Factitious Gastrointestinal Disease

Acknowledgment

The authors thank Marc D. Feldman, MD, from the Departments of Psychiatry and Psychology at the University of Alabama, Tuscaloosa, Alabama for his many contributions to this chapter in the 10th edition.

An accepted principle of the patient-physician relationship is that the patient should make every attempt to regain health, including faithfully and unreservedly communicating to his or her physician the supposed cause of illness. In at least 4 recognized disorders, patients typically or sometimes deviate from this covenant by self-inducing disease, feigning illness, withholding information regarding the cause of illness, exaggerating the severity of symptoms, or presenting a false medical history or medical records. These disorders include factitious disorder (FD), somatic symptom disorder (SSD), malingering, and eating disorders. The presumed motive for deviation from normal illness behavior varies in these 4 disorders, but regardless of motive, the result is that the physician is deceived.

The purposes of this chapter are to discuss the possible etiologies of these abnormal illness behaviors, provide suggestions on how to recognize them, and point out some ethical conflicts that confront physicians taking care of such patients. We will emphasize the types of deceptive behaviors most likely to be encountered in the practice of gastroenterology and the iatrogenic diseases that are most likely to develop because of them. We will not discuss patients within these groups who present with psychiatric symptoms or with extreme manifestations of FD, such as Munchausen syndrome or Munchausen syndrome by proxy.

Factitious Disorder, Subtle Form

The subtle form of FD was first described in 1864 by Hector Gavin. He observed it mainly in “indulged females” who “mimicked or counterfeited illness to gain compliance with their wishes, or to excite interest, or for the pleasure of deceiving.” The motive for this behavior is believed to be relief of emotional distress by assumption of the “sick role.” These patients are usually women in their 30s. Typically they lead an outwardly normal life, are employed and medically insured, and are highly cooperative with their caregivers. FD is considered a psychiatric illness, but the patients seek medical care from nonpsychiatric physicians. Case 1 illustrates subtle FD, which is also referred to as the “socially conformist” type of FD.

CASE 1

A 37-Year-Old Woman With Diarrhea

The patient began to have diarrhea a few days after undergoing reconstructive jaw surgery. Extensive evaluations failed to reveal a cause of diarrhea, and the patient was referred to our medical center, where she was evaluated as an outpatient. By quantitative stool collection, her average stool weight was 1008 g/day (normal stool weight for women is 87 ± 8 g/day.) The diarrhea was secretory in nature according to electrolyte analysis. Fecal fat output was within normal limits. Serum gastrin and vasoactive intestinal polypeptide (VIP) concentrations were normal, and stool culture revealed no pathogens.

Because we were unable to find a cause of the patient’s chronic secretory diarrhea, and because of multiple other medical and surgical illnesses prior to the onset of diarrhea (see later), we suspected surreptitious laxative ingestion with bisacodyl or senna. However, the patient denied ingestion of laxatives, a urine and stool laxative screen (Toxi-Lab) were negative, and the patient did not have pseudomelanosis coli on colonic biopsy specimens (see Chapter 128 ). We did not search her personal belongings (which were kept in her hotel room), and we did not confront her with our suspicion. She was discharged with advice on fluid and electrolyte replacement and symptom management, and with an offer to return at any time.

Approximately 1 year after her evaluation at Baylor University Medical Center, the patient went to another medical center, where endoscopies were repeated, but no diagnosis was forthcoming. A colonoscopy with biopsy was complicated by severe bleeding, and she required transfusion of multiple units of blood. Owing to continuing weight loss, parenteral nutrition was begun. After the diarrhea had been present for about 4 years, she returned to Baylor University Medical Center. By that time, we had shown that the Toxi-Lab assay for laxatives was unreliable. We therefore had her urine analyzed by thin-layer chromatography, and it tested positive for bisacodyl.

We decided to confront the patient in a supportive manner (see later) and did so in the presence of her husband, who was with her continuously during her outpatient evaluation. With a few tears, she calmly said that she had “absolutely not” been taking laxatives and added, “I don’t know what bisacodyl is.” After discharge, her husband searched her closet at home and found an empty box of Correctol for Women, which contains bisacodyl. The husband and her local physician agreed to obtain psychiatric help for the patient.

Later, we spoke with members of the patient’s family to try to gain insight into her motivation for surreptitious laxative ingestion. According to her family, there was no evidence of an eating disorder or sexual abuse. For the previous 6 years, she had worked in a doctor’s office, where her knowledge of medicine had increased. “She’s always been a great believer in medicine, and she doesn’t see the risks.” She had undergone multiple orthopedic surgeries without any clear need, and the jaw surgery was done for a questionable indication. These surgeries made her the center of attention. She was married to a loving and caring husband. The diarrheal illness started about 3 months after her diagnosis of infertility. (Others have observed that the onset of FD often begins shortly after a stressful event).

