Today’s topic: Factitious Disorder in Children and Adolescents

1. child & youth Mental Health Series Today’s topic: Factitious Disorder in Children and Adolescents Speaker: Dr. Aaron Silverman, MD, FRCPC Date

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6. Objectives • Describe factitious disorder and understand how it differs from other related conditions in children and adolescents • Learn to recognize factitious symptoms in children and adolescents • Develop an approach to managing children or adolescents with factitious symptoms

7. Factitious Disorder Imposed on Self1 • Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception • The individual presents himself or herself to others as ill, impaired, or injured. • The deceptive behaviour is evident even in the absence of obvious external rewards. • The behaviour is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

8. Spectrum of Severity

9. History • 1838: “factitious disorder” introduced by Gavin2 • 1951: term “Munchausen’s Syndrome coined by Asher2 • Birch suggested they be blacklisted from hospitals • 1971: Supportive psychotherapy approaches suggested in combination with neuroleptic drugs • Non-confrontational versus confrontational approach • 1977: term “Munchausen’s Syndrome by Proxy” introduced by Meadow9 • 1988: Introduction of quantitative testing by psychologists2

10. Prevalence • Adults • Estimated to be 1.3% of patients in medical practices • 0.62 – 0.8% of patients referred to CL services in Canada • 9% of patients with fever of unknown origin • 0.3% of patients in neurology department • 0.5% of patients in psychiatry ward • Children • 0.71% of patient referred to CL services • 0.03% of inpatients in tertiary care setting

11. Prevalence • Difficulties in accurate estimation: • Patients able to hide deception7 • Lack of training and awareness in health care providers7 • Multiple providers involved in patients’ care7 • Patients not interested to participate in research • patients often leave hospital against medical advice9 • Much higher prevalence has been suggested (up to 5%)7

12. Case AB 17F presenting with hallucinations • Grade 9 – blood in eye • Grade 10 - Increasing visual hallucinations -> hospitalized • Grade 11 – assessment – not psychotic: • ran away from home and drank bleach • Prescribed antipsychotic medication – 15 lbs weight gain • Summer Grade 11 - unusual paranoid behaviour -> hospitalized • Switched from antipsychotic to antidepressant • Grade 12 – Hospital admission - worsening hallucinations • planning a “breakdown” where she would “let the voices take over”

13. Case AB • Admission • high functioning • very detailed organized story • Seemed unaffected • inconsistencies in reporting voices to staff • Unusual characteristics of voices • Continuously hearing voices • Seeing things in black and white • Unusual behaviors in inpatient unit • episode of falling to ground • Leaving unit and running to pharmacy

14. Making Diagnosis • Clinicians not good at detecting deception2 • Warning signs: ***History of deceptive illness8*** • Vague or inconsistent histories7 • Lack of objective findings7 • Physical exams showing self-inflicted injuries7 • Conditions always begin when patient unobserved6 • Seeking treatment at multiple sites7

15. Other Features • “Bland indifference” to unpleasant procedures/hospitalization6 • High level of interest or sophistication in medical world6 • Overfamiliarity with hospital staff8 • Multiple allergies listed8 • Typically very cooperative during hospital stay7

16. Characteristics • Most common induced conditions: • Skin disease3 • Seizures2 • Fever 6 • Diabetic Ketoacidosis 6 • Purpura 6 • Infections 6 • Symptoms:3 • 66% simulated symptoms • 33% produced symptoms

17. Characteristics Younger than 14 :6 • Simple, concrete deceptions • 100% admission when confronted • Greater likelihood of positive outcome 15 and older:6 • More convincing • 55% admission when confronted • More harmful outcomes

18. Consequences • Average duration of medical investigations before confirmation of deception = 1.5 years6 • Invasive radiological workup • Invasive procedures/surgeries • Skin biopsies, pancreatectomy • Unneeded medications • Steroids • Heparin • Recovery rare as few patients agree to comply with treatment2

19. Co-Morbidities • Not well-studied in children and teens:3 • Incipient personality disorder (3/12) • Self-harm (5/12) • Suicide attempt (3/12)

20. Differential Diagnosis • Medical condition or other mental disorder1 • Somatic Symptom Disorder1 • Conversion Disorder1 • Malingering1 • Borderline Personality Disorder1 • Factitious Disorder by Proxy6

21. Somatic Symptom Disorder • A. One or more somatic symptoms distressing or disrupting daily life • B. Excessive thoughts, feelings, or behaviours related to somatic symptoms • Thoughts about seriousness of symptoms • Persistently high anxiety about health or symptoms • Excessive time and energy devoted to symptoms

22. Malingering • The intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives2 • Not present or absent; an individual might be exaggerating genuine difficulties2

24. Factitious Disorder Imposed on Another • Falsification of or induction of illness or injury in another1 • Perpetrator, not victim receives diagnosis1 • Intergenerational transmission: encouragement of illness falsification by a caregiver9

