Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis.

BACKGROUND: Consultation psychiatrists are often asked to assess factitious disorder (FD), yet this is challenging as confirmation depends on rarely achieved direct evidence of illness-inducing behaviors. Diagnosis is thus based on other variables, such as atypical features of the medical presentation and certain patient behaviors. This study sought to assess a cohort of patients with FD for demographic and clinical variables, but also psychological and behavioral ones unexamined in previous studies. METHODS: 49 previously-identified FD patients at a single site were reviewed retrospectively and variables collected included demographic, medical, psychiatric, social, behavioral, and treatment-related. Descriptive statistical analysis was used. RESULTS: Patients were mostly: 1) under age 40 (82%), 2) female (90%), 3) with past psychiatric (92%), family psychiatric (78%), and traumatic (69%) histories; 4) direct intravenous access (67%); and 7) some exposure to healthcare training (67%). All (100%) subjects had an identifiable family dynamic issue, including household abuse, parental divorce, parental influence/enmeshment, grief, and/or significant other conflict. Financial, emotional, or social incentives were common, and most patients (88%) exhibited at least 4 FD-related behaviors. CONCLUSION: FD represents a complex disorder of abnormal illness behaviors with predisposing developmental and perpetuating sociobehavioral variables previously unexplored. Future investigational, educational, and quality improvement directions are considered.

Triparesis: an unusual presentation of factitious disorder.

Factitious disorder (FD) has diverse presentations but neurological presentation is unusual. In this report, we discuss a case of FD who presented with triparesis, that is, weakness of both lower limbs and right upper limb. Diagnosis of FD was made after detailed clinical evaluation, review of past medical records that revealed extensive evaluation to rule out physical illness, and inability to find any associated stressful event or material gain associated with illness. Management was largely supportive and was based on psychotherapy. Identification of FD depends on a high index of suspicion by the physician and the presence of atypical and medically unexplainable signs/symptoms.

Ganser Syndrome.

Ganser's syndrome is a rare and controversial condition, whose main and most striking feature is the production of approximate answers (or near misses) to very simple questions. For instance, asked how many legs a horse has, Ganser patients will reply "5", and answers to plain arithmetic questions will likewise be wrong, but only slightly off the mark (e.g., 2 + 2 = 3). This symptom was originally described by Sigbert Ganser in 1897 in prisoners on remand and labeled Vorbeigehen ("to pass by"), although the term Vorbeireden ("to talk beside the point") is also frequently used. A number of associated symptoms were also reported: "clouding of consciousness," somatoform conversion disorder, hallucinations, sudden and spontaneous recovery, subsequent amnesia for the episode, premorbid traumatic psychosocial experience and/or (usually mild) head trauma. Etiological, epidemiological and diagnostic issues have never been resolved for Ganser's syndrome. Ganser saw it as a form of "twilight hysteria," whereas others suggested that malingering, psychosis or dissociation were more appropriate labels, oftentimes combined with organic impairment and a subjectively intolerable psychosocial context. A central conundrum of Ganser's syndrome is whether it could simultaneously be a cultural and pathological representation of insanity, whereas cognitive, organic, affective, motivational and social factors would converge towards a naïve idea of what mental illness should look like, especially through the provision of approximate answers.

Conversion, Factitious Disorder and Malingering: A Distinct Pattern or a Continuum?

This chapter is aimed at highlighting the recent findings concerning physiopathology, diagnosis, and management of conversion, factitious disorder, and malingering. Conversion disorder is the unintentional production of neurological symptom, whereas malingering and factitious disorder represent the voluntary production of symptoms with internal or external incentives. They have a close history and this has been frequently confounded. Practitioners are often confronted to medically unexplained symptoms; they represent almost 30% of neurologist's consultation. The first challenge is to detect them, and recent studies have confirmed the importance of "positive" clinical bedside signs based on incoherence and discordance, such as the Hoover's sign for the diagnosis of conversion disorder. Functional neuroimaging has allowed a better understanding of the pathophysiology, and highlighted abnormal cerebral activation patterns in conversion disorder in relation to motor, emotional, and limbic networks, different from feigners. This supports the theory evoked by Charcot of a "psychodynamic lesion," which is also reflected by the new term introduced in the DSM-5: functional neurological disorder. Multidisciplinary therapy is recommended with behavioral cognitive therapy, antidepressant to treat frequent comorbid anxiety or depression, and physiotherapy. Factitious disorder and malingering should be clearly delineated from conversion disorder. Factitious disorder should be considered as a mental illness and more research on its physiopathology and treatment is needed, when malingering is a non-medical condition encountered in medico-legal cases.

