Diagnostic legitimacy of factitious disorder with psychological symptoms

The authors question the clinical status of factitious disorder with psychological symptoms as a mental disorder. In particular, they argue that unresolved issues regarding the motivational basis of this disorder and the lack of clearly delineated inclusion, exclusion, and outcome criteria seriously compromise its diagnostic legitimacy. Two case reports are presented to illustrate these difficulties. Future studies should consider these empirical and conceptual difficulties in refining the diagnosis of factitious disorder with psychological symptoms for DSM-IV.     

Factitious disorders with psychological symptoms.

BACKGROUND: Factitious disorders with psychological symptoms have been underdiagnosed and hence undertreated. Historically, the literature has focused on factitious disorder with physical symptoms, particularly Munchausen's syndrome. METHOD: The authors report three cases of factitious disorder with psychological symptoms that had diverse clinical presentations. RESULTS: Two of the patients had features of a psychiatric Munchausen's syndrome--being middle-aged, aggressive men who falsified their symptoms, treatments, and backgrounds. The third patient was a younger woman with comorbid substance abuse, dysthymia, and borderline personality disorder. CONCLUSION: The authors feel that there is a need for refinement of diagnostic criteria, greater awareness, and evaluation of treatment approaches for this condition.     

A case report of comorbid eating disorder and factitious disorder

A review of the literature on comorbid eating disorder and factitious disorder reveals that they are very rare. In this report the authors present the case of a 26-year-old Japanese female, who, in the midst of treatment for eating disorder, was found to be fabricating her physical symptoms, by injecting unclean water into her intravenous bottle. As a result she was diagnosed with factitious disorder.     

A bewitching case of factitious disorder in Zimbabwe

A rural Zimbabwean man attributed the appearance of needles in his leg to witchcraft, but medical practitioners suspected that the needles were self-introduced. Psychiatric evaluation revealed no major mental illness. The patient met criteria for the Euro-American diagnosis of factitious disorder, persisting in his claim that he had been the victim of witchcraft. The patient's claim cannot be considered delusional because belief in witchcraft is culturally sanctioned within Shona culture. The case appears to be one of factitious disorder with both physical and psychological symptoms. Differential diagnoses must be broadened to consider culturally specific phenomena such as witchcraft.     

Factitious disorder on an inpatient psychiatry ward

The authors present 6 cases of factitious disorder seen on a general adult inpatient psychiatry unit of a university hospital. They review the clinical features of this disorder and suggest that factitious disorder is much more prevalent among psychiatric inpatients than is commonly recognized. Strategies to assist in the diagnosis and management this disorder are detailed.     

Munchausen's syndrome: a reconceptualization of the disorder

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) delineates three categories of factitious disorders: chronic with physical symptoms (Munchausen's syndrome); factitious disorder with psychological symptoms; and other factitious disorders with physical symptoms. Munchausen's syndrome served as the prototype for all factitious disorders at the time DSM-III was drafted, partly due to the disproportionate attention given to this variant of the disorder. Clinical experience suggests that existing categories do not adequately provide for commonly seen forms of factitious illness. It is now recognized that factitious disorder is the result of a complex interaction of personality factors and psychosocial stressors that often present with both medical and psychiatric symptomatology. Proposed changes in the revised edition of the diagnostic manual DSM-III-R include separate categories of factitious disorder with psychological, physical, and both psychological and physical symptoms. A case report of a patient for whom extensive records and thorough psychological assessment were available is exemplary of a more common course of the disorder (both psychological and physical symptoms) that by current classification would be considered "atypical." A reconceptualization of the disorder that gives emphasis to course and clinical features is suggested.     

