Comment
10 11
12
13
Galambos NL, Barker ET, Krahn HJ. Depression, self-esteem, and anger in emerging adulthood: seven-year trajectories. Dev Psychol 2006; 42: 350–65. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003; 60: 837–44. Fergusson DM, Horwood LJ, Riddler EM, Beautrais AL. Subthreshold depression in adolescence and mental health outcomes in adulthood. Arch Gen Psychiatry 2005; 62: 66–72. Merikangas KR, Zhang H, Avenevoli S, Acharyya S, Neuenschwander M, Angst J. Longitudinal trajectories of depression and anxiety in a prospective community study. Arch Gen Psychiatry 2003; 60: 993–1000.
14
15
Steinhausen HC, Haslimeier C, Metzke CW. The outcome of episodic versus persistent adolescent depression in young adulthood. J Affect Disord 2006; 96: 49–57. Rohde P, Lewinsohn PM, Klein DN, Seeley JR. Association of parental depression with psychiatric course from adolescence to young adulthood among formerly depressed individuals. J Abnorm Psychol 2005; 114: 409–20.
B Boissonnet/BSIP/Science Photo Library
Abnormal illness behaviours: a developmental perspective
Published Online March 6, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62640-9 See Series pages 1412 and 1422
1368
In two Series articles1,2 in The Lancet, Christopher Bass and colleagues examine fabricated or induced illness in children, and factitious disorders and malingering, respectively, which fall under the umbrella of abnormal illness behaviours. A common theme is the strategic use of illness behaviours in relationships with other individuals, including doctors and other health professionals. Abnormal illness behaviours are inherently social and interpersonal; they have no strategic or communicative function except when someone else can observe and respond to the behaviour. When clinicians begin to suspect that patients are exaggerating symptoms or fabricating or inducing illness, the basic tenets of the clinician–patient relationship—trust and confidentiality—have to be recalibrated, potentially leading clinicians onto uncomfortable, uncertain ground. Rather than taking information at face value, clinicians should collaborate with other health professionals to assemble a chronology of involvement with medical services. Of particular importance are any discrepancies between patient reports and clinical findings. However, for various reasons, and as the two papers mention, clinicians can be reluctant to start such a process. In paediatric practice, some clinicians will be afraid, for legal reasons, to proceed with attempts to identify possible fabricated or induced illness; some will not devote the time needed to address the situation; and some will take the stance of least resistance, which is to do nothing, thereby avoiding any potential liability or confrontation. These responses emphasise some familiar issues with health-care systems: the risk of litigation; overscheduling and the absence of discretionary time; the bureaucratisation and fragmentation of health care; demoralisation and burnout of health professionals; and, especially relevant here, low confidence in the child protection system.
Although clinicians’ ethical obligations are clear—when children’s health and wellbeing are at risk, clinicians need to act—the legal and organisational context will either aid or hinder appropriate action. In the UK and some Australian jurisdictions, statutory frameworks and national treatment guidelines enable clinicians to share information, without legal risks, in specified circumstances. However, many countries do not have such statutes and guidelines, and many do not even have legally mandated child protection services. Likewise, the availability of longitudinal medical records varies between countries. In adult practice with patients who fabricate illness, unavailability of longitudinal medical records in addition to a scarcity of patient consent might restrict the data-gathering process from the outset. But why do patients engage in such behaviours at all? Bass and colleagues’ papers1,2 point to an apparent intergenerational connection between illness fabrication, somatisation, and factitious illness. Mothers who fabricate or induce illness in their children have childhood histories characterised by high rates of privation, abuse, loss, and bereavement; a longstanding history of relational dangers and disrupted attachment. In adolescence or adulthood, these mothers are also more likely to have somatoform, factitious, or personality disorders than are mothers whose childhoods were free of such relational disruptions. Children have an inbuilt need for interpersonal connection and do not respond well to maltreatment or disrupted attachment relationships.3,4 Because selfregulation skills are learnt within the attachment relationship, early developmental disruptions result in dysregulations of the body’s stress systems (which might generate somatic symptoms);5–7 difficulties with emotional regulation;8 disturbances in development of an integrated self (personality disorders);8 and wide-ranging www.thelancet.com Vol 383 April 19, 2014
Comment
