Factitious Disorders

Factitious Disorders

Introduction

A patient with factitious disorder consciously induces or feigns illness in order to obtain a psychological benefit by being in the sick role. It is the conscious awareness of the production of symp-toms that differentiates factitious disorder from the somatoform disorders in which the patient unconsciously produces symptoms for an unconscious psychological benefit. It is the underlying mo-tivation to produce symptoms that separates factitious disorders from malingering. Patients who malinger consciously feign or induce illness in order to obtain some external benefit such as money, narcotics, or excuse from duties. While the distinctions among these disorders appear satisfyingly clear, in practice, pa-tients often blur the boundaries. Patients with somatoform dis-orders will sometimes consciously exaggerate symptoms which they have unconsciously produced, and it is a rare patient who consciously creates illness and yet receives no external gain at all, be it disability benefits, excuse from work, or even food and shelter.

Talcott Parsons described the “sick role” in 1951 and noted that in our society there are four aspects of this role. First, the patient is not able to will himself or herself back to health but instead must “be taken care of”. Secondly, the patient in the sick role must regard the sickness as undesirable and want to get bet-ter. Thirdly, the sick patient is obliged to seek medical care and cooperate with his or her medical treatment. Finally, the sick pa-tient is exempted from the normal responsibilities of his or her social role (Parsons, 1951).

Patients with factitious disorder seek, often desperately, the sick role. They usually have little insight into the motivations of their behaviors but are still powerfully driven to appear ill to others. In many cases, they endanger their own health and life in search of this role. Patients with this disorder will often induce serious illness or undergo numerous unnecessary, invasive proce-dures. As most people avoid sickness, the actions of these patients appear to run counter to human nature. Also, since entry into the “sick role” requires that the sick person should try to get better, pa-tients with factitious disorder must conceal the voluntary origin of their symptoms. The inexplicability of their actions combined with their deceptive behavior stir up both intense interest and intense (usually negative) countertransference in health care providers.

Patients have been known to create or feign numerous ill-nesses, both acute and chronic, in all of the medical specialties. These illnesses can be either physical or psychological. It appears that the only limit is the creativity and knowledge of a given pa-tient. In fact, there is at least one case report of a patient who feigned factitious disorder itself (Gurwith and Langston, 1980). The patient claimed to have Munchausen’s syndrome, to have undergone numerous unnecessary procedures and operations and, as a result, to need immediate hospitalization. He displayed his abdomen, which appeared to have numerous surgical scars and hinted that searches of his hospital room would be fruitful. However, collateral information revealed that the physicians and hospitals he had reported had never treated the patient, and his “scars” washed off with soap and water. Patients with factitious disorder are often quite medically sophisticated. Even though ac-quired immune deficiency syndrome was not described until the early 1980s, the first factitious cases followed shortly thereafter, at least as early as 1986.

Definition

For a diagnosis of factitious disorder (see DSM-IV-TR criteria for factitious disorder) to be justified, a person must be intention-ally producing illness; his or her motivation is to occupy the sick role, and there must not be external incentives for the behavior. The diagnosis is further subclassified, depending on whether the factitious symptoms are predominantly physical, psycho-logical, or a combination. The DSM also includes a category(see DSM-IV-TR criteria for factitious disorder not otherwise specified) for patients with factitious symptoms who do not meet the listed criteria. The most common example of factitious dis-order not otherwise specified is factitious disorder by proxy, in which the individual creates symptoms in another person, usu-ally a dependent, in order to occupy the sick role. Patients who readily admit to inducing symptoms, such as self-mutilating pa-tients, are not diagnosed with factitious disorder as they are not using their symptoms to occupy the sick role.

Factitious Disorder with Predominantly Physical Signs and Symptoms

Patients with this subtype of factitious disorder present with phys-ical signs and symptoms. The three main methods patients use to create illness are: 1) giving a false history, 2) faking clinical and laboratory findings, and 3) inducing illness (e.g., by surreptitious medication use, inducing infection, or preventing wound heal-ing). There are reports of factitious illnesses in all of the medi-cal specialties. Particularly common presentations include fever, self-induced infection, gastrointestinal symptoms, impaired wound healing, cancer, renal disease (especially hematuria and nephrolithiasis), endocrine diseases, anemia, bleeding disorders and epilepsy (Wise and Ford, 1999). True Munchausen’s syn-drome fits within this subclass and is the most severe form of the illness. According to the DSM-IV, patients with Munchausen’s syndrome have chronic factitious disorder with physical signs and symptoms, and in addition, have a history of recurrent hospi-talization, peregrination, and pseudologia fantastica – dramatic, untrue, and extremely improbable tales of their past experiences (American Psychiatric Association, 2000).

