He Factitious disorder Is that suffered by those who present physical or psychic symptoms that are feigned or intentionally produced with the purpose on the part of the subject to assume the role of patient.
Factitious disorders have been classified differently in diagnostic manuals for mental illness. In the International Classification of Diseases (ICD), factitious disorder appears to belong to the category of other personality disorders and adult behavior.
Young african nurse comforting female patient in doctor's office
In the Diagnostic Handbook of Mental Illness DSM version 4, they form an independent category, called factitious disorders.
In DSM-5, however, it is part of the general category of disorders of somatic symptoms and related disorders, along with disorders such as: somatic symptom disorder; Disease anxiety disorder; Conversion disorder; Psychological factors affecting other medical conditions; Other disorders of specified somatic symptoms and related disorders and, finally, disorders of somatic symptoms and related disorders not specified.
Diagnosis of factitious disorder
Self-imposed factitious disorder
A. Falsification of physical or psychological signs or symptoms, or induction of injury or illness, associated with an identified deception.
B. The individual presents himself / herself to others as sick, incapacitated or injured.
C. Misleading behavior is evident even in the absence of an obvious external reward.
D. The behavior is not best explained by another mental disorder, such as delusional disorder or another psychotic disorder.
There are two possible subtypes of specifications: single episode or recurrent episodes (two or more events of disease falsification and / or induction of injury).
Factitious disorder applied to another (Formerly called Factitious Disorder of the neighbor).
A. Falsification of physical or psychological signs or symptoms, or induction of injury or illness, in another, associated with an identified deception.
B. The individual presents another individual (victim) to others as ill, disabled or injured.
C. Misleading behavior is evident even in the absence of obvious external reward.
D. The behavior is not best explained by another mental disorder, such as delusional disorder or another psychotic disorder.
Note: When an individual forges a disease in another individual (eg, children, adults, pets), the diagnosis is of factitious disorder applied to another. The diagnosis applies to the perpetrator, not the victim. This can be made a diagnosis of abuse.
There are two possible subtypes of specs: single episode or recurrent episodes (two or more events of disease falsification and / or induction of injury).
Characteristics of factitious disorder
In factitious disorder, behaviors are considered voluntary because they are deliberate and have a purpose. While it is true that they can not be considered as controllable and sometimes there is a compulsory component. The diagnosis requires demonstrating that the individual is committing actions to misrepresent, simulate or cause signs or symptoms of illness or injury in the absence of obvious external rewards.
There are occasions in which, although there may be a pre-existing medical condition or disease, there is a misleading behavior or induction of injuries associated with the simulation in order that others may consider them more ill or with greater disability. This can lead to high clinical intervention.
Subjects with factitious disorder use a variety of methods to falsify the disease, such as exaggeration, manufacturing, simulation and induction.
There are cases in which subjects with factitious disorder refer to feelings of depression and suicidal tendencies after the death of a spouse. However, it is not true that anyone has died or it is not true that the person has a spouse.
Individuals with factitious disorder, after injury or illness, may seek treatment for themselves or others.
Other associated features
Individuals with factitious disorder imposed on oneself or another person present a high risk of suffering great psychological suffering or functional deterioration due to the damage done to themselves and to others.
People close to the patient such as family members, friends and health professionals are sometimes affected by their behavior.
There are clear similarities between factitious disorders and other disorders in the persistence of behavior and intentional efforts to conceal behavioral disorder through self-deception. We talk about substance use disorders, eating disorders, impulse control disorders, pedophilia, personality disorders ??.
The relationship of these disorders to personality disorders is especially complex because of the chaotic lifestyle; Altered interpersonal relationships; identity crisis; substance abuse; Self-mutilations and manipulative tactics.
In many of these cases they may receive the additional diagnosis of Borderline personality disorder . Sometimes they also present histrionic traits because of their need for attention and drama.
Although some factitious disorders may represent criminal behavior, criminal behavior and mental illness are not mutually exclusive. The diagnosis of factitious disorder emphasizes the objective identification of the simulation of signs and symptoms of disease, rather than inferring about the intention or possible underlying motivation.
Münchausen syndrome and factitious disorder by proxy
Factitious disorders with predominantly psychological signs and symptoms are often distinguished from those in which physical symptoms predominate, also called Münchausen syndrome . This syndrome has already been discussed in a previous chapter, however, some of the main features will be recalled.
The essential aspect of the latter is the patient's ability to present physical symptoms that allow them to be admitted to the hospital and for prolonged periods in hospital stays.
