Factitious Disorder with Psychological Signs and Symptoms

We are reporting two cases of factitious disorder with psychological signs and symptoms highlighting the diagnostic difficulties, using current (DSM IV) criteria. Based on the analysis of these difficulties, cases already reported in literature and suggestions made by other authors we suggest several, more operational, guidelines to diagnosis. The progresses in diagnosis, understanding and management of this severe and not uncommon disorder require the analysis of a large number of homogeneously reported cases. For that purpose we finally suggest the creation of a database containing uniform reported cases.

The first probable cases of factitious disorder were reported in 1843 by Gavin (cited in Bhugra 1988). However, we could consider that Asher’s article (Asher 1951), in which he introduced the term of Munchausen syndrome, is the origin of the ongoing medical interest in this specific pathology. It entered the DSM classification for the first time as factitious disorder in 1980 (Hiler and Spitzer 1978, American Psychiatric Association 1980).

Factitious disorder with psychological presentation was first reported by Gelenberg in 1977 (Gelenberg 1977). Since then it was considered a variant of the factitious disorder particular only in its expression. As a consequence, the same diagnostic criteria (i.e. intentional feigning of symptoms, motivation to assume the sick role and absence of external incentives), first designed for the factitious disorder with physical signs and symptoms, were used (American Psychiatric Association 1994). However, because of the specificity of the psychiatric diagnostic, i. e. that it entirely relies on statements made by the patient, the diagnostic criteria of factitious disorder with physical manifestations are difficult to use for factitious disorder with psychological symptoms.

Thus this condition is underdiagnosed (Pope et al 1982) and often cases of factitious PTSD and factitious bereavement are reported (Sparr and Pankratz 1983, Snowdon et al 1978, Chaine et al 1994, Meagher and Bell 1998). In these conditions the diagnosis relies more on detection of feigned causes (e. g. traumatic events or death of a parent) than on recognition of factitious symptoms.

In current practice, as pointed in most papers reviewed in this article, the diagnosis is made on the basis of more operational criteria. These are in majority criteria that suggest a non-genuine psychiatric pathology (uncommon symptomatology and course of the disorder). However, there is no consensus on criteria that must be used for diagnosis and thus reliability of factitious disorder with psychological signs and symptoms diagnostic is poor.

Case 1

A 46 years old, single, unemployed man, presented to the hospital complaining of sleeping disturbances (insomnia, nightmares), loss of appetite and recurrent depressive thoughts which began two months before, soon after his mother's death. Physical examination revealed: left index amputation, a surgical scar in the thyroidal region, a global aspect suggesting acromegaly (salient face bones, large extremities) but no signs of weight loss. He explained the index amputation by a work accident, the neck scar by surgery for thyroid carcinoma and when asked he stated that he changed the size of his shoes several times in the few last years. He also said he suffered from epilepsy for more than 15 years.

Laboratory data (including GH levels) were normal. During the hospitalisation we noted a labile and suggestible symptomatology, no appetite disturbances and no insomnia. The patient stopped talking about his mother’s death and giving his suggestibility we avoided referring to this issue. No relative or friend could be contacted in order to get more information. Despite maintaining his previous treatment, the symptoms disappeared quickly and he left the hospital within 10 days.

The study of prior medical records revealed important clues for diagnosis. He has not been hospitalised for the last four years but between the age of 29 and 42 he has been hospitalized 32 times for various complaints, most often of the anxious and depressive spectrum. The symptomatology was shifting and the response to most medication unpredictable. The "thyroid carcinoma" proved to be a benign nodule, there was no definite evidence for epilepsy (the EEG presented non-specific abnormalities and he never had seizures while in hospital). Most important, ten years ago he told a nurse he was not mentally ill, but he "knew what one must say for being admitted to a hospital". Our diagnosis was factitious disorder with predominantly psychological signs and symptoms, although factitious disorder with both psychological and physical signs and symptoms could be considered.

Case 2

A 36 years old, married, unemployed man, walked in the hospital complaining of auditory and visual hallucinations, insomnia and inability to control his excessive alcohol intake. Both physical examination and laboratory work were unremarkable. The hepatic enzymes were in the normal range. The patient was unable to provide precise description of his symptoms (e.g. the content of his visual or auditory hallucinations). No objective signs (blocking, insomnia, speech disorders) were noted.

During hospitalisation we noted frequent changes in symptomatology unrelated to medication.

Once again, medical records were very informative. Since his first hospitalisation, at the age of 26, he was admitted at the same psychiatric hospital for more than 20 times and received various diagnosis such as: paranoid schizophrenia, alcoholism, paranoia, severe neurosis, sensitive personality, depression. The symptomatology was noted to change markedly from an episode to another and during the same episode, most often independently of the treatment. We also found records of numerous suicide attempts usually of no real severity.

