Factitious Disorder

SALONI
INTRODUCTION
o Factitious Disorder is a mental health condition characterized by the deliberate
fabrication, exaggeration, or induction of physical or psychological symptoms.
Individuals with this condition aim to assume the role of a sick person, often without
external incentives like financial gain or avoidance of responsibilities.
o According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition), Factitious Disorder is classified under "Somatic Symptom and
Related Disorders". It is defined by the intentional production or feigning of physical
or psychological symptoms for no external rewards (e.g., financial gain or avoiding
legal responsibility).
o Factitious means “artificial , false, “from the Latin facticius, “made by art”.
 HISTORY
o The understanding and recognition of Factitious Disorder have evolved significantly over centuries, with
key developments shaping its conceptualization in psychiatry.
o Early Descriptions
• 17th Century:
• The earliest descriptions of malingering or symptom fabrication were observed in individuals seeking to avoid
military service or other duties.
• These cases were not differentiated from factitious illness at the time.

• 18th Century:
• Physicians like Guillaume de Baillou (a French physician) began recognizing feigned illnesses, noting their
prevalence in society.
o Munchausen Syndrome (1951)
• Coined by British psychiatrist Dr. Richard Asher, the term "Munchausen Syndrome"
described individuals who chronically fabricated medical illnesses to gain attention and
sympathy.
• Named after Baron von Munchausen, an 18th-century German nobleman known for telling
exaggerated and fantastical tales.
o Key Features of Munchausen Syndrome:
• Frequent travel to different hospitals ("doctor shopping").
• Willingness to undergo painful and unnecessary procedures.
• Deep knowledge of medical terminology.
Introduction of Factitious Disorder (DSM-III, 1980)

•The term Factitious Disorder was formally introduced in the DSM-III (1980), shifting focus from Munchausen Syndrome
to a broader category.
•This change aimed to classify individuals with less dramatic but still intentional symptom fabrication.
o Expansion to Factitious Disorder Imposed on Another (1987)

• Recognized as Munchausen Syndrome by Proxy, this subtype described cases where caregivers, often parents, fabricated or induced
illnesses in dependents (e.g., children or elderly individuals).

• The condition became a focus of legal and ethical discussions due to its severe consequences for victims.
o Factitious Disorder in DSM-5 (2013)
• Consolidated and updated in the DSM-5, where Factitious Disorder was categorized under Somatic Symptom
and Related Disorders.
• It now includes:
• Factitious Disorder Imposed on Self.
• Factitious Disorder Imposed on Another.

1. Self-Imposed Symptoms: Individuals may fake or induce illnesses in themselves.

2. Imposed on Another (formerly Munchausen Syndrome by Proxy): A person, often a caregiver, induces or
fabricates symptoms in someone under their care, like a child or dependent.
o Modern Understanding
• Advances in medical technology (e.g., electronic health records) have made it easier to identify patterns of
deception.
• However, Factitious Disorder remains challenging to diagnose due to the deliberate concealment of deceptive
behaviors.
• Ongoing research focuses on psychological profiles, motivations, and treatment strategies.
 Symptoms (According to DSM-V)
o Factitious Disorder Imposed on Self
o Falsification of physical or psychological signs or symptoms, or induction of injury or
disease, associated with identified deception.
o The individual presents himself or herself to others as ill, impaired, or injured.
o The deceptive behavior is evident even in the absence of obvious external rewards.
o The behavior is not better explained by another mental disorder, such as delusional
disorder or another psychotic disorder
o Factitious Disorder Imposed on Another (Previously Factitious Disorder by
Proxy)
Falsification of physical or psychological signs or symptoms, or induction of injury or
disease, in another, associated with identified deception.
The individual presents another individual (victim) to others as ill, impaired, or injured.
The deceptive behavior is evident even in the absence of obvious external rewards.
The behavior is not better explained by another mental disorder, such as delusional
disorder or another psychotic disorder.
Note: The perpetrator, not the victim, receives this diagnosis
 ONSET

o Onset is usually in early adulthood, often after hospitalization for a medical condition or a
mental disorder.
o When imposed on another, the disorder may begin after hospitalization of the individual’s child
or other dependent.
o In individuals with recurrent episodes of falsification of signs and symptoms of illness and/or
induction of injury, this pattern of successive deceptive contact with medical personnel,
including hospitalizations, may become lifelong.
 CASE STUDY