In order to support his history, the patient pretends or causes a series of very variable symptoms, which may include hematomas, hemoptysis (discharge of blood from the mouth from the respiratory tract), hypoglycemia, nausea, vomiting, abdominal pain, fever or episodes Of neurological symptoms such as dizziness or seizures.
Other strategies that are usually performed are manipulating laboratory tests, for example, contaminate the urine to be tested, with blood or feces; On the other hand, you can take anticoagulants, insulin or other drugs to falsify medical records and indicate a disease by inducing an abnormal laboratory result.
They are often patients who are constantly confronted with the opinions of others about the falsity of statements about diseases?? Which they usually maintain, especially when any of their complaints are questioned. Also, when they think they are going to be discovered, they leave the hospital where they are admitted.
However, there does not end the cycle, but quickly go to another hospital and again. It is curious that many of them present different symptoms every time they go to the hospital to be admitted.
According to Asher in 1951, three different clinical types were described:
to) Acute abdominal type : It can be the most frequent form. These are those with antecedents of multiple Laparotomies (Surgeries performed to open the abdomen of people to explore and examine existing problems), in which the subject consciously ingests objects and requests surgical interventions to remove them.
B) Hemorrhagic type : These are those patients who present episodic hemorrhages through several holes, sometimes use animal blood or consume anticoagulants.
C) Neurological type : Subjects have seizures, fainting, severe headaches, anesthesia or cerebellar symptoms.
Other dermatological, cardiological, or respiratory pictures may be added to these original types.
On the other hand, apart from the Muchaussen syndrome we find factitious power disorder (Meadow, 1982). Such a disorder occurs in patients who intentionally produce symptoms in another individual under their care, usually a child.
The motivation behind this situation is that the caregiver indirectly assumes the role of the patient. This should not be confused with the physical abuses and consequent attempts of the abusers to conceal them.
As for the aspects that may make us suspect that there is a factitious disorder and not a real medical illness, we find the existence of:
- Fantastic seudología (creation of a surprising, exaggerated or impossible medical history).
- The presence of extensive and extensive medical knowledge about procedures, symptoms, signs, treatments?
- The fluctuating clinical course with new complications or symptoms when complementary examinations of the former were negative.
- Misconduct in the health context.
- The use and abuse of painkillers.
- The history of multiple surgical interventions.
- The shortage of friends and the absence of visits during their entry.
Prevalence
The prevalence is 0.032-9.36% in different care resources (Kocalevent et al., 2005). In the last edition of the DSM, dating from 2014, they mention that prevalence in the general population of this disorder is unknown, due in part to the role of deception in the population. And that among hospitalized patients, about 1% of individuals may have presentations that meet the criteria for factitious disorder.
One aspect to be taken into account is that the factitious disorder in which psychological signs and symptoms predominate is probably higher than is thought, but is overlooked by the absence of objective physical evidence, and because it is often accompanied by other Pathologies such as personality disorders, psychosis , Dissociative disorders, depressive symptoms.
Development and course
The onset of the disorder usually occurs in early adulthood, and often occurs after hospitalization for a medical problem or mental disorder. When the disorder is imposed on another, it can begin after the hospitalization of the child of someone in his charge.
The course is usually in the form of intermittent episodes, since the unique episodes that are characterized by being persistent and without remissions, are less frequent.
In subjects with recurrent episodes of falsification of signs and symptoms of illness and / or induction of injury, the pattern of successive misleading contacts with medical personnel may remain lifelong.
Differential characteristics with other disorders
Within the factitious disorder it is important to make a differential diagnosis with two other disorders that can lead to confusion. On the one hand, the conversion disorder and on the other hand the simulation disorder.
At Conversion disorder , Where there are one or more symptoms in the person in voluntary or sensory motor functions, which lead one to think that there is a neurological or medical illness. The difference is that the subject is not aware of doing something, or of the remote motivation of the symptomatology.
In the simulation , The subject pretends consciously to be, that is to say, it presents physical or psychic symptoms that are produced intentionally or faked. However, such behavior is motivated by the existence of external, non-psychological incentives, such as avoiding work or military responsibilities, avoiding criminal prosecution (wanting to get out of a trial), getting toxic for personal use or obtaining pensions.
It should cause suspicions of simulation diagnosis in someone in cases such as:
A) Presentations in medical-legal contexts (simulations by disease, or simulations of legal type, such as economic gains, avoidance of legal responsibilities like custodies??)
