Factitious Disorder

Factitious disorder, which was previously called Munchausen syndrome, is a mental illness characterized by faking illness or purposely becoming ill or injured. It may take the form of self-harm and injury or faking one’s own illness. The disorder also may involve hurting someone else or presenting another person as being sick or injured when they are not. Factitious disorder can range from mild to severe, from exaggerating illness to completely faking an illness or intentionally causing harm.

This is a difficult mental disorder to identify and treat. Someone with factitious disorder wants to be in the role of patient or of being sick, or wants to have someone else, often a child, be in that role. The motives and the reasons for this are challenging to understand.

Treatment typically includes medical care and therapy. Medications may be helpful, and in some cases an individual may need to be hospitalized. Treatment can be difficult because it requires that the patient recognize they have the condition. Without this acceptance the prognosis is not always good, but treatment is worth trying because the complications of factitious disorder can be serious and may include real physical harm.

There are two main types of factitious disorder, based on whether the person with the condition is faking or causing his or her own illness or injury or is doing it to someone else.

• Factitious disorder imposed on self. This type of factitious disorder, which used to be called Munchausen syndrome, occurs when someone fakes psychological or physical symptoms of an illness, disorder, or injury. In some cases the individual may purposely get sick or cause their own injury or harm.
• Factitious disorder imposed on another. Previously called Munchausen by proxy, this form of factitious disorder occurs when someone fakes or imposes injury or illness on someone else. The other person is usually someone in the person’s care, such as a child, an elderly relative, or a disabled individual. It may also be a pet. The most common form of this type of the disorder is a mother faking illness or causing illness in a child.

Factitious disorder can also be categorized by the type of illness faked or triggered. Some people fake psychological symptoms, while others fake or cause physical symptoms. Some people with the disorder may include a combination of both.

There are not many statistics available for factitious disorder, as it has been studied less than other mental illnesses and because patients often don’t admit to having the condition. This makes it difficult to collect information about factitious disorder.

• It is thought that about one percent of people admitted to hospitals are diagnosed with factitious disorder, but it is probably under-reported.
• One study of patients in a psychiatric hospital found that eight percent showed some symptoms of factitious disorder.
• Another study reviewed papers to determine statistical information about factitious disorder. From a sample of 455 diagnosed patients they found that 66 percent were female.
• The mean age of the patients in the study was 34.
• More than half of the patients, 58.7 percent, chose to actually cause themselves harm rather than to only fake illness or injury.

Diagnosis of factitious disorder is very difficult. One reason is that a person with this condition is good at faking symptoms and illness. They may use multiple doctors, fake names, and rely on privacy rules to make collecting medical records difficult. Another reason this mental illness is challenging to diagnose is that people with factitious disorder are unlikely to admit to or even be able to recognize their own flawed thinking and behaviors. In other words, they don’t think there is anything wrong with them.

To make a diagnosis, a doctor or psychiatrist should be able to access medical records, but there other ways they can get the necessary information: an interview with the patient, interviews with close family members, the criteria for factitious disorder from The Diagnostic and Statistical Manual of Mental Disorders, as well as medical tests.

The first professional to suspect factitious disorder is usually a physician treating a patient for something that seems to be self-imposed or fake. Some signs that may make a doctor take note and suspect factitious disorder include:

• An illness that does not follow the expected course
• A medical history and present observations inconsistent with each other
• Multiple admissions to different hospitals or visits with several doctors on the medical record
• Textbook knowledge of illnesses
• Failure to find evidence of a patient’s complaint, such as no dehydration when a patient complains of constant diarrhea
• Appropriate treatments don’t improve symptoms
• Signs of self-injury
• Multiple surgical scars
• New symptoms after diagnostic tests come back negative
• Catching a patient lying about symptoms or medical history, or even tampering with medical equipment or records

The symptoms of factitious disorder imposed on another may be similar, but the supposed or imposed illness or injury is observed in another person. Some of the common medical presentations seen in the victim include:

• Poisoning
• Bleeding
• Seizures
• Depression of the central nervous system
• Diarrhea or vomiting
• Fever
• Skin rashes
• High or low blood sugar
• Apnea

Some other signs of factitious disorder imposed on another include multiple or recurrent illnesses in the victim, a perpetrator who is extremely attentive to the victim but who is less worried than medical professionals, a child or other victim who resists treatment, and discrepancies between the victim’s medical records, medical tests, symptoms, and general health.

There is no known cause of factitious disorder. It is likely that there is a complex combination of biological, psychological, and environmental factors that play a role in its development. There are certain conditions or factors that are commonly seen in people diagnosed with factitious disorders. These may be significant risk factors for the condition:

• Childhood trauma, especially abuse or serious illness or injury
• Loss of a loved one to illness
• Having been sick a lot early in life
• Having a family member who was often sick or hospitalized
• A history of social isolation
• Being a professional in the medical field
• Other mental illnesses, especially depression or personality disorders
• Poor self-esteem or lack of a sense of identity or self

Factitious disorder may occur with other mental illnesses or with a substance use disorder. There are few statistics about this, but there is some evidence that personality disorders and major depression are common with factitious disorder. One study of 455 patients with factitious disorder found that those with comorbid conditions were most likely to have depression. About 42 percent of the patients studied were also diagnosed with depression. A significant portion of the patients (about 16 percent) also had a personality disorder.

Treatment for factitious disorder is challenging, largely because the patient often cannot recognize that there is anything wrong with their behaviors or thought patterns. The best outcomes from treatment occur when the patient realizes there is a problem. To get to this point is difficult or even sometimes impossible. An approach that is supportive rather than critical is important. Unsupportive or judgmental confrontation can cause the patient to become angry and defensive and to refuse any mental health treatment.

This is a unique mental health condition in that treatment requires both physicians and mental health professionals. The role of the physician is to make sure the patient is getting necessary medical treatments for actual physical complaints or self-injuries. The mental health professionals provide therapy and, if necessary, medications for depression or anxiety.

Individual therapy and family therapy can be useful. The latter helps educate the family while also guiding them to learn how to support their loved one in a productive way. Individual therapy can help the patient learn to recognize their flawed thinking, make positive changes, and manage stress with healthy coping strategies.

Treatment is difficult and in many cases is not accepted by the patient. In these cases treatment may center on preventing self-injury and avoiding treatments or procedures that are unnecessary or risky. The prognosis for factitious disorder relies strongly on the ability of the patient to accept treatment. If they do, the outlook is positive and ongoing care can lead to a resolution of symptoms.