Factitious Disorder: Symptoms, Causes, Diagnosis

The factitious disorder is one that experienced by people who have physical or psychological symptoms that are feigned or intentionally produced in order by the subject of assuming the sick role.

Factitious disorders have been classified differently in the diagnostic manuals of mental illness. In the International Classification of Diseases (ICD), the factitious disorder appears to belong to the category of other personality disorders and adult behavior.

In the Diagnostic Manual of Mental Illness DSM version 4, they form an independent category, called factitious disorders.

Factitious Disorder

In the DSM-5, however, it is part of the general category of somatic symptom disorders and related disorders, together with disorders such as: somatic symptom disorder; Anxiety disorder due to illness; conversion disorder; psychological factors that affect other medical conditions; other disorders of somatic symptoms and related disorders specified and, finally, disorders of somatic symptoms and related disorders not specified.

Factitious Disorder

Factitious disorder diagnosis

Factitious disorder applied to oneself

A. Falsification of physical or psychological signs or symptoms, or induction of injury or illness, associated with an identified deception.

B. The individual presents himself to others as sick, incapacitated or injured.

C. Deceptive behavior is evident even in the absence of an obvious external reward.

D. Behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

There are two possible subtypes of specifications: single episode or recurrent episodes (two or more events of falsification of disease and / or induction of injury).

Factitious disorder applied to another  (formerly called Factitious Disorder of neighbor).

A. Falsification of physical or psychological signs or symptoms, or induction of injury or illness, in another, associated with an identified deception.

B. The individual presents another individual (victim) in front of others as sick, incapacitated or injured.

C. Deceptive behavior is evident even in the absence of obvious external reward.

D. Behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Note: When an individual falsifies a disease in another individual (for example: children, adults, pets), the diagnosis is factitious disorder applied to another. The diagnosis applies to the author, not the victim. This can be diagnosed with abuse.

There are two possible subtypes of specifications: single episode or recurrent episodes (two or more events of falsification of disease and / or induction of injury).

Factitious disorder characteristics

In factitious disorder, behaviors are considered voluntary because they are deliberate and have a purpose. Although, it is true that they can not be considered as controllable and sometimes there is a compulsive component. The diagnosis requires demonstrating that the individual is committing actions to misrepresent, simulate or cause signs or symptoms of illness or injury in the absence of obvious external rewards.

There are occasions in which, although there may be a pre-existing condition or medical illness, there is a deceptive behavior or the induction of injuries associated with the simulation with the purpose that others consider them more ill or with greater disability. This can lead to clinical intervention to a high degree.

Subjects with factitious disorder use a variety of methods to falsify the disease such as exaggeration, manufacture, simulation and induction.

There are cases in which people with factitious disorder report feelings of depression and suicidal tendencies after the death of a spouse. However, it is not true that nobody has died or it is not true that the person has a spouse.

Individuals with factitious disorder, after causing the injury or illness, can seek treatment for themselves or for others.

Other associated characteristics

Individuals with factitious disorder imposed on oneself or another person present a high risk of experiencing great psychological suffering or functional impairment for the damage caused to themselves and others.

People close to the patient such as family members, friends and health professionals are also sometimes affected by their behavior.

There are clear similarities between factitious disorders and other disorders in terms of persistent behavior and intentional efforts to conceal conduct disorder through self-deception. We talk about substance use disorders, eating disorders, impulse control disorders, pedophilia, personality disorders ??.

The relationship of these disorders with personality disorders is especially complex due to appearance as: chaotic lifestyle; altered interpersonal relationships; identity crisis; substance abuse; self-mutilations and manipulative tactics.

In many of these cases, they may receive the additional diagnosis of borderline personality disorder. Sometimes they also present histrionic features due to their need for attention and drama.

Although some factitious disorders may represent criminal behavior, criminal behavior and mental illness are not mutually exclusive. The diagnosis of factitious disorder emphasizes the objective identification of the simulation of signs and symptoms of disease, rather than inferring the intention or possible underlying motivation.

Münchausen syndrome and factitious disorder by proxy

Factitious disorders with predominantly psychological signs and symptoms are often distinguished from those in which physical symptoms predominate, also called Münchausen syndrome. This syndrome was already treated in a previous chapter, however, some of the main characteristics will be remembered.

The essential aspect to emphasize of these last ones is the capacity of the patient to present physical symptoms that allow them to obtain that they are admitted in the hospital and during prolonged periods in hospital stays.

