Psychiatry Board Review Manual

Statement of
Editorial Purpose
The Hospital Physician Psychiatry Board Review
Manual is a study guide for residents and prac
ticing physicians preparing for board exami
nations in psychiatry. Each manual reviews
a topic essential to the current practice of
psychiatry.

PUBLISHING STAFF
PRESIDENT, Group PUBLISHER

Bruce M. White
editorial director

Debra Dreger
SENIOR EDITOR

Bobbie Lewis
EDITOR

Tricia Faggioli

Factitious Disorder
Editor:
Jerald Kay, MD
Professor and Chair, Department of Psychiatry, Wright State University
School of Medicine, Dayton, OH

Contributors:
Josephine de Guzman, MD
Junior Resident Instructor, Department of Psychiatry, Wright State
University School of Medicine, Dayton, OH

Terry Correll, DO
Assistant Professor, Department of Psychiatry, Wright State University
School of Medicine; Attending Psychiatrist, Twin Valley Behavioral
Healthcare, Dayton, OH

assistant EDITOR

Farrawh Charles
executive vice president

Barbara T. White
executive director
of operations

Jean M. Gaul
PRODUCTION Director

Suzanne S. Banish
PRODUCTIONassociate

Kathryn K. Johnson
ADVERTISING/PROJECT Director

Patricia Payne Castle

sales & marketing manager

Deborah D. Chavis

NOTE FROM THE PUBLISHER:

This publication has been developed with
out involvement of or review by the Amer
ican Board of Psychiatry and Neurology.

Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Case. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Clinical Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Pathogenesis/Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Prognosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Factitious Disorder by Proxy . . . . . . . . . . . . . . . . . . . . . . . . 8
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Summary Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Cover Illustration by Kathryn K . Johnson

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Psychiatry Volume 11, Part 1 

Psychiatry Board Review Manual

Factitious Disorder
Josephine de Guzman, MD, and Terry Correll, DO

INTRODUCTION
Factitious disorder has been described as both
disease and deception, presenting one of the most
challenging (and potentially vexing) variants of psychopathology in medical experience.1 Indeed, factitious
disorders can be exasperating to the physician and
treatment team, as patients with these disorders consume valuable time, resources, and energy. However, a
deeper understanding of this disorder reveals that patients are powerfully compelled to appear ill and have
little insight into their behaviors.
Individuals who create, amplify, or feign symptoms of
illness can be categorized as having either somatoform
disorder, factitious disorder, or malingering (Table 1).
Patients with somatoform disorders unconsciously produce symptoms for an unconscious psychologic benefit
(eg, paralysis preventing the patient from acting on
an urge to harm another individual). On the other end
of the spectrum is malingering, where an individual
intentionally produces symptoms for external gain (ie,
money, shelter, narcotics, or excuse from duties). Factitious disorders fall somewhere in the middle, where
patients consciously create symptoms not for external
gain but for the sole purpose of assuming the sick role
and the associated privileges that result.
There are records of individuals feigning illness as
early as biblical times and in ancient Greece.2 In 1838,
Gavin3 described medical and psychologic ruses put on
by soldiers and seamen. Most sought discharge from
the military or relief from unpleasant duties, but a small
portion seemed driven simply to excite compassion
or interest. In 1951, Asher4 brought factitious illness
into general medical knowledge and coined the term
Munchausens syndrome after Baron von Munchausen, a retired German cavalry officer known to tell
dramatic, exaggerated stories about his travels. Asher
described individuals wandering from hospital to hospital subjecting themselves to multiple operations and
procedures. Factitious illnesses have evolved with time.
Factitious cases of AIDS appeared a few years after the
disease was first described,5 and with the advent of the
internet, there are reports of individuals offering false

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stories of illness to online support groups to garner attention and sympathy.6

CASE
A 35-year-old man presents to the emergency department with hypoglycemia. He reports a 13-year history
of diabetes and states that he accidentally gave himself
250 U of insulin glargine because he used the wrong
syringe. He denies suicidal intent, stating I didnt do
this on purpose. I dont want to die. I have a nice life, a
nice girlfriend, friends, and a good job. He states that
he currently works as a professional singer but previously worked as a nurse for 3 years and quit because
it was too stressful. Review of past medical records
reveals 12 admissions in the past 7 years to different
area hospitals with similar presentations.
On this admission, the patient is found to have an
infected central line. The patient claims that the line
was placed during a recent hospitalization for longterm intravenous antibiotic treatment of osteomyelitis
in his right foot. Magnetic resonance imaging of the
foot is performed and reveals no evidence of osteomyelitis. Further psychiatric history reveals a history
of emotional and physical abuse by his stepfather and
grandfather.
The patients blood glucose levels are stabilized, and
he is discharged after 5 days with a referral to a psychiatrist for outpatient psychotherapy. Review of subsequent records revealed 2 additional admissions in the
next 6 months for repeated self-injection of insulin.

