Dr. IsHak is Director of Psychiatry Residency Training and Medical Student Education in Psychiatry at Cedars-Sinai Medical Center (CSMC) and Associate Clinical Professor of Psychiatry at the University of California, Los Angeles (UCLA), the University of Southern California, and CSMC, all in Los Angeles, California. Dr. Rasyidi is the CSMC Psychiatry Chief Resident. Dr. Saah is former research physician volunteer at CSMC and current psychiatry resident at Emory University in Atlanta, Georgia. Dr. Vasa is on medical staff at CSMC. Dr. Ettekal is Research Psychiatrist at California Clinical Trials in Glendale, California. Dr. Fan is Associate Director of Inpatient Psychiatry at CSMC and Assistant Clinical Professor of Psychiatry at UCLA and CSMC.

Disclosures: Dr. IsHak receives grant support from the National Alliance for Research on Schizophrenia and Depression and Pfizer. Drs. Saah, Rasyidi, Vasa, Ettekal, and Fan report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Waguih William IsHak, MD, FAPA, Cedars-Sinai Medical Center, Department of Psychiatry and Behavioral Neurosciences, 8730 Alden Dr, Thalians W-157, Los Angeles, CA 90048; Tel: 310-423-3515; Fax: 310-423-3947; E-mail: Waguih.IsHak@cshs.org.


Focus Points

• Factitious disorder is the intentional production of symptoms to assume the sick role in the absence of secondary gain.
• Factitious disorder could present with physical, psychological, or combined symptoms.
• Factitious disorders are commonly misdiagnosed with medical conditions, somatoform disorders, or malingering.
• Medical records from previous hospitalizations and healthcare providers are essential.
• Factitious disorder needs to be suspected in frequent acute care utilizers with atypical presentations and negative results.

 

Abstract

In the clinical setting, factitious disorder is often mistaken for malingering or somatoform disorders. Three cases of factitious disorder with physical, psychological, and combined symptoms are reported. Comparing these patients may help facilitate identification of factitious disorder, especially with improving recognition in patients who are high utilizers of acute medical and psychiatric services. A high level of suspicion regarding the diagnosis of factitious disorder is needed, especially in cases with frequent utilizers of emergency room and inpatient services, atypical presentations, and negative diagnostic results.

Introduction

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision,1 refined the diagnosis for factitious disorder by providing three diagnostic criteria (Table 1).2 Studies indicate a .5% to .8% prevalence of factitious disorders in hospital patients, with a prevalence of up to 6% to 8% on psychiatric units.2-5 However, patients with factitious disorders are commonly misdiagnosed with medical conditions, somatoform disorders, or malingering. Due to diagnostic difficulties, only the most severe cases of factitious disorder are diagnosed correctly. In other cases, factitious disorder may be suspected but not diagnosed. The following three cases of factitious disorder with disparate presentations are based on the subtypes described in the DSM-IV-TR (Table 2).1 Patient A presented with mainly physical symptoms. Patient B presented with physical and psychological symptoms. Patient C presented with mainly psychological symptoms. The patients presented depict the wide spectrum of severity and presentations in factitious disorders that contribute to the difficulty of accurate diagnosis. The management of these cases also demonstrates the diagnostic strategy needed for improving diagnosis of factitious disorder.

 

Factitious Disorder Case Reports

Patient A: Factitious Disorder with Predominantly Physical Signs and Symptoms

Patient A, a 27-year-old female, would often present to the emergency department with vague complaints of abdominal pain and bright red blood per rectum, which she stated was typical for her Crohn’s disease. The patient also freely reported a psychiatric history with multiple diagnoses, including bipolar disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), panic disorder, a history of anorexia nervosa, and Asperger’s syndrome, as well as a history of suicide attempts and self-injurious behaviors. The patient had a stable income through state disability and lived in a comfortable home with her parents in an affluent neighborhood. Psychiatric consultation was requested on her third admission to the medical center and after 13 previous presentations to the emergency department. At that point she had undergone extensive diagnostic testing, including computed tomography scans, upper gastrointestinal (GI) endoscopy with small bowel follow through, colonoscopy, and biopsies, all of which had been unsuccessful in finding the cause of GI bleeding. She was transferred to the inpatient psychiatric hospital for complaints of depressed mood and her diagnosis was refined to PTSD and borderline personality disorder. During hospitalization, a nurse found the patient in the bathroom one night inserting a toothbrush into her rectum, producing the bloody stools that she had been complaining of for the past several days. When confronted, the patient articulated that she desired the attention that came with her medical work-ups and that it instilled a sense of control over her environment. This behavior was different from previous suicide attempts in that there was no intent to die. It was also distinct from her self-injurious behaviors which were performed openly and freely admitted to. As for the discrepancy between reported psychiatric diagnoses and those at time of discharge, this was due to diagnostic errors on the part of previous treatment teams, not due to misrepresentation by the patient. The patient thus met criteria for factitious disorder with predominantly physical symptoms.

