Article summary of Factitious disorders in medical and psychiatric practices by Yates et al. - Chapter

What are factitious disorders?

Patients with factitious disorders deliberately falsify symptoms associated with physical or psychological illness, injury, or impairment in themselves or others. They may engage in a variety of deceptive behaviors in order to exaggerate or entirely feign the appearance of a medical problem. Common forms of such behaviors are exaggerating the severity of a genuine medical problem, falsely reporting symptoms, acting as if certain symptoms are present when they are not, or interfering with medical tests or test results. Two types of factitious disorders are distinguished, namely factitious disorder imposed on self (FDIOS) and factitious disorder imposed on another (FDIOA). 

How have factitious disorders been diagnostically classified?

We can date the modern scientific recognition of factitious disorders to 1951 with Richard Asher’s introduction of the term Munchausen’s syndrome to describe a chronic pattern of feigned illness behavior. In 1977 Roy Meadow introduced the term Munchausen by proxy to describe a parallel condition in which parents or caretakers falsify health information or produce factitious disease in children. 

How have factitious disorders been classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM)?

Factitious disorders were first included in the third edition of the DSM in 1980. They identified three criteria: 1) deliberately feigned symptoms, 2) sick-role motivation, 3) absence of external incentives. These criteria were maintained until the fifth edition of the DSM in 2013. In that edition there are a few important changes:

• Factitious disorders are no longer a separate chapter, but are part of somatic symptoms and related disorders. This change was made, because somatic symptoms are often the predominant feature in factitious disorders, and most of the cases are found in medical settings rather than psychiatric settings. 

• The terms “FD imposed on self”  and “FD imposed on another” are introduced. 

• The criteria for factitious disorders are changed, to shift the focus of diagnostic assessment away from drawing inferences about underlying motivation. More importantly is the identification of intentional deception, because somatic syndromes lack this intentionally deceptive quality. Motivation to assume the sick role has been removed as a requirement. The revised criteria now are: 1) feigning or the covert production of illness, 2) pretending to be ill, impaired, or injured, 3) deception that occurs without apparent external motivation, 4) exclusion of other disorders. 

What is factitious disorder imposed on self (FDIOS)?

The clinical presentation of factitious medical disorders is highly variable and medical falsification can come in multiple forms, such as exaggerated symptoms or medical history, outright lies about symptoms or medical history, simulations of medical illnesses through the production of compelling signs or symptoms, manipulations to prolong or exacerbate an existing illness, or actual self-induction of a disease. Most of the time a patient will use more than one of these methods of deception. Research indicates that almost any medical problem can be falsified, and with the internet patients are able to research complex diagnoses, forge laboratory reports, and order pharmaceutical drugs. A factitious disorder is more likely to be uncovered in cases that include simulation or self-induction of medical signs, because the diagnosis relies on conclusive evidence of intentional medical deception. For patients that only falsify their medical history or exaggerate symptoms it is more difficult to diagnose factitious disorder. 

What are factitious psychological disorders?

Patients with factitious disorder imposed on self may feign or produce psychiatric illnesses such as alcohol abuse, hallucinations, suicidal or homicidal ideation, pain disorders, Stockholm syndrome, dissociative identity disorder, cult brainwashing, pedophilia, zoophilia, exhibitionism. The symptoms of the patient are often more pronounced when the doctors or medical staff are present and the discrepancies between what the patients describe and what their actual behavior or appearance is become visible. Patients’ symptoms often represent their stereotyped understanding of the mental illness, and medications indicated for that mental illness seem ineffective. The patients are also often unusually receptive to psychiatric hospitalization.  

What role does drug abuse play in factitious psychological disorders?

Among patients with factitious psychological disorders the misuse of drugs and alcohol is common. They may use psychoactive substances to produce actual signs that suggest a mental disorder. The difference between factitious and actual drug abusers is that the factitious disorder patient induces an altered state as a way to mislead caregivers and others, not as an end in itself. 

