Factitious disorder imposed on self refers to the psychiatric condition in which patients deliberately produce or falsify symptoms and/or signs of illness in themselves for the principle purpose of achieving emotional gratification. The symptoms or signs can be psychological or physical. (See the image below)
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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....
Signs and symptoms
Individuals with factitious disorder imposed on self (including the historical term Munchausen syndrome) may feign illness by any of the following means:
A false or exaggerated (i.e., factitious) history alone
A factitious history plus the manipulation of assessment samples (e.g., blood or urine), instruments (e.g., thermometer) or reports (e.g., laboratory findings)
A factitious history plus the use of external agents that mimic disease (e.g., application of caustic agents or ingestion of unwarranted medications)
A factitious history plus the induction of an actual medical condition (e.g., injection of fecal bacteria)
The presence of the following factors raises the possibility that the illness is factitious:
Dramatic or atypical presentation
Inconsistencies between history and objective findings
Details that are vague and inconsistent, though possibly plausible on the surface
Long medical record with multiple admissions at various hospitals in different cities
Knowledge of textbook descriptions of illness; a presentation that hews too closely to the textbook example
Admission circumstances that do not conform to an identifiable medical or mental disorder
Employment or education in a medically related field
Pseudologia fantastica (gratuitous, often self-aggrandizing lies)
Presentation during times when old medical records are difficult to access or when experienced staff are less likely to be present, or refusal to allow access to outside records
The physical examination frequently suggests an extensive history of illnesses and injuries. Findings that may raise suspicions include the following:
Multiple surgical scars (if on the abdomen, they often create a so-called gridiron abdomen)
Evidence of self-induced physical signs
Inconsistent or implausible findings on examination
Absence of physical signs consistent with the history (e.g., lack of dehydration in patients complaining of persistent diarrhea and vomiting)
Cardiac presentations (cardiac Munchausen syndrome, or cardiopathia fantastica)
Manifestations that appear worse when the patient is undergoing active examination than when he or she is unaware of being observed
On mental status examination, possible findings include the following:
Attitude ranging from overeager for assessment and even invasive treatment to evasive and vague regarding details
Mood and affect that are brighter than would be expected on the basis of the patient’s ostensible medical condition
In factitious disorder with predominantly psychological signs and symptoms, perceptual abnormalities, suicidality or homicidality, or aberrant cognitive functioning such as suspect problems in orientation and recall
See Presentation for more detail.
Diagnosis
Fundamental diagnostic principles in the setting of suspected factitious disorder are as follows:
Follow the basic procedures for responding to the patient’s apparent signs and symptoms
Know the reliability and validity of the medical tests performed
Respect base-rate information about the prevalence of various diseases that must be excluded
Laboratory studies can be especially helpful in facilitating the diagnosis of many physical illnesses as factitious. Examples include the following:
Determining the serum insulin−to−C-peptide ratio during a hypoglycemic episode to assess for exogenous insulin injection
Filtration of urine and chemical analysis to assess for authentic versus spurious kidney stones
Tissue biopsy to help detect foreign material injected to simulate naturally occurring disease
A common finding is test results that are inconsistent with the claimed illness. A particular difficulty in this setting is that many of these patients have a medical background and thus are likely to be familiar with the routine tests performed for a particular presentation.
Other studies that may be considered include the following:
Diagnostic imaging, particularly when the patient presents with a well-established medical problem of a type that can be easily imaged
Electromyography
Nerve conduction velocity tests
See Workup for more detail.
Management
Initial care and stabilization are driven by the presenting symptoms. Even when there are good reasons for suspecting factitious disorder, ordinary care must be provided until the patient is fully diagnosed. However, physicians should remain alert to the possibility of deception. Patients should receive surgical care as needed to treat any comorbid conditions and complications.
If the diagnosis of factitious disorder is clear or strongly suspected, psychiatric consultation and referral should be offered even if admission for the medical problems is declined. In the inpatient setting, the psychiatric consultant can assist in clarifying the diagnosis, provide education to the medical team regarding the illness, and discuss options for confronting the patient.
Confrontation should be done in a supportive manner, informing the patient of the team's suspicions and the evidence upon which it is based. The medical team should maintain an attitude that is understanding and supportive during the confrontation and throughout treatment. Team members may express empathy for the distress the patient must have been in, or the stress he or she was under that resulted in illness-producing behaviors. Comments that express a concern for the ongoing health and wellbeing of the patient and a desire to continue taking care of the patient will be helpful in maintaining the relationship.
Psychiatric treatment should be offered to the patient and the importance of follow-up care for the patient's mental health and wellbeing should be emphasized. Some patients will resist the involvement of psychiatry, but concerns about the possibility of recurrence of the condition without adequate follow-up should be voiced. The presence of a skilled and empathic consulting psychiatrist who is introduced as an intrinsic part of the medical team may also help encourage participation.
In the treatment of factitious disorder, supportive psychotherapy can be beneficial. However, little information is available on which type is most helpful. Options include the following:
Family therapy
Cognitive-behavioral therapy
Supportive psychotherapy
There is little evidence to support the efficacy of any particular pharmacologic intervention in treating factitious disorder; however, the following principles should apply:
Pharmacologic therapy may be indicated for concurrent psychiatric diagnoses
Drugs may also be considered for treatment of the presenting symptoms
Caregivers should routinely copy each other on every progress note and prescription, with ongoing care contingent on the patient’s signing consent forms; if abusable medications are used, written contracts must be signed by doctor, patient, and witness
Factitious disorder imposed on self (including what is often referred to as Munchausen syndrome) is 1 of the 2 forms of factitious disorder (the other being factitious disorder imposed on another).[1, 2] In this psychiatric condition, a patient deliberately produces or falsifies symptoms and/or signs of illness for the principal purpose of emotional gratification from appearing to be sick. In so doing, the patient disobeys the following unwritten rules of being a patient:
The patient attempts to provide an honest history
The patient’s symptoms result from accident, injury, or chance
The patient seeks treatment with the goal of recovering and so will cooperate with treatment toward that end
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.”
