Factitious Disorders
DSM-IV-TR Diagnostic Criteria
Intentional production or feigning of physical or psychological signs or symptoms.
The motivation for the behavior is to assume the sick role.
External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent.
(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington DC: American Psychiatric Association, 2000.)
Factitious disorders are consciously determined surreptitious simulations or productions of diseases. Factitious illness behavior is relatively uncommon, but when present it consumes large amounts of professional time and medical costs. The Munchausen syndrome by proxy is a particularly malignant form of child abuse that physicians must identify and manage in order to save the health or lives of children.
DSM-IV-TR lists the following four diagnostic subtypes of factitious disorder:
Patients with factitious disorders may simulate psychological conditions and psychiatric disorders. For example, a patient may feign bereavement by reporting that someone to whom he or she was close has died or been killed in an accident. Patients may simulate symptoms of posttraumatic stress disorder or provide false reports of previous trauma (e.g., a civilian accident or combat experience). Closely related to factitious posttraumatic stress disorder is the false victimization syndrome, in which the patient falsely claims some type of abuse. For example, a woman may falsely report that she had been raped. Other simulated psychological disorders include various forms of dementia, amnesia, or fugue; multiple personality disorder; and more rarely, schizophrenia.
The production of physical symptoms or disease is probably the most common form of factitious disorder. Essentially all medical diseases and symptoms have been either simulated or artificially produced at one time or another. Among the most common of these disorders are factitious hypoglycemia, factitious anemia, factitious gastrointestinal bleeding, pseudoseizures, simulation of brain tumors, simulation of renal colic, and more recently, simulation of AIDS.
A patient may be admitted to the hospital with factitious physical symptoms and, in the course of hospitalization, perhaps in an attempt to obtain more sympathy or interest, may report or simulate a variety of psychological symptoms such as having experienced the recent loss of a close relative or friend or having been raped in the past.
This category is reserved for forms of factitious disorder that do not fit one of the other categories. It includes the Munchausen syndrome by proxy, in which one person surreptitiously induces disease or reports disease in another person. Most commonly, this is the behavior of a mother in reference to a young child.
Factitious illnesses have been known since the Roman era and were described in Galen’s textbook of medicine. Modern interest in this surreptitious production of symptoms presented to physicians was spurred by Ashers 1951 description and naming of “The Munchausen Syndrome;” subsequently over 2000 articles in professional journals have described, and tried to explain, this perverse form of illness behavior.
The true incidence of factitious illness behavior is unknown but is probably more common than is recognized. One Canadian study estimated that approximately 1 in 1000 hospital admissions is for factitious disease. However, another investigation of an entirely different type determined that approximately 3.5% of renal stones submitted for chemical analysis were bogus and represented apparent attempts to deceive the physician. A study of patients referred with fever of unknown origin to the National Institutes of Health found that almost 10% had a factitious fever. One can conclude that the incidence of factitious disorder, except in certain specialized clinical settings, is relatively uncommon but may be more frequent than is recognized.
Age and gender distribution varies according to the clinical syndromes described in the next section. Patients with the full-blown Munchausen syndrome are most frequently unmarried middle-aged men who are estranged from their families. Patients with common factitious disorder are most likely to be unmarried women in their 20 s or 30 s who work in health-service jobs such as nursing. Perpetrators of the Munchausen syndrome by proxy are most often mothers of small children who themselves may have previously engaged in factitious disease behavior or meet the criteria for somatization disorder.
Explanations for the apparently nonsensical and bizarre behavior of factitious disorder are largely speculative. Underlying motivations for this behavior are probably heterogeneous and multidetermined. The following explanations have been suggested:
Individuals in the sick role are characteristically excused from societal obligations and cared for by others. When alternative sources of care, support, and nurturance are lacking, a person may deliberately induce illness as a way of seeking such support. Many patients with factitious disorder are themselves caretakers. Factitious illness behavior allows for a reversal of roles: instead of caring for others, the patient assumes the dependent cared-for role.
Patients with factitious disorders sometimes use illness to obtain disability benefits or release from usual obligations such as working. Their illnesses may elicit from family members attention that might not otherwise be forthcoming. When litigation is involved, the boundary between factitious disorder and malingering becomes blurred or disappears.
A person who successfully perpetuates a ruse may have a feeling of superiority in his or her capacity to fool others. This has been described as “putting one over” or “duping delight.” Thus, the individual can experience a transformation from feeling weak and impotent to feeling clever and powerful over others. Simultaneously the individual may devalue others whom he or she regards as stupid or foolish because they have been deceived.
Some patients have used factitious illness to obtain drugs. Even those patients who have sought controlled substances appear to have done so more for the thrill of fooling the physician than because of addiction.
