Factitious Disorder DSM-5 300.19 (F68.10)

Factitious Disorder DSM-5 300.19 (F68.10)

DSM-5 Category: Somatic Symptom and Related Disorders

Factitious Disorder

Factitious disorder is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who falsify illness in themselves or in another person, without any obvious gain. The diagnosis for an individual falsifying illness of another person is factitious disorder imposed on another.

Introduction

Factitious disorder —often referred to as Munchausen’s syndrome (Steel, R. M. 2009)—is categorized by the intentional falsification of physical and/or mental signs and symptoms in oneself or in another individual, for no obvious external gain or reward.

This combination of intentional falsification and lack of any obvious gain sets factitious disorder apart from similar conditions, such as somatic symptom disorder (where someone seeks excessive attention for genuine concerns) and malingering (where an individual falsifies symptoms for personal gain), and also makes the condition difficult both to diagnose and treat. Only 1% of individuals in hospital present with criteria matching the disorder, but the prevalence of factitious disorder throughout the general population is unknown. (American Psychiatric Association 2013)

Case studies suggest that the two main groups of people most commonly affected by factitious disorder are women between the ages of 20 and 40 with a healthcare background, and unmarried white men aged between 30 and 50 (NHS 2016).

Diagnosis of factitious disorder often requires a number of investigatory steps in order to accurately identify the condition without wrongful accusation, and treatment options can be both limited and difficult to administer if the individual refuses to admit the deception. The strain that factitious disorder causes not only on the relationship between patient and doctor, but also between the individual and their friends, family, work and daily life, can be immense. (Steel, R. M. 2009)

Symptoms of factitious disorder

By its nature, factitious disorder can seem asymptomatic. In order to make a diagnosis of factitious disorder, it may be necessary for a health professional to look for clues and patterns in behavior that suggest an individual is being misleading. Some behaviors, however, do make factitious disorder easier to spot, including:

  • Inconsistencies between patient history and medical observations.
  • Vague details that seem plausible on the surface but that don’t hold up to scrutiny.
  • Lengthy medical records with multiple admissions at different hospitals.
  • Willingness to accept any discomfort and risk from many medical procedures, even surgery.
  • Overdramatic or outlandish presentation of a factitious illness, or hostility when challenged.

(Jaghab, K., Skodnek, K. B., & Padder, T. A. 2006)

Once the initial indicators have been identified, other avenues of investigation open up. An individual presenting with any of the above symptoms may have a history in the medical profession, or an otherwise textbook knowledge of their factitious illness and overall medical practice, which can make the deception more difficult to uncover.

The individual may have unexplained injuries that present as being potentially self-inflicted, ranging from minor cuts to abscesses or sepsis induced by injecting themselves with fecal matter. Other signs can include significant surgical scarring from repeated unnecessary operations - a so-called ‘gridiron abdomen’, for example - and affected individuals may even resort to tampering with hospital charts or contaminating test samples. Symptoms of the factitious illness may only appear when the individual believes they have attention, or in the case of negative test results. (Elwyn, T. S. 2018)

Whatever the symptoms, it is important that as many as possible are evidenced and preferably reviewed by a peer to rule out the possibility of a genuine rare or obscure illness, as many of these symptoms on their own can be purely circumstantial. (Steel, R. M. 2009)

Diagnostic criteria for factitious disorder

There are four primary criteria for diagnosing factitious disorder. These are:

  • Intentional induction or falsification of physical or psychological signs or symptoms
  • The individual presents themselves as ill, impaired or injured to others
  • The deceptive behavior persists even in the absence of external incentives or rewards
  • Another mental disorder does not better explain the behavior

Factitious disorder may be diagnosed as either a single episode or as recurrent episodes (two or more instances of illness falsification and/or induction of injury).

Diagnostic criteria for factitious disorder in another

Factitious disorder in another (formerly known as previously called Munchausen syndrome by proxy) may be broadly diagnosed using the same four criteria as above:

  • Intentional induction or falsification of physical or psychological signs or symptoms in another person
  • The individual presents another individual (the victim) as ill, impaired or injured to others
  • The deceptive behavior persists even in the absence of external incentives or rewards
  • Another mental disorder does not better explain the behavior

As with factitious disorder, factitious disorder in another may be diagnosed as either a single episode or as recurrent episodes (two or more instances of illness falsification and/or induction of injury). With factitious disorder in another, the victim may be assigned an abuse diagnosis as a result of the perpetrator’s behavior or actions. (American Psychiatric Association 2013)

Causes of factitious disorder

Factitious disorder is still not very well understood - a low number of individuals from a wide range of backgrounds are successfully diagnosed with the condition. As such, it’s difficult to identify causes of factitious disorder with any certainty.

