Factitious disorders and malingering: challenges for clinical assessment and management

[Factitious disorder imposed on self and Munchausen syndrome: An update]

Factitious disorder imposed on self (FDIS) is a mental disorder characterized by conscious manipulative behavior from patients with no clearly identifiable external objective. It affects subjects with a wide range of characteristics, only some of whom fit the stereotypical profile of the young female working in the health sector. It can take the form of a variety of symptoms or clinical signs, and is likely to involve all specialties. Munchausen syndrome is a particular form of FDIS, more prevalent in men and marked by its severity. Psychiatric comorbidities are common in patients with FDIS. Death is rare but possible, either as a result of the disease itself, complications of examinations or treatments, or suicide. The diagnostic approach must seek to identify positive arguments in favor of the disorder. Diagnosis by elimination remains possible when no other hypothesis can explain a clinical picture suggestive of FDIS. The prognosis is often poor, at least in the short and medium term. Avoiding unnecessary prescriptions is essential to prevent iatrogenesis. The management of FDIS is poorly codified. In all cases, the practitioner must adopt a non-aggressive, empathetic attitude.

Munchausen Syndrome in the Context of Liaison Psychiatry: A Case Report and a Narrative Review

Munchausen Syndrome (MS) has been widely recognized as a severe manifestation of factitious disorder, a condition where individuals intentionally fabricate or exaggerate symptoms for psychological gratification. It represents a complex diagnostic challenge due to its elusive nature and intricate relationship with various medical conditions. We present a clinical case of a 44-year-old woman observed in the context of Liaison Psychiatry, demonstrating the intricate interplay between chronic medical conditions, psychiatric factors, and the challenges in diagnosing and managing MS. The patient exhibited a history of recurrent hospitalizations, difficult-to-heal injuries, and a pronounced preference for surgical interventions. Despite diagnostic difficulties and poor therapeutic adherence, a multidisciplinary team approach involving plastic surgery, orthopedics, physical medicine, and rehabilitation, alongside Liaison Psychiatry, led to the diagnosis of MS with chronic osteomyelitis, ultimately necessitating a transtibial amputation. The case underscores the importance of early detection, a multidisciplinary approach, and the role of Liaison Psychiatry in managing MS. While early diagnosis may not alter the disease course, it can prevent unnecessary interventions and mitigate associated risks. The case also highlights the need for continuous psychiatric support and family involvement in addressing the recurrence of self-injurious behaviors. Further research is essential to enhance our understanding and develop effective treatment strategies for MS, contributing to improved diagnostic precision and overall management of this challenging psychiatric disorder.

Consultation-Liaison Case Conference: A Case of Factitious Disorder Imposed on Self

We present the case of a young woman with an extensive medical history that most notably includes over 60 emergency-room visits for unfounded respiratory distress that often prompted intubations. Each presentation displays elements of deceitfulness or inappropriate demands that align with factitious disorder imposed on self. Top experts in the Consultation-Liaison field provide guidance for this commonly encountered clinical case based on their experience and review of available literature. Key teaching topics include a review of risk factors for development of deceptive syndromes, distinguishing factitious disorder from malingering and conversion disorder, and the role of a consulting psychiatrist in such cases. Patients with factitious disorder often show signs of pathologic lying, obstinance, and erratic behavior. Such attributes frequently arouse negative countertransference in providers, causing frustration and dread with continuing care, rendering psychiatric involvement. We address the unique challenges in managing factitious disorder and how to effectively collaborate with an interdisciplinary inpatient team with these cases.

Practical pathway for the management of depression in the workplace: a Canadian perspective

Major depressive disorder (MDD) and other mental health issues pose a substantial burden on the workforce. Approximately half a million Canadians will not be at work in any week because of a mental health disorder, and more than twice that number will work at a reduced level of productivity (presenteeism). Although it is important to determine whether work plays a role in a mental health condition, at initial presentation, patients should be diagnosed and treated per appropriate clinical guidelines. However, it is also important for patient care to determine the various causes or triggers including work-related factors. Clearly identifying the stressors associated with the mental health disorder can help clinicians to assess functional limitations, develop an appropriate care plan, and interact more effectively with worker's compensation and disability programs, as well as employers. There is currently no widely accepted tool to definitively identify MDD as work-related, but the presence of certain patient and work characteristics may help. This paper seeks to review the evidence specific to depression in the workplace, and provide practical tips to help clinicians to identify and treat work-related MDD, as well as navigate disability issues.

Clinical impact and misdiagnosis of functional ophthalmological symptoms: a case report

BACKGROUND

There is a high prevalence of somatoform disorders and medically unexplained symptoms. When it comes to deciding whether a patient is able to work, it is essential to differentiate a somatoform disorder from a factitious disorder. The case presented demonstrates the impact on disability benefits and the subsequent psychosocial repercussions of misdiagnosing between a factitious disorder and a somatoform disorder.

CASE PRESENTATION

A 42-year-old Caucasian woman worked as a 100% fiduciary accountant until the age of 32 when she was placed on medical leave due to persistent trigeminal neuralgia. Afterward, she developed total blindness, not explained by a physiological process, accompanied by distress in a crucial emotional context. We evaluated the patient for a revision of a disability income after a diagnosis of factitious disorder with severe consequences such as disability income suspension and family conflict. Our psychiatric examination concluded the diagnoses of pain disorders related to psychological factors and a dissociative neurological symptom disorder with visual disturbance.

