Factitious disorder is falsification of physical or psychological symptoms without an obvious external incentive; the motivation for this behavior is to assume the sick role. Symptoms can be acute, dramatic, and convincing. Patients often wander from one physician or hospital to another for treatment. The cause is unknown, although stress and a severe personality disorder, most often borderline personality disorder, are often implicated. The diagnosis is clinical. There are no clearly effective treatments.
Factitious disorder imposed on self is a condition characterized by the deliberate falsification or induction of illness in oneself with associated deception, in the absence of obvious external rewards. Factitious disorder imposed on self was previously called Munchausen syndrome, particularly when manifestations were dramatic and severe. (Factitious disorder imposed on another person [previously called factitious disorder by proxy] is a related but separate entity.)
These patients often become the initial, and sometimes chronic, responsibility of medical or surgical clinics. Nevertheless, factitious disorder must be recognized as a genuine psychiatric condition, representing a complex issue rooted in severe emotional difficulties rather than merely dishonest symptom simulation.
Patients may have prominent features of borderline personality disorder and may demonstrate high levels of intelligence and resourcefulness. They may also exhibit a sophisticated knowledge of medical practices. Feigning illness may be a way to increase or protect self-esteem by blaming failures on their illness, by being associated with prestigious physicians and medical centers, and/or by appearing unique, heroic, or medically knowledgeable and sophisticated.
These patients differ from malingerers because, although their deceits and simulations are conscious and volitional, there are no obvious external incentives (eg, economic gain, time off from work) for their behavior. Their motivations and quest for attention are largely unconscious and obscure but may, in part, be due to a desire to maintain the sick role and deceive clinicians.
Risk factors for factitious disorder include an early history of emotional and physical abuse (1). Patients may also have experienced a severe illness during childhood or had a seriously ill relative. Patients appear to have problems with their identity (ie, sudden and dramatic shifts in self-image) as well as unstable relationships.
General reference
1. Jimenez XF, Nkanginieme N, Dhand N, Karafa M, Salerno K. Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis. Gen Hosp Psychiatry. 2020;62:93-95. doi:10.1016/j.genhosppsych.2019.01.009
Symptoms and Signs of Factitious Disorder Imposed on Self
Patients with factitious disorder imposed on self may complain of or simulate physical symptoms that suggest certain disorders (eg, abdominal pain suggesting an acute surgical abdomen, hematemesis). Patients often consciously feign many associated symptoms and features of the disorder that they are feigning (eg, that pain from a myocardial infarction may radiate to the left arm or jaw or be accompanied by diaphoresis).
Sometimes they simulate or induce physical findings (eg, pricking a finger to contaminate a urine specimen with blood, injecting bacteria under their skin to produce fever or abscess; in such cases, Escherichia coli is often the infecting organism). Their abdominal wall may be crisscrossed by scars from exploratory laparotomies, or a digit or a limb may have been amputated.
Diagnosis of Factitious Disorder Imposed on Self
Psychiatric assessment
Sometimes general medical evaluation to exclude other etiologies
The diagnosis of factitious disorder imposed on self is based on its characteristic symptoms and signs according to DSM-5-TR (1):
Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
The individual presents himself or herself 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.
The diagnosis of factitious disorder is usually clinical, and often also requires tests necessary to exclude general medical conditions and the demonstration of exaggeration, fabrication, simulation, and/or induction of physical symptoms (1).
Diagnosis reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022.
Treatment of Factitious Disorder Imposed on Self
No clearly effective treatments
The treatment of factitious disorder imposed on self is usually challenging. No robust evidence-based treatment exists for factitious disorder imposed on self. Patients may obtain initial relief by having their treatment demands met, but their symptoms typically escalate despite such treatment, ultimately surpassing what clinicians are willing or able to do. Confrontation or refusal to meet treatment demands often results in angry reactions, and patients usually seek care from more than one physician or hospital.
Recognizing the disorder and requesting psychiatric or psychological consultation early is important, so that risky invasive testing, surgical procedures, and excessive or unwarranted use of medications can be avoided.
A nonaggressive, nonpunitive, nonconfrontational approach should be used to present the diagnosis of factitious disorder to patients. To avoid suggesting guilt or reproach, a physician can present the diagnosis as a cry for help. Alternatively, some experts recommend providing psychiatric treatment without requiring patients to admit their role in causing their illness. It is helpful to focus on harm reduction and long-term engagement and to convey to the patient that the physician and patient together can cooperatively resolve the problem.