The modern history of factitious disorder began in 1951, when Richard Asher described case reports of patients who habitually migrated from hospital to hospital, seeking admission through feigned symptoms while embellishing their personal history.[3] Asher named this condition Munchausen's syndrome, after Baron von Munchhausen, a well-respected, retired German cavalry officer who had tales of his life stolen and parodied in a booklet published in England in 1785. The following were said to be typical of persons with this syndrome:
Exhibiting numerous surgical scars, especially in the abdomen
Displaying a truculent or evasive manner
Providing a dramatic medical history of questionable veracity
Attempting to conceal such documents as hospital discharge forms or insurance claims
Abdominal, hemorrhagic, and neurologic subtypes of the syndrome were distinguished in Asher's report.
Since Asher’s initial description, numerous reports of patients producing or falsifying almost every conceivable 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" is best reserved for the subset of patients who have a chronic variant of factitious disorder with predominantly physical signs and symptoms as described below. In practice, however, many still use this term interchangeably with factitious disorder, and this confusion is reflected in the case literature. The case literature on factitious disorder reflects a bias toward the more extreme cases and those that pose the greatest medical danger—that is, cases that almost always involve induction of severe illness by the patient (eg, suppression of bone marrow through surreptitious use of chemotherapy medications).
In 1977, the term "Munchausen syndrome by proxy" entered the medical lexicon as a means of describing cases in which an individual artificially produces illness in another person—typically, a mother producing illness in a young child.
Diagnostic criteria (DSM-5)
In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), factitious disorder is divided into the following 2 types:[4]
Factitious disorder imposed on self
Factitious disorder imposed on another (formerly factitious disorder by proxy)
The specific DSM-5 criteria for factitious disorder imposed on self are as follows[4] :
Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception
The individual presents himself or herself to others as ill, impaired, or injured
The deceptive behavior is evident even in the absence of obvious external rewards
The behavior cannot be better explained by another mental disorder, such as delusional disorder or another psychotic disorder
When an individual falsifies illness in another (eg, a child, an adult, or a pet), the diagnosis is factitious disorder imposed on another. This diagnosis is applied to the perpetrator, not the victim; the victim may be given an abuse diagnosis (eg, child physical abuse). The specific DSM-5 criteria for factitious disorder imposed on another are as follows[4] :
Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception
The individual presents another individual (ie, the victim) to others as ill, impaired, or injured
The deceptive behavior is evident even in the absence of obvious external rewards
The behavior cannot be better explained by another mental disorder, such as delusional disorder or another psychotic disorder
In both types of factitious disorder, the duration is specified as either a single episode or recurrent episodes (≥2 events of falsification of illness or induction of injury).
Although many health professionals still use the term Munchausen syndrome to describe all persons who intentionally feign or produce illness to assume the sick role, this syndrome is not included as a discrete mental disorder either in DSM-5[4] or in the World Health Organization’s International Statistical Classification of Diseases, 10th Revision (ICD-10) . In both systems, the official diagnosis for such cases is factitious disorder (300.19 in DSM-5, F68.1 in ICD-10).
Nevertheless, numerous experts have identified a distinct subset of patients with factitious disorder for whom they reserve the term Munchausen syndrome. The subtype referred to as Munchausen syndrome can be distinguished by the following characteristics:
The factitious illness behavior is particularly chronic and severe and may be practiced to the exclusion of most other activities; the signs and symptoms of illness or injury are intentionally produced through medically dangerous manipulations of the patient’s body (eg, self-inflicted infection or excessive warfarin ingestion), thereby virtually guaranteeing hospitalization; these patients willingly, even eagerly, submit to invasive interventions (eg, surgery)
Peregrination (itinerancy, or wanderlust) is observed; the patient may move from hospital to hospital, from town to town, and even from country to country to find a new audience once his or her ruse is uncovered
In classic cases, pseudologia fantastica is present; the patient makes false claims about distinguished accomplishments, educational credentials, relations to famous persons, and so forth
In addition to this diagnostic triad, some authors invoke further diagnostic elements. For instance, in relation to peregrination and pseudologia fantastica, the patient may use aliases or adopt false identities. Patients with Munchausen syndrome have little or no significant social contact with anyone other than health care professionals.
The pathophysiology of factitious disorder has not been determined. No causative brain defect or dysfunction has been identified. A study of 5 cases suggested neurocognitive deficits. One case study reported that single-photon emission computed tomography (SPECT) found hyperperfusion of the right hemithalamus in a patient with factitious disorder.[5] It remains to be seen whether these results are replicable in larger samples and, if so, how these brain dysfunctions are linked to factitious illness behavior. Electroencephalography (EEG) has not been specific.
Some patients with factitious disorder show abnormalities on psychological testing. Such individuals often have associated personality disorders (eg, poor impulse control, self-destructive behavior, or borderline or passive-aggressive personality trait or disorder). However, it remains unclear how these constellations of personality disorders are related to the primary syndrome. Patients are adept at concealing the factitious nature of their illnesses and are markedly resistant to psychiatric evaluation. Information is often difficult to obtain.
