Factitious disorder

Overview
A factitious disorder or FD is a mental disorder where the 'ill' individual's symptoms are either self-induced or falsified by the patient. Essentially, it is faking sick: the act of an individual faking, exaggerating, or even inflicting self injuries. Their state of consciousness in this act falls somewhere between (and involves both) the conscious and unconscious mind. The main reasons why individuals develop this disorder is to assume the status of a 'patient'. Hence, they win over the attention, nurturance, sympathy, and even leniency that they feel they are unable to obtain any other way. FD individuals produce or exaggerate the symptoms of mental or physical illness. They do so by contaminating urine samples, taking hallucinogens, injecting themselves with bacteria to produce infections, and other such similar behaviour.

Motives
The motives of the patient can vary: for a patient with Munchausen syndrome their primary aim is to obtain sympathy, nurturance and attention, while in the case of malingering the patient wishes to obtain external gains such as disability payments or to avoid an unpleasant situation, such as military duty [add internal gain through drugs]. Strictly speaking, FD and malingering cannot be diagnosed in the same patient, yet clinicians find that patients' motives for the ruses can vary over time and, as a result, both diagnoses may apply. FD and Munchausen syndrome are considered mental disorders; malingering, though sometimes a focus of clinical attention, is not. Malingering, thus, is not diagnosed as FD for it is not a mental disorder, but, rather, done in reaction to the external stimuli; in other words, malingering is done to obtain some sort of benefit or to be relieved of something unwanted. (ie a fake injury to sue in a car accident, etc.) FD is diagnosed by the absence of malingering. Individuals with FD wish to assume the role of a 'patient'.

Differential Diagnosis
Factitious disorders should be distinguished from conversion disorder, in which the patient is unaware that the symptoms being experienced are not medically caused. In hypochondriasis, the patient honestly believes he or she has a particular medical disorder and, like the FD patient, may seek contact from multiple physicians, emergency departments, and hospitals. In Somatization disorder medical examination detects the presence of physical symptoms that can't be attributed solely to a general medical condition, the effects of substances (drugs) or by other mental disorders (e.g. panic disorder). In other words, in somatization disorder, patients have a verifiable medical condition such as pain, gastrointestinal, sexual, or neurological symptoms that "cannot be fully explained by a known general medical condition or the direct effects of a substance."

Inclinations Towards FD
Inclinations toward the disorder include females usually employed in medical fields such as nursing or medical technology, women ages of 20-40 years old, and loners with early childhood trauma. Cases rarely occur over the age of 45 for the disorder usually lasts from adolescence to mid-adulthood.

Criteria
Criteria for diagnosis includes intentionally fabricating (or faking) to produce physical or psychological signs of symptoms. Motivation for their behaviour must be to assume the 'sick role', and they do not act sick for personal gain as in the case of malingering sentiments. When the individual applies this pretended sickness to a dependant (ex - child), it is often referred to as 'factitious disorder by proxy.'

Offshoots of FD
There are three separate offshoots of Factitious Disorder. These include the Munchausen syndrome (a chronic variant of FD), Munchausen by proxy, and Ganser syndrome. In order to have these mental disorders, the individual must reflect symptoms of both FD and the specified symptoms that their offshoot requires.

Munchausen Syndrome
Munchausen syndrome, or chronic FD, have specified symptoms along with FD diagnosis. Specified symptoms are that FD symptoms are greatly exaggerated, individuals undergo major surgery repeatedly, and they 'hospital jump' or migrate in order to avoid detection. Many are in the health care business and the illness often begins in early adulthood. Individuals are typically unmarried men estranged from their families and are usually middle-aged.

Munchausen by proxy
The word 'proxy' is defined as the infliction of a disorder unto another individual -- the 'substitution' of it. Specific symptoms include FD produced in children because of their caregivers or parents (almost always mothers) who induce illnesses on their children. The parent may falsify the child's medical history or tamper with laboratory tests in order to make the child appear sick. Occasionally, in Munchausen by proxy, the caregiver will actually injure the child to ensure that the child will be treated. Such parents enjoy the indirect attention that they receive.

