Forensic assessment of somatoform and functional neurological disorders.

Functional neurological disorders (FND) and somatization are common in clinical practice and medicolegal settings. These conditions are frequently disabling and, if arising following an accident, may lead to claims for legal compensation or occupational disability (such as social security disability insurance). However, distinguishing FND and somatization from symptoms that are intentionally produced (i.e., malingered or factitious) may pose a major forensic psychiatric challenge. In this article, we describe how somatoform disorders and FND lie along a spectrum of abnormal illness-related behaviors, including factitious disorder, compensation neurosis, and malingering. We provide a systematic approach to the forensic assessment of FND and conclude by describing common litigation scenarios in which FND may be at issue. Forensic testimony may play an important role in the resolution of such cases.

Consideration of Factitious Disorder in Management of Patients With Autoinflammatory Disease.

ABSTRACT: Factitious disorder, a disorder characterized by the falsification of symptoms to obtain primary gain, continues to be one of the more challenging cases that psychiatrists encounter. We describe a case of a woman we treated on the medical unit who falsified several of her symptoms but also was diagnosed with Yao syndrome, a disease that can also cause unexplained symptoms such as abdominal pain and fever. We navigate the difficulties in managing this type of patient and comanaging her with medicine and rheumatology. Although the prevalence of factitious disorder is anywhere from 1% to 2% of patients on the medical floor, they typically utilize a disproportionate number of resources. Despite this, the literature is still inconclusive when it comes to the management and treatment approaches. More study is warranted on this complex and burdensome illness.

Comorbidity Between Factitious and Borderline Personality Disorder: A Narrative Analysis.

BACKGROUND: Factitious disorder (FD) illnesses have increased recently, primarily due to comorbidity with borderline personality disorder (BPD). Psychiatrists, hospital doctors, and general practitioners are interested in and concerned about patients with comorbid FD-BPD. SUBJECTS AND METHODS: We used a qualitative analysis of prototypical narratives collected as vignettes by merging individual contributions, case histories, naturalistic observations, and data from mental health practitioners into specific descriptions. Our study used a phenomenological and narrative method to illustrate the contents and behaviours in FD-BPD comorbidity. RESULTS: Fourteen case vignettes were created from our case studies. These categories included knowledge of symptoms and medical terms, dramatisation, symptoms ambiguity, unexplainable deterioration of symptoms, symptom inventiveness, craving for painkillers, conflicts with health carers, hospital migration, piling of medication and search for invasive diagnostic procedures. CONCLUSIONS: The combined use of narrative analysis and naturalistic observation has helped identify a unique comorbid condition of FD-BPD, which is not yet clearly described in its behavioural components by the international literature. The current study presents novel findings into a condition becoming progressively popular in psychiatric and medical settings.

Munchausen syndrome by proxy (MSBP): a review regarding perpetrators of factitious disorder imposed on another (FDIA).

Munchausen syndrome by proxy (MSBP) is well-known to clinicians, but its usage is discouraged now in favor of other terms placing emphasis on the victim. This study aims to determine the most common characteristics of perpetrators but only in case reports labeled as MSBP, published in PubMed literature in the past 15 years. MSBP has been described as a rare form of abuse due to illness falsification, where the perpetrator usually receives the diagnosis of factitious disorder imposed on another (FDIA). We extracted data from 108 articles, including 81 case reports. Almost all perpetrators were female (91% female, 1% female and male, 7% unreported). Twenty-three cases (28%) had a perpetrator with psychiatric diagnosis: factitious disorder imposed on self (10%), depression (9%), and personality disorders (7%). In more than one-third (36%) there was familial conflict or abuse. Fourteen cases (17%) had perpetrators working in healthcare. The most common type of falsification was induction (74%); however, 15% of cases had more than one type of falsification. The most common outcomes were: separation (37%); no follow-up (22%); imprisonment (14%); death of victim (12%); treatment of the perpetrator (10%); continued living together (4%); and suicide of perpetrator (1%). Recurrence was present in more than three quarters of cases. Our results reiterate that awareness of the most common findings in MSBP allows physicians to identify them in a clinical context.

[Functional coma: case report and systematic review]. / Functioneel coma: casusbeschrijving en systematisch literatuuroverzicht.

