Tag Archives: Sick Role

Factitious Disorders | Factitious Disorder by Proxy | Munchausen Syndrome

Factitious Disorders and Factitious Disorder by Proxy covers the disorders formerly known as Munchausen Syndrome.  By definition, factitious disorders are a condition in which symptoms are feigned or created by the patient.  This might manifest in by someone complaining about a pain that doesn’t exist, or it might result in the client drinking a pint of Drain-o to get sick.  Generally speaking, the goal or objective is to assume the “sick role,” and subsequently obtain the benefits that are generally imbued on them as a result.

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Do kids start lying as early as age 2?  It would appear that they learn to lie about the same time they learn how to talk.

“As children, many of these patients experienced rejection, mistreatment, and parental loss.  For them, the hospital provides a haven or refuge.”  (Netherton, Holmes, & Walker, 1999, p. 305-306)  I have trouble identifying with this… you couldn’t pay me to go to a hospital; I avoid them like I avoid the plague.  I don’t know if most “normal” people feel like that, but it’s about the last place I would consider a refuge…

Factitious disorders are best differentiated from malingering by accessing the goal.  “Only when the sick role becomes part of the child’s life can the diagnosis of factitious disorder be considered.”  (Netherton et al., 1999, p. 306)  So, factitious disorders represent more than malingering in a sense that they are persistent efforts to appear sick, without any apparent short term goal other than to obtain the sick role status.  If that means the client has to lie, they often do.  The symptoms are intentionally produced, and the patient can voluntarily make them appear or disappear.  In that respect, they differ from somatoform disorders because they are voluntary, not involuntary.  Where malingerers pretend to be sick, somatoform sufferers feel doomed to be sick, and sufferers of factitious disorder creating symptoms that to ensure that status.  (Netherton et al., 1999, p. 307)

Treatment begins with confrontation.  A “normal” person (I am not sure I can ever write the word normal again without the “”) would probably stop lying right there and the problem would be solved.  Unfortunately, that confrontation does not typically resolve the issue with factitious disorders.  I was surprised to see that the relationship typically improves after that process occurs though… I wonder if there is a sense of relief on the part of the client that they have been caught.

The “by proxy” version of Factitious Disorder is fascinating.    Check out this video… I couldn’t believe my eyes! http://www.youtube.com/watch?v=UVLqADEdrig&feature=related People who suffer from this disorder make their kids sick, or engage in deceptive behavior to make them appear sick… ultimately in an effort to gain attention or sympathy.  The average time taken to uncover the proxy diagnosis was estimated to be 14.9 months!  (Netherton et al., 1999, p. 310)  Although the text makes a case for more widespread general knowledge, that process has unfortunately led to many false identifications and misdiagnosis.  One surefire way to identify the proxy diagnosis is to remove the child from the care of the parent or caregiver and see if their issues persist.  Another (more controversial, if that’s even possible) method is to covertly attempt to videotape the act of child abuse.  Imagine the legal ramifications if you were wrong!  It’s a pretty hefty gamble; we could potentially lose a license over a misdiagnosis like that.

How does mandatory reporting play into this “by proxy” diagnosis.  I mean, if you even suspect this as a possible diagnosis, don’t you have to report it?

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Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Somatoform Disorders



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Somatoform Disorders could be summed up in the following statement… “there are more questions than answers.”  (Blaney & Millon, 2009, p. 499)  As a collection of disorders, it appears as though they don’t belong under the same heading or classification.  Many have more in common with Obsessive-Compulsive Disorder (OCD) than they have with each other.

“The common feature of the somatoform disorders is the presence of physical symptoms that suggest a general medical condition and are not fully explained by a general medical condition, nor by the direct effects of substance, or by another mental disorder.”  (Blaney & Millon, 2009, p. 483)  Somatoform can only be diagnosed by the process of exclusion… which seems odd to me.  It represents a “curve ball” for medical and mental health professionals, because the underlying consensus is that the client “believes they have an ailment, but they don’t.”  I don’t use “very, very” very often, but this has to make it very, very difficult to diagnose.  It might give some explanation to the very low prevalence rates.

I would have expected a greater degree of stress or anxiety in a patient that presents with this disorder, as would be typical of someone who presents with symptoms that can’t be explained.  “Patients with these disorders typically experience little or no anxiety, whereas those with so-called preoccupation disorders are excessively concerned or anxious about the notion that there is something physically wrong with their bodies.”  (Blaney & Millon, 2009, p. 483)  Can we use this lack of anxiety as a “flag” for diagnosis?

The “sick role” seems to be an underlying sociological construct among all the somatoform disorders.  Sick role implies granted privileges (staying home from work) and avoidance of obligations because one has to comply with medical instructions.

I was particularly interested and enthralled with the cultural differences in the presentation of Conversion Disorder (CD).  Not only is it more prevalent among rural residents from low socioeconomic backgrounds, but there is remarkable differences between geographical areas.  The text cited frequent cases of “burning hands” in Asia, which are typically never reported in the Western world.  (Blaney & Millon, 2009, p. 487)

Pain disorder is another anomaly.  What surprised me is that typical clients don’t come to treatment because of the degree or intensity of the perceived pain, but are more likely to come seeking respite from the psychological costs of pain management.  I could anticipate that this would be one of the most debilitating somatoform disorders because of its ability to disconnect clients from family, friends, work, and recreation.  (Blaney & Millon, 2009, p. 487)

I was relatively familiar with the concept of hypochondriasis before reading the text, but I was wholly unaware of the underlying theoretical etiology.  The concept of increased sensitivity to innocuous bodily sensations is new to me.  I was aware that some clients have formed selective attention to illness formation, risk perception, and misinterpretation of benign symptoms.  The suggestion that it is triggered by critical incidents, and is predispositioned by parental attitudes rings true to me.  I was also suitably surprised by the transient nature of the disorder, since it can apparently go into full remission and then appear again when a stressor appears.

Body Dysmorphic Disorder (BDD) is fascinating, quite honestly I have never heard of it.  I think this probably has more to do with societal views of “what is beautiful” than we think.  I was not at all surprised by the suggestion that some believe it to be delusional in nature.  I am a “perfectionist type” myself, but I never in my life would have dreamed this could be one of the results of that predisposition.  The text suggests that it may be compounded by being teased or bullied as a teenager (during puberty), leading to a general lack of social skills and self conscious maladaptive behavior.

Factitious Disorder is when “physical symptoms are produced or feigned intentionally to assume the sick role.”  (Blaney & Millon, 2009, p. 492)  The concept of “hospital hopping” in effort to undergo medical procedures, even surgery, is amazing.  The fact that these patients frequently lie about the nature of their symptoms, and life circumstance in general, probably contribute to the difficulty of diagnosing and treating this disorder.  I mean, how can you believe them?  I would question everything that came out of their mouth, it might be increasingly difficult to sort out “real issues” from “fake ones.”

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.