Conversion syndromes in neurology. A psychopathological and psychodynamic differentiation of conversion disorder, somatization disorder and factitious disorder

Conversion syndromes are frequent among medically unexplained somatic symptoms in neurology. A careful differential diagnosis must be carried out in a psychiatric consultation service. In a prospective study lasting for over four years 169 patients with pseudoneurological signs of conversion were included. From a clinical point of view the following conversion syndromes were presented: astasia/abasia: 27.2%, paresis/plegia: 24.3%, aphonia: 1.8%, hyp-/anaesthesia: 21.9%, blindness: 5.3%, non-epileptic seizures: 19.5%. According to the diagnostic criteria of DSM-III-R three subgroups were differentiated: conversion disorder (n = 132), somatisation disorder (n = 28), factitious disorder (n = 9). Intermittent courses of illness were prevailing in conversion disorder, whereas chronic courses predominated in the other two subgroups. High rates of psychiatric comorbidity were typical signs of somatisation disorder. Frequent autodestructive motives (suicidality, deliberate and covert self-harm, chronic pain, high rate of operations) in illness behaviour had to be registered in somatisation and factitious disorder. Both subgroups were characterised by frequent traumatic events during early development. Important socio-economic aspects of illness behaviour above all in somatisation and factitious disorder were underlined. The results are discussed in terms of psychiatric differential diagnosis and psychiatric comorbidity, psychodynamic evaluation, illness behaviour and therapeutic options in a C/L-service.     

The differential diagnosis of multiple personality. A comprehensive review

This review offers guidelines for the diagnosis of multiple personality disorder and other dissociative disorders and presents diagnostic criteria for psychotic disorders, factitious disorders, affective disorders, anxiety disorders, psychosexual disorders, and others that may or may not coexist with multiple personalities.     

False allegations of child physical abuse: a case of Münchausen by proxy-like syndrome?

The diagnosis of factitious disorder by proxy is still under investigation. Few studies have researched the psychological status and potential underlying psychopathology of the perpetrator, as well as the impact on the child's development and the pathological reactions of rearing a child within the context of a distorted reality. In this article, we present the case of a 12-year-old boy where this diagnosis was suspected. Both he and his parents brought forth false allegations of repeated physical abuse induced by his schoolteacher. The parents presented with shared psychosis and the child presented with conduct disorder, factitious disorder, and emotional problems. We suggest that this case represents a Münchausen by proxy-like syndrome involving both the legal and medical systems. Hypotheses regarding the pathogenesis of symptoms in the child are noted, underscoring the differences between Münchausen by proxy syndrome appearing in infancy with that appearing in older children.     

Ethical and management considerations in factitious illness: one and the same

The literature on factitious illness raises many ethical problems regarding diagnosis and treatment. The author briefly reviews ethical issues in factitious illness and argues for viewing these patients as autonomous citizens, capable of accepting responsibility for their behavior. Some factitiously ill patients psychologically resemble those with borderline personality disorder, and ethical implications are developed. In a case example, the author illustrates how good clinical management assists with the resolution or prevention of these ethical dilemmas.     

A case of factitious homicidal ideation

Homicidal ideation is often fabricated or embellished by psychiatric patients in both the emergency room and inpatient settings. Typically, this symptom is malingered to achieve short-term hospital admission and temporary relief from complications of substance abuse, homelessness, and illicit activities. Very rarely, a patient may feign homicidal intent for the primary purpose of remaining in the role of patient (factitious disorder). Although factitious disorder with psychological symptoms has been described in a variety of circumstances, the psychiatric literature lacks any reports of factitious homicidal ideation. This is a report on the case of a patient who was civilly committed on numerous occasions for protracted periods based solely on his self-professed homicidal ideation. The case raises both forensic and clinical questions and reinforces the authors' belief that further investigation is needed to develop more sophisticated methods of detection, evaluation, and treatment of factitious disorder with psychological symptoms.     

Posttraumatic stress disorder: a thirty-year delay in a World War II veteran

Some clinicians doubt the validity of a diagnosis of delayed posttraumatic stress disorder for Vietnam veterans. Precombat psychopathology, drug abuse, factitious symptoms, and malingering in pursuit of disability compensation are cited as alternative explanations for the syndrome. The authors discuss the case of a much decorated World War II veteran whose symptoms of posttraumatic stress disorder first occurred more than 30 years after combat. They consider the alternative explanations for his symptoms to be inadequate.     

