Factitious Disorders, Malingering And Psychiatric Emergencies

Psychiatry II Factitious Disorder, Malingering, Psychiatric Emergencies Dra. Aireen Capitan and Dr. Joge Los Baños 3rd Shifting/November 27, 2008 Shar, Maqui, Viki FACTITIOUS DISORDER -

Intentional production of symptoms Entire motivation: o SICK ROLE o Assume the role of a patient WITHOUT an external incentive

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Epidemiology: o Largely unknown general population  Hospital and healthcare worker > general population o Probably female > male o 1% in psych consult in general hospital o 9% among in-patients in one study o 10% of Fever of Unknown Origin in one study

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Co-morbidity: o Mood disorders o Personality disorders o Substance-related disorders

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Etiology: o Psychosocial factors:  Psychodynamics poorly understood because of difficulty in psychotherapy among patients

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Factitious Disorder with Combined Psychological and Physical S/Sxs o Both psychological and physical s/sxs present o Neither type predominates

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Factitious Disorder not Otherwise Specified o Factitious Disorder by Proxy  Person intentionally produces s/sxs in another person who is under the first person’s care  Purpose: • Caretaker indirectly assume sick role • Relieved of the caretaking role  DSM-IV-TR Diagnostic Criteria • Intentional production of s/sxs in another person who is under the individual’s care • Motivation for the perpetrator’s behavior: assume sick role by proxy • Absent external incentive • Behavior is not better accounted for by another mental disorder

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Pathology and Laboratory Exam: o Psychological testing:  IQ – normal or above average  Strong independence  Narcissistic  POOR • Sense of identity • Sexual adjustment • Frustration tolerance

impaired

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DSM-IV-TR Diagnostic Criteria: o Intentional production of S/Sxs o Motivation: assume sick role o Absent external incentives

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Clinical features: o Secure information from other sources  Family/relatives/friends o Verify facts about  Previous hospitalizations/medical care

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Factitious Disorder with Predominantly Psychological S/Sxs: o Feigned symptoms:  Depression  Hallucination  Dissociative symptoms

Impostorship

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History of child abuse/deprivation  hospitalization

Brain dysfunction  information processing

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Factitious Disorder with Predominantly Physical S/Sxs: o Aka: Munchausen Syndrome, Hospital Addiction, Polysurgical Addiction o Essential feature: present sxs very well to be able to gain admission to, and stay in a hospital o Patients:  Familiar with a lot of medical disorder  Myriad clinical presentation  Demand specific medications for treatment  Demanding and difficult

Families from rejecting moms/absent fathers  recreate positive parentchild bond Biological factors:

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Conversion symptoms Pseudologica fantastica

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MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

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o

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Minnesota Multiphasic Personality Inventory –2  Invalid test profile  Elevation of all clinical scales  “fake bad” Other lab tests like drug screening

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Differential Diagnosis: Factitious Disorder Somatoform disorder Voluntary production of S/Sxs Submit to mutilating procedures Personality disorder Request for invasive (Anti-social) procedure Multiple hospitalizations Schizophrenia Do not meet diagnostic criteria for schizophrenia except for fixed delusion Malingering No external incentive Substance abuse Requests for specific medication Ganser’s Syndrome May give appropriate answers -

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Course and Prognosis: o Begin early adulthood o Onset may follow real illness/loss/rejection/abandonment o Previous hospitalization due to real illness  successive hospitalization  increased medical know-how o Most cases --- POOR PROGNOSIS o Few patients die because of needless meds, instrumentation or surgery o Good Prognosis:  (+) depressive-masochistic personality  Functioning at a borderline, not a continuously psychotic level Attributes of antisocial personality disorder with minimal symptoms

Treatment: o No specific therapy o Management rather than cure o MD’s early recognition of the disorder o Good liaison between psychiatrist medical/surgical staff o Confrontation?! o Pharmacotherapy? MALINGERING

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External motivation: o Avoid difficult or dangerous situations/responsibilities/ punishments o Receive compensation, free hospitalization, source of drugs o Retaliate when patient feels guilt or suffers financial loss, legal penalty job loss

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Epidemiology: o Incidence: unknown o Common in settings with a preponderance for men

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Should be strongly suspected if: o Medicolegal context of presentation o Person’s claimed stress/disability ≠ objective findings o Lack cooperation during diagnostic evaluation and treatment compliance o Presence of antisocial personality disorder

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Differential diagnosis: o Factitious Disorder  no external incentives o Somatoform Disorder

Ganser’s Syndrome o Condition associated with prison inmates o Patients respond to simple questions with astonishingly incorrect answers o Maybe a variant of malingering

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Characterized by: o Voluntary production of false sxs

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Production of symptoms not intentional Symptom relief may be obtained by suggestion or hypnosis

Treatment: o Thorough evaluation o Preserve doctor-patient relationship o Intensive treatment approach as though symptoms were real PSYCHIATRIC EMERGENCIES