25. How to identify • Note discrepancies between patient reports and clinical findings5 • Carefully document • Collaborate with other health professionals5 • Using same question at different times to note inconsistencies8 • Gather records from other health-care institutions8

26. Challenges • Clinician reluctance:5 • Feels contrary to empathic, trusting relationship • Increased time needed • Legal reasons • Patient reluctance: • Nature of condition • Patient confidentiality3

27. Case AB • Reviewed inconsistencies with interdisciplinary staff members • Factitious Disorder Suspected • Psychological testing done for help with diagnostic clarification: • SIMS (Structured Inventory of Malingered Symptomatology): Positive • Miller Forensic Assessment of Symptoms: Positive

30. Risk Factors • Witnessing severe somatic illness in family • Being victim of Factitious Disorder by Proxy • History of physical or sexual abuse • Foster home placements

31. Other Theories Suggested7 • Intergenerational transfer2 • Thrill of undergoing medical procedure • Need for attention or care • Sense of control through the deception of health care providers • Masochistic behavior • Poor self-identity • Intrapsychic defenses

32. Treatment/Approach “The most important thing is the formation of a therapeutic relationship—which is what they are seeking and which is what stops them from lying.”4 -Gary Rodin

33. Treatment/Approach • Goal: Limit patient’s risk of adverse reaction and health care costs7 • Interdisciplinary approach3, 7 • Non-confrontational Strategies:3 • Inexact interpretations of psychological defenses • Therapeutic use of double bind • Techniques allowing patient to give up factitious symptoms without losing face • Limit setting and close supervision

34. One Approach • Psychoeducation7 • Delineate from malingering7 • Help patient understand symptoms7 • Describe treatment7 • Psychotherapy – multiple case reports7 • Confrontation of symptoms7 • Therapeutic Discharge8

35. Therapeutic Discharge8 • Formal hospital policy – eliminate variable reinforcement • Indications: • Confidence in diagnosis • Contraindications: • Need for inpatient care -> enhanced supervision • Safety assessment prior to time of discharge • Maintain usual interactions until definitive decision made

36. Therapeutic Discharge8 – Delivering News • Neutral tone, direct language • Emphasis on safety • Align with distress • Not being “fired from treatment” • Emphasis on alternative treatment options to hospitalization

37. Factitious Disorder in Children and Adolescents: A Retrospective Study3 • Outcomes • 8/12 of patients admitted to their deception when confronted • 8/12 patients voluntarily underwent inpatient psychiatric treatment • 4/12 left AMA • Of those who were followed 3/7 obviously resumed their factitious behaviours • Only 1/7 followed seemed to improve

38. Case AB • Diagnosis made and shared with family • Proposed an understanding – means of coping with stress • Recommendation • reducing workload, taking leave from part-time job • Psychotherapy to focus on developing healthier ways of communicating distress • Met with school to discus diagnosis and how best to support her • At follow up family was happy with diagnosis and patient doing well

39. Conclusions • Factitious Disorder: uncommon, but important to be aware of • Early detection can prevent harm • Involve whole team to support patient • Back of your mind

40. “it’s better to be a good doctor than a bad detective”

41. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disordes, Fifth Edition. Arlington, Va, American Psychiatric Association, 2013. 2. Bass, C. & Halligan P. Factitious disorders and malingering in relation to functional neurologic disorders. Handbook of Clinical Neurology, 2016; (Vol) 139. http://dx.doi.org/10/1016/B978-0-12-801772-2.0004204. Accessed March 2, 2019. 3. Ehrlich, S., Pfeiffer, E., Salbach, H., Lenz, K., & Lehmkuhl, U. (2008). Factitious Disorders in Children and Adolescents: A Retrospective Study, Psychosomatics, 49;5. 4. Levin, A. (2007, July 20). Factitious Disorder criteria need review for DSM-V. Psychiatric News, p. 1, https://doi.org/10.1176/pn.42.14.0012 5. Kozlowska, K. (2014). Abnormal illness behaviours: a developmental perspective. The Lancet, 383, pp. 1368-1369, http://dx.doi.org/10.1016/S0140-6736(13)62640-9 6. Libow, J. A. (2000). Child and adolescent illness falsification. Pediatrics, 105, pp. 336 – 342. 7. Jafferany, M., Khalid, Z., McDonald, K. A., & Shelley, A. J. (2018). Psychological aspects of factitious disorder. Prim Care Companion CNS Disord, 20(1). 8. Taylor, J. B., Beach. S. R., & Kontos, N. (2017). The therapeutic discharge: An approach to dealing with deceptive patients. General Hospital Psychiatry, 46, pp. 74 – 78. 9. Bass, C. & Glaser, D. (2014). Early recognition and management of fabricated or induced illness in children. Lancet, 383, p. 1412-21

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44. Areas of Controversy 1. Clinical validity of diagnosis 2. Difficulties in measuring intentionality and motivation