Factitious disorder: Difference between revisions
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==Overview== | ==Overview== | ||
A '''factitious disorder''' or '''FD''' is a mental disorder where the 'ill' individual's symptoms are either self-induced or falsified by the patient. Essentially, it is faking sick: the act of an individual faking, exaggerating, or even inflicting self injuries. Their state of consciousness in this act falls somewhere between (and involves both) the conscious and unconscious mind. The main reasons why individuals develop this disorder is to assume the status of a 'patient'. Hence, they win over the attention, nurturance, sympathy, and even leniency that they feel they are unable to obtain any other way. FD individuals produce or exaggerate the symptoms of mental or physical illness. They do so by contaminating [[urine]] samples, taking [[hallucinogen]]s, injecting themselves with bacteria to produce [[infection]]s, and other such similar behaviour. | A '''factitious disorder''' or '''FD''' is a mental disorder where the 'ill' individual's symptoms are either self-induced or falsified by the patient. Essentially, it is faking sick: the act of an individual faking, exaggerating, or even inflicting self injuries. Their state of consciousness in this act falls somewhere between (and involves both) the conscious and unconscious mind. The main reasons why individuals develop this disorder is to assume the status of a 'patient'. Hence, they win over the attention, nurturance, sympathy, and even leniency that they feel they are unable to obtain any other way. FD individuals produce or exaggerate the symptoms of mental or physical illness. They do so by contaminating [[urine]] samples, taking [[hallucinogen]]s, injecting themselves with bacteria to produce [[infection]]s, and other such similar behaviour. | ||
== | ==Historical Perspective== | ||
The motives of the patient can vary: for a patient with Munchausen syndrome their primary aim is to obtain sympathy, nurturance and attention, while in the case of malingering the patient wishes to obtain external gains such as disability payments or to avoid an unpleasant situation, such as military duty [add internal gain through drugs]. Strictly speaking, FD and malingering cannot be diagnosed in the same patient, yet clinicians find that patients' motives for the ruses can vary over time and, as a result, both diagnoses may apply. FD and Munchausen syndrome are considered mental disorders; malingering, though sometimes a focus of clinical attention, is not. Malingering, thus, is not diagnosed as FD for it is not a mental disorder, but, rather, done in reaction to the external stimuli; in other words, malingering is done to obtain some sort of benefit or to be relieved of something unwanted. (ie a fake injury to sue in a car accident, etc.) FD is diagnosed by the absence of malingering. | The motives of the patient can vary: for a patient with Munchausen syndrome their primary aim is to obtain sympathy, nurturance and attention, while in the case of malingering the patient wishes to obtain external gains such as disability payments or to avoid an unpleasant situation, such as military duty [add internal gain through drugs]. Strictly speaking, FD and malingering cannot be diagnosed in the same patient, yet clinicians find that patients' motives for the ruses can vary over time and, as a result, both diagnoses may apply. FD and Munchausen syndrome are considered mental disorders; malingering, though sometimes a focus of clinical attention, is not. Malingering, thus, is not diagnosed as FD for it is not a mental disorder, but, rather, done in reaction to the external stimuli; in other words, malingering is done to obtain some sort of benefit or to be relieved of something unwanted. (ie a fake injury to sue in a car accident, etc.) FD is diagnosed by the absence of malingering. | ||
Individuals with FD wish to assume the role of a 'patient'. | Individuals with FD wish to assume the role of a 'patient'. | ||
== | ==Classification== | ||
There are many possible causes for this disorder. One such possibility is an underlying personality disorder. Individuals with FD may be trying to repeat a satisfying childhood relationship with a doctor. Perhaps also the individual has a desire to deceive or test authority figures. The underlying desire to resume the role of a patient and to be cared for can also be considered an underlying personality disorder. Abuse in childhood is also another probable cause for the disorder. A background of neglect and abandonment may contribute to the development of FD. These individuals may be trying to reenact unresolved issues with their parents. A history of frequent illnesses may also contribute to the development of this disorder. Perhaps the individual afflicted with FD is accustomed to actually being