Factitious Disorder Clinical Presentation

Patients may feign illness by means of a factitious history alone (eg, falsely claiming to have had a syncopal episode), by a factitious history plus the manipulation of assessment instruments (eg, claiming illness and manipulating a thermometer to show fever), by a factitious history and the use of external agents that mimic disease (eg, adding exogenous blood to urine and claiming hematuria), or by a factitious history and inducing an actual medical condition (eg, injecting bacteria to produce infection, ingesting CNS-active medications to induce psychiatric symptoms). Individuals with an actual medical condition may provide a fictitious history consistent with their condition (eg, pseudoseizures in a patient with epilepsy).

Detection of factitious disorder is typically slowed by the natural tendency among physicians to believe what patients say. Indeed, this tendency may be even greater because many patients with factitious disorder work in the health care field and are colleagues. The detection of factitious disorder among those who have an actual medical condition can be even more difficult.

• The presence of the following factors may raise the possibility that the illness is factitious:

  • Dramatic or atypical presentation
  • Inconsistencies between history and objective findings
  • Vague and inconsistent details, although possibly plausible on the surface
  • Long medical record with multiple admissions at various hospitals in different cities
  • Knowledge of textbook descriptions of illness
  • Admission circumstances that do not conform to an identifiable medical or mental disorder
  • An unusual grasp of medical terminology
  • Employment in a medically related field
  • Pseudologia fantastica (ie, patients' uncontrollable lying characterized by the fantastic description of false events in their lives)^[7]
  • Presentation in the emergency department during times when obtaining old medical records is hampered or when experienced staff are less likely to be present (eg, holidays, late Friday afternoons)
• Other clues that may arise during the course of treatment include the following:

  • A patient who has few visitors despite giving a history of holding an important or prestigious job or a history that casts the patient in a heroic role
  • Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
  • Acceptance, with equanimity, of the discomfort and risk of surgery
  • Substance abuse, especially of prescribed analgesics and sedatives
  • Symptoms or behaviors only present when the patient is being observed
  • Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
  • Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
  • Giving approximate answers to questions (eg, a horse has 3 legs; 7 X 6 = 41), usually occurring in factitious disorder with predominantly psychological signs and symptoms (see Ganser Syndrome)

Suspicion of factitious disorder is raised when the patient has multiple surgical scars or a gridiron abdomen, indicating the chronic form of factitious disorder, or with evidence of self-induced physical signs.

Mental Status Examination

Patients with factitious disorder may vary in their presentation, and no findings have been shown to be pathognomonic. The following findings are possible:

• Appearance may include physical findings described above.
• Attitude may range from cooperative with assessment and treatment to evasive and vague regarding details.
• Mood and affect may be brighter than what would be expected given the patient's medical condition.
• Perceptual abnormalities, such as hallucinations and disturbances of thought process or thought content, and suicidality and/or homicidality, may be present with factitious disorder with predominantly psychological signs and symptoms. Suicidal or homicidal ideation should be taken seriously regardless of whether the suspicions is that it is factitious. Patients having factitious disorder with predominantly physical signs and symptoms usually do not confess to thoughts of harming themselves or others, even when they have actually harmed themselves by deliberately inducing physical illness.
• Cognitive functioning may be aberrant if the patient presents with Ganser syndrome. For example, such a patient may answer simple questions with wrong or nonsensical answers, such as answering "three" when asked: "How many legs on a dog?"
• Orientation and recall may be aberrant if the patient is feigning mental illness.

An example of a patient with factitious disorder follows.

A woman presented to the emergency department as disheveled with poor eye contact. She was dressed unremarkably in street clothes. She was unable to answer basic questions about her past and grimaced as she appeared to concentrate, to no avail. She spoke with an English accent and claimed no memory of who she was or how she got to the hospital. She cooperated with the examiner but could provide little useful information. Her mood was serious and affect was restricted. Thought process was linear. Thought content was impoverished. She did not endorse any hallucinations, delusions, or thoughts about suicide or homicide.

After some efforts by a social worker at the hospital, she was discovered to be a house wife from another city who was in an unhappy marriage and decided to leave to start a new life and had a history of psychiatric hospitalizations. She lost her British accent and acknowledged that she indeed had simulated her symptoms and her history. She was diagnosed with factitious disorder with predominantly psychological signs and symptoms.

• The causes of factitious disorder are not well defined. One psychodynamic explanation asserts that patients with factitious disorder, who often have a background of neglect or abandonment, are attempting to reenact unconscious and unresolved early issues with parents. The following explanations are also possible:

  • Underlying masochistic tendencies
  • A need to be the center of attention and to feel important
  • A need to assume a dependent status and receive nurturance
  • A need to ease feelings of worthlessness or vulnerability
  • A need to feel superior to authority figures (eg, the physician) that is gratified by being able to deceive the physician
• Explanations offered for factitious disorder by proxy parallel those for factitious disorder, except that the parent is using the children to meet these needs. Thus, the child is used as a tool with which to recreate unresolved issues with parents and authority figures.

  • Alternatively, the mother is presumed to gain vicarious satisfaction of attention and nurturance needs that may be missing from her marriage through projective identification.
  • Another explanation asserts that the behavior stems from narcissism, sociopathy, and the desire to manipulate authority figures.
• The risk factors for developing factitious disorder remain largely unclear. Based on the histories of patients with factitious disorder, the following can be projected as characteristics that may predispose an individual to develop a factitious illness:

  • Presence of other mental disorders or medical conditions in childhood or adolescence that resulted in extensive medical attention
  • Holding a grudge against the medical profession or having had an important relationship with a physician in the past
  • Presence of a personality disorder, especially borderline, narcissistic, or antisocial personality disorder