Psychiatric factitious disorder From Wikipedia, the free encyclopedia
Factitious disorder imposed on self (FDIS), sometimes referred to as Munchausen syndrome, is a complex mental disorder where individuals play the role of a sick patient to receive some form of psychological validation, such as attention, sympathy, or physical care.[2] Patients with FDIS intentionally falsify or induce signs and symptoms of illness, trauma, or abuse to assume this role.[3] These actions are performed consciously, though the patient may be unaware of the motivations driving their behaviors. There are several risk factors and signs associated with this illness and treatment is usually in the form of psychotherapy but may depend on the specific situation,[4] which is further discussed in the sections below. Diagnosis is usually determined by meeting specific DSM-5 criteria after ruling out true illness as described below.
Factitious disorder imposed on self | |
---|---|
Other names | Munchausen syndrome[1] |
Specialty | Psychology, psychiatry |
Factitious disorder imposed on self is related to factitious disorder imposed on another, which refers to the abuse of another person in order to seek attention or sympathy for the abuser. This is considered "Munchausen by proxy", and the drive to create symptoms for the victim can result in unnecessary and costly diagnostic or corrective procedures.[3] Other similar and often confused syndromes/diagnoses are discussed in the "Related Diagnoses" section.
The name "Munchausen syndrome" derives from Baron Munchausen, a literary character loosely based on the German nobleman Hieronymus Karl Friedrich Freiherr von Münchhausen (1720–1797).[5] The historical baron became a well-known storyteller in the late 18th century for entertaining dinner guests with tales about his adventures during the Russo-Turkish War. In 1785, German-born writer and con artist Rudolf Erich Raspe anonymously published a book in which a heavily fictionalized version of "Baron Munchausen" tells many fantastic and impossible stories about himself. Raspe's Munchausen became a sensation, establishing a literary exemplar of a bombastic liar or exaggerator.[6][7]
In 1951, Richard Asher was the first to describe a pattern of self-harm, wherein individuals fabricated histories, signs, and symptoms of illness. Remembering Baron Munchausen, Asher named this condition Munchausen's Syndrome in his article in The Lancet in February 1951.[7] Asher's nomenclature sparked some controversy, with medical authorities debating the appropriateness of the name for about fifty years. While Asher was praised for bringing cases of factitious disorder to light, participants in the debate objected variously that a literary allusion was inappropriate given the seriousness of the disease; and that the name's connection to works of humor and fantasy, and to the essentially ridiculous character of the fictional Baron Munchausen, was disrespectful to patients with the disorder.[8] Some healthcare providers avoid this term because it downplays the complexity of the illness and devalues the patient experience. The term "factitious disorder imposed on self" provides a more accurate and encompassing description of this mental disorder; however, both terms may still be used interchangeably in practice.[9]
The exact cause of this illness is unknown due to limited research but is likely the result from multiple psychosocial factors. Specific risk factors have been assocaited with developing FDIS, specifically a history of childhood trauma, abandonment, having a serious childhood illness, and certain personality disorders.[10][11] Patients are more likely to be female, middle aged, and work in the healthcare industry.[12] Individuals with this disorder may also have a history of recurrent hospitalizations and frequent visits to multiple different physicians (i.e. doctor shopping).[13] They are also more likely to have underlying depression, though it is unclear if it is a cause or symptom of this illness.[9]
In factitious disorder imposed on self, the affected person exaggerates or creates physical or psychological symptoms of illnesses in themselves to gain examination, treatment, attention, sympathy or comfort from medical personnel. Because these symptoms can vary depending on how patients induce these symptoms, there is no consistent symptom specific for this illness. However, there are several common themes that may raise suspicion for FDIS. Some of these common themes include:
Common examples of commonly induced physical symptoms include intentionally infecting a wound with debris or unsanitary material, taking laxatives to induce diarrhea, and ingesting thyroid hormone replacement medication to simulate a hyperactive thyroid or hyperthyroidism.[13]
Due to the behaviors involved, diagnosing factitious disorder is very difficult. Because induced symptoms may mimic those of a real disease or disorder, physicians must first rule out genuine disease. Therefore, FDIS is usually a diagnosis of exclusion.[15] To rule out genuine illness, lab tests may be required, including complete blood count (CBC), urine toxicology, drug tests, blood cultures to rule out infection, coagulation tests, assays for thyroid function, or DNA typing, depending on the mimicked disease. In some cases CT scan, magnetic resonance imaging, psychological testing, electroencephalography, or electrocardiography may be required. A more extensive list of how organic illness is differentiated from FDIS is provided below.[16]
If the healthcare provider finds no physical reason for the symptoms, they may refer the person to a psychiatrist or psychologist (mental health professionals who are specially trained to diagnose and treat mental illnesses). Psychiatrists and psychologists use thorough history, physical examinations, laboratory tests, imagery, and psychological testing to evaluate a person for physical and mental conditions and to distinguish between feinged versus real illness. Once the person's history has been thoroughly evaluated, diagnosing factitious disorder imposed on self requires a clinical assessment, typically performed by a psychiatrist.[17]