We describe a case of a patient with a functional coma ,and give a systemic review of literature. Functional coma is an extremely rare disorder with only 21 described cases in the literature. The disease is linked to a conversion disorder or a dissociative disorder and is predominantly found in females. Predisposing factors are a history of sexual or physical abuse, psychiatric disorders, previous episodes of functional coma, and recent surgery with general anesthesia. Several clinical signs are suggestive for the diagnosis, however none of them is sufficiently sensitive or specific. Therefore, functional coma remains an exclusion diagnosis. Vital signs must be normal, just as a routine blood examination, an electroencephalogram and imaging of the central nervous system. The most important differential diagnosis are catatonia, factitious disorder, and malingering. Spontaneous recovery can be expected after a duration of about 45 minutes to 4 days.

Munchausen by internet and false perinatal crises.

BACKGROUND: In representative cases of Munchausen by internet (MBI), an individual (or "poser") goes online to falsely report or exaggerate illnesses or life crises. The principal goal, as in factitious disorder imposed on self or another, is to garner emotional satisfaction. We provide the first evidence that MBI can target a specific type of health care provider-in this case, birthing doulas. METHODS: We describe 5 cases in which individuals have utilized social media platforms to report factitious perinatal illnesses and crises, including neonatal death, in real time. Current health headlines, such as those involving the COVID-19 pandemic, can be relevant to the ruses. Posers can engage in deceptions with several health care professionals concurrently or serially, and may portray multiple people ("sock puppets") at the same time. RESULTS: MBI has consequences that can be highly disruptive. In the cases highlighted in this report, many hours of support were given to individuals who had fabricated their pregnancies, infants, and perinatal complications. The doulas experienced feelings ranging from resignation to anger and betrayal. CONCLUSIONS: Health care professionals of all types who offer services online should be vigilant to the risks of potential MBI.

A brain origin for factitious disorder (Munchausen's) with malingering? A single case with an old frontal lobe lesion.

We describe a patient who presented with gender identity dysphoria and stroke-like symptoms who we diagnosed with Munchausen's syndrome (factitious disorder). We discuss whether a brain lesion in the left frontal cortex is a possible risk factor, and support this hypothesis through neuropsychological investigation, EEG abnormalities, and a personality assessment. This case report supports previous suggestions that underlying brain disease/lesions might be risk factors for Munchausen's syndrome (factitious disorder).

A descriptive, retrospective case series of patients with factitious disorder imposed on self.

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.

The factitious/malingering continuum and its burden on public health costs: a review and experience in an Italian neurology setting.

Factitious disorder is classified as one of the five aspects of somatic symptom disorders. The fundamental element of factitious disorder is deception, i.e., pretending to have a medical or psychiatric disorder, but the enactment of deception is considered unconscious. Indeed, volition, i.e., the perception of deliberate deception, is blurred in patients presenting with factitious disorder. In the USA and the UK, factitious disorder has received constant media attention because of its forensic implications and outrageous costs for the National Health Systems. Unfortunately, a comparable level of attention is not present in Italian National Health System or the Italian mass media. The review analyzes the classifications, disorder mechanisms, costs, and medico-legal implications in the hope of raising awareness on this disturbing issue. Moreover, the review depicts 13 exemplification cases, anonymized and fictionalized by expert writers. Finally, our paper also evaluates the National Health System's expenditures for each patient, outlandish costs in the range between 50,000 and 1 million euros.

Evaluation and Management of Factitious Disorder Imposed on Another.

Munchausen by proxy refers to an individual who abusively and compulsively falsifies physical, psychiatric or developmental disorders in a child or adult victim in order to satisfy a psychological need. Factitious disorder imposed on another refers to the psychopathology in the abuser. Psychologists in medical settings may: (1) identify patients they come to suspect as being victims or perpetrators of MBP, (2) conduct or assist in clinical or forensic evaluations; (3) offer recommendations for clinical case management, and/or (4) provide treatment or referrals. The purpose of this paper is to provide guidance to psychologists and other mental health professionals in medical settings who may encounter individuals with this potentially lethal form of psychopathology.

Factitious disorders in Germany-a detailed insight.

