Comorbidity Between Factitious and Borderline Personality Disorder: A Narrative Analysis.

BACKGROUND: Factitious disorder (FD) illnesses have increased recently, primarily due to comorbidity with borderline personality disorder (BPD). Psychiatrists, hospital doctors, and general practitioners are interested in and concerned about patients with comorbid FD-BPD. SUBJECTS AND METHODS: We used a qualitative analysis of prototypical narratives collected as vignettes by merging individual contributions, case histories, naturalistic observations, and data from mental health practitioners into specific descriptions. Our study used a phenomenological and narrative method to illustrate the contents and behaviours in FD-BPD comorbidity. RESULTS: Fourteen case vignettes were created from our case studies. These categories included knowledge of symptoms and medical terms, dramatisation, symptoms ambiguity, unexplainable deterioration of symptoms, symptom inventiveness, craving for painkillers, conflicts with health carers, hospital migration, piling of medication and search for invasive diagnostic procedures. CONCLUSIONS: The combined use of narrative analysis and naturalistic observation has helped identify a unique comorbid condition of FD-BPD, which is not yet clearly described in its behavioural components by the international literature. The current study presents novel findings into a condition becoming progressively popular in psychiatric and medical settings.

Munchausen syndrome by proxy (MSBP): a review regarding perpetrators of factitious disorder imposed on another (FDIA).

Munchausen syndrome by proxy (MSBP) is well-known to clinicians, but its usage is discouraged now in favor of other terms placing emphasis on the victim. This study aims to determine the most common characteristics of perpetrators but only in case reports labeled as MSBP, published in PubMed literature in the past 15 years. MSBP has been described as a rare form of abuse due to illness falsification, where the perpetrator usually receives the diagnosis of factitious disorder imposed on another (FDIA). We extracted data from 108 articles, including 81 case reports. Almost all perpetrators were female (91% female, 1% female and male, 7% unreported). Twenty-three cases (28%) had a perpetrator with psychiatric diagnosis: factitious disorder imposed on self (10%), depression (9%), and personality disorders (7%). In more than one-third (36%) there was familial conflict or abuse. Fourteen cases (17%) had perpetrators working in healthcare. The most common type of falsification was induction (74%); however, 15% of cases had more than one type of falsification. The most common outcomes were: separation (37%); no follow-up (22%); imprisonment (14%); death of victim (12%); treatment of the perpetrator (10%); continued living together (4%); and suicide of perpetrator (1%). Recurrence was present in more than three quarters of cases. Our results reiterate that awareness of the most common findings in MSBP allows physicians to identify them in a clinical context.

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.

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.

Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis.

BACKGROUND: Consultation psychiatrists are often asked to assess factitious disorder (FD), yet this is challenging as confirmation depends on rarely achieved direct evidence of illness-inducing behaviors. Diagnosis is thus based on other variables, such as atypical features of the medical presentation and certain patient behaviors. This study sought to assess a cohort of patients with FD for demographic and clinical variables, but also psychological and behavioral ones unexamined in previous studies. METHODS: 49 previously-identified FD patients at a single site were reviewed retrospectively and variables collected included demographic, medical, psychiatric, social, behavioral, and treatment-related. Descriptive statistical analysis was used. RESULTS: Patients were mostly: 1) under age 40 (82%), 2) female (90%), 3) with past psychiatric (92%), family psychiatric (78%), and traumatic (69%) histories; 4) direct intravenous access (67%); and 7) some exposure to healthcare training (67%). All (100%) subjects had an identifiable family dynamic issue, including household abuse, parental divorce, parental influence/enmeshment, grief, and/or significant other conflict. Financial, emotional, or social incentives were common, and most patients (88%) exhibited at least 4 FD-related behaviors. CONCLUSION: FD represents a complex disorder of abnormal illness behaviors with predisposing developmental and perpetuating sociobehavioral variables previously unexplored. Future investigational, educational, and quality improvement directions are considered.

The Incidence of Diagnosis of Munchausen Syndrome, Other Factitious Disorders, and Malingering.