The etiology of factitious disorder is poorly defined. These patients are so elusive that it is very difficult to conduct systematic empiric research on them. Most of the literature consists of anecdotal or case reports. Psychoanalytic hypotheses have been put forth to explain this disorder, but the volume of this literature is quite small in comparison with the pertinent literature on the psychodynamics of other conditions in the category of somatic symptom and related disorders.
Whereas false illness experiences in similar disorders are regarded as unconsciously produced and thus amenable to traditional psychoanalytic explanations involving the notion of defense against unacceptable wishes or unspeakable fears, the false illness behavior in factitious disorder is conscious and intentional and thus less amenable to such explanations. Nevertheless, some psychoanalytic writers have argued that whereas the illness behavior of patients with factitious disorder is conscious, the reasons for the behavior are not.
Since Asher’s original description, several authors have suggested that factitious illness behavior is a primitive defense mechanism against sexual and aggressive impulses. Others have proposed that patients with factitious disorder subject themselves to painful medical procedures as a form of self-punishment. Still others have hypothesized that the cruel and embarrassing deception of physicians is an expression of oedipally based hostility toward authority figures.
More contemporary authors, noting the high degree of comorbidity with cluster B personality disorders, have suggested that the sick-role behavior seen in factitious disorder might be a means of establishing or stabilizing patients’ sense of self and their relations to others. Adoption of the sick role brings them unconditional acceptance and concern, and admission to a hospital gives them a clearly defined role in a social network. This automatic sense of importance and belonging might be difficult for them to secure in more routine social contexts.
Case studies support the role of social learning mechanisms in factitious illness behavior. Many patients with factitious disorder either personally experienced a severe illness in childhood or, as a child, had a family member who experienced a severe illness. These experiences introduce the child to the various benefits and dispensations attached to the sick role, and they may predispose a person with other psychological vulnerabilities to engage in factitious illness behavior.
Risk factors
Risk factors for developing factitious disorder remain largely unclear. On the basis of histories obtained from patients with factitious disorder, the following can be projected as characteristics that may predispose an individual to develop a factitious illness:
Having had 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
Having a personality disorder, especially borderline, narcissistic, or antisocial personality disorder
The prevalence of factitious disorder is unclear. Epidemiologic data on this disorder are scarce, in large part because patients manifesting factitious illness behavior generally are not open and honest about their medical deceptions.
Many authorities believe that factitious disorder is underdiagnosed because patients' willful deceptions are commonly missed by medical staff. Others, however, believe that it may actually be overdiagnosed in some cases because patients may migrate from hospital to hospital and receive a discrete diagnosis at each one. It is unclear which factitious illnesses are most common; however, it is generally agreed that overall, factitious psychological symptoms are much less common than factitious physical symptoms.
Studies of medical patients suggest that the prevalence of factitious disorder among hospital inpatients is probably in the range of 0.2–1%.[6, 7] Although patients with factitious disorder have claimed to have almost every medical condition known, the prevalence of the disorder is particularly high in a few select groups, including patients who present with persistent rashes and nonhealing wounds, unexplained anemia, neurologic problems, endocrine-related problems, hematuria, or joint and connective-tissue symptoms.[8]
As might be expected, the prevalence is even higher among patients with unexplained or intractable medical complaints. For example, 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. In one study, an astounding 40% of brittle diabetics intentionally altered their medication compliance or diet to produce diabetic instability.
International statistics
Whether the epidemiology of factitious disorder differs in countries other than the United States is unclear. Case reports indicate that the diagnosis has been made in eastern Europe, Mediterranean countries, Asia, Africa, and South America.
Of patients referred to the consultation-liaison service of a large teaching hospital in Toronto, 0.8% (10 of 1288) had factitious disorder. Physicians surveyed in Germany regarding the 1-year prevalence of factitious disorder among their patients provided an average estimate of 1.3%.[7]
Age-related demographics
The age range for persons with factitious disorder tends to be women between 20 and 40 years of age. Persons with chronic factitious disorder (i.e., Munchausen syndrome) tend to be middle-aged men.[9] Factitious disorder imposed on self has been noted in the pediatric population;[10] this condition must be distinguished from factitious disorder imposed on another (including Munchausen by proxy), in which an adult simulates or creates symptoms in a child to receive a generally ill-defined satisfaction from the attention and/or health care the child receives.
Sex-related demographics
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), on the other hand, tend to be unmarried men who are estranged from their families and unemployed.
The typical presentation of Munchausen syndrome is characterized by a restless journey from physician to physician and from hospital to hospital, an ever-changing list of complaints and symptoms, and an alarming variety of self-intoxications and self-injuries designed to create a better portrayal of the illness that the patient asserts he or she has.
There exists, however, a subset of adult female patients who vary from the classic presentation in that they reproduce a single set of symptoms, repeatedly. Patients in this subset exhibit less evidence of comorbid personality dysfunction than the average patient with Munchausen syndrome, and they have a strong tendency to form personal bonds with a single physician or group of physicians.
Race-related demographics
The case literature clearly shows that most patients with factitious disorder are white. In the absence of demographic data describing the racial or ethnic composition of the patient populations in which these cases were identified, it is currently impossible to know whether race represents a significant risk factor.
The more chronic and severe Munchausen variant of factitious disorder appears to follow an unremitting course, and the prognosis is generally poor. Patients frequently are unwilling to undergo mental health treatment, and even if they are willing, no well-established effective therapeutic strategy exists. Treatment may transiently ameliorate symptoms but does not appear to last in most cases, though a few individuals have recovered.
Patients with simple factitious disorder follow a more variable course, and the overall prognosis may be regarded as fair. Case reports in the literature suggest that some patients who seek treatment for factitious disorder may be able to overcome their illness. It appears that even without treatment, simple factitious disorder sometimes remits in the fourth decade of life.