A patient with severe characterological defects may have a poor sense of self. The creation of the sick role and the associated pseudologia fantastica (pathologic lying) may provide the patient with a role by which his or her personal identity is established. Such a person is no longer faceless but rather the star player in high drama.
A patient with overwhelming anxiety due to fears of abandonment or powerlessness may use a factitious illness to defend against psychological decompensation. Through the perpetuation of a successful fraud and the simultaneous gratification of dependency needs, the patient feels powerful, in control, and cared for.
No information is available regarding a relationship between factitious disorders and heredity.
DSM-IV-TR diagnostic criteria do not adequately describe the different clinical syndromes of persons who present with factitious disorder. Three major syndromes have been identified, although some overlap may exist.
The original Munchausen syndrome, as first described by Asher in 1951, consists of the simulation of disease, pseudologia fantastica, and peregrination (wandering). Some patients with this disorder have achieved great notoriety. These patients typically present to emergency rooms at night or on the weekends when they are more likely to encounter inexperienced clinicians and when insurance offices are more likely to be closed. Their symptoms are often dramatic and indicate the need for immediate hospitalization. Once hospitalized, they become “star patients” because of their dramatic symptoms, the rarity of their apparent diagnosis (e.g., intermittent Mediterranean fever), or because of the stories that they tell about themselves (e.g., tales of being a foreign university president or a former major league baseball player). These patients confuse physicians because of inconsistencies in their physical and laboratory findings and because of their failure to respond to standard therapeutic measures. They rarely receive visitors, and it is difficult to obtain information concerning prior hospitalizations; their frequent use of aliases makes it difficult to track them. When confronted with their factitious illness behavior, they often become angry, threaten to sue, and sign out of the hospital against medical advice. They then travel to another hospital, where they once again perpetuate their ruses.
Personal historical information about Munchausen syndrome patients is limited because they are unreliable historians and are reluctant to divulge accurate personal information. What is known may be somewhat selective in that it is derived from a subgroup of patients who have allowed themselves to be studied. These individuals often come from chaotic, stressful childhood homes. They sometimes report that they were institutionalized or hospitalized during childhood, experiences that were not regarded as frightening but rather were considered a reprieve from stress at home. Childhood neuropathic traits (e.g., lying or fire setting) are often reported. Many of these patients have worked in health-related fields (e.g., as a hospital corpsman in the military). Many have a history of psychiatric hospitalization and legal difficulties.
The most common form of factitious disorder is common factitious disorder. Disease presentations may involve dermatologic conditions from self-inflicted injuries or infections, blood dyscrasia from the surreptitious use of dicumarol or self-phlebotomy, hypoglycemia from the surreptitious use of insulin, and other diseases. The patient generally has one primary symptom or finding (e.g., anemia) and is characteristically hospitalized on multiple occasions, but the physician or hospital staff never learns the true nature of the underlying “disease.” In the process of their hospitalizations, these patients become the object of considerable concern from physicians, colleagues, and family members, with whom they typically have conflicted relationships.
Patients with common factitious disorder often lie, exaggerate, and distort the truth but not to the same extent, or with the degree of fantasy, as those with the Munchausen syndrome. Patients with common factitious disorder may perpetuate the ruse for years before being discovered. Unmasked, these patients typically react with hostility, eliciting angry disbelief from treating physicians, nurses, and other staff. Even in the face of incontrovertible evidence, these patients often continue to deny the true nature of their problems.
Patients with common factitious disorder typically come from dysfunctional families and exhibit histrionic or borderline personality characteristics.
This invidious disorder, in which a mother produces disease in her child, was first described in 1978. Subsequently, hundreds of case reports from all over the world have confirmed this form of child abuse. Every major children’s hospital will see several cases per year.
In the Munchausen syndrome by proxy, the perpetrator (usually the mother) presents a child (usually an infant) for medical treatment of either simulated or factitiously produced disease. For example, the child may have collapsed after the mother surreptitiously administered laxatives or other medications, or the child may have experienced repeated attacks of apnea secondary to suffocation (e.g., by pinching the nostrils). After the child has been hospitalized, the mother is intensely involved in her child’s care and with the ward staff. Interestingly, the mother is surprisingly willing to sign consent forms for invasive diagnostic procedures or treatment. The child may inexplicably improve when the mother is out of the hospital for a period of time. The child’s father is usually uninvolved or absent.
When the mother is confronted with suspicions (or proof) that she has caused the child’s illness, she often reacts with angry denial and hospital staff may also express disbelief. Reasonable suspicion of Munchausen syndrome by proxy mandates reporting, as a form of child abuse, to the appropriate child protective services. Children who have been victims of Munchausen syndrome by proxy have a high mortality rate (almost 10% die before reaching adulthood). Studies of their siblings show a similarly high mortality rate because this disease-producing behavior may be perpetrated on subsequent children. These children may need to be placed outside the home (e.g., with other relatives or in a foster-care setting).
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