eMedicine Specialties > Psychiatry > Psychosomatic

Factitious Disorder

Author: Todd S Elwyn, MD, Staff Psychiatrist, Tripler Army Medical Center, Schofield Barracks Soldier Assistance Center
Coauthor(s): Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Contributor Information and Disclosures

Updated: Oct 22, 2009

Introduction

Background

Factitious disorder refers to the psychiatric condition in which a patient deliberately produces or falsifies symptoms of illness for the sole purpose of assuming the sick role. Patients with factitious disorder waste precious time and resources through unnecessary hospital admissions, expensive investigatory tests, and sometimes, lengthy hospital stays. Moreover, patients with factitious disorder are among the most challenging and troublesome for busy clinicians. Patients with factitious disorder can generate feelings of anger, frustration, or bewilderment, because they violate the expectations of physicians and staff that patients should "behave like patients." Patients with factitious disorder disobey the following unwritten rules of being a patient: (1) patients attempt to provide an honest history; (2) symptoms result from accident, injury, or chance; and (3) patients are seeking treatment with the goal of recovering and so will cooperate with treatment toward that end.

Patients with factitious disorder likely have been present throughout human history. Their appearance in the literature extends back to the time of the Roman physician Galen who wrote about them in the second century. In the 1800s, the British physician Gavin described how some soldiers and seamen pretended illness to excite compassion or interest.

The modern history of factitious disorder began in 1951 when a clinician (Asher) described case reports of patients who habitually migrate from hospital to hospital, seeking admission through feigned symptoms while embellishing their personal history.¹ He assigned the name Munchausen syndrome to this condition after Baron von Munchausen, a well-respected, retired German cavalry officer who had tales of his life stolen and parodied in a booklet in 1785. Persons with Munchausen syndrome were said to typically (1) exhibit numerous surgical scars, especially in the abdomen, (2) display a truculent or evasive manner, (3) provide a dramatic medical history of questionable veracity, and (4) attempt to conceal such documents as hospital discharge forms or insurance claims. Asher distinguished abdominal, hemorrhagic, and neurologic subtypes.

Since the publication of Asher's article, numerous reports of patients producing or falsifying almost every conceivable kind of illness have appeared in the literature. The type of patient described by Asher is now thought to represent a minority of cases of factitious disorder. The term Munchausen syndrome most appropriately refers to the subset of patients who have a chronic variant of factitious disorder with predominantly physical signs and symptoms. In practice, however, many still use the term Munchausen syndrome interchangeably with factitious disorder. In 1976, the term Munchausen syndrome by proxy entered the medical lexicon and came to describe cases in which an individual artificially produces illness in another person; typically a mother who produces illness in a young child.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)² requires that the following 3 criteria be met for the diagnosis of factitious disorder: (1) intentional production or feigning of physical or psychological signs or symptoms, (2) motivation for the behavior is to assume the sick role, and (3) absence of external incentives for the behavior (eg, economic gain, avoiding legal responsibility, improving physical well-being, as in malingering).

The DSM-IV-TR recognizes the following 3 types of factitious disorder: (1) factitious disorder with predominantly psychological signs and symptoms, (2) factitious disorder with predominantly physical signs and symptoms, and (3) factitious disorder with combined psychological and physical signs and symptoms.

A fourth type, factitious disorder not otherwise specified, includes those disorders with factitious symptoms that do not meet the criteria for factitious disorder. The DSM-IV-TR places factitious disorder by proxy (ie, Munchausen syndrome by proxy) into this category, defining it as "the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care for the purpose of indirectly assuming the sick role." Factitious disorder by proxy has yet to be recognized as an official separate category in the DSM-IV-TR. Appendix B of the DSM-IV-TR lists the following research criteria for factitious disorder by proxy.

• Factitious disorder by proxy is the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care.
• The motivation for the perpetrator's behavior is to assume the sick role by proxy.
• External incentives for the behavior (such as economic gain) are absent.
• The behavior is not better accounted for by another mental disorder.

