11/9/2012
Objectives
Factitious Disorder or Eating Disorder?
An Argument for Underscoring the Sick Role
Dr. Aaron Keshen, MD, FRCPC
Eating Disorder Psychiatrist
Capital District Health Authority/Dalhousie University
Halifax, Nova Scotia
Relevant Trends in Eating Dysfunction
• Argument for there being factitious elements
in some eating disorder patients
• Framing the factitious elements (sick role) as
being a vehicle for avoidance
• Approach to addressing factitious elements in
eating disorder patients
History of Psychosomatic Distress
•Culture dictates to the unconscious minds of severely distressed individuals
what can be considered legitimate symptoms of illness. (Liles and Woods
1999)
Cultural
changes in
psychosomatic
presentations
Medicalization
of selfstarvation
Medicalization for Self-Starvation
“Fasting
girls”
Anorexia
Nervosa
“Hunger
Artists”
1550s-1860s
Spiritual, admired behavior
Early 1900s
Neuroasthenia
Spinal irritation
Catalepsy
2000s?
Eating
Disorders
1800s
Paralysis
Late 1900s
CFS
Coma
FIbromyalgia
Cultural trends catalyze
eating dysfunction as
psychosomatic outlet
Third party
billing
Opening
treatment
centers
1873
1700s
Medicalization of SelfStarvation
Increased
Diagnosis
Increases
hospitalization
More motivation to
engage in symptoms
Hospitalization Increases
1900s-2000s
Medical condition
Reinforces
psychosomatic
elements
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11/9/2012
Factitious/Iatrogenic Disorders
• Production of physical or psychological
symptoms with the unconscious motivation of
obtaining treatment or playing the Sick Role
(SR).
• An iatrogenic disorder is a condition that
develops through exposure to the
environment of a health care facility.
Identifying SR patients
• Desire/pressure to enter hospital/treatment
• Suspicion of overt/covert attempt to escape
external stressors
• Poor boundaries/overly attached to staff
• Poor response/sabotaging recovery
Chain Reaction
Primary Eating
Disorder
Iatrogenisis
• Rigid
adherence to
food rules
leads to
weight loss
Secondary
Eating Disorder
• Exposure to
health care
facility
• Adoption of
factitious
elements
Why this is Important?
• Ea ti ng disorder notoriously difficult to treat (5%40% remission rate)
• Fra ming patient within Factitious model explains
why s ome resistant patients must remain ill in
order to have their needs met.
• Sta ndard treatment does not a ddress this well.
• Confronting sick role head-on may work better.
Why this is Important?
Approach to Sick Role
• 4 of most difficult patients.
Avoid hospital if possible
• Years of hospitalization in inpatient,
residential programs.
• Dramatic shifts with direct challenge to the
Sick Role.
Minimize inpatient  Day Hospital; Shortest time possible
Switch primary clinician; Avoid non-specific supportive talk-time
Target
Avoidance in parallel with standard approach
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Eating Disorder/Sick Role as Vehicle for Avoidance
Acceptance and Commitment Therapy
Hayes, 1995
Existential
Anxiety
Pain
Avoidance
• Distressing
emotion or
thought
Suffering
• Short term
avoidance of
Pain
Relationship
Anxiety
Existential
Predictability
Existential
Substitution
Avoid
Relationships
Safe
Relationships
Structure
Identity
Safety
Staff/Patients
Pain
• Long term
consequences
of Avoidance
Avoidance/Sick Role
Pain
Avoidance
Pain
Suffering
Poor School/ Job Performance
Avoidance
Suffering
Poor School/ Job Performance
Afraid to try New Things
Afraid to try New Things
Avoidant Coping
Retreat into Sick Role of
Eating Disorder to
Avoid Pain
Perfectionism
Poor Confi dence
Unwilling or unable to
challenge/ accept m aladaptive
patterns, fears and behaviors
Avoidant Coping
Poor Confi dence
Unwilling or unable to
challenge/ accept m aladaptive
patterns, fears and behaviors
Pain
Social Anx iety
Social Anx iety
Non- Avoidant Coping
Tolerate/ Accept/
Ex perience Feelings
Mindfulness
Journal
Access Support
Problem Solving
Fear of Rejection
Isolation
People Pleasing
Pain
Avoidance
Retreat into Sick Role of
Eating Disorder to
Avoid Pain
Perfectionism
Disability
Isolation
People Pleasing
Poor School/ Job Performance
Pain
Non- Avoidant Coping
Fear of Rejection
Suffering
Disability
Tolerate/ Accept/
Ex perience Feelings
Mindfulness
Journal
Access Support
Problem Solving
Disability Approach
• 22 y.o. female
Afraid to try New Things
Avoidant Coping
Retreat into Sick Role of
Eating Disorder to
Avoid Pain
Perfectionism
Poor Confi dence
Unwilling or unable to
challenge/ accept m aladaptive
patterns, fears and behaviors
Social Anx iety
Isolation
People Pleasing
• Anorexia (binge/purge type), Borderline PD and
Polysubstance Dependence.
