Recommended
Recommended
More Related Content
Similar to factitiousdisorder-160207131044777778777888877.pptx
Similar to factitiousdisorder-160207131044777778777888877.pptx (20)
More from ssuser7567ef
More from ssuser7567ef (13)
Recently uploaded
Recently uploaded (20)
factitiousdisorder-160207131044777778777888877.pptx
- 1. Introduct ion • Factitious disorder is a condition in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms. • Unlike malingerers who have material goals, such as monetary gain or avoidance of duties, patients with factitious disorder undertake these tribulations primarily to gain the emotional care and attention that comes with playing the role of the patient. • In doing so, they practice artifice and art, creating hospital drama that often causes frustration and dismay.
- 2. Introduc tion • F .D.canleadtosignificantmorbidityorevenmortality . • Hencepresentingcomplaintsarefalsified,themedicaland psychiatricneedsofthepatientsmustbetakenseriously . • Foreg,anoperatingroomtechnician,thedaughterofaphysician, repetitivelyinjectedherselfwithPseudomonaswhichcaused multipleboutsofsepsisandbilateralrenalfailurethatledtoher death.
- 4. EpidEmiol ogy • F .D.maycompriseapproximately0.8to1.0% ofpsychiatry consultationpts. • prevalencegreaterinhighlyspecializedtreatmentsettings. • Adatabankofpersonswhofeignillnesshasbeenestablishedtoalert hospitalsaboutsuchpatients,manyofwhomtravelfromplaceto place,seekadmissionunderdifferentnames,orsimulatedifferent illnesses.
- 5. EpidEmiol ogy • 2/3rdofpatientswithMunchausensyndromearemale. • Theytendtobewhite,middle-aged,unemployed,unmarried,and withoutsignificantsocialorfamilyattachments. • 20to40yearsofagewithahistoryofemploymentoreducationin nursingorahealthcareoccupation. • Usuallyrangesfrom4to79yearsofage.
- 6. Comorbi dity • Manypersonsdiagnosedwithfactitiousdisorderhavecomorbid psychiatricdiagnoses e.g.: • mooddisorders • personalitydisorders • substance-relateddisorders.
- 7. Aetiol ogy A. PsychosocialF actors: • Anecdotalcasereportsindicatethatmanyofthepatientssufferedchildhood abuseordeprivation,resultinginfrequenthospitalizationsduringearly development. • Insuchcircumstances,aninpatientstaymayhavebeenregardedasanescape fromatraumatichomesituation,andthepatientmayhavefoundaseriesof caretakers(e.g.,doctors,nurses,andhospitalworkers)tobelovingandcaring. • Incontrast,thepatients'familiesoforiginincludedarejectingmotheroranabsent father .Theusualhistoryrevealsthatthepatientperceivesoneorbothparentsas rejectingfigureswhoareunabletoformcloserelationships.
- 8. Aetiol ogy • Thefacsimileofgenuineillness,therefore,isusedtorecreatethedesired positiveparent-childbond. • Thedisordersareaformofrepetitionalcompulsion,repeatingthebasicconflict ofneedingandseekingacceptanceandlovewhileexpectingthattheywillnot beforthcoming. • Hence,thepatienttransformsthephysiciansandstaffmembersintorejecting parents. • Patientswhoseekoutpainfulprocedures,suchassurgicaloperationsand invasivediagnostictests,mayhaveamasochisticpersonalitymakeupinwhich painservesaspunishmentforpastsins,imaginedorreal.
- 10. Aetiolo gy • Manypatientshavethepooridentityformationanddisturbedself-image thatischaracteristicofsomeonewithborderlinepersonalitydisorder . • Somepatientsareas-ifpersonalitieswhohaveassumedtheidentitiesof thosearoundthem.Ifthesepatientsarehealthprofessionals,theyare oftenunabletodifferentiatethemselvesfromthepatientswithwhom theycomeincontact. • Significantdefencemechanismsarerepression,identificationwiththe aggressor ,regression,andsymbolization.