DEFINITION • A psychiatric emergency is any disturbance in thoughts, feelings, or actions for which immediate therapeutic intervention is necessary PSYCHIATRIC EMERGENCIES • Suicide and self-injury • Violence and Assault o Homicide o Rape o Abuse of children, spouses • Others o Abuse of substances o Altered mental status in medical disease o Social issues (homelessness, aging, competence) o Specific psychiatric disorders/entities GENERAL STRATEGIES IN EVALUATING PATIENTS • Self-protection A. Know as much as possible about the patients before meeting them B. Leave physical restraint procedures to those who are trained to handle them

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C. Be alert to risks of impending violence D. Attend to the safety of the physical surroundings (e.g., door access, room objects) E. Have others present during the assessment if needed F. Have others in the vicinity G. Attend to developing an alliance with the patient (e.g., do not confront or threaten patients with paranoid psychoses) Prevent harm A. Prevent self-injury and suicide. 1. Use whatever methods are necessary to prevent patients from hurting themselves during the evaluation B. Prevent violence toward others. During the evaluation, briefly assess the patient for the risk of violence. If the risk is deemed significant, consider the following options: 1. Inform the patient that violence is not acceptable. 2. Approach the patient in a nonthreatening manner. 3. Reaasure or calm the patient or assist in reality testing. 4. Offer medication. 5. Inform the patient that restraint or seclusion will be used if necessary. 6. Have teams ready to restrain the patient. 7. When patients are restrained, always closely observe them, and frequently check their vital signs. Isolate restrained patients from agitating stimuli. Immediately plan a further approach medication, reasseurance, medical evaluation.

RULE OUT: • cognitive disorders

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caused by general medical condition impending psychosis

SUICIDE DEFINITION “A conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which the act is perceived as the best solution” – Edwin Shneidman • • • • •

Incidence Sex Methods Age Race

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Religion Marital status Occupation

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Climate Physical health Mental health

THEORIES • Durkheim o Anomic o Egoistic o Altruistic • Freud • Meninger FACTORS Rank Order 1 2 3 4 5 6 7 8 9 10 11 12 13

ASSOCIATED WITH SUICIDE RISK Factor Age (45 and older) Alcohol dependence Irritation, rage, violence Prior suicidal behavior Male Unwilling to accept help Longer than usual duration of current episode of depression Prior in-patient psychiatric treatment Recent loss or separation Depression Loss of physical health Unemployed or retired Single, widowed, or divorced

EVALUATION OF SUICIDE RISK Demographic and Social Variable High risk Age Over 45 years Sex Male Marital status Divorced or widowed Employment Unemployed Interpersonal Conflictual relationship Family Chaotic or background conflictual Health Variable High Risk Physical Chronic illness hypochondriac Excessive substance intake Mental Severe depression psychosis Severe personality disorder Substance abuse hopelessness Suicidal Activity Variable High Risk Suicidal ideation Frequent, intense, prolonged Suicidal attempt Multiple

Profile Low risk Below 45 years Female Married Employed Stable Stable Low Risk Good health Feels healthy Low substance use Mild depression Neurosis Normal personality Social drinker optimism Low Risk Infrequent, low intensity, transient First attempt

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attempts planned Rescue unlikely Unambiguous wish to die Communication internalized (selfblame) Method lethal and available Variable Personal

Social

Resources Variable Poor achievement Poor insight Affect unavailable or poorly controlled Poor rapport Socially isolated Unresponsive family

Brain diseases, global or with frontal lobe findings; less commonly with temporal lobe findings (controversial) Assess the risk for violence o Consider violent ideation, wish, intention, plan, availability of means, implementation of plan, wish for help o Consider demographics – sex (male), age (15-24), socioeconomic status (low), social support (few) o Consider the patient’s history: violence, nonviolent antisocial acts, impulse dyscontrol (e.g., gambling, substance abuse, suicide or self-injury, psychosis) o Consider overt stressors (e.g. marital conflict, real or symbolic loss) o

Impulsive Rescue inevitable Primary wish for change Communication externalized (anger) Method of low lethality or not readily available Variable Good achievement Insightful Affect available and appropriately controlled Good rapport Socially integrated Concerned family

HISTORY, SIGNS, AND SYMPTOMS OF SUICIDAL RISK 1 Previous attempt or fantasized suicide 2 Anxiety, depression, exhaustion 3 Availability of means of suicide 4 Concern for effect of suicide on family members 5 Verbalized suicidal ideation 6 Preparation of a will, resignation after agitated depression 7 Proximal life crisis such as mourning or impending surgery 8 Family history of suicide 9 Pervasive pessimism or hopelessness TREATMENT • Hospitalization • Out-patient management • Pharmacotherapy • Psychotherapy VIOLENCE AND ASSAULT ASSESSING AND PREDICTING VIOLENT BEHAVIOUR • Signs of impending violence o Recent acts of violence, including property violence o Verbal or physical threats (menacing) o Carrying weapons or other objects that may be used as weapons (e.g., forks, ashtrays) o Progressive psychomotor agitation o Alcohol or other substance intoxication o Paranoid features in a psychotic patient o Command violent auditory hallucinations – some but not all patients are at high risk

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SUBSTANCE ABUSE • •

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Determine the nature of substance Determine the nature of use  Duration  Amount  Frequency  Last intake Treat specific substance toxicology

