Gender Identity Disorder and Transsexualism

Gender identity disorder is characterized by a strong, persistent cross-gender identification; people believe they are victims of a biologic accident and are cruelly imprisoned in a body incompatible with their subjective gender identity. Those with the most extreme form of gender identity disorder are called transsexuals. These disorders are considered mental disorders because the body does not match the person's psychologic (felt) gender. Core gender identity is a subjective sense of knowing to which gender one belongs, ie, the awareness that I am a male or I am a female. Gender identity is the inner sense of masculinity or femininity. Gender role is the objective, public expression of being male, female, or androgynous (blended). It is everything that people say and do to indicate to others or to themselves the degree to which they are male or female. For most people, there is congruity between their anatomic sex, gender identity, and gender role. However, those with gender identity disorder experience some degree of incongruity between their anatomic sex and their gender identity. The incongruity experienced by transsexuals is usually complete, severe, disturbing, and long-standing. Labeling the condition a disorder can add to the distress that frequently occurs, and the term should not be construed as being judgmental. Treatment is aimed at helping patients adapt rather than trying to dissuade them from their identity; in any case, the latter approach is ineffective. Gender role behaviors fall on a continuum of traditional masculinity or femininity, with a growing cultural recognition that some people do not fit into the traditional male-female dichotomy. Western cultures are more tolerant of tomboyish behaviors in young girls (generally not considered a gender identity disorder) than effeminate or sissy behaviors in boys. Many boys role-play as girls or mothers, including trying on their sister's or mother's clothes. Usually, this behavior is part of normal development. Only in extreme cases does this behavior and an associated expressed wish to be the other sex persist. Most boys with gender identity disorder of childhood do not have the disorder as adults, but many are homosexual or bisexual as adults. Etiology Although biologic factors (eg, genetic complement, prenatal hormonal milieu) largely determine gender identity, the formation of a secure, unconflicted gender identity and gender role is influenced by social factors (eg, the character of the parents' emotional bond, the relationship that each parent has with the child). Rarely, transsexualism is associated with genital ambiguity or a genetic abnormality (eg, Turner's syndrome, Klinefelter's syndrome). When sex labeling and rearing are confusing (eg, in cases of ambiguous genitals or genetic syndromes altering genital appearance, such as androgen insensitivity syndrome), children may become uncertain about their gender identity or role, although the level of importance of environmental factors remains controversial. However, when sex labeling and rearing are unambiguous, even the presence of ambiguous genitals often does not affect a child's gender identity.

Symptoms and Signs Childhood gender identity problems are usually present by age 2. Children experiencing difficulty with gender identity commonly do the following:

Prefer cross-dressing Insist that they are of the other sex Intensely and persistently desire to participate in the stereotypical games and activities of the other sex Have negative feelings toward their genitals

For example, a young girl may insist she will grow a penis and become a boy; she may stand to urinate. A boy may fantasize about being female, and avoid rough-and-tumble play and competitive games. He may sit to urinate and wish to be rid of his penis and testes. For boys with a gender identity disorder, distress at the physical changes of puberty is often followed by a request during adolescence for feminizing somatic treatments. Most children with these disorders are not evaluated until they are age 6 to 9, at a point when the disorder is already chronic. Although most transsexuals began having gender identity problems in early childhood, some do not present until adulthood. Male-to-female transsexuals may be cross-dressers first and only later in life come to accept their cross-gender identity. Marriage and military service are common among transsexual men who seek to run from their cross-gender feelings. Once they accept their cross-gender (transgender) feelings, many transsexuals adopt a convincing public feminine gender role. Some are satisfied with mastering a more feminine appearance and obtaining an identity card (eg, driver's license) as a female to help them work and live in society as women. Others experience problems, which may include depression and suicidal behavior. Diagnosis Diagnosis in children requires the presence of both of the following:

Cross-gender identification (the desire to be or insistence that they are the other sex) A sense of discomfort about their sex or sense of substantial inappropriateness in their gender role

Cross-gender identification must not be merely a desire for perceived cultural advantages of being the other sex. For example, a boy who says he wants to be a girl so that he will receive the same special treatment his younger sister receives is not likely to have gender identity disorder. Assessment of adults focuses on determining whether there is significant distress or obvious impairment in social, occupational, or other important areas of functioning. Treatment

For selected, motivated patients, hormone therapy, sex reassignment surgery, and

psychotherapy Cross-gender behavior, such as cross-dressing, may not require treatment if it occurs without concurrent psychologic distress or functional impairment or if a person has a physical intersex condition (eg, congenital adrenal hyperplasia, ambiguous genitals, androgen insensitivity syndrome). Most transsexuals who request treatment are natal males who claim a feminine gender identity and regard their genitals and masculine features with repugnance. However, as treatments improve, female-to-male transsexualism is increasingly seen in medical and psychiatric practice. Transsexuals' primary objective in seeking medical help is not to obtain psychologic treatment but to obtain hormones and genital surgery that will make their physical appearance approximate their felt gender identity. The combination of psychotherapy, hormonal reassignment, and sex reassignment surgery is often curative when the disorder is appropriately diagnosed and clinicians follow the internationally accepted standards of care for the treatment of gender identity disorders, available from the World Professional Association for Transgender Health (WPATH). Male-to-female transsexualism: Taking moderate doses of a feminizing hormone (eg, ethinylestradiol 0.1 mg once/day) plus electrolysis and other feminizing treatments may make the adjustment to a feminine gender role more stable. Many male-to-female transsexuals request sex reassignment surgery. Surgery involves removal of the penis and testes and creation of an artificial vagina. A part of the glans penis is retained as a clitoris, which is usually sexually sensitive and retains the capacity for orgasm in most cases. The decision to pursue sex reassignment surgery often raises important social problems for patients. Many of these patients are married and have children. A parent or spouse who changes sex will have substantial adjustment issues in all intimate relationships and may lose loved ones in the process. In follow-up studies, genital surgery has helped some transsexuals live happier and more productive lives and so is justified in highly motivated, appropriately assessed and treated transsexuals who have completed a 1- to 2-yr real-life experience in the opposite gender role. Before surgery, transsexuals often need assistance with passing in public, including help with gestures and voice modulation. Participation in gender support groups, available in most large cities, is usually helpful. Female-to-male transsexualism: Patients ask for mastectomy early, then hysterectomy and oophorectomy. Androgenic hormones (eg, IM testosterone

ester preparations 300 to 400 mg q 3 wk or equivalent doses of androgen transdermal patches or gels) are given to permanently alter the voice, induce a more masculine muscle and fat distribution, and promote growth of facial and body hair. Patients may opt for an artificial phallus (neophallus) to be fashioned from skin transplanted from the inner forearm (phalloplasty) or for a micropenis to be created from fat tissue removed from the testosterone-hypertrophied clitoris (metoidioplasty). Surgery may help

certain patients achieve greater adaptation and life satisfaction. Similar to male-to-female transsexuals, female-to-male transsexuals should live in the male gender role for at least 1 yr before surgery. Anatomic results of neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for male-tofemale transsexuals. Complications are common, especially in procedures that involve extending the urethra into the neophallus.

