The factitious disorder (FD) also known as Munchausen syndrome is a kind of mental disorder categorized under the group of Somatoform disorders. Individuals with this kind of mental disorder display overstated complaints concerning their physical symptoms without medical cause, for a vulnerable person around them. They have an emotional need to get attention from practitioners and non-staff members as well as want to be seen as committed mothers to receive consideration for having a sick child. There is no certainty of the causes of this mental disorder, but in some cases, an individual that displays the symptoms of this syndrome might have undergone an abuse when growing up as a child. In some instances, the exaggeration or stimulation of sickness is a demonstration of resentment, anger, or the urge to manipulate others (Moreno-Arino & Bayer, 2017). The caregiver, usually the mothers, could go to the extremes to falsify symptoms of sickness on their children when that is not indeed the case.
Thus the paper aims at providing an articulated discourse regarding clinical features such as symptoms and manifestation of the factitious disorders; a diagnosis that includes psychiatric and psychological exams; and management of the disorder. Also, a factitious disorder as a form of physical child abuse will be discussed in tandem amongst other types of physical child abuse with similar characteristics. A literature review of various sources regarding the disorders followed by recommendations and conclusion will be proffered as well.
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Clinical features, Diagnosis, and Management of Factitious Disorders
Diagnosis regarding factitious disorders such as Munchausen by proxy is not directed to the victim but rather to the perpetrator. Thus, some of the significant clinical features to be considered, examined, or diagnosed include
Unclear and uncontrollable symptoms that worsen or change once the treatment has commenced,
Presence of many surgical scars,
Willingness or eagerness to undergo intrusive medical procedures such as surgery,
An appearance of new additional symptoms following a negative test result, as well as
Refusal to participate in a psychiatric or psychological examination.
While most of these clinical features or signs are about factitious disorders imposed on self such as Munchausen by proxy, others such as extreme manipulation ability, skilled deception, and reluctance to undergo a psychological evaluation also influence diagnosis. Other psychological features include exaggeration, neglect, falsifying information, as well as simulation.
Diagnosis of factitious disorders includes physical examinations to determine the presence of injuries or a history of illness. Here, the physician investigates the presence of multiple scars such as various exploratory surgical procedures or a gridiron abdomen to determine the chronicity of the factitious disorder. Upon examination, if the doctor or physician finds no evidence of physical harm, psychiatric or psychological evaluation is considered. Thus, despite the deceptive nature of the individuals involved, the doctor has to completely rule out any possibility of physical or mental illness through a variety of other tests before considering factitious disorder diagnosis. The doctor thus has to evaluate and observe the patient’s attitudes and behaviors such as unwillingness to be discharged or sabotaging similar processes. The psychiatrist or psychologist, on the other hand, diagnoses through considering medical history, laboratory tests, physical exams, imagery, as well as psychological evaluation to determine the type of factitious disorder and its severity.
There are no medications for factitious disorders. However, management of factitious disorder generally involves changing the patient’s behavior to reduce his misuse of medical resources. Subjectively, in the case of factitious disorder imposed on another such as Munchausen by proxy, management interventions involve ensuring safety and protection of any real or potential victims. Here separation of the victim (usually children) from the abuser such as a guardian, clinician, or teacher is critical. While treatment aims at resolving the underlying psychological issues resulting in the person’s behavior, psychotherapy as a form of treatment is salient. Another related type of management is family therapy meant to help the family reinforce or reward the behavior of the member with the disorder.
Factitious Disorder as a Form of a Physical Child Abuse
Some psychologists indicate that the forgery and conviction of sickness is a type of maltreatment, rather than a mental illness. The caregiver would do everything so that the child displays symptoms of a disease (Yorker, Alexander, & Sanders, 2018). The caregivers majorly are staff members of a health center or have prior knowledge of the medical field. As a result, the child passes through the hands of many practitioners, gets hospitalized frequently, and undergoes numerous surgeries or other medical processes. The child would also exhibit queer symptoms that do not define any disease. According to research, several individuals have indicated that they have been part of illness falsification, mainly female caregivers. Formal psychiatric interviews, as well as psychological tests, reveal that no psychopathology exists in most times
Between 30 and 70 percent of clients that give a false impression about the illness of their children also falsify sickness (Moreno-Arino & Bayer, 2017). This rampant situation should be prevented through awareness and offering therapy to sensitive patients. The cases of medical, psychiatric and developmental disorders can be misinterpreted in several ways. Children that fall victim to this situation, suffocate, get poisoned or go through types of induction and may probably die. Medical noncompliance because of the exaggeration of a situation in children can be greatly lethal to them (Yorker, Alexander, & Sanders, 2018).
