Evaluation for Factitious Disorder in the Outpatient Setting

[QofQuimica]

Curious if anyone has advice for how to involve psych in evaluating a possible case of factitious disorder in a patient who is not currently admitted to the hospital. Given that the patient does not believe the issue is psych, I suspect that a referral for outpatient psych eval is unlikely to be embraced or complied with. Still, admitting someone to the hospital or transferring them to another facility for the sole purpose of consulting psych seems a bit excessive.

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[Merovinge]

Curious if anyone has advice for how to involve psych in evaluating a possible case of factitious disorder in a patient who is not currently admitted to the hospital. Given that the patient does not believe the issue is psych, I suspect that a referral for outpatient psych eval is unlikely to be embraced or complied with. Still, admitting someone to the hospital or transferring them to another facility for the sole purpose of consulting psych seems a bit excessive.

Really great question. If the patient does not have otherwise abnormal mental status, it is my opinion that factitious disorder can and sometimes should be diagnosed by the specialist for which the patient has the concern (GI, Pul etc). Psychiatric consultation should be offered if available but there is not some secret trick psychiatrists have to make the diagnosis. If you can find more empiric evidence for a factitious disorder (that is, caught red handed, collateral from family/other hospitals or providers being the most common), one can feel a lot more comfortable.

Explaining the diagnosis to the patient is very challenging and of utmost importance, particularly in factitious disorder. I make sure to cover the ways in which our minds can play tricks on us and that we understand how hard this situation must be for them. Gently offer consultation/followup with psychiatry/therapy in a way that shows you understand the symptoms are real to the patient and are likely debilitating and that we as a profession do want to help them get better.

These cases are emotionally, intellectually, and time intensive for hospitalists or whoever else is caring for the patient so just checking in with oneself to know ahead of time that A) These are tough cases, just like very rare/unusual medical phenomenon that we do understand B) Making an accurate diagnosis after being 100% sure all medical causes are ruled out C) These patients will need your support and you can make a difference.

 

[SeniorWrangler]

Investigating the role of stress and behavioral factors in patient presentation is often very helpful, but psychiatrist don't have any special ability to detect factiousness unless they walk into the office and find the paralyzed patient doing jumping jacks to pass the time. I have sometimes argued against this diagnosis as a consultant when I thought the patient was just embellishing, showing poor coping skills, etc., which did not make me very popular. If there is access to psychological testing, the MMPI can be pretty helpful with its fake bad scales.

 

[smalltownpsych]

"These physical problems and the fact we haven't found the answer for you must be very upsetting, anxiety-provoking, and stressful. The stress and worry make those physical symptoms worse and often a psychiatrist or psychologist just might be able to help you feel just a little bit better." I always emphasize that I don't think it is all in their head because everyone else they know has already told them that and that is where they will jump to with the referral. This is a variation of how I communicate to patients with various somatoform disorders. Not really sure if I have had a patient with true factitious disorder as it is fairly rare so take it for what it's worth.

Also, I don't really care if a patient's physical problem is real or not as it does not alter the treatment for their psychological problem.

 

[QofQuimica]

Also, I don't really care if a patient's physical problem is real or not as it does not alter the treatment for their psychological problem.

Agree. I'm not really looking to diagnose the patient's exact psychiatric issue just for the intellectual interest of it, and I don't think anyone would dispute that the patient is truly suffering and truly believes that more medical procedures/admissions/workups would be helpful or even necessary. But at this point, even the ER janitor thinks the patient has a psych disorder, never mind surgery, medicine, and everyone else who had been involved. Yet somehow, no one has ever taken what seems to be the next logical step and consulted psych, which I suspect is in large part because we all sense that the patient will almost certainly be resistant to the idea. And of course these types of patients are "difficult" patients that, as one colleague put it, "can't ever be pleased." Also, it doesn't help the situation that no one is ever happy to see this patient show up in the ER in the middle of the night for the third time this week with the same exact problems, and no doubt the patient is aware of how the ER and inpatient staff feel.

I believe I have possibly built up enough rapport with this patient that broaching the subject of seeing psych would at least be worth a try. And I really like the idea of presenting a psych referral as a way of helping to cope with the stress of having this debilitating illness that no one has been able to resolve. Besides being respectful of the patient's experience with being ill, this avenue could be pursued at the same time as other non-psych avenues are being pursued, and it may be met with less resistance. Thanks to you all for that suggestion.