About 3 years after the diagnosis of FD, the patient’s family and some of her local physicians were contacted again for an update. Generally, things were much better. Although the decision to confront the patient was probably wise, the patient had felt betrayed. She never accepted the diagnosis and refused to see a psychiatrist. She still had various medical problems with frequent appointments with specialists. She remained fascinated with illness but was less dramatic and received less attention because of it. Two weeks before these conversations, the patient had had hip surgery, and several months before she had had a cholecystectomy. Earlier in the year she had had surgery to correct damage caused by teeth grinding. “She’s probably not taking laxatives anymore, but several times a year her potassium level is low, and on one occasion a diuretic was found in her urine.” Based on this information, it seems clear that her fascination with medicine and her “polysurgical addiction” continue.

Etiology and Motives

According to generally accepted teachings, patients with the subtle form of FD consciously and intentionally feign or self-induce physical symptoms to assume the “sick role” and thereby obtain relief from emotional distress. They present themselves with disabilities and disturbances that fall within the purview of physicians.

There are several possible explanations for FD behaviors, and one can draw on various theoretical frameworks. Learning theory suggests that excessive or deceptive illness behavior learned earlier in life is the best response the person knows. Psychodynamic theories draw on a number of possible conflicts—particularly in the child-parent relationship—resulting in the need to be cared for, the need to deceive, the need for revenge, the need to feel in control, the need for mastery over abusive parents, and the need to be punished or hurt. By focusing on a physical illness, the patient can avoid the underlying painful feelings prompting these needs. The longing for nurturance and the need for distraction from authentic life problems are also possible motivations. Behavioral theories point to exposure to and reinforcement of sick-role activity. The self-enhancement model suggests that individuals covet the specialness of their ailments and their relationships with high-status professionals (especially doctors).

There is usually no apparent symbolic significance to the selection of the illness that is induced or feigned. Patients with FD can simulate authentic disease in almost all organ systems ( Table 23.1 ). Indeed, a given patient may use different manufactured symptoms and diseases at different times. It is generally believed that patients with FD are aware of what they are doing, as evidenced by careful planning in most cases. They know right from wrong. Their intelligent quotients (IQs) are usually normal or high (even if their educational attainment is relatively limited), and only very few are psychotic. Some are depressed and may have thoughts of suicide. As a group, they are sometimes described as being immature and lacking interpersonal skills.

TABLE 23.1

Manifestations of Factitious Diseases by Mechanism ∗

Mechanism	Manifestations
Self-induced infection	Abscesses, bacteremia, fever, sepsis, wound infection
Surreptitious ingestion of medicines, vitamins, minerals	Bartter syndrome, bleeding or purpura from coagulation disorder (dicumarol, heparin), bone marrow depression, diarrhea, hyperthyroidism, hypoglycemia, hypokalemia (laxatives and/or diuretics), hypomagnesemia, liver disease, pheochromocytoma (epinephrine injection), renal failure, salt poisoning, vomiting
Self-induced injury	Bruises, complex regional pain syndrome (reflex sympathetic dystrophy), deformities, dermatoses (may also be induced by ingestion of certain drugs), unhealed wounds
Phlebotomy (self or animal)	Anemia, hematemesis, hematochezia, hematuria, melena
Thermometer manipulation or substitution of thermometer	Fever
Simulation of the clinical manifestations of specific diseases or syndromes (sometimes using falsified medical records or contamination of body fluids)	AIDS, cancer, CF, depression, multiple sclerosis, pain syndromes, pancreatitis, proteinuria, seizures, psychosis, renal stones

∗ Organization was modified from Reference.

Risk of Iatrogenic Disease

Patients with FD are usually willing and sometimes appear eager to accept dangerous diagnostic procedures in order to sustain the sick role. As a result of their deception, unneeded invasive and potentially dangerous diagnostic tests, procedures, and treatments are prescribed, and these may, in turn, result in iatrogenic disease. In most cases, the greatest damage to these patients is due to doctors’ actions, rather than from any direct action by the patient. FD patients presenting with GI symptoms or signs may receive needless laparotomies, gastric or intestinal resections, pancreatectomy, renal biopsy, adrenalectomy, or prolonged treatment with glucocorticoids. Case 2 illustrates some of these points.