maladaptive behaviours, including ones that put the self or one’s progeny at risk.5,9,10 A third of maltreated children will go on to maltreat their own progeny.11 Individuals deprived of nurturing attachments early in life might experience recurrent states of emotional dysregulation and will enact behaviours addressing unmet emotional needs. The emotional strategies used by this group of children and adults will often involve dissimulation or deception.4,9,10 In this context, the abnormal illness behaviours examined in the two articles1,2 represent extensions and distortions of childhood patterns of behaviour whose function was to obtain, when otherwise unavailable, comfort and protection from others, with clinicians now placed in the caregiving role. Against this background, the line between volitional and non-volitional processes is difficult to identify. The adaptive use of dissimulation and deception develops early in life, before language and explicit cognitive processes arise. These early behavioural patterns become progressively embedded, over time, in increasingly complex behavioural patterns, which are themselves further distorted by subsequent losses and traumas. Distinguishing between caregivers’ volitional and nonvolitional behaviour is, in this context, no simple matter, and might not even be possible. In their summary of present knowledge, the papers emphasise the need for further research on fabricated or induced illness in children, and factitious disorders and malingering. A systemic-developmental framework might elucidate, over time, the developmental pathways leading to factitious illness, illness fabrication in children, and somatisation. Likewise, research on dissimulation and deception, and of their emergence through human interactions (especially with parents), could clarify the pathological use of these processes, including in the abnormal illness behaviours discussed here. Methods for assessment of attachment are also likely to be useful in this context.12 Finally, because developmental disruptions affect the body’s stress systems, neurophysiological studies of this patient population might identify dysregulations of body–brain systems that could lead patients to give undue attention to somatic signals, thereby affecting both behaviour and decision making.13 The last thing to be considered is treatment. In discussing fabricated or induced illness in children,1 Bass and colleagues conceptualise this subset of caregiver behaviours on a continuum that includes extreme neglect www.thelancet.com Vol 383 April 19, 2014
(failure to seek medical care), lackadaisical approaches to children’s health, appropriate health service consultations (the midpoint of the continuum), increased frequency of medical consultations fuelled by increased caregiver anxiety (with or without exaggeration of symptoms), and fabricated and induced illness. This continuum—in addition to caregivers’ capacity to accept a rehabilitative approach—identifies varying degrees of risk and provides clinicians with a useful framework to assess whether to opt for child protection versus therapeutic interventions. In our own work, for children and families at low risk, we focus on the therapeutic option as a pathway to health. We work with families to improve children’s safety, physical wellbeing, functional ability to engage in standard activities, and capacity to regulate their bodies, and to improve the emotional functioning of each child and family as a whole.14 Kasia Kozlowska Psychological Medicine, The Children’s Hospital at Westmead, Westmead 2145, NSW, Australia; and Disciplines of Psychiatry and of Paediatrics and Child Health, University of Sydney Medical School, Sydney, NSW, Australia [email protected] I declare that I have no competing interests. 1
2
3 4 5 6
7
8 9
10 11
12
13 14
Bass C, Glaser D. Early recognition and management of fabricated or induced illness in children. Lancet 2014; published online March 6. http:// dx.doi.org/10.1016/S0140-6736(13)62183-2. Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet 2014; published online March 6. http://dx.doi.org/10.1016/S0140-6736(13)62186-8. Harlow H. The nature of love. Am Psychol 1958; 13: 673–85. Crittenden PM. Chapter VII. Danger and development: The organization of self-protective strategies. Monogr Soc Res Child Dev 1999; 64: 145–71. Flaviola G, Macri S. Adaptive and maladaptive aspects of developmental stress. New York: Springer, 2013. Kozlowska K. Stress, distress, and bodytalk: co-constructing formulations with patients who present with somatic symptoms. Harv Rev Psychiatry 2013; 21: 314–33. Rask CU, Ørnbøl E, Olsen EM, Fink P, Skovgaard AM. Infant behaviors are predictive of functional somatic symptoms at ages 5–7 years: results from the Copenhagen Child Cohort CCC2000. J Pediatr 2013; 162: 335–42. Schore A. Affect dysregulation and disorders of the self. New York: Norton, 2003. Crittenden PM. Why do inadequate parents do what they do. In: Mayseless O, ed. Parenting representations: theory, research and clinical implications. New York: Cambridge University Press, 2006: 388–433. Crittenden PM. Raising parents: attachment, parenting and child safety. Portland, OR: Willan Publishing, 2008. Administration for Children and Families, US Department of Health and Human Services. Cycle of Abuse. https://www.childwelfare.gov/can/ impact/longterm/abuse.cfm (accessed Jan 9, 2014). Farnfield S, Hautamaki A, Nørbech P, Nicola S. DMM assessments of attachment and adaptation: procedures, validity and utility. Clin Child Psychol Psychiatry 2010; 15: 313–28. Damasio AR. Descartes’ error: emotion, reason, and the human brain. New York: GP Putnam, 1994. Kozlowska K, Foley S, Savage B. Fabricated illness: working within the family system to find a pathway to health. Fam Process 2012; 51: 570–87.