sick, and thus returns to their previous state in order to recapture what was once considered to be the 'norm.' | There are many possible causes for this disorder. One such possibility is an underlying personality disorder. Individuals with FD may be trying to repeat a satisfying childhood relationship with a doctor. Perhaps also the individual has a desire to deceive or test authority figures. The underlying desire to resume the role of a patient and to be cared for can also be considered an underlying personality disorder. Abuse in childhood is also another probable cause for the disorder. A background of neglect and abandonment may contribute to the development of FD. These individuals may be trying to reenact unresolved issues with their parents. A history of frequent illnesses may also contribute to the development of this disorder. Perhaps the individual afflicted with FD is accustomed to actually being sick, and thus returns to their previous state in order to recapture what was once considered to be the 'norm.' | ||
==Pathophysiology== | |||
== Differential Diagnosis == | == Differential Diagnosis == | ||
*[[Borderline personality disorder]]<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> | |||
*[[Conversion disorder]] ([[functional neurological symptom disorder]])<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> | |||
*[[Hypochondriasis]] | |||
*[[Malingering]]<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> | |||
*Medical condition or mental disorder not associated with intentional symptom falsification<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> | |||
*Somatic symptom disorder: | |||
:*Pain | |||
:*[[Gastrointestinal]] symptom | |||
:*Sexual symptom | |||
:*Neurological symptom<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
===Prevalence=== | ===Prevalence=== | ||
The prevalence of factitious disorder is unknown in the overall population. | The prevalence of factitious disorder is unknown in the overall population.<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> | ||
==Risk Factors== | ==Risk Factors== | ||
==Natural History, Complications, and Prognosis== | |||
==Diagnostic Criteria== | ==Diagnostic Criteria== | ||
| Line 51: | Line 66: | ||
'''''AND''''' | '''''AND''''' | ||
*D.The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder. | *D.The behavior is not better explained by another mental disorder, such as [[delusional disorder]] or another psychotic disorder. | ||
Specify: | Specify: | ||
| Line 81: | Line 96: | ||
*Recurrent episodes (two or more events of falsification of illness and/or induction of injury) | *Recurrent episodes (two or more events of falsification of illness and/or induction of injury) | ||
}} | }} | ||
== | ==History and Symptoms== | ||
Inclinations toward the disorder include females usually employed in medical fields such as nursing or medical technology, women ages of 20-40 years old, and loners with early childhood trauma. Cases rarely occur over the age of 45 for the disorder usually lasts from adolescence to mid-adulthood. | Inclinations toward the disorder include females usually employed in medical fields such as nursing or medical technology, women ages of 20-40 years old, and loners with early childhood trauma. Cases rarely occur over the age of 45 for the disorder usually lasts from adolescence to mid-adulthood. | ||
== | ==Laboratory Findings== | ||
There are three separate offshoots of Factitious Disorder. These include the [[Munchausen syndrome]] (a chronic variant of FD), [[Munchausen by proxy]], and [[Ganser syndrome]]. In order to have these mental disorders, the individual must reflect symptoms of both FD and the specified symptoms that their offshoot requires. | There are three separate offshoots of Factitious Disorder. These include the [[Munchausen syndrome]] (a chronic variant of FD), [[Munchausen by proxy]], and [[Ganser syndrome]]. In order to have these mental disorders, the individual must reflect symptoms of both FD and the specified symptoms that their offshoot requires. | ||
== | ==Other Imaging Studies== | ||
[[Munchausen syndrome]], or chronic FD, have specified symptoms along with FD diagnosis. Specified symptoms are that FD symptoms are ''greatly'' exaggerated, individuals undergo major surgery repeatedly, and they 'hospital jump' or migrate in order to avoid detection. Many are in the health care business and the illness often begins in early adulthood. Individuals are typically unmarried men estranged from their families and are usually middle-aged. | [[Munchausen syndrome]], or chronic FD, have specified symptoms along with FD diagnosis. Specified symptoms are that FD symptoms are ''greatly'' exaggerated, individuals undergo major surgery repeatedly, and they 'hospital jump' or migrate in order to avoid detection. Many are in the health care business and the illness often begins in early adulthood. Individuals are typically unmarried men estranged from their families and are usually middle-aged. | ||