Neglected phenomena in factitious illness: A case study and review of literature

Illustrated by casuistics, a review of factitious disorders is given. In the present report, problems concerning definition, incidence, diagnosis, and treatment are discussed. Emphasis is put on patients suffering from a factitious disorder superimposed on an already existing somatic disease. It is stated that the conscious refrain from adequate actions as a result may lead to factitious symptoms.     

A case of factitious disorder involving menstrual blood smeared on the face

This article presents a case of factitious disorder in which a female smeared menstrual blood on her face. The patient was admitted to our otolaryngology clinic complaining of bleeding from the mouth, nose, ears and eyes. This event reportedly occurred three to four times on a daily basis. She acknowledged nine prior admissions to different specialists over the last two years. Following psychiatric consultation, we diagnosed factitious disorder with predominantly physical signs and symptoms. She was started on Fluoxetine 20 mg/day and supportive interviews were organized. After diagnosis, we observed that her symptoms decreased over two months. The symptoms did not reoccur three to nine months after treatment. This case report outlines two important features. The first is that a case of this type has not been reported before, and the second feature is that this case demonstrates the effect of cultural factors greatly different from those seen in classical factitious disorder.     

A pediatric case of factitious disorder with unexplained bleeding symptoms

Factitious disorder is characterized by deliberate production or imitation of physical or psychological symptoms in order to adopt the sick role. The disorder can be seen as factitious bleeding. Factitious bleeding is a rare disorder in pediatric population. The concomitant appearance of hemoptysis and hematuria in the same patient has not been previously reported. In this case report, we present a pediatric case of factitious disorder with both hemoptysis and hematuria.     

Devenir des troubles bipolaires et place du trouble dysphorique prémenstruel dans le DSM-5

In the field of bipolar disorders, the fifth edition of the DSM has clarified the definition of manic mood, which includes irritability and expansiveness. This elevated mood is associated with increased goal-directed activity or energy. A full manic episode that emerges during an antidepressant treatment (e.g., medication, electroconvulsive therapy) is now sufficient evidence for a manic episode diagnosis and therefore for a bipolar disorder I diagnosis. If so a mood-stabilizer treatment is required. The DSM-5 authors call for more caution in case of hypomanic episodes induced by antidepressant treatment, especially if only one or two symptoms are present. On the other hand, if there are psychotic features, the episode is, by definition, manic. Several studies have judged the bereavement exclusion criteria irrelevant to fulfil the diagnosis of major depressive episode, that is why this exclusion criteria has disappeared from DSM-5. This might help for a better management of major depressive episode in case of mourning. The lack of consensual definition of mixed state led to the suppression of the mixed episode in this new edition of the DSM. It is however possible to specify the mixed features in manic, hypomanic and depressive episodes. This decision is in coherence with Emil Kraepelin's inheritance. In fact, Kraepelin himself described several mixed states, essentially as transition states between the two main clinical pictures (mania and depression) of the manic-depressive illness. In this perspective, clinical pictures such as agitated depression, dysphoric manic or hypomanic episodes can be reconsidered and one can hope that studies will be conducted to deepen the knowledge of those episodes from a clinical, physiopathological and therapeutic point of view. Finally the premenstrual dysphoric disorder has moved from the appendix B (for the research) of the DSM-IV to the “diagnostic criteria and codes” (section II) of the DSM-5. This disorder is quite frequently associated with bipolar disorder II whose prognosis it worsens while complicating its therapeutic management. In the paper, the premenstrual dysphoric disorder is described on an historical, clinical, physiopathological and therapeutic level, within the limits of current knowledge about this uncommon psychiatric syndrome. Its DSM-5 diagnostic criteria are also summarized and commented upon. This official entry of the premenstrual dysphoric disorder in the DSM-5 shows the willingness of the American Psychiatric Association to incorporate uncommon psychiatric syndromes in its diagnostic classification.     