- 11. Aetiolo gy B.BiologicalFactors: • Someresearchershaveproposedthatbraindysfunctionmaybeafactorin factitiousdisorders. • Ithasbeenhypothesizedthatimpairedinformationprocessing contributestothepseudologiafantasticaandaberrantbehaviorof patientswithMunchausendisorder . • however ,nogeneticpatternshavebeenestablished,and electroencephalographic(EEG)studiesnotednospecificabnormalitiesin patientswithfactitiousdisorders.
- 12. CLINICAL FEATURES AND DIAGNOSIS • Thepsychiatricexaminationshouldemphasizesecuringinformationfromany availablefriends,relatives,orotherinformants,becauseinterviewerswithreliable outsidesourcesoftenrevealthefalsenatureofthepatient’ sillness. • F .D.hasbeendividedinto2groups: a.markedbypsychologicalsymptom s. b.markedbyphysicalsymptom s. • Bothmayoccurtogether . • DSM5doesnotdistinctbetweenthe2;itisdividedinto‘imposedonself’and ‘ imposedonanother’(factitiousdisorderbyproxy).
- 13. CLINICAL FEATURES AND DIAGNOSIS Presentations in Factitious Disorder with Predominantly Psychological Signs and Symptoms • Bereavement • Depression • Posttraumaticstressdisorder • Paindisorder • Psychosis • Hypersomnia • BipolarIdisorder • Eatingdisorder • Amnesia • Substance-relateddisorder • T rans-sexualism • Paraphillias • Dissociativeidentitydisorder
- 14. CLINICAL FEATURES AND DIAGNOSIS Chronic f.d. with PREdominantly physical signs and symptoms • F .D.withpredominantlyphysicalsignsandsymptomsisthebest knowntypeofMunchausensyndrome. • Thedisorderhasalsobeencalledhospitaladdictionpolysurgical addiction-producingtheso-calledwashboardabdomen– and professionalpatientsyndrome.
- 15. CLINICALFEATURESAND DIAGNOSIS Chronic f.d. with PREdominantly physical signs and symptoms • Essentialfeature– abilityofpatientstopresenttheirphysicalsymptoms sowellthattheycangainadm issiontoandstayinahospital. • T osupporttheirhistory ,thesepatientsmayfeignsymptomssuggestinga disorderinvolvinganyorgansystem. • Theyarefamiliarwiththediagnosisofmostdisordersthatusuallyrequire hospitaladmissionormedicationandcangiveexcellenthistoriescapable ofdeceivingevenexperiencedclinicians.
- 16. CLINICALFEATURESAND DIAGNOSIS Chronic f.d.with PREdominantlyphysicalsigns and symptoms • Inabouthalfthereportedcases,thesepatientsdemandtreatment withspecificmedications,ususallyanalgesics. • Onceinhospital,theycontinuetobedemandinganddifficult. • Aseachtestisreturnedwithanegativeresult,theymayaccuse docyorsofincompetence,threatenlitigationandbecomegenerally abusive.
- 17. CLINICAL FEATURES AND DIAGNOSIS Chronic f.d. with PREdominantly physical signs and symptoms • Somemaysignoutabruptlyshortlybeforetheybelievetheyare goingtobeconfrontedwiththeirfactitiousbehaviour . • Hencetheykeepongoingtoanotherhospitalinthesamecityor anothercityandbeginthecycleagain.
- 18. F.D. by proxy (F.D. imposed on another) • Apersonintentionallyproducesphysicalsignsorsymptomsinanother personwhoisunderthefirstperson’ scare. • Oneapparentpurposeofthebehaviourisforthecaretakertoindirectly assumethesickrole;anotheristoberelievedofthecaretakingroleby havingthechildhospitalized. • Mostcommoncause-involvesamotherwhodeceivesmedicalpersonnel intobelievingthatherchildisill. • Thedeceptionmayinvolveafalsemedicalhistory,contaminationoflab samples,alterationofrecords,orinductionofinjuryandillnessinthe child.
