Behavioral Health

Diagnosis and reasoning

The individual who fabricates physical or psychological symptoms is often a diagnostic challenge for even a highly astute clinician.

Falling prey to a well staged deception may result in misdiagnosis - or even worse, fruitless interventions and investigations, which then convert the pretender into a person with an iatrogenically induced medical condition.

Consider this 22 year old woman; she has presented with a textbook history of cluster headaches, but has not shown any response to medications; in addition, her investigations have all been unremarkable, while her previous care provider was suspicious that her signs and symptoms were artificially fabricated.

Thus, there is high suspicion that this may be a psychiatric disease - either malingering, somatization disorder, or factitious disorder.

While she complains of a severe headache, note that she does not demonstrate a commensurate degree of agony; this makes somatisation disorder unlikely, as these patients genuinely experienc

e pain.

Note also the absence of an incentive, financial or otherwise; this makes malingering unlikely.

Her physical examination reveals no abnormalities; however, the psychiatric evaluation shows a socially isolated individual who craves for attention and who is extremely defensive of her symptoms.

When considered together, these findings meet the Diagnostic and Statistical Manual, Fifth edition (DSM-5) criteria for Factitious Disorder with Predominantly Physical Signs and Symptoms (also known as Munchausen Syndrome).

Depression is a well known comorbidity in these patients; evaluation in this regard with the Beck Depression Inventory confirms the presence of mild depression.

Note that invasive diagnostic procedures such as CT angiography, CSF analysis, and temporal artery biopsy are not indicated in his patient.

In theory, cognitive behavioral therapy (CBT) is the treatment of choice in these patients; in her case, this will additionally treat the mild depression.

However, in practice, it is it extremely difficult to convince these patients that they require psychiatric attention; they may default on treatment and attempt to visit a different clinician.

Thus, an important secondary goal of the management is to somehow prevent future iatrogenic damage; in addition, care should be coordinated with social service providers, so as to build her a network of support at home (and work, if applicable).

Note that sumatriptan and oxygen are indicated in the acute management of cluster headache; propranolol is used for the prophylaxis of migraine.


Factitious Disorder (FD) is an umbrella term used to refer to conditions where individuals intentionally produce signs and/or symptoms of mental or physical illness for no obvious gain other than increased medical attention.

FD is categorized under "somatic symptom and related disorders" in the Diagnostic and Statistical Manual, Fifth edition (DSM-5) of the American Psychiatric Association (APA) along with "Psychological Factors Affecting Other Medical Conditions".

According to the DSM-5, the criteria that should be fulfilled in order to diagnose FD include the following:

Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

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.

Thus, FD is distinguished from malingering by the absence of specific secondary gains, while the presence of deliberate fabrication of symptoms differentiates FD from somatisation disorders, in which patients genuinely feel the symptoms.

Note that FD also lacks anxiety which is out of proportion to the physical or psychological symptoms; that is a feature characteristic of hypochondriasis.

The disease consists of two main different types; FD imposed on self (individual presents himself or herself to others as ill, impaired, or injured), and FD imposed on another (previously known as FD by proxy).

FD imposed on another is a rare disorder where the symptoms and/or signs are imposed on infants or young children by parents or caregivers; in most cases the perpetrator being the mother.

Factitious disorder can further be classified into different subtypes, although the differences between these are arbitrary:

Factitious Disorder with Predominantly Psychological Signs and Symptoms

Factitious Disorder with Predominantly Physical Signs and Symptoms

Factitious Disorder with Combined Psychological and Physical Signs and Symptoms

The widely known term "Munchausen's Syndrome" refers to FD with physical signs and symptoms and is of nostalgic importance as the name is derived from Lord Munchausen, a German Cavalry officer who told fantastic stories to entertain the public - even though his stories were not in the least related to illness-behavior or the deception of health professionals.

From the limited epidemiological data available, FD is diagnosed in approximately 1% of patients seen in general hospitals; the more specialized the treatment setting, greater the prevalence of the disease.

A slight preponderance of the disease is noted in Caucasian, unmarried, unemployed, or socially isolated individuals.

Note that studies indicate that feigned physical symptoms and signs are more commonly reported than psychiatric symptoms.

Although the majority of cases of FD are male, females outnumber males approximately 3:1 in the subtype of factitious disorder with physical symptoms and signs (Munchausen Syndrome).

Patients with Munchausen syndrome typically present between 20 to 40 years of age (although this may vary); a significant number of them have a history of education or employment related to health care.

Although the exact etiology of FD has not been identified, a number of associated risk factors have been described, including personality disorders and childhood deprivation or abuse.

Many patients with FD have personality traits characteristic of borderline personality disorder, such as, disturbed self image and poor identity formation; it has been speculated that borderline personality disorder and depressive disorder are comorbid psychiatric conditions that may frequently coexist with FD.

Some patients with factitious physical disorder may truly suffer from physical disability/disfigurement, as a consequence of iatrogenic injury during multiple hospital admissions and interventions, i.e. "gridiron abdomen" caused by multiple surgical scars is one such instance.

Patients with masochistic personality traits often justify the pain they experience during self-sought invasive procedures and investigations as a punishment for their sins, imagined or real.

In FD with psychiatric symptoms, patients may occasionally use psychoactive medications in order to feign the symptoms.

Note the fact that the majority of patients with FD have experienced deprivation, child abuse or social isolation; thus their symptoms can be explained as a form of repetitional compulsion where the patients repeatedly yearn and seek for the love and acceptance they have waited for so long.

Some researches propose that brain dysfunction leading to impaired information processing contributes to pseudologia fantastica in FD; however, no neuroimaging abnormalities or genetic patterns have been found.

The clues that point towards a diagnosis of FD which should not be missed by an astute physician include, medical conditions that do not respond to appropriate treatment, a history of doctor shopping or employment in health care, and an excessive eagerness to undergo diagnostic or therapeutic interventions regardless of the cost, invasiveness and clinical relevance.

Most patients with FD tend to act alone, however, very rarely, participation of friends or relatives in illness fabrication is reported.

Treatment of FD is difficult as the patients may insist that their symptoms are physical and vehemently refuse psychologically oriented treatment claiming them to be useless.

The primary treatment modality is cognitive behavioral therapy (CBT), aimed at reducing the overindulgence of medical resources. In FD by proxy, the main goal should be to ensure the safety of the victim.

In addition, family members should be educated to discourage the aberrant behavior and refrain from any reinforcing action; and also not to deprive the patients from affectionate care and family support.

Pharmacological therapy is not indicated in FD; although a certain degree of compulsive behavior is observed, antidepressant agents (such as SSRIs) are not prone to be effective in attenuating factitious symptoms.

Pharmacotherapy may however be used to treat underlying comorbidities such as depression.

The overall prognosis of FD is poor, particularly in Munchausen syndrome, with the majority of patients experiencing a chronic course of disease.

Take home messages

1. In factitious disorder (FD), the patient imposes fabricated symptoms upon himself/herself or another (FD by proxy) in order to gain medical attention.

2. The diagnosis and treatment of FD is difficult as the patients usually insist upon the physical nature of their symptoms, and refuse psychotherapy.

3. Pharmacotherapy is of no proven benefit in reducing factitious symptoms.


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