== | ==Other Diagnostic Studies== | ||
The word 'proxy' is defined as the infliction of a disorder unto another individual -- the 'substitution' of it. Specific symptoms include FD produced in children because of their caregivers or parents (almost always mothers) who induce illnesses on their children. The parent may falsify the child's medical history or tamper with laboratory tests in order to make the child appear sick. Occasionally, in [[Munchausen by proxy]], the caregiver will actually injure the child to ensure that the child will be treated. Such parents enjoy the indirect attention that they receive. | The word 'proxy' is defined as the infliction of a disorder unto another individual -- the 'substitution' of it. Specific symptoms include FD produced in children because of their caregivers or parents (almost always mothers) who induce illnesses on their children. The parent may falsify the child's medical history or tamper with laboratory tests in order to make the child appear sick. Occasionally, in [[Munchausen by proxy]], the caregiver will actually injure the child to ensure that the child will be treated. Such parents enjoy the indirect attention that they receive. | ||
== | ==Medical Therapy== | ||
*[[SSRI]]s, which are used to treat mood disorders, can be used to treat an individual with factitious disorder. | |||
[[ | *In some cases, antipsychotic drugs can also be used to treat factitious disorder. | ||
== | ==Psychotherapy== | ||
No true psychiatric medications are prescribed for Factitious Disorder. SSRIs ([[selective serotonin reuptake inhibitors]]), however can help cure underlying problems. Medicines used to treat personality disorders such as these (SSRIs) can be used to treat FD, as a personality disorder may be the underlying cause of FD. Some (authors such as Prior and Gordon 1997) also report good responses to antipsychotic drugs such as Pimozide. Family Therapy can also prove to be of assistance. In such therapy, families are helped to better understand patients (the individual in their family with FD) and their need for attention. In this therapeutic setting, the family is urged not to condone or reward the FD individual's behavior. This form of treatment can be unsuccessful if the family is uncooperative or displays signs of denial and/or antisocial disorder. Psychotherapy is another method used to treat the disorder. These sessions should focus on the psychiatrist establishing and maintaining a relationship with the patient. Such a relationship may help to contain symptoms of FD. Monitoring is also a form that may be implicated for the FD patient's own good. Video cameras, etc. are not illegal to use in such monitoring, for in many cases, FD (especially proxy) can prove to be very detrimental to an individual's health if they are, in fact, causing true physiological illnesses. (Even faking can be dangerous and might be monitored for fear that unnecessary surgery may subsequently be performed.) | No true psychiatric medications are prescribed for Factitious Disorder. SSRIs ([[selective serotonin reuptake inhibitors]]), however can help cure underlying problems. Medicines used to treat personality disorders such as these (SSRIs) can be used to treat FD, as a personality disorder may be the underlying cause of FD. Some (authors such as Prior and Gordon 1997) also report good responses to antipsychotic drugs such as Pimozide. Family Therapy can also prove to be of assistance. In such therapy, families are helped to better understand patients (the individual in their family with FD) and their need for attention. In this therapeutic setting, the family is urged not to condone or reward the FD individual's behavior. This form of treatment can be unsuccessful if the family is uncooperative or displays signs of denial and/or antisocial disorder. Psychotherapy is another method used to treat the disorder. These sessions should focus on the psychiatrist establishing and maintaining a relationship with the patient. Such a relationship may help to contain symptoms of FD. Monitoring is also a form that may be implicated for the FD patient's own good. Video cameras, etc. are not illegal to use in such monitoring, for in many cases, FD (especially proxy) can prove to be very detrimental to an individual's health if they are, in fact, causing true physiological illnesses. (Even faking can be dangerous and might be monitored for fear that unnecessary surgery may subsequently be performed.) | ||
== | ==Brain Stimulation Therapy== | ||