What is factitious psychosis?

Factitious presentation of psychotic symptoms are very common. Two groups can be identified. The first group is associated with hysterical psychosis. The patients in this group seemed to be suggestible and hypnotizable, which indicates that they may possess a degree of voluntary control over their symptoms. The second group consists mostly of women with severe personality disorders, and involves patients with voluntary control over psychotic symptoms. They appeared to perform more poorly on measures of global assessment and social functioning than patients with actual manic and schizophrenic disorders. 

What is factitious traumatization? 

Patients sometimes fabricate the loss of a loved one with resulting depression or suicidality. They often reveal especially tragic or gruesome deaths. They also often display more pathological moods and behaviors than those of the genuinely bereaved, such as variable or angry affect, feigned physical illness, suicide attempts, pathological lying, and refusal or treatment. Patients may also falsify PTSD symptoms, or they may falsify both their traumas and their symptoms. 

How can patients be diagnosed with a factitious disorder?

Research has indicated some common factors that have often led to a diagnosis of FDIOS, namely: 

• a discrepancy between the patient’s reported symptoms and the results of objective tests

• patients that are caught in the act, or when a search of their belongings reveals suspicious items

• when factitious illness and its response to treatment are atypical, improbable, or impossible

• when patients give dramatic, inconsistent, or selective information about themselves and their medical history (the information is often contradictory with the information gathered from medical notes or family or friends)

• when patients have an usual use of medical terminology and an eagerness for uncomfortable or invasive medical procedures

A problem with the diagnosis of FDIOS is the difficulty of establishing deceptiveness. The criterion is not well established and defined. Psychological and behavioral parameters of voluntariness of symptom production are not given. 

How common is FDIOS? 

Reliable epidemiological data regarding the prevalence of FDIOS is difficult to obtain as secretiveness and intentional deceit are central features. Clinicians are also reluctant to document the disorder for fear of patients taking legal action, disengaging from care, or failing to be taken seriously by hospital staff at a future time when they are in genuine need of medical care. The course of FDIOS is difficult to ascertain as the patients cannot be relied upon to give an accurate history of their medical past, so not much is known about the onset or development of the illness, nor the long-term outcomes. It is expected that patients typically progress from less to more extreme modes of medical deception, and from an episodic to a chronic pattern. 

What are the characteristics of FDIOS patients?

The majority of patients are women with the mean age of 34. Most are reasonably well educated, employed, or in school, and persons with medical or laboratory training are significantly represented. They are connected to a network of family and social contacts, though get few visitors in hospital. They often show signs of lawlessness, self-destructiveness, problems with developing and maintaining relationships, and pathological lying. Also reported is substantial comorbidity with other mental disorders (most common depression, followed by personality disorder and substance abuse). 

What are the causes of FDIOS?

Patients know that they are fabricating a disease, but may not know why they are doing so. It may be a way of coping with poor interpersonal attachments and identity problems, which is supported by strong associations between FDIOS and a history of abuse. The lies often seem to increase self-esteem and solicit interest and admiration from others. 

What is the prognosis of FDIOS?

Factitious disorders imposed on self are associated with morbidity and mortality. The behaviors may lead to disease and disability (not always intentional) and causes physicians to have to perform unnecessary surgeries and treatments. 

What is the treatment for FDIOS?

Treatment is considered impossible due to a lack of cooperation, personality disorders, and sudden departures. Patients often react with denial, aggression, or threats of legal action when confronted. The suspicion of FDIOS must be communicated to others involved in the patient’s medical care. Depending on the symptoms, medical care and psychotherapy may be prescribed and in some cases (when there is risk of engaging in harmful illness behavior) involuntary hospitalization may be necessary (as willingness to enter into treatment is low). Pharmacological interventions are not effective. The best achievable goal is cessation of the illness behavior, for example by telling the patient that not responding to standard treatment confirms self-induced illness. Then while treating the primary comorbid condition, the factitious behaviors can be dealt with. 

