Challenges in Diagnosing Factitious Disorder a Case Report and Literature Review

Introduction

Factitious disorder (FD) is a psychiatric disorder in which sufferers intentionally fabricate physical or psychological symptoms in order to assume the part of a patient, without any obvious gain.ⁱ Patients with FD oftentimes gain hospital admission and undergo invasive procedures and surgeries exposing themselves to a considerable risk of iatrogenic impairment.

Factitious patients are hard to detect and they take a heavy impact on the wellness care services and National Health Service. The need for improving and speeding upwardly the diagnostic approach and, consequently, therapeutic treatments is felt.

It is possible to identify some predisposing factors to FD such as other mental disorders, general medical conditions that crave handling and hospitalization, especially in babyhood or boyhood, deprivation stories (losses, family unit breakdowns, etc.), and emotional and physical abuses in childhood.ⁱⁱ

The exact prevalence of the disorder is currently unknown only information technology has been estimated betwixt 0.6% and 3% of referrals from general medicine to psychiatry and betwixt 0.02% and 0.ix% of cases reviewed in specialist clinics.³

FD appeared in the Diagnostic and Statistical Manual of Mental Diseases (DSM) from the third edition. According to DSM-Three-R (1986), FD should exist distinguished from malingering in which fabrication is motivated past an external advantage.

In DSM-IV-TR, FD represents an autonomous diagnostic category. 3 subtypes of distinct FD are distinguished by predominant symptoms:

1. with predominant psychic signs and symptoms;
2. with predominant physical signs and symptoms;
3. with combined psychic and physical signs and symptoms.

In DSM-5, FD are part of the largest department of Somatic Symptom and Related Disorders. All the disorders discussed in this article accept in common the relevance of somatic symptoms associated with pregnant discomfort and harm. These diagnostic formulations are more than useful to general practitioners and non-psychiatric specialists in the field of general medicine and in other clinical areas where individuals who nowadays disorders with meaning somatic symptoms are more common than in mental wellness care services. The current classification considers the central aspect of the involvement of the torso and the broad overlapping to somatoform disorders.

Early on detection of FD is very important to limit harm to patients, and early direction of FD may facilitate improved outcomes for patients with the disorder.

However, the clinical and demographic profile of patients with FD has non been sufficiently antiseptic.^4,v Recommendations and guidelines have non been supported past wide evidence on how FD is diagnosed past clinicians or how methods for detecting FD earlier may vary amidst medical specialties.

Studies on FD demonstrate the huge impact of unnecessary investigations, treatments, and hospital admission on the health intendance system. Early detection of FD is necessary in order to limit wastage of wellness care resource and impairment to patients.^{half-dozen,seven}

Articles on FD are mostly instance reports and reviews. But a limited number of studies have been published in the literature and those published to appointment have been limited to a pocket-sized number of cases.

Thus, the aim of this written report was to draft a comprehensive systematic review of all cases of FD published in the professional literature. It is useful to behave out a literature review to characterize the contour of patients with FD. Purposely, the end points are

• to outline a demographic and clinical profile of a large sample of patients with FD;
• to report the evolution of position of FD in the DSM.

Methods

A systematic review of all case reports and case serial of developed patients which fulfilled DSM-five diagnostic criteria was conducted. The enquiry involved cases diagnosed according to DSM-3, DSM-Iv, or ICD-10 criteria. A broad keyword search of the professional literature published in English language from January 1950 to Nov 2016 was conducted. The databases MEDLINE, Scopus, and PsycINFO were searched using the MeSH terms factitious and Munchausen. The terms artefacta, fabricated illness, and medically unexplained symptoms were included. Exclusion criteria were the following:

• Cases by proxy
• Age <xviii years old
• Articles not in English

The PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) flowchart of the search is shown in Figure 1. A total of 1636 records were returned based on key search terms, after exclusion of duplicate records. Five hundred seventy-seven articles were identified as potentially eligible for the study, of which 314 studies were retrieved for total-text review. These studies included 514 cases. Single cases accept been extracted from 74.ane% of the studies, whereas 25.9% of the selected manufactures contained multiple cases.

Figure 1 PRISMA menstruation chart.