Treatment for FD proxy is not so subtle. Physicians, upon suspecting the disorder, should notify authorities immediately. Authorities will then initiate steps for immediate protection of the affected child. Criminal charges may be deemed necessary. Many times, help may be sought for the mother (parent) with Munchausen by proxy as well as the child affected and perhaps even their siblings. Careful monitoring of the family for an extended period of time is often a necessary precaution. This is to prevent translocation (i.e. the family moving to return to old ways, etc.) and to prevent the insinuation of a possible upheaval of the detrimental disorder. | Treatment for FD proxy is not so subtle. Physicians, upon suspecting the disorder, should notify authorities immediately. Authorities will then initiate steps for immediate protection of the affected child. Criminal charges may be deemed necessary. Many times, help may be sought for the mother (parent) with Munchausen by proxy as well as the child affected and perhaps even their siblings. Careful monitoring of the family for an extended period of time is often a necessary precaution. This is to prevent translocation (i.e. the family moving to return to old ways, etc.) and to prevent the insinuation of a possible upheaval of the detrimental disorder. | ||
== | ==Cost-Effectiveness of Therapy== | ||
Some experience only a few outbreaks of the disorder. However, in most cases, the disorder is chronic and factitious disorder is a long-term condition that is difficult to treat. There are poor positive outcomes for this disorder; in fact, treatment provided a poorer percentage of positive outcomes than did treatment of those with genuine psychoses such as schizophrenics. In addition, many individuals with Factitious Disorder will not seek treatment. Most deny that they are faking symptoms and therefore do not seek treatment for the disorder. There is, however, some hope. Age seems to help the disorder greatly. There are many possible explanations for this occurrence, although none are currently deemed as the definitive cause, though it is proven that the disorder does indeed grow milder with age. Some say perhaps it is because the FD individual has mastered the art of faking sickness over so many years of practice that the disorder can no longer be discerned. Another hypothesis is that many times an FD individual will be put in a home or experience ''real'' health issues. Thus, in this way, the problem with obtaining the 'patient' status is resolved because, in fact, it is inherently real. | Some experience only a few outbreaks of the disorder. However, in most cases, the disorder is chronic and factitious disorder is a long-term condition that is difficult to treat. There are poor positive outcomes for this disorder; in fact, treatment provided a poorer percentage of positive outcomes than did treatment of those with genuine psychoses such as schizophrenics. In addition, many individuals with Factitious Disorder will not seek treatment. Most deny that they are faking symptoms and therefore do not seek treatment for the disorder. There is, however, some hope. Age seems to help the disorder greatly. There are many possible explanations for this occurrence, although none are currently deemed as the definitive cause, though it is proven that the disorder does indeed grow milder with age. Some say perhaps it is because the FD individual has mastered the art of faking sickness over so many years of practice that the disorder can no longer be discerned. Another hypothesis is that many times an FD individual will be put in a home or experience ''real'' health issues. Thus, in this way, the problem with obtaining the 'patient' status is resolved because, in fact, it is inherently real. | ||
==Future or Investigational Therapies== | |||
==References== | ==References== | ||
| Line 181: | Line 191: | ||
| id = ISBN -415-94934-3 | | id = ISBN -415-94934-3 | ||
}} | }} | ||
==References== | |||
{{reflist|2}} | |||
== See also == | == See also == | ||
Latest revision as of 19:49, 16 January 2019
| https://https://www.youtube.com/watch?v=719a0kAzeo4&t=4s |350}} |
Template:DiseaseDisorder infobox
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2] Yashasvi Aryaputra[3]
Overview
A factitious disorder or FD is a mental disorder where the 'ill' individual's symptoms are either self-induced or falsified by the patient. Essentially, it is faking sick: the act of an individual faking, exaggerating, or even inflicting self injuries. Their state of consciousness in this act falls somewhere between (and involves both) the conscious and unconscious mind. The main reasons why individuals develop this disorder is to assume the status of a 'patient'. Hence, they win over the attention, nurturance, sympathy, and even leniency that they feel they are unable to obtain any other way. FD individuals produce or exaggerate the symptoms of mental or physical illness. They do so by contaminating urine samples, taking hallucinogens, injecting themselves with bacteria to produce infections, and other such similar behaviour.