CONCLUSIONS

Blindness not explained by a physiological process may accompany trauma and psychological distress. Differentiating this pathology from factitious disorder or simulation is essential from an insurance medicine point of view, but also for its treatment.

Factitious Disorder Imposed on Another in Palliative Care: A Case Report

In palliative care, many end-of-life (EOL) patients are physically dependent on their caregivers. These patients may also have difficulty expressing their needs because of their underlying disease and are vulnerable to abuse. Factitious disorder imposed on another (FDIA) describes a condition in which an individual intentionally feigns physical or psychological signs or symptoms in another person with the intention of deceiving medical providers. Although FDIA is a form of abuse that palliative care workers must be aware of because of its multiple impacts on EOL care, it has never been reported in the palliative care literature. In this case discussion, we highlight a woman with advanced dementia who was subjected to FDIA. We discuss the impact of FDIA on EOL care and the management of FDIA in palliative care.

Psychosocial and Psychodynamic Considerations Informing Factitious Disorder

Factitious disorder is a condition in which patients deceitfully present themselves as injured or ill in the absence of obvious external reward. It is difficult to diagnose and treat, and little rigorous evidence exists in the literature. While larger studies have revealed some clinical and sociodemographic patterns, there is a lack of consensus on psychosocial factors and mechanisms contributing to factitious disorder. This in turn has led to conflicting recommendations on management. In this article, we review major psychopathological theories of factitious disorder, including the role of early trauma and subsequent development of interpersonal dysfunction, as well as maladaptive gratification obtained from assuming the sick role. Common themes of interpersonal disruptions in this patient population include a pathologic need for attention and care, as well as aggression and desire for dominance. In addition to psychodynamic and psychosocial etiologic models of factitious disorder, we also review associated treatment approaches. Finally, we offer clinical implications, including countertransference considerations, as well as directions for future research.

The mind and the hand

Symptoms are determined in large part by mindsets. Feelings of distress and unhelpful thoughts (misinterpretations) of symptoms account for much of the variability in comfort and capability with the severity of the underlying pathophysiology making a more limited contribution. Incorporating this experimental evidence into the daily practice of hand surgery will help us find ways to develop healthy mindsets, to prioritize the alleviation of distress and the gentle redirection of unhelpful thoughts, to avoid unnecessary surgery, and to provide better psychological and social support for people recovering from injury and surgery.

Dermatitis Artefacta: A Challenging Case Report

We report a 31-year-old female presented with a history of recurrent skin and oral lesions for 10 years. She brought a histopathology report confirming the diagnosis of pemphigus vulgaris (PV), which was found to be faked with no patient information and lacked letterhead. Skin and oral examination only reveal multiple linear upper lip erosions. We believed the patient had a preliminary diagnosis of PV, and we asked the patient to continue her medications. Based on the conflicting history and occurrence of contradictory issues, a diagnosis of dermatitis artefacta was made. The patient improved after four sessions of dialectical therapy.

Epistaxis: An Unusual Presentation of Factitious Disorder

Introduction: About 1% of psychiatric consultations are concerned with a factitious disorder. Unlike malingering, factitious disorder is a special psychiatric disorder that should be taken into consideration by the medical staff. Case Presentation: This case reports a woman with fever and epistaxis as a primary clinical manifestation of a factitious disorder which was diagnosed and treated after further investigation and psychiatric consultation. Conclusions: Procrastination of diagnosis usually leads to an increase in the length of stay for unnecessary clinical and paraclinical investigations. The purpose of this case presentation was to raise the issue of psychiatric problems and their importance alongside physical problems.

A case report and literature review of cognitive malingering and psychopathology

Malingering of cognitive difficulties constitutes a major issue in psychiatric forensic settings. Here, we present a selective literature review related to the topic of cognitive malingering, psychopathology and their possible connections. Furthermore, we report a single case study of a 60-year-old man with a long and ongoing judicial history who exhibits a suspicious multi-domain neurocognitive disorder with significant reduction of autonomy in daily living, alongside a longtime history of depressive symptoms. Building on this, we suggest the importance of evaluating malingering conditions through both psychiatric and neuropsychological assessment tools. More specifically, the use of Performance Validity Tests (PVTs)-commonly but not quite correctly considered as tests of "malingering"-alongside the collection of clinical history and the use of routine psychometric testing, seems to be crucial in order to detect discrepancies between self-reported patient's symptoms, embedded validity indicators and psychometric results.

Rare Mental Health Disorders Affecting Urologic Care: A Comprehensive Review

Management of mental health illnesses and needs are important in fostering psychosocial support, interprofessional coordination, and greater adherence to treatment protocols in the field of urology. This can be especially true for mental health conditions that may greatly impact the presentation of a patient in the healthcare setting with urologic symptoms. This review describes the history, epidemiology, pathophysiology, clinical presentation, and treatment of somatic symptom disorder, illness anxiety disorder, compulsive sexual behavior/hypersexuality, factitious disorder, malingering symptoms, and conversion disorder in the realm of urology. Given the newly updated psychiatric diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, there has been a lack of studies reviewing how these illnesses may present in a urology patient encounter. Additionally, as these mental health illnesses may carry a rare incidence compared to other well-known mental health illness such as generalized depression or generalized anxiety disorder, we have found that the lack of provisions and recognition of the diseases can prolong the timeline for diagnosis and lead to an increased cost in both healthcare and quality of life of patients with these mental health illnesses. This review provides awareness on these mental health conditions which may greatly impact patient history and presentation within the field of urology. Additionally, urologic care providers may have an improved understanding of interdisciplinary management of such illnesses and the common symptoms patients may present with such diseases.

