Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Factitious Disorder


Related Terms

  • Compensation Neurosis
  • Hospital Addiction
  • Munchausen Syndrome
  • Polysurgical Addiction
  • Professional Invalid Syndrome

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Family Physician
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

Delays in the proper diagnosis of this disorder are inherent. Multiple operations and medical treatments may produce their own disabilities. Positive influences include early detection, psychiatric treatment, and a strong family support system.

Medical Codes

ICD-9-CM:
300.16 - Factitious Illness with Psychological Symptoms; Compensation Neurosis
301.51 - Chronic Factitious Illness with Physical Symptoms; Hospital Addiction Syndrome; Multiple Operations Syndrome; Munchausen Syndrome

Overview

Factitious disorders are characterized by the intentional falsification of medical and psychological signs and symptoms in oneself or others in order to assume the role of a sick person in an attempt to win attention, nurturance, or acceptance that cannot be obtained another way. There are no external incentives for the behavior such as economic gain, avoidance of legal responsibility, or improvement of physical well-being, as in malingering. Subtypes are factitious disorder imposed on self and factitious disorder imposed on another (previously called factitious disorder by proxy in the DSM-IV-TR).

The DSM-5 does not distinguish the type of factitious disorder based on the predominance of either psychological or physical signs and symptoms; rather, it places factitious disorders in a new category called somatic symptom and related disorders. The DSM-IV-TR term somatoform disorders proved to be confusing because there was a great deal of overlap and lack of clarity about diagnoses. The DSM-5 classification recognizes this overlap by reducing the total number of disorders and subcategories, as well as by defining the major diagnosis of somatic symptom disorder on the basis of distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to those symptoms (DSM-5).

The disease is usually chronic. In some cases, there is an array of hospitalizations beginning in adolescence or early adulthood and extending to the late forties. Factitious disorders appear to be rare in individuals older than age forty-five. This is thought to be the case because (1) individuals in contact with the "genuine" pathology become more skilled in faking those conditions, thus making it more difficult to diagnose their symptoms as a factitious disorder; and (2) aging individuals may develop, whether or not in connection with their factitious disorder and/or treatments, a genuine illness that allows them to assume the "patient" role without faking.

The psychological basis for factitious disorders is poorly understood, but the internally driven behavior implies psychopathology. Some cases have been traced to childhood trauma, either physical or mental. Families of origin often reveal a rejecting mother or absent father. Factitious disorder is used to recreate the desired parent-child bond. It is an attempt to resolve the conflict of seeking acceptance and love from an absent or rejecting parent.

Incidence and Prevalence: Because of the difficulty in establishing the diagnosis, solid epidemiological data are not available on the prevalence of factitious disorder. It is estimated that in hospital settings up to 1% of individuals meet the criteria for factitious disorder (Elwyn).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The disorder is found to be more common in females aged 20 to 40, especially those employed in medical fields; however, chronic factitious disorder (Munchausen syndrome) is more common in middle-aged males (Elwyn). The majority of individuals with factitious disorder are white (Elwyn).

Source: Medical Disability Advisor



Diagnosis

History: The essential feature of factitious disorder, whether it is in oneself or imposed on another, is the falsification of medical and psychological signs and symptoms associated with the identified deception. As the DSM-5 emphasizes, the diagnosis requires demonstrating the individual is surreptitiously taking actions to misrepresent, simulate, or cause signs or symptoms that lead to the diagnosis of an illness or injury in themselves or another. It is possible that a legitimate medical condition exists but the individual characterizes the illness or injury in such a way that clinical intervention may be excessive.

A typical history includes frequent office visits to health care providers and multiple prior workups, surgeries, and hospitalizations for physical or psychological symptoms or both. Symptoms may be unconventional and fantastic or may be vague and inconsistent. Sometimes, the reported symptom patterns are suspiciously textbook perfect. The individual’s real medical history and biographical data may be difficult to confirm. Verifying medical care and reports is helpful in discovering if the information has been factitiously presented by the afflicted individual. It is important to rule out malingering by verifying that the deceptive behavior is not reaping any obvious external rewards.

Victims of factitious disorder imposed on another may have unexplainable, refractory, or recurrent diarrhea and vomiting, fever (either actual or feigned through falsification of records), bleeding, hematuria or guaiac-positive stools, seizures, central nervous system depression, apnea, rash, hypoglycemia, hyperglycemia, poisoning, multiple infections with varied or unusual organisms, or apparent life-threatening events. Symptoms and signs may occur only in the presence of the perpetrator, and there may be discrepancies between the history, physical signs, and victim’s general health. The diagnosis is assigned to the perpetrator, not to the victim.

