Off The Couch #8 Dissociative & Factitious Disorder

Why do people simulate medical conditions? A fascinating discussion with renowned clinical psychologists about factitious disorder, dissociative disorder, Munchausen syndrome, conversion disorder and somatic disorder. In the 1990s, Dr. Daniel P. Brown got involved in the “false memory movement” and worked on over 100 malpractice cases.

Read the Full Transcript About “Factitious Disorder”:

Caroline Baltzer: Can you say something about the differences between factitious disorder, conversion disorder, and somatoform disorder?

Dan Brown: Yeah, I got interested in factitious disorder. Factitious means that people adopt a sick role for the sense of getting attention, and they make up symptoms. Historically, the work on factitious disorders was based on medical conditions. People would simulate medical conditions, for which there was no evidence that the medical conditions were genuinely existing.

Caroline Baltzer: So, they were doing it knowingly, on purpose.

Dan Brown: Yeah, like Munchausen syndrome. But in the original literature that came out on factitious disorders in the late 1990s, there was also the idea that people not only simulated medical conditions but could simulate psychiatric conditions and trauma conditions. But in DSM, that got lost. I’m interested in putting that back in. Just before DSM 3 came out in 1978, there was a paper by Hyler and Spitzer called “Splitting Hysteria Asunder.” They wanted to make psychiatric diagnoses more scientific, so they decided to get rid of the old over-inclusive diagnosis of hysteria. It’s like calling somebody insane. It doesn’t mean anything. It’s too overgeneralized. They broke it down into four diagnoses. Histrionic personality disorder, factitious disorder, somatoform disorders, and dissociative disorders. They thought that, by making it four diagnoses, they could get more scientific credibility for the different diagnoses. But the problem with “Splitting Hysteria Asunder” was that they failed to see that these different types of disorders are often highly comorbid. So, if somebody has trauma history, they also would have a dissociation history, and they’d also have a conversion disorder history, and they might even have factitious behavior. So, you have to read four chapters in DSM to see the comorbid diagnoses, rather than seeing that in a single source. Some people were thinking that we should have put Humpty Dumpty back together again and not split hysteria apart, because trauma and dissociation are often highly intercorrelated, just like somatoform conversion disorder is correlated with trauma, as so is factitious disorder.

So, that was the historic context. Where I got interested in it was in the 1990s, when the proponents of the false memory movement were suing therapists for allegedly engaging in risky mental recovery therapy, and allegedly creating false memories of abuse that never happened. One of the cases that I worked on, in maybe over 100 malpractice cases against clinicians, was a case out of Chicago: the Burguss case, where she had sued Rush Presbyterian Hospital and the main treaters there, Bennett Braun and the other clinicians there, for allegedly implanting false memories. I had read crates and crates of records from this case. She was treated in Iowa for child abuse, physical abuse, before she ever went to Rush Presbyterian. And there were psychiatrists and psychologists previously treating her in Iowa. There, she had manifested a number of alter personality states or parts. So, then she went to Chicago because of the previous observation of those parts – what we used to call multiple personality, or dissociative identity disorder. She was referred to the specialty unit in Rush Presbyterian, and she was there for a number of years along with her two kids, who both had significant mental health problems.

Caroline Baltzer: How old were the kids?

Dan Brown: They were about 8, 9, 10 at the time. And then, after she left that unit, some 10 years later, at the influence of false memory lawyers, she sued Rush Presbyterian for implanting false memories. I took offense to the case as an expert witness, because it doesn’t seem like – They didn’t sue the therapists in Iowa for implanting false memories, because the statute of limitations has run out. So, they sued Rush Presbyterian because they could make a lot of money off of it. But it doesn’t logically follow that the therapist could iatrogenically implant false memories of abuse if she had previously talked about the abuse in her treatment and that’s what she came into treatment for. And it doesn’t logically follow that the therapists were iatrogenically creating multiple personality states in the patient, who had those multiple personality states before she went to the specialty hospital. So, it seemed like the case was, at best, intellectually dishonest. I was prepared to go for a deposition, and I was armed for bear about the facts of this case. And one of the things I found out about the case was that she had made several false accusations of rape, earlier in her life, against people.

Caroline Baltzer: Outside of treatment.

Dan Brown: Also, she had a long medical record of fabricated medical symptoms. So, this was clearly a case of factitious behavior. The morning I was going to get on the plane and fly to Chicago for the deposition, they called me up and canceled the deposition because they dealt out of the case. They dealt out of the case for, I think, $26 million, or something like that.

Caroline Baltzer: The hospital decided to pay that?

Dan Brown: The insurance company decided to pay for it and sold the profession down the tubes. Because that invited every other multiple personality case to go to the same group of lawyers and claim that they were all iatrogenically implanted false memories. And the field went wild. I found out, six months later, the reason why they dealt out. It made no sense to me. I said, “Look, you could have had the deposition, I was armed for bear, and let me beat up on the other side, in terms of the facts of this case. And you would have made a deal on a lower settlement.” But they didn’t want lower settlement. The insurance company wanted a high settlement because it was the end of a tax year, and they wanted a writing off. They sold the profession down the tubes for a tax write-off.