Prevalence and characteristics of factitious hypoglycaemia in non-diabetic patients in a department of endocrinology

INTRODUCTION

Factitious hypoglycaemia is defined as the surreptitious use of insulin or oral hypoglycaemic agents to deliberately induce self-harm. It represents a challenging diagnosis and misdiagnosis is associated with significant morbidity and mortality. The aim of this study was to assess the prevalence and the associated factors of factitious hypoglycaemia in non-diabetic patients.

METHODS

This was a single-centre, retrospective study including 70 non-diabetic patients who were admitted for the investigation of hypoglycaemia. All patients fulfilled the Whipple triad. Epidemiological parameters, medical history, clinical and paraclinical data and the aetiology of hypoglycaemia were collected from medical records.

RESULTS

The diagnosis of factitious hypoglycaemia was held in 11 patients (9 women and 2 men) corresponding to a prevalence of 16%. It was secondary to intentional insulin use in six patients and the ingestion of glibenclamide in five patients. The median age of the patients was 28 years (interquartile range: 21-43). Two patients with factitious hypoglycaemia had a personal history of psychiatric disorders. The other causes of hypoglycaemia were adrenal insufficiency (34%), prediabetes (24%), insulinoma (6%), iatrogenic hypoglycaemia (10%), criminal hypoglycaemia (1%) and alcohol intoxication (2%). Age ≤ 35 years (Odds Ratio = 5.6, p = .017), family history of diabetes mellitus (Odds Ratio = 1.29, p = .015), attention disorders during hypoglycaemia (Odds Ratio = 12.5, p = .017) and fasting glucose level <0.7 g/L (Odds Ratio = 5.75, p = .017) were positively associated with factitious hypoglycaemia.

CONCLUSION

Factors significantly associated with factitious hypoglycaemia were young age, family history of diabetes and a low fasting glucose level.

Recognizing medical child abuse in children presenting with chronic pain

Medical child abuse (MCA), previously referred to as Munchausen by proxy, can present as chronic pain. We report the presentation of five children seeking treatment for chronic pain who we identified as victims of MCA. The index case had essentially not eaten for the 6 years of her life due to alleged allergies to all foods, developed severe pain, used a wheelchair for ambulation beyond a few blocks, and was alleged to have dysautonomia requiring oxygen monitoring at night. Other cases posed as arthritis that resulted in foot amputation and total body pain, fibromyalgia with alleged mutation negative Stickler syndrome who had symptoms only in her mother's presence, severe incapacitating intermittent pains along with abdominal pain that resulted in appendectomy, cholecystectomy, and pancreatectomy, and alleged disabling hypermobile Ehlers-Danlos in a non-hypermobile child for which the mother sought a power wheelchair. The unusual pattern to the pain, the presence of multiple additional, atypical symptoms and diagnoses, and a generally well appearing child are characteristic. The perpetrator is typically over-invested in the symptoms, derives tangible and intangible secondary gain from the child's alleged illnesses, and is able to present the child in such a fashion to enlist the physician to aid in perpetuating the abuse. These children are highly over-medicalized and suffer significant morbidity. Multiple barriers exist to identifying and reporting these children to Child Protective Services, which need to be recognized and overcome in order to protect these vulnerable children.

A Fatal Case of Factitious Aplastic Anemia

We report the case of a 26-year-old female who intentionally ingested busulfan, an oral chemotherapy agent, to induce severe aplastic anemia. The patient was initially thought to be suffering from idiopathic aplastic anemia, before clues suggesting the diagnosis of a factitious disorder were identified. The patient underwent a bone marrow transplant and ultimately died 5 weeks later following a lengthy admission to the intensive care unit. It is unclear whether confrontation about a patient's self-induction of physical illness is beneficial in the treatment of patients with factitious disorder. Cases such as this pose substantial diagnostic challenges, making early recognition of factitious disorder and initiation of treatment difficult. The patient described in this case report had risk factors for a factitious disorder, including age, gender, professional involvement in health care, recent loss and developmental trauma. Factitious disorder, while rare, can have lethal consequences for the patient. This diagnosis must be considered as part of a full diagnostic assessment.

Hypoglycemia and Factitious Disorders: A Case Report and Review

Hypoglycemia may present with a multitude of signs and symptoms ranging from subjective feelings of anxiety or diaphoresis to neuroglycopenic manifestations of altered sensorium or seizure. The differential diagnosis of hypoglycemic disorders is broad, and in rare instances may occur following intentional induction by undisclosed insulin administration or insulin secretagogue ingestion in patients with an underlying factitious disorder. While basic laboratory studies can reliably confirm the presence of exogenous insulin in patients with hyperinsulinemic hypoglycemia, increased endogenous insulin secretion following sulfonylurea ingestion can mimic a biochemical pattern of findings also seen with insulinoma, a rare pancreatic insulin-producing tumor. We present a case of severe hypoglycemia manifesting as diminished consciousness in a patient with multiple medical comorbidities. Following initial laboratory workup suggestive of endogenous hyperinsulinemic hypoglycemia, the results of a serum oral hypoglycemic panel confirmed the presence of glipizide, an unprescribed insulin secretagogue of the sulfonylurea class, in the patient’s serum. In conjunction with psychiatric services, the patient was diagnosed with an underlying factitious disorder and her hypoglycemia was deemed likely the result of surreptitious sulfonylurea ingestion as a pathologic healthcare-seeking behavior. Our case report and subsequent review shed light on critical components in the diagnostic approach to hypoglycemic disorders, which carry significant morbidity for patients regardless of the underlying cause and emphasize several clinical and ethical considerations associated with the identification and management of persons with factitious disorder in medical practice.

