DSM-IV-TR criteria for factitious disorder
Although Mr. B experienced some depressive symptoms and anxiety just before discharge, we were hesitant to diagnose major depression because his symptoms appeared tied to situational factors. He also did not fit a particular personality disorder, although he showed characteristics of:- Intentional production or feigning of physical or psychological signs or symptoms.
- The motivation for the behavior is to assume the sick role.
- External incentives for the behavior are absent.
Source:Reference 6. Reprinted with permission
- cluster A (odd ideas, solitary lifestyle)
- cluster B (self-harm, narcissistic tendencies)
- and cluster C (avoiding his relatives, dependence on others to meet his needs).
Mr. B’s intentional production of physical symptoms strongly suggested malingering, but we instead diagnosed factitious disorder because he was clearly motivated to play the sick role despite lack of a secondary gain (Box 2). The patient admitted causing the gunshot wound and clearly connected his subsequent emotional relief with both his positive childhood experience in the hospital and his satisfaction after donating a kidney.
Researchers have tried to distinguish between factitious disorder and other types of self-harm. Claes and Vandereycken4 would consider Mr. B’s behavior “self-mutilation” rather than factitious. Turner calls DSM-IV-TR criteria for factitious disorder nebulous and says that lying about symptoms or their origin should be a necessary criterion.5 If so, then Mr. B’s condition might fit no DSM diagnosis.6
The authors’ observations
Although Mr. B’s diagnosis remained elusive, he needed a treatment plan before discharge to prevent another shooting and save his life.
Although we did not diagnose a major depressive or anxiety-spectrum disorder, we felt an SSRI such as citalopram could help. According to some investigators, SSRIs might benefit patients with over-valued ideas that are not as persistent as delusions.7,8
Additionally, we felt supportive therapy could help Mr. B establish a therapeutic relationship with a provider to whom he could turn during future crises. Should Mr. B contemplate self-harm, the therapist could suggest medications, hospitalization, or other interventions. We also recommended pastoral counseling to increase his support within his faith.
OUTCOME Another shot?
Before discharge, we start citalopram, 10 mg/d, and schedule a follow-up appointment within 2 weeks. We also suggest that Mr. B:
- move into an apartment near his outpatient doctors
- get involved with the local Catholic community to build his support network.
Mr. B calls his recent hospitalization upsetting because “I did not get the attention I wanted.” He endorses no immediate plan to shoot himself but voices concern that when his physical problems resolve, he might shoot Himself in the liver—as he had done 40 years ago—to bring himself full circle. “There’s still something attractive about this,” he says.
The authors’ observations
Patients with factitious illness commonly refuse mental health treatment.9
We feel Mr. B needs frequent ongoing appointments in a medical clinic where doctors can provide sufficient attention to counter his persistent self-harm urges. Regular appointments with a primary care physician—regardless of whether Mr. B is medically ill—could help him feel supported.
Related resources
- Feldman MD, Eisendrath SJ, eds. The spectrum of factitious disorders. Washington, DC: American Psychiatric Press; 1996.
- Sutton J, Martinson D. Self-injury Web site: What self-injury is.www.palace.net/~llama/psych/fwhat.html.
- Citalopram • Celexa
- Omeprazole • Prilosec
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.