- Email: [email protected]
Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis
General Hospital Psychiatry xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: www.elsevier.com/locate/genhospsych
Short communication
Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis ⁎
Xavier F. Jimeneza,d, , Ngozi Nkanginiemeb, Niyati Dhandc, Matt Karafaa, Karen Salernoa a
Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, United States of America Massachusetts General Hospital, Boston, MA, United States of America c Meridian Partners, Chicago, IL, United States of America d Quantitative Health Statistics, Cleveland Clinic, Cleveland, OH, United States of America b
A R T I C LE I N FO
A B S T R A C T
Keywords: Factitious disorder Abnormal illness behavior Psychodynamic Consultation psychiatry
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.
1. Introduction Consultation psychiatrists are often asked to assess patients for suspected factitious disorder (FD), defined as falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception [1]. FD is rare yet estimated to range between 0.5 and 2% of a general clinical population [2,3]. Identifying FD is challenging as confirmation depends on direct evidence of illnessinducing behaviors, though this is rarely achieved. As a result, clinical suspicion is based on other variables, such as atypical features of the medical presentation and certain patient behaviors [4]. Based on numerous studies, most FD patients tend to be young females with healthcare vocational experience [4–10]. Yates and Feldman [5] conducted the largest retrospective review of published FD cases (n = 455) to date, recommending clinical suspicion and vigilance for FD amongst young women with healthcare vocational experience
and depression. However, this review included many cases of “unsubstantiated illness” (instances in which investigations/analyses were normal or inconclusive, such as reporting of chest pain with negative laboratories); in fact, the vast majority of FD cases in that study were “unsubstantiated” (78%). Given this, we sought to more directly examine demographic, medical, psychiatric, social, and other shared clinical features in a group of patients with confirmed or highly suspected FD as defined narrowly by physically-deliberate illness induction. Additionally, we sought to examine broader risk factors and findings, such as psychological phenomena (including behavioral reinforcers and psychodynamic issues), certain FD-related behaviors, and practices by involved clinicians.
⁎ Corresponding author at: Neurological Institute, Department of Psychiatry and Psychology, Cleveland Clinic, 9500 Euclid Ave, C15, Cleveland, OH 44195, United States of America. E-mail address: [email protected] (X.F. Jimenez).
https://doi.org/10.1016/j.genhosppsych.2019.01.009 Received 5 January 2019; Received in revised form 23 January 2019; Accepted 30 January 2019 0163-8343/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Xavier F. Jimenez, et al., General Hospital Psychiatry, https://doi.org/10.1016/j.genhosppsych.2019.01.009
General Hospital Psychiatry xxx (xxxx) xxx–xxx
X.F. Jimenez, et al.
2. Methods
Table 1 Demographic, medical, psychiatric, social, behavioral, clinician/treatment, and FD-specific findings amongst patients with factitious disorder (FD).
In this IRB-approved retrospective study, 49 pre-selected patients with confirmed or highly-suspected FD evaluated by consultation psychiatry were reviewed independently by four investigators. Patients were identified a single institution (Cleveland Clinic), a single clinical service (the consultation psychiatry service), over a limited time period (2012 through 2015), and via the consultation psychiatry case database. The specific patient cases were identified by 4 involved consultation psychiatry clinicians (authors XFJ, ND, NN, and KS) over the 2012 through 2015 timeframe based on their individual experiences with the patients; given this, there may have been many more other patients with confirmed or highly-suspected FD in the broader consultation psychiatry service that were not designated as such by other clinicians and thus not included in this analysis. “Confirmed” FD was defined as a patient with witnessed evidence of physically-deliberate illness induction, whereas “highly suspected” was defined when high suspicion of physically-deliberate illness induction was communicated by more than two clinicians involved. The admission of interest in which a patient was highly suspected or confirmed of having FD was identified and demographic, medical, psychiatric, social, behavioral, clinician/treatment-related, and FD-specific factors were collected (see Table 1). It should be noted that all reports of trauma and/or psychological difficulties were based on patient self-report. Furthermore, “family dynamics” was agreed upon by the reviewers to include either of the following categories: abuse within the household; parental divorce; parental influence/enmeshment; unresolved/active grief; or ongoing conflict with significant other. FD-specific behavioral features reviewed were based on those proposed by Bass et al. [4]. Meetings were held to standardize the review process amongst the reviewers. In each case, primary medical team, consultation psychiatry, social work, nursing, and other consultation notes were reviewed, as was the medication administration record. Descriptive analyses (percentages) were utilized to determine frequencies of various factors.