The presence of a treatable concurrent mental disorder, such as major depression, is a positive prognostic sign. Some investigators believe that both disorders attenuate with age and maturity, as is the case with personality disorders.
Factitious disorder can result in morbidity and mortality either from the patient's re-creation of actual medical conditions (eg, exogenous administration of insulin) or from the measures the physician undertakes to diagnose or treat the condition (eg, unnecessary cardiac catheterizations or surgical procedures). 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.
The more chronic and severe Munchausen variant of factitious disorder appears to follow an unremitting course, and the prognosis is generally poor. Patients frequently are unwilling to undergo therapy, and even if they are willing, no well-established effective therapeutic strategy exists. Treatment may transiently ameliorate symptoms but does not appear to last in most cases, though a few individuals have recovered.
Patients with simple factitious disorder follow a more variable course, and the overall prognosis may be regarded as fair. Case reports in the literature suggest that some patients who seek treatment for factitious disorder may be able to overcome their illness. It appears that even without treatment, simple factitious disorder sometimes remits in the fourth decade of life.
The presence of a treatable concurrent mental disorder, such as major depression, is a positive prognostic sign. Some investigators believe that both disorders attenuate with age and maturity, as is the case with personality disorders.
Factitious disorder can result in morbidity and mortality either from the patient's re-creation of actual medical conditions (eg, exogenous administration of insulin) or from the measures the physician undertakes to diagnose or treat the condition (eg, unnecessary cardiac catheterizations or surgical procedures). 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.
Features that increase morbidity and mortality
Four features of factitious disorder that are particularly prominent in the more chronic and severe form of the disorder (Munchausen syndrome) significantly increase morbidity and mortality risk in this setting.
The first feature is that patients perform dangerous manipulations on their own bodies (eg, ingestion of chemical toxins, self-infection, or aggravation of wounds). Although patients with Munchausen syndrome are generally medically knowledgeable and sophisticated, their manipulations sometimes result in unintended serious injury, permanent disability, or death.
The second feature is that patients incur a substantial risk of iatrogenic illness and injury by repeatedly engaging in deceptions that cause medical care providers to perform risky diagnostic and treatment procedures. In some cases, the resultant damage is part of the patient's plan. For example, a patient who pretends to have a malignancy may desire the adverse effects of chemotherapy, or a patient may simulate adrenal gland dysfunctions with the intention of having an adrenal grand removed.
In other cases, the iatrogenic damage results from unintended medical accidents, such as adverse medication effects, allergic reactions, or surgical complications. Because patients with Munchausen syndrome subject themselves to so many medical procedures, their lifetime risk of experiencing an unintended adverse medical event is many times greater than that of the average person.
The third feature is that patients with Munchausen syndrome frequently provide incomplete or false medical history information that, by intention or through an oversight, causes increased morbidity or mortality. For example, they may experience dangerous adverse medication effects because they withhold information about known drug allergies, or they may suffer surgical complications because they fail to inform the medical staff that they have taken anticoagulant medications.
The fourth feature is that because of their factitious illness behavior, these patients may not receive serious attention from medical staff when they truly need it. Although they are more likely to claim illness or injury than typical patients are, this does not mean that they are any less likely to sustain an actual illness or injury. In some cases, even when a patient with a known history of factitious complaints is genuinely ill, medical staff may delay or withhold necessary measures so as to minimize iatrogenic risks and avoid reinforcing inappropriate behavior.
A patient confronted with suspicions that his or her illness is factitious may not be receptive to attempts at patient education. Nevertheless, 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 of the hospital against medical advice.
Efforts to educate the patient should include the following steps:
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 to the patient that without treatment, the condition is unlikely to improve, and he or she may again seek hospitalization
Emphasize to the patient that each episode of producing or feigning illness can result in significant morbidity or even mortality resulting either from the production of illness or from the performance 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 can be used to help the patient understand more about his or her illness, including the presumed origins of the factitious illness behavior and the importance of regular follow-up care with the psychiatrist.
Educational efforts targeted toward the general public are not likely to decrease the incidence of factitious disorder. It has been asserted that such efforts might help friends, family members, teachers, or coworkers to identify persons with this disorder and urge them to seek mental health care, but this assertion is debatable. It is equally possible that such efforts could lead to cruel and unwarranted skepticism toward people who have genuine chronic illnesses.
For patient and family education resources, see the Mental Health Center, as well as Munchausen Syndrome. The following Web sites may also be useful:
WebMD, Mental Health: Factitious Disorders
Cleveland Health Clinic, An Overview of Factitious Disorders
Patients with factitious disorder can and do litigate. A potential trigger of litigation that must be avoided is rushing to a diagnosis of factitious disorder and, as a result, missing the presence of an authentic organic disease. Symptoms should not be attributed to factitious disorder without proper investigation, and an adequate effort must be made to distinguish this disorder from malingering and conversion disorders. In particular, a patient must not be misdiagnosed as having factitious disorder merely on the basis of unpleasant personality traits.
In the past few years, a variant of factitious disorder called Munchausen by Internet has been reported in which individuals with this condition use Internet bulletin boards and online patient self-help groups to further gratify their primary need to "be sick." Challenges to the deceptions, whether online or in person, can lead to extensive civil legal proceedings. Physicians may become involved as expert witnesses or as witnesses-of-fact to one of the Munchausen patient's multiple presentations to a hospital.
