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Factitious Disorder Imposed on Self

by Joel E. Dimsdale, MD

Factitious disorder is pretending to have or producing physical or psychologic symptoms for no apparent external reason.

  • The cause is unknown, but stress and a severe personality disorder may contribute.

  • Symptoms may be dramatic and convincing.

  • People may wander from one doctor or hospital to another in search of treatment.

  • Doctors diagnose the disorder after excluding other disorders and after discovering evidence that symptoms have been faked.

  • There are no clearly effective treatments, but psychotherapy may help.

Factitious disorder imposed on self was previously called Munchausen syndrome. Factitious disorder may also be imposed on another person (see Factitious Disorder Imposed on Another).

People with factitious disorder imposed on self repeatedly fake having a disorder. If they have a disorder, they exaggerate or lie about the symptoms, pretending that they are sicker or more impaired than they are. However, this disorder is more complex than simple dishonesty. It is a mental health problem that is associated with severe emotional difficulties.

The cause is unknown, but stress and a severe personality disorder, most often borderline personality disorder (see Borderline personality disorder), may be involved. People may have an early history of emotional and physical abuse, or they may have experienced a severe illness during childhood or had a seriously ill relative. They appear to have problems with their identity and/or self-esteem, as well as unstable relationships. Faking an illness may be a way to increase or protect self-esteem by blaming social or work problems on their illness, by being associated with prestigious doctors and medical centers, or by appearing unique, heroic, or medically knowledgeable and sophisticated. People with this disorder resemble malingerers because their actions are conscious and intentional. However, unlike malingerers, people with factitious disorder are not motivated by external rewards (such as collecting insurance or getting time off from work).

Symptoms

People may report physical symptoms that suggest a particular disorder, such as chest pain that resembles a heart attack. Or they may report symptoms that could result from many different disorders, such as blood in their urine, diarrhea, or fever. They often know a lot about the disorder they are pretending to have—for example, that pain from a heart attack may spread from the chest to the left arm or jaw. They may change medical records to provide evidence that they have a disorder. Sometimes they do something to themselves to produce the symptom. For example, they may prick a finger and put the blood in a urine specimen. Or they may inject bacteria under their skin to produce a fever and sores.

People with the disorder are usually quite intelligent and resourceful. They not only know how to convincingly fake a disorder, but they also have sophisticated knowledge of medical practices. They can manipulate their care so that they are hospitalized and subjected to intense testing and treatment, including major operations. Their deceits are conscious, but their motivation and quest for attention are largely unconscious. They often wander from one doctor or hospital to another for treatment.

The disorder may continue throughout life.

Diagnosis

Doctors first check for a physical and mental health disorders by taking a thorough medical history, doing a thorough physical examination, and doing tests. Most of the time, the person's description of symptoms is convincing, sometimes misleading doctors. However, doctors may suspect the disorder based on the following:

  • The medical history is dramatic but inconsistent.

  • Treatment worsens rather than relieves symptoms.

  • After test results come back negative or after they are treated for one group of symptoms, people develop different symptoms or go to another hospital for care.

  • People have an extensive knowledge of medical practice.

  • People are willing or eager to have diagnostic tests and surgical procedures.

  • They have a history of frequent visits to many different doctors and hospitals.

  • They resist letting doctors talk to family members and to doctors who have treated them in the past.

The diagnosis is made after other disorders are ruled out and when doctors observe or discover evidence of exaggeration, faking, falsification, self-induced production of symptoms, or alterations in the medical history.

Doctors may refer the person to a psychiatrist or other mental health practitioner.

If the disorder is diagnosed early, risky invasive testing, surgical procedures, and unnecessary treatments can be avoided.

Treatment

There are no clearly effective treatments. If people are treated for the disorder that they are faking, they may temporarily feel relief but then typically report additional symptoms and demand further treatments. An important part of treatment is avoiding unnecessary treatments.

Psychotherapy, particularly cognitive-behavioral therapy, may help. It focuses on changing the thinking and behavior of the person. It may also help the person identify and work on underlying issues that are causing the disorder.

Factitious Disorder Imposed on Another

Factitious disorder imposed on another is falsifying or producing symptoms of a physical or psychologic disorder in another person. It is usually done by caregivers (typically parents) to someone in their care.

This disorder used to be called factitious disorder by proxy or Munchausen syndrome by proxy.

Factitious disorder imposed on another is similar to factitious disorder imposed on self, except that people (usually caregivers, typically a parent) intentionally falsify or produce physical or psychologic symptoms in a person in their care (usually a child).

The caregiver falsifies history and may injure the child with drugs or other agents or add blood or bacterial contaminants to urine specimens to simulate disease. The caregiver seeks medical care for the child and appears to be deeply concerned and protective. The child typically has a history of frequent hospitalizations, usually for a variety of nonspecific symptoms, but no firm diagnosis was made. Such children may be seriously ill and sometimes die because of the caregiver's attempts to simulate an illness.