o A 22-year-old female single patient was admitted in our adult psychiatric ward after an unsuccessful serious suicidal
attempt, by taking a significant overdose of diazepam. The patient was already diagnosed with Emotionally Unstable
Personality Disorder (EUPD) and mild depression.
o There was history of emotional dysregulation since adolescence and occasionally self-harming behavior by cutting. There
were no previous admissions in psychiatric hospitals documented and there was no history of previous overdoses or
suicide attempts. She was feeling low in mood for more than a year due to stressors, including her physical health and
history of sexual abuse. She was intermittently experiencing auditory pseudo-hallucinations (the voice of the abuser). The
patient described the voice as coming from her inner subjective space and lacked the objectivity and sensory realness of a
true hallucination.
o The patient under investigation was physically unwell since childhood (asthma and epilepsy), which resulted in several
hospital admissions during childhood and excessive school absenteeism.
o She had started studying nursing science but was dropped out of university.
o The relationship with family members was poor after several incidents of aggression/agitation towards them.

o During the last year prior to admission in our psychiatric ward she had several admissions in the local hospitals, in various wards
with a variety of physical symptoms (chest pain, seizures, etc). Staff noticed unusual behavior (simulating to be ill) and she was
referred for psychiatric assessment six months prior to admission in our ward. The patient at that point was uncooperative in
disclosing any information and the psychiatric team concluded that there was insufficient evidence to make the diagnosis of FD.

o During the last 6 months prior to psychiatric admission she used to attend others departments more frequently, especially during
the nights and she got admitted on several wards.

o She used to present with chest pain, alleged seizures, dizziness, difficulty breathing, abdominal pain, urinary retention, etc. Her
mother reported that as the time progressed she was leaving the house only to go to the hospital or to the GP surgery.

o During her hospitalisation staff noticed again unusual behaviour: “she was saying she couldn’t pass urine in order to have a
catheter put in. She was repeatedly asking for intramuscular injections and more cannula insertions, even asking for central line
insertion. She was putting herself on the floor and saying she had a seizure (one incident was recorded on one of the cameras).

o She used to phone the respiratory ward roughly twice a week saying she was unwell and needed to be seen urgently. When she
went to the ward and doctors said her chest was fine, she would then wish to say a list of other problems unrelated to her
respiratory health, such as back pain, tooth ache, etc.
o A second referral to the psychiatric services had been made, but in the meantime the patient took the overdose that
resulted in her admission to our psychiatric ward.

o The patient had been suffering from asthma since childhood (poorly controlled when young), epilepsy, gastro-
oesophageal reflux disease, irritable bowel syndrome, spinal epidural lipomatosis and osteoporosis.

o On admission, she was on 33 different medications from various medical specialties, including inhalers, painkillers, etc.
She had been taking cimetidine, ranitidine and omeprazole simultaneously. She had also been taking paracetamol,
oxycodone, gabapentin, amitriptyline, fentanyl patches and, when required, oramorph for neuropathic pain. The only
psychotropic medication was diazepam 5mg twice a day. We considered that amount of medication as a significant
substance misuse and we tried, with the assistance of the respiratory and medical team, to reduce her medication from 33
to 19 drugs. Initially, she was very aggressive towards staff and was constantly asking for her initial medication to be
prescribed again.

o During her admission she used to simulate all kind of physical symptoms on a daily basis and several times during the
day. She was very well informed about various medical conditions to the extent that all the on-call doctors used to find the
interaction with her really challenging. She knew how to instigate an asthmatic crisis or how to successfully pretend she
was having a seizure. Staff and doctors were trying not to reinforce her attention seeking behavior by not paying much
attention to her constant physical complaints, but they were very stressed because this patient has already serious physical
health problems and staff and doctors were afraid of being accused of negligence. There is one incident documented,
when she had a genuine asthmatic crisis and she was ignored by staff members. There were also a few incidents of head
banging, as well as some self-strangulation attempts.
o but she was explicitly denying the diagnosis of FD, despite plenty of evidence showing her pretending to be ill. She used to
become very aggressive and hostile towards the consultant in charge of treatment once she was confronted with the diagnosis
of FD and she used to keep saying that it was a false diagnosis and that she was only physically unwell.

o Treatment

o In terms of treatment she had weekly hourly appointments with the ward psychologist for stabilisation with a view to starting
psychotherapy in the future.

o Initially she did not engage well with the stabilisation therapy and she missed lots of sessions.

