A descriptive, retrospective case series of patients with factitious disorder imposed on self, 2021, Berar et al

Abstract

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.

Open access, https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-021-03582-8

 

I can't press like on the above. This is like going back to the Dark Ages.

 

I think the only valid evidence for factitious disorder is actual evidence of fabricating an illness or a patient admitting to it while they're not being pressed or forced to do so.

The "indirect evidence" means nothing bcause there are so many other explanations that are at least as valid as factitious disorder.

 

Being found with a block of soap in your mouth or the thermometer in the coffee is the only level of evidence that proves factitious disease.

The preponderance of females is just as likely a reflection of misogyny in the medical profession especially as the diagnosis is inferred rather than proven. Just awful, it smacks of McEvedy and Beard.

 

This looks to me like a very reasonable, measured account of factitious illness cases. I think it is unwise to dismiss it as inappropriate.

Illness of this sort is real. I have only come across two clear cases under my specific care but they were not in doubt.

If most of them are women then that is a fact that should be documented.
It seems that about half are health care professionals. One of my cases was.

Even within this category there are almost certainly very different processes in different individuals but I thin the paper accepts that.

It is very important that ME is not confused with this problem but the authors appear to be well aware of the need to distinguish different problems. They make the point that factitious illness is not malingering and that motives are often very hard to identify or describe.

If someone has needle-track marks positive for staph aureus or feigns a combination of meningism and coma there is no need to doubt that the problem is factitious. I see no reason to think that the authors are overstitching the diagnosis - they discarded the majority of candidate cases.

Rather than pooh pooh this I think it would be useful to recognise it as a real illness and try to define what it is that makes it clear that it has nothing to do with ME.

 

Fairly rare, although the authors claim a likely underestimation.

The authors write:

'' When they finally suspect FDIS, evidence of the deception is required to make a definitive diagnosis, but it is not easy to demonstrate. Warning signs are helpful but cannot suffice to reach a diagnosis, as they can also apply to patients with chronic illnesses: for example, these chronic patients may also exhibit high health service utilization, normal test results, atypical presentations or treatment failure." (in bold and highlighted by me)

The danger that such a diagnosis will be made without proof is always there for those who suffer from an unrecognized and poorly understood disease like ME. I am sometimes so tired that there are so many categories of psychiatric disorders that a professional incompetent or devoid of common sense can affix us. Sigh... !

 

Had an exam today so my brain is fried and not able to read the article atm.

But I am confused about the difference between Factious disorder and Munchhausen. Or are they the same thing? I've heard description of both involving 'feigning' or inducing illness/symptoms for some kind of secondary gain (often emotional / getting attention) to the point of causing themselves bodily harm to get positive test results and so on.

If so, how do they differ from malingering? I mostly hear the latter term applied to people who are into financial gain, but also to describe someone exaggerating an actual condition to get 'more attention' or help than what the condition requires.

And all of these of course differ from hypochondria/health anxiety where someone is scared they have a health condition and their fears are not alleviated by negative tests results.

I don't remember the details properly, but we had a case in Norway many years ago where a woman showed up to the hospital and stabbed herself in the stomach 2-3 times just to get admitted She wasn't suicidal or wanted drugs, but had a history of attention seeking behavior and had been in and out of psychiatry since she was a teenager. It was a really sad case, but her psychiatrists at least seemed to be doing as good a job as they could.

 

I think this is relatively unlikely as a formal diagnosis although I see it as a major concern as an unproven presumption of what might underlie someone's ME.

In my experience factitious illness stands out as very out of place. Something is very inconsistent with normal illness but often stereotypic of factitious illness. Moreover, my impression is that people with factitious illness are so powerfully motivated to appear ill that they are relatively unlikely to get misdiagnosed or ignored.

 

As the authors say, this is quite different from malingering. The malingerer presents a plausible account of a standard illness such as back pain with the conscious intention of getting a sick note and then going to work. I remember a man with an immobile 'frozen shoulder' unable to work who nevertheless had thick calluses on his palms ingrained with cement dust.

I am not sure that factitious illness and Munchhausen are different. I have never used the second term as it is so often banded about inappropriately.

Where I would query what the authors say is in suggesting any motivation at all for self-harm in factitious illness. One would think that there must be a 'motive'. But my impression is that we do lots of things for which we have no obvious 'motive'. Why dogs like fetching sticks? As far as I can see there is no benefit to gain from factitious illness. The idea that there is a sort of hidden version of the malingerer's desire for free hand outs seems to me naive. Why do people stammer?

 

It's a long time since I've read about these things so i don't remember where i have my information from, only that i keep hearing 'they do it for attention'. I took it as that they have some unfortunate wiring like an addiction or it turns into their 'thing' which gives them an identity / personality or place in social group, like others would have with a hobby, going to the gym or their profession, so more akin to a sad way of covering some human need.

