Factitious Disorder Imposed on Self

Background

• Factitious disorder imposed on self (also simply called "factitious disorder") is characterized by the fabrication or simulation of illness, injury, or impairment to receive medical care in order to satisfy psychological needs.
  • The motivation for deception is psychological and internal, such as the desire for the sick role, an "adrenaline rush" from medical procedures, or the sense of control through manipulation of healthcare professionals.
  • Methods of deception or fabrication may include exaggeration or lying about medical symptoms or history, mimicking or "acting out" medical symptoms, interfering with diagnostic procedures, or directly inducing an illness or injury.
  • Malingering, or fabricating an illness for external incentives or secondary gain, such as disability or workers' compensation claims, is not characteristic of factitious disorder.
• Factitious disorder appears to be rare, but may be underdiagnosed due to the hidden nature of the condition.
• The most commonly reported clinical scenario of factitious disorder in the medical literature is a young adult or middle-aged woman with a history of occupational or personal experience with the medical field.
• There is a high degree of comorbidity between factitious disorder and other mental and behavioral disorders, including somatic symptom disorder, self-harming, factitious disorder imposed on another, and borderline personality disorder.
• The course may be chronic and enduring, but due to the problematic nature of detection, diagnosis, and the common loss to follow-up of individuals with factitious disorder after diagnosis, there is limited evidence to precisely characterize many clinical aspects of this condition.

Evaluation

• Patients with factitious disorder may present with any type of medical or psychiatric symptom.
• Typical manifestations of factitious disorder include
  • false, exaggerated reports of symptoms, diagnoses, events, or previous diseases
  • reinterpreting known trivial findings
  • feigning signs of disease, as well as concealing disease until it becomes particularly impressive or incurable
  • induction of signs and symptoms, such as by exacerbating existing diseases and injuries or introducing contaminated substances into bodily orifices
  • feigned psychiatric symptoms and diagnoses of all types with or without use of psychoactive substances
• Perform a careful physical exam guided by the type of medical symptoms and presenting concerns. Physical exam findings may detect the methods of deception.
• Recognize and promptly identify warning signs that might suggest factitious disorder, including:
  • history of frequent and varied healthcare use
  • information provided by the patient is inconsistent, selective, or misleading, or the patient is unwilling to allow access to outside information sources
  • atypical presentation, such as an unusual disease course or implausible test results
  • concerning patient behavior such as aggression with healthcare staff, eagerness for medical testing or procedures, or defensiveness when disease process or history is questioned
  • laboratory test results suggestive of deception or fabrication, such as results that are inconsistent or contradictory to patient's report of symptoms
  • remarkable number of tests, consultations, and medical and surgical treatments with no improvement in symptoms
• Diagnose factitious disorder based on Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. (DS.M-5) criteria for factitious disorder imposed on self, which includes fulfillment of all of the following:
  • falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception
  • individual presents themselves to others as ill, impaired, or injured
  • deceptive behavior is evident even in absence of obvious external rewards
  • behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder
• Consider lab testing investigations based on presenting symptoms and exam findings; early recognition of possible tampered specimens or discrepancies in symptoms and testing results may help prevent further harm to patient.
• Consider psychometric and projective testing to assess effort or suboptimal performance, which may help identify malingering or factitious behavior.

Management

• There is very limited information to guide the treatment of factitious disorder, as many patients with this condition are lost to follow-up after diagnosis.
• Treat acute simulated or induced illness per standard management.
• Consider consulting with a psychiatrist and establishing a multidisciplinary team consisting of a psychiatrist, primary care physician, therapist, social worker, and family members to develop treatment a plan, help patient recover, and discuss the discharge plan.
• Request that patients participate in general health-promoting measures in an active and motivated manner as a precondition for further treatment (with or without proof of factitious behavior), such as acceptance of wound closure measures, cessation of substance use, and/or participating in an initial psychotherapy interview.
• To communicate the diagnosis of factitious disorder and encourage treatment, consider constructive confrontation.
  • Involve a psychiatry specialist and ≥ 2 members of the clinical staff at the constructive confrontation meeting with the patient, if possible.
  • Aim for a nonjudgmental discussion regarding the diagnosis.
  • Convey that the intent is to reduce patient harms from self-inflicted methods and iatrogenic intervention.
  • Ensure patient safety prior to discharge from care.
• Consider psychotherapy to offer low-threshold psychological counseling, as in all severe chronic disorders, and to engage in open discussion about factitious behavior.
• Consider therapeutic discharge from the hospital if inpatient care is complete and patient is unwilling to accept the diagnosis or work with the medical team to reduce harm, while reassuring patient that they can return for follow-up care if symptoms worsen.