DÄ internationalArchive26/2020Factitious Disorders in Everyday Clinical Practice

Review article

Factitious Disorders in Everyday Clinical Practice

Dtsch Arztebl Int 2020; 117: 452-9. DOI: 10.3238/arztebl.2020.0452

Hausteiner-Wiehle, C; Hungerer, S

Background: The pathological feigning of disease can be seen in all medical disciplines. It is associated with variegated symptom presentations, self-inflicted injuries, forced but unnecessary interventions, unusual and protracted recoveries, and frequent changes of treating physician. Factitious illness is often difficult to distinguish from functional or dissociative disorders on the one hand, and from malingering on the other. Many cases, even fatal ones, probably go unrecognized. The suspicion that a patient’s problem may be, at least in part, factitious is subject to a strong taboo and generally rests on supportive rather than conclusive evidence. The danger of misdiagnosis and inappropriate treatment is high.

Methods: On the basis of a selective review of current literature, we summarize the phenomenology of factitious disorders and present concrete strategies for dealing with suspected factitious disorders.

Results: Through the early recognition and assessment of clues and warning signs, the clinician will be able to judge whether a factitious disorder should be considered as a differential diagnosis, as a comorbid disturbance, or as the suspected main diagnosis. A stepwise, supportive confrontation of the patient with the facts, in which continued therapeutic contact is offered and no proofs or confessions are demanded, can help the patient set aside the sick role in favor of more functional objectives, while still saving face. In contrast, a tough confrontation without empathy may provoke even more elaborate manipulations or precipitate the abrupt discontinuation of care-seeking.

Conclusion: Even in the absence of systematic studies, which will probably remain difficult to carry out, it is clearly the case that feigned, falsified, and induced disorders are underappreciated and potentially dangerous differential diagnoses. If the entire treating team successfully maintains an alert, transparent, empathic, and coping-oriented therapeutic approach, the patient will, in the best case, be able to shed the pretense of disease. Above all, the timely recognition of the nature of the problem by the treating team can prevent further iatrogenic harm.

LNSLNS

Feigned disorders are encountered in all disciplines of clinical medicine. Long considered to be primarily malingering, it was not until Freud’s concept of the subconscious that they were implicated as having possible characteristics of a disease (1). “Polysurgical addiction” was described in 1923/1934 (2, 3) and “Münchhausen’s syndrome” in 1951 (4). The etiopathogenesis of these disorders is ultimately unknown. Today, one mainly invokes psychodynamic, developmental psychological, and above all trauma psychological models, in which objectification and manipulation of the own body, as well as assuming the sick role are attempts to solve subconscious needs and conflicts (1, 5, 6, 7, 8, 9).

The ICD-10 currently defines “factitious disorders” as the “intentional production or feigning of symptoms or disabilities, either physical or psychological” (10). Affected individuals are compelled to feign sickness or cause harm to themselves “repeatedly and for no plausible reason” (10). The motivation for this is described as “obscure”: “the aim is presumably to assume the sick role.” For “factitious disorder imposed on self/on another,” the ICD-11 will, in addition, explicitly require that the deception is not motivated solely by obvious external incentives (10). Subtypes include “Münchhausen’s syndrome” (“hospital hopper”) and “Münchhausen’s syndrome by proxy” (fabricating symptoms in another person, usually children or dependents) (10, 11). The current article will not deal with these “by-proxy” constellations, which represent a separate entity and are also ethically and legally complex. Factitious disorders “for proxy” (symptoms that benefit others) and “by Google” or “by internet” (stories of illness disseminated on the internet) have also been described, depending on the purpose or means of deception (1, 12, 13, 14, 15, 16).

The current conceptualizations are criticized primarily for the fact that differentiating between functional/dissociative/somatoform disorders, as well as simulation/aggravation, is challenging (1, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25). Although these phenomena may clinically resemble one another at first glance, they differ significantly in terms of intention, motive, findings, propensity to self-harm, and willingness to change—which are, in turn, clinically challenging to differentiate (Table). Due to their considerable heterogeneity on the one hand, and their blurred boundaries on the other, factitious disorders ought to be understood as a particularly severe manifestation on a broad spectrum of dysfunctional illness behavior (1, 16, 17, 18, 22).