Factitious disorders (FDs) are well known to a majority of physicians; however, the corresponding ICD-10 diagnosis F68.1 remains severely under assigned and often misdiagnosed. Based on a previously conducted nationwide survey in Germany, we extended the analyzed variables to further understand FD characteristics.The assignments regarding the following variables in the German diagnosis-related group statistics were analyzed: residence of the patient and location of the diagnosing institution, primary referral to the diagnosing institution, reason for admission and discharge, specialty department, total length of stay, length of stay in the longest treating department, surgery performed, case mix revenue, regional type of the treating institution, and patients' region of origin.A very distinct difference was observed in the assignment rates based on the homeland of the diagnosed patient and diagnosing institution. The assignment rate showed no significant difference across German regions. Based on our findings, a patient with FD in Germany might exhibit the following "typical" traits: A woman in her late thirties from a rural area is referred by a physician or another hospital wherein she was previously treated for more than a day to an institution for fully inpatient hospital treatment wherein she completes her treatment regularly. Dermatology, neurology, emergency, and internal medicine departments tend to be confronted with patients with FDs more often than other departments; however, surgery is performed in every fifth case. Patients are primarily treated in only one department for ~ 25 days. The case mix revenue will most probably not exceed €5000.

[A suspected case of factitious disorder]. / Een vermoeden van nagebootste stoornis.

Factitious disorder (FD) is defined as the intentional production or feigning of disease in oneself to relieve emotional distress by assuming the role of a sick person. We describe a case of a 46-year-old woman with unexplained prolongation of the prothrombin time and hematomas. A careful evaluation, history taking and multidisciplinary discussion led to a suspected diagnosis of factitious disorder. With this case report we want to emphasize the importance of being attentive to this complex diagnosis and the need for more research.

[To pretend or to really suffer ? Questions from caregivers about the factitious disorder]. / Faire semblant ou souffrir vraiment ? Questions des soignants face au trouble factice.

The diagnosis of factitious disorder can only emerge when caregivers are in difficulty in caring for their patient. This disorder is a real challenge for healthcare teams throughout the treatment, from its discovery to its treatment. Secrecy and self-inflicted injuries are components that we can be uncomfortable with as caregivers. The factitious problem requires well-coordinated care between the various specialists and often questions our practices. In this article we deal with the questions frequently asked by the care teams to the liaison psychiatrists that we are, by working on the identification of the problem in the clinic, the therapeutic issues and the attitude to adopt.

Le diagnostic de trouble factice ne peut émerger que lorsque les soignants sont en difficulté dans la prise en soins de leur patient. Ce trouble est un véritable défi pour les équipes soignantes tout au long de la prise en charge, de sa découverte à sa prise en soins. Mise en échec, secret et lésions auto-infligées sont autant de composantes avec lesquelles nous pouvons être mal à l'aise comme soignants. La problématique factice demande une prise en charge bien coordonnée entre les divers spécialistes et, souvent, questionne nos pratiques. Dans cet article, nous traitons des questions fréquemment posées par les équipes de soins aux psychiatres de liaison que nous sommes, en s'occupant de l'identification du problème en clinique, des enjeux thérapeutiques et de l'attitude à tenir.

[Hypoglycaemia and seizures in a 32-year-old woman with maple syrup urine disease]. / Hypoglykämien und Krampfanfälle bei einer 32­jährigen Patientin mit Ahornsiruperkrankung.

A 32-year-old woman with maple syrup urine disease presented with recurring episodes with hypoglycaemia and cerebral seizures. In most cases a connection to the inborn metabolic disorder is assumed, resulting in symptomatic treatment. Due to these treatments invasive procedures are required. This leads to prescriptions of multiple medications and medical aids. After 2 years of unexplained symptoms a routine examination led to the diagnosis of factitious disorder. The patient received the offer for psychiatric/psychotherapeutic treatment. Further prognosis remains uncertain.

[Pitfall cryothermic dermatitis artefacta]. / Fallstrick kryothermische Dermatitis artefacta.

We present four clinicopathological correlated cases of young patients with cryothermic dermatitis artefacta. They were initially misdiagnosed as primary bullous dermatoses or fixed drug eruptions. Cryothermic dermatitis artefacta can imitate authentic dermatoses such as linear IgA bullous dermatosis, herpes virus infection, bullous pemphigoid or fixed drug eruption. It should be considered as differential diagnosis in uncommon cases of recurrent bullae in adolescent and young adult patients. We summarize helpful clinical and histopathological criteria for correct diagnosis and therewith causative treatment.

Factitial panniculitis as a manifestation of self-imposed factitious disorder.

