FACTITIOUS DISORDERS

David Straker, D.O. Steven Hyler, M.D.

Columbia University Medical CenterNew York, NY

OVERVIEW

• Definition

• History

• Diagnosis and Treatment Options

• Evidence Based Data

• Novel Issues: Internet and Children

• Conclusions

DEFINITION

• The patient consciously (voluntarily) produces signs and symptoms of an illness

• Intentional production• It can be physical or psychological• Primary goal to receive medical, surgical or

psychiatric care• No external incentive (no monetary gain)• Primary gain to maintain the sick role

HISTORY

• DSM III

• DSM III-R

• DSM IV

• Other historical Issues

DSM III

• First entered DSM III in 1980• FD patient assumes the “patient role”• Filled the middle ground between hysterical disorders and

malingering

• Subtypes: 1) with psychological symptoms 2) with physical symptoms 3) chronic factitious disorder with physical symptoms (Munchausen's syndrome) 4) atypical factitious disorder

DSM III-R

• Revised in 1987• Assume the “sick role”

• Subtypes:

1) with psychological symptoms

2) with physical symptoms

3) factitious disorder not otherwise specified

DSM IV

• Revised in 1994• Factitious disorder by proxy included• DSM IV-TR has same criteria

• Subtypes 1) with psychological symptoms 2) with physical symptoms 3) factitious disorder not otherwise specified

OTHER HISTORICAL ISSUES• 1951 - Munchausen’s syndrome coined by Richard Asher: a

more chronic, severe form of factitious disorder with multiple hospitalizations, extending over years and where the patient adopts a role of “patient” as a career

• 1983 - Paper by Reich and Gottfried: first paper to review factitious disorders in the teaching hospital

• 1994 - Factitious Disorder by proxy introduced into DSM-IV. Defined as the “deliberate production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care

DIAGNOSIS AND TREATMENT

• Contact prior treatment providers, family members and friends to obtain parallel history

• Room and belonging searches to look for paraphernalia used by the patient to create symptoms may be helpful

• Cross-checking medical record numbers, social security numbers and aliases also may be helpful

• Continuous observation (1:1 aid)

DIAGNOSIS AND TREATMENT (continued)

• Laboratory Tests 1) c-reactive protein can detect exogenous insulin use in hypoglycemia

2) stool can be tested for phenolphthalein to evaluate for laxative abuse 3) lab tests can be done to check for exogenous epinephrine,

anticoagulants, thyroid hormone, and vanilla extract (VMA in pheochromocytoma)

• Use of “blacklists” in emergency rooms ?• Use of computerized medical record systems may be helpful• Possible role of Dialectic Behavioral Therapy (no reports in the literature)

EVIDENCE BASED DATA

• Limited to mostly anecdotal case reports

• No randomized controlled or clinical trials in the past 7 years

• Two meta-analysis in the past 7 years

• Eighty-one review articles (in English), more than half of which are on factitious disorder in children and on Munchausen's by proxy

• Most review articles are case series

SELECT REVIEW ARTICLES

• Fliege et al (2002):

Factitious Disorders & Pathological self-harm

• Krahn et al (2003):

Factitious Disorders & physical symptoms

FACTITIOUS DISORDER AND PATHOLOGICAL SELF HARM

• 7.5 percent of patients engaged in self-harm• Three subtypes:

1) artefact (direct self harm): scratching, burning, cutting, picking

2) self-induced (artificial disease): use of medication or infectious substances

3) delegated self harm: such as amputation or operation• 15.1 % of patients engaged in all 3 behaviors• Those who engaged in self harm were: more than 3 times as likely to have

a personality disorder and were generally younger, female, and single

Fliege et al 2002 (Germany)

FACTITIOUS DISORDERS WITH PHYSICAL SYMPTOMS:

A RETROSPECTIVE EXAMINATION

• 21 year review of ninety-three patients• Mean age 30.7 years old• 72 % female, 90 % Caucasian • 68.8 % employed, 47.3 % had health care training,

71.3 % were high school graduates

• 19.4 % left hospital AMA• Approximately 20 % agreed to psychiatric treatment

Krahn et al 2003 (Mayo Clinic, USA)

NOVEL ISSUES IN FACTITIOUS DISORDER

• Factitious Disorder via Internet

• Factitious Disorder in Children

• Factitious Disorder via phone / hoax calls

FACTITIOUS DISORDER AND THE INTERNET

• Virtual chat rooms

• Support Groups

• Web sites

• M.A.M.A (Mothers Against Munchausen’s Allegations) @ www.msbp.com

FACTITIOUS DISORDER AND THE INTERNET (continued)

• Google search - Munchausen’s Syndrome:

250,000 sites• Google search - Factitious Disorder: 31,500 sites• Most popular sites: www.munchausen.com,

www.mbpexpert.com, and www.emedicine.com

• Barnes and Noble and Amazon web sites: 19 and 31 books respectively on factitious disorders

FACTITIOUS DISORDER ON THE INTERNET

• More than 14 cases have been described• Terms “Virtual Factitious Disorder” and

“Munchausen by Internet” coined by Marc D. Feldman, MD in 1998 and 2000

• People who simplify the “real-life” process of factitious disorder by carrying out their deceptions online

• Person/patient jump from one support group to the next; use different names and accounts; can pretend to be the patient, son, mother, etc. to make the story seem even more convincing

FACTITIOUS DISORDERS IN CHILDREN

• Factitious Disorder by children (without parental involvement)

• Factitious Disorder by Internet in Adolescents

• Factitious Disorder by proxy (via internet)

• Co-morbid Factitious Disorder and Factitious Disorder by proxy

FACTITIOUS DISORDERS IN CHILDREN: REVIEW ARTICLES

• Libow et al (2000): Review Article - 42 case reports• Saez-de-Oscariz (2004): Review Article - 29 case

reports

• Most commonly reported falsified conditions were: 1) fevers 2) purpura 3) ketoacidosis 4) infections

FACTITIOUS DISORDER IN THE 21ST CENTURY

• Increasing availability of computer-based medical records may help facilitate communication between institutions and may help early recognition and diagnosis

• Awareness of the use of the internet by such patients may also help earlier detection and treatment

• Understanding that this is an illness that often starts in childhood may help make clinicians aware that early intervention and detection can prevent chronicity of illness