Factitious disorders, malingering/aggravation, as well as functional, dissociative, and somatoform disorders
Table
Factitious disorders, malingering/aggravation, as well as functional, dissociative, and somatoform disorders

Almost every physician has been confronted with the “vexing medical puzzles” (1) posed by the possible feigning, falsification, induction, or exacerbation of diseases. What is the background to these disorders, what are typical indicators and difficulties, and what is an appropriate approach?

Methods

This review article presents the phenomenology of, as well as the practical approach to, suspected or proven factitious disorders. It is based on a selective literature search in PubMed using the search terms “Münchhausen”, “Munchhausen”, “Munchausen”, “factitious”, and “factitia”. In particular, current reviews and case series on the subject published since 2000 were taken into account. Recommendations in relevant specialist reference books and from own experience in a supra-regional trauma center were also included.

Results

Epidemiology and clinical presentations

Little is known about the frequency of factitious disorders in their widely varying forms and degrees of severity. Current data from the central Norwegian patient registry showed a prevalence of only 0.0026%; however, careful review revealed that diagnoses were frequently incorrect and far too rarely made (23). A 1-year prevalence of around 1% (to 5%) is usually assumed in clinical populations (1, 5, 16, 19, 26, 27, 28, 29, 30). Numbers vary considerably depending on the survey method used and familiarity with the diagnosis, as well as on the specialty (26, 27, 28, 29, 30). The (suspected) diagnosis was made in 7.5% of pre-selected patients in a psychosomatic consultation liaison service (28). Systematic reviews of published case studies reported a high proportion of case reports in psychiatry (19%), accident and emergency departments (12%), neurology/neurosurgery (10%), infectiology and dermatology (9% each), endocrinology (13%), as well as cardiology and dermatology (10% each) (29). Between 40 and 64% of cases remain suspected cases (18, 26, 27, 28, 30).

Approximately 90% of patients feign sickness by fabricating symptoms in a self-harming manner. These “factitious” disorders in the narrower sense occur primarily in younger females (1, 18, 19, 26, 27, 28, 29). Likewise, across medical specialities and clinical presentations, patients with factitious disorders tend to be younger females (1, 29). Merely in neurology and cardiology, as well as in investigations for HIV/sexual dysfunction, the proportion of males appears to be higher, while in dermatology this is the case for older patients (1, 29). Only around 10% of cases correspond to the “Münchhausen” subtype of “evasive hospital hopper with a dramatic medical history.” These cases are predominantly middle-aged males with dissocial personality traits (1, 4, 9, 18, 19). However, the term “Münchausen’s syndrome” is proposed in some cases in the literature for severe, chronic fabrication of symptoms (23). In clinical routine, the term is often—misleadingly—used in an undifferentiated manner for the entire spectrum of factitious disorders.

Clinical manifestations involve all organs and organ systems, are staged secretly and often with considerable skill, and range from inventing medical histories to inducing fatal diseases. Mental and behavioral disorders such as post-traumatic stress disorder or schizophrenia are also feigned (1, 5, 7, 27). Factitious behavior is usually conscious, in contrast to the motives behind it, but may also occur in dissociative (unconscious, trance-like) states (1, 5, 6, 7). Individuals in medical (assistant) professions, or who fantasize thereof (“...actually, I wanted to be a doctor”), appear to master this “mimicry of the sick person” (1) particularly well, and 22–66% have medical qualifications (1, 18, 26, 27, 29). Patients that have undergone early or frequent hospitalization or that have sick relatives potentially have a lower inhibition threshold, extensive knowledge, and specific skills with which to feign illness. In addition, the Internet now enables unimpeded access to specialist information as well as anonymous self-presentation to a wide audience (1, 7, 13, 14, 15). In the setting of insurance, asylum, and criminal law, occupational medicine as well as the military, malingering due to external incentives predominates, with, however, blurred boundaries to factitious disorders (1, 16, 17, 18, 22, 31, 32, 33).