Pain
Non- Avoidant Coping
Fear of Rejection
Disability
Tolerate/ Accept/
Ex perience Feelings
Mindfulness
Journal
Access Support
Problem Solving
• 3 admissions at C&A and 2 admissions at Adult
eating disorder program
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Disability Approach
• Sta ndard treatment approach keeps stuck i n sick
rol e:
• Support/attachment from caring staff
• Avoidance of anxiety provoking expectations in life
Pain
Poor School/ Job Performance
Avoidant Coping
Retreat into Sick Role of
Eating Disorder to
Avoid Pain
Perfectionism
Poor Confi dence
Non- Avoidant Coping
Tolerate/ Accept/
Ex perience Feelings
Mindfulness
Journal
Access Support
Problem Solving
Fear of Rejection
Isolation
Disability Approach
Disability Approach
Parents’ house:
Problem?
Still No Incentive to Change
– Staying stuck in illness:
• Continues to elicit support
• Means of avoid anxiety provoking expectations.
Disability Approach
• After discussions with team, parents decide to
not enable
• Income assistance and own apartment
Disability
Pain
Social Anx iety
People Pleasing
• Can stay in basement apartment
• Access to car, money
• No expectations (school, work, own
apartment)
Suffering
Afraid to try New Things
Unwilling or unable to
challenge/ accept m aladaptive
patterns, fears and behaviors
….with no behavioral indication to change:
• Secretive purging, laxatives found hidden, substance
use on passes
Avoidance
Pain
Avoidance
Suffering
Poor School/ Job Performance
Afraid to try New Things
Avoidant Coping
Retreat into Sick Role of
Eating Disorder to
Avoid Pain
Perfectionism
Poor Confi dence
Without Sick Role being supported by
Hospital/Parents…………………
Unwilling or unable to
challenge/ accept m aladaptive
patterns, fears and behaviors
Social Anx iety
Disability
Pain
Non- Avoidant Coping
Fear of Rejection
Isolation
People Pleasing
Tolerate/ Accept/
Ex perience Feelings
Mindfulness
Journal
Access Support
Problem Solving
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Pain
Avoidance
Pain
Suffering
Poor School/ Job Performance
Avoidance
Poor School/ Job Performance
Afraid to try New Things
Afraid to try New Things
Avoidant Coping
Retreat into Sick Role of
Eating Disorder to
Avoid Pain
Perfectionism
Poor Confi dence
Unwilling or unable to
challenge/ accept m aladaptive
patterns, fears and behaviors
Avoidant Coping
Poor Confi dence
Unwilling or unable to
challenge/ accept m aladaptive
patterns, fears and behaviors
Non- Avoidant Coping
Fear of Rejection
Isolation
People Pleasing
Tolerate/ Accept/
Ex perience Feelings
Mindfulness
Journal
Access Support
Problem Solving
How to we Support the Hard Work?
Expos ure
Therapy
Exi s tential
Therapy
Retreat into Sick Role of
Eating Disorder to
Avoid Pain
Perfectionism
Disability
Pain
Social Anx iety
ACT
Suffering
Disability
Pain
Social Anx iety
Non- Avoidant Coping
Fear of Rejection
Isolation
People Pleasing
Tolerate/ Accept/
Ex perience Feelings
Mindfulness
Journal
Access Support
Problem Solving
Conclusion
• Historical trends have facilitated
factitious/iatrogenic eating dysfunction
Relationship Anxiety
Existential Anxiety
• Framing some patients in factitious context
may be helpful for understanding certain kinds
of treatment resistance
• Sick role is a vehicle for avoidance
Conclusion
Historical Perspective
• Cha llenging sick role:
– Acceptance and commitment therapy
– “Disability Approach”
• Directly challenges resistance and exerts more pressure on
patient to do exposure work, challenge anxiety and facilitate
existential growth
• Trea tment supports for existential growth rather
tha n replacing, or inadvertently stifling i t.
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Disability Approach
Questions?
6