B) When there are significant discrepancies between the subject's complaints and subjective manifestations about his or her discomfort or disability and the objective data obtained through medical examinations
C) If the subject does not cooperate at the time of the diagnostic evaluation and compliance with the treatment.
D) In case there is a previous history of antisocial behavior, Antisocial personality disorder Or personality limit and / or drug addiction (LoPiccolo et al., 1999).
Finally, it should be mentioned that caregivers who have abused dependent dependents, when they lie about injuries for abuse only to protect themselves from liability, are not diagnosed of factitious disorder applied to another because the protection against liability It is an external reward.
These types of caregivers lie about how and when they supervise their dependents; On the analysis of medical records and / or interviews with professionals and others, much more than would be necessary for their self-protection. They would be diagnosed of factitious disorder imposed on another.
CONCLUSIONS
It is necessary to continue deepening in the approach and detection of these cases because the investigations are scarce. To detect them requires the collaboration of an interdisciplinary team, and the use of methods to detect, evaluate and treat more sophisticated, for the disorder with psychological symptoms.
Bibliography
- AMERICAN PSYCHIATRIC ASSOCIATION (APA). (2002). Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR . [Links]
- AMERICAN PSYCHIATRIC ASSOCIATION (APA). (2014). Diagnostic and Statistical Manual of Mental Disorders DSM-5 . [Links]
- Belloch, A. (2008) Manual of psychopathology II. S.A. McGraw-Hill / Inter-American of Spain.
- Cabo Escribano, G. and Tarrío Otero, P. Factitious disorder with predominantly psychological symptoms and signs . Journal of the Galician Association of Psychiatry.
- ICD-10 (1992). Mental and behavioral disorders. London: Oxford University Press.
- Vallejo Ruiloba, J. (2011) Introduction to psychopathology and psychiatry . Elsevier España S.L. Barcelona.
The Effects of stress
The stress response involves the production of a series of psychophysiological changes in the organism in response to an overdemand situation. Such an answer is adaptive in preparing the person to face emergency situations, in the best way possible.
In spite of this, there are occasions in which the maintenance of this response for long periods, the frequency and the intensity of the same, end up hurting the organism.
Stress can cause various symptoms such as ulcers, increase of certain glands, atrophy of certain tissues, which lead to pathologies.
Today, there is an increasing chance of knowing how emotions and biology interact with each other. An example of this is the abundant research that exists between direct and indirect relationships between stress And disease.
Effects of stress on human health
1- Effects on the cardiovascular system
When a stressful situation occurs a series of changes are generated at the level of the cardiovascular system Such as:
- Increased heart rate.
- Constriction of the main arteries that cause the increase of the blood pressure, mainly occur in those that channel the blood to the digestive tract.
- Constriction of arteries that supply blood to the kidneys and skin, facilitating blood supply to the muscles and brain.
On the other hand, Vasopressin (Antidiuretic hormone that causes increased water reabsorption) causes the kidneys to slow down the production of urine, leading to a decrease in the elimination of water, resulting in an increase in blood volume and an increase in blood pressure .
If this set of changes occur repeatedly over time, there is a major wear and tear on the cardiovascular system.
To understand the possible damages that occur, it must be taken into account that the circulatory system is like a huge network of blood vessels covered by a layer called the cell wall. This network reaches all the cells and there are bifurcation points in which the blood pressure is greater.
When the vascular wall layer is damaged, and in response to the stress response that is generated, there are substances that are discharged into the bloodstream as free fatty acids, Triglycerides Or cholesterol, which penetrate the vascular wall, adhere to it and consequently thicken and harden it, forming plaques. Thus, stress influences the appearance of the so-called atherosclerotic plaques that are located inside the artery.
This series of changes can cause damage to the heart, brain and kidneys. These damages result in a possible angina pectoris (Pain in the chest produced when the heart does not receive enough blood supply); in a myocardial infarction (Stop or severe alteration of the rhythm of the heart beats by obstruction of the corresponding artery / s); renal insufficiency (Kidney failure); Cerebral thrombosis (obstruction of the flow of some artery that waters part of the brain).
Three examples of stressful phenomena of different nature will be presented below to illustrate the above.
In a 1991 study by Meisel, Kutz and Dayan, the three days of Gulf War missile attacks were compared in the population of Tel Aviv with the same three days of the previous year, and a higher incidence (The triple), of myocardial infarction in the inhabitants.
It is also worth noting this increased incidence in the face of natural disasters. For example, after the earthquake in Northrige in 1994, there was an increase in cases of sudden cardiac death during the six days following the catastrophe.