DEFINITION
The DSM-IV-TR diagnostic criteria for factitious
disorder are outlined in Table 2.7 Factitious disorder
not otherwise specified includes patients with factitious symptoms but who do not meet the criteria for
factitious disorder. Included in this category is factitious
disorder by proxy, commonly known as Munchausens
by proxy, in which an individual creates symptoms in another person as a way to assume the sick role (Table 3).

Psychiatry Volume 11, Part 1 

Factitious Disorder
Table 1. Distinguishing Characteristics of Factitious Disorders
and Related Disorders
Category

Table 3. Research Criteria for Factitious Disorder by Proxy

A.

Intentional production or feigning of physical or psychologi

cal signs or symptoms in another person who is under the
individuals care

Voluntary Production
Presence of
of Symptoms
External Incentive

Somatoform disor
ders

No

No

B.

The motivation for the perpetrator is to assume the sick role

by proxy

Factitious disorders

Yes

No

C.

Malingering

Yes

Yes

External incentives for the behavior (such as economic gain)

are absent

D.

The behavior is not better accounted for by another mental

disorder

Table 2. Diagnostic Criteria for Factitious Disorder

A.

Intentional production or feigning of physical or psychological

signs or symptoms

B.

The motivation for the behavior is to assume the sick role

C.

External incentives for the behavior (such as economic gain,

avoiding legal responsibility, or improving physical well-being,
as in Malingering) are absent
Subtypes
300.16with predominantly psychological signs and symptoms
300.19with predominantly physical signs and symptoms
300.19with combined psychological and physical signs and symp
toms
Reprinted with permission from the American Psychiatric Association.
Diagnostic and statistical manual of mental disorders. 4th ed., text
revision.Washington (DC):The Association; 2000:517. Copyright
2000, American Psychiatric Association.

Although it is not an official diagnosis, Munchausens

syndrome is described in the DSM-IV-TR as the most
severe and chronic form of factitious disorder with
predominantly physical signs and symptoms.7 Characteristics of Munchausens syndrome include recurrent
hospitalization, peregrination (traveling), and pseudologia fantastica (pathological lying).

EPIDEMIOLOGY
Because patients with factitious disorder are often
secretive and deceptive, it is difficult to obtain accurate
epidemiologic data. Therefore, data must be inferred
from case reports, a few large series, and referral patterns. The prevalence of factitious disorder appears
to vary between 0.3% to 9.3%, depending on the particular patient population and setting.8,9 Sutherland
and Rodin10 noted that 10 of 1288 patients (0.8%)
referred for psychiatric consultation were diagnosed
with factitious disorder. In a prospective study of 1538
patients hospitalized in a Berlin neurology department
over 5 years, Bauer and Boegner8 found 5 (0.3%) cases

 Hospital Physician Board Review Manual

Reprinted with permission from American Psychiatric Association.

Diagnostic and statistical manual of mental disorders. 4th ed., text
revision.Washington (DC):The Association; 2000:783. Copyright
2000, American Psychiatric Association.

of factitious disorder. In studies of fever of unknown

origin, it is estimated that 2.2% to 9.3% of the fevers
were factitious.9,11 Herring12 reported that about 1%
of 10,000 renal stone specimens were factitious. Gault
and colleagues13 found that 2.6% of 3300 renal stones
were nonphysiologic and thought to be presented by
factitious or malingering patients. Data regarding the
prevalence of factitious disorder with psychologic signs
and symptoms vary as well. In a study of psychiatric inpatients, Bhugra14 reported 0.5% of admissions were a
result of a factitious psychologic condition. In 100 consecutive admissions to an inpatient psychiatric ward,
Gregory and Jindal15 reported a 6% prevalence rate of
factitious disorder with psychologic features.
Patients with factitious disorder are commonly young
women with experience in the health care field (Table 4).
Reich and Gottfried19 studied 41 patients with factitious
disorder, and of these patients, 95% were women, the
average age was 33 years, and 68% worked in the medical
field. Krahn et al20 examined 93 patients with factitious
disorder and found that 72% were women (mean age,
30.7 years), and 65.7% had experience in health care.
Approximately 10% of patients with factitious disorder
have Munchausens syndrome.21 These patients tend to
be middle-aged, unmarried men who are estranged from
their families.22