Historical Perspective
The motives of the patient can vary: for a patient with Munchausen syndrome their primary aim is to obtain sympathy, nurturance and attention, while in the case of malingering the patient wishes to obtain external gains such as disability payments or to avoid an unpleasant situation, such as military duty [add internal gain through drugs]. Strictly speaking, FD and malingering cannot be diagnosed in the same patient, yet clinicians find that patients' motives for the ruses can vary over time and, as a result, both diagnoses may apply. FD and Munchausen syndrome are considered mental disorders; malingering, though sometimes a focus of clinical attention, is not. Malingering, thus, is not diagnosed as FD for it is not a mental disorder, but, rather, done in reaction to the external stimuli; in other words, malingering is done to obtain some sort of benefit or to be relieved of something unwanted. (ie a fake injury to sue in a car accident, etc.) FD is diagnosed by the absence of malingering. Individuals with FD wish to assume the role of a 'patient'.
Classification
There are many possible causes for this disorder. One such possibility is an underlying personality disorder. Individuals with FD may be trying to repeat a satisfying childhood relationship with a doctor. Perhaps also the individual has a desire to deceive or test authority figures. The underlying desire to resume the role of a patient and to be cared for can also be considered an underlying personality disorder. Abuse in childhood is also another probable cause for the disorder. A background of neglect and abandonment may contribute to the development of FD. These individuals may be trying to reenact unresolved issues with their parents. A history of frequent illnesses may also contribute to the development of this disorder. Perhaps the individual afflicted with FD is accustomed to actually being sick, and thus returns to their previous state in order to recapture what was once considered to be the 'norm.'
Pathophysiology
Differential Diagnosis
- Borderline personality disorder[1]
- Conversion disorder (functional neurological symptom disorder)[1]
- Hypochondriasis
- Malingering[1]
- Medical condition or mental disorder not associated with intentional symptom falsification[1]
- Somatic symptom disorder:
- Pain
- Gastrointestinal symptom
- Sexual symptom
- Neurological symptom[1]
Epidemiology and Demographics
Prevalence
The prevalence of factitious disorder is unknown in the overall population.[1]
Risk Factors
Natural History, Complications, and Prognosis
Diagnostic Criteria
DSM-V Diagnostic Criteria for Factitious Disorder[1]
| “ |
Factitious Disorder Imposed on Self
AND
AND
AND
Specify:
Recurrent episodes (two or more events of falsification of illness and/or induction of injury) Factitious Disorder Imposed on Another(Previously Factitious Disorder by Proxy)
AND
AND
AND
Note:The perpetrator, not the victim, receives this diagnosis. Specify.
|
” |
History and Symptoms
Inclinations toward the disorder include females usually employed in medical fields such as nursing or medical technology, women ages of 20-40 years old, and loners with early childhood trauma. Cases rarely occur over the age of 45 for the disorder usually lasts from adolescence to mid-adulthood.
Laboratory Findings
There are three separate offshoots of Factitious Disorder. These include the Munchausen syndrome (a chronic variant of FD), Munchausen by proxy, and Ganser syndrome. In order to have these mental disorders, the individual must reflect symptoms of both FD and the specified symptoms that their offshoot requires.
Other Imaging Studies
Munchausen syndrome, or chronic FD, have specified symptoms along with FD diagnosis. Specified symptoms are that FD symptoms are greatly exaggerated, individuals undergo major surgery repeatedly, and they 'hospital jump' or migrate in order to avoid detection. Many are in the health care business and the illness often begins in early adulthood. Individuals are typically unmarried men estranged from their families and are usually middle-aged.
Other Diagnostic Studies
The word 'proxy' is defined as the infliction of a disorder unto another individual -- the 'substitution' of it. Specific symptoms include FD produced in children because of their caregivers or parents (almost always mothers) who induce illnesses on their children. The parent may falsify the child's medical history or tamper with laboratory tests in order to make the child appear sick. Occasionally, in Munchausen by proxy, the caregiver will actually injure the child to ensure that the child will be treated. Such parents enjoy the indirect attention that they receive.