What is factitious disorder imposed on another (FDIOA)?

Patients take on the role of caregiver for a sick person by intentionally feigning or producing signs and symptoms of disease in that person. The victims are often children, but can also be disabled adults, elders, or even fetuses. Here is mainly spoken of the relationship of mother and child. The mother may claim that the child is medically or psychiatrically ill, or may make the child actually ill. She will then deny knowledge of the cause of the problem while the child undergoes diagnostic tests, medication trials, and surgeries. Symptoms commonly induced are bleeding, apnea by suffocation, diarrhea, vomiting, fever, abnormal levels of consciousness (for example induced by medications), rash, and false or exaggerated psychiatric or behavioral abnormalities.

How can FDIOA be diagnosed?

There is no empirical evidence that psychiatric examinations are helpful for identifying parents with FDIOA. A big problem is that the alleged abuser often appears a dedicated and concerned parent. However, Dr. Marc Feldman proposed these criteria that focus on objective observation to diagnose FDIOA: 

1. Episodes of illness begin when the mother is or has recently been alone with the child, or the child has symptoms only the mother has seen 

2. Illness disappears when the child is separated from the mother 

3. Other children in the family have had unexplained illnesses

4. The mother has provided false information about the child 

5. Physiological results are consistent with induced illness 

6. The suspected disease or disease pattern is extremely rare 

7. Symptoms do not respond to appropriate treatment 

8. The child has seen several different medical care providers without a cure or diagnosis 

9. The mother has medical or nursing training 

10. The mother has a personal history of somatic symptom disorder 

11. The mother is unresponsive to the child’s needs when unaware of being observed 

12. Additionally, covert video surveillance can provide proof of FDIOA if the parent continues to abuse the child during hospitalization. 

How common is FDIOA?

Reliable epidemiological data regarding the prevalence of FDIOA is constrained by the elusive nature of the diagnosis, and pediatricians’  lack of familiarity with the diagnosis. Illnesses most often fabricated are asthma and allergies. The perpetrators are mostly the mothers of the children, though in some cases also other relatives or caretakers, day care providers, and health care providers. The perpetrators often also have FDIOS and a history of excessive illness behavior. Their behavior seems motivated by different unmet psychological needs, often extending to the wider family system. 

What is the treatment for FDIOA?

Child protection agencies must be alerted when FDIOA is suspected. Even if only temporary, to be able to detect FDIOA, the mother must be separated from the child. This separation is often accompanied by changes in the medication, therapeutic services and diet (also to make clear the role played by the perpetrator with regards to the victim’s health problems). Whether or not a child can be reunited with the parent depends on the following criteria: a) if the child has sufficient cognitive development to report abuse, b) only mild abuse, c) an understanding of the perpetrators as to why the abuse took place, d) identification of trigger situations, and e) understanding of partner complicities. The extended family should also be committed to the safety of the victim and long-term monitoring must be provided. 

What is recommended for the future? 

As patients with factitious disorders respond to confrontation with denial and disengagement, it is a very difficult area of research. However, the following recommendations are made:

• Consolidation of (anonymous) case reports to detect patterns. That will allow authors to submit cases that are unsuitable for journal publications. 

• Increasing the implementation of screening measures for psychosocial correlates in primary care facilities (which is where cases of factitious disorders are most often found). Being able to test for a Cluster B personality trait can be useful for assessing evidence of psychosocial motivations underlying factitious presentations and corroborate other clinical information. 

• Using the experience of health care professionals who have encountered factitious disorders. 

• Anonymous data collection (for example through the internet)

• More widespread use of electronic medical records to be able to reveal previous patterns of excessive and unnecessary treatment-seeking behavior. The problems with electronic medical records are, however, that they often lack narrative comments and that they can only be revealed if the patient agrees to release them.