Running head: RESEARCH FINDINGS ON FACTITIOUS DISORDER

Research Findings on Factitious Disorder Meredith Reed James Madison University

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Abstract This paper defines factitious disorder and discusses recent relevant research findings on the disorder. The disorder is differentiated from similar disorders, specifically Munchausens syndrome and malingering. Prevalence remains underreported, and controversy exists as to the typical client diagnosed with the disorder. Counseling interventions are discussed, with emphasis on cognitive behavioral therapy. Factitious disorder remains puzzling for physicians and counselors but research continues to be conducted.

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Research Findings on Factitious Disorder A puzzling and challenging disorder for medical practitioners to diagnose and treat continues to be factitious disorder. While many people desire health and wellness, many people suffer from a disorder in which they strive to assume the role of a sick patient. Factitious disorder remains complicated as it can be presented with or without physical symptoms, or a combination of both. This paper reports recent research findings on factitious disorder and attempts to explain counseling considerations and interventions for clinicians working with those diagnosed. The Diagnostic Statistics Manual IV lists criteria necessary to be diagnosed with factitious disorder including intentional production of physical/psychological signs and symptoms, motivation for behavior to assume a sick role, and external incentives for the behavior are absent (i.e., improving physical well-being, economic gain, avoiding legal responsibility, etc.). The disorder can present itself with psychological symptoms, or physical symptoms, or both. People with this disorder tend to demonstrate the ability to deceive and exhibit unclear motivation. Some even self-induce infections and wounds and simulate disease symptoms. Posing difficulty for physicians, many people with the disorder describe symptoms that are incongruent with known diagnoses (Pasic, Combs, & Romm, 2009). The typical age of onset is early adulthood; however, the disorder can begin in childhood or adolescence (Rana & Singhal, 2009). The prevalence of the disorder is difficult to assess since some people suffering from factitious disorder tend to jump around from one hospital to another. Identifying the typical client diagnosed with the disorder has been controversial. Some research suggests

FACTITIOUS DISORDER the typical client is a white man aged thirty to fifty, although researchers do not present reason for this commonality (Rana & Singhal, 2009). Research conducted in the Netherlands, however, suggests that the typical client tends to be a woman around the age of 35 (Kinsella, 2001). While some research suggests that the typical client is male, extensive research is pointing to females as the ones diagnosed (Krahn, Li, & OConnor, 2003). What has been concluded across research is the tendency for the client to be in a nursing, healthcare, or caretaking profession (Kinsella, 2001; Rana & Singhal, 2009). Clients diagnosed with the disorder also tend to have high school education or higher and are employed or full time students (Krahn, Li, & OConnor, 2003). Research also is congruent in finding that people who suffer from factitious disorder tend to have a past of emotionally deprived childhoods, history of abuse, rape, or trauma (Kinsella, 2001; Rana & Singhal, 2009). Other trends include a history of self-harm, suicide attempts, and psychopathic personality traits. The course of the disorder is difficult to assess but often times begins with an initial hospitalization. As visits to hospitals increase, the person begins to gain medical knowledge and understand medical terminology, giving him/her additional tools to produce symptoms. With several hospitalizations, people suffering from the disorder have difficulty maintaining stable jobs and relationships (Rana & Singhal, 2009).

Factitious disorder is commonly confused with malingering, which is the deliberate feigning of a disability, intentionally producing false systems, or exaggerating existing symptoms in order to obtain a tangible reward. A very important difference between factitious disorder and malingering is that the former includes psychological problems

FACTITIOUS DISORDER while the latter does not. Factitious disorder also is different in that the stability of the problem is continual, there are frequent recurrent episodes, the behavioral response is

uncooperative, and the emotional response tends to be belligerent. Some research suggests malingering typically occurs in people with antisocial personality symptoms, while factitious disorder may occur in people with more borderline personality symptoms (Overholser, 1990). Factitious disorder is also similar to somatoform disorder, which differs in that physical symptoms not attributable to a physical diagnosis are present but not feigned (Kinsella, 2001). Factitious disorder has several variants that tend to further the complexity of this disorder. Some variants include factitious disorder with mostly psychological symptoms, with mostly physical symptoms, or with a combination of the two symptoms. People who do not fit into any of the stated categories fit under the classification of factitious disorder not otherwise specified. Factitious disorder by proxy is another variant in which a person is feigning illness on to someone else, such as a child (Rana & Singhal, 2009). A well known variant of the disorder is Munchausens syndrome, which tends to be much more severe and complex in its symptoms. Those suffering from Munchausens syndrome tend to wander from one geographical location to another seeking hospitalizatons, create false identities, and exhibit pseudologia fantastica. Those suffering from Munchausens syndrome present cases that are longer-lasting and more repetitive than cases of factitious disorder (Overholser, 1990). As puzzling as the disorder may seem, treatment options for the disorder are also complex. As with any initial patient, physicians should treat the patient under the