Medical Therapy
- SSRIs, which are used to treat mood disorders, can be used to treat an individual with factitious disorder.
- In some cases, antipsychotic drugs can also be used to treat factitious disorder.
Psychotherapy
No true psychiatric medications are prescribed for Factitious Disorder. SSRIs (selective serotonin reuptake inhibitors), however can help cure underlying problems. Medicines used to treat personality disorders such as these (SSRIs) can be used to treat FD, as a personality disorder may be the underlying cause of FD. Some (authors such as Prior and Gordon 1997) also report good responses to antipsychotic drugs such as Pimozide. Family Therapy can also prove to be of assistance. In such therapy, families are helped to better understand patients (the individual in their family with FD) and their need for attention. In this therapeutic setting, the family is urged not to condone or reward the FD individual's behavior. This form of treatment can be unsuccessful if the family is uncooperative or displays signs of denial and/or antisocial disorder. Psychotherapy is another method used to treat the disorder. These sessions should focus on the psychiatrist establishing and maintaining a relationship with the patient. Such a relationship may help to contain symptoms of FD. Monitoring is also a form that may be implicated for the FD patient's own good. Video cameras, etc. are not illegal to use in such monitoring, for in many cases, FD (especially proxy) can prove to be very detrimental to an individual's health if they are, in fact, causing true physiological illnesses. (Even faking can be dangerous and might be monitored for fear that unnecessary surgery may subsequently be performed.)
Brain Stimulation Therapy
Treatment for FD proxy is not so subtle. Physicians, upon suspecting the disorder, should notify authorities immediately. Authorities will then initiate steps for immediate protection of the affected child. Criminal charges may be deemed necessary. Many times, help may be sought for the mother (parent) with Munchausen by proxy as well as the child affected and perhaps even their siblings. Careful monitoring of the family for an extended period of time is often a necessary precaution. This is to prevent translocation (i.e. the family moving to return to old ways, etc.) and to prevent the insinuation of a possible upheaval of the detrimental disorder.
Cost-Effectiveness of Therapy
Some experience only a few outbreaks of the disorder. However, in most cases, the disorder is chronic and factitious disorder is a long-term condition that is difficult to treat. There are poor positive outcomes for this disorder; in fact, treatment provided a poorer percentage of positive outcomes than did treatment of those with genuine psychoses such as schizophrenics. In addition, many individuals with Factitious Disorder will not seek treatment. Most deny that they are faking symptoms and therefore do not seek treatment for the disorder. There is, however, some hope. Age seems to help the disorder greatly. There are many possible explanations for this occurrence, although none are currently deemed as the definitive cause, though it is proven that the disorder does indeed grow milder with age. Some say perhaps it is because the FD individual has mastered the art of faking sickness over so many years of practice that the disorder can no longer be discerned. Another hypothesis is that many times an FD individual will be put in a home or experience real health issues. Thus, in this way, the problem with obtaining the 'patient' status is resolved because, in fact, it is inherently real.
Future or Investigational Therapies
References
- American Psychiatric Association (1997). DSM-IV Somatoform Disorders. APA. pp. 445–450.
- Eisendrath, Stuart J. (Feb 1984). Factitious illness: a clarification. Psychosomatics. pp. 25(2):110-3, 116–7. PMID 6701283.
- Feldman, Marc D. (1993). Patient or Pretender: Inside the Strange World of Factitious Disorders. John Wiley & Sons Inc. ISBN 0-471-58080-5. Unknown parameter
|coauthors=ignored (help) - Feldman, Marc D. (editor) (August 1996). The Spectrum of Factitious Disorders (Clinical Practice, 40). American Psychiatric Publishing; 1st ed edition. p. 229. ISBN 0-88048-909-X. Unknown parameter
|coauthors=ignored (help) - Feldman, Marc D. (2004). Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering and Factitious Disorder. Brunner-Routledge. p. 288. ISBN -415-94934-3.