 

[FlowRate]

Agree. I'm not really looking to diagnose the patient's exact psychiatric issue just for the intellectual interest of it, and I don't think anyone would dispute that the patient is truly suffering and truly believes that more medical procedures/admissions/workups would be helpful or even necessary. But at this point, even the ER janitor thinks the patient has a psych disorder, never mind surgery, medicine, and everyone else who had been involved. Yet somehow, no one has ever taken what seems to be the next logical step and consulted psych, which I suspect is in large part because we all sense that the patient will almost certainly be resistant to the idea. And of course these types of patients are "difficult" patients that, as one colleague put it, "can't ever be pleased." Also, it doesn't help the situation that no one is ever happy to see this patient show up in the ER in the middle of the night for the third time this week with the same exact problems, and no doubt the patient is aware of how the ER and inpatient staff feel.

I believe I have possibly built up enough rapport with this patient that broaching the subject of seeing psych would at least be worth a try. And I really like the idea of presenting a psych referral as a way of helping to cope with the stress of having this debilitating illness that no one has been able to resolve. Besides being respectful of the patient's experience with being ill, this avenue could be pursued at the same time as other non-psych avenues are being pursued, and it may be met with less resistance. Thanks to you all for that suggestion.

Just wanted to say major props for actually tackling the issue.

I don't have any special expertise in the issue aside from having seen it several times as a medical student (rotating at "quaternary care" hospitals will do that.) I think one of the big things that often gets omitted (in my very limited experience) is an unequivocal note in the EMR saying "hey, I'm an attending doctor and I think this patient does not have XYZ, please strongly reconsider any additional procedures in the future."

 

[nexus73]

In factitious disorder the patient knows they're faking with the goal of taking on the sick role. Essentially malingering for primary gain of being perceived as ill. Unlikely psychiatry can help much with this.

In conversion disorder the patient has physical symptoms stemming unconsciously from underlying psychological issues, which may be more amenable to psychiatry intervention.

 

[SeniorWrangler]

I believe I have possibly built up enough rapport with this patient that broaching the subject of seeing psych would at least be worth a try. And I really like the idea of presenting a psych referral as a way of helping to cope with the stress of having this debilitating illness that no one has been able to resolve. Besides being respectful of the patient's experience with being ill, this avenue could be pursued at the same time as other non-psych avenues are being pursued, and it may be met with less resistance. Thanks to you all for that suggestion.

Yeah, it goes down a lot better if it is perceived as part of medical care and not as an alternative to care (AKA turf to psychiatry).
If the ED has a frequent flier care planning program, it would be really helpful to get them on board, too. Having a good care plan that lays out contingencies can really help shape patient behavior, for example stressing non-opioid pain treatment for patient's typical pain complaint or plan to manage patient's typical symptoms with minimal treatment and reassurance rather than a full workup. This needs to be done carefully and professionally, of course.

 

[QofQuimica]

Right. We already have all agreed (EM, IM, and surgery) not to give the patient any opiates. The patient is aware of this; several docs in all three departments have explained that opiates are not helpful for this problem and will not be given. I think many of us figured after we made this agreement that it would stop the patient from coming in several times per week. No doubt if the patient's main motivation were to gain opiates, that would be true. However, there has been no change in the number of the patient's visits to the ER. One would logically also assume that having surgery would solve the problem, if it were a "real" surgical issue. Clearly that has not happened either. Which is why I have to think there is some other non-surgical, non-addiction motivation for the patient to continue coming in. The patient still wants to be in the hospital and still wants to undergo additional tests and procedures, even while lamenting that nothing is helping, and even knowing that no opiates will be given.

 

[Shikima]

Right. We already have all agreed (EM, IM, and surgery) not to give the patient any opiates. The patient is aware of this; several docs in all three departments have explained that opiates are not helpful for this problem and will not be given. I think many of us figured after we made this agreement that it would stop the patient from coming in several times per week. No doubt if the patient's main motivation were to gain opiates, that would be true. However, there has been no change in the number of the patient's visits to the ER. One would logically also assume that having surgery would solve the problem, if it were a "real" surgical issue. Clearly that has not happened either. Which is why I have to think there is some other non-surgical, non-addiction motivation for the patient to continue coming in. The patient still wants to be in the hospital and still wants to undergo additional tests and procedures, even while lamenting that nothing is helping, and even knowing that no opiates will be given.