[Suspected factitious disorder: identifying self-inflicted wounds in plastic surgery]

BACKGROUND

Patients with factitious disorders artificially generate, aggravate or feign injuries or illnesses, which can result in severe physical impairment and misuse of the healthcare system. The symptomatology is characterized by a protracted course of disease with frequent changes of practitioners and multiple invasive procedures due to anomalous, mostly chronic findings. Elaborate clinical presentations, lack of knowledge of disease characteristics and the fast-paced everyday clinical practice can lead to maintaining the disease through non-recognition or mistreatment.

METHODS

Based on selective literature research and clinical case reports from a university clinic for plastic surgery, this article provides a review about common features of factitious disorders as well as treatment strategies.

RESULTS

If a factitious disorder is suspected, invasive treatments should be restricted and psychosomatic or psychiatric expertise obtained. Within an empathic physician-patient relation and with psychotherapeutic support, patients can be gradually introduced to the diagnosis and therapy options and treatment terminations could be avoided.

CONCLUSION

Knowledge of indicators for factitious disorders, which may become evident in medical history, findings and illness-affirming behaviour, is key to identify affected patients and initiate appropriate treatment. For this purpose, factitious disorders should be included in differential diagnostic considerations even in primarily somatic medical specialties. Since the diagnosis is often based on evidence and complicated by withheld information or medical confidentiality, the establishment of a central reporting register could facilitate the diagnostic process and improve therapy in the future.

OUP accepted manuscript

OBJECTIVE

Individuals with early-onset dysexecutive Alzheimer's disease (dAD) have high rates of failed performance validity testing (PVT), which can lead to symptom misinterpretation and misdiagnosis.

METHOD

The aim of this retrospective study is to evaluate rates of failure on a common PVT, the test of memory malingering (TOMM), in a sample of clinical patients with biomarker-confirmed early-onset dAD who completed neuropsychological testing.

RESULTS

We identified seventeen patients with an average age of symptom onset at 52.25 years old. Nearly fifty percent of patients performed below recommended cut-offs on Trials 1 and 2 of the TOMM. Four of six patients who completed outside neuropsychological testing were misdiagnosed with alternative etiologies to explain their symptomatology, with two of these patients' performances deemed unreliable based on the TOMM.

CONCLUSIONS

Low scores on the TOMM should be interpreted in light of contextual and optimally biological information and do not necessarily rule out a neurodegenerative etiology.

A descriptive, retrospective case series of patients with factitious disorder imposed on self

BACKGROUND

Despite cases of factitious disorder imposed on self being documented in the literature for decades, it appears to remain an under-identified and under-diagnosed problem. The present study aimed to explore factitious disorder imposed on self in a series of French patients.

METHODS

Patients 18 years old and over with factitious disorder imposed on self were retrospectively included by two independent reviewers according to DSM-5 criteria in Rennes University Hospital for the period 1995 to 2019. Patients were identified from a clinical data warehouse.

RESULTS

49 patients with factitious disorder imposed on self were included. Among them, 36 (73.5%) were female. The average age at diagnosis was 38.4 years. The 16 patients with a health-related profession were all female. Direct evidence of falsification was found in 20.4% of cases. Falsification was mainly diagnosed on the basis of indirect arguments: history of factitious disorder diagnosed in another hospital (12.2%), extensive use of healthcare services (22.4%), investigations that were normal or inconclusive (69.4%), inconsistent or incomplete anamnesis and/or patient refusal to allow access to outside information sources (20.4%), atypical presentation (59.2%), evocative patient behaviour or comments (32.7%), and/or treatment failure (28.6%). Dermatology and neurology were the most frequently involved specialities (24.5%). Nine patients were hospitalized in intensive care. Some of them received invasive treatments, such as intubations, because of problems that were only reported or feigned. The diagnosis of factitious disorder imposed on self was discussed with the patient in 28 cases (57.1%). None of them admitted to making up the disorder intentionally. Two suicide attempts occurred within 3 months after the discussion of the diagnosis. No deaths were recorded. 44.9% of the patients returned to the same hospital at least once in relation to factitious disorder imposed on self.

CONCLUSIONS

The present study reinforces data in favour of a predominance of females among patients with factitious disorder imposed on self. This diagnosis is difficult and is based on a range of arguments. While induced cases can be of low severity, cases that are only feigned can lead to extreme medical interventions, such as intubation.

An evaluation of the association between fault attribution and healthcare costs and trajectories in the first three years after transport injury

BACKGROUND

People with complex medical and psychosocial issues have high healthcare needs. This registry-based cohort study sought to quantify the association between external fault attribution, recorded during compensation claim lodgement, and the cost and patterns of healthcare utilisation.