CLINICAL PRESENTATION
Feigned illnesses occur across every medical specialty,
and the spectrum of presentations is broad (Table 5).
Some patients with factitious disorder present mainly
with physical signs and symptoms. Fabricated histories,
falsified clinical and laboratory findings (eg, mimicking
a grand mal seizure or adding blood to urine samples),

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Factitious Disorder
Table 4. Summary of Studies Evaluating Factitious Disorder
with Physical Signs and Symptoms

Study

No. of
Cases

Patients with
Experience
Women, Mean
in Medical
%
Age, yr
Field, %

Table 5. Common Presentations in Factitious Disorder with

Predominantly Physical Signs and Symptoms
Fever of unknown origin
Self-induced infection
Chronic diarrhea
Hypoglycemia

Hawkings et al16

19

84

25

73

Petersdorf and
Bennett17

16

86

33

36

OReilly and
Aggeler18

25

84

38

60

Aduan et al9

32

78

23

50

Seizures

Reich and
Gottfried19

41

95

33

68

Nonhealing wounds

Krahn et al20

93

72

33

44

Sutherland and
Rodin10

10

70

31

30

Hyperthyroidism
Anemia
Hematuria
Renal stones

Rash

or induced illnesses (eg, surreptitious medication use,

inducing infection, or preventing wound healing) may
be a part of the clinical presentation.23 Feigned illnesses
can range from the common urinary tract infection to
giving a false history of having AIDS.5,24 Patients can
present in all settings, from their primary care physicians office with recurrent headaches to the emergency
department with severe hypoglycemia.
Patients with factitious disorder with predominantly
psychologic signs and symptoms almost always have real
or fabricated physical symptoms as well.22 Reports of
patients with factitious disorder with only psychologic
symptoms are rare, but some studies suggest that these
patients have a high rate of suicide and a poor prognosis.22,25,26 Popli26 reported that patients with factitious
disorder and psychologic symptoms have some of the
characteristics of Munchausens syndrome, including
itinerancy (wandering), aggressiveness, a lack of intimate or sustained relationships, and falsification of
background information. Patients may feign bereavement, presenting with symptoms of depression and
suicidal ideation linked to the reported death of a loved
one.27,28 Collateral information often reveals that the
reported dead relative is in fact alive or the death occurred years earlier under much less dramatic circumstances.22 There are also cases of feigned posttraumatic
stress disorder (PTSD).29 Patients may report PTSD
symptoms from combat, rape, or assault that never
occurred. These individuals differ from those seeking
monetary gain or disability benefits that would be more
appropriately diagnosed as malingering.

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Other presentations in factitious disorder with predominantly psychologic signs and symptoms include
psychosis, dissociative identity disorder, bipolar I disorder, amnesia, substance-related disorders, and eating
disorders.1 Of note, some authors advise particular caution when diagnosing factitious disorders with psychologic symptoms, as some patients eventually manifest
true psychotic disorders, such as schizophrenia.30

PATHOGENESIS/ETIOLOGY
As with many psychiatric illnesses, the etiology of factitious disorder remains largely speculative. It is likely
that multiple contributing factors lead to the development of factitious disorder.
BIOLOGIC FACTORS
Some researchers have hypothesized that underlying
brain dysfunction may contribute to factitious disorder.
In a review of 72 factitious patients with pseudologia
fantastica (pathological lying), King and Ford31 found
central nervous system abnormalities, including abnormal electroencephalogram findings, head injury, prior
infections of the central nervous system, and neurologic
abnormalities, in 40% of the patients. Babe et al32 reported frontal temporal cortical atrophy in 1 case of
Munchausens syndrome. Pankratz and Lezak33 observed
defects in conceptual organization and processing complex information in 2 of 5 patients with Munchausens
syndrome. There have also been case reports of abnormalities found on magnetic resonance imaging and
single photon emission computed tomography scanning
in patients with Munchausens syndrome.34,35

