Continuing Education Activity

Factitious disorder is a condition in which a patient intentionally falsifies medical or psychiatric symptoms. Symptoms can be self-induced or fabricated. This activity describes the evaluation and management of factitious disorder and reviews the role of the inter-professional team in improving care for patients with this condition.

Objectives:

• Identify the etiology of factitious disorder.
• Review the appropriate evaluation of patients with factitious disorder.
• Outline the management options available for factitious disorder.
• Describe the interprofessional team strategies for improving care coordination and communication to advance factitious disorder and improve outcomes.

Introduction

Factitious disorder imposed on self - Munchausen syndrome - is a syndrome in which patients consciously induce, feign, or exaggerate physical or psychiatric symptoms for primary gain.[1] These patients are motivated purely by internal gains, such as a desire for attention, coping with stress, or enjoyment in stumping healthcare workers.[2][3] Patients with factitious disorder can pose a significant danger to themselves by undergoing a plethora of unnecessary procedures or in the induction of symptoms.[1][4] Additionally, they often over-utilize limited healthcare resources.[5] The inherent deception in this condition poses a significant challenge for healthcare providers in making a diagnosis. Due to a lack of willing participants for large-scale randomized treatment trials, evidence-based recommendations for the management of these patients is limited. Current recommendations are largely based on expert opinion, case reports, and systematic reviews. Based on information from these sources, treatment options are limited, and the prognosis for these patients is generally poor.

Etiology

The etiology of factitious disorder is largely based on speculation. There are no high-quality, large-scale studies demonstrating consistent etiological factors; however, observations have been made based on case reports and small studies. Many experts consider factitious disorder to be largely developmental. It is thought that the behaviors exhibited are maladaptive responses to life events, especially during childhood.[3] This reasoning is supported by several commonalities among patients with factitious disorder:

• Patients with factitious disorder are more likely to have suffered a major childhood illness. It appears that for some patients, this early experience with the healthcare system is pivotal in the development of this disorder. One review of 20 cases reported 60% of patients had a history of significant childhood illness.[6] 
• Most experts agree that patients with factitious disorder are much more likely to have suffered from a difficult or traumatic childhood.[7] A study that reviewed dialogue obtained from online support groups for factitious disorder found that out of 57 members, only three described having a good childhood while the majority described various forms of emotional and physical abuse.[8]
• There is a strong association among patients with personality disorders and factitious disorder, and many overlapping behavioral traits are evident, further supporting the developmental theory.[7]

There are several proposed mechanisms behind the behavior found in factitious disorder:

• Most obvious is the affection one may derive from the sick role, especially in those who sensed a lack of affection during childhood.[9] 
• Seeking and maintaining relationships.
• Enjoying being cared for by others.
• Coping with stressful life events or a lack of identity.
• A sense of accomplishment in duping physicians 

Some experts have described factitious disorder as a type of behavioral addiction. Patients with factitious disorder have described an uncontrollable urge to maintain the sick role and, conversely, a desire to overcome their dependence.[8]

Epidemiology

The prevalence of factitious disorder in the general population is very difficult to estimate and varies widely among different studies. Due to the secretive nature of this disorder, it is likely underdiagnosed; further, there is no defined threshold for the level of deception required to make a diagnosis.[3] One study involving 241 german physicians in primary care and various subspecialty fields estimated factitious disorder prevalence to be 1.3%.[10] Another study analyzing 100 consecutive admissions to an inpatient psychiatric ward in New York found a diagnosis of factitious disorder in 6% of the study population.[7]

Factors that have been ascertained to increase the diathesis of this disease include female sex, employment in the healthcare field, and being unmarried.[4] Most often, factitious disorder onsets in early adulthood or middle age.[1] 

Pathophysiology

Little is known about the pathophysiology of factitious disorder. One study of five individuals with a diagnosis of factitious disorder found that all had excellent intellectual and verbal skills, but neuropsychological testing revealed deficits in conceptual organization and judgment. Based on this, the authors hypothesized that factitious disorder may be related to dysfunction in the right cerebral hemisphere in certain patients.[11] Numerous isolated case reports exist documenting neuroimaging and other findings in patients with factitious disorder. These include hyperperfusion of the right hemithalamus, pathological EEG findings, and mitochondrial disorders.[12][13][14]

History and Physical

Patients with factitious disorder may present to any specialty with self-induced, feigned, or exaggerated symptoms. Some patients with factitious disorder present with simple but serious symptoms such as chest pain, as they know this is more likely to result in hospital admission.[1] Other patients may present with much more complex and elaborate symptoms. A good history and physical exam is essential in making the diagnosis. Many clues may raise a clinician's suspicion, including:[3][4] 

• Inconsistent information provided by the patient
• Symptoms that are especially dramatic or out of proportion with the suspected diagnosis
• Inconsistencies among symptoms and exam findings (e.g., Face-hand test, Hoover's sign)[15]
• Symptoms that are inconsistent with anatomy or physiology (e.g., A sensory deficit that is inconsistent with peripheral nerve distribution.)
• Inconsistencies with patient-provided information and past medical records
• The patient resists the release of medical records.
• The patient has an extensive past medical history and may have numerous ailments.
• Extensive workup and no definite diagnosis - Patients may even have undergone invasive procedures or surgeries.
• Exam findings that contradict patient-provided information (e.g., A patient who denies any surgeries but surgical scars are seen on a physical exam.)

