What are factitious disorders?

Causes and Symptoms

Although factitious disorders cover a wide array of physical symptoms and are believed to be closely related to a subset of psychophysiological disorders (somatoform disorders), they are unique in all of medicine for two reasons. The first distinguishing factor is that whatever the physical disease for which treatment is sought and regardless of how serious, the patients who seek its treatment have deliberately and intentionally produced the condition. They may have done so in one of three ways, or in any combination of these three ways. First, patients fabricate, invent, lie about, and make up symptoms that they do not have; for example, they claim to have fever and night sweats or severe back pain that they actually do not have. Second, patients have the actual symptoms that they describe, but they intentionally caused them; for example, they might inject human saliva into their own skin to produce an abscess or ingest a known allergic food to cause the predictable reaction. Third, someone with a known condition such as pancreatitis has a pain episode but exaggerates its severity, or someone else with a history of migraines claims his or
her headache to be yet another migraine when it is not. Factitious disorders may manifest as complaints about psychological problems, physical problems, or both.

The second element that makes these disorders unique (and at the same time both fascinating to study and frustrating to treat) is that the sole motivation for causing or claiming the symptoms is for these patients to become and remain patients, to assume the sick role wherein little can be expected from them. These patients are not malingerers, individuals who consciously use actual or feigned symptoms for some other gain (such as claiming a fever so one does not have to go to work or school, or insisting that one’s post-traumatic stress is worse than it is to enhance the judgment in a lawsuit). In fact, it is the absence of any discernible external benefit that makes these disorders so intriguing.

Technically, psychiatrists and psychologists understand factitious disorders as having three subtypes. In the first, patients claim to have predominantly psychological symptoms such as memory loss, depression, contemplation of suicide, the hearing of voices, or false memory of childhood molestation. Characteristically, the symptoms worsen whenever the patients know themselves to be under observation. In the second, patients have predominantly physical symptoms that at least superficially suggest some general medical condition. In a more extreme form called Münchausen syndrome, individuals will have spent much of their lives getting admitted to medical facilities and, once there, remain as long as possible. While common complaints include vomiting, dizziness, blacking out, generalized rashes, and bleeding, the symptoms can involve any organ and seem limited only to the individuals’ medical knowledge and experience with the medical system. The third subtype combines both psychological and physical complaints in such a way that neither predominates.

Regardless of the subtype, factitious disorders are difficult to diagnose. Usually, the diagnosis is considered when the course of treating either a medical or a mental illness becomes atypical and protracted. Often, the person with a factitious disorder will present in a way that seems odd to the experienced clinician. The person may have an unusually extensive history of traveling, much familiarity with medical procedures and terminology, a complex medical and surgical history, few visitors during the hospitalization, behavioral disruptions and disturbances while hospitalized, exacerbation of symptoms while under observation, and/or fluctuating illness with new symptoms and complications arising as the workup proceeds. When present, these traits along with others make suspicion of factitious disorders reasonable.

No one knows how many people suffer with factitious disorders, but the condition is generally regarded as uncommon. It is certainly rarely reported, but this in part may be attributable to the difficulties in determining the diagnosis. While brief episodes of the condition occur, most people who claim a factitious disorder have it chronically, and they usually move on to another physician or facility when they are confronted with the true nature of their illness. It is therefore likely that some individuals are reported more than once by different hospitals and providers.

There is little certainty about what causes factitious disorders. This is true in large measure because those who know the most about the subject—patients with the disorder—are notoriously unreliable in providing information about their psychological state and often seem only dimly aware of what they are doing to themselves. It may be that they are generally incapable of putting their feelings into words. They are unaware of having inner feelings and may not know, for example, that they are sad or angry. It is possible that they experience emotions more physically, behaviorally, and concretely than do most others.

Another view suggests that people learn to distinguish their primitive emotional states through the responsivity of their primary caretaker. A normal, healthy, average mother responds appropriately to her infant’s differing affective states, thereby helping the infant, as he or she develops, to distinguish, define, and eventually name what he or she is feeling. When a primary caretaker is, for any of several reasons, incapable of responding in consistently appropriate ways, the infant’s emotional awareness remains undifferentiated and the child experiences confusion and emotional chaos.

It is possible, too, that factitious disorder patients are motivated to assume what sociology defines as a sick role wherein people are required to acknowledge that they are ill and are required to relinquish adult responsibilities as they place themselves in the hands of designated caretakers.

Treatment and Therapy

Understanding how to identify individuals with factitious disorders early in their treatment process is crucial to public health for three important reasons. First, early identification will help the individual obtain a more appropriate referral. Second, it will conserve valuable health care resources, so that clients who have pressing medical needs get the treatment that they deserve. Third, the earlier in the process these individuals can be identified, the sooner valuable health care dollars can be saved, lowering the cost of health care as a whole.

Internists, family practitioners, and surgeons are the specialists most likely to encounter patients with factitious disorders, although psychiatrists and psychologists are often consulted in the management of these patients. These patients pose a special challenge because, in a real sense, they do not wish to become well even as they present themselves for treatment. They are not ill in the usual sense, and their indirect communication and manipulation often make them frustrating to treat using standard goals and expectations.

Sometimes mental and medical specialists’ joint, supportive confrontation of these patients results in a disappearance of the troubling and troublesome behavior. During these confrontations, the health professionals are acknowledging that such extreme behavior evidences extreme distress in these patients, and as such is its own reason for psychotherapeutic intervention. These patients are not psychologically minded, however; they also have trouble forming relationships that foster genuine self-disclosure, and they rarely accept the recommendation for psychotherapeutic treatment. Because they believe that their problems are physical, not psychological, they often become irate at the suggestion that their problems are not what they believe them to be. Taken from the patient’s perspective, this anger makes some sense. For them, they have endured significant time in evaluation and often also a good bit of money, and if they are lacking insight into their condition, such a confrontation may leave them feeling helpless and misunderstood. As such, even in these circumstances, empathy remains an important element in successful intervention.

Bibliography:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Arlington, Va.: Author, 2013.

Feldman, Marc D. Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York: Brunner-Routledge, 2004.

Mayo Clinic Staff. "Munchausen Syndrome." Mayo Clinic, May 13, 2011.

McCoy, Krisha, Rebecca Stahl, and Brian Randall. "Factitious Disorder." Health Library, Mar. 15, 2013.

New, Michelle. "Munchausen by Proxy Syndrome." KidsHealth. Nemours Foundation, Mar. 2012.

Phillips, Katherine A., ed. Somatoform and Factitious Disorders. Washington, D.C.: American Psychiatric Association, 2001.