Case 2

Iatrogenic Disease in a 33-Year-Old Woman

The patient felt well until 8 years earlier when she developed constipation requiring laxatives; later that year she developed diarrhea. Colonoscopy revealed mild colitis, and X-rays suggested ileitis. Over the next 2 years, the diarrhea persisted despite many different diets and medications, including prednisone. Salt depletion occurred frequently, requiring multiple hospitalizations. The patient developed aseptic necrosis of both hips, presumably the result of prednisone therapy, and had a total left hip replacement. Severe diarrhea continued, and she underwent several surgical procedures: exploratory laparotomy, loop ileostomy without bowel resection, and subsequently a total colectomy with standard ileostomy. The pathology report showed nonspecific chronic inflammation. Postoperatively, the patient had severe ileostomy diarrhea. A neuroendocrine tumor syndrome was suspected, and she was referred for further studies.

A balance study revealed that the ileostomy volume was 2561 mL/day (normal 600), the diarrhea was secretory in type, and intestinal absorption of dietary fat was normal. Intestinal perfusion studies showed normal small bowel absorption of water and electrolytes. The patient denied use of laxatives since the onset of her diarrhea. However, her room was secretly searched, and a box of Carter’s Little Pills was discovered, which contained several anthraquinones including podophyllum and aloin (see Chapter 19 ). A review of her medical records near the time of her colectomy revealed a pathology report on a rectal biopsy specimen that described pseudomelanosis coli.

Diagnosis and Detection

Early recognition of patients with FD is the best way to prevent iatrogenic disease, but most internists and gastroenterologists never consider FD in the differential diagnosis of patients with idiopathic physical symptoms. A factitious etiology of physical symptoms simply does not make sense in a traditional medical context. Therefore, negative test results for authentic diseases are considered false-negative results. The tests are repeated, new doctors are consulted, tests with low specificity for extremely rare authentic diseases may be performed, and false-positive results lead to more tests.

Even if FD is considered in the differential diagnosis, several factors make it difficult for physicians to recognize the subtle form of FD. First, these patients do not appear to be different from other patients with similar symptoms caused by authentic disease. Second, the psychiatric illnesses they have are not easily recognized, and there is usually no obvious excessive secondary gain that these patients are receiving. Third, the patients convincingly deny self-induced illness if they are asked. Fourth, there is a lack of communication between current and previous doctors, as well as a failure to study old medical records. Fifth, physicians are afraid to discuss the possibility of FD with their patients.

Several clues, if present, increase the likelihood of FD in a particular patient ( Box 23.1 ); however, the diagnosis of FD cannot be made solely on the basis of clues, so some form of confirmation must be obtained. Box 23.2 provides a list of some of the methods that have been used to bolster or confirm a suspicion of self-induced illness.

BOX 23.1

Clues That Increase the Likelihood of Subtle Forms of Factitious Disorder

Predominantly women
Previous experience in the medical field, which provides an unusual grasp of terminology and access to medical supplies
Multiple surgeries, multiple procedures
Inexplicable laboratory test results
Inconsistency and implausibility of certain aspects of the history
Visits to 3 or more medical centers previously for the same symptoms or to a nationally known referral center, despite residing far away
History of substance abuse or prior psychiatric disorder
Vagueness about details of past history and/or reluctance to allow release of previous medical records

Box 23.2

Methods That Have Been Used to Bolster or Confirm a Suspicion of Self-Induced or Factitious Disorder

Review old medical records and discuss the case with previous doctors and family members, if appropriate. Identify discrepancies and inconsistencies and estimate the influence of gain derived from the sick role. Inquire about psychosomatic illness, previous psychiatric treatment, suicide attempts, stress in the patient’s life, childhood abuse, marital/sexual problems, eating disorders, etc. The Internet can be used to facilitate such a review. A forensic consultant with access to multiple records can be uniquely helpful in identifying conflicting stories.

Review previous biopsy slides to look for foreign body material in wounds, pseudomelanosis coli, and other clues, as appropriate for the patient’s symptoms.

Obtain a psychiatric evaluation to help determine whether the patient has a personality disorder or psychiatric disease, absence of which would argue against factitious disease.

If symptoms and signs may be explained by surreptitious ingestion of medications and poisons, obtain appropriate medication and toxicology screens. Consider obtaining a urine test for diuretics even in the absence of renal or electrolyte abnormalities. Evaluate the results of such screens in light of the sensitivity and specificity of the tests used.

Test biological fluids collected under direct observation and compare the results with those for fluids collected privately by the patient. For example, compare fecal material obtained at an “unprepped” sigmoidoscopy with fecal material submitted by the patient.

Have a member of the nursing staff observe the patient to detect tampering behavior.

Search the patient’s personal belongings (see text).

If the attending physician considers FD and obtains a psychiatric consultation, it is important to recognize that even an experienced psychiatrist cannot reliably make or rule out a diagnosis of FD by taking a psychiatric history from a patient who is suspected of having FD but denies it.