Psychiatry Volume 11, Part 1 

Factitious Disorder
PSYCHOSOCIAL FACTORS
Disturbances in childhood development may contribute to factitious disorder. A childhood history of
emotional insecurity, unavailable or rejecting parents,
and broken homes leading to foster care placement
is common.36 McKane and Anderson37 identified factitious disorder in a parent and serious childhood illness,
especially if the illness was associated with attention and
nurturing in an otherwise aloof family, as predisposing
factors for factitious disorder.
There are several common psychodynamic motiva
tions for factitious disorder identified in the literature.2,36,3840 Dependency needs are usually the most
prominent. In the sick role, patients with factitious
disorder receive the attention, caring, and nurturing
they do not receive elsewhere. Patients also tend to
have a poor sense of self, and the sick role may provide
them with a well-defined identity. Through pseudologia
fantastica associated with Munchausens syndrome, patients can even become exciting and important people
with extraordinary histories. Patients with a history of
abuse create a situation over which they have control, in
contrast to the trauma they experienced with absolute
vulnerability. Some patients have masochistic tendencies and want to suffer at the hands of their physicians.
These patients feel they deserve punishment or abuse
for forbidden feelings or low self-esteem. Reich and
Gottfried19 contend that deeply ingrained hypochondriacal beliefs and fears could motivate some factitious
behavior. For example, in their study, some patients
were convinced that they had an illness (eg, a tumor or
a urogenital tract abnormality) and exhibited factitious
behavior in order to undergo elaborate testing in hopes
of finding the disease they believed truly existed.19

DIAGNOSIS
Factitious disorders are a diagnostic challenge because patients actively attempt to deceive their physicians. In fact, factitious disorder is usually not diagnosed
until 5 to 10 years after its onset, generating substantial
social and medical costs.41 Heightened awareness and
early diagnosis are key to minimize expenditure of
resources.24 At the same time, diagnostic rigor is essential. Once a treatment team suspects a patient is
deliberately fabricating an illness, countertransference
issues can hinder compassionate and sound medical
care by engendering anger and negative views towards
the patient.20
Factitious disorders can be diagnosed in a number of

 Hospital Physician Board Review Manual

ways, depending on the particular case. Some patients

are discovered in the act of creating symptoms (eg,
tampering with a nonhealing wound) or are found with
incriminating paraphernalia (eg, insulin-filled syringes,
thyroid medication).10 Patients with inconsistent or unexplainable signs or symptoms or who fail to respond
to appropriate treatment should raise suspicion of fac
titious illness.42 Collateral history from family members
or other treatment facilities can also assist with the
diagnosis. The clinician should be suspicious when the
patient refuses to allow contact with family members
or with other health care providers. At times, a health
care worker may recognize the patient from a previous
presentation. In some situations, laboratory tests can
facilitate the diagnosis of factitious disorder, as in cases
of exogenous thyroid or insulin administration.24 In a
review of 93 cases of factitious disorder, the diagnosis
was most often established by inexplicable laboratory
results (eg, stool samples from patients with factitious
diarrhea consisting entirely of water).20
Most of the available literature focuses on factitious disorder with predominantly physical signs and
symptoms.10 Factitious disorder with psychologic signs
and symptoms can be especially difficult to diagnose
because much of the diagnosis relies on the patients
own history.42 Evidence is mixed regarding the utility
of neuropsychologic testing. Some authors report that
feigned PTSD can be detected using the Minnesota
Multiphasic Personality Index,4345 while others were
unable to replicate this finding.46 Rawling47 reported
that the Wechsler Adult Intelligence Scale-Revised and
Wechsler Memory Scale were useful and reliable in
identifying factitious mental impairment from reported
head injury. As in factitious disorder with physical signs
and symptoms, careful history taking, close observation, and information obtained from family members
or previous health care providers can be extremely
useful in making the diagnosis of factitious psychologic
disorders.
Even if inclusion criteria for factitious disorder are
met, there is always the possibility that a serious underlying or coexisting medical or psychiatric condition exists.10 The differential diagnosis for factitious disorder is
extensive and includes true physical illness, somatoform
disorders, malingering, substance use disorders, eating
disorders, and other psychiatric disorders. In addition,
personality disorders, especially antisocial and borderline disorder, are frequently comorbid in the factitious
disorder population.36 Physicians must be cautious
when suspecting a diagnosis of factitious disorder to
ensure legitimate illnesses are not overlooked.

