The Geezer’s Dirty Dozen on Factitious Disorder and Malingering

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Welcome to another Dirty Dozen with video about Factitious Disorder and Malingering. As a psychiatric consultant in the general hospital, I’m infrequently called upon to render an opinion about and assistance with managing patients who are thought to be lying about symptoms (usually medical although factitious disorder can be about psychological symptoms as well).

The patients are frequently not motivated to cooperate with psychiatrists and most often (but not invariably) deny that they are self-inducing medical problems such as infections, bleeding, hypoglycemia, or fevers. In every case, the challenge is to try to develop a therapeutic alliance and to show the utmost respect for the patient, to listen for understanding, and to offer him/her a face-saving way to give up abnormal illness-affirming behavior at the very least. I always hope for a way to offer psychiatric treatment and to offer alternatives to self-harm and deception as a way of getting emotional needs met. And for more on the subject, see the shortlink to my post “Thoughts on Munchausen’s Syndrome” http://wp.me/p1glcu-Av.

ADDENDUM: The DSM-5 and the book “Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5 by Dr. Allen Frances, MD have a lot to say about the somatoform disorders. The DSM-5 now has a new category called Somatic Symptom and Related Disorders into which Factitious Disorder has been subsumed. While the name Conversion Disorder is still in the DSM-5, in parentheses it’s also called Functional Neurological Symptom Disorder. Dr. Frances says “This new category is ridiculously overinclusive…” recommending it be used only when clearly necessary. My opinion is that the new DSM-5 category will not change the management recommendations from psychiatric consultants. The suggestions will still be to avoid invasive procedures, medications with the potential for toxicity and addiction, and specialist referrals unless the risk to benefit ratio is safe, favorable to the patient, and address an objectively demonstrable disease process.

Slide 3: This describes the DSM-IV-TR diagnostic criteria for factitious disorder and malingering. Because malingering is not a psychiatric disorder per se and there is no specific treatment, it won’t be discussed further. That doesn’t mean there is no approach to communicating with someone who is malingering. The respectful and validating approach is probably best. Validating doesn’t necessarily agreeing with the individual about the decision to lie to doctors in order to get or avoid something. It means listening for understanding and trying to allow the person a face-saving way to give up symptoms while also offering the matter-of-fact explanation for why he/she is not entitled to whatever special treatment is being sought.

Slide 4: These are a few historical notes about the evolution of medical and psychiatric thought about factitious disorder over the last several decades, beginning with Dr. Asher’s landmark paper published in Lancet in 1951. The state of Iowa has a place in this history because of Dr. John S. Chapman’s case report and review in 1957 about a legendary patient with Munchausen’s Syndrome (the name reserved for the 10% of those with the most severe form of factitious disorder) called The Indiana Cyclone, and this is the first such case report coming out of Iowa. The Indiana Cyclone was hospitalized at The University of Iowa Hospitals and Clinics in 1954 and the story about that episode was set to a long, dramatic poem called The Munchausen Saga by Dr. William Bean, another Iowa connection because he was professor and head of internal medicine at UIHC in the late 1940s, which begins:

In the summer of nineteen and fifty-four

At Iowa City, to our hospital door–

Mecca for hundreds every day–

A merchant seaman found his way,

A part-time wrestler, in denim jacket,

He crashed through the door with a horrible racket,

Two hundred and sixty pounds at least,

And covered with blood like a wounded beast…

The other interesting historical note is the publishing of an article in The New England Journal of Medicine (NEJM) about Factitious Munchausen’s Syndrome (see slide 7).

The disorder first appeared in the DSM in 1980; the first review was published 3 years later. And in 1994, Factitious Disorder by proxy was introduced in the DSM-IV. This is actually considered a form of child abuse and is not diagnosed in the perpetrator, but in the child. There is a huge literature about this phenomenon, mostly in the form of case reports similar to Factitious Disorder in adults, which this presentation is about.

Slide 5: This is a very quick literature review because it is massive and limited space doesn’t allow me to discuss this in detail in a Dirty Dozen presentation. Many persons with factitious disorder were variously diagnosed with personality disorders, hysterical neuroses, and schizophrenia. There are not controlled trials in the medical literature, but 1,900 papers published from 1985 through 2008–and they’re still coming. A couple of meta-analyses concludes that early detection with the goal of prevention is key, especially since some victims of factitious disorder by proxy may grow up to develop factitious disorders as adults. Not surprisingly the key to treatment is developing a therapeutic alliance, which is virtually impossible to do. One review shows that most patients are white females who are young and tend to be educated in the health care field. Another systematic review about treatment unfortunately was not very encouraging, failing to find any published evidence supporting the efficacy of any management approach (Eastwood, et al, see reference below).

Slide 6: A retrospective study by Krahn et al found that, in factitious disorder patients with physical symptoms, the majority were in their thirties, employed, Caucasian females with health care training. Although 20% left the hospital against medical advice, about 20% accepted psychiatric treatment (though outcome is unknown).