Caroline Baltzer: It started a whole –

Dan Brown: It started a whole feeding frenzy of suing therapists for implanting false memories. So, that’s how I got interested in factitious behavior. And it seemed to me that, what had gone wrong with the field – If you look in the history of ideas at the first papers on factitious behavior, i.e., Munchausen syndrome talked about not just medical symptoms but psychiatric symptoms, and also about making up false stories of the person’s life. And we needed to not restrict it to psychiatric conditions, or medical conditions, but look at how people tell false stories of their lives, because it happens all the time.

I used to, in the 1990s, work as a consultant to CEOs of big international companies. I remember a CEO of seven multinational companies, who I worked for, saying that he was hiring this mover-and-shaker for one of his parent companies; and the guy was very controversial because he had a prisoner of war background from the Korean War. And people didn’t know how stable he was, but the CEO of this multinational company loved him, and he says, “I want an independent opinion from a psychologist.” So, I did detailed testing on this guy, and he flagged all the credibility scales. All the self-report scales were all showing–

Caroline Baltzer: Raised?

Dan Brown: They were all elevated, all showing that he was exaggerating his report. And he did it on every scale, which is hard to do. So, I called up the CEO of this multinational company and said, “I hate to burst your bubble, but this guy is probably not a prisoner of war, and the whole story of his life is fabricated.” So, the CEO got his private investigators to investigate, because at that level, a lot of money is involved. He called me up three days later and said, “You’re absolutely right. Thank you for saving us here.” So, that got me interested in how people tell false stories of their lives.

Caroline Baltzer: And also working with CEOs, which you have done a lot of.

Dan Brown: So, then we published a special edition in the Journal of Psychiatry and Law on factitious behavior and its interface with dissociative behavior.

Caroline Baltzer: What year was that?

Dan Brown: 1999. So, I invited people like Frank Putnam and others to submit articles about what we knew about factitious behavior. Later, I learned more about it – when we got interested in attachment behavior. And what we found was that most people with factitious disorders have insecure attachment, mostly disorganized attachment. Then, in later childhood, they have a major illness, and they learn to use the caregiving system to get treatment for their attachment needs, which they didn’t get met at home. So, after a while, that becomes a learned pattern. They learn compulsively to fabricate new disorders and really wonderful symptoms and stories about their lives to get their attachment needs met.

Caroline Baltzer: And what’s the best way to handle something like that?

Dan Brown: It’s not easy, but you have to do a careful and accurate assessment on them and then confront them about attachment needs.

Caroline Baltzer: So, you need the patient to be consciously aware of the structure of the problem.

Dan Brown: Yeah. For example, I was asked, in another state, to assess a patient who had filed false claims, false police reports. And the DA said that, if we can come up with some compassionate explanation for why she does this, he would be more lenient. So, I assessed her; she had dissociative identity disorder. She had disorganized attachment. She had a history of medical problems as a kid, and she learned to use the medical system to get attachment needs met. Then, later in therapy, she got attention by making up stories about more and more wild abuse scenarios, including ritual abuse involving everybody in the general community. So, the story got bigger, and bigger, and bigger, and involved everybody in the community. And then the state police investigated and found out there was no evidence to support it. They arrested her for filing false police reports, but she actually believed the stories. We were able to recommend that she gets treatment for the attachment disorder as a way of putting a stop to all that compulsive behavior. So, we hooked her up with somebody that we had trained. She worked with that person for a while and stopped engaging in this compulsive factitious behavior.

Caroline Baltzer: How long did the treatment take, do you remember?

Dan Brown: I followed it for two years, I didn’t know what happened after.

Caroline Baltzer: So, when these individuals are getting their attachment needs met through the medical system, it’s ineffective. It’s not actually therapeutic, it’s not a corrective emotional or relational experience.

Dan Brown: No, it wastes lots of medical resources on labs and diagnoses that are inappropriate.

Caroline Baltzer: But how come, ultimately, they can’t get the attachment needs met in this format of being cared for medically, if it’s a repetition compulsion?

Dan Brown: Because you need to keep going back for more and more appointments, and there’s limited time that the doctors have for these appointments. If they’re in a private practice model, where they have limited resources, they’re going to stop seeing the patient for economic reasons.

Caroline Baltzer: Some are set up for failure in terms of –

Dan Brown: Some are set up for failure. The system doesn’t provide multiple appointments.

Caroline Baltzer: Right. So, there’s a rejection that starts happening on the part of the caregivers.

Dan Brown: Because it’s just not practical. It’s too expensive, and they should be identified as factitious patients and treated accordingly. We know something about the treatment of those attachment disorders.

Caroline Baltzer: Yes

Watch the full clinical interview series:
1. Meet Dr. Daniel P. Brown
2. Overview of Trauma Treatment
3. Attachment Disturbances 
4. CCRT (Core Conflictual Relationship Themes)
5. Three Pillars Approach (Treatment for Attachment)
6. Teaching Psychology
7. Conversion Disorders
8. Factitious & Dissociative Disorder
9. Psychological Assessments
10. Bipolar Disorder Treatment
11. Trauma Bonding Maps
12. Conclusion

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