Dr. SNEHA ARYA PG STUDENT, DY PATIL UNIVERISTY, NAVI MUMBAI

1. Factitious Disorder
Sneha Arya

2. 1. Introduction.
2. Epidemiology.
3. Comorbidity.
4. Etiology.
5. Clinicalfeatures and diagnosis.
6. Pathologyand laboratory diagnosis.
7. Differential diagnosis.
8. Course andprognosis.
9. Treatment.

3. Introduction
• Factitiousdisorder is a condition in which a person acts as if he or she
has an illness by deliberatelyproducing, feigning,or exaggerating
symptoms.
• Unlikemalingererswho have materialgoals, such as monetarygain
or avoidance of duties, patientswith factitiousdisorder undertake
thesetribulations primarily to gain theemotionalcare and attention
thatcomes with playing the role of the patient.
• In doing so, they practice artifice and art, creating hospital drama that
often causes frustration and dismay.

4. Introduction
• F.D. can lead to significantmorbidity or even mortality.
• Hence presentingcomplaints are falsified,the medical and
psychiatric needs of the patientsmust be takenseriously.
• For eg, an operating room technician,the daughterof a physician,
repetitively injected herself withPseudomonas which caused
multiplebouts of sepsis and bilateral renalfailure thatledto her
death.

5. Introduction
• In a 1951 article in Lancet, Richard Asher
coined the term ‘Munchausen syndrome’
to refer to asyndrome in which patients
embellish their personal history,
chronically fabricate symptoms to gain
hospital admission, and move from
hospital to hospital.
• The syndrome was named after Baron
Hieronymus Friedrich Freiherr von
Munchausen(1720-1797), German
cavalry officer.

6. EpidEmiology
• F.D. may comprise approximately 0.8 to 1.0 % of psychiatry
consultationpts.
• prevalence greater in highlyspecialized treatmentsettings.
• A data bank of persons who feignillness has been established to alert
hospitals about such patients,many of whom travelfrom place to
place, seek admission underdifferentnames, or simulatedifferent
illnesses.

7. EpidEmiology
• 2/3 rd of patientswith Munchausensyndrome are male.
• They tendto be white,middle-aged, unemployed, unmarried,and
withoutsignificantsocial or familyattachments.
• 20 to 40 years of age with a history of employmentor education in
nursingor a healthcare occupation.
• Usually ranges from 4 to 79 years of age.

8. Comorbidity
• Many persons diagnosed withfactitiousdisorder have comorbid
psychiatric diagnoses
e.g. :
• mood disorders
• personality disorders
• substance-relateddisorders.

9. Aetiology
A. Psychosocial Factors :
• Anecdotal case reports indicate that many of the patients suffered childhood
abuse or deprivation, resulting in frequent hospitalizations during early
development.
• In such circumstances, an inpatient stay may have been regarded as an escape
from a traumatic home situation, and the patient may have found a series of
caretakers (e.g., doctors, nurses, and hospital workers) to be loving and caring.
• In contrast, the patients' families of origin included a rejecting mother or an absent
father. The usual history reveals that the patient perceives one or both parents as
rejecting figures who are unable to form close relationships.

10. Aetiology
• The facsimile of genuine illness, therefore, is used to recreate the desired
positive parent-childbond.
• The disorders are a form of repetitional compulsion, repeating the basic conflict
of needing and seeking acceptance and love while expecting that they will not
be forthcoming.
• Hence, the patient transforms the physiciansand staffmembers into rejecting
parents.
• Patients who seek out painful procedures, such assurgicaloperations and
invasive diagnostic tests, may have a masochistic personality makeup in which
pain serves as punishment for past sins, imagined or real.

11. Aetiology
• Some patientsmay attemptto master thepast and the early trauma
of serious medical illness or hospitalization by assumingtherole of
the patientand reliving the painfuland frighteningexperience over
and over again throughmultiplehospitalizations.
• Patientswho feignpsychiatric illness may have had a relative who
was hospitalized with the illness they are simulating.Through
identification,patients hopeto reunitewith therelative in a magical
way.