METHODS

6,144 survivors of transport-related major trauma between 1 July 2010 and 30 June 2016 were extracted from the Victorian State Trauma Registry (VSTR) and linked to treatment payments from the Transport Accident Commission (TAC). Associations between fault and healthcare costs were examined with Generalised Linear Regression. Healthcare trajectories were identified using Group-Based Multi-Trajectory Modelling and included medical treatments from a physician, or pain, mental health and physical therapy treatments for the first three years post-injury. Trajectories were validated against the EQ-5D-3L health status summary score using mixed linear regression.

RESULTS

While injury severity had the strongest association with healthcare use, people who attributed fault to another had 9% higher healthcare costs. Six multi-trajectory groups were identified: 36% had low treatments over time; 25% had a rapid decline from high medical and physical therapy by 12-months; 12% had moderate to high medical and physical therapy that declined by 2-3 years; 11% had a gradual decline in medical treatment, an early increase in physical therapy but low pain and mental health treatment; 8% had high or increasing medical and physical therapy, moderate mental health therapy and low pain treatment; and 7% had moderate-high treatment across all domains. All groups had poorer health status compared with the group with low treatment levels, and people who attributed fault to another had higher risk of following trajectories with higher levels of treatment versus the low treatment group (beta=0.34, SE=0.12, p=0.01).

CONCLUSION

These findings highlight the need to provide pro-active multidisciplinary care coordination for people with complex needs after injury to better optimise recovery.

Factitious Gastrointestinal Bleeding: A Case Series and Review

Factitious gastrointestinal bleeding (GIB) is a manifestation of factitious disorder (FD) wherein patients feign GIB in the absence of external gain. As it can be a challenging diagnosis to make, factitious GIB often leads to multiple tests, exposure to contrast agents and radiation, invasive endoscopic and surgical procedures, an increased risk of iatrogenic complications, and increased healthcare costs. Patients who feign GIB often demonstrate characteristic behaviors that may go unnoticed unless they are explicitly addressed. We report a series of patients admitted to our institution for further evaluation of obscure overt GIB with an eventual diagnosis of factitious GIB and review of the epidemiology and development of FD, a diagnostic approach to factitious GIB, and current management strategies.

Factitious disorder, presenting haemolacria in a Pakistani tribal illiterate female: A rare case report

INTRODUCTION

It could be challenging for healthcare workers to diagnose patients with factitious disorder who present with rare ophthalmologic manifestations such as haemolacria, because of the unavailability of adequate literature and associated guidelines. The present case report aims to fulfill this knowledge gap.

CASE PRESENTATION

A 20-year-old tribal illiterate married female patient with symptoms of bleeding episodes from her left eye was admitted to the hospital. An extensive workup was done for diagnosing possible bleeding disorders but all the parameters were normal. Later on, she was diagnosed with factitious disorder presenting haemolacria after sufficient evidence at the psychiatric unit observations. The patient was treated accordingly, counseled and discharged, but lost-out to follow-ups.

PRACTICAL IMPLICATIONS

The present case is reported from a developing country, Pakistan, for the first-time may help in diagnosing patients suffering from factitious disorder with unusual ophthalmologic problems.

The girl who cried wolf: A literature review and case report of pediatric factitious disorder

Pediatric presentations of factitious disorder (Munchausen syndrome) remain underdiagnosed and poorly understood compared to adult cases. The purpose of this study is to review the current literature on child and adolescent factitious disorder in order to better understand the differences between pediatric and adult presentations of this disorder. We also present the case of an adolescent girl with factitious disorder; her hospital course draws attention to the excessive healthcare expenditures and risk of iatrogenic complications associated with this diagnosis. We utilized MEDLINE and Google Scholar databases to conduct our review. Despite the limited number of high-quality studies analyzing pediatric presentations of factitious disorder, our review yielded several important findings. Studies suggest that the general acceptance of somatization as a common way for young people to manifest emotional stress may explain the under-diagnosis of this disorder in pediatric populations. Studies also highlighted differences in the clinical characteristics of factitious disorder when patients are stratified by age; most notably, younger patients are more willing to admit intentional falsifications when confronted and more likely to accept treatment, making them a potentially more effective target for intervention.

Malingering in the Emergency Setting

Malingering is the intentional fabrication of symptoms for material gain. Malingering among frequent utilizers and patients with psychiatric symptoms is suspected to be common in emergency settings but difficult to detect and manage. We present a case report of a 50-year-old man feigning psychosis and suicidality in order to obtain shelter. Strategies to identify malingered psychiatric symptoms are presented. Understanding how malingering is adaptational can help clinicians begin to manage these patients and symptoms in a compassionate manner that preserves healthcare resources, improves patient care, and reduces the risk of burnout for clinicians.

Posttraumatic functional movement disorders and litigation

The concept of functional movement disorders has evolved considerably over the past few decades. More specifically, the views on the relation with psychological stressors or personality disorders have substantially changed, emphasizing a shift from the previously dominant dualistic scheme. This evolution is reflected in adaptations to diagnostic criteria and management approaches. Functional movement disorders which arise in a close temporal relationship with a peripheral trauma are specifically challenging with respect to diagnosis and treatment, but similar considerations seem to apply. The relationship of functional disorders with trauma appears to be much closer than is often thought. Clinical and pathophysiological research has identified shared factors underlying functional posttraumatic as well as primary movement disorders. These evolving insights impact on discussions in terms of litigation for compensation after trauma. The literature is reviewed and the consequences for argumentation in litigation are outlined, including ethical and legal considerations. Finally, we formulate a number of recommendations.