The following quantitative and qualitative variables were obtained: age, gender, marital status, race and ethnicity, reported occupation, psychopathology, medical diseases, clinical presentation, multiple surgeries, corruption in childhood, substance abuse, experience of illness or long-lasting hospitalization, traumatic experiences, alien relationships, premature familiar bereavements, grudge toward the medical profession, employ of paramedical facilities, suicidal beliefs, cause of expiry, and psychiatric counseling.

Factors leading to the diagnosis of FD were extracted using a checklist adapted from 2 surveys of clinical information that might raise the suspicion of FD.^five,eight

Starting from the review of Yates and Steel, the following items were considered: past wellness care service use, atypical presentation, exclusion of organic and/or psychiatric causes, prove of fabrication, patient behavior, treatment failure, and recurrent affliction.^three,5

The past health care services use consists in a history of extensive use of medical services, history of peregrination between health care services and multiple medical examinations request.

The atypical presentation includes the manifestation of symptoms when the patient is not under ascertainment, the grade of illness is incommunicable or highly improbable or does not follow the natural history of the presumed diagnosis.

Organic causes are excluded through clinical exam, instrumental diagnostic and laboratory investigations. The evidence of fabrication occurs through search, surveillance, or directly access past the patient.

The patient'due south behavior includes unusual medical knowledge or the use of medical and scientific terms, the extreme eagerness for medical procedures, including invasive ones, attitude of revenge toward health workers, poor adherence to the proposed treatments, pseudologia fantastica, and opposition to the psychiatric consultation instead of medical or surgical procedures. The failure of treatments includes numerous illness relapses and the advent of new symptoms in conjunction with the handling or worsening of the medical condition.

To collect the elements of the database for the statistical analysis, missing or doubtful sociodemographic medical and clinical data have been considered equally "unknown". Clinical presentation of FD was extracted on the basis of clinical and diagnostic investigations described in the studies.

IBM SPSS 22 was used to summate descriptive statistics. Statistical significance was investigated using a Pearson test and linear regression models.

Results

As shown in Table one, the sample is composed of 34.ii% males and 65.4% females. In 0.4% of cases, it was not possible to plant the gender of subjects from the anamnestic data reported. From the data analysis, at that place is a articulate prevalence of the diagnosis of FD in female gender. The average historic period of general population is 33.5 years (SD x.6), and the average age of women is 32.8 years (SD x.nine), while that of males is 35 years (SD 9.7).

Table 1 Basic demographic characteristics of patients diagnosed with FD Abridgement: FD, factitious disorder.

As far as the employment is concerned, health care workers business relationship for 22% of the sample (n=113), other professions represent xviii.three% (n=94), and the data are unavailable or unreliable for 59.vii% (due north=307). Despite the unavailable information, in the group in which employment is available (n=207), the number of the nurse is the virtually meaning with the 23.seven%. A rate of unemployment of 11.1% was found.

For a large number of patients, the civil condition is non available (63.one% of women and 58.6% of men); where this datum is available, a prevalence of married people both in men (17.6%) and women (19.6%) emerged.

In the sample, 28.4% (north=146) of patients present a medical comorbidity and twoscore.one% (n=206) show 1 or more psychiatric disorders. The nigh frequent psychiatric pathologies associated with FD are personality disorders (specifically borderline personality disorder) in 43.1% and depressive disorders in 37.7%. The presence of psychiatric comorbidity is excluded in 39.5% (due north=203).

In the family history, the presence of psychiatric diseases and related disorders is positive in iv.nine% (n=25) of patients. In well-nigh cases (96%), the diagnosis is substance corruption.

With regard to the medical specialties to which factitious patients are concerned, in that location are minimal differences between the gender of the sample: for men, the near represented specialty is psychiatry (31.5%), followed by emergency department (16.seven%) and internal medicine (8%); and for women, the psychiatric ward appears in 22.one% of cases, followed past internal medicine (vii.five%) and gynecology (6.5%; Table 2).

Tabular array 2 Clinical presentation Abbreviations: AIDS, caused immune deficiency syndrome; ARDS, acute respiratory distress syndrome; DVT, deep vein thrombosis; FUO, fever of unknown origin; GN, glomerulonephritis; HIV, human immunodeficiency virus; IBD, inflammatory bowel disease; MI, myocardial infarction; NOS, not otherwise specificated; ORL, otolaryngologic; PTSD, posttraumatic stress disorder; SLE, systemic lupus erythematosus; UTIs, urinary tract infections.

