is it factitious disorder or more related to inability to tolerate any stress

[Igor4sugry]

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I have been doing more C/L this year (but this is 4th year I'm seeing C/L patients in residency, just more this year). And have been noticing that patients who manipulate their PICC lines, play with their wounds, etc. usually come with long and psychiatric histories, neglectful/traumatic upbringing, multiple psychiatric diagnoses, ongoing major social stressors.
I have more difficulty with attributing their medical behavior to factitious disorder rather than poor coping skills or another example of self-injurious behavior. DSM V now has this Psychological Factors Affecting Other Medical Conditions diagnosis as well. So it is all starting to blur in my mind. Certainly the behavior of these patients is dangerous, but it is unclear which diagnosis to sign? Or even what is the point of assigning the diagnosis rather than naming the behavior and referring to therapy to treat this.

 

[wolfvgang22]

Good observation, you aren't wrong.
Expand your differential. Don't forget about things like Munchausen's, somatoform, and personality disorders.

 

[DD214_DOC]

Don't worry about the label so much, person already has plenty to choose from.

I'm guessing the behavior of fiddling around with medical stuff/wounds/whatever pisses off authority figures/caretakers (nurses, docs) who then start to hate him/her and act hostile or passive-aggressive towards him/her, then the person laments that all the medical staff are jerks and none of them really care?

 

[watto]

Sometimes I feel like half the content of my therapy sessions is "What are you feeling and how can you express it in as crystal clear a manner as is possible? Anything less is such an inefficient way of having your needs met."

The other half goes something like this:
Michael: The feeling that you're feeling is what many of us call...a feeling.
Gob: It's not like envy, or even hungry.
Michael: Could it be love?
Gob: I know what an erection feels like, Michael. No, it's the opposite. It's like my heart is getting hard.[/QUOTE]

 

[smalltownpsych]

Don't worry about the label so much, person already has plenty to choose from.

I'm guessing the behavior of fiddling around with medical stuff/wounds/whatever pisses off authority figures/caretakers (nurses, docs) who then start to hate him/her and act hostile or passive-aggressive towards him/her, then the person laments that all the medical staff are jerks and none of them really care?

Exactly. The diagnostic label can sometimes be helpful in determining the cause of the behavior but ultimately the question people want to know is not what the label is but the why. Once you know the determinants of the behavior, then you tell the staff how to handle it. When this works, the behavior shifts and you did your job. Going on a consult and saying it's Munchausens and they need therapy is something anyone can do. Advising staff to react minimally while still treating the medical to these behaviors to eliminate the scondary gain and to focus on other aspects of patient might be helpful advice. Eliminating self harm behaviors is fairly easy when principles of conditioning are understood and implemented well. Focus on the cause not the behavior. It's sort of a problem throughout our field since the design of the DSM is the opposite.

 

[DD214_DOC]

Exactly. The diagnostic label can sometimes be helpful in determining the cause of the behavior but ultimately the question people want to know is not what the label is but the why. Once you know the determinants of the behavior, then you tell the staff how to handle it. When this works, the behavior shifts and you did your job. Going on a consult and saying it's Munchausens and they need therapy is something anyone can do. Advising staff to react minimally while still treating the medical to these behaviors to eliminate the scondary gain and to focus on other aspects of patient might be helpful advice. Eliminating self harm behaviors is fairly easy when principles of conditioning are understood and implemented well. Focus on the cause not the behavior. It's sort of a problem throughout our field since the design of the DSM is the opposite.

Yep, the DSM made us stupid, and the, "quest for the right label" is one of the dumbest things in this field.

Honestly, I fall back a lot on my undergraduate education in psychology. I always continued to learn more about human behavior, especially in areas that psych residency doesn't even touch, such as learning theory. (You get a very simplified version). I tossed around going for a master's or phd just for the added knowledge, but decided it's cheaper to just buy the books and read them.

9/10 patients and parents react to the behavior and never ask, "why". THis is the whole point of therapy, to assist the pt in developing psychological mindedness if they have the capacity to do so, or to develop it to whatever capacity they are capable. I force people to think about their behavior and what they get out of it, and I will directly ask this: "What does it do for you when you do that?" Usually that's followed by, "You wouldn't keep doing it if you didn't get something out of it". You may not get a real answer or the first answer may not be right, but you've planted the seed that there's more to behavior than the behavior itself. I'm willing to bet this is the first time anyone has asked them that question.

We really neglect the basic stuff. Ignoring basic learning theory and human behavior in psychiatry is like an ER doc ignoring the ABCs

 

[deleted343839]

I force people to think about their behavior and what they get out of it, and I will directly ask this: "What does it do for you when you do that?" Usually that's followed by, "You wouldn't keep doing it if you didn't get something out of it". You may not get a real answer or the first answer may not be right, but you've planted the seed that there's more to behavior than the behavior itself. I'm willing to bet this is the first time anyone has asked them that question.

If someone has the insight to give you a good answer to that question, that's great. But in line with your comments and smalltownpsych's, I think that formal behavioral assessment is really underutilized in the C/L setting.

 

[nitemagi]

A large majority of our diagnoses are really maladaptive patterns of behavior that are ineffective to get your needs met, once did, and are now causing problems. Symptom-Context.

 

[thoffen]

I don't know that I see it the same way. Faking or intentionally producing medical symptoms for secondary gain, particularly identification with the sick role is factitious disorder. The error I think is stopping there. It's the and that's important, which may or may not include further DSM-style diagnoses -- also recognition that the DSM is a starting point and not a practice manual. However identifying factitious behavior is highly important as it leads to appropriate investigation of harm reduction strategies and setting priorities in treatment. I agree that they have maladaptive coping mechanisms, but the behavior is dangerous to self, to the system, or to both.

 

[nitemagi]

I don't know that I see it the same way. Faking or intentionally producing medical symptoms for secondary gain, particularly identification with the sick role is factitious disorder. The error I think is stopping there. It's the and that's important, which may or may not include further DSM-style diagnoses -- also recognition that the DSM is a starting point and not a practice manual. However identifying factitious behavior is highly important as it leads to appropriate investigation of harm reduction strategies and setting priorities in treatment. I agree that they have maladaptive coping mechanisms, but the behavior is dangerous to self, to the system, or to both.

It's not conscious/deliberate much of the time.

 

[smalltownpsych]

I don't know that I see it the same way. Faking or intentionally producing medical symptoms for secondary gain, particularly identification with the sick role is factitious disorder. The error I think is stopping there. It's the and that's important, which may or may not include further DSM-style diagnoses -- also recognition that the DSM is a starting point and not a practice manual. However identifying factitious behavior is highly important as it leads to appropriate investigation of harm reduction strategies and setting priorities in treatment. I agree that they have maladaptive coping mechanisms, but the behavior is dangerous to self, to the system, or to both.

What I see in the OP's description sounds more like self-harm or anxiety as opposed to factitious disorder. It could also be a lack of impulse control along the lines of telling a kid not to touch something and then they touch it again and again. People with significant trauma histories often have activated limbic systems that override frontal cortex inhibitions all day long and this can definitely be exacerbated by medical procedures which by definition are traumatic.

 

[FlowRate]

(edited: decided I was going off topic)