Factitious Disorder with Predominantly Psychological Signs and Symptoms

Another subtype of factitious disorder includes patients who present feigning psychological illness. They both report and mimic psychiatric symptoms. These patients can be particularly difficult to diagnose as psychiatric diagnosis depends greatly on the patient’s report. There are reports of factitious psychosis, post traumatic stress disorder and bereavement. In addition, there are reports of psychological distress due to false claims of being a victim of stalking, rape, or sexual harassment, and these cases are often diagnosed with a factitious psychological disorder such as post traumatic stress disorder. While patients with factitious psychological symptoms feign psychiatric illness, they also of-ten suffer from true comorbid psychiatric disorders, particularly Axis II disorders and substance abuse. Case reports suggest that patients with psychological factitious disorder have a high rate of suicide and a poor prognosis. While Munchausen’s syndrome is considered a subset of physical factitious disorder, there are case reports of patients presenting with psychological symptoms who also have some of the key features of Munchausen’s (pathological lying, wandering and recurrent hospitalizations).

Factitious Disorder with Combined Psychological and Physical Signs and Symptoms

DSM-III separated factitious disorder into two disorders, based on whether the symptoms were physical or psychological. However, case reports clarified that this distinction was often ar-tificial (Merrin et al., 1986; Parker, 1993). Some patients present with simultaneous psychological and physical factitious symp-toms, and some patients move between physical and psychologi-cal presentations over time. For example, a patient who presented with factitious post traumatic stress disorder was confronted about the nature of his symptoms and then began complaining of physical symptoms. DSM-IV was revised to account for pa-tients who present with both psychological signs and symptoms, though this category of patients is the least well-studied.

Factitious Disorder not Otherwise Specified (Factitious Disorder by Proxy)

Some individuals pursue the sick role not by feigning illness in themselves, but instead by creating it in another person, usually someone dependent on the perpetrator. They seek the role of car-ing for an ill individual (the sick role by proxy). While the victim is usually a child, there are reports of victimization of elders and developmentally delayed adults. The veterinary literature even reports cases of factitious disorder by proxy in which the victim is a pet..

Clinical Findings

Due to the inherently deceptive nature of patients with facti-tious disorder, the literature is largely confined to case reports and case series. It is likely that many patients with less severe forms of the disease escape detection and their clinical charac-teristics might be quite different. In addition, the literature on factitious disorder with physical symptoms is much more ex-tensive than the literature on the other subtypes. As a result, we will discuss the features of the factitious disorders as a whole, referring to specific characteristics of patients with psychologi-cal symptoms (either alone or accompanying physical symp-toms) when they are known.

Numerous reports in the literature describe two different subclasses of factitious patients. The first type fits with the classic Munchausen’s syndrome diagnosis: they have chronic factitious symptoms associated with antisocial traits, pathological lying, minimal social supports, wandering from hospital to hospital, and very poor work and relationship functioning. They are oftenvery familiar with hospital procedure and use this knowledge to present dramatically during off-hours or at house officer transi-tion times when the factitious nature of their symptoms is least likely to be discovered. Male patients compromise the majority of these cases. Patients with Munchausen’s syndrome appear to have an extremely poor prognosis. Fortunately, this most severe class of patients makes up the minority of factitious patients probably fewer than 10%.

The second, and more typical, type of patient does not dis-play pathological lying or wandering. Their recurrent presenta-tions are usually within the same community, and they become well known within the local health care system. They often have stable social supports and employment, and a history of a medi-cally related job. This larger class of factitious patients is mostly made up of women, and is more likely to accept psychiatric treat-ment and to show improvement. Plassmann (1994a) reviewed 1070 cases of patients with factitious, but not Munchausen’s dis-order. He found that 78% of the patients were women and 58% had a medically related job. Finally, there are individuals who may have an episode of factitious disorder in reaction to a life stressor, but may return to premorbid functioning after the stres-sor is resolved.

All types of factitious disease show a strong associa-tion with substance abuse as well as borderline and narcissistic personality disorders. In a case series by Ehlers and Plassman (1994), nine of 18 patients had personality features that met cri-teria for borderline personality disorder, and another six of 18 had personality features that met criteria for narcissistic person-ality disorder. Factitious patients span a broad age range. Reports in the literature show patients ranging from four to 85 years. Of note, a 4-year-old patient with factitious disorder reported that he had been coached by his mother and may be better diagnosed as a victim of factitious disorder by proxy. The next youngest case found was 8 years old. Ethnicity is frequently not reported in case studies and series, so it is difficult to determine if there are any ethnic differences in the prevalence or presentation of factitious disorder.