Sunday, May 14, 2017

Looking for Empathy in All the Wrong Places: Bizarre Cases of Factitious Disorder




Factitious disorder is a rare psychiatric condition where an individual deliberately induces or fabricates an ailment because of a desire to fulfill the role of a sick person. This differs from garden variety malingering, where an individual feigns illness for secondary gain (drug seeking, financial gain, avoidance of work, etc.). The primary goal in factitious disorder is to garner attention and sympathy from caregivers and medical staff.

The psychiatric handbook DSM-5 identifies two types of factitious disorder:
  • Factitious Disorder Imposed on Self (formerly known as Munchausen syndrome when the feigned symptoms were physical, rather than psychological).
  •  
  • Factitious Disorder Imposed on Another: When an individual falsifies illness in another, whether that be a child, pet or older adult (formerly known as Munchausen syndrome by proxy).

Since the desire to elicit empathy is one of the main objectives in this disorder, it is odd indeed when the “patient” feigns a frightening or repellent condition. A recent report by Fischer et al. (2016) discussed a particularly flagrant example: the case of a middle-aged man who falsely claimed to be a sexually sadistic serial killer to impress his psychotherapist. Not surprisingly, his ruse was a complete failure.

The case report noted that Mr. S had been a loner his entire life:
 ... He described having anxiety growing up, mainly in social situations. ... Mr. S had a history of alcohol abuse starting in his mid-twenties and continuing into his early forties. He denied any significant medical history. He denied legal difficulties, psychiatric hospitalizations, and suicide attempts. He was single, had never been married, had no children, and reported having only one close friend for most of his life. He never had a close long-term romantic relationship and stated a clear preference for living a solitary life. 

Mr. S had served in the military but did not see combat, and afterwards worked the graveyard shift as a security guard (all the better to avoid people).
One year prior to his admission to the psychiatric hospital, Mr. S sought outpatient therapy for depression and engaged in weekly supportive psychotherapy with a young female psychology intern. His psychiatrist started an SSRI antidepressant and a low dose of antipsychotic medication for “depression with psychotic features.” Mr. S's alleged psychosis consisted of “voices” of crowds of people saying things that he could not make out, which he experienced while working the night shift. He consistently attended his therapy sessions and was noted to be making progress. However, several months into his therapy, Mr. S told his therapist that he had been involved in of military combat and described himself as a decorated war hero. After several therapy sessions in which he [falsely] recounted his combat experiences, Mr. S was queried as to whether he ever killed anyone, to which Mr. S replied, “During the military or after the military?” He then told his therapist that he had followed, raped, and killed numerous women during the 20 years since leaving the military.

He recounted his imaginary crimes to the young female intern:
Mr. S reported that he would follow a potential female victim for several months before raping and strangling her to death with a rope. Although he claimed to rape and kill the women, he did not describe any sexual arousal from the subjugation, torture, or killing of his alleged victims. He refused to disclose how many women he had killed, where he had killed them, or how he had disposed of their bodies. He described having purchased various supplies to aid in abduction, which he kept in the back of his van while cruising for victims. These supplies included rope and two identical sets of clothes and shoes to help evade detection by the police. He described using various techniques to track his victims, as well as evade surveillance of his activities. He informed his therapist that he was actively following a woman he had encountered in a local public library several days earlier. Mr. S acknowledged that he studied the modus operandi of famous sexually sadistic serial killers by reading books. The patient's therapist, feeling frightened and threatened by these disclosures, transferred his case to her supervisor, who then saw the patient for a few therapy sessions. Mr. S reported worsening depression, hearing more “voices,” and attempting to self-amputate his leg using a tourniquet. Consequently, Mr. S was involuntarily detained as a “danger to self” and “danger to others” for evaluation in the local psychiatric hospital.

He was diagnosed with major depressive disorder, single episode, unspecified severity, with psychotic features. His routine physical, neurological exam, and lab work all yielded normal results.
...The inpatient treatment team contacted the District Attorney's office in order to file for continued involuntary hospitalization due to the patient's homicidal ideation and history of violence. Subsequent police investigation and review of records could not substantiate any of the patient's claims of committing multiple homicides in the Pacific Northwest.
. . .

After the District Attorney accepted the application for the prolonged involuntary civil commitment (180-day hold), Mr. S was confronted with the inconsistencies between his self-reported symptoms and objective findings and the failure to corroborate his claims of prior homicides. In response, Mr. S then confessed that he “had made the whole thing up…about the killings…all of it” because he “wanted attention.” He said that he had never followed, raped, or killed anyone and never had an intention to do so. He said that he did not know why he claimed this, other than an “impulse came over me and I acted on it.”

His false identity as a serial killer backfired, and he couldn't understand why his therapist had discontinued their sessions:
He had believed that his feigned history and symptomatology would make him a “more interesting” patient to his therapist. He reported feeling rejected when his therapist transferred his care to her supervisor. He had little insight into why his therapist may have been frightened by his behavior. Mr. S revealed that following his initial fabrications, and despite his initial involuntary hospitalization, he had felt too embarrassed to admit the truth.

His original diagnosis was revised to “factitious disorder with psychological symptoms, and cluster A traits (particularly schizoid and schizotypal traits) without meeting criteria for any one specific personality disorder.” Because of these personality traits, he had no insight into why his therapist might feel threatened by his terrifying stories.

There are at least two other papers describing cases of factitious disorder with repugnant feigned symptoms: one reported a case of factitious pedophilia, and the other reported a case of factitious homicidal ideation.


Thanks to Dr. Tannahill Glen for the link.


References

Fischer, C., Beckson, M., & Dietz, P. (2017). Factitious Disorder in a Patient Claiming to be a Sexually Sadistic Serial Killer. Journal of Forensic Sciences, 62 (3), 822-826 DOI: 10.1111/1556-4029.13340

Porter, T., & Feldman, M. (2011). A Case of Factitious Pedophilia. Journal of Forensic Sciences, 56 (5), 1380-1382 DOI: 10.1111/j.1556-4029.2011.01804.x

Thompson CR, & Beckson M (2004). A case of factitious homicidal ideation. The journal of the American Academy of Psychiatry and the Law, 32 (3), 277-81. PMID: 15515916



Appendix

What are the symptoms of Factitious Disorder?

  • Dramatic but inconsistent medical history
  • Unclear symptoms that are not controllable, become more severe, or change once treatment has begun
  • Predictable relapses following improvement in the condition
  • Extensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illness
  • Presence of many surgical scars
  • Appearance of new or additional symptoms following negative test results
  • Presence of symptoms only when the patient is alone or not being observed
  • Willingness or eagerness to have medical tests, operations, or other procedures
  • History of seeking treatment at many hospitals, clinics, and doctors’ offices, possibly even in different cities
  • Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior health care providers

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