1369
10 11
12
13
Galambos NL, Barker ET, Krahn HJ. Depression, self-esteem, and anger in emerging adulthood: seven-year trajectories. Dev Psychol 2006; 42: 350–65. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003; 60: 837–44. Fergusson DM, Horwood LJ, Riddler EM, Beautrais AL. Subthreshold depression in adolescence and mental health outcomes in adulthood. Arch Gen Psychiatry 2005; 62: 66–72. Merikangas KR, Zhang H, Avenevoli S, Acharyya S, Neuenschwander M, Angst J. Longitudinal trajectories of depression and anxiety in a prospective community study. Arch Gen Psychiatry 2003; 60: 993–1000.
14
15
Steinhausen HC, Haslimeier C, Metzke CW. The outcome of episodic versus persistent adolescent depression in young adulthood. J Affect Disord 2006; 96: 49–57. Rohde P, Lewinsohn PM, Klein DN, Seeley JR. Association of parental depression with psychiatric course from adolescence to young adulthood among formerly depressed individuals. J Abnorm Psychol 2005; 114: 409–20.
B Boissonnet/BSIP/Science Photo Library
Abnormal illness behaviours: a developmental perspective
Published Online March 6, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62640-9 See Series pages 1412 and 1422
1368
In two Series articles1,2 in The Lancet, Christopher Bass and colleagues examine fabricated or induced illness in children, and factitious disorders and malingering, respectively, which fall under the umbrella of abnormal illness behaviours. A common theme is the strategic use of illness behaviours in relationships with other individuals, including doctors and other health professionals. Abnormal illness behaviours are inherently social and interpersonal; they have no strategic or communicative function except when someone else can observe and respond to the behaviour. When clinicians begin to suspect that patients are exaggerating symptoms or fabricating or inducing illness, the basic tenets of the clinician–patient relationship—trust and confidentiality—have to be recalibrated, potentially leading clinicians onto uncomfortable, uncertain ground. Rather than taking information at face value, clinicians should collaborate with other health professionals to assemble a chronology of involvement with medical services. Of particular importance are any discrepancies between patient reports and clinical findings. However, for various reasons, and as the two papers mention, clinicians can be reluctant to start such a process. In paediatric practice, some clinicians will be afraid, for legal reasons, to proceed with attempts to identify possible fabricated or induced illness; some will not devote the time needed to address the situation; and some will take the stance of least resistance, which is to do nothing, thereby avoiding any potential liability or confrontation. These responses emphasise some familiar issues with health-care systems: the risk of litigation; overscheduling and the absence of discretionary time; the bureaucratisation and fragmentation of health care; demoralisation and burnout of health professionals; and, especially relevant here, low confidence in the child protection system.
Although clinicians’ ethical obligations are clear—when children’s health and wellbeing are at risk, clinicians need to act—the legal and organisational context will either aid or hinder appropriate action. In the UK and some Australian jurisdictions, statutory frameworks and national treatment guidelines enable clinicians to share information, without legal risks, in specified circumstances. However, many countries do not have such statutes and guidelines, and many do not even have legally mandated child protection services. Likewise, the availability of longitudinal medical records varies between countries. In adult practice with patients who fabricate illness, unavailability of longitudinal medical records in addition to a scarcity of patient consent might restrict the data-gathering process from the outset. But why do patients engage in such behaviours at all? Bass and colleagues’ papers1,2 point to an apparent intergenerational connection between illness fabrication, somatisation, and factitious illness. Mothers who fabricate or induce illness in their children have childhood histories characterised by high rates of privation, abuse, loss, and bereavement; a longstanding history of relational dangers and disrupted attachment. In adolescence or adulthood, these mothers are also more likely to have somatoform, factitious, or personality disorders than are mothers whose childhoods were free of such relational disruptions. Children have an inbuilt need for interpersonal connection and do not respond well to maltreatment or disrupted attachment relationships.3,4 Because selfregulation skills are learnt within the attachment relationship, early developmental disruptions result in dysregulations of the body’s stress systems (which might generate somatic symptoms);5–7 difficulties with emotional regulation;8 disturbances in development of an integrated self (personality disorders);8 and wide-ranging www.thelancet.com Vol 383 April 19, 2014
Comment
