatient treatment.
 Other than targeting comorbid psychiatric disorders, there is no
standard pharmacologic treatment for factitious disorder
 the greatest challenge is getting the patient to engage and commit to
long-term therapy.
 Brief regularly scheduled contact on a time-contingent rather than a
distress contingent basis is the mainstay of therapy

59.  Consistent long-term psychotherapy is aimed at enabling patients to
express their feelings,
 gain insight and coping skills, and provide a reliable and supportive
outlet for communication.
 Relapses of factitious behavior should be expected.
 Clinicians should not despair at relapses, but instead take them as
opportunities to further understand their patient.

60. 3. Managing Legal and Ethical Issues:
 Patients’ right to privacy and implicit injunctions against
unwarranted searches and seizures are major issues., once a patient
acknowledges having factitious disorder, the patient can be asked,
“I’d like to minimize harm to you. Can I have your permission
to alert emergency rooms and some doctors in the community?”
 patient’s right to confidentiality should be respected when gathering
collateral information in nonemergent situations.
 Verbal permission or, preferably, signed releases of information
should be obtained prior to contacting collateral sources, except in
emergency situations.

61.  Clinicians should be careful about revealing information to the
patient’s employers, friends, or family.
 The diagnosis of factitious disorder must never be revealed, even to
spouses or significant others, without a patient’s explicit permission,
as this will likely lead to accusations of confidentiality breachnship.
 Covert surveillance should only be undertaken after careful legal
consultation.

62.  Keep in mind that active pursuit of a prompt diagnosis can minimize
the risk of morbidity and mortality.
 Minimize harm.
 Avoid unnecessary tests and procedures, especially if they are
invasive.
 Treat according to clinical judgment, keeping in mind that subjective
complaints may be deceptive.
 Arrange regular interdisciplinary meetings to reduce conflict and
splitting among staff.

63.  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 in an empathic,
nonconfrontational, face-saving manner.
 Avoid aggressive direct confrontation.
 Treat underlying psychiatric disturbances such as Axis I disorders
and Axis II disorders.

64.  In psychotherapy, address coping strategies and emotional
conflicts.
 Appoint a primary care provider as a gatekeeper for all
medical and psychiatric treatment.
 Consider involving risk management and bioethicists from an
early point.
 Consider appointing a guardian for medical and psychiatric
decisions.
 As a behavioral disincentive, consider prosecution for fraud.

65. Factitious Disorder Imposed on Another
 Protection of the victim is the first priority
 When evidence of factitious disorder imposed on another is felt to be
sufficient, both parents should be informed together.
 In this manner, a nonperpetrating parent, usually the father, might
be enlisted as an ally.
 Child protective services should be informed and a legal hold should
be instituted if clinicians feel that parents might flee with the child.

66.  such children suffer from posttraumatic stress disorder and should
be treated.
 many victims avoid medical care as adults, others develop factitious
disorder
 The perpetrator should also undergo treatment to diagnose and
address underlying psychiatric conditions.
 If reunification is unrealistic, then psychotherapy should focus on
the parent’s underlying psychopathology, as well as their loss of a
child.

67.  If reunification is the goal, then treatment should address emotional
maturation, an ability to put the child’s needs before their own,
relinquishing the defense of denial, and learning to seek help and to
express themselves in more appropriate ways.

68.  Make sure the child is safe.
 Make sure the child’s future safety is also assured.
 Allow treatment to occur in the least restrictive setting possible.
 A pediatrician should serve as “gatekeeper” for medical care
utilization.
 All other physicians should coordinate care with the gatekeeper.
 Child protective services should be informed whenever a child is
harmed.
 Family psychotherapy and/or individual psychotherapy should be
instituted for the perpetrating parent and the child.

69.  Health insurance companies, school officials, and other nonmedical
sources should be asked to report possible medical abuse to the
physician gatekeeper.
 Permission of a parent or of child protective services must first be
obtained.
 The possibility should be considered of admitting the child to an
inpatient or partial hospital setting to facilitate diagnostic
monitoring of symptoms and to institute a treatment plan.
 The child may require placement in another family.
 The perpetrating parent may need to be removed from the child
through criminal prosecution and incarceration.

70. Factors associated with positive outcomes according to Bools et al.’s
study included:
 (1) continuous positive input from spouse or grandparents;
 (2) successful short-term foster care before returning to live with
the perpetrating caregiver;
 (3) the perpetrator’s long-term relationship with a social worker;
 (4) successful remarriage for the perpetrator;
 (5) early adoption of the victim; and
 (6) long-term foster care placement.

71.  In a series of 219 consecutive cases of psychosis, 9 (0.04 percent) met
criteria for factitious disorder. All 9 patients demonstrated severe
personality disorder. These patients were doing poorly when
followed up 4 to 7 years later, with multiple hospitalizations and
poor quality of life. Their outcome was no better than for
schizophrenics concurrently followed.
 In another study of six patients who presented with feigned
psychosis at the University Hospital of South Manchester, five of the
six were diagnosed with schizophrenia on follow-up 3 months to 10
years later. Consistent with psychodynamic theories about factitious
disorders representing an attempt to feel mastery, feigning
psychosis may have been an attempt to feel control over early
psychotic symptoms.

72.  An operating room technician, the daughter of a physician,
repetitively injected herself with Pseudomonas, which caused
multiple bouts of sepsis, bilateral renal failure, and ultimately her
death

73.  In an unusual case of adult factitious disorder imposed on another,
a 34-year-old man drugged his wife with sleeping pills in her coffee,
then injected gasoline into her skin to cause lesions from which she
eventually died. Subsequently, he hired a female babysitter to care
for his children and repeated his actions with her. In each case, he
assumed the role of the concerned caretaker in the center of medical
drama. He was finally arrested for murder, and in prison, he sought
to work in the infirmary
 In Great Britain in 1993, pediatric nurse Beverly Allitt was
convicted of killing 4 children under her care and was given 13 life
sentences.

74.  Nancy Reagan presented a Mother of the Year award in 1988 to
foster mother Yvonne Eldridge for her valorous care of ill children.
Eldridge was later recognized as a factitious disorder imposed on
another perpetrator and was convicted of child abuse in 1996.
 Hillary Rodham Clinton publicly recognized Kathy Bush’s dedication
to her daughter. Bush was later recognized as a perpetrator of
factitious disorder imposed on another and was sent to prison in
2002 for child abuse that had resulted in 200 hospitalizations, 40
surgeries, and 15 bouts of sepsis for her daughter.

75. THANK YOU