Factitious disorders.

Reports of factitious disorders, Munchausen's syndrome, and self-induced illness exist throughout medical history. In practice, disease simulation represents a spectrum of behaviors that range from relatively common and benign (e.g., pleading illness to avoid an unwanted social obligation) to rare and malignant forms (e.g., Munchausen's syndrome and factitious disorder by proxy). Factitious disorders are differentiated from malingering by the goal that motivates the individual's behavior. The only apparent goal in factitious illness is to gain the sick role; the goal in malingering is to gain rewards, such as compensation, or to avoid the unwanted, such as military service or jail. This article summarizes clinically relevant information on factitious disorders for primary care physicians.

Somatization and fashionable diagnoses: illness as a way of life.

The history of "nondisease" dates back, at least 4000 years, to early descriptions of hysteria. More recently somatization became a part of the official diagnostic nomenclature by creation of the DSM III category, "somatoform disorders." Somatization can serve as a rationalization for psychosocial problems or as a coping mechanism, and for some illness, becomes a way of life. One variation of somatization can be the "fashionable diagnosis", for example, fibromyalgia, multiple chemical sensitivities, dysautonomia, and, in the past, "reactive hypoglycemia". These disorders are phenomenologically related to environmental or occupational syndromes and mass psychogenic illness. Fashionable illnesses are characterized by (i) vague, subjective multisystem complaints, (ii) a lack of objective laboratory findings, (iii) quasi-scientific explanations, (iv) overlap from one fashionable diagnosis to another, (v) symptoms consistent with depression or anxiety or both, (vi) denial of psychosocial distress or attribution of it to the illness. Fashionable diagnoses represent a heterogeneous collection of physical diseases, somatization, and anxiety or depression. They are final common symptomatic pathways for a variety of influences including environmental factors, intrapersonal distress and solutions to social problems. A fashionable diagnosis allows psychosocial distress to be comfortably hidden from both the patient and the physician, but premature labeling can also mask significant physical disease. Hysteria remains alive and well and one contemporary hiding place is fashionable illness.

Dimensions of somatization and hypochondriasis.

A significantly large group of patients who communicate their psychosocial distress in the form of physical symptoms are called somatizers. They tend to overuse medical services. The syndromes with which they present have indistinct boundaries, and there tends to be some fluidity of their symptomatic presentations. Underlying psychiatric disorders such as mood disorders, anxiety disorders (including obsessive compulsive disorder), and personality disorders are frequently present.

Deceiving others/deceiving oneself: four cases of factitious rape.

Although patients with factitious disorders typically seek the "patient" role through illness portrayals, some instead portray themselves falsely as "victims." We discuss the cases of four women who claimed to have been victims of rape; the allegations ultimately were disproved. Factitious rape may be prompted by a search for nurturance; by dissociation, leading individuals to believe that trauma earlier in life is ongoing; by a need to be rescued from real, current abuse; and by projection of anger onto specific male targets. Although dramatic, factitious rape is rare, we advocate thorough investigation of rape claims even when patients have known histories of deceptive behavior.

Attention deficit hyperactivity disorder in adults: diagnosis, treatment, and prognosis.

Attention deficit hyperactivity disorder (ADHD) is a common, disabling disease in adults. Newly developed diagnostic measures are available to screen for and support the diagnosis. ADHD typically causes complaints of disturbances of attention, impulsivity, and hyperactivity, although a subgroup of patients have only problems with attention. The disorder may be subtle or it may be obscured by secondary problems; the boundaries of the syndrome often blur with those of other disease entities. Once the diagnosis is confirmed, effective pharmacologic treatments are available. Psychologic treatment serves an important adjunctive role for associated problems and concurrent psychologic disorders. Marked improvement in quality of life often occurs after diagnosis and appropriate treatment.

Fellowship training in consultation-liaison psychiatry. Education goals and standards.

Consultation-liaison (C-L) psychiatry, which focuses on the psychiatric care of patients in medical-surgical settings, has evolved into an increasingly recognized subspecialty. The Academy of Psychosomatic Medicine, using consultants and a database created from 49 extant C-L fellowship programs, has specified goals and standards for C-L fellowship training. These standards include organizational issues, clinical skills, a didactic curriculum, research training, and evaluation issues. The important contributions of C-L psychiatry to medical education are emphasized.

Illness as a lifestyle. The role of somatization in medical practice.

Persons with psychological problems who translate their distress into somatic symptoms (somatize) are frequent users of medical care. These patients often have underlying depression, anxiety, obsessive--compulsive symptoms, or personality disorders. Descriptions of the somatizing syndromes are provided in association with recommendations as how to recognize and manage the patient with somatization.

Pathological lying associated with thalamic dysfunction demonstrated by [99mTc]HMPAO SPECT.

The authors report a case in which pathological lying is associated with right hemithalamic dysfunction as shown by [99mTc]HMPAO SPECT brain scanning. This association has not been demonstrated previously and is noteworthy because it supports the hypothesized roles of the thalamus and associated brain regions in the modulation of behavior and cognition.

A curriculum for education in geriatric psychiatry.

The authors present recommendations for educating medical students and psychiatric residents in geropsychiatry. They are primarily concerned with the objectives and methods rather than the content of training. Proposals are structured in terms of training objectives and educational settings in which such training takes place. The proposals are intended to be specific enough to be truly useful and at the same time sufficiently generalizable to adapt to geropsychiatric training in a variety of institutions. Priority is given to integrating knowledge of normal and abnormal aging with the clinical skills and empathy necessary to approach patients with competence and understanding.

Lies and liars: psychiatric aspects of prevarication.

The authors discuss the phenomenon of lying, a common psychic process that has received remarkably little scrutiny. The ubiquity of lying and others forms of deception suggests that they have "normal" aspects, but lying which is persistent or destructive to the quality of a person's life becomes pathological. Lying has many determinants, including developmental, biological, social, and psychodynamic. Antisocial, histrionic, narcissistic, borderline, and compulsive personalities have been associated with lying. The treatment of lying needs to be individualized according to the overall symptom complex in which it is embedded.

Pseudologia fantastica.

Pseudologia fantastica has not been reviewed in the English literature in over 50 years, but the term is still used, for example, among the diagnostic criteria for the Munchausen syndrome. Based upon a review of 72 cases of pseudologia fantastica collected from 26 reports since its initial description in 1891, pseudologia is distinguished from other types of lying. Pseudologia fantastica is typified by these characteristics: (1) the stories are not entirely improbable and are often built upon a matrix of truth; (2) the stories are enduring; (3) the stories are not told for personal profit per se and have a self-aggrandizing quality; and (4) they are distinct from delusions in that the person when confronted with facts can acknowledge these falsehoods. The authors compile phenomenological data about "the pseudolouge", who is represented equally males and females. Intelligence varies, but at least 40% have evidence of central nervous system dysfunction. The authors suggest that disease simulation, peregrination, and imposture are secondary behavioral manifestations of pseudologia, which is deserving of additional study.

Internship: what is stressful?

We periodically evaluated 27 interns for mood states and psychophysiologic functions during their internship year. At the end of the year they were questioned as to what they had found to be stressful and/or supportive during the year. Stressful issues were inadequate sleep, inadequate time to pursue personal matters, and inadequate personal interest and support from attending physicians. Helping to reduce stress were support from, and camaraderie with, fellow house officers. Those interns who had more emotional distress experienced less support from others and felt more isolated. The amount of sleep did not differentiate those who were more dysphoric from those who had less distress. We conclude that the major issue in determining the amount of distress experienced during the internship is the quality of the individual's social support system.