BACKGROUND: Systematic studies on factitious disorders and malingering in large populations are rare. To address this issue, we performed a nationwide epidemiological study in Norway on the incidence of these diagnoses in an unselected patient population. In particular, we tried to confirm the diagnoses and to estimate the contribution of Munchausen syndrome to the spectrum of factitious disorders. METHODS: We analyzed data obtained from the Norwegian Patient Registry (NPR), which provided a deidentified list of all patients from 2008 to 2016 who had received the ICD-10 diagnosis of F68.1 or the diagnosis code Z76.5. RESULTS: Altogether, 237 patients (99 females; 138 males) received a diagnosis of F68.1. Code Z76.5 was applied to 52 patients (12 females; 40 males), all diagnosed within health institutions. Three of 1700 specialists (somatic specialist, psychologist, or psychiatrist) in private practice had diagnosed a factitious disorder in altogether 87 patients. After contacting these specialists, we could identify no true case of F68.1. For 24 of 146 patients who were equally distributed by gender within health institutions, we managed to identify the diagnosing healthcare providers. Of these 24 patients, only 11 correctly qualified for code F68.1. Only two female patients qualified for a Munchausen syndrome diagnosis. CONCLUSIONS: There is a male predominance for the diagnosis of malingering. An earlier suspicion of a female predominance for Munchausen syndrome is upheld. There is significant underdiagnosing and misdiagnosing for both conditions and for factitious disorders in general. To separate the most serious form of factitious disorders from milder forms and to facilitate more systematic research, we recommend a specific ICD diagnosis for Munchausen syndrome.

Changing incidence of factitious renal stone disease
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PURPOSE: We sought to describe patterns of factitious urinary stone submission over time by investigating a contemporary stone analysis database and comparing two distinct time points. MATERIALS AND METHODS: We retrospectively reviewed a single stone analysis lab database at two time points, 1990 and 2010, and compared total incidence of factitious stone submission, as well as gender patterns and type of factitious stone submitted. RESULTS: A total of 27,014 stones were analyzed, 16,216 (60%) from 1990 and 10,798 (40%) from 2010 with a decrease in total incidence from 2.6% (428/16,216) in 1990 to 1.2% (131/10,798) in 2010 (p < 0.001). In 1990, women were significantly more likely to submit a factitious stone (RR 1.5, 95% CI 1.4 - 1.7, p < 0.001), while in 2010 there was no gender difference (RR 0.9, 95% CI 0.8 - 1.03, p < 0.05). Plant material and geologic material represented the most common factitious stone types respectively, in both 1990 and 2010. CONCLUSION: In the largest contemporary review of spurious urinary stones, we find a decreased incidence and increased gender equivalence of factitious urinary stones in 2010 compared to 1990.
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Psychological Aspects of Factitious Disorder.

Factitious disorder can present in multiple health care settings, with patients intentionally producing symptoms to assume the sick role. This assumption of the sick role can result in multiple hospitalizations with unnecessary diagnostic workup, as well as invasive diagnostic procedures that can lead to worrisome side effects. Differential diagnoses that should be ruled out include malingering, somatic symptom disorder, and anxiety disorders. For many providers, patients with factitious disorder can be a challenge to treat because the etiology of the disorder remains unclear. There are multiple psychological theories that attempt to explain the motivation and thought process behind the voluntary production of symptoms. Some of these theories have addressed disruptive attachments during childhood, possible intergenerational transfer of the disorder, personal identity conflicts, somatic illness as a form of masochistic activity toward oneself, and intrapsychic conflicts. Confrontation and psychotherapy with a multidisciplinary team has been proposed as a form of treatment. An understanding of the psychological factors associated with factitious disorder can help providers understand the rationale behind the patient's presentation and aid in the formulation of a treatment plan.

Psychocutaneous disease: Clinical perspectives.

Psychocutaneous disease, defined in this review as primary psychiatric disease with skin manifestations, is commonly encountered in dermatology. Dermatologists can play an important role in the management of psychocutaneous disease because patients visit dermatology for treatment of their skin problems but often refuse psychiatric intervention. This review describes common psychocutaneous syndromes, including delusional, factitious, obsessive-compulsive and related, and eating disorders, as well as psychogenic pruritus, cutaneous sensory (pain) syndromes, posttraumatic stress disorder, and sleep-wake disorders. The updated classification of these disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition is included. Strategies for management are reviewed.

Factitious disorder: a systematic review of 455 cases in the professional literature.

