Factitious Disorders

Persons with factitious disorder fake illness. They simulate, induce, or aggravate illness, often inflicting painful, deforming, or even life-threatening injury on themselves or those under their care. Unlike malingerers, who have material goals, such as monetary gain or avoidance of duties, patients with factitious disorder undertake these tribulations primarily to gain the emotional care and attention that comes with playing the role of the patient. In doing so, they practice artifice and art, creating hospital drama that often causes frustration and dismay. The disorders have a compulsive quality, but the behaviors are considered voluntary in that they are deliberate and purposeful, even if they cannot be controlled. Clinicians can assess whether a symptom is intentional both by direct evidence and by excluding other causes.

In a 1951 article in Lancet, Richard Asher coined the term “Munchausen’s syndrome” to refer to a syndrome in which patients embellish their personal history, chronically fabricate symptoms to gain hospital admission, and move from hospital to hospital. The syndrome was named after Baron Karl Friedrich Hieronymus Freiherr von Munchausen (1720-1791), a German cavalry officer who was known for humorously exaggerated tales of his adventures.

EPIDEMIOLOGY

No comprehensive epidemiological data on factitious disorder exist. Limited studies indicate that factitious disorder patients may comprise approximately 0.8 to 1.0 percent of psychiatric consultation patients. According to the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), factitious disorder is diagnosed in about 1 percent of patients who are seen in psychiatric consultation in general hospitals. The prevalence appears to be greater in highly specialized treatment settings. Cases of feigned psychological signs and symptoms are reported much less commonly than those of physical signs and symptoms. A data bank of persons who feign illness has been established to alert hospitals about such patients, many of whom travel from place to place, seek admission under different names, or simulate different illnesses.

Approximately two thirds of patients with Munchausen’s syndrome are male. They tend to be white, middle-aged, unemployed, unmarried, and without significant social or family attachments. Patients diagnosed with factitious disorders with physical signs and symptoms are mostly women, who outnumber men 3 to 1. They are usually 20 to 40 years of age with a history of employment or education in nursing or a health care occupation. Factitious physical disorders usually begin for patients in their 20s or 30s, although the literature contains cases ranging from 4 to 79 years of age.

Factitious disorder by proxy (discussed separately later) is most commonly perpetrated by mothers against infants or young children. Rare or underrecognized, it accounts for less than 0.04 percent, or 1,000 of 3 million cases, of child abuse reported in the United States each year. Good epidemiological data are lacking, however.

COMORBIDITY

Many persons diagnosed with factitious disorder have comorbid psychiatric diagnoses (e.g., mood disorders, personality disorders, or substance-related disorders).

ETIOLOGY

Psychosocial Factors

The psychodynamic underpinnings of factitious disorders are poorly understood because the patients are difficult to engage in an exploratory psychotherapy process. They may insist that their symptoms are physical and that psychologically oriented treatment is therefore useless. Anecdotal case reports indicate that many of the patients suffered childhood abuse or deprivation, resulting in frequent hospitalizations during early development. In such circumstances, an inpatient stay may have been regarded as an escape from a traumatic home situation, and the patient may have found a series of caretakers (such as doctors, nurses, and hospital workers) to be loving and caring, in contrast to their families of origin, which may have included a rejecting mother or an absent father. The usual history reveals that the patient perceives one or both parents as rejecting figures who are unable to form close relationships. The facsimile of genuine illness, therefore, is used to recreate the desired positive parent-child bond. The disorders are a form of repetitional compulsion, repeating the basic conflict of needing and seeking acceptance and love while expecting that they will not be forthcoming. Hence, the patient transforms the physicians and staff members into rejecting parents.

Patients who seek out painful procedures, such as surgical operations and invasive diagnostic tests, may have a masochistic personality makeup in which pain serves as punishment for past sins, imagined or real. Some patients may attempt to master the past and the early trauma of serious medical illness or hospitalization by assuming the role of the patient and reliving the painful and frightening experience over and over again through multiple hospitalizations. Patients who feign psychiatric illness may
have had a relative who was hospitalized with the illness they are simulating. Through identification, patients hope to reunite with the relative in a magical way.