As mentioned in Overview, the DSM-5 no longer distinguishes the type of factitious disorder based on the predominance of either psychological or physical signs and symptoms; instead, the types are factitious disorder imposed on self or factitious disorder imposed on another (previously factitious disorder by proxy) (DSM-IV-TR).

Physical exam: Because the individual with factitious disorder imposed on self is skilled at appearing ill and knowledgeable about symptoms and physical signs, it is possible that the examiner may find physical signs in single or multiple systems. For example, individuals may scratch their skin to feign an itching rash, use medications that will increase or decrease their heart rate or blood pressure, or use eye drops to dilate one pupil to feign a neurological disorder. The individual may go as far as creating a wound to feign injury. Although the examiner may be correct in diagnosing factitious disorder, for medico-legal reasons, the history and physical findings should be the guide in ordering appropriate tests. Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech provide essential signs to diagnose the disorder.

Tests: Testing is limited to the least expensive approach (usually routine laboratory tests and x-rays) that can discount the related symptoms. An atypical pattern of laboratory results may help to diagnose the condition. However, a complete workup of complex, invasive medical procedures may sometimes be necessary to rule out physical causes of symptoms. Psychological testing may reveal a poor sense of identity, related personality disorders, poor sexual adjustment, a low tolerance for frustration, strong dependency issues and, in some individuals, an inflated sense of self-worth.

Note: It must be kept in mind that just because a physical diagnosis cannot be established as the cause of the presenting symptomatology, it does not necessarily mean that the cause is a mental one. That is to say that the presence of medically unexplained symptomatology does not necessarily establish the presence of a psychiatric condition. The first step in identifying the presence of a mental disorder is excluding the presence of malingering. The strong need for this step is especially true whenever there is a medicolegal context associated with the presenting problem(s). Additionally, using DSM-5 and/or ICD-9-CM or ICD-10-CM, the clinician will find that many presentations fail to fit completely within the boundaries of a single mental disorder. There are systematic ways to go about making psychiatric diagnoses, however.

Source: Medical Disability Advisor



Treatment

An effective treatment of factitious disorder imposed on self has yet to be identified. The desire to maintain the sick role prevents the individual from seeking effective therapy.

If the diagnosis is in doubt, appropriate specialists should be consulted. Hospitalization for physical workup may be needed. When the diagnosis is clearly established, psychiatric referral should always be offered. Psychiatric treatment is usually declined, and this refusal should be documented in the individual's record.

Treatment may be most effective when the focus is on management rather than on cure. The first and most important step in successful management is early recognition of the disorder. A second, essential, and probably more difficult step is securing an enduring, stable patient-physician relationship. Once such a relationship is established, management of the disorder must be oriented to avoid unnecessary hospitalizations and medical procedures.

Some mental health professionals use analytical or cognitive-behavioral approaches to treat factitious disorders. Treatment may also include pharmacological agents such as antipsychotic drugs and selective serotonin reuptake inhibitors (SSRIs). There is little evidence that such medications have any effect on the course or prognosis of this disorder, though medications may be prescribed to treat comorbid psychiatric conditions (Elwyn).

Treatment of factitious disorder imposed on another must include the alleged victim, the perpetrator, and their families. Obtaining their medical and social histories, previous hospitalizations, and medical records and verifying those reports will provide essential information. The alleged victim and the perpetrator’s and victim’s family members are interviewed in the absence of the suspected perpetrator. The alleged victim may be hospitalized to observe the behavior of the suspected perpetrator and the interaction of both (hidden cameras may be used), determine the temporal relation between the symptoms and the presence of the suspected perpetrator, and confirm cessation of the victim’s symptoms in the absence of the suspected perpetrator. Samples are obtained for toxicology screens and other relevant laboratory tests. Arrangements are made for social service, psychological, and psychiatric evaluations of the alleged victim and perpetrator. After an objective evaluation of the records by a team or task force, and after informing the local law enforcement agencies, the perpetrator is informed of the diagnosis, and actions are taken to separate the victim from the perpetrator and to protect the victim. The perpetrator should be approached non-judgmentally and receive short-term and long-term psychological and psychiatric treatment. Reunification requires careful evaluation by a multidisciplinary team and a court.