Expert witnesses in legal proceedings involving patients with factitious disorder (including workers' compensation or tort claims) must obtain and review extensive information from collateral sources in performing a thorough evaluation of the patient. Medical and psychiatric records antedating the injury should be consulted. While one may argue that the pursuing of secondary financial gain through initiating a lawsuit against a treatment provider moves a patient with factitious disorder into the realm of malingering, the patient may also derive important psychological benefits from winning a lawsuit. Family members may criticize the patient with extensive somatic complaints and claims of disability. Initiating and winning litigation may deflect blame for his or her condition onto the treatment provider and validate the patient's explanation for difficulties in his or her life.[11] Expert witnesses should be prepared to make the distinction between primary and secondary gain clear to juries and assist juries in distinguishing among malingering, somatic symptom disorder, and factitious disorder.
Many of the legal and ethical issues arising in cases of medical deception have been debated extensively and have resulted in courtroom judgments. The controversy has yet to resolve most of these issues, which are discussed below, such that no clear guidance is available to direct the treating physician's response.
Status as patient
"Patienthood," as conceptualized by most commentators and organizations, such as the American Medical Association (AMA), includes in part the notion that the individual seeks medical care in order to get well and overcome an illness or injury. One may ask whether an individual with facititious disorder, whose goal is different (ie, to assume the sick role through factitious illness in order to receive care), should appropriately be considered to be a patient. If what it means to be a patient is strictly conceptualized in this way, then the professional obligations owed to patients would not extend to those with factitious disorders. They may not be considered to be entitled to admission, treatment, appropriate notice before termination, and the like.
Responsibility of physician
The physician who has discovered that a person has been feigning illness may be thwarted from sharing that information with others. The patient may explicitly refuse to give permission to share this vital information with other healthcare professionals or even with the patient's own family members. One proposed solution in such cases is for the physician simply to state, "The patient has forbidden me to comment on whether he or she has a factitious disorder," thereby tacitly encouraging others to read between the lines.
Another possible solution echoes the question of whether the duty of confidentiality is owed to someone who may not qualify as a patient. Several commentators have argued that the doctor-patient relationship, through which the right to confidentiality is established, requires that both the doctor and the patient carry out their roles in good faith. According to this view, the doctor-patient relationship ceases to exist when the patient engages in medical deception (ie, acts in bad faith). Without the restrictions imposed by the duty of confidentiality, the physician would be free to share information about the individual.
Legal culpability of patient
Patients who engage in the deliberate production of factitious illnesses steal the time of doctors and other caregivers, and waste medical resources and supplies. An individual who is caught stealing even inexpensive merchandise from a department store will invariably be confronted and often be criminally charged. Yet a patient with factitious disorder will rarely be subjected to criminal indictment, despite the enormous costs. Nevertheless, one such case was heard in Arizona and resulted in a court finding of fraud and an order of reimbursement against the patient. Other such cases are likely.
Mismanagement of real ailment
The standard medical malpractice claim made by patients with factitious disorder against care providers is that the patient's ailment was not factitious, but was real, and was mismanaged such that the patient is now permanently disabled or disfigured. These cases are notoriously difficult to defend, in terms of both time and money, even when the patient has been observed to induce self-harm. Regardless of the evidence, judges and juries tend to find factitious disorder scarcely believable and to assume that a patient who has this condition would be obviously psychotic. The presence of a well-behaved, neatly groomed patient in the courtroom can clash with that erroneous assumption, leading to surprisingly large settlements or verdicts in favor of patients.
Mismanagement of feigned ailment
Another possible malpractice claim is the obverse of the one above. In this scenario, a patient with factitious disorder eventually sues caregivers for their failure to detect that his or her illness was feigned. The patient argues that as a consequence of this failure, any and all treatments were misapplied, the iatrogenic effects were completely unwarranted, and the physician breached the standard of care in diagnosis. In one case of this sort, a settlement in excess of $300,000 was awarded to the patient.
Patient privacy
When facititious disorder is suspected, caregivers may wish to search a patient's belongings for items used in perpetrating the factitious illness. However, doing so without first obtaining consent likely violates the patient's right to privacy. Consent can sometimes be gained, however, by revealing one's 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. In addition, many hospitals require patients to consent to room searches as a condition of admission.
Covert surveillance (eg, with cameras hidden in ceiling panels) intended to catch factitious illness behavior is somewhat more controversial. The use of video cameras to monitor patient behavior probably does not violate privacy considerations if the cameras were already in routine use to monitor patients' rooms (as in some critical care wards). However, covert operation of cameras for the specific purpose of catching a patient with factitious disorder may be problematic.
The arguments for and against these measures hinge on whether there is a reasonable expectation of privacy in a hospital room. Many legal precedents support the notion that such an expectation is unreasonable, but these derive from cases of abuse related to factitious disorder imposed on another (Munchausen syndrome by proxy), in which the suspected abuse could not be confirmed or ruled out without resorting to such interventions (eg, the patient was a nonverbal infant who could not provide any information).
Hospital risk management and legal advisors should meet with team members to formulate a decision as a group before covert video surveillance is initiated. Hospitals are advised to develop relevant standards and policies even if no suspicious case has ever arisen. The authors are not aware of any cases in which search warrants for hospital rooms have been issued solely on the basis of the possibility of self-damaging behavior.
Confidentiality of patient information
Estabilishing registries of patients with factitious disorder that are shared among treatment centers or are made available nationally or internationally has been proposed. These registries would be used to determine whether a patient who is suspected of medical deception has been previously identified as having factitious disorder.
Although the existence of such registries would undoubtedly hinder the ability of such patients to carry out their deceptions at successive hospitals, they appear to be legally problematic in the United States. Such registries of this type appear to violate the patient's confidentiality, particularly since the establishment of the Health Insurance Portability and Accountability Act (HIPAA) rules. Interestingly, registries of troublesome patients are maintained in some other countries.
