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Book Forum: Psychiatry and General Medicine   |    
AJP nov97 Book Forum ? The Spectrum of Factitious Disorders
Richard B. Makover, M.D.
Am J Psychiatry 1997;154:1620-a-1621.
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edited by Marc D. Feldman, M.D., Stuart J. Eisendrath, M.D. Washington, D.C., American Psychiatric Press, 1996, 213 pp., $36.00.

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Illness confers a special status: relief from social obligations, exemption from work, and entitlement to care from family, friends, and health care professionals. When someone obtains this status through deliberate fabrication, society and its caregivers react with chagrin, anger, and rejection.

Factitious disorders must be distinguished from somatization disorders and malingering. Somatizing patients are unaware both of their own role in producing signs and symptoms and of their motivations for doing so. Malingerers deliberately deceive others for an overt benefit: money, drugs, escape from an uncomfortable situation. Patients with factitious disorder consciously counterfeit their disease but are not aware of their motivation. Confronted with such a patient, health care providers find themselves on an uneasy middle ground between legitimacy and fraud.

This book, number 40 in the distinguished Clinical Practice Series, provides a dispassionate examination of a frustrating and emotionally charged subject. The editors and the nine other contributors provide both a useful overview and a close examination of this troublesome group of disorders. They cover its history, physical and psychological features, ethical and legal issues, and management. One chapter uses first-person accounts to depict the damage these patients do to themselves and those who care for them.

Almost half of the book deals with perhaps the most troublesome and tragic of these disorders: factitious disorder by proxy, an appalling example of child abuse. In this disorder, a caregiver (usually the mother) abuses a child with repeated suffocations, injections of drugs or toxins, and other deliberate injuries. The goal is to elicit sympathetic medical care while aggrandizing the perpetrator's role as a compassionate, concerned parent. Factitious disorder by proxy presents a serious challenge not only to health professionals but also to the legal system. Courts, struggling to determine the best interests of the child, have returned these abused children to their parents.

Another factitious disorder is the Munchausen syndrome, the "professional patient" who wanders from hospital to hospital with elaborate but false health histories that induce surgeons to operate on them needlessly. The authors estimate that only 10% of the patients with factitious disorders fall into this most dramatic category.

Perhaps the most important focus of this book is its discussion of treatment issues. Not everyone agrees that these deceptive people deserve treatment or that they can benefit from it. The writers argue for psychotherapeutic intervention and present case examples of its success.

One reason that therapy can help is that patients may have a treatable underlying condition (psychosis, borderline personality disorder, major depression) or a predisposing history, such as a severe childhood illness or abuse. Other patients may respond to a behavioral approach, especially if it includes a face-saving explanation that allows them to stop without acknowledging their culpability.

This concise book is informative and useful; the mental health practitioner will use it repeatedly as the need arises.

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