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Factitious Disorder Imposed on Self Treatment & Management

  • Author: Todd S Elwyn, MD; Chief Editor: Eduardo Dunayevich, MD  more...
 
Updated: Jan 14, 2014
 

Approach Considerations

Healthcare 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, though 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.

Patients with factitious disorder must be evaluated fully and assessed for comorbid psychiatric diagnoses. Treating any other disorders that are present may lead to improvement or resolution of the factitious behavior. A small percentage of patients with factitious disorder will consent to psychiatric treatment. If such consent is obtained, transfer from the medical floor to an inpatient psychiatric department is indicated.

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.

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. 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).

There often comes a time in the care of a patient with factitious disorder when the suspicion of factitious illness has arisen, but evidence is insufficient to establish the diagnosis with certainty. No matter how strong the suspicion of a factitious illness, physicians have a duty not to miss any authentic pathology that may be present. The observation of such patients actually taking steps to feign a symptom in a controlled environment is often the final step in securing the diagnosis of factitious disorder.

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Initial Treatment Measures

The efforts of emergency medical services (EMS) should be directed toward the initial presenting symptoms. It is unlikely that prehospital teams will be able to effectively establish a diagnosis of factitious disorder, and they should not attempt to do so.

Initial care and stabilization of these patients are driven by the presenting symptoms. It is true that these symptoms may well be the result of sophisticated lying or of self-injury or self-intoxication, but this does not make appropriate workup and treatment of the patient any less necessary.

Even when there are good reasons for suspecting factitious disorder, ordinary care must be provided until the patient is fully diagnosed. If (1) a constellation of symptoms has placed, or appears to have placed, the patient in need of certain therapies and (2) the initial hospital lacks the resources or staffing to deal with the symptoms in question, then transfer to a secondary or tertiary referral center should be arranged, in accordance with federal law and established clinical practice.

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General Medical Care

Medical care must be provided as necessary to treat comorbid conditions and complications arising from induced illness. In principle, medical care of patients with suspected factitious disorder should proceed in the same manner as that of any other patients, despite the dramatic or compelling nature of the factitious illness or the constant demands for additional invasive and noninvasive intervention.

Physicians should be alert to the possibility of deception; patients with factitious disorder typically attempt to fool treating physicians into conducting more tests and trying more treatments than are actually necessary. On the other hand, medical professionals are taught that the most important clue to a diagnosis is the information patients provide; accordingly, doctors should not abandon their belief in and advocacy for patients unless risk factors for factitious disorder are present or suggestive signs of this condition arise.

By definition, patients with factitious disorder present repeatedly for medical care. One prolific patient with Munchausen syndrome claimed 800 hospitalizations at 650 hospitals throughout Europe, though this claim may have been an example of pseudologia fantastica. A pattern of signs that remit during inpatient hospitalizations only to recur when the patient is not under observation may constitute an important clue that the patient’s medical problem is simulated or self-induced.

Thorough wrapping of affected areas to prevent access can forestall self-harm and rehospitalization in some cases; however, tampering with bandages is common and often forces rehospitalization due to an unexpected infection, a surprising dehiscence of a skin graft, or a bizarre opening of a closed wound. In the hospital, voluntarily restraining or placing mittens on a patient’s hands can reduce the likelihood of tampering. Painting the wound with scarlet red can provide an important clue if the dye subsequently appears on the fingers.

Although some patients are hospitalized many times at a particular hospital, especially if the primary physician is amenably unquestioning, doting, or naive, patients with true Munchausen syndrome will continually seek new medical audiences whenever their ruse is exposed or whenever they tire of their current hospital setting.

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Psychotherapeutic Interventions

Psychotherapy should focus on establishing and maintaining a relationship with the patient. Supportive psychotherapy may help contain the symptoms of factitious disorder. However, little information is available on which type of psychotherapy is most effective in helping patients overcome factitious disorder.

Family therapy may help families achieve a better understanding of 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 problematic.

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.

Although patients with chronic and severe factitious disorder (ie, Munchausen syndrome) pose a very real and imminent danger to themselves, they are rarely subject to civil commitment. Civil commitment is particularly unlikely in states in which “treatability” or the expectation of improvement is a criterion for petition or commitment. Outpatient commitment can prove difficult for the same reason, though it has been used successfully at least 1 reported case. Even the successful use of house arrest was reported in 1 case.

For a patient with Munchausen syndrome to accept inpatient psychiatric care on a voluntary basis is probably very rare unless the patient is predominantly feigning psychological signs and symptoms or has the combined variant of the syndrome.

Medical guardianship, open access to a hospital bed so that admission is no longer contingent on illness, 12-step programs, and Internet chats among patients have all been proposed or attempted at various times, albeit with mixed results. To the authors’ knowledge, no specialized inpatient (or outpatient) program for patients with factitious disorder exists in the United States, just as no federal or foundation funds have ever been awarded for research into this perplexing and costly syndrome.