To support its history, the patient fakes or provokes a series of very variable symptoms, which may include hematomas, hemoptysis (expulsion of blood through the mouth from the respiratory tract), hypoglycemia, nausea, vomiting, abdominal pain, fever or episodes. of neurological symptoms such as dizziness or seizures.

Other strategies that usually make is to manipulate laboratory tests, for example, to contaminate the urine that is going to be subjected to analysis, with blood or with feces; On the other hand, it can take anticoagulants, insulin or other drugs to falsify medical records and indicate a disease inducing an abnormal laboratory result.

They tend to be patients who constantly face the opinions of others about the falsity of statements about diseases? that they tend to keep, especially when their complaints are questioned. Also, when they think they are going to be discovered, they leave the hospital where they are admitted.

However, the cycle does not end there, but they quickly go to another hospital and again. It is curious that many of them have different symptoms every time they go to the hospital to be admitted.

According to Asher in 1951, three different clinical types were described:

a) Acute abdominal type : it can be treated in the most frequent way. These are those with a history of multiple laparotomies (surgeries that are performed with the aim of opening the abdomen of people to explore and examine existing problems), in which the subject, consciously, ingests objects and requests surgical interventions to remove them.

b) Hemorrhagic type : these are patients who present episodic hemorrhages through several orifices, sometimes using the blood of animals or using anticoagulants.

c) Neurological type : the subjects present attacks, fainting, severe headaches, anesthesia or cerebellar symptoms.

Other dermatological, cardiological or respiratory conditions can be added to these original types.

On the other hand, apart from the Muchaussen syndrome, we find factitious disorder by proxy (Meadow, 1982). This disorder occurs in patients who intentionally produce symptoms in another individual under their care, usually a child.

The motivation behind this situation is that the caregiver indirectly assumes the role of the sick person. This should not be confused with the physical abuses and consequent attempts of the abusers to hide them.

As for the aspects that can make us suspect that there is a factitious disorder and not a real medical disease, we find the existence of:

  • Fantastic pseudology (creation of a surprising, exaggerated or impossible medical history).
  • The presence of extensive and abundant medical knowledge about procedures, symptoms, signs, treatments?
  • The fluctuating clinical course with complications or new symptoms when the complementary examinations of the former were negative.
  • Disordered behaviors in the health context.
  • The use and abuse of analgesics.
  • The history of multiple surgical interventions.
  • The shortage of friends and the absence of visits during their admission.

Prevalence

The prevalence is 0.032-9.36% in different healthcare resources (Kocalevent et al., 2005). In the last edition of the DSM, which dates from 2014, they mention that the general population prevalence of this disorder is unknown, due, partly due to the role of deception in the population. And that, among hospitalized patients, about 1% of individuals may have presentations that meet the factitious disorder criteria.

One aspect to keep in mind is that the factitious disorder in which the psychological signs and symptoms predominate is probably higher than previously thought, but it is overlooked by the absence of objective physical evidence, and because it is usually accompanied by other pathologies such as personality disorders, psychosis, dissociative disorders, depressive disorders.

Development and course

The onset of the disorder usually occurs in early adulthood, and often occurs after hospitalization due to a medical problem or mental disorder. When the disorder is imposed on another, it can begin after the hospitalization of the child of someone in charge.

The course is usually in the form of intermittent episodes, since the unique episodes that are characterized by being persistent and without remissions, are less frequent.

In subjects with recurrent episodes of falsification of signs and symptoms of illness and / or induction of injury, the pattern of successive deceptive contacts with medical personnel may remain throughout life.

Differential characteristics with other disorders

Within factitious disorder, it is important to perform a differential diagnosis with two other disorders that can lead to confusion. On one hand, the conversion disorder and on the other, the simulation disorder.

In conversion disorder, where there are one or more symptoms in the person in voluntary or sensory motor functions, which induce to think that there is a neurological or medical disease. The difference is that the subject is not aware of doing something, nor of the remote motivation of the symptomatology.

In the simulation , the subject consciously pretends to be, that is, presents physical or psychic symptoms that are intentionally or falsely produced. However, this behavior is motivated by the existence of external incentives, not psychological ones, such as avoiding labor or military responsibilities, avoiding criminal prosecutions (wanting to get rid of a trial), getting toxic for personal use or obtaining pensions.