Demographic Age 30 years or younger 40 years or younger Gender Female Male Ethnicity Caucasian African American Other Medical History of present illness/chief complaint GI symptoms Acute pain Past medical history GI Pain Neurological Infectious Allergies (number documented) 5 or more allergies > 10 allergies Opioids Receiving any opioids High dose (> 60 MED) Intravenous access Any present Central line TPN Psychiatric Past Psychiatric History Any History Present Affective/mood disorder Anxiety disorder Personality disorder Family psychiatric history Any history present Immediate family affected Substance use Any history present Opioid dependence Psychotropics Any present Antidepressant Benzodiazepine Anticonvulsant
3. Results Results are featured in Table 1. Of the population (n = 49), 14 (29%) had confirmed physically-deliberate illness induction FD while the remaining 35 (71%) were highly suspected of having physicallydeliberate illness induction FD. Patients across the sample were: 1) under the age of 40 (82%) and 2) female (90%). Medically, most presented with gastrointestinal (82%) and pain (63%) symptoms. The vast majority had preexisting psychiatric histories (92%) as well as family psychiatric histories (78%). Traumatic histories were present in over two-thirds of the group (69%) with approximately even amounts of sexual (56%) and violent/physical (53%) abuse rates. Two-thirds (67%) of the group had direct intravenous, half of which was central line access (55%) while a third specifically had total parenteral nutrition access (33%). Two-thirds (67%) of the study group had some exposure to healthcare-related training. All (100%) subjects had an identifiable family dynamic issue, most notably history of abuse within the household (43%) but also high rates (over 25% each) of parental divorce, parental influence/enmeshment, unresolved grief, and significant other conflict. Reinforcing elements were present: 57% had a possible financial incentive (of which 51% were seeking or maintaining disability status), and 94% had a plausible emotional or social incentive, most notably attention from medical personnel (63%) and friends or family (59%). 88% of patients exhibited at least 4 FD-related behaviors, the most frequently-occurring behaviors being multiple medical visits (82%), multiple medical tests (65%), inconsistent/vague/evasive history reporting (63%), atypical illness trajectories (61%), evasive behaviors (49%), peregrination/migration (45%) and treatment refusal (45%). Other less prevalent yet common FD-related behaviors included exaggerated symptoms (43%), overt deception (43%), attempts to leave the medical setting/unit (41%), adverse reactions to psychiatry
Social Healthcare training history Any experience Nursing experience Family dynamics/conflicts Any conflict present Abuse in household Parental divorce Parental influence/enmeshment Unresolved grief Significant other conflict Trauma history Any history present Sexual trauma Violent/physical Financial gain Any possible gain Disability related Emotional/social gains Any attention Medical attention Family/friend attention Clinician/treatment Treatment plan Sitter/1:1 Observation
55% 82% 90% 10% 86% 12% 2%
82% 63% 76% 59% 49% 35% 60% 27% 84% 35% 67% 55% 33%
92% 76% 51% 33% 78% 71% 61% 27% 96% 55% 61% 51%
67% 27% 100% 43% 25% 25% 25% 25% 69% 56% 53% 57% 51% 94% 63% 59%
71%
(continued on next page) 2
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X.F. Jimenez, et al.
predisposing (developmental and psychodynamic) and perpetuating (reinforcing social and environmental) forces involved in FD. Some authors divide psychopathological mechanisms behind FD into three broad categories: 1) primary/intrinsic psychopathology (such as mood/ anxiety and personality disorders); 2) behavioral learning via operant reinforcement; and/or 3) attachment deficits secondary to formative trauma [11]. Each of these may be tested in future investigations; for instance, attachment/relational patterns have already been explored extensively in complex medical populations [12]. Clinician behaviors were also assessed. Not all patients received close observation in the form of a sitter/companion, and only a paucity of cases utilized a behavioral contract to reduce harm or FD-behaviors. These findings suggest clinicians were uneducated in or uncomfortable with such confrontational techniques, and invite an area of potential quality improvement and education.