Ganser syndrome
Ganser syndrome is an extremely rare variation of factitious disorder. It is a reaction to extreme stress and the patient thereby suffers from approximation or giving absurd answers to simple questions. The syndrome can sometimes be diagnosed as merely malingering; however, it is more often defined as FD. Symptoms include a clouding of consciousness, somatic conversion symptoms, confusion, stress, loss of personal identity, Echolalia, and Echopraxia. Individuals also give approximate answers to simple questions such as, "How many legs on a cat?" "Three"; "What's the day after Wednesday?" "Friday"; and so on. The disorder is extraordinarily rare with less than 100 recorded cases. While individuals of all racial backgrounds have been reported with the disorder, there is a higher inclination towards males (75% or more). The average age of those with Ganser syndrome is 32 and it stretches from ages 15-62 years old.

Causes of Factitious Disorder
There are many possible causes for this disorder. One such possibility is an underlying personality disorder. Individuals with FD may be trying to repeat a satisfying childhood relationship with a doctor. Perhaps also the individual has a desire to deceive or test authority figures. The underlying desire to resume the role of a patient and to be cared for can also be considered an underlying personality disorder. Abuse in childhood is also another probable cause for the disorder. A background of neglect and abandonment may contribute to the development of FD. These individuals may be trying to reenact unresolved issues with their parents. A history of frequent illnesses may also contribute to the development of this disorder. Perhaps the individual afflicted with FD is accustomed to actually being sick, and thus returns to their previous state in order to recapture what was once considered to be the 'norm.'

Treatment
No true psychiatric medications are prescribed for Factitious Disorder. SSRIs (selective serotonin reuptake inhibitors), however can help cure underlying problems. Medicines used to treat personality disorders such as these (SSRIs) can be used to treat FD, as a personality disorder may be the underlying cause of FD. Some (authors such as Prior and Gordon 1997) also report good responses to antipsychotic drugs such as Pimozide. Family Therapy can also prove to be of assistance. In such therapy, families are helped to better understand patients (the individual in their family with FD) and their need for attention. In this therapeutic setting, the family is urged not to condone or reward the FD individual's behavior. This form of treatment can be unsuccessful if the family is uncooperative or displays signs of denial and/or antisocial disorder. Psychotherapy is another method used to treat the disorder. These sessions should focus on the psychiatrist establishing and maintaining a relationship with the patient. Such a relationship may help to contain symptoms of FD. Monitoring is also a form that may be implicated for the FD patient's own good. Video cameras, etc. are not illegal to use in such monitoring, for in many cases, FD (especially proxy) can prove to be very detrimental to an individual's health if they are, in fact, causing true physiological illnesses. (Even faking can be dangerous and might be monitored for fear that unnecessary surgery may subsequently be performed.)

Treatment of Munchausen by proxy
Treatment for FD proxy is not so subtle. Physicians, upon suspecting the disorder, should notify authorities immediately. Authorities will then initiate steps for immediate protection of the affected child. Criminal charges may be deemed necessary. Many times, help may be sought for the mother (parent) with Munchausen by proxy as well as the child affected and perhaps even their siblings. Careful monitoring of the family for an extended period of time is often a necessary precaution. This is to prevent translocation (i.e. the family moving to return to old ways, etc.) and to prevent the insinuation of a possible upheaval of the detrimental disorder.

Prognosis (Outlook)
Some experience only a few outbreaks of the disorder. However, in most cases, the disorder is chronic and factitious disorder is a long-term condition that is difficult to treat. There are poor positive outcomes for this disorder; in fact, treatment provided a poorer percentage of positive outcomes than did treatment of those with genuine psychoses such as schizophrenics. In addition, many individuals with Factitious Disorder will not seek treatment. Most deny that they are faking symptoms and therefore do not seek treatment for the disorder. There is, however, some hope. Age seems to help the disorder greatly. There are many possible explanations for this occurrence, although none are currently deemed as the definitive cause, though it is proven that the disorder does indeed grow milder with age. Some say perhaps it is because the FD individual has mastered the art of faking sickness over so many years of practice that the disorder can no longer be discerned. Another hypothesis is that many times an FD individual will be put in a home or experience real health issues. Thus, in this way, the problem with obtaining the 'patient' status is resolved because, in fact, it is inherently real.