Today we will continue our current theme of psychosomatic disorders as we discuss factitious disorder and malingering.
Today's Content Level: Beginner and Intermediate
Patients with factitious disorder intentionally feign medical or psychological signs or symptoms in order to assume the role of a sick patient (sometimes called "primary gain").
In factitious disorder there is an absence of an external/tangible reward. Symptoms are falsified in order to assume the role of a sick patient.
Münchhausen syndrome is another, older name for factitious disorder with predominantly physical complaints. Münchhausen syndrome by proxy is intentionally producing symptoms in someone else who is under one’s care. Münchhausen syndrome is now typically used to describe a subset of patients (~10% of those with factitious disorder) with severe and chronic form of factitious disorder characterized by recurrent simulated or faked illness, travel from hospital to hospital, production of detailed and colorful symptom presentations (pseudologia fantastica), and typically have worse outcomes.
Individuals who are malingering also intentionally feign or grossly exaggerate medical or psychological signs, however this is done in order to achieve some type of external personal incentives (sometimes called "secondary gain"). Malingering is not considered to be a mental illness.
Common external motivations in malingering individuals include receiving room and board, food, monetary compensation, avoiding the police or judicial system, and obtaining certain medications such as narcotics.
DIAGNOSTIC CRITERIA 2
Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
The deceptive behavior is evident even in the absence of obvious external rewards.
Behavior is not better explained by another mental disorder, such as delusional disorder or a psychotic disorder.
There are two types: 1) Factitious disorder imposed on self. 2) Factious disorder imposed on another (previously called factitious disorder by proxy). The perpetrator, not the victim, receives this diagnosis.
Specifiers: Single episode or recurrent episodes (≥2 events of falsification of illness and/or induction of injury).
Malingering is not considered to be a mental illness. It is considered a "Z code" in the DSM-5.
Intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.
EPIDEMIOLOGY / PATHOGENESIS
Epidemiological data is difficult to obtain and sometimes contradictory regarding factitious disorder and malingering. Authors of these studies comment about difficulties determining prevalence due to the deceptive nature of the disorder.
Factitious Disorder 3
Studies estimate 0.5-2% of individuals presenting to hospital settings and 0.6-3% of referrals from general medicine to psychiatry meet criteria for factitious disorder.
More common in women overall. "Classic factitious disorder" (falsification of symptoms) and factitious disorder imposed on another are more common in women. "Munchausen syndrome" (more severe and chronic subtype with self-induction of actual injury or disease) may be more common in men according to some studies.
Risk factors include being a hospital or health care worker (they learn how to feign symptoms), history of multiple illnesses/hospitalizations, childhood physical or sexual abuse, childhood illness, insecure attachment during childhood, comorbid personality disorders, and being unmarried or socially isolated.
Prevalence is very difficult to determine and varies significantly based on the setting under investigation. Some estimate the overall prevalence in the general population is low, however 8% of medical cases, ~20% of criminal/forensic cases, ~30% of disability and personal injury cases probably involve malingering and symptom exaggeration. In one study of patients admitted to the hospital for suicidal ideation or attempt 10% self-reported malingering.
Common external motivations include receiving room and board, monetary compensation, avoiding the police or legal system, or obtaining narcotics.
Obtain a thorough history, a full review of systems, and a comprehensive physical/neurologic exam.
Early suspicion of factitious disorder or malingering is important in order to avoid unnecessary workup, treatments, and iatrogenic injury. Remember that patients may cause legitimate danger to themselves (central line infections, insulin injections, taking medications inappropriately, causing injury to themselves, and more). Unfortunately, detection of lying in others is difficult and mental health providers are no better than chance (~50% of the time).
Collateral information from family, friends, other providers, medical records, and past hospitalizations should be obtained and often provide helpful patterns of behavior.
Clues that may raise suspicion for factitious disorder or malingering include-> when there is a medico-legal context to the presentation (referred by attorney, self-refers while litigation is pending, etc.), inconsistent histories, treatment at multiple different facilities, patient is reluctant to allow provider to obtain collateral information or past records, patient or caregiver requests/encourages invasive tests, refuse to accept a good prognosis, improvement in symptoms once their desired objective is obtained, or refusal of psychiatric assessment.
The spectrum of potentially feigned symptoms is broad and may include a falsified or exaggerated history, manipulated clinical/laboratory/imaging findings, and/or self-induced illness/injury.
Commonly feigned symptoms can be psychiatric or medical. Psychiatric-> hallucinations, depression, bereavement, and suicidal ideation and behavior.. Medical-> fever (heating the thermometer), infection (placement of feces in urine sample or self-injecting feces), hypoglycemia (inject insulin), abdominal pain, diarrhea (laxative use or watering down stool samples), pseudoseizures, hematuria, electrolyte derangements (salt overload), bleeding (bloodletting or taking anticoagulants inappropriately), chest pain, and much more.
Remember to screen for factitious disorder imposed on another. This may occur by a caregiver that intentionally causes an injury or illness on another while deceiving treating providers with false or exaggerated info. Another way this can be seen is when a caregiver fabricates symptoms to cause overly aggressive medical evaluations or interventions. Victims are typically less than four years old though can be geriatric patients or adults with intellectual or other disabilities. Falsified symptoms are typically physical rather than psychological.
The distinction of malingering and factitious disorder can be challenging. Evidence of a clear external motive ("secondary gain) is not always obvious and there are sometimes tangible benefits if symptoms are feigned in order to assume the sick role ("primary gain") such as increased familial support, shelter, disability benefits, etc.).
A full psychiatric evaluation should also be performed given the high frequency of comorbid psychiatric disease. Evaluate for comorbid anxiety, mood, substance use, personality disorders, trauma, and other somatic disorders.
General approach: Team-based approach with one clinician overseeing patient management (primary care clinician if outpatient and attending of record if inpatient) in collaboration with psychiatry and other relevant specialists. Inform all members of the patient's multidisciplinary team about the diagnosis of factitious disorder, the treatment plan, and ensure consistent communication between all team members. An assessment of suicide risk should be performed and, if inpatient, the patient should be placed on 1:1 observation to prevent self-induction of injury or illness. A difficult balance needs to be found in order to avoid unnecessary diagnostic tests or treatments, while at the same time not overlooking or ignoring genuine medical disorders. Assess and treat comorbid psychiatric disorders.
Presenting the diagnosis: This is sometimes called "supportive confrontation". Discuss the diagnosis of factitious disorder with patients in a neutral tone and a non-judgmental supportive manner while providing feedback regarding clinical findings. Provide assurances that general medical care and support is available for needed conditions. Focus more upon stressors that the patient faces and less upon the deception and feigned symptoms. Keep in mind that the majority of patients who are presented with the diagnosis of factitious disorder often respond with denial (77% in one study 11), and this may lead to disruptive behavior, leaving against medical advice, and seeking care at a different facility. If the patient is hospitalized and there is firm evidenced of feigned illness consider a so-called therapeutic discharge.
Psychotherapy: There is a lack of robust data on the effectiveness of psychotherapy in patients with factitious disorder, however psychotherapy is the standard treatment based on reviews of case reports. Supportive therapy, cognitive behavioral therapy, and interpersonal therapy are suggested in the absence of high-quality studies that have compared different forms of psychotherapy. Unfortunately, the studies that do exist suggest it is often difficult to engage patients in treatment and treatment is often refused or there is a high drop out rate.
Pharmacotherapy: There is no pharmacologic treatment for factitious disorder (antidepressants and antipsychotics not shown helpful in a number of case reports). Comorbid disorders (anxiety, depressive, psychotic, etc.), if present, warrant standard treatment for these conditions.
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