Table 1 (continued) PRN agitation/anxiety med Behavioral contract Suspecting Clinicians 3 or more clinicians 4 or more clinicians 5 or more clinicians Factitious behaviors At least 4 FD behaviors Multiple visits Multiple tests Inconsistent/vague/evasive history Atypical Illness course
55% 8% 88% 76% 47% 88% 82% 65% 63% 61%
GI: Gastrointestinal; MED: Morphine Equivalents per Day; TPN: Total Parenteral Nutrition; PRN: as-needed medication.
consultation (39%), denial of collateral use/contact (31%), and presence of FD paraphernalia (31%).
5. Conclusion In conclusion, FD represents a complex disorder of abnormal illness behaviors with predisposing developmental and perpetuating sociobehavioral variables. Clinician responses to FD appear to be less behavioral and confrontational than might be expected. Each of these findings offers future investigational, educational, and quality improvement directions to consider.
4. Discussion This study's strengths include its relatively large number of FD cases, its narrow definition of physically-deliberate illness induction, and exploration of previously-unexamined psychological and clinician features. Limitations include the retrospective design, subjective coding of various findings, and the lack of a control (non-FD) group. Medically, our specific cohort presented most often with gastrointestinal and pain complaints, central line access, high allergy numbers, opioid use, and complex past medical histories. Unsurprisingly, atypical illness courses, previous evaluation at multiple outside facilities, and inconsistent/vague/evasive history reporting and behaviors were also common. Psychiatrically, our population suffered from high rates of depression. Healthcare vocations were prevalent and included commonly-described nursing, but also medical aids, pharmacists, administrators, and nutritionists. As such, on the surface, these findings collectively capture the usually-described phenotype of FD: young females with healthcare experience and psychopathology [4–10]. However, from a psychological standpoint, our study adds findings of note. Developmentally, personal and family psychiatric and trauma histories were the norm, suggesting the complex origins of abnormal illness behavior patterns. Ongoing dynamic conflicts were also present in every case examined, though our methodology revealed a variety of issues ranging from grief discord, abuse, and pathological enmeshment. It is unclear if this is a comparable rate to general and/or nonclinical populations, though the high presence of such conflicts suggests at minimum the ubiquitous nature of past and/or present stressors in FD. Behaviorally, incentives for attention or relief from obligation were more prominent than financial/secondary gains, findings that are aligned with the more intangible primary gain benefits characterized with FD as opposed to comparably-manifest secondary gain benefits associated with malingering behaviors [4]. Psychological findings in this study invite pathomechanistic questions and investigational directions, particularly in examining
Disclosure There are no conflicts of interest or funding sources to report for any of the authors for this submission. Each contributing author has approved this version of the manuscript and has contributed directly to its composition. References [1] American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. DSM-5. 5th ed.Washington DC: APA; 2013. [2] Gieler U, Eckhardt-Henn A. Factitious disorders. Dermatol Psychosom 2004;5:93–8. [3] Fliege H, Grimm A, Eckhardt-Henn A, Gieler U, Martin K, Klapp BF. Frequency of ICD-10 factitious disorder: a survey of senior hospital consultants and physicians in private practice. Psychosomatics 2007;48:60–4. [4] Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet 2014;383:1422–32. [5] Yates GP, Feldman MD. Factitious disorder: a systematic review of 455 cases in the professional literature. Gen Hosp Psychiatry 2016;41:20–8. [6] Krahn LE, Li H, O'Connor MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry 2014;9. [7] Carney MW, Brown JP. Clinical features and motives among 42 artifactual illness patients. Br J Med Psychol 1983;56(1):57–66. [8] O'reilly BA, Aggeler PM. Covert anticoagulant ingestion: a study of 25 patients and review of world literature. Medicine 1976;55(5):389–99. [9] Petersdorf RG, Beeson PB. Fever of unexplained origin: report on 100 cases. Medicine 1961;40(1):1–30. [10] Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med 1983;99(2):240–7. [11] Noeker M. Factitious disorder and factitious disorder by proxy. Prax Kinderpsychol Kinderpsychiatr 2004;53(7):449–67. [12] Jimenez XF. Attachment in medical care: a review of the interpersonal model in chronic disease management. Chronic Illn 2016;13(1):14–27.