Differential diagnoses, comorbidities, and prognosis

Due to the diversity of clinical presentations seen (Box 1), the list of differential diagnoses is virtually endless. Imitation or induction of common infectious, as well as endocrinological, cardiological, dermatological, and neurological disorders, are frequent. Rarer differential diagnoses include, for example, pyoderma gangrenosum, complex regional pain syndrome, and psychogenic purpura/Gardner–Diamond syndrome.

Typical manifestations of factitious disorders (a selection)
Box 1
Typical manifestations of factitious disorders (a selection)

At around 40% (1, 27, 28, 29), in some case reviews 58–70% (18, 34), comorbidity with mental and behavioral disorders is high: factitious behavior is primarily seen in personality, addiction, eating, and stress-related disorders. The data vary for somatoform and dissociative disorders, attention deficit/hyperactivity disorders, as well as affective, impulse control, anxiety, and obsessive-compulsive disorders. Body dysmorphic or body integrity identity disorders, including apotemnophilia (ranging from the desire to amputate one or more healthy limbs to erotic fetishism for amputation) sometimes result in self-harm in order to get rid of the supposedly deformed body part. Between 20 and 68% of patients have a somatic comorbidity (1, 19, 27, 28). Pre-existing diseases or injuries often form the organic core, which can be complicated by the patient manipulating findings. And finally, patients with factitious disorders can become ill due to complications or incidentally in the course of their disease.

The scant prognostic data that are available indicate drastic differences in the degree of self-harm and the resulting degree of disability: approximately 10–30% of factitious acts appear to be isolated and harmless events; one sees mild disease courses and complete remissions. However, episodic or chronic courses with sometimes lasting disabilities appear to be more common (1, 7, 16, 19, 26, 28, 29). Mortality is likely to be increased: causes of death can include complications from (provoked) interventions or suicide (1, 26, 28, 33, 35), while approximately 14% of patients have suicidal thoughts (27, 29). Failure to recognize feigning and symptom fabrication carries the risk of iatrogenic chronification and worsens the prognosis (1, 16, 17, 22, 36).

Dysfunctional motives, behaviors, and contextual factors

Although affected individuals usually credibly convey a desire to get well, they have contrary (“dark”) motives and dysfunctional behaviors (1, 4, 5, 6, 7, 8, 9, 16, 17, 19, 22). The lying of these patients, who often have serious problems in many areas of their lives, has been described as “a necessary mechanism to keep greater evils at bay” (8).

As in other behaviors that bring short-term gain despite long-term harm, factitious behavior can take on the character of a true addiction (1, 2, 3, 4, 5, 6, 7, 8, 9). Those affected put their health at risk. An upward dynamic emerges, involving ever more hazardous deceptions and an increasing number of medical care providers: The more credibly and dramatically the symptoms are presented, the less one initially suspects deception, but rather diagnoses and treats with growing commitment. Physicians become involved in conflicts, are led down the wrong track, and thus—despite their best intentions—are turned into stooges that risk committing malpractice (1, 5, 7, 8, 16, 17, 18, 19, 22, 37, eBox 1).

Selected ethical and legal aspects of artificial disorders
eBox 1
Selected ethical and legal aspects of artificial disorders

Although openly displayed self-harm (for example, in the context of mental illness, rituals, extreme sports, or in the form of body modifications) as well as deception (imposters, “playing hooky”) occur across times and cultures, factitious actions are particularly strongly tabooed. This hampers their early detection and makes them more attractive to those affected (5, 16, 17, 22). Moreover, in societies with highly performing and freely accessible healthcare systems, the sick role is essentially open to all at all times—its obvious advantages are rarely questioned (1, 8, 16, 17, 22).

Management: primum nil nocere!