On the other hand, the number of myocardial infarctions in soccer world championships increases, especially if the games end in penalties. The highest incidence occurs two hours after the matches.
In general, it can be said that the role of stress is to precipitate the demise of people whose cardiovascular system is severely compromised.
2- Effects on the gastrointestinal system
When a person has an ulcer in the stomach, this can be due to infection with Helicobacter pylori bacteria, or they present without an infection. In these cases is when we talk about the possible role of stress in diseases, although it is unclear what factors are involved. Several hypotheses are discussed.
The first refers to the fact that when a stressful situation occurs, the body reduces the secretion of gastric acids, and simultaneously reduces the thickening of the walls of the stomach, since, during that period, they do not need to be in Functioning of said acids to produce digestion, is it about?? saving?? Some of the functions of the organism that are not necessary.
After this period of intense overactivation there is a recovery of the production of gastric acids, in particular of the hydrochloric acid . If this cycle of reduction of production and recovery occurs repeatedly, an ulcer can develop in the stomach, which is therefore not so related to the intervention of a stressor, but with that period.
It is also interesting to comment on the sensitivity of the intestine to stress. As an example we can think of a person who before going through an important examination, for example, an opposition, has to go to the bathroom repeatedly. Or, for example, someone who has to present the defense of a thesis before a jury composed of five people who evaluate you, and in the middle of the exhibition feels uncontrollable desires to go to the bathroom.
Thus, it is not strange to allude to the causal relationship between stress and certain intestinal diseases, for example, Bowel syndrome irritable , Consisting of a picture of pain and change in the intestinal habit, causing diarrhea or constipation in the person in situations or stressful conditions. However, current studies report the implication of behavioral aspects in the development of the disease.
3- Effects on the endocrine system
When people are fed, a number of changes are made in the body to assimilate nutrients, store them and transform them into energy. It produces a decomposition of food into simpler elements, which can be assimilated into molecules (amino acids, glucose, free acids??). These elements are stored in the form of proteins, glycogen and triglycerides, thanks to insulin.
When a stressful situation occurs, the body has to mobilize the surplus energy and it does so through the Stress hormones Which cause triglycerides to break down into their simplest elements, such as fatty acids released into the bloodstream; That glycogen is degraded in glucose and that the proteins become amino acids.
Both free fatty acids and excess glucose are released into the bloodstream. In this way, by means of this released energy, the organism can cope with the over-orders of the medium.
On the other hand, when a person experiences stress, there is an inhibition of the secretion of insulin and the Glucocorticoids Make the fat cells less sensitive to insulin. This lack of response is mainly due to the gain of weight in people, which causes the adipose cells, when distended, are less sensitive.
In these two processes, diseases such as cataracts or diabetes .
Cataracts, which translate into a cloud in the lens of the eye that hinders vision, are caused by the accumulation of excess glucose and free fatty acids in the blood, which can not be stored in adipose cells and form plaques Atherosclerotic arteries in the arteries obstructing the blood vessels, or propitiating the accumulation of proteins in the eyes.
Diabetes, is a disease of the endocrine system, the most investigated. It is a common disease in the older population of industrialized societies.
There are two types of diabetes, stress is more influential in type II diabetes or non-insulin dependent diabetes, in which the problem is that the cells do not respond well to insulin, although it is present in the body.
In this way, it is concluded that chronic stress in a person predisposed to diabetes, who is obese, with an inadequate diet and elderly, is an essential element in the possible development of diabetes.
4- Effects on the immune system
The immune system of people is composed of a set of cells called Lymphocytes Y Monocytes (White blood cells). There are two classes of lymphocytes, T cells and the B cells , Which originate in the bone marrow. Even so, the T cells emigrate to another area, to the thymus, to mature, that is why they receive the name?? T??.
These cells perform functions of attacking infectious agents differently. On the one hand, T cells produce cell-mediated immunity, ie, when a foreign agent enters the body, the monocyte called macrophage recognizes it and alerts it to a helper T cell. Then these cells proliferate exorbitantly and attack the invader.
On the other hand, B cells produce antibody-mediated immunity. Thus, the antibodies they generate recognize the invading agent and bind to it, immobilizing and destroying the foreign substance.
Stress can influence these two processes and it does so in the following way. When stress occurs in a person, the sympathetic branch of the autonomic nervous system Suppresses the immune action, and the hypothalamic-pituitary-adrenal system, upon activation, produces to a high degree glucocorticoids, stopping the formation of new T lymphocytes and diminishing their sensitivity to warning signals, as well as expelling lymphocytes from the Bloodstream and destroying them through a protein that breaks their DNA.