Slide 7: This is about the Factitious Munchausen’s Syndrome mentioned earlier. This was a hoax perpetrated by a couple medicine residents, who submitted a false case report (Gurwith and Langston) to the NEJM in 1980 about a fictitious patient named Norman U. Senchbau (anagram for Baron Munchausen) who lied about having Munchausen’s Syndrome, which makes you think too hard about the pathologic lying component of the disorder. Ask yourself this: if you lie about having a disorder that has lying as one of its main features, does that prove you have it–or does it prove you don’t? Or can there be a pseudofactitious disorder? Amirault’s views on the pseudologica fantastica (pathologic lying) feature and the paradoxes inherent in factitious disorder are worth reading–over coffee, not beer.

Slide 8: This is about the hope that electronic medical records may help facilitate communication between hospitals about patients with factitious disorders. There used to be “blacklists” pinned up in emergency rooms about persons with factitious disorder; that is now discouraged. Permission to access personal health information still must be sought from the patient.

Slide 9: Continuing the theme of factitious disorder in the computer age, more than 14 cases of factitious disorder or “Virtual Factitious Disorder” (coined by Marc D. Feldman, MD, a published expert on factitious disorder). The deception is carried out on line, and they may wander from on line support group to the next, use aliases and otherwise seek attention without exposing themselves to the risks of self-induced medical illness. This sounds curiously similar to the fictitious factitious disorder described earlier.

Slide 10: There are proposals to make factitious disorder a subtype of somatoform disorders or classifying as a personality disorder rather than a DSM Axis I disorder.

Slide 11: Even though I mentioned the review article about there being no evidence supporting a management strategy, my colleagues in medicine and surgery will still need some assistance when they encounter patients with factitious disorder with physical symptoms. The 4 management principles by Huffman and Stern or Gregory and Jindal are reasonable and are similar to long-established strategies for helping patients with personality disorders.

Slide 12: These are selected references for factitious disorder. Another one would be the web site for the recognized expert on this entire subject, Dr. Marc Feldman, who left a kind comment about this post. The link to Dr. Feldman’s site is http://www.munchausen.com/index.html.

Factitious Disorder and Malingering Quiz:

1. Factitious Disorder is marked by all but one of the following:

A. Tendency to lie about symptoms

B. Motivation is to take the sick role to get emotional needs met

C. The main goal of their illness behavior is to get entitlements (external incentives)

D. High risk for morbidity and mortality from self-induced medical problems

2. Malingering is a DSM-IV Axis I treatable psychiatric disorder:

A. True

B. False

3. A major retrospective review about factitious disorder show that many patients are:

A.  Female

B. Employed in the health care field

C. In their mid-thirties

D. All of the above

4. Systematic reviews indicate that early detection of factitious behavior may prevent future chronic illness:

A. True

B. False

5. The physician who authored the first major paper describing Munchausen’s Syndrome was:

A. Norman U. Senchbau

B. John Chapman

C. William Bean

D. Richard Asher

Answer Key:

1. C

2. B

3. D

4. A

5. D

Amirault, C. (1995). “Pseudologica fantastica and other tall tales: the contagious literature of Munchausen syndrome.” Lit Med 14(2): 169-190.

Amos, J. J., M.D. (2010). Managing factitious disorder and malingering. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. Amos, M.D., and R. G. Robinson, M.D. New York, Cambridge University Press: 82-88.

Bean, W. B. (1959). “The Munchausen syndrome.” Perspectives in biology and medicine 2(3): 347-353.

Chapman, J. S. (1957). “Peregrinating problem patients; Munchausen’s syndrome.” Journal of the American Medical Association 165(8): 927-933.

Eastwood, S. and J. I. Bisson (2008). “Management of factitious disorders: a systematic review.” Psychother Psychosom 77(4): 209-218.

BACKGROUND: The literature regarding the management of factitious disorder (FD) is diverse and generally of case reports or case series. To date there has been no systematic review of the effectiveness of management techniques. METHODS: Systematic review of all evidence reporting the management and subsequent outcome in FD. Data were extracted and outcomes were assessed using an adaptation of the Global Improvement Scale. Results were analysed by parametric statistical tests; a meta-analysis was not possible. RESULTS: Thirty-two case reports and 13 case series were eligible for inclusion. Analysis of the case reports found no significant difference in outcomes between confrontational and non-confrontational approaches [t(29) = 0.72, p = 0.48], between treatment with psychotherapy compared to no psychotherapy [t(30) = 0.69, p = 0.48], and when psychiatric medication had been prescribed compared with not [t(30) = 0.35, p = 0.73]. A trend was observed that a longer length of treatment lead to better outcomes, but this was not significant [F(5, 26) = 1.17, p = 0.35]. The consecutive case series demonstrated that many FD sufferers were not engaged in treatment and were lost to follow-up but did not provide any strong evidence regarding the effectiveness of different management approaches. CONCLUSIONS: There is an absence of sufficient robust research to determine the effectiveness of any management technique for FD. The establishment of a central reporting register to facilitate the development of evidence-based guidelines is recommended.