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Factitious Disorder

TREATMENT
The main goals in the treatment of patients with
factitious disorder are to minimize harm to the patient,
help the patient recover from the disorder, and limit
unnecessary costs to the health care system.2,42 To minimize the patients morbidity, unnecessary procedures
and tests should be avoided and comorbid medical illnesses should be adequately treated. Assembling a multidisciplinary team that includes the primary providers,
a psychiatric consultant, and nursing, social work, and
legal staff is ideal.2 It is essential that the treatment team
be cohesive in their approach and educated about the
disorder as patients with factitious disorder may use
splitting and raise difficult management issues.
Factitious disorders are difficult to cure, and no specific effective treatment exists. Patients with Munchausens
syndrome generally are considered refractory to treatment,21 although Yassa48 reported a case of Munchausens
syndrome that was successfully treated using intense
behavior modification techniques over a 3-year hospitalization. Although most patients with factitious disorder
will refuse psychiatric treatment,49 patients should still be
encouraged to pursue treatment. Several reports have
described successful treatment using long-term psychotherapy. Plassmann50 described a case series where 10 out
of 24 patients with factitious disorder accepted and continued long-term psychodynamic psychotherapy; patients
progressed favorably, with a significant or at least marked
improvement. Klonoff et al51 reported successful treatment of a patient with a variety of neurologic symptoms
using psychodynamic and behavioral techniques over a
9-month period.
Some recommend confronting the patient with fac
titious disorder in a supportive, nonaccusatory manner.19
However, Eisendrath21 reported little success with confrontation and instead suggested 3 alternatives: (1) inexact interpretation, (2) therapeutic double bind, or
(3) face-saving techniques (ie, symptom relief without
exposure or humiliation).
In inexact interpretation, a therapist makes a statement about the patients dynamics without specifically
identifying the factitious behavior. Eisendrath21 reported the case of a young woman with a history of episodes
of septicemia who expressed feelings of guilt about
a sexual relationship to her therapist. The therapist
suggested to the patient that she might feel a need to
punish herself because of the feelings of guilt. Several
sessions later, the patient admitted to producing 3 episodes of septicemia by injecting herself with urine.

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The next technique is the therapeutic double bind,

in which a physician offers a medical intervention to
treat the patients illness and also proposes the possibility that the illness may be factitious. If the illness
is factitious, medical treatment would not be expected
to work. Therefore, the physician provides the patient
with the option of either clinically improving with
the intervention or admitting that he/she does indeed have a factitious illness. Eisendrath21 described a
19-year-old woman who presented with a chronic nonhealing wound from a minor ankle surgery performed
at age 14 years. A previous plastic surgeon had already
confronted her with the diagnosis of factitious disorder,
and she sought referral to a different physician. At the
new institution, the plastic surgeon and psychiatric
consultant presented the patient with a differential
diagnosis of an unusual wound-healing problem that
should respond to 1 more graft attempt or a diagnosis
of factitious disorder. The graft was placed, and there
was no recurrence of infection at a 2-year follow-up.
The patients double bind was to either improve in a
face-saving manner with a minor surgical procedure or
receive a diagnosis of factitious disorder.
The third technique is to provide patients with a way to
relinquish their symptoms without exposure or humiliation. For example, Klonoff et al51 developed a biofeedback
program that allowed a patient with factitious seizures to
give up the seizures without an explicit confrontation.
Hypnosis has also been used. Eisendrath21 described a
25-year-old woman with a nonhealing abdominal wound
despite 15 operations over a 10-year period. The patient
had a history of abuse by her alcoholic father and was also
a heavy smoker. She was offered self-hypnosis as a way to
stop smoking, increase tissue oxygenation, and improve
blood flow to the wound, thereby facilitating healing. The
psychiatric consultant also used inexact interpretation to
suggest that anger about her fathers abuse might make
it difficult for her to benefit from paternalistic figures and
that she might want to defeat her surgeons as a means
of expressing the anger. The patient responded to these
suggestions and began using self-hypnosis regularly. The
patient allowed her wound to heal and remained well at a
6-month follow-up.
There are no clear data addressing the effectiveness
of pharmacotherapy to treat factitious disorders.42 Patients with factitious disorder and comorbid depression
have shown improvement with antidepressant therapy
in addition to psychotherapy.19,52 Medications should
be used as appropriate to treat comorbid Axis I diagnoses; however, patients should be carefully monitored
given their self-destructive tendencies.2