Should cause suspicion of diagnosis of simulation in someone in cases such as, for example:

a) Presentations in medical-legal contexts (simulations due to illness, or simulations of a legal nature, such as economic gains, avoidance of legal responsibilities as custodians?)

b) When there are important discrepancies between complaints and subjective statements of the subject about his discomfort or disability and the objective data obtained through medical examinations

c) If the subject does not cooperate at the time of the diagnostic assessment and compliance with the treatment.

d) In case there is a previous history of antisocial behavior, antisocial personality disorder or personality limit and / or drug addiction (LoPiccolo et al., 1999).

Finally, mention that caregivers who have abused their dependent dependents, when they lie about the injuries due to abuse to these only to protect themselves from liability, do not diagnose factitious disorder applied to another because the protection against liability It is an external reward.

This type of caregiver lies about how and when they supervise the people in their care; about the analysis of medical records and / or interviews with professionals and other people, much more than would be necessary for self-protection. They would diagnose factitious disorder imposed on another.

Conclusions

It is necessary to continue deepening in the approach and detection of these cases because the investigations are scarce. To detect them, it is necessary the collaboration of an interdisciplinary team, and the use of methods to detect, evaluate and treat more sophisticated, for the disorder with psychological symptoms.

Bibliography

  1. AMERICAN PSYCHIATRIC ASSOCIATION (APA). (2002). Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR . Barcelona: Masson.
  2. AMERICAN PSYCHIATRIC ASSOCIATION (APA). (2014). Diagnostic and Statistical Manual of Mental Disorders DSM-5 . Barcelona: Masson.
  3. Belloch, A. (2008) Psychopathology Handbook II. SA McGraw-Hill / Interamerican of Spain.
  4. Cabo Escribano, G. and Tarrío Otero, P. Factitious disorder with predominantly psychological symptoms and signs . Revista de la Asoaciación Gallega de Psiquiatría.
  5. ICD-10 (1992). Mental and behavioral disorders Madrid: Meditor.
  6. Vallejo Ruiloba, J. (2011) Introduction to psychopathology and psychiatry . The servier Spain SL Barcelona.

The effects of stress on the body are both physical and mental: `can cause damage to the cardiovascular system, endocrine, gastrointestinal system, sexual system and even sexuality.


The stress response involves the production of a series of psychophysiological changes in the body in response to a situation of over-demand. This response is adaptive in preparing the person to face emergency situations, in the best possible way.

In spite of this, there are occasions in which the maintenance of this response during long periods, the frequency and intensity of it, ends up harming the organism.

Stress can cause various symptoms such as ulcers, increased glands, atrophy of certain tissues, which give rise to pathologies.

Nowadays, there are more and more possibilities of knowing how emotions and biology interact with each other. An example of this is the abundant research that exists between the direct and indirect relationships that exist between stress and illness.

Effects of stress on human health

1- Effects on the cardiovascular system

When a stressful situation occurs, a series of changes are generated at the level of the cardiovascular system, such as:

  • The increase in heart rate.
  • Constriction of the main arteries that cause increased blood pressure, especially in those that channel blood to the digestive tract.
  • Constriction of the arteries that supply blood to the kidneys and the skin, facilitating the blood supply to the muscles and the brain.

On the other hand, vasopressin (antidiuretic hormone that produces increased water reabsorption), causes the kidneys to slow down the production of urine and thus a decrease in the elimination of water occurs, consequently, an increase in blood volume and an increase in blood pressure.

If this set of changes occur repeatedly over time, significant wear occurs in the cardiovascular system.

To understand the possible damages that occur, we must bear in mind that the circulatory system is like a huge network of blood vessels covered by a layer called cell wall. This network reaches all the cells and in it there are bifurcation points in which the blood pressure is higher.

When the layer of the vascular wall suffers damages, and before the stress response that is generated, there are substances that are poured into the bloodstream as free fatty acids, triglycerides or cholesterol, which penetrate the vascular wall, adhere to it and consequently thickened and hardened, forming plates. Thus, stress influences the appearance of the so-called atherosclerotic plaques that are located inside the artery.

This series of changes can cause damage to the heart, brain and kidneys. These damages translate into a possible angina of chest (pain in the thorax produced when the heart does not receive the sufficient sanguineous irrigation); in a myocardial infarction (stop or serious alteration of the rhythm of the heartbeat due to obstruction of the corresponding artery / s); kidney failure (failure of kidney function); cerebral thrombosis (obstruction of the flow of some artery that waters part of the brain).

Next, three examples of stressful phenomena, of different kinds, will be presented, to illustrate the above.