Factitious disorders threaten the Hippocratic principle “do no harm—nil nocere” insofar as they provoke high-risk interventions. Therefore, their prompt identification is of paramount importance (Box 2). Semi-structured basic documentation can be helpful in the clinical assessment (1, 38, 39) (Figure 1). Vigilance, face-saving confrontation, and support to stop self-harming are essential in the diagnostic and therapeutic approach (Figure 2).

Warning signs of factitious disorders*
Box 2
Warning signs of factitious disorders*
Semi-structured basic documentation for suspected or confirmed self-harm (modified from [39])
Figure 1
Semi-structured basic documentation for suspected or confirmed self-harm (modified from [39])
Dealing with factitious disorders
Figure 2
Dealing with factitious disorders

Vigilance in the team

Various warning signs and indicators (Box 2, eBox 2) in the findings, context, patient behavior, and not least in the medical professionals’ own actions permit a prompt reaction—ideally before the fatal dynamics of the disorder unfold. Unusual findings and medical histories can be recorded relatively easily and specifically (18, 27, 29, 38, 39, 40). The entire team is called upon here: patients sometimes open up in particular to non-medical staff; sometimes non-medical staff in particular observe important details.

Possible, primarily unspecific indicators of factitious disorders
eBox 2
Possible, primarily unspecific indicators of factitious disorders

Nevertheless, none of these warning signs is evidence of feigned illness (1). They are merely indications that could also be attributed to the primary personality of the patient or to previously overlooked disorders. Most people from difficult backgrounds with problematic relational experiences, abnormal personality traits, or from medical professions do not feign illness. Nor should the responsibility for treatment failures be prematurely apportioned to patients as putative saboteurs. Having said that, patients can hide for a long time behind operational blindness and taboos. Precisely the staged drama of suffering, then the injustice, and finally disillusionment are typical of the disorder (1, 5, 6, 7, 8, 9, 19). Ongoing denial shared with the patient and aimed at avoiding conflict or ensuring profitable further treatment is to be avoided at all costs (1, 5, 6, 7, 8, 9, 16, 17, 19, 22, 34).

If there are warning signs, factitious disorder is a legitimate differential diagnosis. If the suspicion is substantiated, it becomes a suspected diagnosis. Suspected feigned illness should be discussed within the entire team to establish team consensus and to make sure that no member of the team behaves in a dysfunctionally over-involved, openly mistrusting, or outraged manner. Instead, the “ill-health dramatics” should be met with an attitude of routine professionalism and empathy, as well as a consistent and broadly consented treatment strategy (1, 7, 16, 17, 22, 34).

Information and confrontation

If there are sufficient indicators, a recommended approach is to inform patients of the differential diagnosis of self-infliction and, where appropriate, confront the patient with the suspected diagnosis in a stepwise, constructive, and supportive approach (indirect confrontational approach) (1, 5, 6, 7, 8, 9, 16, 17, 19, 22, 26, 24, 34). Part of this approach includes not insisting on exposure, evidence, or confessions. Patients should feel secure in the knowledge that they will continue to receive active treatment and that other differential diagnoses are being considered.

Confrontation can bring considerable relief for patients, since their deception is associated with privation and pain. Many of them have wanted to abandon the sick role, and the web of lies it involves, on several occasions (1, 5, 6, 7, 8, 9, 19). A supportive confrontation can also be used to openly explain the opportunities of psychotherapy. Some patients take this offer—even if initially only in order to improve their abilities to relax or cope with stress or pain. On the other hand, for many patients, admitting that their illness is feigned means loss of face and costs them enormous effort. Many deny feigning illness for this reason, but desist after a confrontation. Thus, they are subsequently better able to explain the incipient improvement in their status and still avoid the diagnosis of an artificial disorder (1, 5, 6, 7, 8, 9, 26, 34).

Harsh, indignant, or sarcastic, not to mention sadistic, condemnation is advised against (1, 5, 6, 7, 9, 26, 34). This leads one into the (relational) trap set by patients and is likely to result in patients “going underground” and continuing their deception in a more differentiated manner in other institutions. In a retrospective study, 80 of 93 patients underwent psychiatric consultation, and 71 were confronted with the suspected diagnosis; only 16 admitted feigning illness (26). Only 19 of 93 patients agreed to psychiatric treatment, while 18 left the hospital against medical advice (26). In a review of 32 case reports, 17 patients were confronted with the suspicion of self-infliction, 14 of these with a non-punitive approach, but without a discernible correlation to the outcome (34).