History The study of sexual deviancy began just before the turn of the 20th century as the taboo of discussing sexuality was beginning to lift. Early pioneers included Richard von Kraff-Ebing, Albert Moll, August Forel, Iwan Bloch, Magnus Hirschfield, Havelock Ellis, and Sigmund Freud. Their work was not well accepted, and they were regarded with disdain. Of interest, the Bible contains many statements and stories concerning paraphilias.[1] Several psychiatric concepts were prominent at this time. One of them was a constitutional predisposition of unknown origin called degeneration, which refers to an innate neurologic weakness that is transmitted with increased severity to future generations and produces deviations from the norm. Masturbation was blamed for a list of diseases including insanity, suicide, self-mutilation, and tuberculosis. The law of association of ideas suggests that when sex and another experience occur, one stimulus sets off the other. Ellis worked against the prudish view of sex that existed at the time, and he advocated the decriminalization of homosexuality. Freud wrote on fetishism, masochism, and the theory of perversions. These early investigators of sexual deviation provide an important principal: "Not only must the act be studied, but also the person. The personal roots of deviance spring from an interaction of the individual's biological nature and his early life experiences." Disorders of human behavior remain difficult to understand, identify, and treat. Few data are available, too much of our knowledge is based on speculation and unsupported theory, and societal stereotypes influence our perceptions. Good science-based research remains difficult, and monetary, ethical, and legal concerns complicate such research.

Gender -- being male or female -- is a basic element that helps make up an individual's personality and sense of self. Gender identity disorder is a condition in which a male or female feels a strong identification with the opposite sex. A person with this disorder often experiences great discomfort regarding his or her actual anatomic gender. People with gender identity disorder may act and present themselves as members of the opposite sex and may express a desire to alter their bodies. The disorder affects an individual's selfimage, and can impact the person's mannerisms, behavior, and dress. Individuals who are committed to altering their physical appearance through cosmetics, hormones and, in some cases, surgery are known as transsexuals.

Recommended Related to Sexual Health What Does It Take to Lift Your Sex Life to the Next Level? When it comes to giving your sex life a boost, your first instinct might be to turn to the usual suspects: lacy lingerie, scented oils, maybe a naughty toy or two. But who knew that getting a new dishwasher, practicing Pilates, or having a baby yes, really! could improve your bedroom connection? Read on to find out what worked for these real couples. Read the What Does It Take to Lift Your Sex Life to the Next Level? article > > What Causes Gender Identity Disorder? The exact cause of gender identity disorder is not known, but several theories exist. These theories suggest that the disorder may be caused by genetic (chromosomal) abnormalities, hormone imbalances during fetal and childhood development, defects in normal human bonding and child rearing, or a combination of these factors. How Common Is Gender Identity Disorder? Gender identity disorder is a rare disorder that affects children and adults. It can be evident in early childhood. In fact, most people recognize that they have a gender identity problem before they reach adolescence. The disorder occurs more often in males than in females. What Are the Symptoms of Gender Identity Disorder? Children with gender identity disorder often display the following symptoms:

Expressed desire to be the opposite sex (including passing oneself off as the opposite sex and calling oneself by an opposite sex name). Disgust with their own genitals (Boys may pretend not to have a penis. Girls may fear growing breasts and menstruating and may refuse to sit when urinating. They also may bind their breasts to make them less noticeable.) Belief that they will grow up to become the opposite sex. Rejection by their peer groups. Dressing and behaving in a manner typical of the opposite sex (for example, a female wearing boy's underwear). Withdrawal from social interaction and activity. Feelings of isolation, depression, and anxiety.

Adults with gender identity disorder often display the following symptoms:

Desire to live as a person of the opposite sex. Desire to be rid of their own genitals. Dressing and behaving in a manner typical of the opposite sex.

Withdrawal from social interaction and activity. Feelings of isolation, depression, and anxiety.

How Is Gender Identity Disorder Diagnosed? Gender identity disorder typically is diagnosed by a trained mental health professional (psychiatrist or psychologist). A thorough medical history and psychological exam are performed to rule out other possible causes for the symptoms, such as depression, anxiety, or psychosis. Gender identity disorder is diagnosed when the evaluation confirms the persistent desire to be the opposite sex. What is transsexualism? Transsexualism is a condition in which a person experiences a discontinuity between their assigned sex and what they feel their core gender is. For example, a person who was identified as "female" at birth, raised as a girl, and has lived being perceived by others as a woman, may feel that their core sense of who they are is a closer fit with "male" or "man." If this sense is strong and persistent, this person may decide to take steps to ensure that others perceive them as a man. In other words, they may decide to transition to living as the sex that more closely matches their internal gender. What is involved in the transition process? The answer to this question varies depending on the needs and desires of the individual choosing the transition process. An individual may choose any combination of social, medical and legal steps that will help that person achieve the greatest level of comfort with their body and social roles. Social steps might include asking to be referred to by a different name (perhaps one generally given to people of the "opposite sex") and different pronouns ("she" instead of "he" or vice versa), dressing in clothing traditionally worn by people of the sex they wish to be perceived as, and taking on mannerisms frequently associated with that sex/gender. Medical steps might include hormonal treatment to achieve an appearance more consistent with the target gender expression, and/or surgery to further modify the appearance. There are a variety of surgical options to alter the transsexual person's body to help them achieve the greatest comfort with their gender expression. The transsexual person may choose some, all, or none of these surgical options. Many transsexual people also work with the courts in their area to achieve legal recognition of their new name and gender. Steps taken vary depending on the location. What causes transsexualism? No one knows the answer to this question, although there is much research currently in progress investigating it. Among the theories being investigated are genetic influences, in utero hormonal influences, and other brain structure/brain chemical influences. Human sex and gender are very complex, and it is unlikely that any simplistic analysis will definitively answer this question. What is the treatment for transsexualism? Is there a "cure?"