ALTERED MENTAL STATUS IN MEDICAL DISEASE • • •

Establish symptomatology Determine the medical disease Treat underlying medical disease

FEATURES THAT POINT TO A MEDICAL CAUSE OF A MENTAL DISORDER • Acute onset ( within hours or minutes, with prevailing symptoms) • First episode • Geriatric age • Current medical illness or injury • Significant substance abuse • Non-auditory disturbance of perception • Neurological symptoms o loss of consciousness, seizures, head injury, change in headache pattern, change in vision • Classical mental status signs o diminished alertness, disorientation, memory impairment, impairment in concentration and attention, dyscalculia, concreteness • Other mental status signs o speech, movement or gait disorders • Constructional apraxia o Difficulties in drawing clock, cube, intersecting pentagons, bender gestalt design •

Catatonic features o Nudity, negativism, combativeness, rigidity, posturing, waxy, flexibility,

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echopraxia, muteness

echolalia,

grimacing,

COMMON GLOBAL CNS DISORDER THAT REAQUIRE IMMEDIATE TREATMENT 1. Hypoglycemia – dextrose 50% IV or juice orally, immediately give to all diabetics 2. Wernicke’s encephalopathy – thiamine, 100mg IV, immediately 3. Opioid intoxication – naloxone (Narcan), 4mg IV, immediately COMMON FOCAL CNS DISORDER WITH BEHAVIORAL FEATURES 1. Aphasias – fluent or receptive aphasia results in patient’s not understanding spoken word, although they have fluent but incoherent speech 2. Frontal lobe syndromes – changing in motor behavior, ability to concentrate, reasoning, thinking, social judgment, and impulse control 3. Temporal Lobe Syndromes – psychosis, seizure, personality and Kluver-bucy features 4. Parietal Lobe Syndromes – right lesion with denial and hypomania 5. Occipital lobe Syndrome – Anton’s syndrome (cortical blindness with denial) SOCIAL ISSUES • • •

Homelessness Aging Competence

SPECIFIC PSYCHIATRIC DISORDER/ ENTITIES

RESTRAINTS USES: 1.

2. 3.

4. 5. 6. 7.

Preferably 5 or a minimum of 4 persons should be used to restrain the patient. Leather restraints are the safest and surest type of restraints Explain to the patient why he or she is going into restraints A staff member should always be visible and reassuring the patient who is being restrained. Reassurance helps alleviate the patient’s fear of helplessness, impotence, and loss of control. Patients should be restrained with legs spreadeagled and one arm restrained to one side and the other arm restrained over the patient’s head. Restraints should be placed so that IV fluid can be given if necessary. The patient’s head is raised slightly to decrease the patient’s feeling of vulnerability and to reduce the possibility of aspiration The restraints should checked periodically for safety and comfort

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After the patient is in restraints, the clinician begins treatment, using verbal intervention 9. Even in restraints, a majority of patients still take antipsychotic medication in concentrated form 10. After the patient is under control, one restraint at a time should be removed at 5-minute intervals until the patient has only two restraints on. Both of the remaining restraints should =be removed at the same time, because it is inadvisable to keep a patient in only one restraint 11. Always thoroughly document the reason for the restraints, the course of treatment, the patient’s response to treatment while in restraints I never quite figured out why the sexual urge of men and women differ so much. And I never have figured out the whole Venus and Mars thing. I have never figured out why men think with their head and women with their heart. FOR EXAMPLE: One evening last week, my girlfriend and I were getting into bed. Well, the passion starts to heat up, and she eventually says "I don't feel like it, I just want you to hold me." I said "WHAT??!! What was that?!" So she says the words that every boyfriend on the planet dreads to hear... "You're just not in touch with my emotional needs as a woman enough for me to satisfy your physical needs as a man." She responded to my puzzled look by saying, "Can't you just love me for who I am and not what I do for you in the bedroom?" Realizing that nothing was going to happen that night, I went to sleep. The very next day I opted to take the day off of work to spend time with her. We went out to a nice lunch and then went shopping at a big, big unnamed department store. I walked around with her while she tried on several different very expensive outfits. She couldn't decide which one to take so I told her we'd just buy them all. She wanted new shoes to compliment her new clothes, so I said let's get a pair for each outfit. We went onto the jewelry department where she picked out a pair of diamond earrings. Let me tell you...she was so excited. She must have thought I was one wave short of a shipwreck. I started to think she was testing me because she asked for a tennis bracelet when she doesn't even know how to play tennis. I think I threw her for a loop when I said, "That's fine, honey." She was almost nearing sexual satisfaction from all of the excitement. Smiling with excited anticipation she finally said, "I think this is all dear, let's go to the cashier."

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I could hardly contain myself when I blurted out, "No honey, I don't feel like it." Her face just went completely blank as her jaw dropped with a baffled WHAT?" I then said "honey! I just want you to HOLD this stuff for a while. You'rejust not in touch with my financial needs as a man enough for me to satisfy your shopping needs as a woman." And just when she had this look like she was going to kill me, I added, "Why can't you just love me for who I am and not for the things I buy you?" Apparently I'm not having sex tonight either.