12. Aetiology
• Manypatientshave thepoor identityformationand disturbedself-image
thatis characteristicofsomeonewith borderlinepersonalitydisorder.
• Some patientsare as-ifpersonalitieswhohave assumedthe identitiesof
thosearound them.If thesepatientsare healthprofessionals,they are
oftenunabletodifferentiatethemselvesfrom thepatientswithwhom
they comein contact.
• Significantdefencemechanismsare repression,identificationwiththe
aggressor,regression, and symbolization.

13. Aetiology
B.Biological Factors:
• Some researchers have proposedthatbrain dysfunction maybea factorin
factitiousdisorders.
• It has beenhypothesizedthatimpairedinformationprocessing
contributestothe pseudologiafantasticaandaberrantbehaviorof
patientswithMunchausen disorder.
• however, no geneticpatternshave beenestablished,and
electroencephalographic(EEG) studiesnotedno specificabnormalitiesin
patientswithfactitiousdisorders.

14. CLINICAL FEATURES AND DIAGNOSIS
• The psychiatric examination should emphasize securing information from any
availablefriends, relatives, or other informants, because interviewers with reliable
outside sources often reveal the false nature of the patient’s illness.
• F.D.has been divided into 2 groups:
a. marked by psychological symptoms.
b. marked by physical symptoms.
• Both may occur together.
• DSM 5 does not distinct between the 2; it is divided into ‘imposed on self’ and
‘imposed on another’ (factitious disorder by proxy).

15. CLINICAL FEATURES AND DIAGNOSIS
Presentations in Factitious Disorder with Predominantly Psychological Signs and
Symptoms
• Bereavement
• Depression
• Posttraumatic stress disorder
• Pain disorder
• Psychosis
• Hypersomnia
• Bipolar I disorder
• Eatingdisorder
• Amnesia
• Substance-related disorder
• Trans-sexualism
• Paraphillias
• Dissociative identity disorder

16. CLINICAL FEATURES AND DIAGNOSIS
Chronic f.d. with PREdominantly physical signs and symptoms
• F.D. withpredominantly physical signs and symptoms is the best
known type of Munchausensyndrome.
• The disorder has also been called hospital addiction polysurgical
addiction- producing the so- called washboard abdomen – and
professional patient syndrome.

17. CLINICAL FEATURES AND DIAGNOSIS
Chronic f.d. with PREdominantly physical signs and symptoms
• Essentialfeature–abilityofpatientstopresent theirphysical symptoms
sowell thatthey can gainadmissiontoand stayin a hospital.
• To support theirhistory,thesepatientsmayfeignsymptomssuggestinga
disorder involving any organ system.
• They arefamiliarwiththe diagnosisofmostdisordersthatusuallyrequire
hospitaladmissionor medicationand can giveexcellenthistoriescapable
ofdeceiving even experiencedclinicians.

18. CLINICAL FEATURES AND DIAGNOSIS
Chronic f.d. with PREdominantly physical signs and symptoms
• In about halfthe reported cases, thesepatientsdemand treatment
withspecific medications, ususallyanalgesics.
• Once in hospital, they continueto be demandingand difficult.
• As each testis returned with a negativeresult, they may accuse
docyors of incompetence, threatenlitigationand become generally
abusive.

19. CLINICAL FEATURES AND DIAGNOSIS
Chronic f.d. with PREdominantly physical signs and symptoms
• Some may sign out abruptly shortly before they believe they are
going to be confronted withtheir factitious behaviour.
• Hence they keepon going to anotherhospital in thesame city or
anothercity and begin thecycle again.

20. F.D. by proxy (F.D. imposed on another)
• A person intentionallyproduces physical signs or symptomsin another
person whoisunder thefirst person’s care.
• One apparentpurpose ofthe behaviour is forthe caretakertoindirectly
assumethesick role;another is toberelievedofthecaretakingroleby
having thechildhospitalized.
• Mostcommoncause-involves a motherwhodeceivesmedicalpersonnel
intobelievingthather childis ill.
• Thedeceptionmayinvolve a falsemedicalhistory , contaminationoflab
samples,alterationofrecords, or inductionofinjury and illness in the
child.

