eMedicine Specialties > Psychiatry > Psychosomatic

Factitious Disorder

Todd S Elwyn, MD, Staff Psychiatrist, Tripler Army Medical Center, Schofield Barracks Soldier Assistance Center
Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii

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

Differential Diagnoses

Delusional Disorder
Depression
Schizophrenia

Workup

Laboratory Studies

The diagnosis of factitious disorder is typically made late, after other diagnostic possibilities have been exhausted. Laboratory studies can be especially helpful in facilitating the diagnosis of many physical illnesses as factitious.
- For example, patients with hypoglycemia can be assessed for exogenous insulin injection by a finding of increased serum insulin/C-peptide ratio (>1.0) during a hypoglycemic episode.⁸
- Patients who complain of kidney stones can be asked to filter their urine for stones, and the submitted material can be tested for composition.
- A tissue biopsy can be helpful in revealing the factitious nature of lesions in which foreign material has been injected to simulate naturally occurring disease.
Because the range of factitious illnesses is limited only by the imagination of the perpetrator, listing all possible laboratory tests that might prove useful is impossible. However, suspicion that an illness is factitious should be conveyed to the pathologist, who may be helpful in identifying ways to confirm the diagnosis.⁹

Treatment

Medical Care

Provide medical care as needed to treat comorbid conditions and complications arising from induced illness.

Psychiatric care
- Patients with factitious disorder must be evaluated fully and assessed for comorbid axis I and axis II diagnoses. By treating axis I disorders, improvement or resolution of factitious behavior may also occur.
- Pharmacotherapy must be monitored carefully to prevent patients from perpetuating self-destructive behavior. Medications to treat the symptoms of personality disorders, such as selective serotonin reuptake inhibitors (SSRIs) to reduce impulsivity, may be of benefit.
- Psychotherapy should focus on establishing and maintaining a relationship with the patient. Supportive psychotherapy may help contain the symptoms of factitious disorder. However, there is little literature regarding which type of psychotherapy is most helpful in assisting patients with overcoming factitious disorder.
- Family therapy may help families to better understand patients and their need for attention.
- Cognitive-behavioral therapy may prove difficult when patients are unable to form a collaborative team with the treatment provider; patients with comorbid antisocial personality disorder may be especially difficult.
Involuntary hospitalization into a psychiatric hospital is indicated when the patient meets statutory criteria for admission. Generally, this requires the patient to be at imminent risk of harm to self or others.

Surgical Care

Provide surgical care as needed to treat comorbid conditions and complications arising from induced illness.

Consultations

Psychiatrists
- Obtaining a psychiatric consultation is recommended when the practitioner believes an illness may be factitious.
- Health care providers should work as a team, together with nursing, social work, and legal personnel.
- The patient should be gently confronted with the team's suspicions in a supportive manner that focuses on the patient's psychological distress as the source of illness.
- Psychiatric treatment should be offered to the patient.
- The patient with factitious disorder will probably try to split the team, and this is a danger for the psychiatric consultant who attempts to establish a therapeutic relationship with the patient. Accordingly, some authorities feel that therapy should not be attempted with patients who have factitious disorder unless they can make a good-faith showing of desire for therapy.
- Patients who are confronted typically deny that they have manufactured disease, although a few will admit it.
- Patients with the chronic form of factitious disorder typically become angry and discharge themselves from the hospital to try to perpetuate their illness elsewhere.
- A small percentage of patients with factitious disorder will consent to psychiatric treatment.
Where factitious disorder by proxy is suspected, the law requires physicians to notify the authorities and to initiate steps for the immediate protection of the child.
- Protection may involve removal of the child from the home, at least until the situation can be completely assessed.
- Once protective measures are in place, the mother should be confronted with the evidence. She will almost certainly deny the charge and will attempt to remove the child from the hospital.
- Criminal prosecution of the perpetrator may also be necessary.
- Evaluation should not be limited to the child involved but should also include his or her siblings.
- Psychotherapy should be offered to the mother, the affected children, and the family.
- Pharmacotherapy may be appropriate when the mother has comorbid axis I or axis II conditions that are amenable to treatment.
- The family requires careful long-term monitoring, especially because of the danger that the mother could move her family and seek to perpetrate such behavior in a new location.

