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.     

The diagnosis and treatment of Munchausen's syndrome

Patients with Munchausen's syndrome--a syndrome characterized by the intentional production of physical symptoms to gain the sick role-present a variety of challenges to health care providers. Their treaters quickly become frustrated by their demanding interpersonal styles, by deception and manipulation, and by multiple unrevealing diagnostic procedures. These difficulties can lead to poor outcomes for patients and staff alike. We present the case of a young woman whose presentation and subsequent evaluation led to significant distress among the hospital staff responsible for her care, and discuss the epidemiology, diagnosis, and management of patients with Munchausen's syndrome. The most important role of the psychiatrist in the treatment of Munchausen's syndrome is to help the primary treatment team manage the patient in the safest and most appropriate way. Such management includes avoiding unnecessary procedures, preventing further self-harm, and avoiding angry or threatening interactions with the patient. The prognosis for patients with Munchausen's syndrome appears to be poor; flexible and creative approaches that emphasize consistency of care and regular outpatient psychiatric treatment have had the greatest success.     

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.     

Psychiatric Munchausen's syndrome. Literature review with case reports

The present study reviews the literature on Munchausen's syndrome. In a psychiatric hospital, out of a total of 775 admissions under the age of 65 in 1986, four patients were diagnosed as having Munchausen's syndrome (0.5%). The underlying pathology of these cases is discussed and suggestions for management and further research made.     

Factitious hemiplegia and Munchausen's syndrome.

We report a case of a thirty-year-old woman suffering from chronic factitious disorder with hemiplegia. Such a pathomimia is very uncommon in Munchausen's syndrome. Indeed, most often, the clinical picture is characterised by acute abdominal pain, fainting, haemoptysis, precordialgia, hematemesis or dermatological lesions.     

Factitious torsion dystonia in rehabilitation: a singular new case and literature review

We report a case of a 29-year-old woman suffering from chronic factitious disorder (FD) with torsion dystonia. For nearly five years, she traveled widely over the country, going from one hospital to another, taking serious medical risk in order to prolong her illness. After several admissions to Rehabilitation Units and multiple explorations, we find convincing evidence for factitious origin and the diagnosis of Munchausen syndrome was evoked. Such a clinical presentation is infrequent in Munchausen's syndrome. Indeed, most often the clinical picture is characterized by acute abdominal pain, fainting, hemoptysis, precordialgia, hematemesis or dermatological lesions. Physicians should be aware of this rare and potentially critical form of FD. Awareness in identifying these patients may lead to prevent unnecessary medical and/or surgical interventions.     

Exaggeration of Symptoms or Psychiatric Munchausen's Syndrome by Proxy?

Prompt and accurate diagnosis of Munchausen's syndrome by proxy is essential in order to minimise the risk of iatrogenic and parentally-induced harm to the child. However, inaccurate diagnosis of MSBP may have devastating consequences for the child, family and professionals involved. 'Psychiatric' Munchausen's syndrome by proxy, which involves the presentation of signs and symptoms suggestive of a psychiatric disorder in the child, is even more difficult to diagnose and requires an unbiased and full assessment by the appropriate multidisciplinary team.     

Dual factitious disorder

The DSM-III classification of factitious disorders encourages artificial separation into disorders with physical and those with psychologic symptoms. Despite documented examples of similar patients who present with psychiatric complaints, Munchausen's syndrome is usually considered a form of chronic factitious physical disorder. Three patients with both factitious physical and psychologic symptoms are presented. These patients illustrate the importance of focusing on the fundamental behavior of assuming the patient role, rather than on the specific category of symptoms. We recommend that the category of symptoms be used as a modifying statement, rather than defining separate disorders.     

An empirical comparison of three different borderline concepts

Forty-six inpatients were independently diagnosed according to the DSM-III concept of borderline personality disorder, the diagnostic interview for borderlines (DIB) and the concept of borderline personality organization, which is linked to Kernbergs structural interview. The interviews were videotaped. Satisfactory inter-rater reliability was demonstrated for the DIB, which furthermore showed high sensitivity and specificity in identifying patients with a clinical DSM-III diagnosis of borderline personality disorder from patients with a other personality disorders or schizophrenic disorders. Discriminant features, demographic profile and earlier treatment history for the patients with a borderline personality disorder are described and discussed. The structural interviews were scored according to a specified format. Inter-rater reliability was satisfactory but not too impressive. Borderline personality organization turned out to be a very broad concept and only half of the patients within this concept received a syndrome diagnosis of borderline personality disorder. A general conclusion was that borderline personality organization should not be considered as a diagnostic entity but rather as a different diagnostic dimension representing an intermediate level of personality structure.     

Epileptic Munchausen's syndrome: a form of pseudoseizures distinct from hysteria and malingering

A young woman with seizures and status epilepticus sought and obtained hospitalization in at least 25 hospitals in the province of Quebec between 1980 and 1987. She was thought to have uncontrolled epilepsy; her treatment led to intoxication with anticonvulsants and once to anesthesia for three consecutive periods of 7 days each. The nonepileptic nature of her attacks was proven and a diagnosis of Munchausen's syndrome made. She was transferred to a psychiatric center where she committed suicide. We found no documented cases of epileptic chronic factitious disorder in the literature.     

Are there differential relationships between different types of childhood maltreatment and different types of adult personality pathology?