Factitious disorder imposed on self is characterized by self-induction. Dermatitis artefacta, the cutaneous subtype of factitious disorder imposed on self, can have a variety of atypical presentations. A 36-year-old woman with an extensive past medical history presented with painful nodules on her abdomen, thighs, and arms. Histologic evaluation identified panniculitis with foreign body material seen under polarization. Chart review from previous hospital visits established a history of factitious disorder imposed on self and upon subsequent search of the hospital room, syringes with an unknown substance were found. Factitial panniculitis should be considered in cases with atypical lesions or locations that do not conform to the presentation of organic causes of panniculitis. Management should include a multidisciplinary approach that prioritizes patient safety and establishes a therapeutic patient-provider relationship.

Malingering and factitious disorder.

Although exaggeration or amplification of symptoms is common in all illness, deliberate deception is rare. In settings associated with litigation/disability evaluation, the rate of malingering may be as high as 30%, but its frequency in clinical practice is not known. We describe the main characteristics of deliberate deception (factitious disorders and malingering) and ways that neurologists might detect symptom exaggeration. The key to establishing that the extent or severity of reported symptoms does not truly represent their severity is to elicit inconsistencies in different domains, but it is not possible to determine whether the reports are intentionally inaccurate. Neurological disorders where difficulty in determining the degree of willed exaggeration is most likely include functional weakness and movement disorders, post-concussional syndrome (or mild traumatic brain injury), psychogenic non-epileptic attacks and complex regional pain syndrome type 1 (especially when there is an associated functional movement disorder). Symptom amplification or even fabrication are more likely if the patient might gain benefit of some sort, not necessarily financial. Techniques to detect deception in medicolegal settings include covert surveillance and review of social media accounts. We also briefly describe specialised psychological tests designed to elicit effort from the patient.

Factitious hypoglycemia in children and adolescents with diabetes.

BACKGROUND: Factitious hypoglycemia is a condition of self-induced hypoglycemia due to surreptitious administration of insulin or oral hypoglycemic agents. In adults, it is an uncommon, but well known clinical entity observed in individuals with and without diabetes. OBJECTIVES: To report a case of factitious hypoglycemia highlighting diagnostic pitfalls, to identify common characteristics of children and adolescents with factitious hypoglycemia, and to examine whether the information on long-term outcome exists. METHODS: We present a case of an adolescent with type 1 diabetes who had self-induced hypoglycemia of several years' duration; and we conducted a systematic literature review on factitious hypoglycemia in pediatric patients with diabetes. RESULTS: We identified a total of 83 articles of which 14 met the inclusion criteria (describing 39 cases). All but 1 individual had type 1 diabetes and the majority was female (63%). Average age was 13.5 ± 2.0 years with the youngest patient presenting at the age 9.5 years. Blood glucose control was poor (hemoglobin A1c: 12.1 ± 4.0%). In 35%, psychiatric disorders were mentioned as contributing factors. Only 3 reports provided follow-up beyond 6 months. CONCLUSIONS: Factitious hypoglycemia typically occurs in adolescents with type 1 diabetes who use insulin to induce hypoglycemia. Awareness of this differential diagnosis and knowledge of potentially misleading laboratory results may facilitate earlier recognition and intervention. Little information exists on effective treatments and long-term outcome.

Changing incidence of factitious renal stone disease
.

PURPOSE: We sought to describe patterns of factitious urinary stone submission over time by investigating a contemporary stone analysis database and comparing two distinct time points. MATERIALS AND METHODS: We retrospectively reviewed a single stone analysis lab database at two time points, 1990 and 2010, and compared total incidence of factitious stone submission, as well as gender patterns and type of factitious stone submitted. RESULTS: A total of 27,014 stones were analyzed, 16,216 (60%) from 1990 and 10,798 (40%) from 2010 with a decrease in total incidence from 2.6% (428/16,216) in 1990 to 1.2% (131/10,798) in 2010 (p < 0.001). In 1990, women were significantly more likely to submit a factitious stone (RR 1.5, 95% CI 1.4 - 1.7, p < 0.001), while in 2010 there was no gender difference (RR 0.9, 95% CI 0.8 - 1.03, p < 0.05). Plant material and geologic material represented the most common factitious stone types respectively, in both 1990 and 2010. CONCLUSION: In the largest contemporary review of spurious urinary stones, we find a decreased incidence and increased gender equivalence of factitious urinary stones in 2010 compared to 1990.
.