Medication

There is a lack of evidence to support the efficacy of any particular pharmacological intervention in treating factitious disorder. However, pharmacologic therapy for concurrent psychiatric diagnoses is indicated.

Follow-up

Further Inpatient Care

Further inpatient care may be required if patients relapse. This includes the treatment of any medical or surgical conditions as well as psychiatric hospitalization when necessary.

Further Outpatient Care

Close psychiatric follow-up care and monitoring in the outpatient setting is indicated to prevent relapse. Close medical follow-up care may also be necessary, depending on the condition.

Transfer

Transfer from the medical floor to an inpatient psychiatric department is indicated if patients agree to treatment. In rare cases, involuntary hospitalization may be possible if the patient's health is jeopardized severely by continued production of factitious illness (eg, the patient has already lost a kidney because of factitious disorder and is in danger of losing another).

Deterrence/Prevention

Deterrence and prevention involve clear documentation of patients with a known history of factitious disorder, although it does not involve blacklisting.

Complications

Complications may arise from the induction of factitious illness or arise iatrogenically from the workup or treatment for the condition, in addition to producing high health care costs.

Prognosis

Chronic factitious disorder appears to follow an unremitting course. Treatment may transiently ameliorate symptoms but does not appear to last.
Patients with simple factitious disorder follow a more variable course. Case reports in the literature suggest that some patients who seek treatment for factitious disorder may be able to overcome their illness. Even without treatment, simple factitious disorder appears to sometimes remit in the fourth decade of life.

Patient Education

The patient confronted with staff suspicions that the illness is factitious may be unreceptive to attempts at patient education. Still, education should be attempted in the same gentle and supportive manner with which the patient is confronted. If the patient gives permission, educating family members about the patient's condition may also be helpful. Education as to risks of noncompliance with treatment recommendations is also important, ethically and legally, because the patient may wish to sign out against medical advice.
- Convey empathy for the patient's distress that has led to the feigning or intentional production of illness.
- Inform the patient that his or her distress may improve with treatment.
- Point out that without treatment, the condition is unlikely to improve and he or she may again seek hospitalization.
- Emphasize that each episode of producing or feigning illness can result in significant morbidity or even mortality for the patient through the production of illness or the undergoing of unnecessary tests or treatments.
If the patient is receptive to psychiatric treatment, patient education may be an important component of psychotherapy. Information from this article or other sources may be used to help the patient understand more about his or her illness, including the presumed origins of factitious behavior and the importance of regular follow-up care with the psychiatrist. Some useful Internet sites include the following:
- WebMD, Mental Health: Factitious Disorders
- Cleveland Health Clinic, An Overview of Factitious Disorders

Miscellaneous

Medicolegal Pitfalls

A patient with factitious disorder is entitled to the same rights to privacy and confidentiality of information as any other patient.

Although patients with factitious disorder waste valuable hospital resources, notifying other hospitals of patients with factitious disorder or circulating a blacklist of such patients likely violates the physician's ethical and legal duties; therefore, this practice should be discouraged. Keep in mind that patients with factitious disorder can and do litigate.
Searching a patient's belongings for items used in perpetrating factitious illness without permission likely violates the patient's privacy unless the search is conducted with the patient's consent. Consent can sometimes be gained however, by revealing to the patient that one has suspicions that the illness is factitious and then asking for permission to search. Patients may insist they have nothing to hide and allow the search.
The use of video cameras to monitor patient behavior, if already in routine use to monitor patients' rooms (eg, in some critical care wards) probably does not violate privacy considerations. The covert operation of cameras for the specific purpose of catching the patient with factitious disorder is a more controversial method that is sometimes used.

