Somatic disorders (psychiatric)
Fictitious disorders
Munchausen’s syndrome – self-inflicted
Munchausen’s syndrome by proxy – inflicted by other
Conversion reactions
Malingering (secondary gain)
Somatic disorders present in a variety of ways, including exaggeration of physical symptoms, self-inflicted wounds, and tampering with lab results. By definition, somatic disorders are not associated with conscious secondary gain, although the consequences may appear to provide an aligned agenda. Self-induced psychologically driven infection may facilitate school absence, but “avoiding school” was not a conscious goal. When self-induced, factitious disorder is also known as Munchausen syndrome . Published in 1951, Asher described the most dramatic form of Munchausen syndrome, named for the German nobleman and storyteller. “Like the famous Baron von Munchausen, the persons affected have always traveled widely (“hospital hoppers”), and their stories, like those attributed to him, are both dramatic and untruthful” (Asher 1951).
Munchausen by proxy is caused by an external agent and was defined by Roy Meadow in 1982. It refers to children or debilitated patients that have “parents [or caregivers] who, by fabrication, have caused them innumerable harmful medical procedures” (Meadow 1982). The parent/caregiver feigns or induces illness in a child to satisfy their own psychological needs. This is considered a form of abuse and, once the diagnosis is confirmed, should be treated as such. This condition is associated with high morbidity and mortality (Ferrara 2012).
In a conversion disorder, patients unconsciously feign symptoms. In contrast, patients with factitious disorder are consciously falsifying their mental and physical symptoms, without a clearly defined benefit. It is thought that patients with conversion disorder enjoy the “sick” role or the benefits derived from disability. These patients are often willing to undergo painful diagnostic tests and surgical procedures. Conversion disorders in children may be precipitated by physical or emotional stress at home or in school. Bullying, death of a friend or family member, a divorce, and child abuse may be stress triggers leading to conversion disorder.
Malingering is a feigned illness or disability in which there is secondary gain or an identifiable motive. It is not a mental illness. In children and adolescents, the goal may be to increase parental or peer attention, to decrease responsibility, or to achieve a desired result (e.g., payment for an injury). In children, the goals may be more subtle than in adults.
There is limited literature on malingering in adults and children. Most of the adult literature focuses on patients receiving worker’s compensation benefits, an issue not relevant for pediatric patients. However, the awareness that children and adolescents can falsify subjective and objective symptoms is imperative. Many physicians do not consider that their pediatric patient could be deceiving them, and as such this diagnosis often goes unnoticed.
Epidemiology
Prevalence rate of factitious disorder in adults is estimated to be 1.3 % (Fliege et al. 2008). This rate is similar in the pediatric literature. An Italian study in 2012 reported a 1.8 % prevalence of factitious disorder in children after evaluating 751 hospitalized patients (Ferrara 2012). Munchausen syndrome accounted for 21.4 % of these patients, and Munchausen by proxy accounted for 0.53 % (Ferrara 2012). A retrospective review evaluating patients referred to a psychotherapy outpatient clinic and inpatient hospital setting showed a 0.71 % prevalence rate among all referrals (Ehrlich 2008). This study also showed that somatoform and dissociative disorders were much more common among pediatric patients than factitious disorder. Munchausen by proxy is more common in children less than 1 year of age (Ferrara 2012) and in severely debilitated and dependent subjects.
Factitious disorder is more common in girls (Ehrlich 2008; Libow 2000). The perpetrators of Munchausen by proxy are often mothers with nursing or medical training (Meadow 1982). The mean age of onset is in the early twenties but up to 50 % may begin in adolescence (Jaghab 2006).
It is unclear what the true incidence and prevalence of somatic disorder is, as the goal of these patients is to escape detection of their true intentions. Even if a physician is suspicious of such a diagnosis, confirming it with evidence or patient acknowledgement is often impossible. Physicians are not immune to the deception of their patients, even pediatric ones. The incidence and prevalence of malingering in children is unclear.
Pathophysiology and Applied Anatomy
Although a variety of explanations exist in the literature, attempts to elucidate the etiology of a factitious disorder are difficult. Many patients are lost to follow-up and do not participate in psychological treatment. It is hypothesized that coping mechanisms, the need for control, learned behavior from childhood or role models, positive reinforcement from previous experiences with illness, and the presence of personality disorders, depression, or distorted self-image play a role (Jaghab 2006).