Factitious disorder: a systematic review of 455 cases in the professional literature.

OBJECTIVE: Patients with factitious disorder (FD) fabricate illness, injury or impairment for psychological reasons and, as a result, misapply medical resources. The demographic and clinical profile of these patients has yet to be described in a sufficiently large sample, which has prevented clinicians from adopting an evidence-based approach to FD. The present study aimed to address this issue through a systematic review of cases reported in the professional literature. METHOD: A systematic search for case studies in the MEDLINE, Web of Science and EMBASE databases was conducted. A total of 4092 records were screened and 684 remaining papers were reviewed. A supplementary search was conducted via GoogleScholar, reference lists of eligible articles and key review papers. In total, 372 eligible studies yielded a sample of 455 cases. Information extracted included age, gender, reported occupation, comorbid psychopathology, presenting signs and symptoms, severity and factors leading to the diagnosis of FD. RESULTS: A total of 66.2% of patients in our sample were female. Mean age at presentation was 34.2 years. A healthcare or laboratory profession was reported most frequently (N=122). A current or past diagnosis of depression was described more frequently than personality disorder in cases reporting psychiatric comorbidity (41.8% versus 16.5%) and more patients elected to self-induce illness or injury (58.7%) than simulate or falsely report it. Patients were most likely to present with endocrinological, cardiological and dermatological problems. Differences among specialties were observed on demographic factors, severity and factors leading to diagnosis of FD. CONCLUSIONS: Based on the largest sample of patients with FD analyzed to date, our findings offer an important first step toward an evidence-based approach to the disorder. Future guidelines must be sensitive to differing methods used by specialists when diagnosing FD.

Verbal learning on depressive pseudodementia: accentuate impairment of free recall, moderate on learning processes, and spared short-term and recognition memory.

OBJECTIVE: Depressive pseudodementia (DPD) is a clinical condition characterized by depressive symptoms followed by cognitive and functional impairment characteristics of dementia. Memory complaints are one of the most related cognitive symptoms in DPD. The present study aims to assess the verbal learning profile of elderly patients with DPD. METHODS: Ninety-six older adults (34 DPD and 62 controls) were assessed by neuropsychological tests including the Rey auditory-verbal learning test (RAVLT). A multivariate general linear model was used to assess group differences and controlled for demographic factors. RESULTS: Moderate or large effects were found on all RAVLT components, except for short-term and recognition memory. CONCLUSION: DPD impairs verbal memory, with large effect size on free recall and moderate effect size on the learning. Short-term storage and recognition memory are useful in clinical contexts when the differential diagnosis is required.

Verbal learning on depressive pseudodementia: accentuate impairment of free recall, moderate on learning processes, and spared short-term and recognition memory / Aprendizagem verbal na pseudodemencia depressiva: comprometimento acentuado da evocacao livre, moderado nos processos de aprendizagem e preservacao da memoria de curto prazo e reconhecimento

Objective Depressive pseudodementia (DPD) is a clinical condition characterized by depressive symptoms followed by cognitive and functional impairment characteristics of dementia. Memory complaints are one of the most related cognitive symptoms in DPD. The present study aims to assess the verbal learning profile of elderly patients with DPD. Methods Ninety-six older adults (34 DPD and 62 controls) were assessed by neuropsychological tests including the Rey auditory-verbal learning test (RAVLT). A multivariate general linear model was used to assess group differences and controlled for demographic factors. Results Moderate or large effects were found on all RAVLT components, except for short-term and recognition memory. Conclusion DPD impairs verbal memory, with large effect size on free recall and moderate effect size on the learning. Short-term storage and recognition memory are useful in clinical contexts when the differential diagnosis is required. .