3
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: www.elsevier.com/locate/genhospsych
Short communication
Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis ⁎
Xavier F. Jimeneza,d, , Ngozi Nkanginiemeb, Niyati Dhandc, Matt Karafaa, Karen Salernoa a
Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, United States of America Massachusetts General Hospital, Boston, MA, United States of America c Meridian Partners, Chicago, IL, United States of America d Quantitative Health Statistics, Cleveland Clinic, Cleveland, OH, United States of America b
A R T I C LE I N FO
A B S T R A C T
Keywords: Factitious disorder Abnormal illness behavior Psychodynamic Consultation psychiatry
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.
1. Introduction Consultation psychiatrists are often asked to assess patients for suspected factitious disorder (FD), defined as falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception [1]. FD is rare yet estimated to range between 0.5 and 2% of a general clinical population [2,3]. Identifying FD is challenging as confirmation depends on direct evidence of illnessinducing behaviors, though this is rarely achieved. As a result, clinical suspicion is based on other variables, such as atypical features of the medical presentation and certain patient behaviors [4]. Based on numerous studies, most FD patients tend to be young females with healthcare vocational experience [4–10]. Yates and Feldman [5] conducted the largest retrospective review of published FD cases (n = 455) to date, recommending clinical suspicion and vigilance for FD amongst young women with healthcare vocational experience
and depression. However, this review included many cases of “unsubstantiated illness” (instances in which investigations/analyses were normal or inconclusive, such as reporting of chest pain with negative laboratories); in fact, the vast majority of FD cases in that study were “unsubstantiated” (78%). Given this, we sought to more directly examine demographic, medical, psychiatric, social, and other shared clinical features in a group of patients with confirmed or highly suspected FD as defined narrowly by physically-deliberate illness induction. Additionally, we sought to examine broader risk factors and findings, such as psychological phenomena (including behavioral reinforcers and psychodynamic issues), certain FD-related behaviors, and practices by involved clinicians.
⁎ Corresponding author at: Neurological Institute, Department of Psychiatry and Psychology, Cleveland Clinic, 9500 Euclid Ave, C15, Cleveland, OH 44195, United States of America. E-mail address: [email protected] (X.F. Jimenez).
https://doi.org/10.1016/j.genhosppsych.2019.01.009 Received 5 January 2019; Received in revised form 23 January 2019; Accepted 30 January 2019 0163-8343/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Xavier F. Jimenez, et al., General Hospital Psychiatry, https://doi.org/10.1016/j.genhosppsych.2019.01.009
General Hospital Psychiatry xxx (xxxx) xxx–xxx
X.F. Jimenez, et al.
2. Methods
Table 1 Demographic, medical, psychiatric, social, behavioral, clinician/treatment, and FD-specific findings amongst patients with factitious disorder (FD).
In this IRB-approved retrospective study, 49 pre-selected patients with confirmed or highly-suspected FD evaluated by consultation psychiatry were reviewed independently by four investigators. Patients were identified a single institution (Cleveland Clinic), a single clinical service (the consultation psychiatry service), over a limited time period (2012 through 2015), and via the consultation psychiatry case database. The specific patient cases were identified by 4 involved consultation psychiatry clinicians (authors XFJ, ND, NN, and KS) over the 2012 through 2015 timeframe based on their individual experiences with the patients; given this, there may have been many more other patients with confirmed or highly-suspected FD in the broader consultation psychiatry service that were not designated as such by other clinicians and thus not included in this analysis. “Confirmed” FD was defined as a patient with witnessed evidence of physically-deliberate illness induction, whereas “highly suspected” was defined when high suspicion of physically-deliberate illness induction was communicated by more than two clinicians involved. The admission of interest in which a patient was highly suspected or confirmed of having FD was identified and demographic, medical, psychiatric, social, behavioral, clinician/treatment-related, and FD-specific factors were collected (see Table 1). It should be noted that all reports of trauma and/or psychological difficulties were based on patient self-report. Furthermore, “family dynamics” was agreed upon by the reviewers to include either of the following categories: abuse within the household; parental divorce; parental influence/enmeshment; unresolved/active grief; or ongoing conflict with significant other. FD-specific behavioral features reviewed were based on those proposed by Bass et al. [4]. Meetings were held to standardize the review process amongst the reviewers. In each case, primary medical team, consultation psychiatry, social work, nursing, and other consultation notes were reviewed, as was the medication administration record. Descriptive analyses (percentages) were utilized to determine frequencies of various factors.