There are no identified abnormalities on brain magnetic resonance imaging (MRI), brain computed tomography (CT), or electroencephalography (EEG) in children. A case report of a 35-year-old male with factitious disorder showed an MRI consistent with changes in the hemispheric white matter (normal CT and EEG), and the authors theorized that the brain disease is responsible for the falsified symptoms and perhaps factitious disorder has a cerebral etiology. Alternatively, it was noted that the abnormal MRI was indicative of an acute childhood illness in which the patient experienced gratifying hospital admissions, thus promoting repeated experiences as an adult (Fenelon 1991). The MRI findings could also be coincidental or a result of iatrogenic or self-induced accidents.
Risk Factors
Exposure to sickness and hospitalization at an early age, adoption or foster care, and trauma are risk factors. Some children may have witnessed a family member enduring a prolonged illness or may have experienced it themselves. Fifty percent of patients diagnosed with factitious disorder have witnessed severe somatic illness within their immediate family, and one third have experienced illness (Ehrlich 2008). Furthermore, 50 % of patients with factitious disorder were adopted or in foster care, and over 40 % experienced sexual or physical abuse during childhood (Ehrlich 2008). Patients with factitious disorder have a high incidence of traumatic events, including physical and sexual abuse, early loss, and childhood neglect, and lived in foster care (Ehrlich 2008).
Parents may play a role in the development of factitious disorder, either by acting as role models, outwardly “coaching” their child, or by supporting the child’s manipulated symptoms (Libow 2000). Patients may have also been previous victims of Munchausen by proxy. Often patients will have comorbid psychiatric illness, usually Axis I disorders. Incipient personality disorder is most common with attention-deficit hyperactivity disorder and anxiety and depressive disorder, with anorexia nervosa also being frequent (Ehrlich 2008).
Assessment of Somatic Disorders
Signs and Symptoms
Patients with somatic disorders can present with almost any sign or symptom that can be fabricated reliably. Long, unexplained history of illness with vague details and a willingness to undergo uncomfortable and risky diagnostic testing is common (Jaghab 2006). These patients can be hostile and overly dramatic and engage in exaggeration or lying about aspects of their life aside from the medical history. In contrast, these patients could present with a flat affect and indifference and could be unconcerned, even when informed they would require invasive or painful procedures. Older patients may have extensive knowledge of their supposed illness and can be educated on appropriate diagnostic and therapeutic modalities. These patients may resist conservative treatment in favor of invasive, even painful, diagnostic testing.
Common associated symptoms involve the nervous, gastrointestinal, and respiratory systems. Extensive scarring or wounds seen on physical exam and abnormal test results, such as blood in the urine, and malnourishment (anemia, failure to thrive) are often present (Jaghab 2006). The most frequently produced symptoms in children (33 %) pertain to the skin (eczema, edema, exanthema) and factitious fevers (12.5 %) (Ehrlich 2008; Ferrara 2012).
Symptoms may be feigned by using medications (e.g., laxatives), swallowing or injecting hazardous substances, interfering with lab samples, deliberately injuring their skin (scratching, using sharp instruments to inflict wounds, self-lacerations), or disconnecting intravenous lines or drips (Jaghab 2006).
Evaluation
Thorough physical and mental status exams are both important components when evaluating a patient with a suspected factitious disorder; however, no findings have been shown to be pathognomonic. The evaluation should include an assessment of the family system and psychosocial history. A thorough assessment of the patients’ childhood, any exposure to hospitals or medical professionals, and previous illness should be included.
Patients that present with a history of multiple diagnostic testing and evaluations from numerous physicians and hospital systems without a clearly defined diagnosis should raise a concern for factitious syndrome. Patients may sign out against medical advice if they sense their duplicity is on the verge of being detected (Ehrlich 2008).
Munchausen by proxy should be considered when unexplained illness or inappropriate symptoms and signs in pediatric patients manifest themselves when the parent is present (Ferrara 2012). Heightened alert to this diagnosis should be present if the parent is unconcerned about the illness or amount of diagnostic tests required, never leaves the patient’s bedside, or forms close relationships with the medical and nursing staff (Ferrara 2012).
The physical exam should be focused on determining consistent physical findings that support a physiologic diagnosis.
Imaging and Other Diagnostic Studies
There is no imaging study that can aid in the diagnosis of somatic disorders. Most patients undergo extensive diagnostic testing with negative results. Invasive procedures, such as a skin biopsy or surgery (e.g., diagnostic laparoscopy), are common during the period prior to diagnosis. It is estimated that factitious disorder leads to unnecessary wasting of medical resources, costing the United States up to 40 million dollars per year (Jaghab 2006).
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