Case study

A 25-year-old nursing student was admitted to the medical service of a teaching hospital with complaints of hematamesis. She had been seen at another prominent teaching hospital and diagnosed with peptic ulcer disease but treatment had failed to resolve her symptoms. She requested surgical intervention to resolve the problem. After endoscopy failed to reveal any area of bleeding in the stomach, she became upset at the hospital staff for their inability to help her. She became angry when visited by the psychiatry consultation team and denied having any psychiatric problems, insisting that the medical system had failed her.

Due to lack of findings, factitious disorder was considered and staff was advised to observe her closely over the next few days. She was seen sticking her finger up her nose and causing it to bleed into the back of her throat. She then swallowed the blood. When she was confronted by the medical team she became angry and signed out of the hospital, refusing psychiatric follow-up. The internist on the medical team subsequently learned that she had been admitted to a nearby hospital with an abscess in her thigh. She had apparently injected a foreign substance into her thigh. She was diagnosed with factitious disorder with somatic symptoms.

Pathophysiology

As with many psychiatric illnesses, the pathophysiology of factitious disorder is unclear. Case reports of abnormalities on MRIs of the brains of patients with chronic factitious disorder suggest that brain biology may play a role in some cases. For example, in one report, a patient with Munchausen syndrome that underwent SPECT scan was found to have marked hyperperfusion of the right hemithalamus.³

In addition, some patients with factitious disorder have displayed abnormalities on psychological testing. Results of EEG studies have thus far been nonspecific.

Frequency

United States

The prevalence of factitious disorder is unclear. Many authorities believe the condition is underdiagnosed because it involves willful deception, which may be missed by medical staff. Conversely, the prevalence of chronic factitious disorder may be overdiagnosed in some cases because the same patients with factitious disorder may migrate from hospital to hospital. The frequency of presentation of various factitious illnesses (eg, which factitious illnesses are most common) is unclear. However, most researchers agree that the prevalence of factitious psychological symptoms is much lower than the prevalence of factitious physical symptoms. Studies investigating the prevalence of factitious disorder have found the following:

• Of patients referred for evaluation of fever of unknown origin at the US National Institute for Allergy and Infectious Disease, 9.3% had factitious disorder.
• Of material submitted by patients as kidney stones, 2.6% was found to be nonphysiologic and probably fraudulent.

International

Whether the epidemiology of factitious disorder differs in countries other than the US is unclear.

• Of patients referred to the consultation-liaison service of a large teaching hospital in Toronto, 0.8% (10 of 1288) had factitious disorder.
• Of infants brought to a clinic in Australia because of serious illness, 1.5% were cases of factitious disorder by proxy.
• Physicians surveyed in Germany regarding the 1-year prevalence of factitious disorder among their patients averaged an estimate of 1.3%.⁴

Mortality/Morbidity

Factitious disorder can result in morbidity and mortality from the patient's re-creation of actual medical conditions (eg, exogenous administration of insulin) or from the procedures undertaken by the physician to diagnose or treat the condition (eg, unnecessary cardiac catheterizations, surgeries). The factitious production of illness also can lead to emotional distress and suffering for the patient and those close to the patient. No studies have quantified the total estimated morbidity and mortality from factitious disorder.

Sex

Persons with factitious disorder are usually female and employed in medical fields such as nursing or medical technology. Working in the medical field provides knowledge of how disease might be produced artificially and provides access to equipment (eg, syringes, chemicals) with which to do so.

• Persons with chronic factitious disorder (ie, Munchausen syndrome) tend to be unmarried men who are estranged from their families.
• Perpetrators of factitious disorder by proxy are typically mothers who induce illness in their young children; however, sometimes fathers or others are responsible.

Age

Persons with factitious disorder tend to be women aged 20-40 years. Persons with chronic factitious disorder (ie, Munchausen syndrome) tend to be middle-aged men.⁵ Factitious disorder has been noted in the pediatric population.⁶

Clinical

History

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)

Physical

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.

Causes

• 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

• Search for CME/CE on This Topic »

• Malingering (Psychiatry)
• Munchausen Syndrome (Emergency Medicine)
• Munchausen Syndrome by Proxy (Pediatrics: Developmental and Behavioral)
• Munchausen Syndrome by Proxy (Emergency Medicine)

• The A, B, C's of Factitious Disorder: A Response to Turner
• How Should Psychotic Depression Be Treated?
• What's Causing This Young Woman's Erratic and Dangerous Behavior?