Psychiatry Volume 11, Part 1 

Factitious Disorder

PROGNOSIS
There is general consensus that factitious disorders cause significant morbidity. Patients can undergo
multiple tests, procedures, and treatments, each with
their own risks. These may include medication trials,
angiography, biopsy, laparotomy, lumbar puncture,
and amputation. Fatalities directly linked to factitious
disorder may be less common but do occur. Reich and
Gottfried19 reported 1 death out of 41 cases. Eisendrath
and McNiel53 describe 4 fatal cases out of 20 factitious
disorder patients who were involved in civil litigation.
Causes of death included myocardial infarction caused
by self-administered epinephrine and septicemia from
self-injected bacteria.
The diagnosis of factitious disorder generally carries a poor prognosis. However, there is wide variability
over the course of the illness. Grunberger et al54 followed 10 patients with factitious hypoglycemia due
to surreptitious insulin injections for an average of
5 years; 3 patients successfully transitioned into productive life, while 2 patients eventually committed suicide.
Patients with especially poor prognoses include those
with Munchausens syndrome, antisocial or borderline
personalities, and chronic medical conditions.36

FACTITIOUS DISORDER BY PROXY

CLINICAL PRESENTATION
In factitious disorder by proxy (also known as
Munchausens by proxy), an individual indirectly assumes the sick role by creating illness in another person,
usually a young child. The most commonly induced or
falsified symptoms include bleeding, seizures, impaired
consciousness, apnea, diarrhea, vomiting, fever, and
rash.55 The perpetrator is typically the mother,55 although a small number of fathers have been described
as the perpetrators.56 Mothers are commonly in their
early 20s, married, from middle-class backgrounds, and
tend to have personality disorders, somatizing behaviors,
and considerable family dysfunction.36 When observed,
the mothers appear quite attentive and concerned;
however, when they are unaware of being observed, they
appear indifferent to the child.38
EPIDEMIOLOGY
As in factitious disorder, precise epidemiologic data
regarding factitious disorder by proxy is unavailable, and

 Hospital Physician Board Review Manual

estimates vary. Studies in the United Kingdom, Ireland,

and New Zealand estimated the annual incidence of factitious disorder by proxy (with victims aged < 16 years)
to be 0.5 to 2.0 per 100,000 population.57,58 In a study of
113 children with fever of unknown origin, 3.5% were
found to be factitious.59 A large study of 20,090 children
who presented with apnea revealed that 0.27% were
the victims of factitious disorder by proxy.60 The victims
appear to be equally male and female and are typically
aged younger than 4 years. Average time from onset of
symptoms to diagnosis is 15 to 20 months.2,61
Although factitious disorder by proxy appears to be
less common than factitious disorder, morbidity and
mortality rates are much higher. Rosenberg55 surveyed
117 cases of factitious disorder by proxy and reported
acute morbidity in all cases, permanent disfigurement
and disability in 73% of cases, and a mortality rate of
9%, mostly from apnea and poisoning. One literature
review of 451 cases revealed a mortality rate of 6%.61
DIAGNOSIS AND MANAGEMENT
Diagnosis of factitious disorder by proxy can be difficult and is often accidental. The mother may be observed actively inducing symptoms (eg, smothering her
child with a pillow to induce apneic episodes). Laboratory studies may indicate the surreptitious administration of medication, such as sulfonylureas, laxatives, or
thyroid replacement.55 Covert video surveillance has
been used to make the diagnosis but is controversial, as
it raises issues of invasion of privacy.62 The diagnosis can
be supported if a childs symptoms abate during a trial
separation of mother and child.42
Factitious disorder by proxy is regarded as a form
of child abuse, and perpetrators often face criminal
charges. Health care providers who suspect or diagnose
factitious disorder by proxy must contact childrens
protective services authorities. The immediate protection of the child is of utmost importance and usually
requires removal of the child from the home, at least
temporarily.63 The child should be treated medically as
necessary and should also receive psychiatric evaluation
and therapy.2,64 The perpetrator should also be offered
psychotherapy, as there are some cases of successful
treatment.65

conclusion
Patients with factitious disorders consciously produce,
amplify, or feign physical and/or psychologic symptoms
of illness in order to assume the sick role. Although