Other comorbid conditions or disorders similar to Munchausen by Proxy that results in physical abuse in children include narcissistic or borderline personality disorders. These illnesses similarly proffer characteristics to factitious disorders such as pathological lying, (Moreno-Arino & Bayer, 2017). Medical child abuse as well fits the category of physical child abuse similar to FDIA. In such cases, prescription medications for conditions or illnesses that the child does not have is a typical case resulting in serious complications. Also, syringes may be used to cause harm to the child. Hypochondriasis as well could result in physical child abuse. Primarily, a hypochondriac individual often experiences physical sensations produced by depression and anxiety, and as such, the constant worrying about having a severe illness could result in the release of harmful stress hormones that could culminate in severe physical damage to self or a child, (Harvard Health Guide, 2018). Other forms of child abuse in this respect include pediatric condition falsification and caregiver-fabricated illness in a child which all result or manifest child maltreatment.
Literature Review
Essentially, factitious disorders, especially those directed to another take place when the abusers’ psychological needs take precedence over those of the child thereby giving way for them to harm the child to meet those needs, (APSAC Taskforce, 2018). Further, according to the Taskforce, the prevalence of the disorder is approximately 0.5 to 2 per 100,000 children below sixteen years. However, as the Taskforce reports, despite the statistics above, factitious disorders and the resultant abuse are underreported and under-recognized making its incidence potentially higher.
Furthermore, from the identification of published cases from twenty-four countries around the world, it is evident that factitious disorders and the resultant abuse are global phenomena. Also, there is a 0.9% risk factor of factitious disorders among patients with sickle cell and 4.1% in subjects initially diagnosed with psychosis, (Jaghab, Skodnek, & Padder, 2006). Further, research has indicated that FDs are responsible for between 2.2 and 9.3 percent fevers of unrecognized origin and 3.5% of urinary calculi, (Jaghab, Skodnek, & Padder, 2006). Additionally, FDs tend to be prevalent among women aged between 20 and 40 years. However, the condition has as well been reported in children as young as eight years, (Jaghab, Skodnek, & Padder, 2006).
The roots of factitious disorder as a terminology track back to 1843 when the term was derived from On Feigned and Factitious Diseases , a book by Gavin, an English physician, (Jaghab, Skodnek, & Padder, 2006). Nonetheless, cases of factitious disorders appear in literature going back to the second century AD. However, the modern research and understanding of factitious disorders were advanced in 1961 following an article The Lancet by a British psychiatrist Richard Asher when he coined the terminology Munchausen’s Syndrome in reference of a severe subtype of factitious disorders. However, it was not until 1980 that the term Munchausen’s syndrome debuted in the DSM classification. In essence, the DSM classification and definition distinguished the syndrome from other mental disorders such as hypochondriasis by asserting that the feigned injuries or sickness were not aimed at financial gain but rather for sympathy and special attention. However, following the coining of Munchausen’s syndrome in 1977, the same year saw another English practitioner Roy Meadow advance the term Munchausen’s syndrome by proxy providing the framework for the dissociation between the two types of disorders known currently.
The disorders have neither a known cure nor a specific cause. However, factitious disorders such as Munchausen by proxy could co-occur with other comorbid mental conditions such as autism spectrum disorder, especially in children, bipolar disorder in proxies, as well as learning and attention deficit disorders in children. These concomitant conditions and disorders thus result in traumatic events and numerous hospitalizations, Jaghab, Skodnek, & Padder, 2006). In essence, since most of the individuals with factitious disorders are victims of child abuse, the disorders allow them to feel in control like they never felt during childhood. Most researchers regard this as a coping mechanism. Since FDs, especially those directed to others involve a range of emotions, they are common among women. As such, intervention strategies need to focus on separation before employing treatment to protect the victimized child from the nurse, mother, or caregiver.