Feldman, M. D. (1992). “Factitious Munchausen’s syndrome–a confession.” N Engl J Med 327(6): 438-439.

Feldman, M. D. and S. J. Eisendrath (1996). The spectrum of factitious disorders. Washington, DC, American Psychiatric Press.

Fliege, H., A. Grimm, et al. (2007). “Frequency of ICD-10 factitious disorder: survey of senior hospital consultants and physicians in private practice.” Psychosomatics 48(1): 60-64.

The authors surveyed physicians for frequency estimates of factitious disorder among their patients. Twenty-six physicians in independent practice and 83 senior hospital consultants in internal medicine, surgery, neurology, and dermatology participated. They completed a questionnaire including the estimated 1-year prevalence of factitious disorder among their patients. Frequency estimates averaged 1.3% (0.0001%-15%). The number of patients treated correlated negatively with frequency estimates. Dermatologists and neurologists gave the highest estimations. One-third of the physicians rated themselves as insufficiently informed. Frequency estimations did not differ by information level. The estimated frequency is substantial and comparable to earlier findings. Authors discuss clinical implications.

Gregory, R. J. and S. Jindal (2006). “Factitious disorder on an inpatient psychiatry ward.” Am J Orthopsychiatry 76(1): 31-36.

The authors present 6 cases of factitious disorder seen on a general adult inpatient psychiatry unit of a university hospital. They review the clinical features of this disorder and suggest that factitious disorder is much more prevalent among psychiatric inpatients than is commonly recognized. Strategies to assist in the diagnosis and management this disorder are detailed.

Gurwith, M. and C. Langston (1980). “Factitious Munchausen’s syndrome.” The New England journal of medicine 302(26): 1483-1484.

Huffman, J. C. and T. A. Stern (2003). “The diagnosis and treatment of Munchausen’s syndrome.” Gen Hosp Psychiatry 25(5): 358-363.

Patients with Munchausen’s syndrome–a syndrome characterized by the intentional production of physical symptoms to gain the sick role-present a variety of challenges to health care providers. Their treaters quickly become frustrated by their demanding interpersonal styles, by deception and manipulation, and by multiple unrevealing diagnostic procedures. These difficulties can lead to poor outcomes for patients and staff alike. We present the case of a young woman whose presentation and subsequent evaluation led to significant distress among the hospital staff responsible for her care, and discuss the epidemiology, diagnosis, and management of patients with Munchausen’s syndrome. The most important role of the psychiatrist in the treatment of Munchausen’s syndrome is to help the primary treatment team manage the patient in the safest and most appropriate way. Such management includes avoiding unnecessary procedures, preventing further self-harm, and avoiding angry or threatening interactions with the patient. The prognosis for patients with Munchausen’s syndrome appears to be poor; flexible and creative approaches that emphasize consistency of care and regular outpatient psychiatric treatment have had the greatest success.

Krahn, L. E., H. Li, et al. (2003). “Patients who strive to be ill: factitious disorder with physical symptoms.” Am J Psychiatry 160(6): 1163-1168.

OBJECTIVE: Factitious disorder with physical symptoms characterizes patients who strive to appear medically ill and assume the sick role. Clinical suspicion is highest for female health care workers in the fourth decade of life. This study was designed to analyze the diagnosis of factitious disorder, the demographics of affected patients, and intervention and treatment. METHOD: Retrospective examination was of 93 patients diagnosed during 21 years. Two raters agreed on subject eligibility on the basis of DSM-IV criteria and absence of a somatoform disorder and a plausible medical explanation. RESULTS: The group included 67 women (72.0%); mean age was 30.7 years (SD=8.0) for women and 40.0 years (SD=13.3) for men. Mean age at onset was 25.0 years (SD=7.4). Health care training or jobs were more common for women (65.7%) than men (11.5%). Most often, inexplicable laboratory results established the diagnosis. Eighty had psychiatric consultations; 71 were confronted about their role in the illness. Only 16 acknowledged factitious behavior. Follow-up data were available for only 28 patients (30.1%); maximum duration of follow-up was 156 months. Two patients were known to have died. Few patients pursued psychiatric treatment. Eighteen left the hospital against medical advice. CONCLUSIONS: Factitious disorder affects men and women with different demographic profiles. Diagnosis must be based on careful examination of behavior, motivation, and medical history and not on a stereotype. Laboratory data and outside medical records help identify suspicious circumstances and inconsistencies. Confrontation does not appear to lead to patient acknowledgment and should not be considered necessary for management.

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Comments

  1. This is a terrific review. Thanks for the thorough research!

    Like

    • Hi Dr. Feldman,

      I’m practically speechless (I did say “practically”) about your generous comments about my humble blog post about Factitious Disorder and malingering. I am truly grateful you even noticed it and thrilled you enjoyed it. Is there anything that you, as the recognized expert on Factitious Disorder (readers please see link http://www.munchausen.com/), would care to add?

      Many thanks,

      Jim Amos, MD

      Like

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