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Pharmacologic Therapy

There is little evidence to support the efficacy of any particular pharmacologic intervention in treating factitious disorder; no drug treatment trials have been performed specifically for this purpose. However, pharmacologic therapy for concurrent psychiatric diagnoses is indicated. For example, patients with comorbid depression or anxiety may benefit from nonabusable medications such as SSRIs, though these medicines are very unlikely to reverse the factitious illness behavior. Drugs may also be considered for treatment of the presenting symptoms.

Caregivers should routinely copy each other on every progress note and prescription written, with ongoing care contingent on the patient’s signing the suitable consent forms. If abusable medications must be used (eg, because of a lack of response to nonabusable agents), firm written contracts should be signed by doctor, patient, and at least 1 witness.

Examples of such contracts are usually available from state medical licensure boards or pain-management colleagues. The provisions might include statements that no replacement pills will be provided if the patient claims to have lost their medication in some way and that the patient will submit to random urine or serum blood screens to exclude use of street drugs and to detect drug levels that are too high to be explained by correct use of the medication.

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Surgical Interventions

Patients with factitious disorder should receive surgical care as needed to treat any comorbid conditions and complications arising from induced illness. However, great caution should be exercised in deciding to proceed with surgical treatment, particularly when the procedure is one that involves an irreversible result (eg, amputation, radical mastectomy, or organ removal).

It must not be assumed that patients with factitious disorder will not play out their ruse to the point of undergoing an operation that leaves them with permanent disability or disfigurement; in fact, the case literature is replete with reports of patients who have done so. Many such patients are attracted to surgery because it gives them a legitimate sick-role status—at least during the recovery period, and perhaps longer in cases where the operation appears to result in complications or otherwise creates unexpected and unwanted physical consequences.

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Activity

For hospitalized patients with factitious disorder, it may be important to limit their activities to the unit and to minimize the time they spend alone. Freedom to come and go (as on some psychiatric units) or infrequent checks offer increased opportunities for these patients to self-induce renewed bouts of illness. Room searches (eg, for syringes or hidden medications) may be necessary, and permission to conduct such searches is often part of the consent forms patients sign before admission.

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Prevention

Little can be done directly to prevent the development of factitious disorder. Because patients do not regard the disorder as undesirable, they have no incentive to engage in activities to reduce the morbidity and mortality associated with inauthentic illness behavior.

According to the best current hypothesis, factitious disorder develops from a combination of factors related to personality development and early experiences with illness and medical care. No biologic diathesis has been demonstrated, though magnetic resonance imaging (MRI) and neuropsychological testing have sometimes yielded nonspecifically abnormal results. Factitious disorder can be multigenerational, however, and can precede, follow, or accompany factitious disorder imposed on another (Munchausen syndrome by proxy ).

Deterrence and prevention involve clear documentation of patients with a known history of factitious disorder (to be distinguished from blacklisting). Other measures that may be taken are described below.

Surveillance

In the United States, aside from the Veterans Affairs system, there is no database that would allow examiners to track the readmissions and diagnoses of patients and thus to identify patients who are likely to have factitious disorder. In countries with socialized medicine, this capacity exists, but the extent to which it is used has not been reported.

Certain countries (eg, the United Kingdom and Australia) appear to distribute “black books” of patients who are known to overuse care, but the reasons why these patients are listed may include substance addiction, malingering, or other causes, as well as factitious disorder. Some authorities have expressed concern that patients with legitimate illnesses superimposed on such a diagnosis may be denied urgent medical or surgical care. Such cases have in fact been reported, with at least 1 resulting in death.

Preventive actions by individual physicians

Although surveillance of persons with factitious disorder is not currently possible in the United States, there are steps that individual physicians can take to prevent excessive and unnecessary illness behavior.

First, it is unlikely that severe and continuous medical deceptions begin suddenly. It is more reasonable to suspect that factitious disorder follows a progression starting with more pedestrian forms of feigned or exaggerated illness. For this reason, primary care physicians should take decisive steps to assess and manage the psychological problems of any patient who presents with repeated unexplained medical complaints.

The research literature on medically unexplained symptoms makes it clear that such symptoms are strongly and linearly associated with increasingly severe anxiety and depression. Thus, even if only a small percentage of persons with unexplained medical complaints are destined to develop severe factitious disorder, psychological intervention for all persons with medically unexplained symptoms is fully justified.