Treatments for transsexualism based on attempting to change the individual's sense of their own true gender have proven ineffective. Accepted treatments are based on helping the transsexual person's body and presentation match their inner sense of their gender, usually through hormone treatment and surgery. How common is transsexualism? The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), Fourth edition, says the following ( 1994, American Psychiatric Assoc.): Prevalence: There are no recent epidemiological studies to provide data on prevalence of Gender Identity Disorder. Data from smaller countries in Europe with access to total population statistics and referrals suggest that roughly 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery. Because these numbers reflect only people who have sought traditional medical treatment, they do not reflect the total numbers of people who have some experience of gender discontinuity. Is transsexualism a modern phenomenon? While advances in medical science have only in the last few decades made it possible for individuals to transition with the aid of hormones and surgery, transgendered people have existed throughout history in many societies. Jennifer Reitz's Natural History of Transsexuality provides a brief historical overview. Is transsexualism the same as homosexuality? No. Transsexualism is about a person's core sense of their gender. This is a separate issue from the gender of the people they are attracted to. Just like any other individual, a transsexual person may identify as heterosexual, gay, lesbian, or bisexual. For example, a person raised as a man who transitions to living as a woman may identify as heterosexual, in which case she would seek or continue relationships with men, or lesbian, in which case she would seek or continue relationships with other women. Or she may not feel that it is necessary or meaningful to label herself with regard to sexual orientation at all. Section II: Responses to common reactions and feelings about transition The person I thought I knew is becoming a stranger. A person we know who undergoes gender transition will very likely look and sound quite different after their transition. A person we've known as a woman, for instance, may change his hairstyle, grow facial hair, speak with a lower voice, and adopt an entirely new wardrobe. But he's not likely to adopt an entirely new personality or set of values, and our history with this person is unchanged. Think of any person you care about, and ask yourself what qualities you value most about her or him. You are likely to think of qualities which are not gender-specific, such as sense of humor, intelligence, and loyalty. These qualities are not likely to change as a person undergoes gender transition. In fact, a person who undergoes gender transition is in a process of becoming more comfortable with himself or herself, and so their positive qualities are likely to be enhanced. It can be scary when someone in your life tells you they need to make such a major change, and it's understandable that you may feel you don't know this person as well as you thought. But if you

continue to spend time together, you will likely be comforted to find that they are in many ways the same person you have always known. Altering the body through surgery seems like mutilation. This is also an understandable response. To those of us who are comfortable with our assigned gender, the idea of altering those parts of our bodies that are most associated with our gender can feel alien, frightening, and disturbing. Another person's decision to alter parts of their body can feel threatening. It may help to remember that a person undergoing transition from, for instance, a male to female gender expression, is not making a blanket statement about the value of malehood or the validity of your gender expression. She is simply seeking to become more comfortable in her body. Sex reassignment surgery is the aspect of gender transition that is most difficult for some people to understand, and you may never feel comfortable with it. That's OK. But that discomfort doesn't preclude honoring another person's choice, treating them with respect, and even supporting them through their gender transition. I can't imagine the person ever seeming to me like the sex they want to be. It's hard to let go of our perceptions of someone we've known for a long time. Changes in a person's appearance and behavior can occur gradually, and may be difficult to perceive if you are in regular contact. But if you pay attention to how strangers react to the person, it may help you to see these changes. On the other hand, the gradualness of the change may help you to adapt to the new gender identity step-by-step. You may be surprised, in time, at how completely you accept the person's new chosen gender. It is true, however, that some people who undergo gender transition will continue to have significant characteristics of their previous gender identity. Some male-to-female transsexuals, for instance, may be unusually tall for women, while a female-to-male transsexual may have small features. It may help if you avoid focusing on these specific things, but rather honor the person's chosen gender, and try to see them as they see themselves. How can I support this person in their transition? There are many ways you can be helpful. Perhaps the most important is to convey your intention to be supportive to the person in transition. Let them know you want to be an ally, and ask them what they need from you. Then, to the extent you are able, offer them the support they've asked for. We can offer a couple of specific ideas as well. First, you can adopt the use of the person's new name (if they've chosen one) and appropriate gender pronouns. This change can be uncomfortable at first, and you may slip up once in a while, but eventually this change becomes habitual and comfortable. This small but very important step will demonstrate that you take the person's decision seriously. You can also try to maintain your previous relationship with the person, whether that's the intimate relationship of close friends or once-a-month bowling buddies. Gender transition is new territory for many people, and hence can be scary. "Hanging in" with the person in transition despite feelings of discomfort with the process can be a very supportive act. Also, you may ask the person in transition how you can help in letting others know about their transition. They may want to tell people themselves, or they may be grateful for help "spreading the

word." There may be certain contexts--the softball team, a church you both attend, or the workplace-where your assistance in telling others and expressing your support will be appreciated. Let them be your guide in this.

Transsexualism: Epidemiology, pathophysiology, and diagnosis INTRODUCTION Transsexualism is the condition in which a person with apparently normal somatic sexual differentiation of one gender is convinced that he or she is actually a member of the opposite gender. It is associated with an irresistible urge to be in the opposite gender hormonally, anatomically, and psychosocially. The epidemiology, pathophysiology, and diagnosis of transsexualism will be discussed here. The treatment of transsexualism is reviewed separately. (See "Treatment of transsexualism".) OVERVIEW Gender identity is the sense one has of being male or female [1]. Some people experience a significant incongruence between their gender identity and inborn physical phenotype, labeled as Gender Identity Disorder (GID); the experience is termed gender dysphoria [1]. Living as a member of the opposite biological sex is referred to as transgenderism; this encompasses a wide spectrum. The most extreme expression of this is transsexualism, characterized by an overwhelming desire to undergo phenotypical transition to the subjectively experienced gender by means of hormonal and surgical treatment. Other people with gender dysphoria may seek partial adaptions to the other sex, such as hormonal treatment or forms of surgery [2,3]. EPIDEMIOLOGY Prevalence of transsexualism The prevailing social climate and provisions for medical treatment influence assessments of prevalence data. Further, the definition of the condition, sometimes making no clear distinction between transsexuals and transgender individuals, affects prevalence studies. Some studies identify only subjects who actually undergo hormonal/surgical treatment, while others determine prevalence data based upon patient self-identification. The prevalence of transsexualism, based on data of subjects undergoing sex reassignment treatment in the Netherlands, is 1:11,900 men and 1:30,400 women [4]. The prevalence is similar in Belgium [5], slightly lower in Sweden, but higher in Singapore. The prevalence by self-report in New Zealand is approximately 1:6000 [6]. Apparently, only those for whom gender dysphoria becomes a burden seek medical treatment. An approximate 3:1 ratio of male-to female versus female-to-male transsexuals is widely encountered in the western world, but in other parts of the world female-to-male transsexualism is greater [7,8]. There is no plausible explanation for the variations of sex ratios in different parts of the world. The prevalence of transsexualism appears to be similar over time. PATHOPHYSIOLOGY Sexual differentiation of the brain Traditionally, transsexualism has been conceptualized as a purely psychological phenomenon, but research on the brains of male-to-female transsexuals has found that the sexual differentiation of one brain area, the bed nucleus of the stria terminalis, follows a

female pattern [9,10]. This area of the brain has been proposed to be important for gender identity and may support a biologic basis for transsexualism.

