Factitious disorder is a psychiatric condition in which an individual deliberately produces or falsifies symptoms of an illness for the sole purpose of assuming the role of a patient. Individuals with factitious disorder want to be under medical care, perhaps to obtain attention, care, or nurture. Generally, this disorder signifies a very serious unmet psychological need or psychological trauma.
Anjali has been living in foster care environments since her parents were sent to prison when she was two years old. Now 18, she has recently “aged out” of the foster care system. She was moved from one foster home to another while she was in the system and was never in any one home for longer than 18 months. Emergency department (ED) staff at a local hospital are very familiar with Anjali as she is a frequent and recurring patient in the ED. Anjali is intelligent and has an unusually sophisticated grasp of medical terminology and associated diseases and conditions. When presenting to the ED, her description of symptoms are textbook examples of medical conditions but when examined, the medical staff are unable to validate her symptoms. Anjali has become very adept at timing her ED visits at hectic change of shift times when staff are particularly busy or when there is minimal and less experienced staff during the night shift. Some of the more experienced staff members are beginning to suspect Anjali is falsifying her symptoms and should be medically evaluated for a diagnosis of factitious disorder.
Factitious * disorder is when a person seeks medical treatment for a falsified condition. The person with a factitious disorder visits the doctor persistently complaining of different symptoms of illnesses. The doctor can find no physical or mental condition associated with the symptoms. There is no external reward for faking an illness such as collecting worker's compensation or escaping a stressful situation. The main motivation appears to be the desire to be treated as a sick person.
Underlying motives distinguish factitious disorder from malingering *
Factitious disorder is also distinguished from conversion disorder. With conversion disorder, afflicted persons actually believe they have the physical symptoms. Patients may actually appear to have the symptoms, but the cause is psychological, not physical, relating to internal conflict or external stressors. Conversion disorder may be the result of dissociation, characterized by a disconnection between past and present, lack of identity, no immediate sensations, and loss of control of the body. Dissociation is caused by trauma, extreme problems, or harmful relationships.
Factitious disorder is the name for any self-induced disease. The symptoms are voluntarily controlled. There is a conscious awareness on the part of the deceiver. There is evidence of internal compulsion. The person appears to be unable to control the urge to adopt the symptoms. Additionally, the person seems to maintain the illness because of psychological stressors. The person with factitious disorder needs help from a mental health professional because the feigned illness can do considerable, even irreparable, damage to the health of the afflicted person. The three most common types of factitious disorder are Munchausen (MOON-chow-zen) syndrome, Munchausen by proxy, and Ganser syndrome.
Factitious disorder is a continuum based on the seriousness of the symptoms and the intensity with which the afflicted person is looking for medical attention. Nowhere on this continuum is there any observable extrinsic incentive for the behavior. It is important to note that people afflicted with factitious disorder have the goal of being sick; they want to be sick even when there is no one around to impress.
Depending on the persistence, strength, and danger of the deceit, individual cases of the syndrome may be considered mild to severe. If the symptoms and the portrayal of the affliction do not change the afflicted person's life much, then the disorder is considered mild. However, if the afflicted person is persistent to the point of enduring very painful symptoms, financial difficulties, and lifestyle disruptions, then the disorder is considered severe. On the severe end of the continuum is Munchausen syndrome, named in 1951 by British doctor Richard Asher based on the popular perception of Baron Freiherr von Münchhausen, who exaggerated his exploits in the Russian-Turkish War. Munchausen syndrome involves reporting the symptoms of physical illnesses. Another less common disorder is Ganser syndrome, which involves reporting the symptoms of psychological illnesses.
There are a great many symptoms that may be faked or produced in Munchausen syndrome. For example, a person may complain of abdominal pain, fever, rashes, bleeding, irregular heartbeat, dizziness, fainting spells, or seizures. These symptoms may appear to be signs of such disorders as appendicitis * , dermatitis * , anemia * , a heart problem, or a brain tumor, even though the person never actually had the symptoms they complained of.
People with Munchausen syndrome often are knowledgeable about medicine and hospitals. They may pretend to have a disease by complaining of a symptom, such as pain, that they do not have. Sometimes they exaggerate or imitate a disorder, such as seizures, that they really do have. Some people may actually injure themselves to create a symptom. For example, they may make themselves bleed to produce anemia. They may also describe an elaborate but false medical history to their physicians and demand medical tests and treatment with drugs or even operations. If the faking of illness by people with Munchausen syndrome is discovered and they are denied treatment, they may start all over again, attempting to fool another doctor at another hospital. In some cases, this process may be repeated throughout a person's life.
Ganser syndrome is the factitious disorder in which symptoms of psychological disorders such as dementia * or schizophrenia * are mimicked. Ganser syndrome is very rare and has mostly been reported in prison populations. One of the characteristics of Ganser syndrome is the response of “approximate answers.” The patient gives logically ridiculous answers to simple questions but responds with a number to a question requiring a number answer or with a color to a question requiring a color answer. It is listed in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) as a dissociative disorder. Because it is so rare, the true cause, whether dissociative or factitious, may not be known.
