FACTITIOUS DISORDERS

FACTITIOUS DISORDERS

Voluntarily produced symptoms with no clear external gain, except possibly to assume the sick role for attention

Factitious Disorder Imposed on Another

(previously Munchausen syndrome by proxy) – An adult (often a mother) deliberately causes illness in another (usually a child) for attention or pity.

• Examples:

  • A mother stirred a child’s urine specimen with a menstrual tampon.

  • Another mixed feces into a child’s vomit.

  • A mother injected her urine into a child’s IV line, causing recurring E. coli infections.

• Characteristics: Offending parents often appear caring and cooperative, eluding suspicion from medical staff.

• Detection Methods:

  • Trial separation of parent and child.

  • Video surveillance: In a study of 41 patients with chronic, hard-to-diagnose issues, 23 cases were confirmed as factitious disorders imposed on another, with video surveillance diagnosing over half .

• Relation to Child Abuse: Considered an atypical form of child abuse due to deliberate harm for psychological gain.

UNCONSCIOUS COGNITIVE PROCESSES

these play a significant role in psychopathology, particularly in conversion disorders, where symptoms like paralysis or blindness occur without a medical basis, seemingly driven by unconscious mental processes (not necessarily as Freud envisioned).

Anna O

• At 21, Anna O. was nursing her dying father, experiencing significant stress. During a moment of mental wandering, she hallucinated a black snake moving to bite her father.

• Symptoms:

  • Attempting to grab the snake, she found her right arm "asleep" and imagined her fingers as poisonous snakes.

  • This led to paralysis in her right arm, later extending to the right side of her body and occasionally other areas, triggered by recalling the hallucination.

  • Other symptoms included deafness and an inability to speak her native German (while remaining fluent in English).

• Treatment: Under hypnosis with Josef Breuer, Anna relived the traumatic hallucination, a process called catharsis (emotional purging/releasing).

  • Outcome: Recalling and processing the traumatic images relieved her paralysis and restored her ability to speak German.

Catharsis is noted as an effective intervention for many emotional disorders

BLIND SIGHT

(unconscious vision) the ability to respond to visual stimuli without conscious awareness, observed in individuals with specific brain damage.

• Suggests that unconscious processing of sensory information (e.g., vision, hearing) is possible even in those without brain damage, relevant to conversion disorder symptoms.

Celia’s experiment

• Experiment: Two participants were hypnotized and given a suggestion of total blindness.

  • Participant 1: Instructed to appear blind at all costs, performed far below chance on a visual discrimination task (e.g., identifying an upright triangle), suggesting deliberate faking.

  • Participant 2: Given only the blindness suggestion, performed perfectly on the task but reported no awareness of seeing, indicating unconscious processing akin to conversion symptoms.

Implication: This study highlights differences between unconscious processes in conversion disorders and conscious faking (malingering).

Distinguishing Conversion Symptoms from Malingering

• Case Example: A male with apparent conversion blindness who performed worse than chance on a visual discrimination task, later confirmed to be malingering based on external evidence.

Prevalence

Rare in mental health settings; ~30% in neurological settings

Demographics

Primarily women, onset in adolescence

Historically reported in soldiers exposed to severe combat, particularly during World War I and II

Comorbidity

Common with somatic symptom, anxiety, and mood disorders

Prognosis (Adults)

Poor; ~50% recovery, high rehospitalization, 20% suicide attempts

Prognosis (Children)

Better; 85% recovery after 4 years, early diagnosis improves outcomes

Cultural Context

Symptoms may appear in religious rituals, not a disorder unless impairing to anxious patients without conversion symptoms.

There was no difference found in distress levels between conversion disorder patients and those with organic disease, contradicting Freud’s claim of indifference.

Key Stressors

Combat, interpersonal conflicts, sexual/physical abuse, loss

Social/Cultural Factors

Conversion disorder is more common in less educated, lower socioeconomic groups with limited knowledge of medical illness.

• Example: Only 13% of 30 adults with conversion-related motor disabilities had attended high school, compared to 67% of a control group with physical motor issues.

Prior Exposure: Familiarity with real physical problems in family members influences the choice of specific conversion symptoms.
Declining Incidence: The incidence of conversion disorders has decreased over time, likely due to increased public knowledge of real causes of physical problems, reducing opportunities for secondary gain

Biological Factors

Some cases suggest a biological vulnerability to conversion disorder under stress, linked to somatic symptom disorder.

Neuroscience Evidence: Brain-imaging studies show connectivity between conversion symptoms and emotion-regulating brain regions like the amygdala.

Example: Lower activity in the right inferior parietal cortex during conversion tremors, indicating possible neurological underpinnings.

Psychological Factors

In many cases, interpersonal factors are more significant than biological factors, emphasizing a psychological and social etiology for conversion disorder.

TREATMENT

Few systematic controlled studies exist on conversion disorder treatment, but clinical approaches are informed by its etiology and similarities to somatic symptom disorder.

Primary Treatment Strategy:

• Focus on identifying and addressing the traumatic or stressful life event causing the disorder, either in real life or memory.

• Catharsis: Therapeutic reexperiencing or “reliving” of the traumatic event, as seen in Anna O.’s case, is a key initial step to alleviate symptoms.

Reducing Secondary Gain:

Secondary Gain: Reinforcing consequences (e.g., attention, sympathy, avoidance of responsibilities) that maintain conversion symptoms must be minimized.

Challenges in Treatment

Family dynamics and inconsistent home support can lead to relapse

Cognitive-Behavioral Therapy (CBT)

• Effectiveness: In a study of 45 patients with mostly motor behavior conversions (e.g., difficulty walking), 65% responded well to a CBT-based program..

• Hypnosis: Used in about half the patients but provided little to no additional benefit compared to CBT alone.