Management

Two main assumptions form the basis for the proposed management recommendations. The first is that FD represents the patient’s attempt to cope with emotional distress. The second is that a supportive attitude by the health care team will make it possible for the patient to live through the shame and shattered self-image that may result from a diagnosis of FD. Unfortunately, almost all management recommendations that have been reported were based on experience with patients who were hospitalized. We know of no suggested recommendations for outpatients.

Techniques that have been used for the management of FD include confrontation of the patient, psychotherapy, drug treatment, behavioral therapy, and multidisciplinary approaches. Eastwood and Bisson attempted to evaluate the effectiveness of these management methods by reviewing 32 case reports and 13 case series. Based on their review, these authors concluded that the evidence in the literature is insufficient to evaluate the effectiveness of any management technique.

Nevertheless, there appears to be a general consensus in the literature on several aspects of the treatment of FD, as listed in Box 23.3 . Although these recommendations are probably accepted by most experts, differences of opinion exist on the value and wisdom of confronting a patient with a diagnosis of FD. Combining the recommendations from the authors of 3 studies, there seems to be a consensus that confrontation of patients with “confirmed FD” should be done when there is a danger of significant iatrogenic disease. All agree that the confrontation should be supportive, as enumerated in Box 23.4 . There is no consensus on whether confrontation should be done when FD is suspected but “unproved” or when the danger of iatrogenic disease is judged to be small.

Box 23.3

Consensus Opinions on the Treatment of Factitious Disorder ∗

∗ Derived from the literature.

Achievement of insight should not be the principal early goal of treatment, because it can weaken the patient’s defenses.
One person should have primary responsibility for patient management.
There should be a comprehensive psychiatric evaluation of the patient, including assessment for suicide risk.
All members of a multidisciplinary team should be aware of the assessment and treatment plan.
The treatment plan should be individualized.
Comorbid illness should be treated appropriately.
If confrontational techniques are used, they should be nonpunitive and supportive.

BOX 23.4

Features of Supportive Confrontation

Tell the patient what you suspect without outright accusation.
Support the diagnosis of factitious disease with facts.
Provide empathetic and face-saving comments. ∗

∗ “Maybe you didn’t know what you were taking; this medication could cause you to be sick”; “Maybe you took it in your sleep”; “What you did was a cry for help, and we understand”; “We realize you must be in great distress”; “We want to continue to take care of you.”
Avoid probing to uncover the patient’s underlying feelings and motivations. ^†

Later it may be decided to break this promise in patients with potentially fatal factitious disease, such as patients who are creating sepsis by injecting contaminated material into their bodies. This promise should only be broken after consultation and consensus opinion has been obtained by an ethics committee, legal personnel, and others, as described in the text.

This is done to minimize disruption of essential emotional defenses.
Assure the patient that the physician will not release the diagnosis to others without the patient’s permission, unless required to do so by law. ^‡
Make sure the staff demonstrate continued acceptance of the patient.
Encourage psychiatric help, but do not force the issue.

Management without confrontation is sometimes referred to as a “face-saving technique.” Here the patient is gently given the message that the doctors are wise to the deception and that he or she is being offered a chance to abandon factitious disease before it is exposed. The patient may be told that “if the next treatment fails to work, we are going to be forced to conclude that you are the source of your own illness.” The next treatment (almost any treatment) is then applied, and a surprising number of patients will undergo miraculous improvement rather than risk being exposed as a fraud. One report concluded that after such nonconfrontational approaches, about one third of the patients ended their hoaxes. They may have vigorously denied what they were doing, but if the doctors somehow allowed them to save face, the behavior stopped for some time. Therefore, the embarrassment of discovery is avoided in a substantial minority of patients. Even if patients admit to some or all the deceptions, however, most will continue to induce or feign disease. This trade-off is acceptable, provided the danger of iatrogenic disease is judged to be small, with the recognition that no therapeutic technique is consistently effective. Although this face-saving technique is favored by several experts, the authors are not aware of results of this method in a case series of patients with the subtle form of FD.

In general, treatment of FD seldom leads to “cure.” Some patients temporarily discontinue their illness-seeking behavior, but most are unwilling to accept psychiatric referral and probably will continue to self-induce or feign disease. Whenever possible, a psychiatrist should assess the patient for comorbid psychiatric disorders (e.g., major depression or personality disorders) that may predispose the patient toward, or contribute to expressions of, factitious illness behavior. If underlying psychiatric disorder can be recognized and treated, the psychological forces driving the FD may be lessened. The patient should also be assessed for suicidality and, when appropriate, should be transferred to a more secure setting. Psychiatric hospitalization is indicated when a patient has suicidal ideation or attempts suicide, has a deteriorating social situation, or manifests severe acting-out. When recovery occurs, it most often results from changes in the patient’s life situation rather than from medical intervention.

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