o In our Trust when patients have a history of complex trauma, psychoeducation around the diagnosis and stabilisation skills
are offered as a first phase of psychological treatment.

o The intervention enables clients to understand their diagnosis and develop skills to help regulate their emotional intensity.

o Stabilisation ( the process of making something physically more secure and stable) is a structured psychological intervention.

o
o The number of sessions provided depend on the patients level of understanding and ability to adopt new
skills.

o All clients with complex trauma have this intervention prior to receiving either EMDR (Eye Movement
Desensitization and Reprocessing, a psychotherapy technique that helps people heal from traumatic
memories and other distressing experiences) or psychotherapy.

o They started her initially on quetiapine 200mg three times a day and sertraline 150mg in the morning, to
help her with impulsive behavior and low mood, but she experienced excessive drowsiness with
quetiapine and we had to discontinue it.

o She was subsequently started on zuclopenthixol decanoate 200mg weekly injection. After less than a
month of receiving the injection, she showed significant improvement in terms of pretending less symptoms
and engaging in far less impulsive behaviors.
Factitious Disorder Imposed on Another (Munchausen’s
Syndrome by Proxy Case

o Over a period of 20 months, Jennifer, 8, shown here with her mother, Kathy Bush, was taken to
the hospital more than 130 times, underwent 40 surgeries, and amassed over $3 million in
medical expenses. Doctors and nurses testified that Jennifer’s condition always worsened after
her mother visited her daughter at the hospital behind closed doors. In addition, Jennifer’s
health has significantly improved since being removed from her mother’s care. The jury was
convinced that Kathy Bush was responsible for causing Jennifer’s illnesses. Bush was arrested
and diagnosed with Munchausen’s syndrome by proxy.
 CAUSES
o The causes of Factitious disorder whether physical or psychiatric are difficult to determine because these
patients are often lost to follow-up when they sign out of the hospital
o PSYCHODYNAMIC EXPLANATIONS
o Patients with FD are trying to re-enact unresolved childhood issues with parents.
o They have underlying problems with masochism (the tendency to derive sexual gratification from one's
own pain or humiliation.)
o They need to be the center of attention and feel important.
o They need to receive care and nurturance.
o They are bothered by feelings of vulnerability.
o Deceiving a physician allows them to feel superior to an authority figure.
 RISK FACTORS
o There are several known risk factors for factitious disorder, including:
o The presence of other mental or physical disorders in childhood that resulted in the patients getting
considerable medical attention.
o A history of significant past relationships with doctors, or of grudges against them.
o PREDISPOSING FACTORS
o The presence of other mental disorders or general medical conditions during childhood or adolescence
that may have led to extensive medical treatment and hospitalisation.
o Family disruption or emotional and/or physical abuse in childhood.
o A grudge against the medical profession, employment in a medically related position.
o UNSTABLE INTERPERSONAL RELATIONSHIPS
o These patients often resemble persons with borderline personality in that they
manifest identity disturbances, unstable interpersonal relationships and recurrent
suicidal or self-mutilating behaviour, in addition, their deceitfulness, lack of
remorse, reckless disregard for their safety and repeated failure to sustain
consistent work behavious resemble antisocial disorder )Szoke, 1999)
o It has also been theorised that Munchausen patients are motivated by a desire to be
cared for, a need for attention, dependency, ambivalence towards doctors or an
existing personality disorder
o They may delight in outwitting the medical profession, whom they regard as
highly trained (Feldman, 2004)
 Differential Diagnosis
o Caregivers who lie about abuse injuries in dependents solely to protect themselves from liability are
not diagnosed with factitious disorder imposed on another because protection from liability is an
external reward (Criterion C, the deceptive behavior is evident even in the absence of obvious
external rewards). Such caregivers who, upon observation, analysis of medical records, and/or
interviews with others, are found to lie more extensively than needed for immediate self-protection
are diagnosed with factitious disorder imposed on another.
o Somatic symptom disorder - In somatic symptom disorder, there may be excessive attention and
treatment seeking for perceived medical concerns, but there is no evidence that the individual is
providing false information or behaving deceptively.
o Malingering - Malingering is differentiated from factitious disorder by the intentional reporting of
symptoms for personal gain (e.g., money, time off work). In contrast, the diagnosis of factitious
disorder requires the absence of obvious rewards.
o Conversion disorder (functional neurological symptom disorder) - Conversion disorder is characterized
by neurological symptoms that are inconsistent with neurological pathophysiology. Factitious disorder with
neurological symptoms is distinguished from conversion disorder by evidence of deceptive falsification of
symptoms.
o Borderline personality disorder - Deliberate physical self-harm in the absence of suicidal intent can also
occur in association with other mental disorders such as borderline personality disorder. Factitious disorder
requires that the induction of injury occur in association with deception.
o Medical condition or mental disorder not associated with intentional symptom falsification -
Presentation of signs and symptoms of illness that do not conform to an identifiable medical condition or
mental disorder increases the likelihood of the presence of a factitious disorder. However, the diagnosis of
factitious disorder does not exclude the presence of true medical condition or mental disorder, as comorbid
illness often occurs in the individual along with factitious disorder. For example, individuals who might
manipulate blood sugar levels to produce symptoms may also have diabetes.
 Treatment / Management
Carnahan, K. T., & Jha, A. (2023). Factitious disorder. In StatPearls [Internet]. StatPearls Publishing.

