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Factitious Disorder Imposed on Self

by Joel E. Dimsdale, MD

Factitious disorder is falsification of physical or psychologic symptoms without an obvious external incentive; the motivation for this behavior is to assume the sick role. Symptoms can be acute, dramatic, and convincing. Patients often wander from one physician or hospital to another for treatment. The cause is unknown, although stress and a severe personality disorder, most often borderline personality disorder, are often implicated. Diagnosis is clinical. There are no clearly effective treatments.

Factitious disorder imposed on self was previously called Munchausen syndrome, particularly when manifestations were dramatic and severe. Factitious disorder may also be imposed on another person (see Factitious Disorder Imposed on Another).

Patients may complain of or simulate physical symptoms that suggest certain disorders (eg, abdominal pain suggesting an acute surgical abdomen, hematemesis). Patients often know many associated symptoms and features of the disorder that they are feigning (eg, that pain from an MI may radiate to the left arm or jaw or be accompanied by diaphoresis). Sometimes they simulate or induce physical findings (eg, pricking a finger to contaminate a urine specimen with blood, injecting bacteria under their skin to produce fever or abscess; in such cases, Escherichia coli is often the infecting organism). Their abdominal wall may be crisscrossed by scars from exploratory laparotomies, or a digit or a limb may have been amputated.

These patients initially and sometimes chronically become the responsibility of medical or surgical clinics. Nevertheless, the disorder is a mental problem, is more complex than simple dishonest simulation of symptoms, and is associated with severe emotional difficulties.

Patients may have prominent borderline personality features and are usually intelligent and resourceful. They know how to simulate disease and are sophisticated regarding medical practices. They differ from malingerers because, although their deceits and simulations are conscious and volitional, there are no obvious external incentives (eg, economic gain) for their behavior. It is unclear what they gain beyond medical attention for their suffering, and their motivations and quest for attention are largely unconscious and obscure.

Patients may have an early history of emotional and physical abuse. Patients may also have experienced a severe illness during childhood or had a seriously ill relative. Patients appear to have problems with their identity as well as unstable relationships. Feigning illness may be a way to increase or protect self-esteem by blaming failures on their illness, by being associated with prestigious physicians and medical centers, and/or by appearing unique, heroic, or medically knowledgeable and sophisticated.

Diagnosis

  • Clinical evaluation

Diagnosis is based on history and examination, along with any tests necessary to exclude physical disorders and demonstration of exaggeration, fabrication, simulation, and/or induction of physical symptoms.

Treatment

  • No clearly effective treatments

Treatment is usually challenging, and there are no clearly effective treatments. Patients may obtain initial relief by having their treatment demands met, but their symptoms typically escalate, ultimately surpassing what physicians are willing or able to do. Confrontation or refusal to meet treatment demands often results in angry reactions, and patients usually move from one physician or hospital to another (called peregrination). Recognizing the disorder and requesting psychiatric or psychologic consultation early is important, so that risky invasive testing, surgical procedures, and excessive or unwarranted use of drugs can be avoided.

A nonaggressive, nonpunitive, nonconfrontational approach should be used to present the diagnosis of factitious disorder to patients. To avoid suggesting guilt or reproach, a physician can present the diagnosis as a cry for help. Alternatively, some experts recommend providing mental health treatment without requiring patients to admit their role in causing their illness. In either case, conveying to the patient that the physician and patient can cooperatively resolve the problem is helpful.

Factitious Disorder Imposed on Another

Factitious disorder imposed on another is falsification of manifestations of an illness in another person, typically done by caregivers to someone in their care.

Previously, this disorder was known as factitious disorder by proxy or Munchausen syndrome by proxy. In factitious disorder imposed on another, people, usually caregivers such as a parent), intentionally produce or falsify physical or psychologic symptoms or signs in a person in their care (usually a child), rather than in themselves (as in factitious disorder imposed on self).

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. Victimized children may be seriously ill and sometimes die.

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