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Factitious Disorder: Detection, Diagnosis, and Forensic Implications

Factitious Disorder: Detection, Diagnosis, and Forensic Implications

fac ti tious adj.1. Produced artificially rather than by natural process; contrived. 2. Lacking authenticity or genuineness; sham. [Latin facticius, made by art; from facere, to make, do]

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Few phenomena in medicine are more confounding than the diagnoses involving deception: malingering, Munchausen syndrome, Munchausen by proxy (MBP), and factitious disorder (Table 1). Physicians rely on patient reports of symptoms as a starting point for evaluation and treatment planning. They expect to be able to trust their patients' reports. When they are misled, deliberately or inadvertently, consciously or unconsciously, physicians are thrown off their game plan. Sometimes they are tempted to call factitious disorder "fictitious disorder"; however, in some cases, the ailments are real but self-induced.

       
TABLE 1
Factitious disorder and related disorders: some definitions and distinctions
     
 
 
  • Factitious disorder: conscious and intentional feigning or production of symptoms, because of a psychological need to assume the sick role to obtain emotional gain
  • Malingering: conscious and intentional production or exaggeration of symptoms for material gain, such as money, lodging, food, drugs, avoidance of military service, or escape from punishment
  • Somatization: recurrent and multiple symptoms (eg, pain, GI, sexual, pseudoneurological) with no organic basis, believed to be due to unconscious expressions of suppressed emotional conflict or stress; unlike factitious disorders, the symptoms are not created by voluntary, conscious behavior
  • Hypochondriasis: obsession with fears that one has a serious, undiagnosed disease, presumably based on misinterpretation of bodily sensations
 
 
  Adapted with permission from Savino AC, Fordtran JS. Proc (Bayl Univ Med Cent). 2006.14  
 

Malingering (ie, conscious fabrication of symptoms for external and usually tangible gain) has long been recognized. Its unconscious cousins—what used to be called hysteria and is now more properly called somatoform disorders—have long been studied.

The more extreme forms of factitious disorder, Munchausen syndrome (chronic factitious disorder with wanderlust and self-aggrandizement), and MBP, have only recently begun to get systematic attention. In fact, factitious disorder and Munchausen syndrome only entered the diagnostic nomenclature in 1980. In 1995, MBP was included in DSM-IV for the first time as the research diagnosis factitious disorder by proxy (Table 2). However, experts continue to debate whether these 2 terms are truly synonymous (Figure 1). Although more common in the popular imagination, Munchausen syndrome,based on the humorous 18th-century fantasy book, The Adventures of Baron Munchausen, only accounts for about 10% of the cases of factitious disorder.1

       
TABLE 2
DSM-IV criteria for factitious disorder
     
 
 
  • Intentional production or feigning of physical or psychological signs or symptoms
  • Motivation for the behavior is to assume the sick role
  • External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent
 

Serial factitious disorder and MBP
The evaluation involves detailed clinical examination, including extensive history (and collateral history, if the patient will consent), careful physical examination, and relevant laboratory and radiological studies. Sometimes presenting symptoms are not anatomically plausible, such as tunnel blindness or pain or paresis that does not cross the midline. (The fact that psychiatrists and neurologists are both included in similar board certification processes attests to the historical overlap of these symptom clusters.) More often, the patient's presentation of fabricated signs and symptoms is believable.

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