maladaptive behaviours, including ones that put the self or one’s progeny at risk.5,9,10 A third of maltreated children will go on to maltreat their own progeny.11 Individuals deprived of nurturing attachments early in life might experience recurrent states of emotional dysregulation and will enact behaviours addressing unmet emotional needs. The emotional strategies used by this group of children and adults will often involve dissimulation or deception.4,9,10 In this context, the abnormal illness behaviours examined in the two articles1,2 represent extensions and distortions of childhood patterns of behaviour whose function was to obtain, when otherwise unavailable, comfort and protection from others, with clinicians now placed in the caregiving role. Against this background, the line between volitional and non-volitional processes is difficult to identify. The adaptive use of dissimulation and deception develops early in life, before language and explicit cognitive processes arise. These early behavioural patterns become progressively embedded, over time, in increasingly complex behavioural patterns, which are themselves further distorted by subsequent losses and traumas. Distinguishing between caregivers’ volitional and nonvolitional behaviour is, in this context, no simple matter, and might not even be possible. In their summary of present knowledge, the papers emphasise the need for further research on fabricated or induced illness in children, and factitious disorders and malingering. A systemic-developmental framework might elucidate, over time, the developmental pathways leading to factitious illness, illness fabrication in children, and somatisation. Likewise, research on dissimulation and deception, and of their emergence through human interactions (especially with parents), could clarify the pathological use of these processes, including in the abnormal illness behaviours discussed here. Methods for assessment of attachment are also likely to be useful in this context.12 Finally, because developmental disruptions affect the body’s stress systems, neurophysiological studies of this patient population might identify dysregulations of body–brain systems that could lead patients to give undue attention to somatic signals, thereby affecting both behaviour and decision making.13 The last thing to be considered is treatment. In discussing fabricated or induced illness in children,1 Bass and colleagues conceptualise this subset of caregiver behaviours on a continuum that includes extreme neglect www.thelancet.com Vol 383 April 19, 2014
(failure to seek medical care), lackadaisical approaches to children’s health, appropriate health service consultations (the midpoint of the continuum), increased frequency of medical consultations fuelled by increased caregiver anxiety (with or without exaggeration of symptoms), and fabricated and induced illness. This continuum—in addition to caregivers’ capacity to accept a rehabilitative approach—identifies varying degrees of risk and provides clinicians with a useful framework to assess whether to opt for child protection versus therapeutic interventions. In our own work, for children and families at low risk, we focus on the therapeutic option as a pathway to health. We work with families to improve children’s safety, physical wellbeing, functional ability to engage in standard activities, and capacity to regulate their bodies, and to improve the emotional functioning of each child and family as a whole.14 Kasia Kozlowska Psychological Medicine, The Children’s Hospital at Westmead, Westmead 2145, NSW, Australia; and Disciplines of Psychiatry and of Paediatrics and Child Health, University of Sydney Medical School, Sydney, NSW, Australia [email protected] I declare that I have no competing interests. 1
2
3 4 5 6
7
8 9
10 11
12
13 14
Bass C, Glaser D. Early recognition and management of fabricated or induced illness in children. Lancet 2014; published online March 6. http:// dx.doi.org/10.1016/S0140-6736(13)62183-2. Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet 2014; published online March 6. http://dx.doi.org/10.1016/S0140-6736(13)62186-8. Harlow H. The nature of love. Am Psychol 1958; 13: 673–85. Crittenden PM. Chapter VII. Danger and development: The organization of self-protective strategies. Monogr Soc Res Child Dev 1999; 64: 145–71. Flaviola G, Macri S. Adaptive and maladaptive aspects of developmental stress. New York: Springer, 2013. Kozlowska K. Stress, distress, and bodytalk: co-constructing formulations with patients who present with somatic symptoms. Harv Rev Psychiatry 2013; 21: 314–33. Rask CU, Ørnbøl E, Olsen EM, Fink P, Skovgaard AM. Infant behaviors are predictive of functional somatic symptoms at ages 5–7 years: results from the Copenhagen Child Cohort CCC2000. J Pediatr 2013; 162: 335–42. Schore A. Affect dysregulation and disorders of the self. New York: Norton, 2003. Crittenden PM. Why do inadequate parents do what they do. In: Mayseless O, ed. Parenting representations: theory, research and clinical implications. New York: Cambridge University Press, 2006: 388–433. Crittenden PM. Raising parents: attachment, parenting and child safety. Portland, OR: Willan Publishing, 2008. Administration for Children and Families, US Department of Health and Human Services. Cycle of Abuse. https://www.childwelfare.gov/can/ impact/longterm/abuse.cfm (accessed Jan 9, 2014). Farnfield S, Hautamaki A, Nørbech P, Nicola S. DMM assessments of attachment and adaptation: procedures, validity and utility. Clin Child Psychol Psychiatry 2010; 15: 313–28. Damasio AR. Descartes’ error: emotion, reason, and the human brain. New York: GP Putnam, 1994. Kozlowska K, Foley S, Savage B. Fabricated illness: working within the family system to find a pathway to health. Fam Process 2012; 51: 570–87.
1369