OBJECTIVE: Patients with factitious disorder (FD) fabricate illness, injury or impairment for psychological reasons and, as a result, misapply medical resources. The demographic and clinical profile of these patients has yet to be described in a sufficiently large sample, which has prevented clinicians from adopting an evidence-based approach to FD. The present study aimed to address this issue through a systematic review of cases reported in the professional literature. METHOD: A systematic search for case studies in the MEDLINE, Web of Science and EMBASE databases was conducted. A total of 4092 records were screened and 684 remaining papers were reviewed. A supplementary search was conducted via GoogleScholar, reference lists of eligible articles and key review papers. In total, 372 eligible studies yielded a sample of 455 cases. Information extracted included age, gender, reported occupation, comorbid psychopathology, presenting signs and symptoms, severity and factors leading to the diagnosis of FD. RESULTS: A total of 66.2% of patients in our sample were female. Mean age at presentation was 34.2 years. A healthcare or laboratory profession was reported most frequently (N=122). A current or past diagnosis of depression was described more frequently than personality disorder in cases reporting psychiatric comorbidity (41.8% versus 16.5%) and more patients elected to self-induce illness or injury (58.7%) than simulate or falsely report it. Patients were most likely to present with endocrinological, cardiological and dermatological problems. Differences among specialties were observed on demographic factors, severity and factors leading to diagnosis of FD. CONCLUSIONS: Based on the largest sample of patients with FD analyzed to date, our findings offer an important first step toward an evidence-based approach to the disorder. Future guidelines must be sensitive to differing methods used by specialists when diagnosing FD.

[The phenomenon of covert self-mutilation in the surgical routine]. / Das Phänomen der heimlichen Automutilation im chirurgischen Alltag.

Factitious disorders are conditions which are unknown to many physicians but have a prevalence of 1-5 % in outpatient departments and hospitals. In order to avoid prolonged and complicated (false) treatment in surgery this article gives a review of the definition, epidemiology and pathogenesis of factitious disorders as well as clinical symptoms and therapy options. A focus is placed on the identification of patients, treatment strategies and the prevention of malpractice. Additionally, clinical features of the disorder are illustrated with the description of some characteristic cases.

[Are artificial disorders common in palliative care? A Case report]. / Sind artifizielle Störungen im palliativen Kontext häufig? Ein Fallbericht.

The main task of palliative care specialists is to focus on symptom control such as pain, nausea or fatigue. Thorough anamnesis, physical examination, laboratory examination, and differential diagnosis can ensure appropriate treatment. In an increasing number of cases psychiatric conditions like depression or anxiety increase also occur so palliative care physicians need to be more prepared to handle them. The question of this case report is, how a palliative care specialist can distinguish between a malignant disease or neurological disease progression and a presentation primarily psychiatric in etiology, as is the case in factitious disorders. We are also interested in the incidence rate of such factitious disorders. Our case study demonstrates that it is rare but not impossible that a doctor will encounter factitious symptoms in the palliative setting. This suggest being aware of evidence of psychiatric origins even in discharge letters and referrals that indicate palliative care needs, to ensure that palliative care really is the best treatment option for the patient. We do believe such cases to be rare in a palliative setting, however.

[Factitious diseases in oncology]. / Les pathologies factices en oncologie.

Factitious diseases and pathomimias and particularly Munchausen's syndrome, due to their rarity, are poorly diagnosed by medical teams working in oncology. Consequences can be serious and result in unadapted surgery or non justified implementation of chemotherapy and radiotherapy regimens. These patients simulate diseases in order to attract medical attention. They might become belligerent and are likely to promptly discharge themselves from hospital if they do not get the desired attention or are unmasked. With two following case reports and literature review, we would like to alert clinicians about difficulties encountered in diagnosis and management of factitious disorders. When faced with this diagnosis, the patient will tend to deny reality and break contact with the medical team who exposed him. Medical peregrinating behavior surrounded by conflicts with medical team, past psychiatric illness, history of working in the medical and paramedical field and social isolation can guide the diagnosis. Somaticians and especially surgeons working in the oncologic field must remain vigilant about this diagnosis and collaborate with either the psycho-oncologic team or the consultation-liaison psychiatric team. Some recommendations for medical professionals how to cope with these patients will be suggested.

Dermatitis Artefacta in Childhood: A Retrospective Analysis of 44 Patients, 1976-2006.

