Factitious disorder Health Article

Demographics

The demographics of factitious disorder vary considerably across the different subtypes. Most individuals with the predominantly psychological subtype of FD are males with a history of hospitalizations beginning in late adolescence; few of these people, however, are older than 45. For non-chronic factitious disorder with predominantly physical symptoms, women outnumber men by a 3:1 ratio. Most of these women are between 20 and 40 years of age. Individuals with Munchausen syndrome are mostly middle-aged males who are unmarried and estranged from their families. Mothers involved in MSBP are usually married, educated, middle-class women in their early 20s.

Little is known about the rates of various subcategories of factitious disorder in different racial or ethnic groups.

The prevalence of factitious disorder worldwide is not known. In the United States, some experts think that FD is underdiagnosed because hospital personnel often fail to spot the deceptions that are symptomatic of the disorder. It is also not clear which subtypes of factitious disorders are most common. Most observers in developed countries agree, however, that the prevalence of factitious physical symptoms is much higher than the prevalence of factitious psychological symptoms. A large teaching hospital in Toronto reported that 10 of 1,288 patients referred to a consultation service had FD (0.8%). The National Institute for Allergy and Infectious Disease reported that 9.3% of patients referred for fevers of unknown origin had factitious disorder. A clinic in Australia found that 1.5% of infants brought in for serious illness by parents were cases of Munchausen syndrome by proxy.

Diagnosis

Diagnosis of factitious disorder is usually based on a combination of laboratory findings and the gradual exclusion of other possible diagnoses. In the case of MSBP, the abuse is often discovered through covert video surveillance.

The most important differential diagnoses, when factitious disorder is suspected, are malingering, conversion disorder, or another genuine psychiatric disorder.

Medications

Medications have not proved helpful in treating factitious disorder by itself, although they may be prescribed for symptoms of anxiety or depression if the individual also meets criteria for an anxiety or mood disorder.

Psychotherapy

As of 2002, knowledge of the comparative effectiveness of different psychotherapeutic approaches is limited by the fact that few people diagnosed with FD remain in long-term treatment. In many cases, however, the factitious disorder improves or resolves if the individual receives appropriate therapy for a co-morbid psychiatric disorder. Ganser syndrome usually resolves completely with supportive psychotherapy.

One approach that has proven helpful in confronting patients with an examiner's suspicions is a supportive manner that focuses on the individual's emotional distress as the source of the illness rather than on the anger or righteous indignation of hospital staff. Although most individuals with FD refuse psychiatric treatment when it is offered, those who accept it appear to benefit most from supportive rather than insight-oriented therapy.

Family therapyis often beneficial in helping family members understand the individual's behavior and their need for attention.

Legal considerations

In dealing with cases of Munchausen syndrome by proxy, physicians and hospitals should seek appropriate legal advice. Although covert video surveillance of parents suspected of MSBP is highly effective (between 56% and 92%) in exposing the fraud, it may also be considered grounds for a lawsuit by the parents on grounds of entrapment. Hospitals can usually satisfy legal concerns by posting signs stating that they use hidden video monitoring.

All 50 states presently require hospitals and physicians to notify law enforcement authorities when MSBP is suspected, and to take steps to protect the child. Protection usually includes removing the child from the home, but it should also include an evaluation of the child's sibling(s) and long-term monitoring of the family. Criminal prosecution of one or both parents may also be necessary.

Prognosis

The prognosis of factitious disorder varies by subcategory. Males diagnosed with the psychological subtype of FD are generally considered to have the worst prognosis. Self-mutilation and suicideattempts are common in these individuals. The prognosis for Munchausen's syndrome is also poor; the statistics for recurrent episodes and successful suicides range between 30% and 70%. These individuals do not usually respond to psychotherapy. The prognosis for non-chronic FD in women is variable; some of these patients accept treatment and do quite well. This subcategory of FD, however, often resolves itself after the patient turns 40. MSBP involves considerable risks for the child; 9–10% of these cases end in the child's death.

Ganser syndrome is the one subtype of factitious disorder with a good prognosis. Almost all patients recover within days of the diagnosis, especially if the stressthat precipitated the syndrome is resolved.

Prevention

As of 2002, factitious disorder is not sufficiently well understood to allow for effective preventive strategies—apart from protection of child patients and their siblings in cases of MSBP.