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Fifth stage
Psychiatry
Lec-11
.د
الهام
27/11/2016
Factitious disorder
Factitious disorder (Munchausen's Syndrome)
• In factitious disorder patients intentionally falsify their symptoms and past history
and fabricate signs of physical or mental disorder with the primary aim of obtaining
medical attention and treatment.
• The diagnostic features are the intentional and conscious production of signs,
falsification, or exaggeration of the history and the lack of gain beyond medical
attention and treatment.
Three distinct sub-groups are seen:
• Wandering
• mostly males who move from hospital to hospital, job to job, place to place,
producing dramatic and fantastic stories. There may be aggressive personality
or dissocial PD and comorbid alcohol or drug problems.
• Non-wandering
• mostly females; more stable lifestyles and less dramatic presentations. Often
in paramedical professions; overlap with chronic somatization disorder.
Association with borderline PD.
• By proxy
• mostly female. Mothers, careers, or paramedical and nursing staff who
simulate or prolong illness in their dependents ”here the clinical focus must be
on the prevention of further harm to the dependent.
• The behaviors can mimic any psychical and psychiatric illness.
• Behaviors include:
• self-induced infections,
• simulated illnesses,
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• interference with existing lesions,
• self-medication,
• altering records,
• reporting false physical or psychiatric symptomatology.
• Early diagnosis reduces iatrogenic morbidity and is facilitated by:
• awareness of the possibility;
• a neutral interviewing style using open rather than closed questions;
• alertness to insistencies and abnormalities in presentation;
• use of other available information sources;
• and careful medical record keeping.
Differential diagnosis:
• Any genuine medical or psychiatric disorder.
• Somatization disorder (no conscious production of symptoms and no fabrication of
history),
• malingering (secondary gain for the patient e.g. compensation, avoiding army
service),
• substance misuse (also gain i.e. the prescription of the drug),
• hypochondriasis,
• psychotic and depressive illness (associated features of the primary mental illness).
Etiology:
• Unknown, there may be a background of childhood sexual abuse or childhood
emotional neglect.
• Probably more common in men and those with a nursing or paramedical background.
• Association with personality disorder.
• Production of psychiatric symptoms associated with borderline PD, CSA or emotional
abuse.
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Management:
• There are no validated treatments.
• Patients are often reluctant to consider psychiatric assessment and may leave once
their story is questioned.
• Management in these cases is directed towards reducing iatrogenic harm caused by
inappropriate treatments and medications.
• Direct challenge
• Easier if there is direct evidence of feigned illness;
• the patient is informed that staff are aware of the intent to feign illness and
the evidence is produced.
• This should be in a non-punitive manner with offer of ongoing support.
• Indirect challenge
• Here the aim is to allow the patient a face-saving way out, while preventing
further inappropriate investigation and intervention.
• One example is the double bind if this doesn't work then the illness is
factitious.
• Systemic change
• Here the understanding is that there is no possibility of change in the individual
and the focus is on changing the approach of the health care system to
assessing them in order to minimize harm.
• These strategies can include dissemination of the patient's usual presentation
and distinguishing marks to regional hospitals, black-listing, Munchausen's
registers, etc.
• As these strategies potentially break confidentiality and can decrease the risk
of detecting genuine illness, they should be drawn up in a multidisciplinary
fashion involving senior staff.