Risk factors are believed to include childhood trauma, working in the healthcare profession and suffering from depression or a personality disorder. (Psychology Today 2019)

Other factors that may relate to the onset of factitious disorder include a desire to be nurtured or to be distracted from life stressors, and enjoyment of having relationships with doctors or others of high perceived status.

It is suggested that the dynamics of a parent and child relationship may also be a contributing element if these relationships result in:

- a need to be loved or cared for
- a need to deceive
- a need for control
- a need to master abusive parents
- a need to be hurt or punished

(Dyer, A. R., Feldman, M. D. 2007)

Comorbidity

As a result of its defining characteristics and the deception of those who suffer from the condition, factitious disorder is difficult to study. As such, most reports are single cases or small case studies. (Steel, R. M. 2009)

However, there appear to be meaningful clinical links discovered between factitious disorder and other mental illnesses, such as borderline personality disorder. (Gordon, D. K., & Sansone, R. A. 2013)

Living with factitious disorder

Factitious disorder affects both the individual and those around them to a significant degree. Friends, family and other acquaintances generally experience the effects of factitious disorder more acutely than the sufferer themselves, often as a result of the individual being unwilling to confess to their deception. Obtaining truthful accounts of life with factitious disorder is tricky, and mainly limited to deducing from the causes. (Steel, R. M. 2009)

The individual will have a need to receive attention and care, and will often go through many unnecessary and potentially risky methods like surgery in order to obtain what they desire. They may induce illness in themselves in order to achieve this goal, potentially putting their need for nurture higher than their own safety. (Jaghab, K., Skodnek, K. B., & Padder, T. A. 2006)

Life for those around such individuals can be stressful. Doctors especially risk litigation from diagnosing factitious disorder too hastily, or abuse if they confront the individual about their suspicions.

An individual with factitious disorder may find doctors distance themselves, or cease all treatment except that required to prevent death, rather than risk the individual sabotaging continued treatment and procedures. (Steel, R. M. 2009) It is not unknown for untreated factitious disorder to result in serious and ultimately fatal illness or suicide. (Jaghab, K., Skodnek, K. B., & Padder, T. A. 2006)

Treatment for factitious disorder

There is no known single treatment for factitious disorder. (Steel, R. M. 2009) A key difficulty in creating treatments for the disorder is simply how few cases are reported, and how even fewer of those go on to receive continued long-term treatment options.

Of the few documented cases, it is noted that treating issues around the factitious disorder, such as any comorbid conditions, often brings an end to the factitious disorder itself or enables management of the condition. It is also theorized that treating potential underlying causes, such as historical childhood traumas, may produce similar results.

Therapies that focus on helping the individual identify and address their own emotional need for attention or care may be suggested, although preference is given to supportive over insight-oriented therapies due to the increased recorded benefit. (Jaghab, K., Skodnek, K. B., & Padder, T. A. (2006) It should be noted, however, that few individuals with factitious disorder choose to receive psychiatric treatment.

Cognitive behavioral therapy may be used as a treatment method and family therapy may also be suggested to help those around the individual understand and manage the disorder, which in turn will aid the individual. Medication may be used to treat symptoms and/or any co-occurring psychiatric disorders but not usually to treat factitious disorder itself. (Elwyn, T.S. 2018)


Dr. Kevin Fleming obtained his PhD from Notre Dame and is the Founder of Grey Matters International (www.greymattersintl.com) a neuroscience-based behavior change consulting firm.

References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

NHS (2016) Overview Munchausen's syndrome https://www.nhs.uk/conditions/munchausens-syndrome/ Date Accessed: 02/13/2019.

Gordon, D. K., & Sansone, R. A. (2013). A relationship between factitious disorder and borderline personality disorder. Innovations in clinical neuroscience 10(11-12), 11-3.

Jaghab, K., Skodnek, K. B., & Padder, T. A. (2006). Munchausen's Syndrome and Other Factitious Disorders in Children: Case Series and Literature Review Psychiatry (Edgmont (Pa. : Township)), 3(3), 46-55.

Steel, R. M., (2009) Factitious disorder (Munchausen’s syndrome) J R Coll Physicians Edinb 2009; 39:343–7 doi:10.4997/JRCPE.2009.412

Psychology Today (2019) Factitious Disorder (Munchausen Syndrome) https://www.psychologytoday.com/gb/conditions/factitious-disorder-munchausen-syndrome Date Accessed: 02/12/2019.

Dyer, A. R., Feldman, M. D. Factitious Disorder: Detection, Diagnosis, and Forensic Implications Psychiatric Times. Volume 24. 15 April 2007. https://www.psychiatrictimes.com/factitious-disorder-detection-diagnosis-and-forensic-implications Date Accessed: 02/13/2019.

Elwyn, T.S. (2018) Factitious Disorder Imposed on Self (Munchausen's Syndrome) https://emedicine.medscape.com/article/291304-overview Date Accessed: 02/13/2019

 


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