Transsexualism describes the condition in which an individual identifies with

a gender inconsistent or not culturally associated with their assigned sex, i.e. in which a person's assigned sex at birth conflicts with their psychological gender. A medical diagnosis can be made if a person experiences discomfort as a result of a desire to be a member of the opposite sex,[1] or if a person experiences impaired functioning or distress as a result of that gender identification.[2] Transsexualism is stigmatized in many parts of the world but has become more widely known in Western culture in the mid to late 20th century, concurrently with the sexual revolution and the development of sex reassignment surgery (SRS). Discrimination or negative attitudes towards transsexualism often accompany certain religious beliefs or cultural values. There are cultures that have no difficulty integrating people who change gender roles, often holding them with high regard, such as the traditional role for "two-spirit" people found among certain native American tribes.[3] Diagnosis Transsexualism appears in the two major diagnostic manuals used by mental health professionals worldwide, the American Psychiatric Association'sDiagnostic and Statistical Manual of Mental Disorders (DSM, currently in its fourth edition) and the International Statistical Classification of Diseases and Related Health Problems (ICD, currently in its tenth edition). The ICD-10 incorporates transsexualism, dual role transvestism and gender identity disorder of childhood into its gender identity disorder category, and defines transsexualism as "[a] desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex."[4] The DSM does not distinguish between gender identity disorder and transsexualism, and defines transvestic fetishism as a separate phenomenon which may co-occur with transsexualism. The DSM diagnosis requires four components:[5]

A desire or insistence that one is of the opposite biological sex (that is not due to a perceived advantage of being the other sex) Evidence of persistent discomfort with, and perceived inappropriateness of the individual's biological sex The individual is not intersex (although a diagnosis of GID Not Otherwise Specified is available, which enables intersex people who reject their sex-assignment to access transsexual treatments) Evidence of clinically significant distress or impairment in work or social life.

Relation to gender roles

Binary-identified transsexual people may refer to themselves as trans men or trans women, respectively, and non-binary-identified transsexual people may refer to themselves with other words, such as third gender or genderqueer. Binary-identified transsexual people often desire to establish a permanent gender role as a member of the gender with which they identify, while others may prefer to defy gender roles and express their

unique gender, or express more than one type of gender expression. Some transsexual people pursue medical interventions as part of the process of expressing their gender. These medically based, physical alterations are collectively referred to as sex reassignment therapy, and may include female-to-male or male-to-female hormone replacement therapy, or various surgeries. Surgeries may include genital surgery such as orchiectomy or sex reassignment surgery; chest surgery such as top surgery or breast augmentation; or, in the case of trans women, facial surgery such as trachea shave or facial feminization surgery. The entire process of switching from one physical sex and social gender presentation to another is often referred to astransition, and usually takes several years. Not all transsexual people undergo a physical transition. Some find reasons not to, for example, the expense of surgery, the risk of medical complications, medical conditions which make the use of hormones or surgery dangerous. Some may not identify strongly with another binary gender role. Others may find balance at a midpoint during the process, regardless of whether they are binary-identified. Many transsexual people, including binary-identified transsexual people, do not undergo genital surgery, because they are comfortable with their own genitals, or because they are concerned about nerve damage and the potential loss of sexual pleasure and orgasm. This is especially so in the case of trans men, many of whom are dissatisfied with the current state ofphalloplasty, which is typically very expensive, not covered by health insurance, and which does not result in a fully erectile, sexually sensate penis. Some transsexual people live heterosexual lifestyles and gender roles, while some identify as gay, lesbian, [11] or bisexual. Many trans people find that a shift occurs in their sexual orientation as they undergo transition. Many transsexual people choose the language of how they refer to their sexual orientation based on their gender identity, not their morphological sex,[11] though some transsexual people still find identification with their community: many trans men, for instance, are involved with lesbian communities, and identify as lesbian despite their male identity. Some lesbians are willing to become sexually or romantically involved with trans men; some gay men are willing to do the same with trans women; where both groups typically would not date members of the opposite sex.

F20.1 Hebephrenic Schizophrenia A form of schizophrenia in which affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and mannerisms common. The mood is shallow and inappropirate and often accompanied by giggling or self-satisfied, self-absorbed smiling, or by a lofty manner, grimaces, mannerisms, pranks, hypochondriacal complaints, and reiterated phrases. Thought is disorganized and speech rambling and incoherent. There is a tendency to remain solitary, and behaviour seems empty of purpose and feeling. This form of schizphrenia usually starts between the ages of 15 and 25 years and tends to have a poor prognosis because of the rapid development of negative symptoms, particularly flattening of affect and loss of volition. In addition, disturbances of affect and volition, and thought disorder are usually prominent. Hallucinations and delusions may be present but are not usually prominent. Drive and determination are lost and goals abandoned, so that the patients behaviour becomes characteristically aimless and empty of purpose. A superficial and manneristic preoccupation with religion, philosophy, and other abstract themes may add to the listeners difficulty in following the train of thought. Hebephrenic schizophrenia, more commonly known as disorganized schizophrenia, is one of the subtypes of schizophrenia. It is a complex and chronic psychiatric disorder. The term hebephrenic is an older term which is still used in some classifications of psychiatric disorders with

regards to this type of schizophrenia. The primary symptoms include significant impairment in thought processes, speech, behavior, and emotional expression and response. Characteristics and Symptoms There are three prominent symptoms which are characteristic of hebephrenic schizophrenia: Disorganized speech Disorganized speech may be evidenced in a variety of ways. For example, when responding to a question, the person may give an answer which has little or no relevance to the question. S/he may abruptly jump from one topic to another while talking, or make up words as s/he goes along. In particularly severe cases, the persons words may be complete nonsense, sometimes referred to as word salad. This impairment in speech is due to significant impairment in the persons thinking. His/her thought processes are often illogical, and dont connect very well. Hence it shows up in his/her speech. Hebephrenic schizophrenics often experience something known as thought blocking. They may stop suddenly while talking, as if the thought abruptly left them. They may express feeling as if someone or something removed the thought from their mind. Disorganized behavior When a schizophrenics behavior is considered disorganized, it may mean s/he is unable to or lacks the motivation to start or carry out a given task, such as preparing a meal or getting dressed. Their behavior may be bizarre, such as wearing layer upon layer of clothing in the middle of summer. Or, their behavior may be grossly inappropriate, such as acting out sexually in public. They may completely neglect personal grooming and have a very unkempt appearance. Blunted or inappropriate emotional expression and response A person with hebephrenic schizophrenia will often appear to have no emotions. His/her face may look completely blank, and his/her speech may be monotone. At times, s/he may have an emotional response which is completely irrelevant to the context, such as laughing or giggling suddenly, when nothing funny has occurred. Additional Diagnostic Criteria In order to meet the diagnosis of schizophrenia, regardless of the type, these other criteria must also be met:

A marked decline in functioning, after the onset of symptoms, in at least one of the primary aspects of the persons life (e.g., work, school, relationships, self-care). Signs of the disorder are present continuously for a period of at least 6 months. For at least one month of that time period (less if they subside due to effective treatment), the active-phase symptoms (e.g. delusions,hallucinations, extremely disorganized behavior, etc.) must be present. Schizoaffective disorder (a disorder similar to schizophrenia but with prominent mood episodes) or other mood disorder have been ruled out.

