2nd February 2024

Factitious disorder

Factitious disorder, or Munchausen Syndrome, is named after Baron von Munchausen. He was an 18th-century German officer known to exaggerate the stories of his life. It involves the fabrication of physical or psychological signs or symptoms with no understandable remuneration. 

Factitious disorder is different from illness anxiety disorder and Somatic symptom disorder. In the former, patients are mindful that they are exaggerating, whereas sufferers of the latter two conditions actually believe and accept they have a disease.

Epidemiology

• The prevalence of factitious disorder is not known. This condition mainly involves deception and dishonesty, which makes it difficult to know the incidence. In hospital settings, it is probable that around 1% of them may meet the criteria.
• Factitious disorder is common among women and healthcare workers.
• In factitious disorder imposed on another (FDIA, or Munchausen syndrome by proxy), females are usually the perpetrators, and the majority of them are mothers.
• The onset is usually in the early 20’s.
• Individuals often have a history of numerous hospital admissions and are often keen to undergo invasive procedures.
• These incidents are usually sporadic. However, for some individuals, the pattern of behaviours can become enduring.
• The overall prognosis is usually poor. When challenged, the majority of individuals will refute their behaviours, and very few will seek treatment.
• For factitious disorder imposed on another (FDIA), it usually commences after an initial hospitalisation of their child or other dependent. For the victims of FDIA (–usually children), the mortality is commonly due to poisoning or suffocation and can be between 6 and 22%.

Risk factors

• Patients may have a history of abuse, exploitation or neglect as a child.
• The patient may have experienced a serious medical illness that led to complex, wide-ranging treatment during childhood.
• Past significant associations with a physician.
• They may have primary spiteful intentions towards the medical profession.

DSM 5 Criteria

Criteria A

Falsification (i.e. – deliberately feigning) of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

Criteria B

The individual presents himself or herself to others as ill, impaired, or injured.

Criteria C

The deceptive behaviour is evident even in the absence of obvious external rewards.

Criteria D

The behaviour is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder

Diagnosis

History

• Fabrication of medical or psychological signs and symptoms in oneself or others with high dishonesty
• They take surreptitious actions to misrepresent, stimulate or cause symptoms and signs of illness or injury with no obvious external rewards.
• They might overstate the symptoms, fabricate or even simulate them.
• There might be a pre-existing condition, but the deceptive behaviour, in turn, may lead to excess clinical intervention.
• They are at increased risk of causing harm to themselves or others.

Differential Diagnoses

• Somatic symptom disorder
• Malingering
• Conversion disorder
• Personality disorder

Management

• The primary treatment goal is to modify the individual’s behaviour and diminish misuse or overuse of medical resources and unnecessary investigations, which may have negative consequences for the patient.
• The primary treatment for factitious disorder is psychotherapy, including psychoanalytic therapy or psychodynamic therapy, cognitive behavioural therapy and family therapy. 
• Co-morbid psychiatric disorders should be recognised and treated.
• In factious disorder imposed on another, treatment is similar to those in factitious disorder, with the added concern about the safety of the potential victim.
  • Management often necessitates a team that comprises not only healthcare providers but also social services, foster care (when children are involved), law enforcers, professional regulatory bodies, and child welfare organisations.

References

• Merten, T. and Merckelbach, H. (2020). Factitious disorder and malingering. New Oxford Textbook of Psychiatry, pp.1342–1349. doi:10.1093/med/9780198713005.003.0132.
• bestpractice.bmj.com. (n.d.). Factitious disorders – Symptoms, diagnosis and treatment | BMJ Best Practice. [online] Available at: https://bestpractice.bmj.com/topics/en-gb/695
• Zeshan, M., Cheema, R. and Manocha, P. (2018). Challenges in Diagnosing Factitious Disorder. American Journal of Psychiatry Residents’ Journal, 13(9), pp.6–8. doi:10.1176/appi.ajp-rj.2018.130903.
• rona (2013). Factitious disorder (Munchausen’s syndrome). [online] www.rcpe.ac.uk. Available at: https://www.rcpe.ac.uk/journal/factitious-disorder-munchausens-syndrome [Accessed 24 Jan. 2023].
• Carnahan, K.T. and Jha, A. (2021). Factitious Disorder. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK557547/
• DT; BCW. Malingering and factitious disorder [Internet]. Practical neurology. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/30425128/