21. Clinical Indicators That May Suggest Factitious Disorder
by Proxy
• The symptoms and patternof illness are extremelyunusual,or
inexplicable physiologically.
• Repeated hospitalizationsand workups by numerouscaregivers fail
to reveal a conclusive diagnosis or cause.
• Physiological parameters are consistentwith induced illness; e.g.,
apnea monitortracings disclose massive muscle artifactprior to
respiratory arrest, suggestingthatthe child has been struggling
againstan obstruction to theairways.

22. Clinical Indicators That May Suggest Factitious Disorder by
Proxy
• The patient fails torespond toappropriate treatments.
• The vitality of the patient is inconsistent with the laboratory findings.
• The signs and symptoms abate when the mother has not hadaccess to
the child.
• The mother is the only witness to the onsetof signs and symptoms.
• Unexplained illnesses have occurred in the mother or her other
children.

23. Clinical Indicators That May Suggest Factitious Disorder by
Proxy
• The mother has had medicalor nursingeducation, or exposure to
models of theillnesses afflictingthe child (e.g., a parent withsleep
apnea).
• The mother welcomes even invasive and painfultests.
• The mother grows anxious if thechild improves.
• Maternal lyingis proved.
• Medical observations yield informationthatis inconsistent with
parental reports.

24. Pathology and laboratory examination
• Psychological testingmay reveal specificunderlying pathologyin
individual patients.
• Featuresthatare overrepresented in patientswith F.D.include
normal or above-average intelligencequotient (IQ); absence of a
formal thoughtdisorder; poor sense of identity, including confusion
over sexual identity;poor sexualadjustment;poor frustration
tolerance; strong dependence needs; and narcissism.

25. Pathology and laboratory examination
• Aninvalidtestprofileand elevationsofall clinicalscaleson theMinnesota
MultiphasicPersonality Inventory-2(MMPI-2)indicatean attemptto
appear moredisturbedthan is thecase( fakebad).
• Nospecificlaboratory testsare availablefor factitiousdisorders. Certain
tests(e.g.,drug screening),however,mayhelpconfirmor rule outspecific
mentalor medicaldisorders.

26. Differential diagnosis of factitious disorder with predominantly physical signs
and symptoms. NOS, not otherwise specified.

27. Differential diagnosis
CONVERSION DISORDER:
• F.D.isdifferentiatedfromConversion d/oby thevoluntary production of
factitioussymptoms,theextremecourse ofmultiplehospitalizations,and
theseemingwillingnessofpatientswitha F.D.toundergoan
extraordinarynumberofmutilatingprocedures.
• Patientswithconversion disorder arenot usuallyconversant withmedical
terminologyand hospitalroutines.
• Hypochondriasis differsfromF.D.inthatthehypochondriacal patient
doesnot voluntarilyinitiatethe production ofsymptoms,and
hypochondriasis typically has alaterageofonset.
• Aswithconversion disorder, patientswith hypochondriasis donot usually
submittopotentiallymutilatingprocedures.

28. Differential diagnosis
Personality Disorders
• Because of theirpathological lying,lack of close relationshipswithothers,hostile and
manipulative manner,and associated substance abuse and criminalhistory, patients with
factitiousdisorderare oftenclassified as havingantisocial personalitydisorder.Antisocial
persons, however,donot usually volunteer forinvasive procedures or resorttoa wayof
lifemarkedbyrepeatedor long-termhospitalization.
• Because of attentionseeking andan occasional flairfor thedramatic,patientswith
factitiousdisordermay be classified ashaving histrionic personality disorder. Butnot all
such patientshave a dramatic flair;manyarewithdrawnand bland.
• Considerationof thepatient's chaotic lifestyle,historyofdisturbed interpersonal
relationships,identity crisis,substance abuse, self-damagingacts, and manipulative
tactics may lead tothe diagnosis ofborderlinepersonalitydisorder. Persons with
factitiousdisorderusually do not have the eccentricities of dress,thought, or
communication that characterizeschizotypal personalitydisorder patients.