Anecdotal evidence that excessive sick-role behavior can be trained at an early age suggests that pediatricians may play a particularly important role in preventing factitious illness behavior in their patients when they become adolescents and adults. Parents should be educated explicitly on the pernicious effects of encouraging unnecessary illness behavior in their children, and they should be given clear expectations about the things that their ill or injured child can and cannot do, along with information about the time course of recovery for acute illness.

Prevention of factitious illness behavior can also be improved by implementing several relatively minor changes in the way primary care physicians manage cases. For example, the practice of assigning official medical diagnoses in the absence of adequate evidence should be sharply curtailed.

Often, examination of cases of factitious disorder reveals that decisions to perform excessive diagnostic or treatment procedures were based on seemingly definitive, but incorrect, diagnoses. Although for most patients, providing a definitive diagnosis may be reassuring and may facilitate third-party reimbursement, for patients who are at risk for factitious illness behavior, an official diagnosis can enable medical deception.

Education of healthcare professionals

Educational efforts are most effective when they are targeted toward medical staff, nursing professionals, and other allied health care professionals. In the absence of scientific evidence related to identification and management of patients with factitious disorder, exposure to case reports is the best available method for communicating the types of medical deceptions that have been used and the clues that led to the eventual discovery of the deception.

In almost every medical specialty, there are published case studies describing the specific techniques that have been used to simulate or induce conditions that fall within the purview of that specialty. These cases are invaluable sources of hypotheses that might explain unusual patterns of signs and symptoms that cannot be explained by routine diagnostic means.

However, using published cases as teaching tools is inherently dangerous because the published reports are almost certainly biased toward the most extreme, chronic, and dramatic cases. Educational efforts that do not attempt to correct for this fact may increase the detection rate of Munchausen syndrome but may cause staff to overlook less dramatic cases of factitious disorder. Published case reports should be supplemented with less spectacular cases seen by experienced staff nurses and physicians.

To the extent that factitious disorder is associated with borderline and antisocial personality disorder, the presence of patients with this disorder can produce rifts among the staff. These patients are generally well practiced at identifying staff members whom they can win over as allies and advocates, and they commonly are able to pit these staff members against those who actively question the authenticity of their complaints.

This splitting often leads to acrimony and self-doubt among the staff and always delays the eventual detection of the deception. Regardless of whether a given case is eventually diagnosed as factitious disorder or as an occult medical condition, the treatment team as a whole is hurt. In the former case, those who advocated for the patient feel embarrassed and emotionally abused; in the latter case, those who accused a patient who turned out to be truly ill are left feeling embarrassed and unsure of their medical competence.

The best way of averting these undesired outcomes is to prepare the staff ahead of time for dealing with difficult cases. Educating staff members about the strong emotions and interpersonal tensions elicited in these cases may be the simplest and most effective way of ensuring effective teamwork.

One element of this education might involve emphasizing that the diagnostic question is not whether the patient is ill; rather, the question is what type of illness the patient has. Emphasizing that the accurate and timely diagnosis of factitious disorder is a medically important service to the patient may help reduce polarization and factional strife.

Other potentially useful strategies include training staff to raise concerns about medical deception as soon as they arise, adding medical deception to the working diagnostic hypotheses, and making careful plans for evaluating that hypothesis along with all other viable hypotheses. The earlier the issue is raised and incorporated into the case conceptualization, the less likely it is that decisions will be based on irrelevant emotional factors such as anger, frustration, or sympathy.

Effective implementation of this strategy requires that the treatment team members have a realistic idea about the prevalence of factitious disorder and that they foster a climate in which a member can raise concerns about medical deception without fear of reproach from other team members.

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Consultations

Primary care physicians who encounter patients with factitious disorder often make specialty referrals in response to the patient’s puzzling or intractable symptoms. Such referrals should be carefully coordinated and kept to a minimum; the primary care physician should serve as much more than a conduit for consultations. In some cases involving patients with factitious disorder who filed malpractice suits, the staggering number of concurrent treating and prescribing physicians could incriminate the doctor if he or she failed to ask about outside care.

A patient’s refusal to sign release of information forms should be thoroughly questioned and is a warning sign. The primary care physician should firmly resist attempts by the patient to exert inappropriate control over the consultation (eg, by choosing the specialist or insisting on personally communicating the results to the primary care physician). Termination from the physician’s practice may have to be considered, though this measure does nothing to mitigate the fundamental problem.