For a person to be diagnosed with factitious disorder imposed on self, they must meet the following criteria:[13][18]
There are common methods for inducing certain symptoms and mimicking specfic diseases. As mentioned earlier, it is important ot first rule out true disease. Physicians usually must have a high suspicion for FDIS to pursue it as a likely diagnosis based on abnormal patient behaviors and medical history. Some examples of these are listed in the table below, along with how to differentiate them from real versus mimicked disease using medical laboratory tests or imaging.[19]
Disease Mimicked | Method of Imitation | Laboratory/diagnostic confirmation |
---|---|---|
Bartter syndrome |
|
|
Catecholamine-secreting tumor (i.e. Carcinoid tumor) |
|
Chromogranin A, a tumor marker for Carcinoid tumor, blood levels will be increased for a tumor and normal in those with FDIS.[21] |
Cushing's syndrome |
|
Urine test to detect use of steroids[23] |
Hyperthyroidism |
|
|
Hypoglycaemia | ||
Chronic diarrhea |
|
|
Haematuria (bloody urine) |
|
|
Munchausen by Internet is a term describing the pattern of behavior in factitious disorder imposed on self, wherein those affected feign illnesses in online venues to gain sympathy from online supporters. It has been described in medical literature as a manifestation of factitious disorder imposed on self.[29] Reports of users who deceive internet forum participants by portraying themselves as gravely ill or as victims of violence first appeared in the 1990s due to the relative newness of Internet communications. The specific internet pattern was named "Münchausen by Internet" in 1998 by psychiatrist Marc Feldman.[29] New Zealand PC World Magazine called Munchausen by Internet "cybermunch", and those who posed online "cybermunchers".[30]
When confronted with this diagnosis, patients often refuse to accept it and will continue their behaviors seeking healthcare at different institutions or physicians.[17] Those who accept the diagnosis benefit most from psychotherapy delivered by a skilled therapist or psychiatrist. In doing so, patients can learn the underlying subconscious motivations that drive their conscious behaviors in order to develop a sense of awareness the prevents them from continuing these harmful behaviors.[31][12] If a person is considered to be at risk of harming themself or others, psychiatric hospitalization may be initiated.[32]
Specific forms of therapy may be tailored to underlying personality disorders contributing to their behaviors. For example, dialectical behavior therapy (DBT) can be used to treat borderline personality disorder.[33] Medications may be necessary to treat an underlying mood disorder or anxiety disorder, as many patients with this disorder may have underlying depression.[34] Patients with underlying depression and/or anxiety are typically responsive to antidepressants with or without cognitive behavioral therapy, a form of psychotherapy.[35][36][37]
This disorder can sometimes be diifficult to distinguish from several related diagnoses, but they differ in their motivational gains and control over symptoms.[38] "Gain" is a Freudian psychoanalytic term that is used to describe the psychological benefits that drive certain illnesses and their behaviors.[39] A primary gain refers to internal benefits from a symptom or illness, like feeling a decrease in emotional or psychological stress. A secondary gain refers to the external benefits from a symptom or illness, like receiving financial benefits or avoiding a stressful activity.[40]
Factitious disorder is distinct from malingering in that people with factitious disorder do not fabricate symptoms for material gain such as financial compensation, absence from work, or access to drugs.[41] Somatiform disorders include a range of illnesses where physical symptoms result from psychological stressors.[42] Perhaps the most common subtype, Functional Neurologic Disorder is characterized by psychological distress resulting from neurologic symptoms (e.g. paralysis, seizures, loss of vision) that typically coincide with periods of psychological stress and are not due to an underlying neurologic condition.[43] Below is a table outlining the differences between these related diagnoses.[44][45]
Diagnosis | Production of Symptoms | Motivation for Symptoms | Control Over Symptoms | Gain | Example |
---|---|---|---|---|---|
Factitious Disorder Imposed on Self | Conscious | Unconscious | Voluntary | Primary | Taking laxatives to present as having chronic diarrhea from an unknown origin in order to receive attention/sympathy from playing the sick role |
Malingering | Conscious | Conscious | Voluntary | Secondary | Faking cold-like symptoms to intentionally avoid going into work. |
Somatiform Disorders | Unconscious | Unconscious | Involuntary | Primary | Experiencing vision loss in one eye after being fired despite having normal eye functions on physical exam |
Factitious disorder imposed on another, also referred to as Munchausen's by proxy, occurs when an individual induces symptoms or feigns illness in someone else to receive some form of psychological satisfaction for themselves.[46] This has been documented in the parent or guardian of a child or the owner of a pet animal.[47] The adult ensures that their child will experience some medical condition, therefore compelling the child to suffer through treatments and spend a significant portion during youth in hospitals. Furthermore, a disease may actually be initiated in the child by the parent or guardian. This condition is considered distinct from Munchausen syndrome. There is growing consensus in the pediatric community that this disorder should be renamed "medical abuse" to highlight the harm caused by the deception and to make it less likely that the sufferer can use a psychiatric defense when harm is done.[48]
Seamless Wikipedia browsing. On steroids.