BACKGROUND: Dermatitis artefacta (DA) consists of self-inflicted skin lesions that the patient denies having produced. OBJECTIVES: To conduct a single-center retrospective clinical review of children and adolescents diagnosed with DA. METHODS: From 1976 to 2006, data were collected on children diagnosed with DA who were seen in the Department of Dermatology in our hospital. Clinical and epidemiologic features are described. Forty-four children (mean age 12.9 yrs) were selected, representing 21.9% of the total patients with DA recorded (n = 201) during this period. RESULTS: The most frequent clinical forms were excoriations (16 [36.4%]) and ulcers (10 [22.7%]), followed by blisters (7 [15.9%]), burns (3 [6.8%]), contact dermatitis (3 [6.8%]), hematomas (2 [4.5%]), panniculitis (1 [2.3%]), cheilitis (1 [2.3%]), and hyperpigmentation (1 [2.3%]). Sixteen were located exclusively on the face and neck, whereas 28 also had other locations (upper limbs, n = 10; lower limbs, n = 9; thorax, n = 5; abdomen, n = 4). Cutaneous lesions were treated with occlusive bandages using zinc paste or a plaster splint when necessary. CONCLUSION: To our knowledge, this is the largest reported series of DA in childhood. This complicated psychodermatologic condition requires correct diagnosis, appropriate management, and psychiatric assessment.

Estrategias de promoción del síndrome por déficit de testosterona: un caso paradigmático de invención de enfermedad (disease mongering) / Strategies to promote testosterone deficiency syndrome: a paradigm of disease mongering

El llamado «síndrome por déficit de testosterona» es más bien una amalgama de síntomas inespecíficos propios del proceso fisiológico del envejecimiento. Sin embargo, ha sido objeto de una intensa actividad promocional que ha presentado el problema como de alta prevalencia y de elevado impacto en la salud pública. Dicha estrategia ha ido acompañada de la irrupción de preparados de testosterona de fácil administración en el mercado farmacéutico, y ha generado importantes ventas a las empresas que los han comercializado. La promoción comercial del síndrome por déficit de testosterona y sus remedios ha explotado los tópicos culturales del envejecimiento y la sexualidad mediante campañas de sensibilización promovidas por los laboratorios implicados y divulgadas por medios de comunicación, con participación de numerosos expertos y con el aval de sociedades científicas, lo que supone un caso paradigmático de invención de enfermedad (disease mongering). Conviene considerar este ejemplo para responder a campañas de invención de enfermedades desde la clínica y desde la salud pública (AU)

The so-called «testosterone deficiency syndrome» is a blend of nonspecific symptoms typical of the physiological process of aging. This syndrome has been the subject of intense promotional activity that has presented the phenomenon as highly prevalent and with a major public health impact. This strategy has been accompanied by the emergence of new and easy to administer testosterone devices into the pharmaceutical market and has generated significant sales for drug companies. The commercial promotion of testosterone deficiency syndrome and its remedies has exploited cultural stereotypes of aging and sexuality through awareness campaigns promoted by the laboratories involved and has been disseminated by media with the participation of numerous experts and with the support of scientific associations, representing a paradigmatic case of disease mongering. This example might be of use in the response to disease mongering activities from the clinical and public health fields (AU)

Dermatitis artefacta: a retrospective analysis.

BACKGROUND: Factitial dermatitis describes self-produced and consciously made skin lesions usually intended to win sympathy, avoid responsibilities and even gain disability insurance. Dermatitis artefacta belongs to an extensive spectrum of self-inflicted diseases termed factitious diseases. OBJECTIVES: The study is retrospective, and the patients were seen in our department from 2002 to 2012. MATERIALS AND METHODS: For patients with skin lesions, the demographic features and clinical descriptive characteristics of their lesions were ascertained. Patient files and photographs were reviewed and the patients were called for follow-up. RESULTS: A total of 25 patients were recorded. Mean age of the patients was 25.64 ± 11.80. With the exception of two cases, all patients were females. With regard to location, 27% of the patients showed facial localization, whereas the lesions have been localized on the extremities in 44%. The most common clinical appearance of DA was crusted eroded lesions (24%) and excoriations (24%) followed by ulcers (12%), superficial erosion (12%), acute eczematous lesions (8%), purpuric lesions (8%), pigment application (8%), diffuse erythema (8%), hyperpigmentation (8%), blister (4%), hair cutting (4%), hypopigmentation (4%) and cellulitis (4%). Forty percent of the patients had multiple lesions. There were eight children with dermatitis artefacta whose mean age was 14.50. The predominant lesion in these cases was superficial eroded plaque (37.5%). While patients with mild lesions limited in number receive ambulatory care, almost half of the patients require hospitalization. In this study, all patients were referred to psychiatric consultation, but most of them either refused treatment or did not receive medications. CONCLUSION: Although it is primarily a psychiatric disease, dermatitis artefacta is frequently diagnosed by dermatologists. Detailed history and physical examination are key factors because it imitates an extensive spectrum of diseases.