Patients' rights advocates caution that people who are placed on these lists may receive inadequate care for medical complaints because of a presumption that their complaints must be inauthentic, which may or may not be true. They also express concern that some people may be listed simply because they were uncooperative or because the source of their complaints could not be diagnosed. Supporters of these lists, however, view themselves as helping patients by preventing unwarranted treatment of people whose judgment is impaired.
Individuals with factitious disorder imposed on self (including Munchausen syndrome) may feign illness by any of the following means:
A factitious history alone (eg, falsely claiming to have had a syncopal episode)
A factitious history plus the manipulation of assessment instruments (eg, claiming illness and manipulating a thermometer to show fever)
A factitious history plus the use of external agents that mimic disease (eg, adding exogenous blood to urine and claiming hematuria)
A factitious history plus the induction of an actual medical condition (eg, injecting bacteria to produce infection or ingesting central nervous system [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 the disorder is typically slowed by the natural tendency among physicians to believe what patients say. Indeed, this tendency may even be enhanced in such cases because many patients with factitious disorder work in the healthcare field and are colleagues. Detection of factitious disorder among those who have an actual medical condition can be even more difficult.
Patients with this disorder may present in self-help groups; cases have been reported in which such patients use Internet-based patient support groups to fulfill their need to “be sick.” Physicians who assist these groups may run across cases of this type, or their colleagues may ask about such cases, having become frustrated when dealing with these behaviors.
Medical history
The self-reported medical history of patients with factitious disorder imposed on self may be extensive. In these cases, the lack of medical documentation to substantiate the self-reported medical history is notable, and patients might claim that the previous injuries or illnesses occurred in a foreign country or that the medical records were destroyed in a fire. They often decline to sign releases of information and give odd excuses in denying access to relatives and friends.
Alternatively, patients may lie and deny having an extensive medical history. Such denials are sometimes contradicted by surgical scars, by other evidence from the physical examination, or by laboratory, radiologic, or other test findings that suggest a significant medical or surgical history (eg, the presence of benign surgical clips).
Patients’ descriptions of their current problem and medical history may be overly dramatic or inconsistent. The literature is replete with tales of patients who diverted all attention to themselves in the emergency department (ED) by seemingly spewing blood or undergoing sustained seizures. At the same time, patients may be surprisingly vague or guarded about the details of their medical history, especially regarding details of previous treatments.
The case literature describes cases in which patients repeatedly simulated or self-induced a single medical problem (eg, nonhealing wounds) and a roughly equal number of cases in which individual patients presented over time with a wide range of medical problems. Although a history involving diverse symptoms and organ systems is sometimes regarded as an important indicator of factitious disorder, this feature is not a sensitive indicator.
Psychiatric history
Patients with factitious disorder imposed on self are seldom willing to admit that they have feigned or caused their own medical or psychological problems. When confronted by medical and nursing staff or subjected to policies they find offensive (eg, no leaving the unit at will), they often become angry and discontinue their care at that particular facility. Against-medical-advice discharges are common, as are threats of retribution through lawsuits or physical attacks.
Few patients with this disorder agree to accept psychiatric consultation or psychological assessment. Among those who do, many report a history of physical, emotional, or sexual abuse or physical or emotional neglect. Many describe having been separated from the family for extended periods or state that when they were young, a spontaneous illness (eg, appendicitis) introduced them to the care and concern elicited by the sick role.
A pattern of claimed childhood abuse and neglect is also observed among the wider population of patients who present with chronic unexplained medical complaints. Abuse and neglect are linked to the development of personality disorders, particularly the more florid and dramatic ones, such as borderline personality disorder. Such disorders are frequently comorbid with factitious disorder. Whether a unique link exists between abuse and factitious illness behavior that is independent of their mutual relation to these personality disorders is unknown.
It should be noted that that patients who truly have Munchausen syndrome engage in chronic lying. Their reports of childhood abuse may be spurious, even if detailed and elaborate. This potential indicator is supported by case studies of persons who presented with various sorts of factitious victimization complaints, such as false reports of rape, stalking, battery, or sexual harassment. Given the extent of the lies and deceptions characteristic of this syndrome, the apparent strong connection between it and antisocial personality disorder is not surprising.
Unlike patients with conversion disorder (eg, conversion blindness after witnessing a war atrocity), whose illness behavior is neither planned nor willful, patients with Munchausen syndrome consciously fabricate, exaggerate, or induce signs and symptoms. Like patients with conversion disorder, however, patients with Munchausen syndrome may be quite unaware of the reasons and motivations behind their pursuit of the sick role.
Factors suggestive of factitious disorder
In summary, 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
Details that are vague and inconsistent, though possibly plausible on the surface
Long medical record with multiple admissions at various hospitals in different cities
Knowledge of textbook descriptions of illness; a presentation that hews too closely to the textbook example
Admission circumstances that do not conform to an identifiable medical or mental disorder
An unusual grasp of medical terminology
Employment or education in a medically related field
Pseudologia fantastica (ie, uncontrollable lying characterized by the fantastic description of false events)[12]
Presentation in the ED during times when old medical records are difficult to access or when experienced staff are less likely to be present (eg, holidays and 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 that are only present when the patient is aware of being observed
Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
Evidence of pathologic lying in areas other than the presenting symptoms
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, or 7 x 6 = 41); this usually occurs in factitious disorder with predominantly psychological signs and symptoms
The physical examination of the patient with factitious disorder frequently suggests an extensive history of illnesses and injuries. Suspicion is raised when the patient has multiple surgical scars (reflecting numerous exploratory surgical procedures) or a gridiron abdomen, indicating the chronic form of factitious disorder (Munchausen syndrome), or shows evidence of self-induced physical signs (see the image below).
