Factitious Disorders

Patients with factitious disorder simulate, induce, or aggravate illness in order to receive medical attention whether or not they are actually ill. With factitious disorder patients, there is always the possibility of the patient’s inflicting painful, deforming, or life-threatening injury on themselves, their children, or other dependents. Unlike malingering, the motive of patients with factitious disorder is not for financial gain or avoidance of duties but to acquire medical care and to partake in the medical system.

According to the American Heritage Dictionary, the word factitious means “artificial; false,” derived from the Latin word facticius, which means “made by art.” The art and artifice of factitious patients often creates drama within the hospital and thus causes frustration and dismay for the clinicians and staff involved in their care. Clinicians may dismiss, avoid, or refuse to treat patients with factitious disorder. Strong countertransference of clinicians can be major obstacles toward the proper care of these patients, who arguably are among the most psychiatrically disturbed. Although the presenting complaints by these patients are false, it is still important to take the medical and mental needs of these patients seriously because factitious disorder can lead to significant morbidity and even mortality.

The best known factitious disorder is perhaps factitious disorder with predominantly physical signs and symptoms, popularly known as Munchausen syndrome. This presentation involves persons who travel from hospital to hospital, gaining admission, receiving multiple diagnoses and treatments until they are found out by staff, and then they quickly move on to the next hospital to repeat the same rituals. Common complaints or presenting symptoms include hematomas, abdominal pain, fever, and seizures. Patients have been known to do such bizarre things as inject themselves with feces to induce infections or to willingly undergo repeated unnecessary surgeries.

Despite potentially high stakes, relatively little empirical knowledge is available about the etiology, epidemiology, course and prognosis, and effective treatment of factitious disorders. Most knowledge comes from case reports, information that is frequently suspect, given the false, unreliable nature of the information these patients give. The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) categories for the disorder include predominantly physical signs and symptoms, predominantly psychological signs and symptoms, both physical and psychological signs and symptoms, and factitious disorder not otherwise specified.

Students should study the questions and answers below for a useful review of these disorders.

Helpful Hints

Students should be able to define each of these terms.

approximate answers
as-if personality
borderline personality disorder
Briquet’s syndrome
depressive-masochistic personality
dissociative disorder not otherwise specified
factitious disorder
- by proxy
- not otherwise specified
- with predominantly physical signs and symptoms
- with predominantly psychological signs and symptoms
Ganser’s syndrome
gridiron abdomen
impostorship
malingering
Munchausen syndrome
pseudologia fantastica
pseudomalingering
regression
sick role
somatoform disorders
symbolization
unmasking ceremony

Questions

Directions

Each of the questions or incomplete statements below is followed by five suggested responses or completions. Select the one that is best in each case.

18.1. Which of the following disorders when concurrent with factitious disorder with predominantly physical signs and symptoms bodes a poorer prognosis?

A. Alcohol abuse disorder

B. Bipolar disorder

C. Anxiety disorder

D. Antisocial personality disorder

E. None of the above

View Answer

18.1. The answer is D

In factitious disorder with predominantly physical signs and symptoms, a concurrent mood (i.e., bipolar disorder), anxiety, or substance abuse disorder bodes a better prognosis; comorbid personality disorder, especially antisocial personality disorder, bodes a poorer prognosis. According to some experts, many patients with factitious disorder experience remission around 40 years of age, corresponding to the age of remission for many patients with borderline personality disorder.

Factitious disorder with predominately physical signs and symptoms is the best known type of Munchausen’s syndrome. The essential features of patients with the disorder is their ability to present physical symptoms so well that they can gain admission to and stay in a hospital. The wide spectrum of this disorder should be kept in mind when considering the course and prognosis. At one end of the spectrum, factitious illness behavior can be considered within the range of normal, as when a child exaggerates distress from a knee scrape to gain attention or when a mother magnifies her child’s symptoms to seek reassurance from a physician. Further along the spectrum, factitious illness behavior can be a maladaptive way of coping with stress and does not necessarily imply an ongoing factitious disorder.

18.2. The perpetrators in factitious disorder by proxy

A. often suffer from psychotic or dissociative disorders

B. rarely have personal histories of factitious or somatoform disorders

C. most often suffered direct abuse in childhood themselves

D. are commonly unresponsive to their infants when their behavior is unwitnessed

E. all of the above

View Answer

18.2. The answer is D

By definition, factitious disorder by proxy requires that any external gains for the victim’s fabricated or induced illnesses, such as disability payments or respite from child-rearing responsibilities during hospitalization, are incidental to the pursuit of the vicarious sick role. In contrast to the devoted, even symbiotic, parenting style they reveal in public, these mothers are commonly unresponsive to their infants when their behavior is unwitnessed. Despite the perversity of their behavior, they rarely have psychotic or dissociative disorders, although they often have personal histories of factitious or somatoform disorders. Although they may have been neglected or undervalued, most perpetrators did not suffer direct abuse in childhood. Table 18.1 lists the clinical indicators that may suggest factitious disorder by proxy.

