Factitious disorder Health Article

Definition

Factitious disorder (FD) is an umbrella category that covers a group of mental disturbances in which patients intentionally act physically or mentally ill without obvious benefits. According to one estimate, the unnecessary tests and waste of other medical resources caused by FD cost the United States $40 million per year. The name factitious comes from a Latin word that means "artificial" or "contrived."

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, fourth edition) distinguishes factitious disorder from malingering, which is defined as pretending illness when the individual has a clear motive—usually to benefit economically or to avoid legal trouble.

Factitious disorder is sometimes referred to as hospital addiction, pathomimia, or polysurgical addiction. Variant names for individuals with FD include hospital vagrants, hospital hoboes, peregrinating patients, problem patients, and professional patients.

Description

Cases of factitious disorder appear in the medical literature as early as Galen, a famous Roman physician of the second century A.D. The term factitious is derived from a book by an English physician named Gavin, published in 1843, entitled On Feigned and Factitious Diseases. The modern study of factitious disorder, however, began with a 1951 article in Lancet by a British psychiatrist, Richard Asher, who also coined the term Munchausen's syndrome to describe a chronic subtype of FD. The name comes from an eighteenth-century German baron who liked to embellish stories of his military exploits in order to impress his listeners. In 1977, it was Gellengerg who first reported a case of FD with primarily psychological symptoms. Factitious disorder was recognized as a formal diagnostic category by DSM-IIIin 1980.

DSM-IV-TRdefines factitious disorder as having three major subtypes: FD with predominantly psychological signs and symptoms; FD with predominantly physical signs and symptoms; and FD with combined psychological and physical signs and symptoms. A fourth syndrome, known as Ganser syndrome, has been classified in the past as a form of factitious disorder, although DSM-IV-TRgroups it with the dissociative disorders.

DSM-IV-TRspecifies three criteria for factitious disorder:

• The patient is intentionally producing or pretending to have physical or psychological symptoms or signs of illness.
• The patient's motivation is to assume the role of a sick person.
• There are no external motives (as in malingering) that explain the behavior.

Psychological FD

Factitious disorder with predominantly psychological signs and symptoms is listed by DSM-IV-TRas the first subcategory of the disorder. It is characterized by the individual feigning psychological symptoms.

Some researchers have suggested adding the following criteria for this subtype of FD:

• The symptoms are inconsistent, changing markedly from day to day and from one hospitalizationto the next.
• The changes are influenced by the environment (as when the patient feels observed by others) rather than by the treatment.
• The patient's symptoms are unusual or unbelievable.
• The patient has a large number of symptoms that belong to several different psychiatric disorders.

Physical FD

Factitious disorder wih predominantly physical signs and symptoms is the most familiar to medical personnel. Chronic FD of this type is often referred to as Munchausen's syndrome. The most common ways of pretending illness are: presenting a factitious history (claiming to have had a seizure that never happened); combining a factitious history with external agents that mimic the symptoms of disease (adding blood from a finger prick to a urine sample); or combining a factitious history with maneuvers that produce a genuine medical condition (taking a psychoactive drug to produce psychiatric symptoms). In most cases, these patients sign out of the hospital when they are confronted by staff with proof of their pretending, usually in the form of a laboratory report. Many individuals with Munchausen's syndrome move from hospital to hospital, seeking treatment, and thus are known commonly as "hospital hoboes."

FD with mixed symptoms

Factitious disorder in this category is characterized by a mix of psychological and physical signs and symptoms.

FD not otherwise specified

Factitious disorder not otherwise specified is a category that DSM-IVincluded to cover a bizarre subtype in which one person fabricates misleading information about another's health or induces actual symptoms of illness in the other person. First described in 1977 by an American pediatrician, this syndrome is known as Munchausen syndrome by proxy (MSBP) and almost always involves a parent (usually the mother) and child. MSBP is now understood as a form of child abuseinvolving premeditation rather than impulsive acting out. Many pediatricians in the United States believe that MSBP is underdiagnosed.