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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....
As in conversion disorder, the neurologic examination may reveal inconsistent findings. For example, patients with paralysis may have normal muscle tone in the affected limb, or apparent sensory loss may not follow the anatomic distribution of peripheral nerves.
Other physical inconsistencies include an absence of signs of dehydration in patients complaining of persistent diarrhea and vomiting. Cardiac presentations of Munchausen syndrome are common enough to have allowed cardiologists to identify cardiac Munchausen syndrome—sometimes referred to as cardiopathia fantastica—as a distinct subset of the Munchausen spectrum.[13, 14]
Clinicians should look to case reports in their medical specialties to acquaint themselves with the types of factitious medical complaints that have been observed by their colleagues and the means by which these deceptions were carried out and eventually uncovered.
Patients who have factitious disorder with psychological signs and symptoms, as well as those who are simulating neuropsychological problems, often present with symptom patterns that do not match known syndromes or diagnostic categories. For example, they may portray the euphoric mood and pressured speech characteristic of a manic episode but show no disruptions in sleep.
Specific symptoms may be presented in an atypical manner. For example, a patient feigning dementia may perform poorly on both recent and remote memory tests, or a patient feigning a closed head injury may show more errors on a visual discrimination test than would be expected on the basis of chance alone.
Psychological and neurocognitive symptoms may appear worse when the patient is undergoing active examination than when he or she is casually interacting with staff members or other patients. A patient with feigned dementia who could not remember any of 3 items after 5 minutes may later complain that the cafeteria served the same entrée 2 nights in a row.
Mental status examination
Patients with factitious disorder can vary in their presentation, and no findings have been shown to be pathognomonic. The following findings are possible:
Appearance may include the 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 would be expected on the basis of the patient’s medical condition
Perceptual abnormalities (eg, hallucinations and disturbances of thought process or thought content), suicidality, or homicidality may be present with factitious disorder with predominantly psychological signs and symptoms; suicidal or homicidal ideation should always be taken seriously, regardless of whether it is suspected of being factitious
Patients who have 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
Orientation and recall may be aberrant if the patient is feigning mental illness
Manifold complications can occur in factitious disorder imposed on self, potentially ranging from trivial to lethal. Such complications may arise either from the induction of factitious illness or from the workup or treatment for the condition. High health care costs typically result.
From one point of view, factitious disorder is itself a complication. The combination of patients’ self-harming behavior, physicians’ actions that are not based on accurate medical history information, and the simple additive iatrogenic risks entailed in multiple surgical procedures all greatly increase morbidity and mortality.
Medical assessment of patients with factitious disorder is analogous to piloting an airplane through dense clouds. In such flying conditions, pilots may feel panicky and disoriented. Their best response is to follow the basic rules of flying and trust their navigational instruments; pilots who depart from these procedures and rely instead on their own inner sense of direction and orientation are at risk for bad—even disastrous—outcomes.
Similarly, physicians encountering patients whom they cannot diagnose and who do not respond to the usual treatments may experience a feeling of panic and disorientation. When this occurs, their response should include the following:
Follow the basic procedures for responding to the patient’s signs and symptoms
Understand the reliability and validity of the medical tests that are performed
Respect base-rate information about the prevalence of various diseases that must be excluded
Cases abound in which tests have been repeated needlessly, invasive procedures performed without adequate justification, or medications prescribed with such apparent zeal that iatrogenic problems actually come to dominate the clinical picture.
Patients with factitious disorder use several techniques to disrupt the physician’s usual practices. Typically, they exploit the clinician’s fear of overlooking a rare life-threatening disease while also playing to his or her fascination with thorny medical problems; they well understand the appeal of a medical mystery and the personal satisfaction, notoriety, and esteem that come from solving one. In so doing, these patients encourage the physician to depart from standard procedures and to overlook more benign (and likely) explanations.
Paradoxically, patients with factitious disorder can also disrupt the physician’s usual practices by persuading him or her to forgo basic diagnostic procedures. Striking evidence of this phenomenon is noted in reports of patients who have successfully feigned diseases such as AIDS with Kaposi sarcoma and malignancies such as breast cancer. In both of these real-life examples, definitive tests were available to establish the presence of these diseases, but they were not performed.
One reason for the failure to perform definitive tests in situations such as these is that the patients’ persuasive but false medical history, perhaps combined with their physical appearance, may lead to the mistaken assumption that the tests are unnecessary. Another is that doctors may erroneously believe that such serious and life-threatening illnesses cannot possibly be feigned or self-induced.
Any testing ordered should be based on a well-considered and appropriately prioritized differential diagnosis. The performance of any procedures should be approached very conservatively if suspicions of factitious disorder are raised (eg, if the patient has the “roadmap” abdomen caused by scars from prior exploratory operations). Tests should not be needlessly repeated in the misguided hope that the pathology will suddenly emerge.
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 determining the serum insulin−to−C-peptide ratio during a hypoglycemic episode.[15] 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.
A common finding in factitious disorder is test results that are inconsistent with the claimed illness (eg, no elevated white blood cell [WBC] count or left shift in apparent sepsis or necrotizing fasciitis). Bacterial cultures may grow an overly wide variety of enteric flora when taken from infected sites distant from the pelvis or groin because the patient has contaminated the wound with feces. Self-induced intractable diarrhea or vomiting may be missed unless the laboratory personnel are specifically asked to look for agents such as phenolphthalein or ipecac.