Patient B: Factitious Disorder with Combined Psychological and Physical Signs and Symptoms

Patient B, a 52-year-old female with bipolar depression, was admitted to the inpatient unit for the fifth time in 6 months after presenting with suicidality and depressed mood. The patient stated that she had been diagnosed with OCD, PTSD, and attention-deficit/hyperactivity disorder. She also stated that she was blind and had a guide dog. During hospitalization, she consistently reported that her depression and suicidality were worsening. However, observations showed that the patient joked, laughed, and regaled others with far-fetched stories. She ate and slept well, and ambulated without difficulty. It also became increasingly obvious that Patient B was not blind. She was observed reading, looking in the mirror, and dialing numbers from her phone book. In daily sessions, inconsistencies were noted in her elaborate recollections of traumas. The management plan consisted of performing a diagnostic work-up including medical, neurologic, and neuropsychological evaluations, in addition to a trial of citalopram 40 mg PO and lamotrigine 200 mg PO, both at bedtime, as well as psychotherapy. Ophthalmology and neurology consults did not reveal any visual loss. The psychological and neuropsychological testing confirmed suspicions about the presence of significant antisocial, narcissistic, and borderline personality traits, and showed intact neuro-cognitive functioning. Additional information confirmed the patient’s tendency to move from hospital to hospital, leave against medical advice, and express inconsistent medical and psychiatric complaints, which gave evidence to the diagnosis of a factitious disorder. The most important two differential diagnoses were conversion disorder and malingering. Conversion disorder was ruled out because the patient was shown to have intact vision on medical consultations. Regarding malingering, there were no specific secondary gains as she had a stable housing and financial situation. It became clear that Patient B was intentionally producing both physical (blindness) and psychological (worsening of depression) symptoms in order to assume the sick role. She was informed of the diagnostic possibility of factitious disorder with combined psychological and physical signs and symptoms, and was recommended for continuation of both psychotherapy and pharmacotherapy.

Patient C: Factitious Disorder with Predominantly Psychological Signs and Symptoms

Patient C, a 38-year-old male, presented complaining of a 3–4-month history of depressed mood, poor energy, difficulty sleeping, poor appetite, psychomotor retardation, increasing hopelessness, and suicidal ideation with a plan to walk into traffic. Once on the inpatient wards, the patient remained compliant with his medications; however, no change in mood was seen. Throughout his stay, Patient C demonstrated, on a consistent basis, a discrepancy between what he stated to staff and what was observed on the wards. The patient consistently reported depressed mood and suicidality, but was observed to be euthymic, in good spirits, and carousing with the other patients. The patient’s stay was also significant for two suicide attempts both with low lethality and high possibility of rescue. Elaborate stories regarding the death of his best friend, as well as his previous married life, employment status, and relations with his family, were for the most part later repudiated by the patient’s father. Eventually, the patient was so disruptive to the inpatient milieu that he was placed in seclusion. Within a few hours he arranged to be picked up by a friend and was successful in finding a place to stay. Before being discharged, the patient admitted to never being suicidal and that the two suicide attempts had both been feigned. The treatment team noticed that the patient had traits of antisocial, narcissistic, borderline, and histrionic personality disorders. The likelihood of malingering was low because the patient had stable income and was offered numerous housing options, which he refused. The treatment team concluded that this patient was willing to assume the sick role, by intentionally manifesting psychological symptoms, to gain the social interaction of being in a psychiatric unit.