A further psychopathological attribute useful for analysis is the subdivision in presentation with internal and external signs/symptoms. Depending on the polarity of the factitious behavior, localization of self-harm may be superficial (e.g. skin ulcers) or internal (e.thou. anemia and internal organ damage). The sample shows a prevalence of internal signs/symptoms (87.4%). Xxx-five percent of patients accept a positive history for multiple surgical procedures.

As far as the prevalence of all stressful events in correlation with FD is concerned, the following outcomes emerged: 20.2% of the patients show stressful or traumatic events, 14.6% accept physical or sexual abuses or neglect in childhood, 16.9% bear witness substance abuse, 10.seven% have alien and/or unstable interpersonal relationships, and 7.2% reveal premature familiar bereavements. Also, 13.4% of patients present a suicidal behavior.

During hospitalization, 65.8% of patients got a psychiatric consultation. The remaining 34.2% of patients refused or did non have the consultation.

Amongst the factors considered to be relevant to diagnose these disorders, the exclusion of other organic or psychiatric causes is the well-nigh represented, observed in 91.1% of cases.

An singular presentation is some other key issue (89.iii%), which implies that the patient'southward symptoms or the clinical course of the presumed condition is unusual, sometimes associated with incongruous instrumental findings. In some cases, it is also possible to observe an exacerbation of the symptoms in the presence of the medical staff or, on the contrary, in the absenteeism of any witnesses.

Some other important parameter is patient's unusual behavior (86.2%), followed by treatment failure and/or high disease recurrence (83.7%).

This concluding point is linked to some other parameter that tin address such diagnosis, that is, the by use of wellness services, which in this study has occurred in 72.6% of cases.

Evidence of factitious production has been observed but in 38.ane% of cases.

Discussion

The demographic contour of the sample shows a prevalence of female. The data back up the hypothesis of several case reports and reviews that FD occur mainly in women.^3,9,ten All the same, other studies published in the literature show a clear prevalence in male gender. This illusory disagreement finds an explanation in Freyberger'south words, who asserts that in that location is a prevalence of men in clinical trials for Munchausen Syndrome, while the women are most common in the classic form of FD with a ratio of 3:i.¹¹

People affected by FD tend to come to medical attention in young developed age. This outcome, in line with the results of several surveys, supports the datum that FD patients arrive for medical attention in the young adult historic period.^iii,12,xiii

A preponderance of patients with employment in health care emerged. Co-ordinate to a biopsychosocial model and as confirmed past the literature, this finding, although not an absolute bulk in patients of this study, suggests that a wellness care work tin exist a run a risk factor in the development of FD if associated with other stressful life events.^{eleven,fourteen}

A prevalence of married people emerged. Although this result is in contrast to some research in literature, it cannot be excluded that these data are partly conditioned past the impossibility of obtaining this information from the whole sample examined.^three,15 This aspect deserves a detailed report in the hereafter.

The study shows a preponderance of comorbidity with personality disorders (specifically deadline personality disorder) and depressive disorders. This result is non surprising since the correlation between FD and personality disorders is frequently described in literature.^16,17 In the group with comorbidity, personality disorders and depressive disorders are the well-nigh represented. In that location are many studies published in the professional literature that support these connections, simply the relationship betwixt these diagnosis is nevertheless unclear.^xviii,19

All medical specialties may exist interested in the management of factitious patients as evidenced past the clinical heterogeneity of the sample, but the study reveals a prevalence of psychiatry, emergency room, and internal medicine departments. This finding moves away from previous scientific observations. The departments of psychiatry, emergency room, and internal medicine are potentially at risk of receiving patients with FD. These information show that clinical presentation is considerably heterogeneous, but there are some specific clusters of psychiatric, trauma, and neurological signs and symptoms. Despite the fact that there are some previous researches that disembalm this aspect,^15,twenty the psychiatric presentation has never been prevalent in previous studies.^3,21 This interesting observation emerged from this review suggests the possibility of underestimation of factitious patients who exhibit psychiatric symptoms and indicates the diagnostic and classification difficulties in patients with psychological signs or symptoms rather than physical ones.