Evaluation

The diagnosis of factitious disorder is most often based on DSM-5 criteria:[3]

• Identified deception; involving falsification of psychological or physical symptoms, or induction of injury or disease.
• The individual presents themselves to others as ill, injured, or impaired.
• The deception is evident in the absence of external rewards.
• Another mental disorder does not better explain the behavior.
• Single or recurrent episodes should specify the behavior.

If factitious disorder is suspected, evaluation should be geared toward providing objective evidence of deception and falsification of a medical or psychiatric condition. There are many findings on evaluation that could help lead to a diagnosis. These include:[3][4]

• Absence of supporting lab work, imaging, or other diagnostic findings for the presumed disease
• Specific labwork proving the falsification of symptoms. For example, in patients with factitious diarrhea, a stool sample may be positive for laxatives or stool osmolality may be consistent with water. In non-diabetic hypoglycemia, testing may be done to rule out exogenous insulin use.
• The patient is witnessed inducing symptoms or interfering with treatment.
• A search of the patient’s room reveals means of inducing symptoms. (e.g., syringes, laxatives, blood pressure medications, sedatives, illicit drugs) This is often part of the consent form signed by a patient upon admission.
• The patient seems overly eager to undergo extensive workup and/or treatment.
• The patient predicts or demonstrates a decline when faced with discharge from the hospital.
• The patient admits to behavior when confronted. 

In certain cases, evidence such as direct observation of the behavior or lab values such as laxatives found in the stool may simplify diagnosis. However, many cases lack definitive evidence and determining what level of evidence is sufficient for diagnosis may be challenging.[4]

Some argue that the DSM does not recognize that deception is normal human behavior and should not be considered pathologic in all cases. It is very common for patients to exaggerate symptoms to receive the attention they desire. This further complicates diagnosis because the threshold at which the behavior is considered pathological is not always clear.[3]

Treatment / Management

Studies show that the only currently available effective treatment for factitious disorder is psychotherapy.[16] Based on available research, medication does not significantly improve symptoms of factitious disorder. However, patients with factitious disorder often have comorbid psychiatric conditions such as depression. In these patients, it is important to treat the comorbid symptoms appropriately, as this may indirectly improve factitious behavior.[17]

The approach taken by a clinician in an effort to initiate treatment has been somewhat controversial. One major barrier to initiating proper treatment is the willingness of the patient. Many experts feel that it is necessary to confront the patient prior to any treatment.[18] It is imperative that a strategy is developed, prior to the confrontation, which minimizes embarrassment and accusations. Some experts recommend that an interprofessional approach be utilized. Participants could include nurses, psychiatrists, primary care physicians, therapists, and family.[3]

Oftentimes patients with factitious disorder will deny their behavior and refuse treatment when confronted. Some experts argue that once a diagnosis is made, confrontation is not necessary, and recommend an approach intended to build a trusting relationship with the patient. Therapeutic strategies may then be employed in an effort to reduce factitious behavior. Additionally, comorbid psychiatric conditions may also be treated with better success.[4]

Differential Diagnosis

When a diagnosis of factitious disorder is suspected, it is important to consider other likely etiologies:

• Malingering - the conscious feigning of symptomatology to obtain secondary gain - is one of the most difficult diagnoses to distinguish from factitious disorder, as motivation may be difficult to ascertain in many cases. It is, therefore, important to rule out any external motivation such as monetary gain or avoidance of work, incarceration, or military service.  
• Conversion disorder and somatic symptom disorder - both involving subconscious processes - may also be difficult to distinguish from factitious disorder. To make this distinction, it is imperative to find objective evidence of deceptive behavior.
• Patients with borderline personality disorder often demonstrate deceptive behavior and present with self-injury. However, these patients typically admit to their self-injury. It should also be considered that these two diagnoses frequently coincide.[7]

Prognosis

Patients with factitious disorder are generally considered to have a poor prognosis. When confronted, a majority of patients deny their behavior, and very few consent to treatment. Of those who do initiate therapy, most drop out. However, there is evidence that patients who persist with long-term therapy have favorable outcomes.[16]

Patients may have comorbid psychiatric conditions, most commonly depression. Patients with comorbid mood, anxiety, or substance use disorders generally have a better prognosis. Personality disorders, especially borderline personality disorder, are often comorbid with factitious disorders, and generally, these patients have a poor prognosis.

Complications

Factitious disorder is not a benign disease and is associated with morbidity and mortality. Patients are known to cause potentially lethal self-injury and undergo risky procedures. Additionally, the cost to the healthcare system is substantial. There are case reports of patients costing the healthcare system hundreds of thousands of dollars.[5]

Deterrence and Patient Education

A comprehensive history and physical exam can prevent the patient from undergoing unnecessary workup and risky procedures. Thorough documentation of all findings and diagnoses in patients with factitious disorder is important for future reference of providers caring for these patients. 

Patients with factitious disorder often deny behavior when confronted, and many are lost to follow-up. However, attempts should be made to initiate proper treatment and provide appropriate care for this population.

Enhancing Healthcare Team Outcomes

Factitious disorder is an inherently secretive disorder, and thus, many patients go undiagnosed and untreated. These patients may present to nearly any specialty. Many physicians and other healthcare providers are not familiar with the management of these patients and strategies for providing care. Healthcare providers must familiarize themselves with tools for identifying these patients to prevent unnecessary workup and risky procedures so that appropriate treatment may be initiated.