References

Asher R. Munchausen's Syndrome. Lancet. 1951;1:339-41.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association;2000.
Mountz JM, Parker PE, Liu HG, Bentley TW, Lill DW, Deutsch G. Tc-99m HMPAO Brain SPECT Scanning in Munchausen Syndrome. J Psychiatry Neurosci. 1996;21:49-52.
Fliege H, Grimm A, Eckhardt-Henn A, Gieler U, Martin K, Klapp BF. Frequency of ICD-10 factitious disorder: survey of senior hospital consultants and physicians in private practice. Psychosomatics. Jan-Feb 2007;48(1):60-4. [Medline].
Krahn LE, Li H, O''Connor MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry. Jun 2003;160(6):1163-8. [Medline].
Peebles R, Sabella C, Franco K, Goldfarb J. Factitious disorder and malingering in adolescent girls: case series and literature review. Clin Pediatr (Phila). Apr 2005;44(3):237-43. [Medline].
Newmark N, Adityanjee, Kay J. Pseudologia fantastica and factitious disorder: review of the literature and a case report. Compr Psychiatry. Mar-Apr 1999;40(2):89-95. [Medline].
Lebowitz MR, Blumenthal SA. The molar ratio of insulin to C-peptide. An aid to the diagnosis of hypoglycemia due to surreptitious (or inadvertent) insulin administration. Arch Intern Med. Mar 8 1993;153(5):650-5. [Medline].
Wallach J. Laboratory diagnosis of factitious disorders. Arch Intern Med. Aug 8 1994;154(15):1690-6. [Medline].
Aduan RP, Fauci AS, Dale DC, et al. Factitious fever and self-induced infection: a report of 32 cases and review of the literature. Ann Intern Med. Feb 1979;90(2):230-42. [Medline].
Awadallah N, Vaughan A, Franco K, et al. Munchausen by proxy: a case, chart series, and literature review of older victims. Child Abuse Negl. Aug 2005;29(8):931-41. [Medline].
Banerjee A. Factitious disorders presenting as acute emergencies. Postgrad Med J. Feb 1994;70(820):68-73. [Medline].
Bass C, Halligan PW. Illness related deception: social or psychiatric problem?. J R Soc Med. Feb 2007;100(2):81-4. [Medline].
Benbadis SR. The problem of psychogenic symptoms: is the psychiatric community in denial?. Epilepsy Behav. Feb 2005;6(1):9-14. [Medline].
Bergethon PR. Factitious ventricular tachycardia. Ann Intern Med. Oct 1987;107(4):593-4. [Medline].
Bools C. Factitious illness by proxy. Munchausen syndrome by proxy. Br J Psychiatry. Sep 1996;169(3):268-75. [Medline].
Cramer B, Gershberg MR, Stern M. Munchausen syndrome. Its relationship to malingering, hysteria, and the physician-patient relationship. Arch Gen Psychiatry. Jun 1971;24(6):573-8. [Medline].
Diefenbacher A, Heim G. Neuropsychiatric Aspects in Munchausen's Syndrome. General Hospital Psychiatry. 1997;19:281-285.
Eisendrath SJ, McNiel DE. Factitious physical disorders, litigation, and mortality. Psychosomatics. Jul-Aug 2004;45(4):350-3. [Medline].
Feldman MD. Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York, NY: Routledge; 2004.
Feldman MD, Eisendrath SJ, eds. The Spectrum of Factitious Disorders. Washington DC:. American Psychiatric Press;1996.
Fenelon G, Mahieux F, Roullet E, Guillard A. Munchausen''s syndrome and abnormalities on magnetic resonance imaging of the brain. BMJ. Apr 27 1991;302(6783):996-7. [Medline].
Folks DG. Munchausen''s syndrome and other factitious disorders. Neurol Clin. May 1995;13(2):267-81. [Medline].
Folks DG, Freeman AM 3rd. Munchausen''s syndrome and other factitious illness. Psychiatr Clin North Am. Jun 1985;8(2):263-78. [Medline].
Ford CV, Feldman MD. Factitious disorders and malingering. In: Textbook of Consultation-Liason Psychiatry. The American Psychiatric Press. 1996:533-544.