Need a medical psychologist to help assist you with this conundrum. They'll have the time to be able to fully explore the behavior as related to medical urgency.

 

[splik]

You haven't really described why you think the patient has a factitious disorder. But it's great you are thinking about these things! I think a lot of docs just decide something is "psych" without trying to think of what the diagnosis is. However factitious disorder exists on a spectrum of abnormal illness behavior and many people (include most psychiatrists) do not actually seem to understand this, or the difference between the terms.

Factitious Disorder - Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception, in the absence of obvious external rewards

Munchausen's syndrome - Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception, in the absence of obvious external rewards PLUS chronic peregrination (goes from town to town, hospital to hospital, doctor to doctor) and pseudologia fantastica (tells wicked compelling stories that are ridiculous but you really want to believe)

Malingering - Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception, with obvious external reward

Feigning - Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception, where no determination of motivation is made

Elaboration of symptoms for psychological gain - Physical symptoms compatible with and originally due to a confirmed physical disorder, disease, or disability become exaggerated or prolonged due to the psychological state of the patient. An attention-seeking (histrionic) behavioral syndrome develops, which may also contain additional (and usually nonspecific) complaints that are not of physical origin.

Psychosomatic - This really refers to any chronic medical condition in which psychological factors are important. Rheumatoid Arthritis, Crohn's Disease, Asthma, Diabetes, Multiple Sclerosis and so on are all psychosomatic conditions. Not to be confused with somatoform disorders .. Psychosomatic disorders are recognized in DSM-5 by the "psychological factors affecting another medical condition" diagnosis

Somatoform disorders - repeated presentation of physical symptoms, together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis. c.f. psychosomatic which is often confused with somatoform

Somatization - the use of physical symptoms, often from multiple organ systems as an idiom of distress

Somatization disorder - this was dropped from DSM-5 but refers to individuals with multiple unexplained physical symptoms from 4 different organ systems including pseudoneurological, genitourinary, GI, and musculoskeletal symptoms with recurrent help-seeking behavior

Conversion Disorder - now known as functional neurological disorder (FND), refers to unexplained neurological symptoms. psychological etiology or associated psychosocial factors are no longer necessary or presumed for the diagnosis. It is not a diagnosis of exclusion and should be made on the basis of history and examination identifying physical features compatible with the diagnosis

Compensation neurosis - "Compensation neurosis is a state of mind, born out of fear, kept alive by avarice, stimulated by lawyers, and cured by a verdict". It refers to physical or psychological symptoms that are caused, exaggerated, exacerbated and/or maintained by pending litigation, and where symptoms remit following successful award of damages to the plaintiff.

In practice there is a significant overlap between these different categories. It is not uncommon for factitious disorder patients to be drug-seeking or involved in litigation, but there has to be more to it than that.

 

[nitemagi]

Good advice all around here. The coping with stress approach is often more palatable (and actually true). It ultimately will have to managed through good outpatient care because it takes a while to get to the core, and to develop a deep enough rapport for them to be willing to go there. These can be some of the most difficult cases, even for someone that does this regularly. I've seen a fair share. The biggest difficulty is keeping them engaged long enough to actually work on the issue, and getting therapeutic leverage to want to change (the primary/secondary gain issues can be incredibly fixed sometimes). But I've had a good number of success stories. There are a number of hypnosis approaches that can be very successful with the full range of somatic symptom disorders.

Since many of these people are high utilizers of services, you can also make a case to get the hospital to cover some expert outside psychiatric consultant, as even at a full price private practice provider it'll probably reduce costs. At least that's an argument that can be made.

 

[smalltownpsych]

Need a medical psychologist to help assist you with this conundrum. They'll have the time to be able to fully explore the behavior as related to medical urgency.

Sometimes a psychologist is useful in these cases just because we aren't medical docs. It can still take awhile though for the patient to figure out that I am not going to address any physical complaints and really only want to hear about what they are thinking, feeling, and doing in their life outside of the medical. Initially there is often not much outside of that though. It is amazing to watch when I ask how they feel about some significant real event or relationship in their life and they can't really say anything and then start talking about their medical stuff again. This is one area that some of Freuds thinking still holds up pretty well. Which makes sense since that was the population he was working with.