Recommendations for FDs Management
Management, in this case, refers to treatment strategies as well as intervention. Regardless, treatment of FDs is particularly challenging given the fact that patients are always willing to go to great lengths to avoid detection and lie. In some cases, they become aggressive and hostile when confronted and could move on to the next hospital or physician. Thus, perhaps the first line of management should be psychotherapy. Here, a two-prong treatment approach that uses both analytical and cognitive-behavioral techniques is recommended. Also, supportive psychotherapy for comorbid psychiatric disorders and family therapy are also recommended in improving the patients’ outcomes. Despite the elusiveness of patients during follow up, it is recommended for physicians to implement rigorous follow-up programs to determine the prognosis of the patients as well as their outcomes.
In terms of prevention, medications have proven unpractical since there is no known cure for FDs. However, medications are recommended for patients exhibiting symptoms of concomitant disorders such as depression and anxiety. Jaghab Skodnek & Padder (2006) also suggest the use of pharmacological agents in the treatment of the same. Nonetheless, an evidence-based and efficacious prevention plan is the education of both patients and the community regarding the disorders. This way, educated patients would be more willing to engage in follow up activities thereby improving their health outcome. By educating the community, it would be easier for child abuse cases to be reported and also for family members and society to recognize the manifestations of FDs and report them or seek intervention in time. By so doing, the mortality rates among children will reduce.
Conclusion and Reflection
Factitious disorder is a general term in which Munchausen by proxy disorder, a more severe form of FDs is included. From research and discussion above, it is deduced that the disorders are common among women aged between 20 and 40 years and that they are global phenomena. Moreover, the disorders are substantially underreported and under-recognized making follow-up and prognosis difficult. While the disorders, especially Munchausen by proxy is prevalent in adult women, FD directed to self is as well common in children below eight years. The discussion above has as well edifies the fact that FDs have neither specific cause nor cure. Nonetheless, medications for symptoms of joint disorders such as anxiety and depression, rigorous follow-up programs, and a two-prong psychotherapy approach have been recommended in the management of the disorders. Ultimately, education and awareness to patients and the community remain to be the most effective prevention methods.
In essence learning and in-depth understanding of psychological disorders is salient to my future aspirations of pursuing psychology as a profession. The knowledge will enable me to identify symptoms of factitious disorders as well as physical child abuse as a result of the same promptly thereby implementing interventions expediently. Moreover, this knowledge as well provides a fundamental background into the topic essentials by providing basic tenets on how to deal with mental disorders and improving patient outcomes.
References
APSAC Taskforce. (2018). Munchausen by Proxy: Clinical and Case Management Guidance. ADVISOR 4. Retrieved from https://apsac.memberclicks.net/assets/documents/advisor/APSAC%20Advisor%2030%20(1).pdf
Beatrice Yorker, J. D., Alexander, R., & Sanders, M. (2018). Munchausen by Proxy: Abuse by Pediatric Condition Falsification, Caregiver-Fabricated Illness in a Child, or Medical Child Abuse Due to Factitious Disorder Imposed on Another. ADVISOR, 4. Retrieved from https://apsac.memberclicks.net/assets/documents/advisor/APSAC%20Advisor%2030%20(1).pdf
Harvard Health Guide. (2018). Hypochondriasis. Harvard health publications . Retrieved from https://www.drugs.com/health-guide/hypochondriasis.html
Jaghab, K., Skodnek, K. B., & Padder, T. A. (2006). Munchausen's syndrome and other factitious disorders in children: case series and literature review. Psychiatry (Edgmont) , 3 (3), 46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990557/pdf/PE_3_3_46.pdf
Moreno-Ariño, M., & Bayer, A. (2017). Munchausen syndrome by proxy—illness fabricated by another in older people. Age and aging, 46 , 166-167. Doi: 10.1093/ageing/afw217
