Patients with
this disorder knowingly fake symptoms, but do so for psychological
reasons not for monetary or other discrete objectives as in the case
of Malingering. They usually prefer
the sick role and may move from hospital to hospital in order to receive
care. They are usually loners with an early childhood background of
trauma and deprivation. They are unable to establish close interpersonal
relationships and generally have severe personality disorders. Unlike
many malingerers, they follow through
with medical procedures and are at risk for drug addiction and for
the complications of multiple operations
In the more severe
form known as Münchhausen
Syndrome, a series of successive hospitalizations becomes a lifelong
pattern. Factitious disorder is distinguished from malingering
where there is external motivation for the symptom production, a patient
with a factitious disorder intentionally produces physical symptoms
without external incentives.
Associated
Features:
History of Suicide
Attempts and/or Depression
History of Multiple Medical Procedures
Adjustment Disorder
Substance Abuse
Dysthymic Disorder
Somatoform Disorder
Borderline Personality Disorder
Differential
Diagnosis:
Some disorders have similar symptoms. The clinician, therefore, in
his diagnostic attempt has to differentiate against the following
disorders which need to be ruled out to establish a precise diagnosis
.Most important differential diagnoses are with:
Genuine Psychiatric
Pathology
Malingering
Somatoform Disorders.
Cause:
Little is currently
known about the etiology or psychopathology of factitious disorders
with physical or psychological symptoms. Besides the difficulties
involving the diagnosis, reluctance of those patients to undergone
psychological testing and heterogeneity in details of cases published
in literature are at the origin of this situation.
Many hypotheses have tried try to explain factitious
disorder. Some clinicians have remarked that patients with factitious
disorder often present traumatic events, particularly abuse and deprivation
and numerous hospitalizations in childhood and as adults lack support
from relatives and/or friends. Because of that, they consider that
hospitalization is unconsciously used to recreate the desired parent-child
bond they lacked in reality. Other clinicians consider that factitious
disorder allows patients to feel in control as they never felt in
childhood.
From a behavioral point of view factitious disorder is regarded as
a coping mechanism, learned and reinforced in childhood.
Treatment:
Essential and probably most difficult step is to secure an enduring
and stable patient-physician relationship. For achieving this goal
most clinicians advocate a non-confrontational strategy reframing
the factitious manifestation as a "cry for help".
An interesting approach is that of "contract conference".
In this approach the psychiatrist emphasize the need for the patient
to express him/herself in the common language of difficult relationships,
feelings and problems in living instead of the (factitious) language
of illness. After that patient and clinician can
focus their efforts on resolving those real problems.
Once a stable relationship installed the management of the disorder
must be oriented to avoid unnecessary hospitalizations and medical
acts.
An important goal of management of this condition is recognition and
adequate treatment of concurrent disorders (such as personality disorders,
depression, drug and/or alcohol abuse and dependence etc.).
Counseling
and Psychotherapy
Overall
the results of therapy are not encouraging therefore treatment should
be based on focusing on the management of the disorder rather than
on cure". Both analytical and cognitive-behavioral
approaches have been used to deal with factitious disorder, with some
benefit, in patients who accepted to engage in such therapies.
Pharmacotherapy
Some
case reports focus on the use of pharmacological agents in the treatment
of factitious disorder. A good response have been reported to antipsychotic
drugs (Pimozide) other clinicians, because of resemblance to OCDs
and/or because the impulsive nature of the disorder advocate the use
of SSRIs.