I might be reading you wrong, but are you saying they don't think they are aware of what they are doing? Or more like its some unconscious drive, which us outsiders just like to name without any way of knowing what it is?

Again i don't know much about these things, but i sort of remember a case about one woman who was doing all sorts of weird stuff to fake tests, and it just seemed to involve so many complicated steps that i find it difficult to imagine her not being aware of what she was doing / or at least have some thoughts/rationalizations about it. I guess i can see a case for it if it was a health care worker, because she would be familiar with many of these things, but the person in question was not. So it would require a lot more adult 'learning' steps than some innate instinctive stick fetching drive.

 

People with factitious illness are very aware they are creating their signs. What they do can every elaborate. But a dog may do all sorts of things to try to get the stick, knowing she is trying to get the stick and yet have no idea why she wants to.

The action is deliberate but I am sceptical that we can understand the 'motive' or the 'cause'. We simply do not know enough about how minds work when they go wrong. As to what these people are thinking, again I don't know that anybody really knows, beyond the planning of the action.

I am sceptical of explanations like wanting to draw attention. Drawing attention is easy without causing yourself harm.

 

Yes, there has to be much more going on.

 

What do people with factitious disorder say when asked why they did it?

 

Thanks for clarification, I'm not that good at explaining myself / using the right words, but i think i see what you are saying, and i don't disagree.

 

The problems arise from not needing any evidence when suspected and confusing everything and allowing everyone to accuse mothers or their children with what they term Medically Unexplained Symptoms or Perplexing Presentations as fabrication or Factitious and not understanding the difference. Why the need for proper assessments with those who are at the top of their field. Remember for a child and that is going to get more difficult with the sadness of the Arthur case, it only has to "may cause" for you to lose your child. This problem does not just impact on those with ME it is also huge in autistic, hEDS/EDS, mast Cell, POTS, Lymes

The other issue Fii is now considered a rare disease and places are being set up for Mothers to be taken to and apparently there is treatment.

So my experience is just with Young People and I come at this from that angle only but as this problem will stay with a young person until they are 25 now it is a freighting prospect we face. I think we also need to look at the now emerging Family Court release of actual cases discuss these, as there are no figures kept on Fii but several mothers accused have lost their children as a direct result of the confusion only to find that they had a health condition when it was too late, let us not forget Ean Proctor and what he experienced.

I have been learning a lot about the problems mothers face and have had personal experience of being accused.

What’s New? – Luke Clements


I think Luke Clements research is of great value here and perhaps good to connect with. I have been following him and Andy Bilson's work. If ME shows us one thing is that Fii is over used 90% of mothers are accused when they simply ask for support. There are no assessors or Social Workers that understand ME and as a disability our young people should be protected but they are not. NICE tells us we should have experienced people to support us so they go to the cfs centers and that is when the trouble starts.

There are a couple more cases like this one below on going with schools being the worst as the LA play games

 

Sure there are problems both ways but I think it is unhelpful to deny that factitious illness occurs.

Things are also not helped by certain physicians telling patients they have hEDS or MCAS when it is doubtful that these diagnoses even mean anything. The person may be very ill but these sorts of names simply seed confusion and lack of trust.

 

Then you have to explain to me why you are so against it because there is an explosion of young people being taken and adverts for foster carers for children with complex conditions. Trust is already broken in the denial of symptoms by doctors that young people experience.

We need to understand what research we need to ask for and how to approach what we experience what name do we call it and we need to do this as quick as we can, because there are not enough people fighting to protect our children.

Clinics being built to house mothers who say that they are Fii just so they can have their children back (already happening with Autism) Sonya Murphy, Andy Bilson, Fiona Gullen-Scott and Luke Clements are looking at autism. No one is looking out for those with physical disabilities such as ME. They are seeing the increase with an estimated 1000,000 that will be in care in the next 3-5 years. Mothers can only keep their children if they go to clinics accept they are Fii and go through the process of being cured when they are just stating what they see with regards to their children's symptoms. The death rates in which is used in court is 6 - 9 % with regards to Fii and are taken from Roy Meadows research. The science used to take children is insipid and . Some of the cases blamed on nurses have been found or thought to be mistakes by Drs covering up, we know that is the case with Fii.

In access of £1000,00 for legal expenses is needed to keep your child and a doctor who will stand by your child symptoms. There are possibly 2 with a decrease in those Lawyers who will take on cases due to the confusion in health. There is nowhere for us now to turn, do we just hand our children over because lack of research on the biomedical and so much bad science on the Fii side of things.

I also need to know how do young people, that have never been noted as having bendy joints get them as they grow older and sicker with ME, Lyme and now long covid.

How can Young people with no notable urticaria suddenly have skin that when you draw down it with the back of your nail leave a trail and need antihistamine.