18.3. Which of the following is the gold standard for diagnosis of factitious disorder by proxy?

A. Confession by the child

B. Finding inconsistencies in the medical records

C. Direct observation of the caretaker doing harm

D. Improvement when the child is removed from the caretaker

E. Discovery of illness-inducing agents in the caregiver’s possession

View Answer

18.3. The answer is C

Factitious disorder by proxy should not be considered a diagnosis of exclusion. Confirmatory evidence should be actively pursued, so as to lessen risk to the child. The safety of the child should be ensured at the same time. The gold standard for confirming factitious disorder by proxy is direct observation of a parent causing harm to a child. Covert video has also shown cases in which mothers, who appear concerned in the presence of staff, behave indifferently toward their children when they are not aware of being watched. Covert video should only be undertaken after consultation with legal counsel. A court order may need to be obtained, and a bioethics consultation may be helpful to weigh the potential benefits to the child versus compromises of privacy for the parent.

Table 18.1 Clinical Indicators That May Suggest Factitious Disorder by Proxy

The symptoms and pattern of illness are extremely unusual or inexplicable physiologically.

Repeated hospitalizations and workups by numerous caregivers fail to reveal a conclusive diagnosis or cause.

Physiological parameters are consistent with induced illness (e.g., apnea monitor tracings disclose a massive muscle artifact before respiratory arrest), suggesting that the child has been struggling against an obstruction to the airways.

The patient fails to respond to appropriate treatments.

The vitality of the patient is inconsistent with the laboratory findings.

The signs and symptoms abate when the mother has not had access to the child.

The mother is the only witness to the onset of signs and symptoms.

Unexplained illnesses have occurred in the mother or her other children.

The mother has had medical or nursing education or exposure to models of the illnesses affecting the child (e.g., a parent with sleep apnea).

The mother welcomes even invasive and painful tests.

The mother grows anxious if the child improves.

Maternal lying is proved.

Medical observations yield information that is inconsistent with parental reports.

Adapted from Feldman MD, Eisendrath SJ. The Spectrum of Factitious Disorders. Washington, DC: American Psychiatric Press; 1996.

Other means of confirming factitious disorder by proxy include searching the mother’s belongings for illness-inducing agents, reviewing collateral information and medical records for inconsistencies, gathering information on siblings, recording temporal associations between parental visits and the child’s signs and symptoms, observing the child’s well-being when removed from the parent’s care for extended periods, and analyzing specimens taken in the presence of the parent compared with those taken in the parent’s absence.

18.4. True statements about factitious disorder by proxy include all of the following except

A. The disorder currently accounts for fewer than 1,000 of the almost 3 million cases of child abuse reported each year in the United States.

B. The prevalence of the disorder in life-threatening episodes treated with cardiopulmonary resuscitation has been estimated to be as high as 9 percent.

C. The prevalence of the disorder has been estimated to be approximately 5 percent in children presenting with allergies.

D. The average length of time to establish a diagnosis after the initial presentation is about 2 months.

E. Often a sibling has died of undiagnosed causes before the disorder is recognized.

View Answer

18.4. The answer is D

Factitious disorder by proxy currently accounts for fewer than 1,000 of the almost 3 million cases of child abuse reported each year in the United States, but this number may increase as mass media and professional attention increase recognition of these cases. Authors have attempted to elucidate the prevalence of factitious disorder by proxy within particular populations, such as children presenting with apnea (0.27 percent), allergy (5 percent), asthma (1 percent), apparent life-threatening episodes (1.5 percent), and life-threatening episodes treated with cardiopulmonary resuscitation (more than 9 percent among children in whom final diagnoses were established). The average length of time to establish a diagnosis of factitious disorder by proxy after the initial presentation is 15 months, and often a sibling has died of undiagnosed causes before the disorder is recognized. Table 18.2 summarizes the most common presentations of the disorder.

18.5. Which of the following occurs in factitious disorder by proxy?

A. The mother has had some medical education.

B. The patient fails to respond to appropriate treatments.

C. Maternal lying is observed.

D. Unexplained illnesses have occurred in the mother.

E. All of the above

View Answer

18.5. The answer is E (all)

In factitious disorder by proxy, classified in DSM-IV-TR as a factitious disorder not otherwise specified, a person intentionally produces physical signs or symptoms in another person who is under the first person’s care. The most common cases involve mothers who deceive medical personnel into believing that their child is ill. In this disorder, it has been noted that the symptoms and pattern of illness are extremely unusual. The mothers have often had some medical or nursing education

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