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Factitious Disorder
assumed to be relatively rare, factitious disorders cause
significant morbidity and present many diagnostic and
treatment challenges. The clinical presentations of persons with factitious disorder are varied and impact every
area of medicine. There are likely multiple biologic and
psychosocial factors that play an etiologic role. The main
treatment goals for these pernicious disorders are to
minimize harm to the patient and drain on health care
resources. Factitious disorder by proxy is a particularly
disturbing variant of the disorder in which typically a
young mother indirectly assumes the sick role by creating illness in her child. Clinicians should be especially
vigilant as factitious disorder by proxy carries even greater morbidity and mortality and should be regarded as a
form of child abuse.

Summary Points
Patients with somatoform disorders unconsciously
produce symptoms for an unconscious psychologic
benefit.
Malingering patients intentionally produce symptoms for external gain.
Patients with factitious disorder consciously create
symptoms for the sole purpose of assuming the sick
role and the associated privileges that result.
Patients with factitious disorders are powerfully compelled to appear ill and have little insight into their
behaviors.
Feigned illnesses occur across every medical specialty, and the spectrum of presentations is broad.
The prevalence of factitious disorder appears to vary
between 0.3% to 9.3%, depending on the patient
population and setting.
There are 2 common profiles of the patient with
factitious disorder: the young woman with experience in the health care field (most common) and
the middle-aged, unmarried man estranged from
his family (Munchausens syndrome; about 10% of
patients with factitious disorder).
Munchausens syndrome is the most severe and
chronic form of factitious disorder with predominantly physical signs and symptoms.
Characteristics of Munchausens syndrome include
recurrent hospitalization, peregrination (traveling),
and pseudologia fantastica (pathological lying).
Reports of patients with factitious disorder with only
psychologic symptoms are rare, but some studies
suggest that these patients have a high rate of suicide
and a poor prognosis.

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Some authors advise particular caution when diagnosing factitious disorders with psychologic symptoms, as some patients eventually manifest true
psychotic disorders, such as schizophrenia.
Factitious disorders are a diagnostic challenge because
patients actively attempt to deceive their physicians.
Factitious disorder is usually not diagnosed until 5 to
10 years after its onset.
Some patients are discovered in the act of creating
symptoms or are found with incriminating paraphernalia.
Patients with inconsistent or unexplainable signs
or symptoms or who fail to respond to appropriate
treatment should raise suspicion of factitious illness.
Collateral history from family members or other
treatment facilities can assist with the diagnosis.
Laboratory tests can often facilitate the diagnosis of
factitious disorder.
Physicians must be cautious when suspecting a diagnosis of factitious disorder to ensure that legitimate
illnesses are not overlooked.
The main goals in the treatment of patients with factitious disorder are to minimize harm to the patient,
help the patient recover from the disorder, and limit
unnecessary costs to the health care system.
Factitious disorders are difficult to cure, and no specific effective treatment exists.
Countertransference issues can hinder compassionate and sound medical care.
There are no clear data addressing the effectiveness
of pharmacotherapy to treat factitious disorders.
Medications should be used as appropriate to treat
comorbid Axis I diagnoses, and patients should be
closely monitored.
Factitious disorders cause significant morbidity and
even some mortality.
The diagnosis of factitious disorder generally carries
a poor prognosis.
In factitious disorder by proxy, commonly known as
Munchausens by proxy, the perpetrator is typically
the mother of the young child.
Factitious disorder by proxy is regarded as a form
of child abuse, and perpetrators often face criminal
charges.
Health care providers who suspect or diagnose fac
titious disorder by proxy must contact childrens
protective services authorities.
Acknowledgments
The authors thank Tisha S. Wang, MD, for information provided for the case presentation.

Psychiatry Volume 11, Part 1 

Factitious Disorder

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