Discussion

Although factitious disorders have been formally recognized for >30 years, diagnostic criteria have evolved significantly since the recognition of the disorder. From the DSM-II6 through the DSM-III7 and DSM-III-R,8 factitious disorders had no clear inclusion or exclusion criteria for diagnosis.9 The advent of the DSM-IV10 and DSM-IV-TR11 advanced the diagnosis of factitious disorder by defining three diagnostic criteria: A) intentional production of physical or psychological signs or symptoms, B) motivation to assume the sick role, and C) absence of external incentives or secondary gain.1,12-14 Criterion A differentiates factitious disorder from somatoform disorders by requiring the intentional production of signs or symptoms. Criterion C differentiates factitious disorder from malingering by eliminating the presence of secondary gains for the patient.15 It is also important to note that while patient cases B and C were also clear examples of pseudologia fantastica, where embellished truth and colorful fantasies are presented as fact in order to gain the interest of the listener, this phenomenon is neither pathognomonic nor necessary under our current nosology for the diagnosis of factitious disorder.14

The three cases presented elucidate several effective diagnostic strategies. With Patient A, psychiatric consultation led to psychiatric hospitalization and a careful review of the medical and psychiatric history. The treating psychiatrist had thoughtful discussions with the patient’s other doctors, which confirmed her history of high health services, utilization, and a lack of evidence for a medical etiology. The close observation of the psychiatric nursing staff then caught the patient in an act of self-injury. With Patient B, the treating psychiatrist also had a thorough diagnostic plan, which included consultation with the neurology, medicine, ophthalmology, and neuropsychological testing services. Nursing observations on the inpatient psychiatric unit revealed that the patient did not have the visual or depressive symptoms that she claimed to have. The treating psychiatrist was also able to obtain valuable medical and psychiatric history from collateral sources to confirm a pattern of multiple hospitalizations, inconsistent medical and psychiatric presentations, and hospital discharges against medical advice. With Patient C, nursing observations also found that the patient’s behavior on the psychiatric unit were inconsistent with his reported symptoms. The treating psychiatrist was able to obtain collateral history from the patient’s father, which confirmed that the patient had falsified his symptoms and psychiatric history to gain admission to the psychiatric unit.

The growing literature on factitious disorder indicates that patients have certain common traits. Understanding these traits may help in accurate diagnosis and management. Some studies have found that factitious disorder patients often have work experience in healthcare fields. They can use their medical knowledge to deceive and confuse the treatment team in their search for an accurate diagnosis. Factitious disorder patients are fearful of abandonment and highly sensitive to rejection.16 They usually have comorbid Axis I and II diagnoses. They use the hospital setting to find support, safety, and social relationships that they cannot obtain otherwise. Confronted with their falsification of history and intentional production of symptoms, factitious disorder patients have increased risk of self-harm and exacerbation of psychiatric disorders. They become extremely difficult to manage as the therapeutic rapport is broken.

From the three patients presented and a review of the literature, several recommendations to facilitate the accurate diagnosis and proper management of factitious disorder patients have been provided. In cases in which factitious disorder is suspected, always ask the patient for permission to obtain medical records from previous hospitalizations and healthcare providers. After Patient A had been caught in the act of producing her physical symptoms, she conceded consent. However, even in situations where patients are caught “red-handed,” there may be an impressive level of denial with patients going so far as to assert that events never actually took place. With Patients B and C, consent was obtained by explaining to the patients that access to sufficient information was necessary in providing appropriate treatment. Again, there may be scenarios where patients balk at this proposal. Refusal by the patient of a well-presented, reasonable request should make the treating physician suspicious of a non-medical diagnosis. Similarly, the treating physician should also ask the patient for permission to collect history from collateral sources such as family members, spouses, and friends. A refusal by the patient may indicate a fear of discovering a falsification. In a hospital, the treating physician should ask the nursing staff to closely monitor a patient suspected of factitious disorder. Close observation can reveal a patient’s surreptitious production of clinical signs. The treating physician should also seek consultations from specialists in other fields to exclude a medical etiology for the patient’s signs and symptoms. In a psychiatric unit, the treatment team, including nurses and therapists, needs to be reminded to set appropriate limits and boundaries for suspected factitious disorder patients. These limits and boundaries may decrease the social and psychological gains that a patient may want from a hospitalization.

Conclusion

The dearth of information available on factitious disorder and the difficulty in obtaining epidemiologic and diagnostic information should not preclude the possibility of more accurate diagnosis and better management. Large descriptive and longitudinal studies with adequate diagnostic work-ups, including medical, neurologic, neuropsychological, and personality testing evaluations, are needed in order to develop a clear understanding of factitious disorders. Unfortunately, such studies are very difficult to undertake in a patient population that is adverse to discovery. Nonetheless, factitious disorder should be considered in patients with atypical presentations and negative diagnostic results who are high utilizers of acute care facilities such as the emergency room and inpatient services. PP

References

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15. Drob SL, Meehan KB, Waxman SE. Clinical and conceptual problems in the attribution of malingering in forensic evaluations. J Am Acad Psychiatry Law. 2009;37(1):98-106.
16. Feldman MD. Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York, NY: Brunner–Routledge; 2004.

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