Other Characteristics Other characteristics often exhibited by individuals with hebephrenic schizophrenia may include poor job or school performance, social withdrawal, lack of coordination, odd postures, childlike silliness, or grimacing. While they may have hallucinations or delusions, they are not pronounced. Since they are often quite impaired, living independently may be impossible for them. Schizophrenia Disorganized Type

Schizophrenia - disorganized type Causes Treatment Prevention

Alternative Names Hebephrenic schizophrenia; Disorganized schizophrenia Symptoms

Active behavior, but in an aimless and not constructive way Bizarre and inappropriate emotional responses Difficulty feeling pleasure False, fixed beliefs (delusions) Lack of motivation Seeing or hearing things that aren't there (hallucinations) Strange or silly behavior Speech that makes no sense

Hebephrenic schizophrenia, also commonly referred to as disorganized schizophrenia or disorganized type schizophrenia, is a distinct type of schizophrenic psychosis. This type differs from other forms of this disorder, as it is characterized by nonsensical speech that follows no distinct pattern, as well by erratic and extremely bizarre behavior. Hebephrenic schizophrenia also typically presents in patients during their teen years and who are younger than 25 years of age. It is not known what precisely causes hebephrenic schizophrenia and, although treatment options exist, there is no known cure for its peculiar symptoms. Some research suggests that individuals with a family history of depression may be more prone to its development, however. Researchers also continue to study whether marijuana use may be related to the development of psychoses in general, including schizophrenia. Typically occurring in young patients between the ages of 15 and 25 years old, hebephrenic schizophrenia is marked by a rapid increase in symptoms after its initial onset. One of the primary symptoms of this disorder is severely disorganized speech patterns that also appear to have no grammatical structure. Other symptoms include a seeming inability to feel pleasure, improper emotional responses, a complete loss of motivation, delusions,hallucinations and highly unusual behavior.

As schizophrenia is a chronic disorder, symptoms can be treated, but cannot be cured. Commonly, individuals who are diagnosed with hebephrenic schizophrenia are treated withantipsychotic medications, which may help reduce symptoms. In many cases, however, individuals with this schizophrenic disorder must be hospitalized to prevent harm to self and others. Disorganized type schizophrenia may be negatively impacted by habits and behaviors such as cigarette smoking, marijuana use, and other drug and alcohol abuse. Individuals who avoid these habits, as well as continue to take prescribed medications, often do experience a relief from symptoms and some may even be able to lead productive lives. Many with hebephrenic schizophrenia, however, tend to stop taking medication after symptoms have subsided, which generally causes a relapse. Due to its early onset, hebephrenic schizophrenia was once referred to as a dementia praecox. This term predates the schizophrenia label that is currently applied to symptoms. Certain researchers that study dementia and, specifically, study schizophrenia, believe that the broad term dementia praecox should be reapplied to describe the illness, as it appears to be a distinct form of dementia, though it differs from the type commonly found among elderly populations.

Treatment
Disorganized schizophrenia usually requires lifelong treatment. Antipsychotic medications can help reduce and control some of the symptoms, enabling the person to live a more functional and fulfilling life. If the medication is effective, he/she may be well enough to participate in individual, group, family, or other types of therapy. Vocational skills training may also be very beneficial. Hebephrenic type Symptoms:

Emotional shallowness, tendency to childish silliness, bizarre delusion, hallucination, jumbled speech and gross disintegration of the personality

Conversion disorder
From Wikipedia, the free encyclopedia

A conversion disorder causes patients to suffer from neurological symptoms, such as numbness, blindness, paralysis, or fits without a definable organic cause. It is thought that symptoms arise in response to stressful situations affecting a patient's mental health, however no concrete evidence has been found that proves episodes of conversion are not symptoms of an underlying organic cause. Telling the patient that the blindness, stroke, or movement disorder has no organic cause will not cure them; it is important to recognize that the patient's symptoms are very real, not malingering or factitious. Conversion disorder is considered a psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV).[1]

Formerly known as "hysteria", the disorder has arguably been known for millennia, though it came to greatest prominence at the end of the 19th century, when the neurologists Jean-Martin Charcot and Sigmund Freud and psychiatrist Pierre Janet focused their studies on the subject. Before Freud's studies on hysteria, people who suffered from physical disabilities that were not caused by any physical impairments, known as hysterical patients, were believed to be malingering, suffering from weak nerves, or just suffering from meaningless disturbances. The term "conversion" has its origins in Freud's doctrine that anxiety is "converted" into physical symptoms.[2] Though previously thought to have vanished from the west in the 20th century, some research has suggested it is as common as ever.[3]

Definition DSM-IV defines conversion disorder as follows:

One or more symptoms or deficits are present that affect voluntary motor or sensory function suggestive of a neurologic or other general medical condition. Psychological factors are judged, in the clinician's belief, to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit. A diagnosis where the stressor precedes the onset of symptoms by up to 15 years is not unusual. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). The symptom or deficit, after appropriate investigation, cannot be explained fully by a general medical condition, the direct effects of a substance, or as a culturally sanctioned behavior or experience. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.

The nature of the association between the psychological factors and the neurological symptoms remains unclear. Earlier versions of the DSM-IV employed psychodynamic concepts, but these have been incrementally removed from successive versions. The tenth revision of the World Health Organization's International Classification of Diseases uses the term "conversion" as an alternative descriptor for the dissociative disorders class of mental and behavioural disorders (i.e. the F44 class), with the explicit suggestion that dissociative and conversion symptoms probably share common psychological mechanisms.[4] In ICD-10, the dissociative [conversion] disorders class includes 10 disorders that, in addition to specific criteria for each individual disorder, must each meet the following general criteria:

No evidence of a physical disorder that can explain the symptoms that characterize the disorder (but physical disorders may be present that give rise to other symptoms);

Convincing associations in time between the symptoms of the disorder and stressful events, problems or needs.[4]

Conversion disorder can present with motor or sensory symptoms including any of the following: Motor symptoms or deficits:

Impaired coordination or balance Weakness/paralysis of a limb or the entire body (hysterical paralysis or motor conversion disorders) Impairment or loss of speech (hysterical aphonia) Difficulty swallowing or a sensation of a lump in the throat Urinary retention Psychogenic non-epileptic seizures or convulsions Fixed dystonia unlike normal dystonia[clarification needed] Tremor, myoclonus or other movement disorders Gait problems (Astasia-abasia) Syncope (fainting)

Sensory symptoms or deficits:

Impaired vision (hysterical blindness), double vision Impaired hearing (deafness) Loss or disturbance of touch or pain sensation

Conversion symptoms typically do not conform to known anatomical pathways and physiological mechanisms, but instead follow the individual's conceptualization of a condition. Typically, the less medical knowledge a person has, the more implausible are the presenting symptoms. Persons with more sophisticated medical knowledge tend to have more subtle symptoms and deficits that may closely simulate neurological or other general medical conditions.[10]