Demographic Age 30 years or younger 40 years or younger Gender Female Male Ethnicity Caucasian African American Other Medical History of present illness/chief complaint GI symptoms Acute pain Past medical history GI Pain Neurological Infectious Allergies (number documented) 5 or more allergies > 10 allergies Opioids Receiving any opioids High dose (> 60 MED) Intravenous access Any present Central line TPN Psychiatric Past Psychiatric History Any History Present Affective/mood disorder Anxiety disorder Personality disorder Family psychiatric history Any history present Immediate family affected Substance use Any history present Opioid dependence Psychotropics Any present Antidepressant Benzodiazepine Anticonvulsant
3. Results Results are featured in Table 1. Of the population (n = 49), 14 (29%) had confirmed physically-deliberate illness induction FD while the remaining 35 (71%) were highly suspected of having physicallydeliberate illness induction FD. Patients across the sample were: 1) under the age of 40 (82%) and 2) female (90%). Medically, most presented with gastrointestinal (82%) and pain (63%) symptoms. The vast majority had preexisting psychiatric histories (92%) as well as family psychiatric histories (78%). Traumatic histories were present in over two-thirds of the group (69%) with approximately even amounts of sexual (56%) and violent/physical (53%) abuse rates. Two-thirds (67%) of the group had direct intravenous, half of which was central line access (55%) while a third specifically had total parenteral nutrition access (33%). Two-thirds (67%) of the study group had some exposure to healthcare-related training. All (100%) subjects had an identifiable family dynamic issue, most notably history of abuse within the household (43%) but also high rates (over 25% each) of parental divorce, parental influence/enmeshment, unresolved grief, and significant other conflict. Reinforcing elements were present: 57% had a possible financial incentive (of which 51% were seeking or maintaining disability status), and 94% had a plausible emotional or social incentive, most notably attention from medical personnel (63%) and friends or family (59%). 88% of patients exhibited at least 4 FD-related behaviors, the most frequently-occurring behaviors being multiple medical visits (82%), multiple medical tests (65%), inconsistent/vague/evasive history reporting (63%), atypical illness trajectories (61%), evasive behaviors (49%), peregrination/migration (45%) and treatment refusal (45%). Other less prevalent yet common FD-related behaviors included exaggerated symptoms (43%), overt deception (43%), attempts to leave the medical setting/unit (41%), adverse reactions to psychiatry
Social Healthcare training history Any experience Nursing experience Family dynamics/conflicts Any conflict present Abuse in household Parental divorce Parental influence/enmeshment Unresolved grief Significant other conflict Trauma history Any history present Sexual trauma Violent/physical Financial gain Any possible gain Disability related Emotional/social gains Any attention Medical attention Family/friend attention Clinician/treatment Treatment plan Sitter/1:1 Observation
55% 82% 90% 10% 86% 12% 2%
82% 63% 76% 59% 49% 35% 60% 27% 84% 35% 67% 55% 33%
92% 76% 51% 33% 78% 71% 61% 27% 96% 55% 61% 51%
67% 27% 100% 43% 25% 25% 25% 25% 69% 56% 53% 57% 51% 94% 63% 59%
71%
(continued on next page) 2
General Hospital Psychiatry xxx (xxxx) xxx–xxx
X.F. Jimenez, et al.
predisposing (developmental and psychodynamic) and perpetuating (reinforcing social and environmental) forces involved in FD. Some authors divide psychopathological mechanisms behind FD into three broad categories: 1) primary/intrinsic psychopathology (such as mood/ anxiety and personality disorders); 2) behavioral learning via operant reinforcement; and/or 3) attachment deficits secondary to formative trauma [11]. Each of these may be tested in future investigations; for instance, attachment/relational patterns have already been explored extensively in complex medical populations [12]. Clinician behaviors were also assessed. Not all patients received close observation in the form of a sitter/companion, and only a paucity of cases utilized a behavioral contract to reduce harm or FD-behaviors. These findings suggest clinicians were uneducated in or uncomfortable with such confrontational techniques, and invite an area of potential quality improvement and education.
