Achieve Mastery of Medical Concepts

Study for medical school and boards with Lecturio

Factitious Disorders

Factitious disorder, formerly called Munchausen syndrome, is the intentional falsification of symptoms in order to assume the role of a sick person. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may intentionally produce symptoms in someone else (usually a child or elderly patient), which is known as factitious disorder imposed on another (formerly, Munchausen by proxy). Unlike malingering Malingering Malingering is not a medical disorder, but a behavior of an individual. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients may either invent new ailments or exaggerate current symptoms. Malingering, the falsification of symptoms is not associated with an external reward. Diagnosis is clinical, and treatment centers around nonjudgmental confrontation.

Last updated: 30 Apr, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Epidemiology and Etiology

Epidemiology

  • The estimated prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency is 5% in hospitalized patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
  • More common in men than women
  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency is higher in healthcare workers and those with higher intelligence.
  • Many people with factitious disorders have underlying comorbid psychiatric disorders such as personality, mood, or substance use disorders.

Etiology

  • Unknown 
  • May be associated with a history of abuse or neglect Neglect Child Abuse
  • Hospitalization Hospitalization The confinement of a patient in a hospital. Delirium and medical attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment are thought to provide the safe environment that patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have lacked.

Clinical Presentation and Diagnosis

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • Symptoms are widely variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables and depend on the mechanism of falsification.  
  • Usually presents with dramatic and bizarre clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor that cannot be explained by conventional medical understanding Understanding Decision-making Capacity and Legal Competence
  • No response to usually effective medical or psychological interventions 
  • Common scenarios:
    • Recurrent episodes of hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia from auto-injection of insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin 
    • Recurrent infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease of wounds
  • If missed, factitious disorders may lead to unintentional death.

Diagnosis

The psychiatric interview must include collateral or external sources of information whenever possible. 

  • DSM-V diagnostic criteria for factitious disorder imposed on self
    • Fabrication of physical or psychological signs or symptoms, or distortion Distortion Defense Mechanisms of injury or disease, associated with identified deception
    • Presents to others as ill, impaired, or injured 
    • Deceptive behavior is evident in the absence of obvious secondary gains. 
    • The behavior does not coexist with another mental disorder.
  • DSM-V diagnostic criteria for factitious disorder imposed on another individual
    • Also known as Munchausen syndrome by proxy 
    • The person fabricates symptoms in another person and then presents that person to others as ill, impaired, or injured. 
    • Deceptive behavior is evident in the absence of obvious secondary gains. 
    • Remember: This diagnosis is made for the person who is fabricating the symptoms, not the person being presented as ill.
Table: Features of factitious disorder compared with important differential diagnoses
Willingness to undergo evaluation Intentional deceptive behavior Intentional deceptive behavior Malingering Evidence of external reward Evidence of external reward Malingering
Illness anxiety disorder Illness Anxiety Disorder Illness anxiety disorder, formerly known as hypochondriasis, is a chronic condition characterized by a prolonged and exaggerated concern about one’s health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of a serious medical condition. Illness Anxiety Disorder +
Somatic symptom disorder Somatic symptom disorder Somatic symptom disorder (SSD) is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Somatic Symptom Disorder +
Factitious disorder + +
Malingering Malingering Malingering is not a medical disorder, but a behavior of an individual. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients may either invent new ailments or exaggerate current symptoms. Malingering + +

Management

  • Management of factitious disorders should be focused on 3 principles: 
  • Confront the patient in a nonthreatening manner:
    • Videographic evidence of devious behavior may assist in facilitating conversation, as patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may deny their behavior. 
    • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship should be referred for psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy.
    • Caution must be exercised during confrontation, as therapeutic rapport may be lost and the patient may seek another provider. 
  • Avoid unnecessary procedures.
  • Factitious disorder imposed on another person warrants a referral to child protective services Child protective services Local governmental offices which investigate reports of abuse and neglect of children, and act to assure a safe environment for minors. Child Abuse or appropriate judicial department!
  • Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas is poor and treatment should be focused on managing rather than curing the disorder.

Differential Diagnosis

  • Conversion disorder Conversion disorder Conversion disorder (CD), also called functional neurological symptom disorder, is a psychiatric disorder with prominent motor or sensory impairment which is not compatible with any known neurologic medical condition. The deficits are not consciously produced. Conversion Disorder: the presence of symptoms or deficits that affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment voluntary motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology or sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology function in a way that suggests a neurological condition but is not explained by medical findings. Diagnosis is clinical, and management includes psychological and physical therapy Physical Therapy Becker Muscular Dystrophy. Unlike factitious disorder, there is no evidence of actual disease or deliberate falsification of symptoms.  
  • Borderline personality disorder Borderline Personality Disorder A personality disorder marked by a pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. Cluster B Personality Disorders: the most commonly recognized personality disorder. Characterized by emotional instability, impulsiveness, distorted patterns of thinking, and intense yet unstable relationships. Diagnosis is clinical and management includes psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, notably dialectical behavior therapy (DBT). A patient with borderline personality disorder Borderline Personality Disorder A personality disorder marked by a pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. Cluster B Personality Disorders may deliberately induce injury as part of attention-seeking behavior. They will not attempt to deceive the provider. 
  • Malingering Malingering Malingering is not a medical disorder, but a behavior of an individual. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients may either invent new ailments or exaggerate current symptoms. Malingering: a disorder in which patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with symptoms for secondary gain (e.g., avoiding the police, time off work, disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment benefits). Determination of the external incentive distinguishes malingering Malingering Malingering is not a medical disorder, but a behavior of an individual. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients may either invent new ailments or exaggerate current symptoms. Malingering from factitious disorder. 

References

  1. Sadock, BJ, Sadock, VA, Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 13, Psychosomatic medicine, pages 465–503. Philadelphia, PA: Lippincott Williams and Wilkins.
  2. Jafferany, M, Khalid, Z, McDonald, KA, Shelley, AJ. (2018). Psychological aspects of factitious disorder. The primary care companion for CNS disorders, 20(1), 17nr02229. https://doi.org/10.4088/PCC.17nr02229

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details