In a study conducted in 1991 by Meisel, Kutz and Dayan, the three days of Gulf War missile attacks were compared in the population of Tel Aviv, with the same three days of the previous year, and a higher incidence was observed. (triple), of myocardial infarction in the inhabitants.

Also noteworthy is this higher incidence of natural disasters. For example, after the earthquake in Northrige in 1994, there was an increase in cases of sudden cardiac death, during the six days after the catastrophe.

On the other hand, the number of myocardial infarctions in football world championships increases, especially if the games end in penalties. The highest incidence occurs two hours after the matches.

In general, it can be said that the role of stress is to precipitate the death of people whose cardiovascular system is very compromised.

2- Effects on the gastrointestinal system

When a person presents an ulcer in the stomach this may be due either to infection by the bacteria Helicobacter pylori, or they present it, without there being an infection. In these cases is when we talk about the possible role that stress plays in diseases, although it is not well known what factors are involved. Several hypotheses are considered.

The first one makes reference to that when a stressful situation occurs, the organism reduces the secretion of the gastric acids, and simultaneously, the thickening of the stomach walls is reduced, since, during that period, it is not necessary that they be found in the stomach. Acid said operations to produce digestion, is it ??? economize? some of the functions of the organism that are not necessary.

After this period of intense overactivation, there is a recovery of the production of gastric acids, in particular hydrochloric acid. If this cycle of reduction in production and recovery occurs repeatedly, an ulcer may develop in the stomach, which is therefore not so related to the intervention of a stressor, but to that period.

It is also interesting to comment on the sensitivity of the intestine to stress. As an example we can think of a person who before presenting to an important exam, for example, an opposition, has to go to the bathroom repeatedly. Or, for example, someone who has to expose the defense of a thesis in front of a jury composed of five people who evaluate you, and in the middle of the exhibition feels irrepressible desires to go to the bathroom.

Thus, it is not strange to refer to the causal relationship between stress and certain intestinal diseases, for example, irritable bowel  syndrome, consisting of a picture of pain and change in bowel habit, resulting in diarrhea or constipation in the person facing situations or stressful conditions. However, current studies report the involvement of behavioral aspects in the development of the disease.

3- Effects on the endocrine system

When people feed themselves, a series of changes are produced in the organism destined to the assimilation of nutrients, their storage and their subsequent transformation into energy. There is a decomposition of food into simpler elements, which can be assimilated into molecules (amino acids, glucose, free acids?). These elements are stored respectively in the form of proteins, glycogen’s and triglycerides, thanks to insulin.

When a stressful situation occurs, the body has to mobilize the excess energy and it does so through stress hormones that cause the triglycerides to break down into their simplest elements, such as fatty acids that are released into the bloodstream; that glycogen degrades into glucose and that proteins become amino acids.

Both free fatty acids and excess glucose are released into the bloodstream. Thus, through this released energy, the organism can cope with the over-demands of the medium.

On the other hand, when a person experiences stress, an inhibition of insulin secretion occurs and the glucocorticoids make the fat cells less sensitive to insulin. This lack of response occurs mainly due to the weight gain in people, which causes fat cells, when distended, to be less sensitive.

Faced with these two processes, diseases such as cataracts or diabetes can occur.

Cataracts, which result in a kind of cloud in the lens of the eye that hinders vision, originate due to the accumulation of excess glucose and free fatty acids in the blood, which can not be stored in the fat cells and form plaques. atherosclerotic arteries obstructing blood vessels, or promoting the accumulation of proteins in the eyes.

Diabetes is a disease of the endocrine system, one of the most researched. It is a common disease in the older population of industrialized societies.

There are two types of diabetes, stress influences more in type II diabetes or non-insulin-dependent diabetes, in which the problem is that the cells do not respond well to insulin, although it is present in the body.

Thus, it is concluded that chronic stress in a person predisposed to diabetes, that is obese, with an inadequate diet and elderly, is an essential element in the possible development of diabetes.

4- Effects on the immune system

The immune system of people is composed of a set of cells called lymphocytes and monocytes (white blood cells). There are two kinds of lymphocytes, T cells and B cells, that originate in the bone marrow. Even so, the T cells migrate to another area, to the thymus, to mature, that is why they are called “T”.

These cells perform functions of attacking infectious agents differently. On the one hand, T cells produce cell-mediated immunity, that is, when a foreign agent enters the body, the monocyte called macrophage recognizes and alerts it to an auxiliary T cell. Then these cells proliferate exorbitantly and attack the invader.