While considerable data support the relationship between childhood trauma and adult personality pathology in general, there is little research investigating the specific relationships between different types of childhood maltreatment and adult personality disorders. The present study tested a model incorporating five a priori hypotheses regarding the association between distinct forms of childhood maltreatment and personality pathology in 231 psychiatric patients using multiple self-report measures (Personality Diagnostic Questionnaire-4th Edition, Child Trauma Questionnaire, Conflict in Tactics Scale Parent-Child Child-Adult, and Multidimensional Neglectful Behavior Scale). Step-wise linear regressions supported three out of five hypotheses, suggesting independent relationships between: physical abuse and antisocial personality disorder traits; emotional abuse and Cluster C personality disorder traits; and maternal neglect and Cluster A personality disorder traits after controlling for co-occurring maltreatment types and personality disorder traits. Results did not support an independent relationship between sexual abuse and borderline personality traits nor between emotional abuse and narcissistic personality disorder traits. Additionally, there were three unexpected findings: physical abuse was independently and positively associated with narcissistic and paranoid traits and negatively associated with Cluster C traits. These findings can help refine our understanding of adult personality pathology and support the future development of clinical tools for survivors of childhood maltreatment.     

Cognitive analysis of multiple personality disorder

Multiple personality disorder is not rare, and it can be treated using the principles of cognitive therapy. Noncognitive techniques are also required. The purpose of this paper is to define the basic cognitive map of multiple personality disorder, one which recurs in the majority of cases. Multiple personality patients commonly make the classical cognitive errors such as selective abstraction and dichotomization, but they also have a set of schemata and cognitions derived from their abusive childhoods that are specific for the disorder.     

Personality disorders in patients with panic disorder: association with childhood anxiety disorders, early trauma, comorbidity, and chronicity.

The rates of comorbid personality disorders in patients with panic disorder are reported to be elevated, have an adverse impact on the response to treatment, and increase the likelihood of relapse on treatment discontinuation. We examined the rates of personality disorders in panic disorder patients in a longitudinal, naturalistic study of panic disorder. Of 100 panic disorder patients studied, 42 met criteria for at least one personality disorder as determined by the Personality Disorder Questionnaire-Revised (PDQ-R). The presence of a personality disorder as determined by the PDQ-R was associated with a past history of childhood anxiety disorders, comorbidity with other anxiety disorders and depression, and a chronic, unremitting course of panic disorder in adulthood. The presence of a personality disorder in these patients was not significantly associated with a history of physical or sexual abuse in childhood. Our findings support the notion that an anxiety diathesis, demonstrated by significant difficulties with anxiety in childhood, influences the development of apparent personality dysfunction in panic patients. In other cases, personality pathology may reflect the presence of comorbid anxiety disorders or depression. The association of personality disorder in panic patients with a more unremitting course of illness underscores the importance of axis II pathology in understanding the longitudinal course of panic disorder.     

Intoxication and sobriety. Implications for the understanding of multiple personality

This speculative article compares the switch from drunkenness to sobriety with what transpires in the switch from one personality to another in multiple personality disorder. State-dependent learning is discussed as a particularly fruitful area of investigation into the understanding and interpretation of diverse manifestations of multiple personality disorders as well as alcoholism.     

The limits of Munchausen's syndrome.

The authors review the literature on Munchausen's syndrome and speculate about possible underlying psychological mechanisms. The proposed DSM III classification of factitious illnesses suggests a continuum from hysteria on one end of the spectrum to malingering on the other. Two case studies are presented which represent variants of this syndrome. Both patients were given a sodium amytal interview, a procedure not previously reported in the Munchausen's literature. The procedure was helpful in eliciting a more accurate history and a clearer sense of the underlying dynamics. Some suggestions for further research are made.     

Current status of multiple personality disorder in India

Three consecutive cases of multiple personality disorder seen over a period of 3 years at a psychiatric clinic in India are reported. The prevalence of this disorder at the clinic is about 0.15/1,000 patients per year. The authors discuss the infrequency of this diagnosis in India in contrast to the frequent diagnosis of possession syndrome for patients who have many of the same symptoms. Transcultural differences in diagnostic practices are also discussed.     

A comparison of the family and childhood backgrounds of hospitalised offenders with schizophrenia or personality disorder

Background Previous studies have demonstrated high levels of childhood adversity and familial criminality in offender patients with schizophrenia and/or personality disorder, but few have directly compared these groups. Aims To compare the parenting histories of offender patients with schizophrenia with those with personality disorder. We hypothesised that rates of family criminality and experiences of disrupted parenting would be higher in the personality disorder group than the schizophrenia group. Method A retrospective case‐control methodology compared the family background and childhood experiences of patients with either schizophrenia or personality disorder (n = 3088) admitted to any of the English high‐security hospitals. Results Compared with those with schizophrenia, patients with personality disorder had experienced higher rates of family criminality, parental separation, and multiple changes of caregiver and institutional care. There was no significant difference in the prevalence of family psychiatric history between the groups. Discussion Although our hypotheses were sustained, we were impressed that rates of disruption to parenting were high in the schizophrenia group as well as in the personality disorder group. Less than a third of the personality disorder group had survived childhood without a change in parenting, but this was true for about half of the schizophrenia group, too. Family work tailored for people with schizophrenia is needed, even though within personality disorder services, a greater demand for disorder‐sensitive family work is likely to be encountered. Copyright © 2009 John Wiley & Sons, Ltd.     

Are multiple personalities borderline? An analysis of 33 cases

The authors detail their investigation into the positive relationship between borderline personality and multiple personality and present their finding that although borderline personality disorder is very prevalent in patients with multiple personality disorder, it is not universal and is a separate and distinct disorder.     

Personality styles in patients with fibromyalgia,major depression and healthy controls

Background  

The fibromyalgia syndrome (FMS) is suggested to be a manifestation of depression or affective spectrum disorder. We measured the cognitive style of patients with FMS to assess personality styles in 44 patients with fibromyalgia syndrome (FMS) by comparing them with 43 patients with major depressive disorder (MDD) and 41 healthy controls (HC).