We have known from 2004 Prof White travel paper this could happen and with the C-reactive protein in 2017 all the findings would impact on connective tissue not only of joints but of Mitochondria and red blood cells, which we see the issues arising. We cant have the science because they don't do test in our children or the research.

We need this conversation to be full and open so that we can get a clear trajectory of the complexities as the Judges are feeling that they are being misled. Our whole system relies on science and we need to see the wood from the trees for sure, but we need to protect the innocent children caught in the middle of this organised confusion that simply have the evidence in or on their bodies but have not a name or diagnosis biomarker, made on purpose to enable Fii to take the lead - as cfs did with ME or what ever you want to call it now.

 

I am not sure what you mean by 'it' here but I think you mean use of terms like hEDS and MCAS by fringe physicians.

I am against use of these terms because I don't think they mean anything in the context of children who are severely ill. I am also pretty sure that using them makes the situation worse by encouraging psychiatrists and paediatricians to think that parents have unhelpful beliefs about their children's illness. I think the idea that hEDS or MCSAS explains anything is unhelpful.

You are right that we need the science, but we need real science rather than pseudoscience.

If a child is noted to have bendy joints as they grow older that is not EDS because EDS is a congenital condition where the laxity tis there from the start. So, no, not EDS. Moreover, bendy joints aren't really a problem. Ballerinas make use of their bendy joints. Most people would like to have bendy joints. Unstable joints like knees that bend sideways can be a big problem but there is no reason to think that sort of problem has any link to ME or similar illnesses. The problem is the illness, not the joints.

Similarly, dermographism isn't much of a problem in itself. There is no reason to think it has anything to do with ME or similar illnesses.

Listening to the paediatrician at the NICE roundtable, debating with Nigel Speight, I am in no doubt that safeguarding is used as an excuse to break up families for no good reason. I do not have a solution to severe childhood ME but I can see that nor do the psychiatrists. I suspect managing the illness at home is far the best thing. But I can also see the reasons for concern if psychiatrists think that parents are allowing their children to be looked after by quack doctors who prescribe harmful treatments. This is probably not directly relevant to EDS or MCAS but we have heard of children going to see endocrinologists on the continent who prescribe hormones that could have a seriously negative impact on their lives.

I think we should stop talking about hEDS and MCAS and probably 'chronic Lyme' and focus on the illness itself - the disabling symptoms.

 

I think you are wrong. I think I think they are both huge in the ME and in other conditions and it needs to be noted. The symptoms get dismissed and the connections are not made and children suffer not just in ME but in other diseases too it has to be known and brought out in the open talked about and we need to learn especially in a time of Covid.

Do not tell a child with bendy joints they are a good thing. From experience and the experience of others that have grown with the conditions it is not a good thing at all, we have just learnt to hide the pain as it becomes normal for us. There are 101 reasons we should pick up on the bendy problem - Cyst on the ovaries, testicles torsion, ovary torsions and other organ torsions with endometriosis to name just a few the beighton score can be low or even 0 with mostly bendy in toes, ankles, knees hips making balance difficult and clumsiness (which is my particular problem) writs, shoulders neck none of these are on the beighton list. I think they have now tracked down the genetic code for hEDS and we are just waiting for conformation.

There needs to be a full look at the whole of the issues experienced not what clinicians think they should be and researchers lack of understanding. You cant look if you don't ask the right questions or if do not know of the problems. POTS EDS hEDS mast cell is ME always has been. Some will have less of an impact say with POTS but most or all will see an increasing amount of flexible joints but no one is asking the questions. We do know pain in muscles and joints have always been there we need deeper questions actually actively looking for problems because our young people are in pain and are too frightened to tell their truths. When that happens perhaps research will have a better chance at getting the right direction to look in.

 

@Tilly,

As you probably already know, I have been following this story of bendy joints for 40 years, having started the first hyper mobility research clinic with Rodney Grahame at Guy's in 1978 or thereabouts.

Over that time I have seen a complete lack of meaningful evidence for joint hyper mobility being the sort of problem that people like Alan Hakim now suggest. (Alan was one of my registrars, so I know these people well.)

I contacted a paediatrician who has a special interest in hyper mobility a year or two ago and she pointed out that the only decent studies on populations we have tend to show that hyper mobility is not a major risk factor for generalised pain. The evidence on fatigue is as far as I can see zero. I asked the LSHTM group about their ME Biobank cohort and they said there was no sign of hypermobility

I do not discount the possibility of there being some weak association but I think it is unhelpful to patients to tell them that ME and hEDS are linked or indeed that bendy joints are somehow a cause of widespread pain. Before doing that we need to have some proper evidence - not work on hearsay like the BPS people. And remember that the idea that fatigue goes with hyper mobility is spread by the BPS people as much as anyone, following the paper by Knoop.

I will say no more on this particular thread because we have covered it all before but I think it is important not to put out unsubstantiated medical ideas.