Objetivo A pseudodemência depressiva (PDD) é uma condição clínica onde sintomas depressivos são acompanhados por comprometimento cognitivo e funcional característicos da demência. Queixas de memória são um dos sintomas mais comumente relatados na PDD. O presente estudo almeja investigar a aprendizagem verbal de pacientes idosos com PDD. Método 96 idosos (34 PDD e 62 controles) realizaram testes neuropsicológicos incluindo o Teste de Aprendizagem Auditivo-Verbal de Rey (RAVLT). Adotou-se um modelo linear geral multivariado para comparação dos grupos controlando variáveis sociodemográficas. Resultados Pacientes com PDD apresentaram déficits em todo o RAVLT, com exceção no armazenamento de curto-prazo e reconhecimento, com tamanhos de efeito moderados ou altos. Conclusão A PDD compromete a memória verbal mais intensamente na evocação livre e de forma moderada na aprendizagem. A memória de curto-prazo e de reconhecimento são úteis em contextos onde o diagnóstico diferencial é necessário. .

Tinnitus loudness tracking: a "type V Békésy" pattern does not exist for pseudotinnitus.

BACKGROUND: Evaluation tools are lacking for the identification of patients exhibiting pseudotinnitus. It was hypothesized that tinnitus loudness traces might show a separation between continuous and pulsed tones for participants exhibiting pseudotinnitus, that is, the "type V" pattern shown for threshold tracking among participants exhibiting pseudohypacusis. It was further hypothesized that tinnitus loudness tracking might reveal unreliable tinnitus loudness matches among participants exhibiting pseudotinnitus due to their lack of an internal tinnitus standard. PURPOSE: To determine whether a tinnitus loudness tracking pattern exists for participants exhibiting pseudotinnitus. RESEARCH DESIGN: Nonrandomized posttest-only control design. The experimental group participants were those without tinnitus, and the control group participants were those with tinnitus. STUDY SAMPLE: There were 86 participants, including 45 with tinnitus and 41 without tinnitus. The participants' hearing varied from normal to severe hearing losses by pure-tone average at 1000, 2000, and 4000 Hz. INTERVENTION: Participants without tinnitus were asked to act as if they had tinnitus and to complete tinnitus loudness matching as if they were trying to convince the test (or computer) that they had tinnitus. DATA ANALYSIS: t-tests RESULTS: There were no statistically significant differences between individuals with tinnitus and participants acting out pseudotinnitus for any of six measures: (1) continuous tone tinnitus loudness tracking; (2) pulsed tone tinnitus loudness tracking; (3) differences between continuous and pulsed tone tinnitus loudness tracking; (4) continuous tone excursion width; (5) pulsed tone excursion width; and (6) differences between continuous and pulsed tone excursion width. CONCLUSIONS: Tinnitus loudness tracking does not appear to hold promise as a clinical tool for the identification of participants exhibiting pseudotinnitus.

Physiology of psychogenic movement disorders.

Psychogenic movement disorders (PMDs) are common, but their physiology is largely unknown. In most situations, the movement is involuntary, but in a minority, when the disorder is malingering or factitious, the patient is lying and the movement is voluntary. Physiologically, we cannot tell the difference between voluntary and involuntary. The Bereitschaftspotential (BP) is indicative of certain brain mechanisms for generating movement, and is seen with ordinarily voluntary movements, but by itself does not indicate that a movement is voluntary. There are good clinical neurophysiological methods available to determine whether myoclonus or tremor is a PMD. For example, psychogenic myoclonus generally has a BP, and psychogenic stimulus-sensitive myoclonus has a variable latency with times similar to normal reaction times. Psychogenic tremor will have variable frequency over time, be synchronous in the two arms, and might well be entrained with voluntary rhythmic movements. These facts suggest that PMDs share voluntary mechanisms for movement production. There are no definitive tests to differentiate psychogenic dystonia from organic dystonia, although one has been recently reported. Similar physiological abnormalities are seen in both groups. The question arises as to how a movement can be produced with voluntary mechanisms, but not be considered voluntary.

FMRI in patients with motor conversion symptoms and controls with simulated weakness.

BACKGROUND: Conversion disorder (motor type) describes weakness that is not due to recognized disease or conscious simulation but instead is thought to be a "psychogenic" phenomenon. It is a common clinical problem in neurology but its neural correlates remain poorly understood. OBJECTIVE: To compare the neural correlates of unilateral functional weakness in conversion disorder with those in healthy controls asked to simulate unilateral weakness. METHODS: Functional magnetic resonance imaging (fMRI) was used to examine whole brain activations during ankle plantarflexion in four patients with unilateral ankle weakness due to conversion disorder and four healthy controls simulating unilateral weakness. Group data were analyzed separately for patients and controls. RESULTS: Both patients and controls activated the motor cortex (paracentral lobule) contralateral to the "weak" limb less strongly and more diffusely than the motor cortex contralateral to the normally moving leg. Patients with conversion disorder activated a network of areas including the putamen and lingual gyri bilaterally, left inferior frontal gyrus, left insula, and deactivated right middle frontal and orbitofrontal cortices. Controls simulating weakness, but not cases, activated the contralateral supplementary motor area. CONCLUSIONS: Unilateral weakness in established conversion disorder is associated with a distinctive pattern of activation, which overlaps with but is different from the activation pattern associated with simulated weakness. The overall pattern suggests more complex mental activity in patients with conversion disorder than in controls.