Figures 1 and 2 provide a stepwise approach, while eBox 3 lists concrete examples for use in informative and confrontational interviews. Where possible, these should take place in the presence of a team member familiar to the patient, not held in passing or in the heat of the moment, and should be documented (1, 5, 6, 7, 8, 9, 16, 17, 22, 34).

Supportive information and confrontation
eBox 3
Supportive information and confrontation

Tasks and ways out

Ongoing offers of contact with permanent contact persons, as well as concrete treatment arrangements, can build bridges and open (back)doors (1, 5, 6, 7, 8, 9, 16, 17, 22, 34) (Figures 1 and 2, eBox 3). By providing security, social contacts, autonomy, and an identity beyond the sick role (for example, professional prospects), the often remarkably intricate deception is, in the best case, no longer necessary and patients are able to stop or least reduce the behavior (1, 5, 6, 7, 8, 9, 16, 17, 22, 34).

As a precondition for further treatment, patients should agree to contribute in an active and motivated manner (5, 6, 7, 8, 9, 16, 17, 22, 34). Examples include acceptance of wound closure measures, alcohol/nicotine abstinence, cessation of opioid use, home physiotherapy exercises, participation in stress-management programs, or initial psychotherapy interviews. For general health-promoting measures of this kind, factitious behavior does not need to be proven.

Treatment contracts in the narrower sense can be counterproductive. In cases of severe disorder, they can lead to even more sophisticated deceptive behavior (7). In addition, stipulated conditions (ending tampering and inappropriate behavior) and sanctions (confinement to the unit, discharge) are difficult to implement. Patients should be informed in a dispassionate manner that, according to experience, self-discharge or discharge due to non-cooperation occur more commonly in patients with feigned or malingered disorders and are documented in the discharge papers.

Early assessment by a psychiatric, psychosomatic, or psychological consultant supports specialist diagnostic confirmation, including an assessment of the risk patients pose to themselves or others and the initiation of further contacts. It would seem that consultations are now offered in 50–86% of suspected cases (26, 27, 30, 34). However, many patients dismiss consultations as unnecessary, which is mooted as an indication of factitious behavior (1, 16, 17, 22, 26, 27). If initial consultations do take place, patients often present themselves as particularly competent, capable of suffering, and with an almost ideal setting (“the psychologist thinks I’m completely normal and very brave”) (19). However, experienced practitioners will not let themselves be deflected in this way, but instead suggest at least short consultations in order to build a relationship of trust (1, 5, 6, 7, 8, 9, 19, 34). This primary caregiver should be alert to (early, adverse) experiences, but avoid probing for causes—the focus is always on the situation in the present. The patient should be able to entrust the caregiver with their personal information, but also be made aware that information relevant to their treatment will be shared with the team—otherwise the relationship becomes unilaterally collaborative or even conspiratorial.

Psychotherapy is then provided in a two-track approach (1, 26, 34):

  • Low-threshold psychological counseling as in all severe and chronic disorders, with a focus on coping, acceptance, developing positive life perspectives, as well as monitoring anxiety and depressive and suicidal symptoms
  • Open discussion regarding factitious behavior relevant at least from a differential diagnostic perspective, achieving an understanding for protective measures (for example, negative wound pressure therapy, protective cast), improving motivation to change and self-regulation, for instance using relaxation techniques, reducing self-harming behavior also in the sense of “recovering from past wounds” (1), developing healthier goals (Figure 2).

Consulting psychological counseling as well as in- and outpatient psychotherapy can by all means be successful (5, 6, 7, 9). However, according to an overview of 45 case reports and case series using widely heterogeneous interventions, neither confrontation nor psychopharmacological drugs or psychotherapy affect outcomes. Only a trend towards a more positive course in the case of long-term versus shorter treatment was seen (34).