How Plausible Is the Implausible? Students’ Plausibility and Prevalence Ratings of the Self-Report Symptom Inventory

Some self-report symptom validity tests, such as the Self-Report Symptom Inventory (SRSI), rely on a detection strategy that uses bizarre, extreme, or very rare symptoms. Thus, items are constructed to invite respondents with an invalid response style to affirm pseudosymptoms that are usually not experienced by genuine patients. However, these pseudosymptoms should not be easily recognizable, because otherwise sophisticated over-reporters could strategically avoid them and go undetected. Therefore, we tested how well future psychology professionals were able to differentiate between genuine complaints and pseudosymptoms in terms of their plausibility and prevalence.

Psychology students (N = 87) received the items of the SRSI online and were given the task to rate each item as to its plausibility and prevalence in the community.

Students evaluated genuine symptoms as significantly more plausible and more prevalent than pseudosymptoms. However, 56% of students rated pseudosymptoms as moderately plausible, whereas 17% rated them as moderately prevalent in the general public.

Overall, it appears that psychology students are successful in distinguishing bizarre, unusual, or rare symptoms from genuine complaints. Yet, the majority of students still attributed relatively high prima facie plausibility to pseudosymptoms. We contend that if such a trusting attitude is true for psychology students, it may also be the case for young psychology practitioners, which, consequently, may diminish the probability of employing self-report validity measures in psychological assessments.

Factitious Disorder (Munchausen Syndrome) in Plastic Surgery: A Systematic Review of 42 Cases

INTRODUCTION

Patients with factitious disorder (FD) or "Munchausen syndrome" intentionally fabricate or induce medical problems for psychological gratification. They may deceive plastic surgeons into performing multiple unnecessary procedures. We undertook the first systematic review of FD case reports in plastic surgery. Our aims were 2-fold: (1) describe the adverse outcomes associated with these cases and (2) identify strategies for their prevention by surgeons.

METHODS

MEDLINE, EMBASE, and SCOPUS databases were searched. We included cases in which an adult with FD presented to a plastic surgeon. Our search returned a total of 42 eligible cases reported from North America (43%), Europe (37%), and Asia (20%).

RESULTS

Seventy-six percent of patients were women, and 62% worked in health care. Sixty percent had a comorbid psychiatric disorder, the most common (50%) being depression. Ninety-three percent of our sample presented with self-induced lesions. The average delay in diagnosis of FD was 54 months, with 46% of patients receiving multiple surgical procedures in this time, including debridement (36%) and skin grafts (39%). Surgical wounds were frequently exploited by patients to remain in, or return to, hospital: 50% contaminated or manipulated their wounds to prevent healing. Thirty-six percent of cases resulted in significant long-term disability (24%) or disfigurement (12%). Ten percent of patients received an amputation. Outcomes were improved when patients were confronted by surgeons, however, and 62% were willing to see a psychiatrist. Surgeons were able to support recovery in 33% of cases-for example, by using occlusive wound dressings.

CONCLUSIONS

Patients with FD who present to plastic surgeons are high risk: the majority require surgical intervention for severe self-injury, and many engage in harmful behaviors, such as "doctor-shopping." Early recognition of FD in plastic surgery is, therefore, crucial and may be achieved via careful examination of lesions for unusual morphology. Medical records may reveal extensive health care service use and negative investigations. Finally, plastic surgeons may play an important role in managing such patients. Management strategies include direct observation by nursing staff in the postoperative period and use of strict occlusive dressings to prevent access to surgical wounds.

Factitious Disorder in Seven Patients: A Saudi Experience

Background

Factitious disorder (FD) is a psychiatric disease where signs and symptoms are produced, falsified, or exaggerated consciously in the absence of clear external motivations. Through needless medical visits, costly investigatory testing, and potentially long hospital stays, patients with FD waste valuable time and resources, which affects both the patient and the healthcare system. It can be very challenging for physicians who have never encountered patients with FD to recognize them promptly as symptoms of FD vary greatly.

Methodology

This was a retrospective study of patients diagnosed with FD attending King Abdulaziz Medical City in Riyadh, Saudi Arabia, a tertiary care military hospital and one of the most prominent academic and referral medical institutions in the country. Using the BESTCare health information system, we reviewed patients’ electronic health records from January 2015 to December 2020. The diagnosis of FD was based on the International Classification of Diseases and Related Health Problems 10th edition.

Results

A total of seven patients were included in the study, of whom five (71%) were males and two (29%) were females. Of the total seven patients, three were 21 years old and younger, one was 38 years old, and three were 56 years old and older. Three (43%) patients were married and four (57%) were single. In terms of occupation, three (43%) patients were retired, one (14%) worked in a private company, one (14%) was unemployed, and two (29%) were students. A total of four (57%) patients initially presented to the Emergency Department (ED), and only three (43%) presented to the outpatient clinics. Induced disease or injury was found in five (71%) patients. Induced skin injury was found in four (57%) patients. Counseling and psychotherapy were only offered to one (14%) patient.