Cervical spine segmental vertebral motion in healthy volunteers feigning restriction of neck flexion and extension.

The purpose of this study was to obtain comparative data concerning the percentage contribution of segmental cervical vertebral motion to the cervical range of motion (ROM) in healthy volunteers under two conditions: (1) normal, voluntary neck flexion and extension and (2) feigned restriction of neck flexion and extension. Each healthy subject's angular motion over forward cervical flexion and extension was measured first by X-ray analysis during normal, voluntary motion. Then the subjects were asked to pretend that they had a 50% restricted neck range due to pain or stiffness and thus to move in both flexion and extension only as far as about 50% of their normal range. A total of 26 healthy subjects (ten males and sixteen females, age 28.7+/-7.7 years) participated. The total angular motion from C2 to C7 was normal in the unrestricted condition and was significantly reduced in the feigned restriction condition (p<0.001). The percentage contribution of each of the functional units C2-C3 to C6-C7 to this rotation was different between the normal unrestricted and the feigned restricted conditions. In the feigned restricted neck flexion and extension, a shift occurred in the pattern of how each segment contributes to the total angular range. A greater percentage contribution was made by C2-C3 and C3-C4 than under normal conditions (P<0.01), and the percentage contribution to total rotation made by C6-C7 became much less under the feigned restricted movements than under normal, unrestricted neck range (p<0.001). Thus, simulated or feigned restricted neck ROM affects the percentage contribution of the functional units C2-C3 to C6-C7 by showing a higher percentage contribution of the upper cervical segments and less contribution to the angular rotation by the lowest cervical segment. Feigners of restricted neck range thus produce a pattern different from nonfeigning subjects.

Factitious disorders encountered in patients with the diagnosis of reflex sympathetic dystrophy.

Reflex sympathetic dystrophy (RSD) may be a misdiagnosis or at least not descriptive enough in patients with atypical hand posture and atypical edema. Seven patients with the previous diagnosis of RSD were investigated further because of inconsistent clinical picture with the underlying pathology and bizarre course of the disease. Four patients had clenched fist and three had factitious edema. These seven patients underwent psychological examination, and MMPI was applied to all. In two of these no psychological disorder was obtained according to DSM-IV. One patient could not adapt to MMPI. In two anxiety disorders, in one depression, and in one patient conversion disorder was diagnosed. We suggest that these patients are not motivated enough to improve their conditions and expectations of such patients may show some differences depending on the environment.

Medically unexplained symptoms and neuropsychological assessment.

Several illnesses expressed somatically that do not have clearly demonstrated pathophysiological origin and that are associated with neuropsychological complaints are reviewed. Among them are nonepileptic seizures, fibromyalgia, chronic fatigue syndrome, Persian Gulf War unexplained illnesses, toxic mold and sick building syndrome, and silicone breast implant disease. Some of these illnesses may be associated with objective cognitive abnormalities, but it is not likely that these abnormalities are caused by traditionally defined neurological disease. Instead, the cognitive abnormalities may be caused by a complex interaction between biological and psychological factors. Nonepileptic seizures serve as an excellent model of medically unexplained symptoms. Although nonepileptic seizures clearly are associated with objective cognitive abnormalities, they are not of neurological origin. There is evidence that severe stressors and PTSD are associated with immune system problems, neurochemical changes, and various diseases; these data blur the distinctions between psychological and organic etiologies. Diagnostic problems are intensified by the fact that many patients are poor historians. Patients are prone to omit history of severe stressors and psychiatric problems, and the inability to talk about stressors increases the likelihood of suffering from physiological forms of stress.

Quantitative sensory testing cannot differentiate simulated sensory loss from sensory neuropathy.