If the diagnosis of factitious disorder is clear or strongly suspected, psychiatric consultation and referral should be offered to the patient even if admission for the patient’s medical problems is declined. The patient nearly always declines such referrals, and a refusal should be documented in the patient’s record. Before requesting a psychiatric consultation, however, the primary care physician should consider the following issues:

  • No definitive affirmative psychiatric criteria exist for the diagnosis of factitious disorder
  • Because the patient is unlikely to cooperate with a psychiatric consultation, no new information will be elicited; in addition to refusing the consultation, the patient may even leave the physician’s care, angered by the implication of deception
  • Psychological testing is nondiagnostic, though it can be telling if a patient feigning mental illness receives discrepant scores on objective, well-validated tests; for these reasons, a typical psychiatric or psychological evaluation is not often effective in these cases
  • As a group, psychiatrists and psychologists are no more able to discern lying during interviews than average lay persons are

Nevertheless, it may be helpful for the physician to discuss the case with an experienced psychiatric consultant who can advise the physician—and sometimes the entire treatment team—on how to proceed with the evaluation and management of a patient with factitious disorder.

After a diagnosis of factitious disorder has been established, it may prove more useful to conduct consultations with mental health professionals who practice behavioral medicine, reserving psychopharmacologic management for patients with clear-cut mental disorders such as major depression. These professionals might include psychiatrists, psychologists, or social workers.

Consultations may be acceptable to patients if they are portrayed as means of helping patients cope with their medical problems and understand more about the influence of the brain on the body. The idea is to place patients in contact with mental health professionals in a way that does not directly challenge the claim that the problem is an authentic medical one. Ongoing psychotherapy can provide patients with a time and place where they are guaranteed the exclusive attention of a healthcare professional without resorting to “disease forgery.”[13]

Although it is not intuitively obvious, persons with factitious disorder generally do not meet the criteria for involuntary hospital admission. Typically, they are neither homicidal nor suicidal, and their mental illness usually does not incapacitate them to the point where they cannot adequately perform their activities of daily living. Thus, they fall short of the statutory criteria for involuntary commitment as set forth in many states’ laws. If the issue is unclear in the state or province where care is being provided, a psychiatric consultation should be sought.

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Long-Term Monitoring

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

Reasoning that patients with factitious disorder harm themselves to garner the gratification of the sick role, several commentators have suggested that allowing them to assume the sick role on an outpatient basis, without having to provide any evidence of illness or injury, may reduce morbidity and mortality. Regular and frequent physician consultations that are contingent on time, not on demonstrable medical necessity, may reduce both associated risks and costs.

At least 1 report exists of a patient with Munchausen syndrome being placed under legal restraint, house arrest, and mandatory outpatient psychiatric therapy in an attempt to deal with the patient’s persistent disease.[14] In view of the current poor success rate of psychiatric interventions in this syndrome, such an approach seems appropriate only as a last resort, especially because case reports suggest that those with the syndrome can have long periods of apparent normalcy before symptoms recur.

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Contributor Information and Disclosures
Author

Todd S Elwyn, MD Staff Psychiatrist, Atascadero State Hospital; Private Practice Physician, The Amen Clinics

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

Disclosure: Nothing to disclose.

Coauthor(s)

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Marc D Feldman, MD Clinical Professor of Psychiatry, Department of Psychiatry and Behavioral Medicine, Adjunct Professor, Department of Psychology, University of Alabama School of Medicine

Marc D Feldman, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Psychiatric Association

Disclosure: Nothing to disclose.

Chief Editor

Eduardo Dunayevich, MD Executive Director, Clinical Development, Amgen

Eduardo Dunayevich, MD is a member of the following medical societies: Schizophrenia International Research Society

Disclosure: Received salary from Amgen for employment; Received stock from Amgen for employment.

Acknowledgements

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences,and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

James C Hamilton, PhD Associate Professor, Department of Psychology, Clinical Affiliate Associate Professor of Internal Medicine, University of Alabama

James C Hamilton, PhD is a member of the following medical societies: American Psychological Society, American Psychosomatic Society, International Society for Self and Identity, Phi Beta Kappa, and Society for Personality and Social Psychology

Disclosure: Nothing to disclose.

Robert Harwood, MD, MPH, FACEP, FAAEM Senior Physcian, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine

Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

Jon Donavon Mason, MD, FAAP, FACEP Professor of Emergency Medicine and Pediatrics, Department of Emergency Medicine, Eastern Virginia Medical School

Jon Donavon Mason, MD, FAAP, FACEP is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Michael P Poirier, MD Associate Professor of Pediatrics, Eastern Virginia Medical School; Attending Physician, Division of Emergency Medicine, Children's Hospital of The King's Daughters

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
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  11. 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. 1993 Mar 8. 153(5):650-5. [Medline].

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  14. Elmore JL. Munchausen syndrome: an endless search for self, managed by house arrest and mandated treatment. Ann Emerg Med. 2005 May. 45(5):561-3. [Medline].

 
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Classic multiple scarred abdomen of woman with Munchausen syndrome. Photograph on left shows abdomen as it appeared on presentation, after patient had undergone 42 unwarranted operations. Photograph on right shows abdomen after additional surgery revealed authentic colon cancer.
 
 
 
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