Malingering and factitious disorders and illnesses, active component, U.S. Armed Forces, 1998-2012.

Malingering refers to the intentional fabrication or exaggeration of mental or physical symptoms by a person who is motivated by external incentives (e.g., avoiding military duty, work, or incarceration, obtaining financial compensation, or procuring drugs). Factitious disorders and illnesses are similar to malingering with respect to the fabrication of symptoms; however, these individuals seek to assume "sick roles" (e.g., hospitalization, medical evaluation, treatment). During the 15-year surveillance period, 5,311 service members had at least one health care encounter during which a provider recorded a diagnosis of malingering or factitious illness in the first diagnostic position of the administrative record of the encounter. Over 80 percent of the subject service members had only one such encounter and most (83.9%) of the diagnoses were for malingering. There were higher (unadjusted) rates of these diagnoses among recruit trainees, those under the age of 20, and junior enlisted service members. Trends in these diagnoses during the surveillance period and the small numbers of diagnoses made during deployment do not suggest a discernible correlation between malingering and factitious illness and deployment to combat theater.

Factitious hand disorders: review of 29 years of multidisciplinary care.

PURPOSE: To improve our understanding of factitious hand disorders with a review of our experience over 29 years in a multidisciplinary hand center. METHODS: A retrospective chart review was performed to identify workers' compensation patients treated for factitious hand disorders in the multidisciplinary hand center between January 1981 and September 2010. Multidisciplinary evaluation at this center involved evaluation by hand surgeons, occupational therapists, and psychologists. Data collected include age, sex, race, educational level, clinical presentation, number of diagnostic tests, number of surgeries, time to referral to the multidisciplinary center, direct cost of care, psychological diagnosis, Minnesota Multiphasic Personality Inventory, treatment modalities, and work status. RESULTS: We identified 174 workers' compensation patients with factitious hand disorders. Presentation was used to classify patients into 1 of 4 categories: psychopathological dystonia, factitious edema, psychopathological complex regional pain syndrome, and factitious wound creation and manipulation. There were statistically significant differences between the 4 categories in demographics, utilization of medical resources, psychopathology, treatment modalities, and return-to-work status. Patients with factitious wounds were more educated, used more medical resources, demonstrated an angry or hostile profile, and experienced a lower return-to-work rate. Patients with dystonia were less educated, used less medical resources, demonstrated a hypochondriasis or depressed profile, and experienced a higher return-to-work rate. CONCLUSIONS: Treatment of factitious hand disorders remains frustrating and costly due to failure or recurrence after traditional approaches. This review is a large-scale examination of the factitious hand disorder population that demonstrates the unique pathology involved in each of the 4 categories. There is a specific association between the category of hand disorder and the underlying pathology and prognosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Factitious disorders and Munchausen syndrome: the tip of the iceberg.

This population-based study evaluates the prevalence of factitious disorders, Münchausen syndrome, and Münchausen syndrome by proxy in a clinical setting. All children referred to the Pediatric Unit of the Department of Pediatrics of the Catholic University Medical School (Agostino Gemelli Hospital) in Rome were recruited between November 2007 and March 2010. An experienced interdisciplinary team of medical professionals analyzed all suspected cases. A total of 751 patients were hospitalized. Factitious disorders were diagnosed in 14/751 patients, resulting in a prevalence of 1.8%. Three of 14 (21.4%) patients fulfilled the criteria for Münchausen syndrome. Münchausen syndrome by proxy was identified in four of 751 patients, resulting in a prevalence of 0.53%. The perpetrator was the mother in three of four of these cases. The epidemiological data obtained in this population-based study indicate that the prevalence of factitious disorders, Münchausen syndrome, and Münchausen syndrome by proxy is higher than previously observed. Moreover, early detection was possible thanks to the awareness of an expert interdisciplinary team. We suggest that physicians must consider the possibility of these diagnoses whenever there are discrepancies in a child's illness presentation.