Conclusions

FD remains a rare psychiatric condition that is difficult to recognize. Despite a small sample size, FD in the present study showed a male predominance, affecting patients of all age groups. About half of the patients presented initially to the ED. Induced disease or injury was the most commonly reported pattern of clinical presentation. Induced skin injury was the most common clinical presentation found in around half of the patients. We believe that the number of FD patients in the present study is likely underreported and is expected to be higher. This highlights the need for better awareness of FD among physicians in different medical fields. We emphasize that there is a need for better professional training in the identification of FD.

Striving to Die: Medical, Legal, and Ethical Dilemmas Behind Factitious Disorder

Factitious disorder (FD) imposed on self is one of the most challenging and controversial problems in medicine. It is characterized by falsified medical or psychiatric symptoms where patients misrepresent, simulate, or cause symptoms of an illness in the absence of obvious tangible gains. Munchausen syndrome accounts for approximately 10% of all factitious illnesses and represents its most malignant form. An unknown number of deaths have likely occurred when considering that most cases go unrecognized and unreported. Here we describe a case in which the patient’s condition remained unrecognized, only being diagnosed months before her death from complications of FD.

Psychiatry was consulted to see a 49-year-old Caucasian female regarding depression, poor oral intake, and her insistence on the placement of a feeding tube. The initial evaluation was negative for findings consistent with psychiatric illness. A review of records in our hospital was significant for one previous psychiatric inpatient stay eight months prior during which a diagnosis of FD imposed on self was made. Collateral information suggested a cycle of deception and simulation of illnesses with the patient’s daughter labeling her actions as “doctor shopping.” At our facility alone, she had accrued roughly 40 inpatient medical admissions and 70 ED visits in four years though only two encounters involving Psychiatry. A detailed chronological analysis of her records showed the only documented concern of deception to be that of an Internal Medicine resident two years prior. Psychiatry was not consulted despite this concern. During the present encounter, psychiatry recommended ethics consult, outpatient psychotherapy, and frequent follow-ups with primary care. A formal ethics consult was not completed before discharge. Within two months, the patient died at another facility. 

FD can lead to diagnostic and therapeutic procedures that result in irreversible morbidity and iatrogenic harm. Physicians in other medical specialties often suspect a patient of consciously deceiving others, though fail to assign psychiatric nomenclature due to lack of familiarity or comfort in making the diagnosis. This further substantiates the role of a multidisciplinary collaboration between medical, surgical, and psychiatry teams. Heightened awareness of, and suspicion for, Munchausen syndrome may improve rates of diagnosis and prognosis of these patients.

Functional neurological disorders in patients undergoing spinal surgery: illustrative case

BACKGROUND

“Conversion disorder” refers to bodily dysfunction characterized by either sensory or motor neurological symptoms that are unexplainable by a medical condition. Given their somatosensory context, such disorders often require extensive medical evaluation, and the diagnosis can only be made after structural disease is excluded or fails to account for the severity and/or spectrum of the patient’s deficits.

OBSERVATIONS

The authors briefly review functional psychiatric disorders and discuss the comprehensive workup of a patient with a functional postoperative neurological deficit, drawing from their recent experience with a patient who presented with conversion disorder immediately after undergoing anterior cervical discectomy and fusion.

LESSONS

Conversion disorder has been found to be associated with bodily stress, requiring surgeons to be aware of this condition in the postoperative setting. This is especially true in neurosurgery, given the overlap of true neurological pathology, postoperative complications, and manifestations of conversion disorder. Although accurately diagnosing and managing patients with conversion disorder remains challenging, an understanding of the multifactorial nature of its etiology can help clinicians develop a methodical approach to this condition.

Prognostic Role of Demographic, Injury and Claim Factors in Disabling Pain and Mental Health Conditions 12 Months after Compensable Injury

Identifying who might develop disabling pain or poor mental health after injury is a high priority so that healthcare providers can provide targeted preventive interventions. This retrospective cohort study aimed to identify predictors of disabling pain or probable mental health conditions at 12 months post-injury. Participants were recruited 12-months after admission to a major trauma service for a compensable transport or workplace injury (n = 157). Injury, compensation claim, health services and medication information were obtained from the Victorian Orthopaedic Trauma Outcome Registry, Victorian State Trauma Registry and Compensation Research Database. Participants completed questionnaires about pain, and mental health (anxiety, depression, posttraumatic stress disorder) at 12 months post-injury. One third had disabling pain, one third had at least one probable mental health condition and more than one in five had both disabling pain and a mental health condition at 12 months post-injury. Multivariable logistic regression found mental health treatment 3-6 months post-injury, persistent work disability and opioid use at 6-12 months predicted disabling pain at 12 months post-injury. The presence of opioid use at 3-6 months, work disability and psychotropic medications at 6-12 months predicted a mental health condition at 12 months post-injury. These factors could be used to identify at risk of developing disabling pain who could benefit from timely interventions to better manage both pain and mental health post-injury. Implications for healthcare and compensation system are discussed.

Factitious Disorders in Everyday Clinical Practice

BACKGROUND

The pathological feigning of disease can be seen in all medical disciplines. It is associated with variegated symptom presentations, self-inflicted injuries, forced but unnecessary interventions, unusual and protracted recoveries, and frequent changes of treating physician. Factitious illness is often difficult to distinguish from functional or dissociative disorders on the one hand, and from malingering on the other. Many cases, even fatal ones, probably go unrecognized. The suspicion that a patient's problem may be, at least in part, factitious is subject to a strong taboo and generally rests on supportive rather than conclusive evidence. The danger of misdiagnosis and inappropriate treatment is high.