Table 1 (continued) PRN agitation/anxiety med Behavioral contract Suspecting Clinicians 3 or more clinicians 4 or more clinicians 5 or more clinicians Factitious behaviors At least 4 FD behaviors Multiple visits Multiple tests Inconsistent/vague/evasive history Atypical Illness course
55% 8% 88% 76% 47% 88% 82% 65% 63% 61%
GI: Gastrointestinal; MED: Morphine Equivalents per Day; TPN: Total Parenteral Nutrition; PRN: as-needed medication.
consultation (39%), denial of collateral use/contact (31%), and presence of FD paraphernalia (31%).
5. Conclusion In conclusion, FD represents a complex disorder of abnormal illness behaviors with predisposing developmental and perpetuating sociobehavioral variables. Clinician responses to FD appear to be less behavioral and confrontational than might be expected. Each of these findings offers future investigational, educational, and quality improvement directions to consider.
4. Discussion This study's strengths include its relatively large number of FD cases, its narrow definition of physically-deliberate illness induction, and exploration of previously-unexamined psychological and clinician features. Limitations include the retrospective design, subjective coding of various findings, and the lack of a control (non-FD) group. Medically, our specific cohort presented most often with gastrointestinal and pain complaints, central line access, high allergy numbers, opioid use, and complex past medical histories. Unsurprisingly, atypical illness courses, previous evaluation at multiple outside facilities, and inconsistent/vague/evasive history reporting and behaviors were also common. Psychiatrically, our population suffered from high rates of depression. Healthcare vocations were prevalent and included commonly-described nursing, but also medical aids, pharmacists, administrators, and nutritionists. As such, on the surface, these findings collectively capture the usually-described phenotype of FD: young females with healthcare experience and psychopathology [4–10]. However, from a psychological standpoint, our study adds findings of note. Developmentally, personal and family psychiatric and trauma histories were the norm, suggesting the complex origins of abnormal illness behavior patterns. Ongoing dynamic conflicts were also present in every case examined, though our methodology revealed a variety of issues ranging from grief discord, abuse, and pathological enmeshment. It is unclear if this is a comparable rate to general and/or nonclinical populations, though the high presence of such conflicts suggests at minimum the ubiquitous nature of past and/or present stressors in FD. Behaviorally, incentives for attention or relief from obligation were more prominent than financial/secondary gains, findings that are aligned with the more intangible primary gain benefits characterized with FD as opposed to comparably-manifest secondary gain benefits associated with malingering behaviors [4]. Psychological findings in this study invite pathomechanistic questions and investigational directions, particularly in examining
Disclosure There are no conflicts of interest or funding sources to report for any of the authors for this submission. Each contributing author has approved this version of the manuscript and has contributed directly to its composition. References [1] American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. DSM-5. 5th ed.Washington DC: APA; 2013. [2] Gieler U, Eckhardt-Henn A. Factitious disorders. Dermatol Psychosom 2004;5:93–8. [3] Fliege H, Grimm A, Eckhardt-Henn A, Gieler U, Martin K, Klapp BF. Frequency of ICD-10 factitious disorder: a survey of senior hospital consultants and physicians in private practice. Psychosomatics 2007;48:60–4. [4] Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet 2014;383:1422–32. [5] Yates GP, Feldman MD. Factitious disorder: a systematic review of 455 cases in the professional literature. Gen Hosp Psychiatry 2016;41:20–8. [6] Krahn LE, Li H, O'Connor MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry 2014;9. [7] Carney MW, Brown JP. Clinical features and motives among 42 artifactual illness patients. Br J Med Psychol 1983;56(1):57–66. [8] O'reilly BA, Aggeler PM. Covert anticoagulant ingestion: a study of 25 patients and review of world literature. Medicine 1976;55(5):389–99. [9] Petersdorf RG, Beeson PB. Fever of unexplained origin: report on 100 cases. Medicine 1961;40(1):1–30. [10] Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med 1983;99(2):240–7. [11] Noeker M. Factitious disorder and factitious disorder by proxy. Prax Kinderpsychol Kinderpsychiatr 2004;53(7):449–67. [12] Jimenez XF. Attachment in medical care: a review of the interpersonal model in chronic disease management. Chronic Illn 2016;13(1):14–27.
3