Because the range of factitious illnesses is limited only by the imagination of the perpetrator, it would be impossible to list all of the laboratory tests that might prove useful in one circumstance or another. However, suspicion that an illness is factitious should be conveyed to the pathologist, who may be able to help identify ways of confirming the diagnosis.[16]
A particular difficulty with laboratory testing in patients with factitious disorder is that many of these patients have a medical background and thus are likely to be familiar with the routine tests performed for a particular presentation. For example, a patient with anemia could anticipate that routine blood work would not include screens for the anticoagulants he or she has ingested and that the medical or surgical investigation would consequently be prolonged as the professionals search for the elusive etiology (eg, unexplained hematuria or hematochezia).
The number of other ways in which patients have used tests and test results to mislead doctors is staggering. For example, some individuals self-inject insulin to create a baffling, tenacious, and dangerous hypoglycemic state. As noted (see above), this ruse can be exposed before an erroneous diagnosis of insulinoma is made by assessing whether the C-peptide level is compatible with the serum insulin level. A high insulin level combined with a low C-peptide level indicates factitious hypoglycemia.
As further examples, some patients create alarming laboratory evidence of proteinuria simply by adding a drop of egg white (a pure protein) to their urine specimens. In others, a small amount of blood, perhaps added to a stool specimen or swallowed before endoscopy, appears as conclusive evidence of gastrointestinal pathology. The presence of unexplained puncture sites, especially in odd areas (eg, the base of the tongue) can provide very compelling evidence of such dissimulation.
Some patients enter the nurses’ station or access the clipboards outside their doors and directly change laboratory values from normal to abnormal. Often, they present the doctor with letters from colleagues purporting to verify the pathology, but a follow-up call reveals that the letterhead paper was stolen and the report was typed by the patient. Of course, illnesses that are self-induced but real (eg, extreme lead poisoning from drinking water in which lead-based items were boiled) show corresponding authentic analyses that mandate emergency treatment.
As with laboratory testing, almost any imaging technique is at least potentially useful in the workup of a patient with suspected factitious disorder.
Imaging may be particularly useful when the patient presents with a well-established medical problem of the type that can be easily imaged (eg, inoperable malignancies or strokes). In such cases, errors are made by eschewing these tests to spare the patient the expense or inconvenience of repeating tests that have already returned positive indications of disease. For many patients with factitious disorder, the use of imaging studies becomes part of the search for an explanation for their puzzling signs and symptoms.
Strongly subjective tests, such as electromyography and nerve conduction velocity tests, should be understood as almost never definitive in isolation. An occasional positive finding, which is likely whenever anyone is subjected to extremely extensive and repeated testing, should not be misinterpreted. Clinicians should remember that each intervention poses a risk of iatrogenic complications that only complicate the picture. Indeed, such complications have led to malpractice actions against physicians.
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.[17] 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.[18]
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 possibly reduce impulsivity, can 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 the other).
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.
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.
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.
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 variant of the syndrome that combines medical and psychological symptoms.
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 or United Kingdom, just as no federal or foundation funds have ever been awarded in the United States for research into this perplexing and costly syndrome.
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.
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.
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 may be part of the consent forms patients sign before admission.
Little can be done directly to prevent the development of factitious disorder. Because patients often do not regard the disorder as undesirable, they have little 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 and confidential insurance company summaries, 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 reinforced 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. Books on the subject have recently appeared that are accessible to health professionals and, at times, to family members and friends as part of a psychoeducational approach. Relevant websites devoted to the subject are available as well (eg, http://www.munchausen.com).
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 can be 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 the 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 emotional factors such as anger, frustration, or excessive 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.
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:
Because the patient is unlikely to cooperate with a psychiatric consultation, it is likely that 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 mind 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.”[19]
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, psychiatric and legal consultations should be sought.
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 deceptions.[18] In view of the current poor success rate of psychiatric interventions in this disorder, such an approach seems appropriate only as a last resort, especially because case reports suggest that those with factitious disorder can have long periods of apparent normalcy before symptoms recur.
Todd S Elwyn, MD, Staff Psychiatrist, Atascadero State Hospital; Private Practice Physician, The Amen Clinics
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
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
Disclosure: Nothing to disclose.
Chief Editor
Glen L Xiong, MD, Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Doctor On Demand<br/>Received income in an amount equal to or greater than $250 from: Blue Cross Blue Shield Federal Employee Program<br/>Received royalty from Lippincott Williams & Wilkins for book editor; Received grant/research funds from National Alliance for Research in Schizophrenia and Depression for independent contractor; Received consulting fee from Blue Cross Blue Shield Association for consulting. for: Received book royalty from American Psychiatric Publishing Inc.
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
Feldman MD, Yates GP. Dying to be Ill: True Stories of Medical Deception. New York: Routledge; 2018.
Asher R. Munchausen’s Syndrome. Lancet. 1951. 1:339-41.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. 324-6.
Classic multiple scarred abdomen of woman with Munchausen syndrome. Photograph on left shows abdomen as it appeared on presentation, after patient had undergone 42 largely unwarranted operations. Photograph on right shows abdomen after additional surgery revealed authentic colon cancer. Courtesy of Marc D Feldman, MD, University of Alabama School of Medicine.
Classic multiple scarred abdomen of woman with Munchausen syndrome. Photograph on left shows abdomen as it appeared on presentation, after patient had undergone 42 largely unwarranted operations. Photograph on right shows abdomen after additional surgery revealed authentic colon cancer. Courtesy of Marc D Feldman, MD, University of Alabama School of Medicine.
Classic multiple scarred abdomen of woman with Munchausen syndrome. Photograph on left shows abdomen as it appeared on presentation, after patient had undergone 42 largely unwarranted operations. Photograph on right shows abdomen after additional surgery revealed authentic colon cancer. Courtesy of Marc D Feldman, MD, University of Alabama School of Medicine.
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