METHODS

On the basis of a selective review of current literature, we summarize the phenomenology of factitious disorders and present concrete strategies for dealing with suspected factitious disorders.

RESULTS

Through the early recognition and assessment of clues and warning signs, the clinician will be able to judge whether a factitious disorder should be considered as a differential diagnosis, as a comorbid disturbance, or as the suspected main diagnosis. A stepwise, supportive confrontation of the patient with the facts, in which continued therapeutic contact is offered and no proofs or confessions are demanded, can help the patient set aside the sick role in favor of more functional objectives, while still saving face. In contrast, a tough confrontation without empathy may provoke even more elaborate manipulations or precipitate the abrupt discontinuation of care-seeking.

CONCLUSION

Even in the absence of systematic studies, which will probably remain difficult to carry out, it is clearly the case that feigned, falsified, and induced disorders are underappreciated and potentially dangerous differential diagnoses. If the entire treating team successfully maintains an alert, transparent, empathic, and coping-oriented therapeutic approach, the patient will, in the best case, be able to shed the pretense of disease. Above all, the timely recognition of the nature of the problem by the treating team can prevent further iatrogenic harm.

A case report and literature review: Factitious disorder imposed on another and malingering by proxy

Factitious disorder imposed on another (FDIA) and malingering by proxy (MAL-BP) are two forms of underreported child maltreatment that should remain on physicians’ differential. This case of a 2-year-old boy, which spans 6 years, reveals the complexity in and difficulties with diagnosis. Key features include the patient’s mother using advanced medical jargon to report multiple disconnected concerns and visits to numerous providers. As a result, the patient underwent many investigations which often revealed normal findings. FDIA was suspected by the paediatrician, especially following corroboration with the child’s day care and past primary health care provider. This case demonstrates the possible overlap in diagnoses, which are characterized by a lack of consistent presentation and deceitful caregivers, often complicated by true underlying illness. The authors use clinical experience and limited existing literature to empower paediatricians to confidently diagnose and report FDIA and MAL-BP to limit future harm to children.

Do You Know People Who Feign? Proxy Respondents About Feigned Symptoms

We asked students, clinicians, and people from the general population attending a public university lecture (n = 401) whether they knew others who (had) feigned symptoms. We also asked about the type of symptoms and the motives involved. A slight majority of proxy respondents (59%) reported that they knew a person who (had) feigned symptoms, and 34% knew a person who had admitted to them having feigned symptoms. According to our respondents, the most often feigned symptoms were headache/migraine, common cold/fever, and stomachache/nausea, and the most important reasons for doing so were sick leave from work, excusing a failure, and seeking attention from others. We conclude that feigning is part of the normal behavioral repertoire of people and has little to do with deviant personality traits and/or criminal motives. Also, the current emphasis in the neuropsychological literature on malingering, i.e., feigning motivated by external incentives, might be one-sided given that psychological motives, notably seeking attention from others and excuse making, seem to be important determinants of everyday feigning.

Incidence of the diagnosis of factitious disorders - Nationwide comparison study between Germany and Norway

Factitious disorders (FD) like Munchausen syndrome are well known to most physicians, yet the corresponding ICD-10 diagnosis F68.1 remains severely under-assigned and often misdiagnosed. To approach this problem, we conducted a nationwide inquiry for Germany and Norway as well as a comparison between these two countries regarding the incidence of diagnosis of FD. The assignment rates of F68.1 in somatic hospitals from 2008 to 2016 were analyzed based on the Diagnosis Related Groups statistic from the German Federal Statistical Office and the data provided from the Norwegian Patient Registry. The Norwegian data also included information on individual patients whereas the German data only contained the total number of F68.1 assignment due to strict medical confidentiality laws. The incidence of the diagnosis of FD in Germany and Norway showed similar assignment rates with 3.71 and 3.18 per 100,000, respectively. The mean age was 39.4 years for German patients and 35.6 years for Norwegian patients. The gender distribution was almost equal for the individual patients’ rate (49% female and 51% male). Furthermore, our results indicate that female patients with FD tend to demand healthcare services more frequently than male patients. Smaller studies focusing on the diagnosis of FD have significantly higher assignment rates compared to nationwide inquiries. Our results illustrate substantial differences between estimations of the incidence of FD and the need for further studies. Besides the many obstacles associated with diagnosis of FD, strict medical confidentiality laws prevent reliable and scientific investigations of this matter.

Factitious Disorder Presenting with Refractory Enterocutaneous Fistula that Underwent 7 Surgeries

The formation of a post-appendicectomy fistula is rare but devastating. Major etiological factors include leakage from the appendiceal stump, neoplasm of the appendix and/or cecum, infection, inflammatory bowel disease, and distal obstruction. The management of enterocutaneous fistula involves enteral nutrition, drainage, antibiotic coverage, as well as surgical excision and segmental resection of the involved bowel. Here we present a case where a young female suffered from refractory enterocutaneous fistula after appendicectomy. Despite extensive treatments, her symptoms persisted and contradicted with objective test results. Therefore, a diagnosis of factitious disorder was suspected. After questioning, she finally admitted to having applied feces to her wound to fake fistula. It was estimated that the lifetime prevalence of factitious disorder in the general population was 0.1%, which warrants the awareness of clinicians.