Conversion Disorder

Conversion disorder consists of symptoms or deficits that develop unconsciously and nonvolitionally and usually involve motor or sensory function. Manifestations resemble a neurologic or other physical disorder but rarely conform to known pathophysiologic

mechanisms or anatomic pathways. Onset, exacerbation, or maintenance of conversion symptoms is typically attributed to mental factors, such as stress. Diagnosis is based on history after excluding physical disorders as the cause. Treatment begins by establishing a consistent, supportive physician-patient relationship; psychotherapy can help, as may hypnosis. Conversion disorder tends to develop during late childhood to early adulthood but may occur at any age. It is more common among women. Symptoms and Signs Symptoms often develop abruptly, and onset can often be linked to a stressful event. Symptoms involve apparent deficits in voluntary motor or sensory function and sometimes include seizures, thus suggesting a neurologic or general physical disorder. For example, patients may present with impaired coordination or balance, weakness, paralysis of an arm or a leg, loss of sensation in a body part, seizures, blindness, double vision, deafness, aphonia, difficulty swallowing, sensation of a lump in the throat, or urinary retention. The symptoms are severe enough to cause significant distress or impair social, occupational, or other important areas of functioning. Patients may have a single episode or sporadic repeated ones; symptoms may become chronic. Typically, episodes are brief. Diagnosis The diagnosis is considered only after a physical examination and tests rule out physical disorders that can fully account for the symptoms and their effects. Treatment A consistently trustful and supportive physician-patient relationship is essential. Collaborative treatment that involves a psychiatrist and a physician from another field (eg, neurologist, internist) seems most helpful. After the physician has excluded a physical disorder and reassured patients that the symptoms do not indicate a serious underlying disorder, patients may begin to feel better, and symptoms may fade. The following treatments may help:

Hypnosis may help by enabling patients to control the effects of stress and their mental state on their bodily functions. Narcoanalysis is a rarely used procedure similar to hypnosis except that patients are given a sedative to induce a state of semisleep. Psychotherapy, including cognitive-behavioral therapy, is effective for some people.

Any coexisting psychiatric disorders (eg, depression) should be treated.

Factitious disorder A factitious disorder is a condition in which a person acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms. Factitious disorder by proxy is a condition in which a person deliberately produces, feigns, or exaggerates symptoms in a person in their care.Mnchausen syndrome, a severe form of factitious disorder, was the first kind identified, and was for a period the umbrella term for all such disorders.[1] People with this condition may produce symptoms by contaminating urine samples, taking hallucinogens, injecting themselves with bacteria to produce infections, and other similar behaviour. They might be motivated to perpetrate factitious disorders either as a patient or by proxy as a caregiver to gain any variety of benefits including attention, nurturance, sympathy, and leniency that are seen as not obtainable any other way. In contrast, somatoform disorders are characterised by multiple somatic complaints,[2] albeit both are diagnoses of exclusion. Factitious Disorders Definition Factitious disorders are a group of mental disturbances in which patients intentionally act physically or mentally ill without obvious benefits. The name factitious comes from a Latin word that means artificial. These disorders are not malingering, which is defined as pretending illness when the "patient" has a clear motive, such as financial gain. Description Patients with factitious disorders produce or exaggerate the symptoms of a physical or mental illness by a variety of methods, including contaminating urine samples with blood, taking hallucinogens, injecting themselves with bacteria to produce infections, and other similar behaviors. There are no reliable statistics on the frequency of factitious disorders, but they are more common in men than in women. The following conditions are sometimes classified as factitious disorders: Munchausen syndrome Munchausen syndrome refers to patients whose factitious symptoms are dramatized and exaggerated. Many persons with Munchausen go so far as to undergo major surgery repeatedly, and, to avoid detection, at several locations. Many have been employed in hospitals or in health care professions. The syndrome's onset is in early adulthood. Munchausen by proxy Munchausen by proxy is the name given to factitious disorders in children produced by parents or other caregivers. The parent may falsify the child's medical history or tamper with laboratory tests in order to make the child appear sick. Occasionally, they may actually injure the child to assure that the child will be treated. Ganser's syndrome Ganser's syndrome is an unusual dissociative reaction to extreme stress in which the patient gives absurd or silly answers to simple questions. It has sometimes been labeled as psychiatric malingering, but is more often classified as a factitious disorder.

Causes and symptoms No single explanation of factitious disorders covers all cases. These disorders are variously attributed to underlying personality disorders; child abuse; the wish to repeat a satisfying childhood relationship with a doctor; and the desire to deceive or test authority figures. Also, the wish to assume the role of patient and be cared for is involved. In many cases, the suffering of a major personal loss has been implicated. The following are regarded as indications of a factitious disorder:

dramatic but inconsistent medical history extensive knowledge of medicine and/or hospitals negative test results followed by further symptom development symptoms that occur only when the patient is not being observed few visitors arguments with hospital staff or similar acting-out behaviors eagerness to undergo operations and other procedures

When patients with factitious disorders are confronted, they usually deny that their symptoms are intentional. They may become angry and leave the hospital. In many cases they enter another hospital, which has led to the nickname "hospital hoboes." Diagnosis Diagnosis of factitious disorders is usually based on the exclusion of bona fide medical or psychiatric conditions, together with a combination of the signs listed earlier. In some cases, the diagnosis is made on the basis of records from other hospitals. Treatment Treatment of factitious disorders is usually limited to prompt recognition of the condition and the refusal to give unnecessary medications or to perform unneeded procedures. Factitious disorder patients do not usually remain in the hospital long enough for effective psychiatric treatment. Some clinicians have tried psychotherapeutic treatment for factitious disorder patients, and there are anecdotal reports that antidepressant or antipsychotic medications are helpful in certain cases. Prognosis Some patients have only one or two episodes of factitious disorders; others develop a chronic form that may be lifelong. Successful treatment of the chronic form appears to be rare. Factitious disorder (FD) is an umbrella category that covers a group of mental disturbances in which patients intentionally act physically or mentally ill without obvious benefits. According to one estimate, the unnecessary tests and waste of other medical resources caused by FD cost the United States $40 million per year. The name factitious comes from a Latin word that means "artificial" or "contrived."

The Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV-TR , fourth edition) distinguishes factitious disorder from malingering , which is defined as pretending illness when the individual has a clear motiveusually to benefit economically or to avoid legal trouble. Factitious disorder is sometimes referred to as hospital addiction , pathomimia, or polysurgical addiction. Variant names for individuals with FD include hospital vagrants, hospital hoboes, peregrinating patients, problem patients, and professional patients. Description Cases of factitious disorder appear in the medical literature as early as Galen, a famous Roman physician of the second century A.D. The term factitious is derived from a book by an English physician named Gavin, published in 1843, entitled On Feigned and Factitious Diseases . The modern study of factitious disorder, however, began with a 1951 article in Lancet by a British psychiatrist , Richard Asher, who also coined the term Munchausen's syndrome to describe a chronic subtype of FD. The name comes from an eighteenth-century German baron who liked to embellish stories of his military exploits in order to impress his listeners. In 1977, it was Gellengerg who first reported a case of FD with primarily psychological symptoms. Factitious disorder was recognized as a formal diagnostic category by DSM-III in 1980. DSM-IV-TR defines factitious disorder as having three major subtypes: FD with predominantly psychological signs and symptoms; FD with predominantly physical signs and symptoms; and FD with combined psychological and physical signs and symptoms. A fourth syndrome, known as Ganser syndrome, has been classified in the past as a form of factitious disorder, although DSM-IV-TR groups it with the dissociative disorders. DSM-IV-TR specifies three criteria for factitious disorder:

The patient is intentionally producing or pretending to have physical or psychological symptoms or signs of illness. The patient's motivation is to assume the role of a sick person. There are no external motives (as in malingering) that explain the behavior.