- 19. Clinical Indicators That May Suggest Factitious Disorder by Proxy • Thesymptomsandpatternofillnessareextremelyunusual,or inexplicablephysiologically . • R epeatedhospitalizationsandworkupsbynumerouscaregiversfail torevealaconclusivediagnosisorcause. • Physiologicalparametersareconsistentwithinducedillness;e.g., apneamonitortracingsdisclosemassivemuscleartifactpriorto respiratoryarrest,suggestingthatthechildhasbeenstruggling againstanobstructiontotheairways.
- 20. Clinical Indicators That May Suggest Factitious Disorder by Proxy • Thepatientfailstorespondtoappropriatetreatm ents. • Thevitalityofthepatientisinconsistentwiththelaboratoryfindings. • Thesignsandsymptomsabatewhenthemotherhasnothadaccessto thechild. • Themotheristheonlywitnesstotheonsetofsignsandsymptoms. • Unexplainedillnesseshaveoccurredinthemotherorherother children.
- 21. Clinical Indicators That May Suggest Factitious Disorder by Proxy • Themotherhashadmedicalornursingeducation,orexposureto modelsoftheillnessesafflictingthechild(e.g.,aparentwithsleep apnea). • Themotherwelcomeseveninvasiveandpainfultests. • Themothergrowsanxiousifthechildimproves. • Maternallyingisproved. • Medicalobservationsyieldinformationthatisinconsistentwith parentalreports.
- 22. Pathology and laboratory examination • Psychologicaltestingmayrevealspecificunderlyingpathologyin individualpatients. • FeaturesthatareoverrepresentedinpatientswithF .D.include normalorabove-averageintelligencequotient(IQ);absenceofa formalthoughtdisorder;poorsenseofidentity ,includingconfusion oversexualidentity;poorsexualadjustment;poorfrustration tolerance;strongdependenceneeds;andnarcissism.
- 23. Pathology and laboratory examination • AninvalidtestprofileandelevationsofallclinicalscalesontheMinnesota MultiphasicPersonalityInventory-2(MMPI-2)indicateanattemptto appearmoredisturbedthanisthecase(fakebad). • Nospecificlaboratorytestsareavailableforfactitiousdisorders.Certain tests(e.g.,drugscreening),however ,mayhelpconfirmorruleoutspecific mentalormedicaldisorders.
- 24. Differential diagnosis of factitious disorder with predominantly physical signs and symptoms. NOS, not otherwise specified.
- 25. Differential diagnosis CONVERSIONDISORDER: • F .D.isdifferentiatedfromConversiond/obythevoluntaryproductionof factitioussymptoms,theextremecourseofmultiplehospitalizations,and theseemingwillingnessofpatientswithaF .D.toundergoan extraordinarynumberofmutilatingprocedures. • P atientswithconversiondisorderarenotusuallyconversantwithmedical terminologyandhospitalroutines. • HypochondriasisdiffersfromF .D.inthatthehypochondriacalpatient doesnotvoluntarilyinitiatetheproductionofsymptoms,and hypochondriasistypicallyhasalaterageofonset. • Aswithconversiondisorder ,patientswithhypochondriasisdonotusually submittopotentiallymutilatingprocedures.
- 26. Differential diagnosis Personality Disorders • Because of their pathological lying, lack of close relationships with others, hostile and manipulative manner, and associated substance abuse and criminal history, patients with factitious disorder are often classified as having antisocial personality disorder. Antisocial persons, however, do not usually volunteer for invasive procedures or resort to a way of life marked by repeated or long-term hospitalization. • Because of attention seeking and an occasional flair for the dramatic, patients with factitious disorder may be classified as having histrionic personality disorder. But not all such patients have a dramatic flair; many are withdrawn and bland. • Consideration of the patient's chaotic lifestyle, history of disturbed interpersonal relationships, identity crisis, substance abuse, self-damaging acts, and manipulative tactics may lead to the diagnosis of borderline personality disorder. Persons with factitious disorder usually do not have the eccentricities of dress, thought, or communication that characterize schizotypal personality disorder patients.