Diagnostic errors in psychiatry

Although the importance of nosology has been derided as “pigeonholing” by some American psychiatrists, the science of diagnosis has lately enjoyed a renaissance. Actually, whether or not a psychiatrist possessed diagnostic acumen had little effect on the outcome of treatment until the past two decades, because so much of treatment was nonspecific. But the increasing use of drugs, particularly neuroleptics, antidepressants, and lithium, has made precise diagnosis a necessity.In recent years, several authors have commented upon the misdiagnosis of manic-depressive patients—particularly catatonics¹—as schizophrenics² and a multihospital cross-national study³ has suggested that American psychiatrists overdiagnose schizophrenia and underdiagnose affective disorder. The Iowa group⁴ has demonstrated that strict criteria result in a much lower rate of diagnosed schizophrenia than does the “agreement of experienced clinicians” so often set as the standard. With the compilation of diagnostic criteria for psychiatric disorder by Feighner et al.,⁵ it became clear that 80% or more of psychiatric patients can be definitely classified according to standards that permit accurate prediction of treatment and prognosis. But today, the vast majority of psychiatric diagnoses still are not made on the basis of scientific criteria, and the category of “undiagnosed psychiatric disorder,” at least as used by clinicians, is virtually an empty set.To what extent strict criteria are used no one knows, but from anecdotal case reports in the literature they are probably not overutilized. The resulting margin for disagreement and for downright error is probably enormous. We propose now to review the kinds of erroneous diagnoses commonly made, the reasons for these errors, and their possible consequences. This report, based upon the experience of psychiatrists in private practice, deals with the diagnostic pitfalls encountered despite, or in some cases because of, the use of scientific diagnostic criteria.     

An unusual movement disorder associated with neuroleptic treatment: tardive dyskinesia?

This case report describes a chronically psychotic man presenting signs of a movement disorder exacerbated by neuroleptic treatment and repeatedly diagnosed as tardive dyskinesia. However, this movement disorder differed from classical tardive dyskinesia both in the nature of specific symptoms and in their relationship to neuroleptic treatment. Closer examination revealed evidence of neurolgical disorder preceding the earliest neuroleptic treatment. Although the nature of this disorder remains unclear, serious doubt exists whether it properly deserved a diagnosis of tardive dyskinesia, which opened the way for medicolegal dispute. The numerous ramifications of tardive dyskinesia speak for restrictive use of this diagnosis and for clear diagnostic criteria.     

Diagnostic controversies in adult attention deficit hyperactivity disorder

OBJECTIVE: While it is increasingly recognized that attention deficit hyperactivity disorder (ADHD) persists into adulthood, there is no consensus on diagnostic criteria for adult ADHD. In this article the authors describe and contrast competing approaches for diagnosis of adult ADHD used in clinical and research practice. METHOD: The authors review the Wender Utah criteria, DSM criteria, and laboratory assessment strategies for adult ADHD. Advantages and disadvantages of each approach are described, and recommendations are made as a basis for clinical assessment and future research. RESULTS: Both the Wender Utah criteria and DSM-based approaches identify significantly impaired ADHD adults with neurocognitive, biological, and treatment response patterns similar to pediatric ADHD patients. The Wender Utah criteria established the need for retrospective childhood diagnosis and recognize developmental differences in adult symptom expression. The Wender Utah criteria fail to identify patients with predominantly inattentive symptoms, exclude some patients with significant comorbid psychopathology, and diverge significantly from the DSM conception of ADHD. The DSM criteria have never been validated in adults, do not include developmentally appropriate symptoms and thresholds for adults, and fail to identify some significantly impaired adults who are likely to benefit from treatment. There are insufficient scientific data to justify use of laboratory assessment measures, including neuropsychological tests and brain imaging, in diagnosing adult ADHD. CONCLUSIONS: Adult ADHD remains a clinical diagnosis. Clinicians should be flexible in application of the current ADHD criteria to adults. Additional research is required to validate adult diagnostic criteria.