Confronted to our incredulity, he maintained that his symptoms were true but asked to leave the ward.

Diagnosis at discharge was factitious disorder with psychological signs and symptoms.

Factitious disorder with psychological signs and symptoms is not an exceptional pathology. Pope (7) found the rate being between 4,1 and 6,4% in a sample of patients previously diagnosed as psychotics. Bhugra (1) found only 0,5 percent factitious patients among the patients admitted in a psychiatric hospital but he himself considers that this could be an underestimate.

The prognosis is quite severe; in the previously cited article Pope shows that it is worse that the prognosis of schizophrenia. Self-injury and suicide attempts are not uncommon in these patients and, as usually there are several diagnoses made before that of factitious disorder, several drug regimens, usually at high doses (because of the lack of response), are prescribed. These unnecessary treatments could lead to severe adverse reactions.

Improving diagnosis is important for both clinics and research. From clinical point of view, it permits a better management or at least avoids unnecessary treatments. From a more theoretical point of view, reliable factitious disorder diagnosis is not only important for the progress of understanding factitious disorder itself, but also for all the other psychiatric disorders. The inclusion of large numbers of factitious disorder patients in a "genuine" psychiatric sample (like in the example of Pope et al) risks to alter the conclusions concerning the aetiology, symptoms evolution and efficacy of treatment. (21)

Based on analysis of cases reported in literature (see references) and on suggestions made by other authors (Pope et al 1982, Popli et al 1992) we propose the following guidelines for the diagnosis of factitious disorder with psychological signs and symptoms.

1. Severe disorder, usually incompatible with individuals maintaining steady employment, family ties and interpersonal relationships, with onset in early adulthood and following a generally chronic course.
2. Characteristics of symptomatology

• the symptoms are labile and inconstant, changing markedly from one day to another or from a hospitalisation to the next one;
• the changes in symptoms are not related to the treatment but are often influenced by the environment as manifested by the suggestibility, mimicry and exacerbation when the patient feels observed (Popli et al 1992);
• unconventional and fantastic symptoms (Pope et al 1982);
• an uncommon association of a large number of symptoms occurring simultaneously or successively, belonging to several psychiatric disorders;
• association with other factitious disorder (factitious disorder with physical signs, factitious bereavement).

1. Patient’s real medical history and biographical data are difficult to obtain because:

• the presentation made by the patient is a mixture of exaggerated, dramatic stories (pseudologica phantastica) (Popli et al 1992) and vague details, often putting forward memory dysfunctions;
• typically the patient with factitious disorder has few or no visitors and prevents medical board from contacting family members or other persons able to provide information.

1. The external, material incentives are either absent or the symptomatology is disproportionate considering the advantages. The distinction between material and psychological incentives is an important one for "care behaviour" (Henderson 1974) in others is an important incentive, always present in such cases.

It is obvious that such criteria are only suggestions and that further investigations and debates are likely to refine them.

For improving diagnosis and our knowledge on aetiology and treatment we need a better characterisation of the antecedents, symptoms and evolution of the factitious disorder with psychological signs and symptoms. This in turn supposes the accumulation of numerous case reports presented in a homogenous manner. For this purpose we suggest the creation of a case report database on factitious disorder with psychological signs and symptoms. We are currently designing a Web page containing data on factitious disorder with psychological signs and symptoms. On this Web page we propose a standardised "case report form" in the aim of obtaining reliable statistics trough improvement of homogeneity of case reports.

This case report "form" should include, in our opinion, at least data on:

• demographic characteristics (sex, age, marital status);
• family history and relations with parents during childhood;
• occupational history and present functioning;
• medical and psychiatric history;
• patients symptoms:
• type (depressive, psychotic etc.);
• presence of symptoms suggesting factitious disorder (e. g. pseudologica fantastica, alleged memory disturbances etc.);
• particular characteristics of symptoms (labile, unconventional, large symptoms association);
• evolution (age of onset; number of previous psychiatric hospitalisations);
• results of psychological testing (when available).

We are looking forward for propositions of items to be included in this form and on the Web page.

Factitious disorder with psychological symptoms is not a very uncommon or benign pathology. However our knowledge in this particular pathology is limited mainly because diagnostic difficulties and lack of solid statistical data.

In this article we suggest, on the basis of case report analysis and proposals made by other authors more objective diagnostic criteria.

We also propose to take advantage of the development of the Internet to create a database on factitious disorder with psychological symptoms based on homogenous case reports.

This strategy could prove useful in other disorders for which having large enough samples of patients, in a single setting, is difficult.

References

1. American Psychiatric Association (1980): Diagnostic and statistical manual of mental disorders, 3^rd edition, Washington D.C., American Psychiatric Association.
2. American Psychiatric Association (1994): Diagnostic ands statistical manual of mental disorders, 4^th edition, Washington D.C., American Psychiatric Association.
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