Thus, we conclude that there is an indirect relationship between stress and immune function. The higher the stress, the lower the immune function, and the reverse.
An example can be found in a study by Levav et al in 1988, where they found that the parents of Israeli soldiers killed in the Yom Kippur War showed higher mortality during the mourning period than those observed in the control group . In addition, this increase in mortality occurred to a greater extent in widowed or divorced parents, confirming another aspect studied such as the buffering role of social support networks.
Another much more common example is that of the student that in times of exams, can suffer a diminution of the immune function, getting bad with a cold, flu??
5- Effects on sexuality
A slightly different theme that has been addressed throughout this article is that of sexuality, which of course can also be affected by stress.
Sexual function in men and women may be modified before certain situations experienced as stressors.
In man, given certain stimuli the brain stimulates the release of a releasing hormone called LHRH , Which stimulates the pituitary (Gland that controls the activity of other glands and regulates certain functions of the body, such as development or sexual activity). The pituitary releases the hormone LH and the hormone FSH, producing the release of testosterone and spermatozoa, respectively.
If the man lives a situation of stress, an inhibition occurs in this system. Two other types of hormones are activated; Endorphins and enkephalins, which block the secretion of the hormone LHRH.
In addition, the pituitary secretes Prolactin , Whose function is to decrease the sensitivity of the pituitary to LHRH. Thus, on the one hand, the brain secretes less LHRH, and on the other, the pituitary is protected to respond less to it.
For the most part, the glucocorticoids discussed above block the response of the testes to LH . What is extracted from all this series of changes that occur in the body when there is a situation of stress is that it is prepared to respond to a potentially dangerous situation, leaving aside, of course, having sex.
One aspect that may be more familiar is the lack of erection in man in the face of stress. This response is determined by the activation of the parasympathetic nervous system, which causes an increase in the blood supply to the penis, blockage of blood flow through the veins, and filling of blood from the cavernous bodies of the penis. The hardening of this.
Thus, if the person is stressed or anxious, his body is activated, specifically the activation of the sympathetic nervous system, so that the parasympathetic is not functioning, not producing an erection.
As for the woman, the functioning system is very similar, on the one hand, the brain releases LHRH, which in turn secretes LH and FSH into the pituitary. The first activates the synthesis of Estrogens In the ovaries and the second stimulates the release of ova in the ovaries. And on the other, during ovulation, the corpus luteum formed by the hormone LH, releases progesterone , Thus stimulating the walls of the uterus so that if an egg is fertilized, it can be implanted in them and transformed into an embryo.
There are times when such a system fails. On the one hand, the inhibition of the functioning of the reproductive system can occur when there is an increase in the concentration of Androgens In women (since women also have male hormones), and a decrease in estrogen concentration.
On the other hand, the production of glucocorticoids before the stress can produce the decrease of the secretion of the hormones LH, FSH and estrogens, reducing the probability of ovulation.
In addition, the production of Prolactin Increases the reduction of progesterone which in turn interrupts the maturation of the uterine walls.
All this can lead to fertility problems that affect an increasing number of couples, which become a source of stress that exacerbates the problem.
We can also refer to the Dyspareunia Or painful intercourse, and vaginismus, involuntary contraction of the muscles surrounding the opening of the vagina. With respect to vaginismus, it has been observed that possible painful and traumatic experiences of the sexual type of the woman, can provoke a conditioned response of fear of the penetration, that activates the sympathetic nervous system, causing the contraction of the muscles of the vagina.
Dyspareunia, on the other hand, may be related to women's concerns as to whether it will do well, inhibiting the activity of the Parasympathetic nervous system And activating the sympathetic, making relations difficult for a lack of excitation and lubrication.
CONCLUSIONS
Now that all the possible adverse effects that can be caused by stress are known, there are no excuses to think of facing situations in a more adaptive way using for example relaxation techniques or meditation, which have proved very effective.
Bibliography
- Moreno Sánchez, A. (2007). Stress and illness. More Dermatology . Nº1.
- Barnes, V. (2008). The impact of stress reduction on essential hypertension and cardiovascular disease. International Journal of Sport Sciences. Vol. IV, year IV.
- Amigo Vázquez, I., Fernández Rodríguez, C. and Pérez Álvarez, M. (2009 ). Psychological manual of health (3rd edition). Editions pyramid.