II. Definitions
- Factitious Disorder
- Adoption of physical or psychologogical symptoms (simulated or created)
- Not motivated by material gain
- Motivated instead by desire to play the sick role
- Contrast with Malingering with secondary material gain
- Munchausen Syndrome
- Factitious Disorder characterized by habitual hospital presentations for apparent acute illness
- Patient gives a false, dramatic, but somewhat plausible history
-
Munchausen Syndrome by Proxy
- Parent fabricates childhood illness resulting in unnecessary medical evaluation and treatment
- Malingering
- Purposeful feigning of physical symptoms for material gain (e.g. Substance Abuse, worker's comp)
III. Epidemiology
- Mean Age: 30-50 years
- Gender: Women represent two thirds of cases
- Occupation is frequently in healthcare or laboratory sciences
IV. Diagnosis: Factitious Disorder DSM-5
- Patient intentionally falsifies physical or psychological signs and symptoms or induces injury or illness
- Presents themselves to others as ill, impaired or injured
- Deceptive behavior is not connected to external incentive or reward
- Behavior not explained by other mental disorder
V. Findings
- Common Presentations
- Cardiovascular symptoms (e.g. Chest Pain, Dizziness, Shortness of Breath, Hypertension)
- Endocrine symptoms (e.g. Hypoglycemia, Thyrotoxicosis, Cushing Syndrome)
- Dermatologic symptoms (e.g. generalized skin lesions, or lesions localized to Breast, face, legs)
- Unusual results (e.g. vey low Body Temperature) in an otherwise healthy appearing patient
- Course
- Protracted illness with episodes of spontaneous remission, or unexplainable worsening
- When hospitalized, patients may suddenly worsen or develop new symptoms before intended discharge
VI. Differential Diagnosis
-
Somatic Symptom Disorder
- Unintentional perceived organic symptoms
- Accepts painful or dangerous procedures
- Malingering
- Purposeful feigning of physical symptoms for material gain (e.g. Substance Abuse, worker's comp)
- Avoids painful or dangerous procedures
-
Borderline Personality Disorder
- Impulsive, self-created injury or illness (intended self harm)
- Avoids painful or dangerous procedures
-
Histrionic Personality Disorder
- Impulsive, simulated injury or illness (with grandiose or theatrical presentation)
- Avoids painful or dangerous procedures
-
Illness Anxiety Disorder (Delusional Disorder, Hypochondriasis)
- Preoccupation with either contracting or having a serious medical disorder
- Accepts painful or dangerous procedures
- Factitious Disorder
- Adoption of physical or psychologogical symptoms (simulated or created) and not motivated by material gain
- Seeks painful or dangerous procedures
VII. Management
- Approach acute symptom presentations with the same thoroughness for all patients
- Focus on stabilization of the acute condition and a search for underlying causes
- Do not let suspicion for Factitious Disorder dissuade appropriate medical care for the given presentation
- Factitious Disorder is typically identified after a recurrent pattern of presentations
- Document in the medical record if suspicious of Factitious Disorder
- Use non-judgemental terms (in contrast to lying, pretending, malignering)
- Laboratory testing may be considered to support diagnosis (e.g. Insulin to C-Peptide ratio in Hypoglycemia)
- Avoid confronting patients about Factitious Disorder during acute presentations
- May worsen psychological stress and in some cases precipitate Suicidality
- Mental Health referral
- As with Somatic Symptom Disorder, refer Factitious Disorder to mental health
VIII. Prognosis
- Factitious Disorder is high risk for increased morbidity and mortality
IX. References
- Williams and Mehta (2025) Crit Dec Emerg Med 39(1): 4-12
- Hausteiner-Wiehle (2020) Dtsch Arztebl Int 117(26):452-9 +PMID: 32897184 [PubMed]