Psychological FD Factitious disorder with predominantly psychological signs and symptoms is listed by DSM-IV-TR as the first subcategory of the disorder. It is characterized by the individual feigning psychological symptoms. Some researchers have suggested adding the following criteria for this subtype of FD:

The symptoms are inconsistent, changing markedly from day to day and from one hospitalization to the next. The changes are influenced by the environment (as when the patient feels observed by others) rather than by the treatment. The patient's symptoms are unusual or unbelievable.

The patient has a large number of symptoms that belong to several different psychiatric disorders.

Physical FD Factitious disorder wih predominantly physical signs and symptoms is the most familiar to medical personnel. Chronic FD of this type is often referred to as Munchausen's syndrome. The most common ways of pretending illness are: presenting a factitious history (claiming to have had a seizure that never happened); combining a factitious history with external agents that mimic the symptoms of disease (adding blood from a finger prick to a urine sample); or combining a factitious history with maneuvers that produce a genuine medical condition (taking a psychoactive drug to produce psychiatric symptoms). In most cases, these patients sign out of the hospital when they are confronted by staff with proof of their pretending, usually in the form of a laboratory report. Many individuals with Munchausen's syndrome move from hospital to hospital, seeking treatment, and thus are known commonly as "hospital hoboes." FD with mixed symptoms Factitious disorder in this category is characterized by a mix of psychological and physical signs and symptoms. FD not otherwise specified Factitious disorder not otherwise specified is a category that DSM-IV included to cover a bizarre subtype in which one person fabricates misleading information about another's health or induces actual symptoms of illness in the other person. First described in 1977 by an American pediatrician, this syndrome is known as Munchausen syndrome by proxy (MSBP) and almost always involves a parent (usually the mother) and child. MSBP is now understood as a form of child abuse involving premeditation rather than impulsive acting out. Many pediatricians in the United States believe that MSBP is underdiagnosed. Ganser syndrome Ganser syndrome is a rare disorder (about a 100 documented cases worldwide) that has been variously categorized as a factitious disorder or a dissociative disorder. It is named for a German psychiatrist named Sigbert Ganser, who first described it in 1898 from an examination of male prisoners who were thought to be psychotic. Ganser syndrome is used to describe dissociative symptoms and the pretending of psychosis that occur in forensic settings. There are four symptoms regarded as diagnostic of Ganser syndrome:

Vorbeireden : A German word that means "talking beside the point," it refers to a type of approximate answer to an examiner's questions that may appear silly but usually indicates that the patient understands the question. If examiner asks how many legs a dog has, the patient may answer, "Five." Clouding of consciousness: The patient is drowsy or inattentive. Conversion symptoms: These are physical symptoms produced by unconscious psychological issues rather than diagnosable medical causes. A common conversion symptom is temporary paralysis of an arm or leg.

Hallucinations.

Virtual FD Although virtual factitious disorder does not appear as a heading in any present diagnostic manual, it is a phenomenon that has appeared with increasing frequency with the spread of the Internet. The growing use of the personal computer has affected presentations of factitious disorder in two important ways. First, computers allow people with sufficient technical skills to access medical records from hospital databases and cut-and-paste changes into their own records in order to falsify their medical histories. Second, computers allow people to enter Internet chat rooms for persons with serious illnesses and pretend to be a patient with that illness in order to obtain attention and sympathy. "Munchausen by Internet" can have devastating effects on chat groups, destroying trust when the hoax is exposed. Causes and symptoms Causes The causes of factitious disorder, whether physical or psychiatric, are difficult to determine because these patients are often lost to follow-up when they sign out of the hospital. Magnetic resonance imaging (MRI) has detected abnormalities in the brain structure of some patients with chronic FD, suggesting that there may be biological or genetic factors in the disorder. PET scans of patients diagnosed with Ganser syndrome have also revealed brain abnormalities. The results of EEG ( electroencephalography ) studies of these patients are nonspecific. Several different psychodynamic explanations have been proposed for factitious disorder. These include:

Patients with FD are trying to re-enact unresolved childhood issues with parents. They have underlying problems with masochism. They need to be the center of attention and feel important. They need to receive care and nurturance. They are bothered by feelings of vulnerability. Deceiving a physician allows them to feel superior to an authority figure.

There are several known risk factors for factitious disorder, including:

The presence of other mental or physical disorders in childhood that resulted in the patient's getting considerable medical attention. A history of significant past relationships with doctors, or of grudges against them. Present diagnosis of borderline, narcissistic, or antisocial personality disorder.

Symptoms SYMPTOMS OF FACTITIOUS DISORDER IN ADULTS OR ADOLESCENTS. Reasons for suspecting factitious disorder include:

The individual's history is vague and inconsistent; or the individual has a long medical record with many admissions at different hospitals in different cities. The patient has an unusual knowledge of medical terminology or describes the illness as if they are reciting a textbook description of it. The patient is employed in a medical or hospital-related occupation. Pseudologia fantastica , a Latin phrase for "uncontrollable lying," is a condition in which the individual provides fantastic descriptions of events that never took place. The patient visits emergency rooms at times such as holidays or late Friday afternoons when experienced staff are not usually present and obtaining old medical records is difficult. The patient has few visitors even though he or she claims to be an important person. The patient is unusually accepting of surgery or uncomfortable diagnostic procedures. The patient's behavior is controlling, attention-seeking, hostile, or disruptive. The symptoms are present only when the patient thinks he or she is being watched. The patient is abusing substances, particularly prescription pain-killers or tranquilizers. The course of the "illness" fluctuates, or complications develop with unusual speed. The patient has multiple surgical scars, a so-called "gridiron abdomen," or evidence of selfinflicted wounds or injuries.

SYMPTOMS OF MUNCHAUSEN SYNDROME BY PROXY. Factors that suggest MSBP include:

The victim is a young child; the average age of MSBP victims is 40 months. There is a history of long hospitalizations and frequent emergency room visits. Siblings have histories of MSBP, failure to thrive, or death in early childhood from an unexplained illness. The mother is employed in a health care profession. The mother has been diagnosed with depression or histrionic or borderline personality disorder. There is significant dysfunction in the family.