Summary

Feigning and self-induction of diseases likely occur more frequently than generally assumed and display highly differing degrees of severity and course. Since these behaviors are conflict-laden and potentially hazardous, they require fundamental vigilance in terms of medical due diligence. The physician’s first and foremost duty is to protect affected individuals from themselves, as well as from unnecessary procedures and treatments.

Recommendations on how to deal with these patients are primarily based on accumulated clinical experience and case studies; there is a significant lack of systematic studies. There are no guidelines to date and these would be virtually impossible to formulate. The topic will remain clinically and scientifically difficult since:

  • Due to the nature of the disorder, patient cooperation is poor
  • The feigning and its background often remain undetected or treatment is discontinued
  • The terminology is unclear and the distinction from similar phenomena, including malingering, is blurred
  • One sees numerous mixed clinical presentations involving organic and mental disorders.

In the case of a high-risk constellation, both team and patient should be promptly informed. If clues increase in number, a differential diagnosis becomes a suspected diagnosis. This requires a fundamental understanding of the often powerful motives for feigning. Taking an actionist approach should be avoided. A constructive treatment plan coordinated by the whole team should not focus on medical interventions and exposure, but rather on offering ongoing contact, psychosocial support, and on the patient assuming responsibility for their treatment. In this way, improper treatment can be avoided, the autonomy of the patient preserved, and, ideally, the factitious behavior abandoned for more functional goals.

Conflict of interest statement
The authors state that no conflicts of interest exist.

Manuscript submitted on 16 October 2019, revised version accepted on 9 April 2020

Translated from the original German by Christine Rye.

Corresponding author
Prof. Dr. med. Constanze Hausteiner-Wiehle
BG Unfallklinik Murnau
Prof. Küntscher-Str. 8
82418 Murnau, Germany
c.hausteiner-wiehle@tum.de

Cite this as:
Hausteiner-Wiehle C, Hungerer S:
Factitious disorders in everyday clinical practice.
Dtsch Arztebl Int 2020; 117: 452–9.
DOI: 10.3238/arztebl.2020.0452

Supplementary material

eBoxes:
www.aerzteblatt-international.de/20m0452

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Consultation-Liaison Psychosomatics, Neurocenter, BG Trauma Center, Murnau, and Department of Psychosomatic Medicine and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Munich: Prof. Dr. med. Constanze Hausteiner-Wiehle
Department of Arthroplasty, Consultation-Liaison Psychosomatics, Neurocenter, BG Trauma Center, Murnau, and Institute of Biomechanics, Paracelsus Medizinische Privatuniversität (PMU) Salzburg at BG Trauma Center, Murnau Assoc.-Prof. Dr. med. Sven Hungerer
Typical manifestations of factitious disorders (a selection)
Box 1
Typical manifestations of factitious disorders (a selection)
Warning signs of factitious disorders*
Box 2
Warning signs of factitious disorders*
Semi-structured basic documentation for suspected or confirmed self-harm (modified from [39])
Figure 1
Semi-structured basic documentation for suspected or confirmed self-harm (modified from [39])
Dealing with factitious disorders
Figure 2
Dealing with factitious disorders
Key messages
Factitious disorders, malingering/aggravation, as well as functional, dissociative, and somatoform disorders
Table
Factitious disorders, malingering/aggravation, as well as functional, dissociative, and somatoform disorders
Selected ethical and legal aspects of artificial disorders
eBox 1
Selected ethical and legal aspects of artificial disorders
Possible, primarily unspecific indicators of factitious disorders
eBox 2
Possible, primarily unspecific indicators of factitious disorders
Supportive information and confrontation
eBox 3
Supportive information and confrontation
1.Kapfhammer HP: Artifizielle Störungen. Nervenarzt 2017; 88: 549–70 CrossRef MEDLINE
2.Schultz JH: Zur Psychopathologie der Operationssucht. Z Ges Neurol Psychiatr 1923, 86: 123–35 CrossRef
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