The sample shows a prevalence of internal signs/symptoms, and this could advise that in FD there is a more marked internal dimension and that patients involve strategies such as falsification of clinical and personal history or pseudologia fantastica in order to keep it hidden. Inner pathologies are bars to a less obvious dimension, in which the deed takes place in a hidden, internalized scene and where the subject becomes an executioner of idealistic objects represented in the somatic self, acting every bit a sadomasochistic connection. The external and visible lesions are intrinsically exposed to the observer's gaze, and they are more closely related to the traditional concept of hysteria, in which the somatic cocky-action is loaded with a symbolic and communicative value.^22,23

The review highlights the interesting relationship between FD and recurrent surgery addiction. The American psychoanalyst Karl Menninger,^24,25 dealing with polysurgery dependence or surgery habit, considered FD equally a suicidal equivalent.

Already, Charcot—known for his studies on hysteria and hypnosis—identified passive operating mania in patients and complementary agile operating mania in surgeons. Passive operating mania is an obsessive behavior associated with pain and disability, which entails multiple request of surgical treatments in order to get relief.²³

Various authors have tried to outline the psychological dynamic underlying the behavior of these patients. Concerning recurrent surgery, in 1972, Leon Chertok distinguished "polyopérésnévrotiques", in which relational and psychosexual development disorders prevail, and "polyopéréspsychopathiques", with characteristics of the and then-chosen Munchausen Syndrome, as the recourse to invasive diagnostic techniques and treatments.^26,27

The prevalence of corruption or fail in childhood, substance abuse, alien interpersonal relationships, experience of affliction and/or hospitalization in childhood, and premature familiar bereavements discloses the hypothesis of the existence of a common denominator between FD and depressive disorders.^28–32

Reich and Gottfried identified that the occurrence of many pathologies during childhood is 1 of the major factors for the development of an FD.³³

As already studied by different authors, these individuals answer to stressful life episodes by implementing pathological behavior as a coping mechanism.³⁴

Many authors believe that patients with FD are at a high risk of suicide. The depression percentage emerged, nevertheless, is supported by Yates's recent study, in which only xiv.i% of suicidal behavior is observed.³

In the sample, 34.two% of patients refused or did not have the psychiatric consultation. This fact undoubtedly reveals the difficulty of the doctors who rarely can institute a therapeutic alliance with patients. Subjects with FD with physical signs and symptoms unlikely have to have a psychiatric interview, opposing to it or even go discharged themselves from the hospital.

Among the factors leading to the diagnosis of FD, the exclusion of other organic or psychiatric causes is the most represented. This is undoubtedly of import from a diagnostic point of view and because in patients with FD there may be physical or psychic comorbidity that is not diagnosed considering of the nature of the disorder itself, which functions as a confounding cistron in the clinical presentation.³⁵

In scientific literature, at that place are some studies that highlight the importance of this aspect, and we hope that in future some guidelines will be drawn, which would aid to diagnose FD starting from the unusual clinical presentation.^iii,5,8

An atypical presentation is another key consequence. These patients often apply a scientific language without having whatsoever expertise in the field and they show knowledge of the medical procedures and go on looking for invasive diagnostic examinations. Such beliefs is also characterized by an ambivalent attitude toward the health workers by alternate a collaborative stance and an opposition to the therapeutic program, as well as the apply of pseudologia fantastica. In the 2d case, at that place are repeated therapeutic failures that do not notice an adequate physiological caption as they are often a consequence of the patient'southward repeated pathological behavior.

The difficulty expressed by different authors in trying to reconstruct the clinical history of patients affected by FD is due to the intensive previous use of wellness services in a significant percent of cases.

Evidence of factitious production has been observed in limited number of cases, and this highlights the difficulties in discovering the act itself, while preserving patient'southward privacy.^xi

According to the results of this written report, several authors accept highlighted a frequent comorbidity betwixt FD and depressive disorders,¹⁹ too every bit a significant correlation between FD and deadline personality disorder.¹⁷

The diagnostic criteria for DSM-5 FD were met in 88.7% of cases. The reason for the remaining 11.3% of patients not meeting the criteria tin be institute in the reclassification that these weather condition had in the modern edition of the manual – some patients who first met the criteria of previous editions are at present most likely included in some other diagnostic category. Medically unexplained symptoms are common and frequent in clinical practice and classifications often have limitations.³⁶ This is an intrinsic feature of manuals such as DSM that tend to designate rigid categories to avoid overlapping, merely this inevitably conflicts with the clinical practice where flexibility is essential.