Demographics The demographics of factitious disorder vary considerably across the different subtypes. Most individuals with the predominantly psychological subtype of FD are males with a history of hospitalizations beginning in late adolescence; few of these people, however, are older than 45. For non-chronic factitious disorder with predominantly physical symptoms, women outnumber men by a 3:1 ratio. Most of these women are between 20 and 40 years of age. Individuals with Munchausen

syndrome are mostly middle-aged males who are unmarried and estranged from their families. Mothers involved in MSBP are usually married, educated, middle-class women in their early 20s. Little is known about the rates of various subcategories of factitious disorder in different racial or ethnic groups. The prevalence of factitious disorder worldwide is not known. In the United States, some experts think that FD is underdiagnosed because hospital personnel often fail to spot the deceptions that are symptomatic of the disorder. It is also not clear which subtypes of factitious disorders are most common. Most observers in developed countries agree, however, that the prevalence of factitious physical symptoms is much higher than the prevalence of factitious psychological symptoms. A large teaching hospital in Toronto reported that 10 of 1,288 patients referred to a consultation service had FD (0.8%). The National Institute for Allergy and Infectious Disease reported that 9.3% of patients referred for fevers of unknown origin had factitious disorder. A clinic in Australia found that 1.5% of infants brought in for serious illness by parents were cases of Munchausen syndrome by proxy. Diagnosis Diagnosis of factitious disorder is usually based on a combination of laboratory findings and the gradual exclusion of other possible diagnoses. In the case of MSBP, the abuse is often discovered through covert video surveillance. The most important differential diagnoses, when factitious disorder is suspected, are malingering, conversion disorder , or another genuine psychiatric disorder. Treatments Medications Medications have not proved helpful in treating factitious disorder by itself, although they may be prescribed for symptoms of anxiety or depression if the individual also meets criteria for an anxiety or mood disorder. Psychotherapy As of 2002, knowledge of the comparative effectiveness of different psychotherapeutic approaches is limited by the fact that few people diagnosed with FD remain in long-term treatment. In many cases, however, the factitious disorder improves or resolves if the individual receives appropriate therapy for a co-morbid psychiatric disorder. Ganser syndrome usually resolves completely with supportive psychotherapy . One approach that has proven helpful in confronting patients with an examiner's suspicions is a supportive manner that focuses on the individual's emotional distress as the source of the illness rather than on the anger or righteous indignation of hospital staff. Although most individuals with FD refuse psychiatric treatment when it is offered, those who accept it appear to benefit most from supportive rather than insight-oriented therapy. Family therapy is often beneficial in helping family members understand the individual's behavior and their need for attention. Legal considerations

In dealing with cases of Munchausen syndrome by proxy, physicians and hospitals should seek appropriate legal advice. Although covert video surveillance of parents suspected of MSBP is highly effective (between 56% and 92%) in exposing the fraud, it may also be considered grounds for a lawsuit by the parents on grounds of entrapment. Hospitals can usually satisfy legal concerns by posting signs stating that they use hidden video monitoring. All 50 states presently require hospitals and physicians to notify law enforcement authorities when MSBP is suspected, and to take steps to protect the child. Protection usually includes removing the child from the home, but it should also include an evaluation of the child's sibling(s) and long-term monitoring of the family. Criminal prosecution of one or both parents may also be necessary. Prognosis The prognosis of factitious disorder varies by subcategory. Males diagnosed with the psychological subtype of FD are generally considered to have the worst prognosis. Selfmutilation and suicide attempts are common in these individuals. The prognosis for Munchausen's syndrome is also poor; the statistics for recurrent episodes and successful suicides range between 30% and 70%. These individuals do not usually respond to psychotherapy. The prognosis for non-chronic FD in women is variable; some of these patients accept treatment and do quite well. This subcategory of FD, however, often resolves itself after the patient turns 40. MSBP involves considerable risks for the child; 910% of these cases end in the child's death. Ganser syndrome is the one subtype of factitious disorder with a good prognosis. Almost all patients recover within days of the diagnosis, especially if the stress that precipitated the syndrome is resolved. Prevention As of 2002, factitious disorder is not sufficiently well understood to allow for effective preventive strategiesapart from protection of child patients and their siblings in cases of MSBP.

Conversion Disorder vs Factitious Disorder vs Malingering

Conversion disorder, factitious disorder, and malingering have one major characteristic in common: they represent conditions that are not real. However, real is a vague word and it is important to understand the differences between these conditions. Properly diagnosing your patient with one of these psychiatric ailments will allow you to create appropriate plans of care for your patients. 1. Conversion Disorder: is a psychiatric condition that results in a neurological complaint or symptom, without any underlying neurological cause. Patients may experience seizures (i.e. pseudoseizures), weakness, non-responsiveness, numbness, and even vision loss. The symptoms are not intentional, the patient is not faking or intentionally creating his/her complaints, yet upon further investigation no biological explanation for the symptoms can be found. The symptoms, therefore, are real to the patient but are not caused by any real pathology. The current thought is that the symptoms are somehow caused by an overload of emotional stress in the body. The name conversion disorder comes from Sigmund Freud who stated that stress can cause a psychiatric ailment to convert to a medical problem. Do not fall into the trap, however, of many students/doctors/nurses who say the patient is faking. While you may know that a patient complaining of sudden vision loss has a completely healthy eye without disease, the patients eye and brain are actually NOT processing any sight. Alternatively, a case that I have seen a number of times, a patient with syncope from

conversion disorder whose labs, tests, vital signs, and clinical status are completely normal will actually NOT respond to painful stimuli (sternal rub, nail bed pressure, supraorbital pressure) during an episode. It is important to remember the unintentional nature of conversion disorder when discussing the condition with a patient. To them it is REAL, even if to you it seems fake. 2. Factitious Disorder (a Somatoform Disorder): is a condition where patients intentionally fake disease, or intentionally cause disease in order to play the patient role. The main distinction between this and conversion disorder is the intentionalnature of factitious disorder. Often referred to a Munchausen Syndrome, factitious disorder is characterized by patients frequently feigning illness to obtain attention, sympathy, or other emotional feedback. They achieve this goal through exaggerating symptoms, deliberately faking symptoms, or even intentionally creating real symptoms. Patients have been known to contaminate their own body fluids, even injecting themselves with dirt, bacteria, or fecal matter in order to create illness that will then lead to primary emotional gain. A related disorder is known as Munchausen by Proxy, which is characterized by a person intentionally faking or causing illness in another (usually a child) in order to obtain the same emotional feedback. Victims of Munchausen by Proxy are often children who return to the hospital time and time again with infections or other ailments that are either fabricated or intentionally created by their caregiver. 3. Malingering: is the intentional faking or creating of illness in order to obtain secondary gain (e.g. workers compensation, disability payments, avoiding work or jail time, pain medication, etc.) Malingering is NOT a psychiatric illness; this is the first major distinction from the other two disorders. Malingering is an intentional abuse of the medical system to obtain personal benefit. The difference between malingering and factitious disorder is the goal of the patient; malingerers abuse the system to obtain secondary gain while patients with factitious disorder attempt only to obtain emotional, or primary gain. In simpler terms, the end goal of a malingerer usually involves monetary value, while the goals of patients with factitious disorder have no such value.