FACTITIOUS DISORDER principles of medical care. The physician should also rely on objective symptoms before

running any intrusive or possibly risky medical tests. Once a physician suspects factitious disorder in a patient, research has found that it is best to attempt to build a supportive relationship to prevent the patient from lashing out on the physician. Typically, however, the patient will deny possibilities of any psychological troubles and relocate to another hospital. If a relationship is able to be built, the physician should refer the patient to psychiatric and psychological services. No specific treatment or drug therapy has been declared for the treatment of factitious disorder; however cognitive behavioral techniques prove to be effective in the therapeutic approach (Kinsella, 2001; Rana & Singhal, 2009). Direct confrontation with the client is ineffective for both physicians and counselors (Krahn, Li, & OConnor, 2003). A cognitive behavioral model is recommended for therapeutic interventions. The assumption is that a client with factitious disorder may have cognitions of needing to be looked after and desiring dependency from the counselor. The counselor should address these cognitions early on in therapy and be aware of transference (Hagglund, 2009). The counselor should also assume a nonjudgmental, accepting role, which will hopefully help limit the clients potential feelings of shame. Behaviorally, the counselor should help the client in identifying triggers and alternative coping strategies. By discussing a recent episode, the counselor should work with the client to assess the immediate triggers. The counselor should help the client identify the needs being met through the episodes and other ways to meet those needs.

FACTITIOUS DISORDER It is important to bring to the clients attention the dangers of the disorder. Much

like eating disorders or self-injury, there are certain physical risks and harm being inflicted on the clients body. People suffering from factitious disorder tend to seek several medical exams, procedures, and possibly dangerous interventions that are in fact unnecessary. The counselor should help the client to identify the benefits and risks of his/her behavior to hopefully reveal that the risks outweigh the benefits. The counselor should also help the client to assess the strain his/her behavior has had on relationships with family members and others. In an attempt to help the client gain independence, the client should identify behavioral targets to meet in changing his/her unhealthy behavior. When it comes to termination, it is important for the counselor to slowly fade out sessions to prevent feelings of rejection or abandonment in the client (Kinsella, 2001). A formal treatment plan for a client diagnosed with factitious disorder must be completed based on psychological symptoms and behavior, as opposed to the medical issues he/she may present. There are no existing drug therapies targeted specifically for people diagnosed with factitious disorders, although some psychiatric medications may be given and closely monitored. The typical treatment plan for a person diagnosed with factitious disorder includes psychotherapy and cognitive behavioral techniques (Plassmann, 1994). The client has distorted cognitions, so by reframing his/her thoughts the client can work toward changing his/her behavior. Goals of the therapeutic treatment include reframing cognitions, modifying behavior, gaining independence, and reaching these goals through talk therapy and behavior modification. The time frame of the therapy is not specified but should be assessed on a client to client basis (Kinsella, 2001).

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Factitious disorder remains puzzling for the medical and therapeutic worlds. Often times, cases go unreported and statistics do not do justice to the amount of people suffering from this disorder (Hagglund, 2009). It is difficult to diagnose the disorder, as many clients may become defensive and seek medical attention from another hospital (Krahn, Li, & OConnor, 2003). It is important not to confront clients suffering from this disorder but instead attempt to create an empathetic and trusting relationship. While no single method has proven effective for treating clients with factitious disorder, cognitive behavioral therapy has shown improvement in clients. Clients irrational thoughts and subsequent behavior is challenged in therapy and hopefully modified.

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References Hagglund, L. A. (2009). Challenges in the treatment of factitious disorder: A case study. Archives of Psychiatric Nursing, 23(1), 58-64. doi:10.1016/j.apnu.2008.03.002 Kinsella, P. (2001). Factitious disorder: A cognitive behavioural perspective. Behavioural and Cognitive Psychotherapy, 29(2), 195-202. doi:10.1017/S1352465801002065 Overholser, J. C. (1990). Differential diagnosis of malingering and factitious disorder with physical symptoms. Behavioral Sciences & the Law, 8(1), 55-65. Retrieved from http://search.ebscohost.com/login.aspx? direct=true&db=a9h&AN=12116917&site=ehost-live&scope=site Pasic, J., Combs, H., & Romm, S. (2009). Factitious disorder in the emergency department. Primary Psychiatry, 16(1), 61-66. Retrieved from http://search.ebscohost.com/login.aspx? direct=true&db=a9h&AN=36431658&site=ehost-live&scope=site Plassmann, R. (1994). Inpatient and outpatient long-term psychotherapy of patients suffering from factitious disorder. Psychotherapy and Psychosomatics, 62(1-2), 96107. Rana, A. K., & Singhal, A. (2009). Factitious disorder. Foundation Years Journal, 3(7), 32-37. Retrieved from http://search.ebscohost.com/login.aspx? direct=true&db=a9h&AN=44623079&site=ehost-live&scope=site