Factitious disorder is falsification of physical or psychologic symptoms without an obvious external incentive; the motivation for this behavior is to assume the sick role. Symptoms can be acute, dramatic, and convincing. Patients often wander from one physician or hospital to another for treatment. The cause is unknown, although stress and a severe personality disorder, most often borderline personality disorder, are often implicated. Diagnosis is clinical. There are no clearly effective treatments.
(See also Overview of Somatization.)
Factitious disorder imposed on self was previously called Munchausen syndrome, particularly when manifestations were dramatic and severe. Factitious disorder imposed on another person may also occur.
These patients initially and sometimes chronically become the responsibility of medical or surgical clinics. Nevertheless, the disorder is a psychiatric issue, is more complex than simple dishonest simulation of symptoms, and is associated with severe emotional difficulties.
Patients may have prominent borderline personality features and are usually intelligent and resourceful. They know how to simulate disease and are sophisticated regarding medical practices. They differ from malingerers because, although their deceits and simulations are conscious and volitional, there are no obvious external incentives (eg, economic gain, time off from work) for their behavior. It is unclear what they gain beyond medical attention for their suffering, and their motivations and quest for attention are largely unconscious and obscure.
Patients may have an early history of emotional and physical abuse. Patients may also have experienced a severe illness during childhood or had a seriously ill relative. Patients appear to have problems with their identity as well as unstable relationships. Feigning illness may be a way to increase or protect self-esteem by blaming failures on their illness, by being associated with prestigious physicians and medical centers, and/or by appearing unique, heroic, or medically knowledgeable and sophisticated.
Symptoms and Signs
Patients with factitious disorder imposed on self may complain of or simulate physical symptoms that suggest certain disorders (eg, abdominal pain suggesting an acute surgical abdomen, hematemesis). Patients often know many associated symptoms and features of the disorder that they are feigning (eg, that pain from a myocardial infarction may radiate to the left arm or jaw or be accompanied by diaphoresis).
Sometimes they simulate or induce physical findings (eg, pricking a finger to contaminate a urine specimen with blood, injecting bacteria under their skin to produce fever or abscess; in such cases, Escherichia coli is often the infecting organism). Their abdominal wall may be crisscrossed by scars from exploratory laparotomies, or a digit or a limb may have been amputated.
Diagnosis
Clinical evaluation
Diagnosis of factitious disorder imposed on self is based on history and examination, along with any tests necessary to exclude physical disorders and demonstration of exaggeration, fabrication, simulation, and/or induction of physical symptoms. The behavior must occur in the absence of obvious external incentives (eg, time off work, financial compensation for injury).
Treatment
No clearly effective treatments
Treatment of factitious disorder imposed on self is usually challenging, and there are no clearly effective treatments. Patients may obtain initial relief by having their treatment demands met, but their symptoms typically escalate, ultimately surpassing what physicians are willing or able to do. Confrontation or refusal to meet treatment demands often results in angry reactions, and patients usually move from one physician or hospital to another (called peregrination).
Recognizing the disorder and requesting psychiatric or psychologic consultation early is important, so that risky invasive testing, surgical procedures, and excessive or unwarranted use of drugs can be avoided.
A nonaggressive, nonpunitive, nonconfrontational approach should be used to present the diagnosis of factitious disorder to patients. To avoid suggesting guilt or reproach, a physician can present the diagnosis as a cry for help. Alternatively, some experts recommend providing mental health treatment without requiring patients to admit their role in causing their illness. In either case, conveying to the patient that the physician and patient together can cooperatively resolve the problem is helpful.