Decision

An extensive systematic review on FD published in the professional literature was conducted. The survey of numerous cases had led to typhoon a demographic profile of the sample highlighting some of import points for early on diagnosis.

The second end betoken of this written report is to evaluate the evolution of the classification of FD inside the Diagnostic and Statistical Transmission of Mental Disorders. With regard to this aim, the study showed that patients did not meet DSM-5 diagnostic criteria in 11.iii% of cases; this is due to the fact that the diagnostic reformulation has plainly caused the outplacement of diagnosis of some disease in other new additional sections of the DSM.

This study includes some limitations. First, the choice of case reports implies a bias of publication and choice: it may happen that some authors decide not to publish some cases as they are similar to other works in the literature or because they present already found or less severe manifestations. Another possible limitation is the fact that results of the study are based on case written report or case series, as nearly of the literature on FD, and the pattern of the studies included is not randomized controlled trials.

In almost cases, the diagnosis of personality disorder has not been confirmed by the administration of structured interviews; this could be a possible limitation of the analysis. Finally, information technology is impossible to exclude some instance reports that illustrate the same patient who comes to medical attention in different times and places since sometimes this kind of patients tend to get to various hospitals with a imitation identity.

This study lays the foundations for hereafter research that could confirm or deny some hypotheses: offset, the prevalence of psychiatric presentations amongst FD patients and, 2nd, the correlation betwixt FD and depressive syndrome that outlines the possibility of detailed diagnostic and therapeutic study.

The study of FD shows the swell difficulty of the physicians to obtain a complete and veritable history from these patients; this aspect inevitably involves defoliation and delayed diagnosis, and it exposes these patients to invasive and reiterated investigations.

The reality of general practice could advise a solution to this problem because general practitioners could have a global clinical view on the patient. In this manner, a proposal could be to raise the sensation in all physicians and to create a system that allows a dialog among them in society to protect patients from useless procedures or diagnostic interventions. The goal is an early diagnosis and early psychiatric treatment.

It is also desirable to undertake a thorough inquiry focusing specifically on the group of patients who do not fulfill the diagnostic criteria of the electric current DSM in club to understand clinical and psychopathological elements beyond the classification.

Disclosure

The authors report no conflicts of involvement in this piece of work.