Hamilton JC, Feldman MD, Janata JW. The A, B, C's of factitious disorder: a response to Turner. Medscape J Med [serial online]. Jan 27, 2009;11:27. Accessed June 12, 2009. [Medline]. Available at http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19295948.
Huffman JC, Stern TA. The diagnosis and treatment of Munchausen' s syndrome. Gen Hosp Psychiat. Sep-Oct 2003;25(5):358-363.
Justus PG, Kreutziger SS, Kitchens CS. Probing the dynamics of Munchausen''s syndrome. Detailed analysis of a case. Ann Intern Med. Jul 1980;93(1):120-7. [Medline].
Kass FC. Identification of persons with Munchausen''s syndrome: ethical problems. Gen Hosp Psychiatry. Jul 1985;7(3):195-200. [Medline].
Keiser HR. Surreptitious self-administration of epinephrine resulting in ''pheochromocytoma''. JAMA. Sep 18 1991;266(11):1553-5. [Medline].
Kokturk N, Ekim N, Aslan S, Kanbay A, Acar AT. A rare cause of hemoptysis: factitious disorder. South Med J. Feb 2006;99(2):186-7. [Medline].
Kooiman CG. Neglected phenomena in factitious illness: a case study and review of literature. Compr Psychiatry. Nov-Dec 1987;28(6):499-507. [Medline].
Krahn LE, Bostwick JM, Stonnington CM. Looking toward DSM-V: should factitious disorder become a subtype of somatoform disorder?. Psychosomatics. Jul-Aug 2008;49(4):277-82. [Medline].
McBride A. Quite sane: the true syndrome of Baron Munchausen and a case report of Ophthalmic Munchausen syndrome. Psychiatric Bulletin. 1992;16:432-4.
McDermott BE, Leamon MH, Feldman MD, Scott CL. Factitious disorder and malingering. In: Hales RE, Yudofsky SC, Gabbard GO, eds. The American Psychiatric Publishing Textbook of Psychiatry. 5^th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2008:[Full Text].
Meadow R. Munchausen syndrome by proxy. Arch Dis Child. Feb 1982;57(2):92-8. [Medline].
Mitchell CC, Frank MJ. Pseudobradycardia during Holter monitoring. The electronic Munchausen syndrome?. JAMA. Jul 23 1982;248(4):469-70. [Medline].
Roberts I, Cohen H, Reeves WG. Characterisation of antibodies to insulin to help diagnose factitious hypoglycaemia. Br Med J (Clin Res Ed). May 11 1985;290(6479):1391-2. [Medline].
Rogers R, Bagby RM, Rector N. Diagnostic legitimacy of factitious disorder with psychological symptoms. Am J Psychiatry. Oct 1989;146(10):1312-4. [Medline].
Stern TA, Cremens CM. Factitious pheochromocytoma. One patient history and literature review. Psychosomatics. May-Jun 1998;39(3):283-7. [Medline].
Taylor S, Hyler SE. Update on factitious disorders. Int J Psychiatry Med. 1993;23(1):81-94. [Medline].
Turner MA. Factitious disorders: reformulating the DSM-IV criteria. Psychosomatics. Jan-Feb 2006;47(1):23-32. [Medline].
Wise MG, Ford CV. Factitious disorders. Prim Care. Jun 1999;26(2):315-26. [Medline].

Keywords

Munchausen syndrome, Munchausen syndrome by proxy, factitious disorder, Ganser syndrome, somatoform illnesses, malingering, somatization disorder, conversion disorder, hypochondriasis

Contributor Information and Disclosures

Author

Todd S Elwyn, MD, Staff Psychiatrist, Tripler Army Medical Center, Schofield Barracks Soldier Assistance Center
Todd S Elwyn, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Psychiatry and the Law, American College of Legal Medicine, and American Psychiatric Association
Disclosure: Nothing to disclose.

Coauthor(s)

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Sarah C Aronson, MD, Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland
Sarah C Aronson, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories
Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

Further Reading