Source: Medical Disability Advisor



Prognosis

The course and prognosis of factitious disorder is not fully known because individuals are usually lost in the follow-up stages of research. Overall, treatment reports for this disorder are disappointing. Outcome can be even worse than in cases of genuine psychoses. Self-injury, attempted suicide, and suicide are not uncommon. The individual's willingness to undergo treatment with unnecessary high doses of antipsychotic and antidepressant medication or with electroconvulsive therapy (ECT) can lead to severe adverse reactions. The outcome may be somewhat better with analytical and cognitive-behavioral approaches.

Source: Medical Disability Advisor



Complications

In factitious disorder, the invention of physical symptoms is a complication in itself. If real physical symptoms appear, hospital staff, clinicians, and therapists are likely to dismiss them as factitious given the individual's past medical history. Delayed diagnosis may preclude treatment. Coexisting psychiatric illnesses, including substance abuse, makes diagnosis almost impossible. In addition, treatment of a feigned psychological illness can produce real psychological signs and symptoms, thus clouding the true clinical picture.

Individuals with factitious disorder imposed on self go to great lengths to feign symptoms, even to the point of taking drugs or exposing themselves to chemicals that may cause injury or real medical problems. Treatment of the feigned illness with drugs or surgery can also produce real physical symptoms or mental signs that cloud the true clinical picture. Many treatments and procedures carry the possibility of medical complications.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

In order to feign physical signs, individuals may attempt to use drugs to induce abnormal findings, causing serious or life-threatening consequences for themselves and their co-workers; therefore, individuals should be restricted from working with or around medications and in hazardous situations.

Risk: There may be risk to affected individuals and their coworkers if there is a tendency toward self-injury, suicidal ideation, or fabrication of hallucinations. In some cases, individuals with factitious disorder imposed on self may present a risk to both themselves and coworkers if they are taking narcotics or other medications to artificially alter their vital signs, creating a potential safety hazard. Individuals with a low frustration tolerance may require assignment to simple work tasks that may be performed unobserved and without coworker interaction.

Individuals with factitious disorder imposed on another may, in rare instances, choose a coworker as the victim; this situation may present a risk to coworkers.

Capacity: Capacity is typically not a concern with this disorder. The vast majority of the time, the imagined symptoms are not real and do not affect physical ability. Work tasks that are familiar, simple, and not safety-sensitive may be appropriate. Individuals with the disorder who are willing to undergo psychiatric counseling should be able to arrange appointments outside of working hours.

Tolerance: Tolerance is dependent on the willingness of the individual to engage in psychiatric treatment and the successful management of the condition.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 months of treatment or less.

Note: MMI is estimated under the assumption that the vagaries involved in psychiatric diagnoses have been taken into consideration.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has diagnosis been confirmed?
  • Was diagnosis based on individual's past health history of multiple hospitalizations (including psychiatric institutions) and frequent office visits to healthcare providers?
  • If individual or possible victim has a history of multiple hospitalizations and frequent office visits to health care providers, have prior hospitalizations and medical care been verified?
  • With medico-legal issues in mind, have appropriate diagnostic tests been done?
  • Have legitimate psychological conditions been identified or ruled out?
  • If initial chief complaint proved negative, has individual complained of another physical problem and produced more symptoms?
  • Is individual eager to undergo multiple invasive procedures or operations?

Regarding treatment:

  • How long was the feigned condition and/or factitious disorder going on before individual sought treatment with current health care provider?
  • If diagnosis is in doubt, have appropriate specialists been consulted?
  • Is hospitalization for physical workup warranted?
  • Once diagnosis was clearly established, was psychiatric referral offered?
  • If psychiatric treatment was declined, was refusal documented in the individual's record?
  • Has treatment focused on management, to avoid unnecessary hospitalizations and medical procedures, rather than on cure?
  • Because a trusting relationship with the physician is essential to treatment, has individual been able to establish a good patient-physician relationship? If not, what can be done to build or restore this relationship?
  • Have analytical or cognitive-behavioral approaches been used effectively?
  • Would individual benefit from the addition of pharmacological agents such as antipsychotic drugs and selective serotonin reuptake inhibitors (SSRIs)?

Regarding prognosis:

  • Although effective treatment for factitious disorder has yet to be identified, was an attempt made to provide a way for individual to give up the symptoms without being embarrassed?
  • Does individual's history of needless medications and invasive procedures pose a threat to his or her current health status?

Source: Medical Disability Advisor



References

Cited

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Elwyn, Todd S., and Igbal Ahmed. "Factitious Disorder Imposed on Self." eMedicine. Eds. Sarah C. Aronson, et al. 14 Jan. 2014. Medscape. 1 Apr. 2015 <http://emedicine.medscape.com/article/291304-overview#showall>.

Source: Medical Disability Advisor






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