The characteristics include a parent or caregiver who constantly seeks medical attention for a child or dependent and who always presents the child or dependent to the doctors as weak and sickly and vulnerable to a number of ailments. The parent with this disorder will allow the child to go through any number of physical examinations, even the most intrusive and uncomfortable. If the parent obtains laboratory reports, the parent will tend to reach his or her own conclusions from the tests. If the doctor tells the parent that there is nothing wrong with the child, the parent will not accept the doctor's conclusion. The typical behavior of the parent in receiving the doctor's conclusion is to selectively hear the doctor's report, focusing on the small phrases that could support the parent's contention that the child is seriously ill. Otherwise, the parent might argue with the doctor, find another doctor, or not acknowledge hearing anything that the doctor said. Always the parent acts like a responsible, caring parent.
As with the other factitious disorders, with Munchausen by proxy, there is no extrinsic incentive for this pretense for either the afflicted caregiver or the person in his or her care, and it can range in the degree of severity. On the mild end, a mother may be only exaggerating symptoms that currently naturally exist in the child. On the severe end, a parent may be actually causing the child to be sick or injured. This may be done by giving the child something toxic to eat or by ignoring the treatment prescribed by the doctor.
The motivations for Munchausen by proxy vary. Although the most common motivations are pathological, there are cases in which the mother is extremely stressed by her responsibilities, and her deceit is her way of making a desperate plea for help. When this is the motivation, she is relieved to be discovered, and therapy involves education in the areas in which she feels most vulnerable. There are also parents who are micromanagers of their children's health. These individuals might try to second-guess the doctor's advice, seek out the opinions of other doctors, and meticulously monitor the child's progress. Although this behavior may be extreme and obstructive to the child's therapeutic relationship with the doctor, it is not factitious or pathological.
There are two general pathological motivations for the behavior seen in Munchausen by proxy. The first is an obsession with obtaining medical treatment, which is commonly referred to as a “doctor addiction.” The perpetrator is more likely to exaggerate an existing illness than to actually bring on some malady in the child.
It is difficult to develop a typical profile for someone with a factitious disorder because the reported cases are so few. An early study of Munchausen syndrome found more women than men tended to have the disorder. The afflicted was usually a young woman with poor psychosocial development. For most of her life, she had been dependent on her mother, but her dependency needs remained unfulfilled. She tended to have very little emotional support from her father, and her verbal skills were poor. This pattern implies that she is looking to fulfill unmet needs but does not have the social skills necessary to seek them in direct, adaptive manners.
There is a belief that people with Munchausen syndrome have an intense need for care and sympathy. Why people with the disorder have this driving need differs for each person. Often, the disorder begins in early adulthood, after hospitalization for a real medical condition. Other influencing factors may include an important past relationship with a physician, medical employment, or even ill will harbored toward the medical profession.
Ganser syndrome mostly afflicts men, but this finding may be based on the prison context of most studies. Most of those afflicted with Munchausen by proxy are young mothers.
Factitious disorders are very difficult to diagnose and treat. Because of the persistent deceit on the part of the afflicted, it is not easy for the doctor to determine what the problem actually is. The doctor must first rule out the possibility that the symptoms are real. If a factitious disorder is suspected, the doctor must determine how familiar the patient is with the disease being faked. The patient may know the symptoms but not their proper order. If the patient then reports something unusual, such as the symptoms appearing in the wrong sequence, then the doctor may be cued that the patient does not really have the illness.
A complete diagnosis should involve a careful reading of the medical records for any inconsistencies or abnormalities. The doctor should also interview friends and family. Because the factitious disorder patient is not trying to get well, there should be some system of monitoring the patient's compliance with treatment.
Treatment is not easy because the causes of these disorders usually signify deep psychological problems, likely an underlying personality disorder. The mental health professional offering therapy has to be careful at first to develop a supportive relationship with the afflicted. There should be no early confrontation regarding the patient's lies except in a crisis situation. Therapy can follow a conventional pattern after the rapport has been established. The therapist has to be constantly aware that the patient has a weak ego and low self-esteem.
Munchausen syndrome is treated with psychotherapy. The therapist attempts to help patients understand why they have an excessive need for sympathy, care, and attention. Therapists also help patients find more honest and less destructive ways to satisfy their emotional needs. In the meantime, attempts are made to protect the patient from having unnecessary operations or other medical procedures.
There is no way to prevent the development of a factitious disorder. In most mental health issues, the person's family should be able to notice behavioral irregularities and provide the necessary support. If early studies of Munchausen syndrome are correct, afflicted individuals often do not have family support. Ganser syndrome is also not preventable.
See also Conversion Disorder • Hypochondria • Somatoform Symptom Disorder
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* factitious means false. In this case, it refers to an impression of illness produced falsely.
* malingering (ma-LING-er-ing) means intentionally pretending to be sick or injured to avoid work or responsibility.
* appendicitis (ah-pen-dih-SY-tis) is an inflammation of the appendix, the narrow, finger-shaped organ that branches off the part of the large intestine in the lower right side of the abdomen.
* dermatitis is a skin condition characterized by a red, itchy rash. It may occur when the skin comes in contact with something to which it is sensitive.
* anemia (uh-NEE-me-uh) is a blood condition in which there is a decreased hemoglobin in the blood and, usually, fewer than normal numbers of red blood cells.
* dementia (dih-MEN-sha) is a loss of mental abilities, including memory, understanding, and judgment.
* schizophrenia (skit-so-FREE-neeah) is a serious mental disorder that causes people to experience hallucinations, delusions, and other confusing thoughts and behaviors, which distort their view of reality.