References

1.		American Psychiatric Association. DSM-five Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
2.		Callegari C, Vender S, Ceccon F, I disturbi Fittizi. In: Callegari C, Poloni Due north, Vender S, editors. Fondamenti Di Psichiatria. Milano: Raffaello Cortina Editore; 2013:267–276.
3.		Yates GP, Feldman Doctor. Factitious disorder: a systematic review of 455 cases in the professional literature. Gen Hosp Psychiatry. 2016;41:20–28.
4.		Feldman Md, Eisendrath SJ, Tyerman Yard. Psychiatric and behavioral correlates of factitious blindness. Compr Psychiatry. 2008;49(2):159–162.
v.		Steel RM. Factitious disorder (Munchausen's syndrome). J R Coll Physicians Edinb. 2009;39(iv):343–347.
half-dozen.		Hoertel North, Lavaud P, Le Stratt Y, Gorwood P. Estimated cost of a factitious disorder with vi-years follow upward. Psychiatry Res. 2012;200(2–iii):1077–1107.
seven.		Bright R, Eisendrath Due south, Damon L. A instance of factitious aplastic anemia. Int J Psychiatry Med. 2001;31(iv):433–441.
viii.		Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet. 2014;383(9926):1422–1432.
9.		Krahn LE, Li H, O'Connor MK. Patients who strive to exist ill: factitious disorder with concrete symptoms. Am J Psychiatry. 2003; 160(vi):1163–1168.
ten.		Eastwood South, Bisson JI. Direction of factitious disorders: a systematic review. Psychother Psychosom. 2008;77(4):209–218.
eleven.		Feldman MD, Eisendrath SJ. The Spectrum of Factitious Disorders. 1st ed. Washington DC: American Psychiatric Press; 1996.
12.		Carney MW, Chocolate-brown JP. Clinical features and motives amongst 42 artifactual affliction patients. Br J Med Psychol. 1983;56(Pt 1):57–66.
13.		Donegan D, Hickey DP, Smith D. Hypoglycemia after simultaneous pancreas-kidney transplant: fact or factitious. Pancreas. 2012;41(vi):974–976.
14.		Plassmann R. Münchhausen syndromes and factitious diseases. Psychother Psychosom. 1994;62:7–26.
15.		Kanaan RA, Wessel SC. Factitious disorders in neurology: an analysis of reported cases. Psychosomatics. 2010;51(one):47–54.
16.		Limosin F, Loze JY, Rouillon F. Clinical features and psychopathology of factitious disorders. Ann Med Interne (Paris). 2002;153(8):499–502.
17.		Nadelson T. The Munchausen spectrum: deadline grapheme features. Gen Hosp Psychiatry. 1979;i(1):eleven–17.
xviii.		Gordon DK, Sansone RA. A relationship between factitious disorder and borderline personality disorder. Innov Clin Neurosci. 2013;10(11–12):eleven–13.
19.		Earle JR, Folks DG. Factitious disorder and coexisting depression: a study of successful psychiatric consultation and instance management. Gen Hosp Psychiatry. 1986;8(6):448–450.
twenty.		Bretz SW, Richards JR. Munchausen syndrome presenting acutely in the emergency department. J Emerg Med. 2000;xviii(four):417–420.
21.		Nicholson SD, Roberts GA. Patients who (need to) tell stories. Br J Hosp Med. 1994;51(10):546–549.
22.		De Martis D, Vender South, Barale F. Atti del XXXVII Congresso Nazionale SIP. In: Progressi in Psichiatria. Standard Diagnostici ed Epidemiologia. I disturbi fittizi: aspetti clinici e psicodinamici. Roma: CIC Edizioni Internazionali; 1989.
23.		Callegari C. I Modelli Interpretativi dei Disturbi Fittizi. In: Southward. Vender, editor. La Maschera Della Finzione. Roma: Il pensiero scientifico editore; 1997:63–75.
24.		Callegari C, Caperna Due south, Isella C, Bianchi L, Vender Due south, Poloni North. Multiple surgical interventions: diagnosis and psychopathology in recurrent operated patients. Minerva Psichiatrica. 2014; 55(iv):215–223.
25.		Menninger KA. Polysurgery and polysurgic habit. J Nerv Ment Dis. 1934;81(1):93.
26.		Callegari C, Caselli I, Bianchi L, Isella C, Vender S. Four clinical cases of recurrent surgery habit (polyopérés): diagnostic classification in the DSM-IV-TR vs DSM-5. Neuropsychiatry. 2016;half dozen(4):178–184.
27.		Callegari C, Bortolaso P, Vender S. A single case report of recurrent surgery for chronic dorsum hurting and its implications concerning a diagnosis of Münchausen syndrome. Funct Neurol. 2006;21(2):103–108.
28.		Norman RE, Byambaa 1000, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child concrete corruption, emotional corruption, and neglect: a systematic review and meta-assay. PLoS Med. 2012;9(11): e1001349.
29.		Bovasso GB. Cannabis abuse every bit a risk factor for depressive symptoms. Am J Psychiatry. 2001;158(12):2033–2037.
thirty.		Boden JM, Fergusson DM. Booze and depression. Addiction. 2011;106(5):906–914.
31.		Gao J, Li Y, Cai Y, et al. Perceived parenting and take chances for major low in Chinese women. Psychol Med. 2012;42(5):921–930.
32.		Geracioti TD, Van Dyke C, Mueller J, Merrin E. The onset of Munchausen'south syndrome. Gen Hosp Psychiatry. 1987;9(half-dozen):405–409.
33.		Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med. 1983;99(ii):240–247.
34.		Merrin EL, Van Dyke C, Cohen S, Tusel DJ. Dual factitious disorder. Gen Hosp Psychiatry. 1986;8(4):246–250.
35.		Poloni N. Vender S, Bolla East, Bortolaso P, Costantini C, Callegari C. Gluten encephalopathy with psychiatric onset: a instance report. Clin Pract Epidemiol Ment Health. 2009;5:16.
36.		Ferrari S, Poloni North, Diefenbacher A, Barbosa A, Cosci F. Modern psychopathologies or sometime diagnoses? From hysteria to somatic symptom disorders: searching for a mutual psychopathological ground. J Psychopathol. 2015;21(i):372–379.

michalecnursucher.blogspot.com

Source: https://www.dovepress.com/epidemiology-and-evolution-of-the-diagnostic-classification-of-factiti-peer-reviewed-fulltext-article-PRBM

Share this post