21 de diciembre de 2011

Factitious disorder


Factitious disorder refers to the psychiatric condition in which a patient deliberately produces or falsifies symptoms of illness for the sole purpose of assuming the sick role. Patients with factitious disorder waste precious time and resources through unnecessary hospital admissions, expensive investigatory tests, and sometimes, lengthy hospital stays. Moreover, patients with factitious disorder are among the most challenging and troublesome for busy clinicians. Patients with factitious disorder can generate feelings of anger, frustration, or bewilderment, because they violate the expectations of physicians and staff that patients should "behave like patients." Patients with factitious disorder disobey the following unwritten rules of being a patient: (1) patients attempt to provide an honest history; (2) symptoms result from accident, injury, or chance; and (3) patients are seeking treatment with the goal of recovering and so will cooperate with treatment toward that end.

Patients with factitious disorder likely have been present throughout human history. Their appearance in the literature extends back to the time of the Roman physician Galen who wrote about them in the second century. In the 1800s, the British physician Gavin described how some soldiers and seamen pretended illness to excite compassion or interest.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)[2] requires that the following 3 criteria be met for the diagnosis of factitious disorder: (1) intentional production or feigning of physical or psychological signs or symptoms, (2) motivation for the behavior is to assume the sick role, and (3) absence of external incentives for the behavior (eg, economic gain, avoiding legal responsibility, improving physical well-being, as in malingering).

The DSM-IV-TR recognizes the following 3 types of factitious disorder: (1) factitious disorder with predominantly psychological signs and symptoms, (2) factitious disorder with predominantly physical signs and symptoms, and (3) factitious disorder with combined psychological and physical signs and symptoms.

A fourth type, factitious disorder not otherwise specified, includes those disorders with factitious symptoms that do not meet the criteria for factitious disorder. The DSM-IV-TR places factitious disorder by proxy (ie, Munchausen syndrome by proxy) into this category, defining it as "the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care for the purpose of indirectly assuming the sick role." Factitious disorder by proxy has yet to be recognized as an official separate category in the DSM-IV-TR. Appendix B of the DSM-IV-TR lists the following research criteria for factitious disorder by proxy.

•Factitious disorder by proxy is the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care.

•The motivation for the perpetrator's behavior is to assume the sick role by proxy.

•External incentives for the behavior (such as economic gain) are absent.

•The behavior is not better accounted for by another mental disorder