o Studies show that the only currently available effective treatment for factitious disorder is psychotherapy.
o 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.
o In these patients, it is important to treat the comorbid symptoms appropriately, as this may indirectly improve
factitious behavior.
o The approach taken by a clinician to initiate treatment has been somewhat controversial. One major barrier
to initiating proper treatment is the willingness of the patient.
o Many experts feel that it is necessary to confront the patient before any treatment.
o A strategy must be developed before the confrontation to minimize embarrassment and accusations.
Some experts recommend that an interprofessional approach be utilized. Participants could include
nurses, psychiatrists, primary care physicians, therapists, and family.
o Oftentimes, patients with factitious disorder deny their behavior and refuse treatment when confronted.
o 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 to reduce factitious behavior. Additionally, comorbid psychiatric conditions may also be
treated with better success.
o Psychotherapy
o The main treatment goal for Munchausen syndrome is to change the person's behavior and lessen the
misuse/overuse of medical resources.
o Treatment usually consists of psychotherapy (mental health counseling).
o During treatment sessions, the therapist may try to challenge and assist in changing the thinking and behavior of
the person (this is known as cognitive behavioral therapy). Therapy sessions may also try to uncover and address
any underlying psychological issues that may be causing the person's behavior.
o In addition to individual therapy, treatment may also include family therapy. Teaching family members how to
properly respond to a person diagnosed with Munchausen syndrome/FDIS can be helpful.
o The therapist can teach family members not to reward or reinforce the behavior of the person with the disorder.
This may lower the person's need to appear sick since they may no longer be receiving the attention they are
seeking
o Medication
o Medication is typically not used in the treatment of FD. If the person is also experiencing anxiety or depression,
however, a doctor may prescribe medication, including selective serotonin reuptake inhibitors (SSRIs), serotonin-
norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, and tricyclic antidepressants (TCAs).
o If this is the case, it is important that the person is closely monitored because of the higher likelihood of using
these medications to purposely hurt themselves.
 DIFFERENCES

o In factitious disorder the person intentionally produces psychological or physical symptoms (or both).
Although this may strike you as strange, the person’s goal is to obtain and maintain the benefits that
playing the “sick role” (even to the extent of undergoing repeated hospitalizations) may provide, including
the attention and concern of family and medical personnel. However, there are no tangible external
rewards. In this way, factitious disorder differs from malingering.
o In malingering the person is intentionally producing or grossly exaggerating physical symptoms and is
motivated by external incentives such as avoiding work or military service or evading criminal
prosecution (APA, 2013; Maldonado & Spiegel, 2001).
o Conversion disorder involves unintentional neurological symptoms, such as motor or sensory deficits,
symptoms are real to the person experiencing them, but there's no known medical cause and symptoms
are often triggered by stressful events, emotional issues, or mental health disorders.
 References

o Neeraj, A. (2006). A short text book of psychiatry. New Delhi, Jaypee Brothers Medical
Publishers (P) Ltd.,, 178-181.
o Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM‐5: Classification and criteria
changes. World psychiatry, 12(2), 92-98.
o Coleman, T. R., Butcher, J. N., & Carson, R. C. (1974). Abnormal psychology. MSS
Information Corporation.
o https://youtu.be/eNDDyC25QgA?si=10U2lnrYSs8H-bvZhttps://youtu.be/eNDDyC25QgA?
si=10U2lnrYSs8H-bvZ