29. Differential diagnosis
Schizophrenia
• The diagnosis of schizophrenia is oftenbased on patients'admittedly
bizarre lifestyles, but patientswithfactitiousdisorder do not usually
meetthe diagnostic criteria for schizophrenia unlessthey have the
fixed delusionthatthey areactually illand act on thisbelief by
seekinghospitalization.

30. Differential diagnosis
Malingering
• Malingerers have an obvious, recognizable environmentalgoal in
producing signs and symptoms.
• They may seek hospitalizationto secure financialcompensation,
evade thepolice, avoid work, or merelyobtain free bed and board for
the night,but they always have some apparent end for their
behaviour.
• Moreover, thesepatientscan usuallystop producing their signs and
symptoms whenthey are no longer considered profitable or when
the risk becomes too great.

31. Differential diagnosis
Substance Abuse
• Althoughpatientswithfactitiousdisorders may have a complicating
history of substanceabuse, they should be considered not merelyas
substanceabusers but as having coexistingdiagnoses.

32. Differential diagnosis
Ganser'sSyndrome
• a controversial condition most typically associated with prison inmates, is
characterized by the use of approximate answers.
• Persons with the syndrome respond to simple questions with astonishingly
incorrect answers.
• Eg : when asked about the color of a blue car, the person answers ‘red’ or answers
‘2 plus 2 equals 5’.
• Ganser's syndrome may be a variant of malingering, in that the patients avoid
punishment or responsibility for their actions. Ganser's syndrome can be classified
in DSM 5 as atype of dissociative disorder and in ICD-10 under other dissociative
or conversion disorders.
• Patientswith factitious disorder with predominantly psychological signs and
symptoms may intentionally give approximate answers, however.

33. Course and prognosis
• The prognosis in most cases is poor. A few patientsoccasionally
spend timein jail, usuallyfor minor crimes, such as burglary,
vagrancy, and disorderly conduct. Patientsmay also have a history of
intermittent psychiatrichospitalization.
• Possible features thatindicate a favourable prognosis are (1) the
presence of a depressive-masochistic personality; (2) functioningat a
borderline, not a continuouslypsychotic, level;
(3) the attributesof an antisocial personality disorder withminimal
symptoms.

34. Treatment
• The three major goals in thetreatmentand managementof F.D.are:
1. To reduce the risk of morbidity and mortality.
2. To address the underlyingemotionalneeds or psychiatric diagnosis
underlying factitiousillness behaviour.
3. To be mindfulof legaland ethicalissues.

35. Guidelines for Management and Treatment of Factitious
Disorder
• Activepursuit of apromptdiagnosiscan minimizetherisk ofmorbidity
and mortality.
• Minimizeharm.Avoidunnecessary testsand procedures, especiallyif
invasive.Treat accordingtoclinical judgment,keepingin mindthat
subjectivecomplaintsmaybedeceptive.
• Regularinterdisciplinarymeetingstoreduce conflictand splittingamong
staff.Managestaffcountertransference.
• Consider facilitatinghealingby usingthedouble-bindtechniqueor face-
savingbehavioralstrategies,such as self-hypnosisor biofeedback.

36. Guidelines for Management and Treatment of Factitious
Disorder
• Steerthepatienttowardpsychiatric treatmentin an empathic, non
confrontational,face-savingmanner.Avoid aggressive direct
confrontation.
• Treatunderlying psychiatric disturbances.In psychotherapy,address
copingstrategiesand emotionalconflicts.
• Appointa primary careprovider as agatekeeperfor allmedicaland
psychiatric treatment.
• Consider involving riskmanagementprofessionals and bioethicistsfrom
an early point.
• Consider appointinga guardian formedicaland psychiatric decisions.
• Consider prosecution forfraud, as a behavioraldisincentive.

38. Thank you