OBJECTIVE: To differentiate the quantitative sensory testing (QST) results of subjects simulating small and large fiber sensory loss from those of normal subjects and subjects with sensory peripheral neuropathy. BACKGROUND: QST is used to measure sensory thresholds in clinical, epidemiologic, and research studies. It is not known whether there are objective test results that characterize the subject seeking to deceive the examiner. METHODS: The Computer Aided Sensory Examination IV 4, 2, and 1 stepping algorithm was used to determine vibration and cold perception in nine naïve subjects. Subjects were asked to simulate sensory loss (on two occasions) and to respond normally on one occasion. Test results were compared to those of subjects with diabetic sensory neuropathy. Each QST trial was performed three times. RESULTS: Reproducibility, measured by the intraclass correlation coefficient, was similar in all groups for the vibration perception test (simulation 1: 0.68 [95% CI 0.31, 0.91], simulation 2: 0.82 [95% CI 0.54, 0.95], normal response: 0.77 [95% CI 0.47, 0.94], and subjects with peripheral neuropathy: 0.76 [95% CI 0.18, 0.95]) and the cold perception test (simulation 1: 0.53 [95% CI 0.12, 0.85], simulation 2: 0.82 [95% CI 0.55, 0.95], normal subjects: 0.67 [95% CI 0.30, 0.90] and subjects with peripheral neuropathy: 0.88 [95% CI 0.57, 0.97]), all just noticeable difference units. There were no differences between performance characteristics in the two simulation trials. Responses to null stimuli did not differentiate between groups. CONCLUSION: Test performance characteristics do not permit discrimination among subjects simulating sensory loss, subjects with normal responses, and subjects with peripheral neuropathy.

Brain single photon emission computed tomography findings in depressive pseudodementia patients.

BACKGROUND: Recently, there have been studies suggesting that depressive pseudodementia would include early-stage dementing disorder. Through the comparison of the 99mTc-HMPAO single photon emission computed tomography (SPECT) image of depressive pseudodementia subjects, healthy comparison subjects, depressed subjects free of cognitive impairment, and dementia of Alzheimer's type (DAT) subjects, we aimed to see part of pathophysiology of the depressive pseudodementia of elderly patients. METHODS: Study subjects consisted of seven patients with depressive pseudodementia, seven healthy comparison subjects, seven patients with depression free of cognitive impairment, and eleven patients with DAT. Depression patients were diagnosed according to DSM-III-R. DAT patients were diagnosed by DSM III-R and NINCDS-ADRDA criteria of DAT. Other measures for assessment include Hamilton Rating Scale for Depression and Mini Mental State Exam. All underwent 99mTc-HMPAO SPECT scan. The images of each group were analyzed using statistical parametric mapping of Friston, which compares the images on voxel-by-voxel basis. RESULTS: The results were as follows (1) The DAT group showed significant decreases of cerebral blood flow (CBF) in the right frontal, right temporal region, and both parietal regions as compared with control group (P < 0.05). (2) The depression group showed a significant decrease of CBF in the left frontal region as compared with control group (P < 0.05). (3) The depressive pseudodementia group showed significant decreases of CBF in both parietal regions as compared with control group (P < 0.05). (4) The depressive pseudodementia group showed significant decreases of CBF in the right temporal region and both parietal regions as compared with depression group (P < 0.05). (5) The DAT group showed significant decreases of CBF in the right temporal region, both frontal regions, and both parietal regions as compared with depressive pseudodementia group (P < 0.05). LIMITATIONS: The small number of subjects may make it difficult to generalize from our results. Because decreased CBF in depressive pseudodementia is found while the subjects were depressed, we cannot tell whether it is a state marker or a trait marker. CONCLUSIONS: The depressive pseudodementia group showed decreased CBF in the temporo-parietal region, similar to that of the DAT group and different from that of the depression group.

Verbal learning and visuomotor attention in Alzheimer's disease and geriatric depression.

We compared the verbal learning and visuomotor attention of 34 Alzheimer's patients and 18 depressive patients. Verbal learning was assessed using The Hopkins Verbal Learning Test--Revised (HVLT--R); visuomotor attention was assessed using the Trail Making Test (TMT). The Alzheimer's patients had significantly lower scores on immediate and delayed recall of a word list. There was a nonsignificant trend in this group toward a fewer number of true positives and a greater number of false positives. Alzheimer's patients were significantly slower on Trails A, with a nonsignificant trend toward slower performance on Trails B. No difference was observed in accuracy of attentional processing. The results are discussed in terms of other factors, such as stage of cognitive decline, which might have influenced the findings.