Many patients have the poor identity formation and disturbed self-image that is characteristic of someone with borderline personality disorder. Some patients are as-if personalities who have assumed the identities of those around them. If these patients are health professionals, they are often unable to differentiate themselves from the patients with whom they come in contact. The cooperation or encouragement of other persons in simulating a factitious illness occurs in a rare variant of the disorder. Although most patients act alone, friends or relatives participate in fabricating the illness in some instances.

Significant defense mechanisms are repression, identification with the aggressor, regression, and symbolization.

Some researchers have proposed that brain dysfunction may be a factor in factitious disorders. It has been hypothesized that impaired information processing contributes to pseudologia fantastica and aberrant behavior of patients with Munchausen’s disorder; however, no genetic patterns have been established, and electroencephalographic studies noted no specific abnormalities in patients with factitious disorders.

DIAGNOSIS AND CLINICAL FEATURES

The diagnostic criteria for factitious disorder in DSM-IV-TR are given in Table 15-1. The psychiatric examination should emphasize securing information from any available friends, relatives, or other informants because interviews with reliable outside sources often reveal the false nature of the patient’s illness. Although time consuming and tedious, verifying all the facts presented by the patient about previous hospitalizations and medical care is essential.

Psychiatric evaluation is requested on a consultation basis in about 50 percent of cases, usually after a simulated illness is suspected. The psychiatrist is often asked to confirm the diagnosis of factitious disorder. Under these circumstances, it is necessary to avoid pointed or accusatory questioning that may provoke truculence, evasion, or flight from the hospital. A danger may exist of provoking frank psychosis if vigorous confrontation is used; in some instances, the feigned illness serves an adaptive function and is a desperate attempt to ward off further disintegration.

Table 15-1 DSM-IV-TR Diagnostic Criteria for Factitious Disorder

A.	Intentional production or feigning of physical or psychological signs or symptoms.
B.	The motivation for the behavior is to assume the sick role.
C.	External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent.
Code based on type:
	With predominantly psychological signs and symptoms: if psychological signs and symptoms predominate in the clinical presentation
	With predominantly physical signs and symptoms: if physical signs and symptoms predominate in the clinical presentation
	With combined psychological and physical signs and symptoms: if both psychological and physical signs and symptoms are present but neither predominates in the clinical presentation
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.

Factitious Disorder with Predominantly Psychological Signs and Symptoms

Some patients show psychiatric symptoms judged to be feigned. This determination can be difficult and is often made only after a prolonged investigation (Table 15-1). The feigned symptoms frequently include depression, hallucinations, dissociative and conversion symptoms, and bizarre behavior. Because the patient’s condition does not improve after routine therapeutic measures are administered, he or she may receive large doses of psychoactive drugs and may undergo electroconvulsive therapy.

Factitious psychological symptoms resemble the phenomenon of pseudomalingering, conceptualized as satisfying the need to maintain an intact self-image, which would be marred by admitting psychological problems that are beyond the person’s capacity to master through conscious effort. In this case, deception is a transient ego-supporting device.

Recent findings indicate that factitious psychotic symptoms are more common than had previously been suspected. The presence of simulated psychosis as a feature of other disorders, such as mood disorders, indicates a poor overall prognosis.

Inpatients who are psychotic and found to have factitious disorder with predominantly psychological signs and symptoms—that is, exclusively simulated psychotic symptoms—generally have a concurrent diagnosis of borderline personality disorder. In these cases, the outcome appears to be worse than that that of bipolar I disorder or schizoaffective disorder.

Patients may appear depressed and may explain their depression by offering a false history of the recent death of a significant friend or relative. Elements of the history that may suggest factitious bereavement include a violent or bloody death, a death under dramatic circumstances, and the dead person’s being a child or a young adult. Other patients may describe either recent and remote memory loss or both auditory and visual hallucinations. According to DSM-IV-TR,

The individual may surreptitiously use psychoactive substances for the purpose of producing symptoms that suggest a mental disorder (e.g., stimulants to produce restlessness or insomnia, hallucinogens to induce altered perceptual states, analgesics to induce euphoria, and hypnotics to induce lethargy). Combinations of psychoactive substances can produce very unusual presentations.

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