On the other hand, the B cells, produce an immunity mediated by antibodies. Thus, the antibodies they generate recognize the invading agent and bind to it, immobilizing and destroying the foreign substance.

Stress can influence these two processes and it does it in the following way. When stress occurs in a person, the sympathetic branch of the autonomic nervous system suppresses the immune action, and the hypothalamic-pituitary-adrenal system, when activated, produces high-grade glucocorticoids, stopping the formation of new T lymphocytes and decreasing the sensitivity of the same to the alert signals, as well as expelling the lymphocytes from the bloodstream and destroying them through a protein that breaks their DNA.

Thus, it is concluded that there is an indirect relationship between stress and immune function. The more stress, the less immune function, and vice versa.

An example can be found in a study conducted by Levav et al in 1988, where they saw that the parents of the Israeli soldiers who died in the Yom Kippur War, showed a higher mortality during the period of mourning than those who observed in the control group . In addition, this increase in mortality occurred to a greater extent in widowed or divorced parents, confirming another aspect studied such as the buffering role of social support networks.

Another much more common example is that of the student who, during exam periods, may suffer a decrease in immune function, getting sick with a cold, flu?

5- Effects on sexuality

A slightly different topic that has been discussed throughout this article is that of sexuality, which of course can also be affected by stress.

Sexual function in men and women can be modified before certain situations experienced as stressful.

In the man, before certain stimuli the brain stimulates the release of a liberating hormone called LHRH, which stimulates the pituitary (gland that is in charge of controlling the activity of other glands and regulating certain functions of the body, such as sexual development or sexual activity). ). The pituitary releases the hormone LH and the hormone FSH, producing the release of testosterone and sperm, respectively.

If the man lives a stress situation there is an inhibition in this system. Two other types of hormones are activated; endorphins and enkephalins, which block the secretion of the hormone LHRH.

In addition, the pituitary secretes prolactin, whose function is to decrease the sensitivity of the pituitary to LHRH. Thus, on the one hand, the brain secretes less LHRH, and on the other, the pituitary protects itself to respond less to it.

For more inri, the glucocorticoids discussed above, block the response of the testicles to LH. What is extracted from this whole series of changes that occur in the body when a stress situation occurs is that it is prepared to respond to a potentially dangerous situation, leaving aside, of course, having sex.

One aspect with which you may be more familiar is the lack of erection in men in the face of stress. This response is determined by the activation of the parasympathetic nervous system, through which there is an increase in the blood supply to the penis, the blockage of blood flow through the veins and the filling of blood from the corpus cavernosum. the hardening of this one.

Thus, if the person is stressed or anxious, his or her body is activated, specifically the activation of the sympathetic nervous system, so that the parasympathetic is not in operation, not producing an erection.

As for the woman, the functioning system is very similar, on the one hand, the brain releases LHRH, which in turn secretes LH and FSH in the pituitary. The first activates the synthesis of oestrogens in the ovaries and the second stimulates the release of ovules in the ovaries. And on the other, during ovulation, the corpus luteum formed by the hormone LH, releases progesterone, thus stimulating the walls of the uterus so that in case an ovule fecundates, it can implant in them and become an embryo.

There are occasions when this system fails. On the one hand, the inhibition of the functioning of the reproductive system can occur when there is an increase in the concentration of androgens in women (since women also present male hormones), and a decrease in the concentration of estrogens.

On the other hand, the production of glucocorticoids in the face of stress can produce a decrease in the secretion of the hormones LH, FSH and estrogen, reducing the probability of ovulation.

And in addition, the production of prolactin increases the reduction of progesterone which in turn interrupts the maturation of the uterine walls.

All this can lead to fertility problems that affect an increasing number of couples, which become a source of stress that aggravates the problem.

We can also refer to dyspareunia or painful intercourse, and vaginismus, involuntary contraction of the muscles that surround the opening of the vagina. With regard to vaginismus, it has been observed that possible painful and traumatic experiences of a woman’s sexual type, can provoke a conditioned response of fear of penetration, which activates the sympathetic nervous system, causing the contraction of the muscles of the vagina.

Also Read: Dog Therapy: 11 Surprising Benefits for Health

The dyspareunia on the other hand, can be referred to concerns of women in case it will do well, inhibiting the activity of the parasympathetic nervous system  and activating the sympathetic, making relationships difficult by a lack of excitement and lubrication.

Conclusions

Now that we know all the possible adverse effects that may be caused by stress, there are no excuses to think about facing situations in a more adaptive way, for example using relaxation or meditation techniques, which have proved very effective.

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