Factitious Disorders and Malingering

Key Concepts

Patients who have consciously synthesized symptoms and signs may be divided into two broad diagnostic categories: (1) those with obvious secondary gain (malingering), who control their actions, and (2) those with a motivation of achieving the sick role (factitious disorders), who cannot control their actions.
The initial management of patients suspected of fabricating disease should include a caring, nonjudgmental attitude and a search for objective clinical evidence of treatable medical or psychiatric illness. Review of old medical records and interviews of family members are often helpful.
Unnecessary tests, medications, and hospitalizations should be avoided in the absence of objective evidence of a medical or psychiatric disease, and patients should be referred for ongoing primary care.
In cases of suspected factitious disorder imposed on another (FDIA) involving children or elders, protection of the victim takes first priority.

Foundations

Patients may present to the emergency department (ED) with symptoms that are simulated or intentionally produced. The reasons that cause this behavior define two disorders: factitious disorders and malingering.

Factitious disorders are characterized by symptoms or signs that are intentionally produced or feigned by the patient in the absence of apparent external incentives. ^, These patients constitute up to 3% of general psychiatric referrals. However, the prevalence of factitious disorders in emergency departments is thought to be higher because these patients rarely accept psychiatric treatment and are frequently undiagnosed. ^, These patients are often seen in other health care settings including infectious disease for fever of unknown origin, epilepsy clinics for psychogenic seizures, and nephrology clinics for renal stones. Factitious disorders have been associated with costs up to $1 million per case. Early diagnosis of factitious disorder can have a significant impact on the utilization of unnecessary investigations, treatments, and hospital admissions within a health care system.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies factitious disorders into two types: factitious disorder imposed on self (FDIS) and factitious disorder imposed on another (FDIA).

Munchausen syndrome , the most dramatic form of FDIS, was originally described in 1951. This rare syndrome takes its name from Baron Karl F. von Munchausen (1720–1797), a revered German military officer and noted raconteur who had his embellished life stories stolen and parodied in a 1785 pamphlet. While commonly discussed, the incidence of Munchausen syndrome is estimated to be approximately 0.5 to 2 per 100,000 children. Other names used to describe FDIS include the “hospital hobo syndrome” (patients wander from hospital to hospital seeking admission), peregrinating (wandering) patients, hospital addict, polysurgical addiction, and hospital vagrant. ^,

Factitious disorder imposed on another (FDIA) involves the simulation or production of a factitious mental or physical disease in an individual by a caregiver. It was first described in 1977. Due to the difficulty in identification, the prevalence of FDIA is not known. This condition often involves a child and a mother. The condition excludes straightforward physical abuse or neglect and simple failure to thrive; mere lying to cover up physical abuse is not FDIA. The key discriminator is motive: the caregiver is making the child ill so that they can vicariously assume the sick role with all its benefits. FDIA has a mortality rate of 6% to 30%. ^, Permanent disfigurement or permanent impairment of function can occur directly from induced disease or indirectly from invasive procedures, multiple medications, or major surgery. Other names applied to this condition include Polle syndrome (Polle was a child of Baron Munchausen who died mysteriously), factitious disorder by proxy, pediatric condition falsification, Munchausen syndrome by proxy, and Meadow syndrome. ^,

Malingering is the simulation of disease by the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives, such as avoidance of military responsibility, avoidance of work, obtaining financial compensation, evading criminal prosecution, obtaining medication, hospital admission (for the purpose of obtaining free room and board), or securing of better living conditions. The most common goal among such “patients” presenting to the ED is to obtain medications, whereas in the office or clinic the gain is more commonly insurance payments or industrial injury settlements. The true incidence of malingering is difficult to gauge because of underreporting, but estimates include a 1% incidence among mental health patients in civilian clinical practice, and as high as 10% among inpatient psychiatric patients with suicidality. In one review, 33% of patients assessed in a psychiatric emergency department were suspected of malingering. Some clinicians are resistant to document malingering in a patients’ chart due to concern for lack of reimbursement and legal liability. ^, The most likely conditions to be feigned are conditions that are difficult to exclude objectively, such as suicidal ideations, depression, mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain. ^, ^,

Clinical Features

Factitious Disorders

Factitious Disorders Imposed on Self

The diagnosis of FDIS depends on specific criteria ( Box 100.1 ). With a factitious disorder, the production of symptoms and signs is compulsive; the patient is unable to refrain from the behavior even when its risks are known. The behavior is voluntary only in the sense that it is deliberate and purposeful (intentional) but not in the sense that the acts can be fully controlled. The underlying motivation for producing these deceptions, securing the sick role, is primarily unconscious. ^, Individuals who readily admit that they have produced their own injuries (e.g., self-mutilation) are not included in the category of factitious disorders. Presentations may be acute, in response to an identifiable recent psychosocial stress (termination of romantic relationship, threats to self-esteem), or a chronic life pattern, reflective of the way in which the person deals with life in general. The symptoms involved may be either psychological or physical. ^, ^,

BOX 100.1

DSM-5 Criteria for the Diagnosis of Factitious Disorder Imposed on Self

Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , ed 5. Arlington, VA: American Psychiatric Association; 2013.

1.
Falsification of psychological or physical signs or symptoms, or induction of disease or injury associated with identified deception.
2.
The individual presents to others as injured, ill, or impaired.
3.
The deceptive behavior is apparent even in the absence of external incentives.
4.
The behavior is not better explained by another mental disorder.

Psychological Symptoms

Individuals may intentionally produce or feign psychological (often psychotic) symptoms suggestive of a mental disorder. Stimulants may be used to induce restlessness or insomnia; hallucinogens, to create altered levels of consciousness; and hypnotics, to produce lethargy. This psychological factitious condition is less common than factitious disorders with physical symptoms and is almost always superimposed on a severe personality disorder. ^, ^,

Physical Symptoms

The intentional production of physical symptoms may take the form of fabricating symptoms without signs (e.g., feigning abdominal pain), simulation of signs suggesting illness (e.g., fraudulent pyuria, induced anemia), self-inflicted conditions (e.g., the production of abscesses by injection of contaminated material under the skin), or genuine complications from the intentional misuse of medications (e.g., hypoglycemic agents). These patients are predominantly unmarried women younger than 40 years old. They typically accept their illness with few complaints and are generally well-educated, responsible workers or students with moral attitudes and otherwise conscientious behavior. A majority of individuals with factitious disorder are employed in health care settings, including laboratory technicians, nurses, and physicians. There is an increased rate of personality disorders and depression among individuals with factitious disorder. ^,

These patients are willing to undergo incredible hardship, limb amputation, organ loss, and even death to perpetuate the masquerade. Although multiple hospitalizations often lead to iatrogenic physical conditions, such as postoperative pain syndromes and drug addictions, patients continue to seek hospitalization for its own sake. They typically have a fragile and fragmented self-image and are susceptible to psychotic and suicidal episodes. Interactions with the health care system and relationships with caregivers provide the needed structure that stabilizes the patient’s sense of self. Some patients are driven by the conviction that they have a real but as yet undiscovered illness. Consequently, artificial symptoms are contrived to convince the physician to continue a search for the elusive disease process. Factitious illness behavior has also emerged on the internet. “Virtual support groups” offering person-to-person communications through chat rooms or websites have been perpetrated by individuals, under the pretense of illness or personal crisis, for the purpose of extracting attention or sympathy, acting out anger, or exercising control over others.

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