- 28. Differential diagnosis Malingering • Malingerershaveanobvious,recognizableenvironmentalgoal inproducingsignsandsymptoms. • Theymayseekhospitalizationtosecurefinancialcompensation, evadethepolice,avoidwork,ormerelyobtainfreebedandboardfor thenight,buttheyalwayshavesomeapparentendfortheir behaviour . • Moreover ,thesepatientscanusuallystopproducingtheirsignsand symptomswhentheyarenolongerconsideredprofitableorwhen theriskbecomestoogreat.
- 30. Differential diagnosis Ganser'sSyndrome • acontroversialconditionmosttypicallyassociatedwithprisoninmates,is characterizedbytheuseofapproximateanswers. • Personswiththesyndromerespondtosimplequestionswithastonishingly incorrectanswers. • Eg:whenaskedaboutthecolorofabluecar ,thepersonanswers‘red’oranswers ‘2plus2equals5’. • Ganser'ssyndromemaybeavariantofmalingering,inthatthepatientsavoid punishmentorresponsibilityfortheiractions.Ganser'ssyndromecanbeclassified inDSM5asatypeofdissociativedisorderandinICD-10underotherdissociative orconversiondisorders. • P atientswithfactitiousdisorderwithpredominantlypsychologicalsignsand symptomsmayintentionallygiveapproximateanswers,however .
- 31. Course and prognosis • Theprognosisinmostcasesispoor .Afewpatientsoccasionally spendtimeinjail,usuallyforminorcrimes,suchasburglary , vagrancy ,anddisorderlyconduct.Patientsmayalsohaveahistoryof intermittentpsychiatrichospitalization. • Possiblefeaturesthatindicateafavourableprognosisare(1)the presenceofadepressive-masochisticpersonality;(2)functioningata borderline,notacontinuouslypsychotic,level; (3)theattributesofanantisocialpersonalitydisorderwithminimal symptoms.
- 32. Treatm ent • ThethreemajorgoalsinthetreatmentandmanagementofF .D.are: 1. T oreducetheriskofmorbidityandmortality . 2. T oaddresstheunderlyingemotionalneedsorpsychiatricdiagnosis underlyingfactitiousillnessbehaviour . 3. T obemindfuloflegalandethicalissues.
- 33. Guidelines for Management and Treatment of Factitious Disorder • Activepursuitofapromptdiagnosiscanminimizetheriskofmorbidity andmortality . • Minimizeharm.Avoidunnecessarytestsandprocedures,especiallyif invasive.T reataccordingtoclinicaljudgment,keepinginmindthat subjectivecomplaintsm aybedeceptive. • Regularinterdisciplinarymeetingstoreduceconflictandsplittingamong staff.Managestaffcountertransference. • Considerfacilitatinghealingbyusingthedouble-bindtechniqueorface- savingbehavioralstrategies,suchasself-hypnosisorbiofeedback.
- 34. Guidelines for Management and Treatment of Factitious Disorder • Steerthepatienttowardpsychiatrictreatmentinanempathic,non confrontational,face-savingmanner .Avoidaggressivedirect confrontation. • T reatunderlyingpsychiatricdisturbances.Inpsychotherapy ,address copingstrategiesandemotionalconflicts. • Appointaprimarycareproviderasagatekeeperforallmedicaland psychiatrictreatment. • Considerinvolvingriskmanagementprofessionalsandbioethicistsfrom anearlypoint. • Considerappointingaguardianformedicalandpsychiatricdecisions. • Considerprosecutionforfraud,asabehavioraldisincentive.
- 36. Thank you