Factitious disorder | a serious mental disorder

DEFINITION

Factitious disorder is a serious mental disorder in which someone deceives others by appearing sick, by purposely getting sick, or by self-injury. Factitious disorder symptoms can range from mild (slight exaggeration of symptoms) to severe (previously called Munchausen syndrome). The person may make up symptoms or even tamper with medical tests to convince others that treatment, such as high-risk surgery, is needed.

A factitious disorder is not the same as inventing medical problems for practical benefit, such as getting out of work or winning a lawsuit. Although people with factitious disorder know they are causing their symptoms or illness, they may not understand the reasons for their behavior.

Factitious disorder is mysterious and hard to treat. However, medical and psychological help are critical for preventing serious injury and even death caused by the self-harm typical of this disorder.

SYMPTOMS

Factitious disorder symptoms involve mimicking or producing illness or injury. People go to great lengths to avoid discovery of their deception, so it may be difficult to realize that their symptoms are actually part of a serious mental disorder.

Factitious disorder imposed on another (previously called Munchausen syndrome by proxy) is when someone makes another person sick, requiring medical attention. Usually this involves a parent harming a child. This form of child abuse can put a child in serious danger of injury or unnecessary medical care.

Factitious disorder signs and symptoms may include:

• Clever and convincing medical problems
• Frequent hospitalizations
• Vague or inconsistent symptoms
• Conditions that get worse for no apparent reason
• Conditions that don't respond as expected to standard therapies
• Eagerness to have frequent testing or risky operations
• Extensive knowledge of medical terms and diseases
• Seeking treatment from many different doctors or hospitals, which may include using a fake name
• Having few visitors when hospitalized
• Reluctance to allow health professionals to talk to family or friends or to other health care providers
• Arguing with hospital staff
• Frequent requests for pain relievers or other medications

How those with factitious disorder fake illness

Because people with factitious disorder become experts at faking symptoms and diseases or inflicting real injuries upon themselves, it may be hard for medical professionals and loved ones to know if illnesses are real or not.

People with factitious disorder make up symptoms or cause illness in several ways, such as:

• Exaggerating existing symptoms. Even when an actual medical condition exists, they may exaggerate symptoms to appear sicker or more impaired than is true.
• Making up histories. They may give loved ones, health care providers or support groups a false medical history, such as claiming to have had cancer or AIDS. Or they may falsify medical records to indicate an illness.
• Faking symptoms. They may fake symptoms, such as stomach pain, seizures or passing out.
• Causing self-harm. They may make themselves sick, for example, by injecting themselves with bacteria, milk, gasoline or feces. They may injure, cut or burn themselves. They may take medications, such as blood thinners or diabetes drugs, to mimic diseases. They may also interfere with wound healing, such as reopening or infecting cuts.
• Tampering. They may manipulate medical instruments to skew results, such as heating up thermometers. Or they may tamper with lab tests, such as contaminating their urine samples with blood or other substances.

When to see a doctor

People with factitious disorder may be well aware of the risk of injury or even death as a result of self-harm or the treatment they seek. Still, they are unable to control their compulsive behavior and are unlikely to seek help. Even when confronted with proof — such as a videotape — that they're causing their illness, they often deny it and refuse psychiatric help.

If you think a loved one may be exaggerating or faking health problems, it may help to attempt a gentle conversation about your concerns. Try to avoid anger, judgment or confrontation. Offer support and caring and, if possible, help in finding treatment.

If your loved one causes self-inflicted injury or tries to commit suicide, call 911 or emergency medical help or, if you can safely do so, take him or her to an emergency room immediately.

CAUSES

The cause of factitious disorder is unknown. However, people with this disorder may have experienced a severe illness when they were young or may have been emotionally or physically abused.

RISK FACTORS

Several factors may increase the risk of developing factitious disorder, including:

• Childhood trauma, such as emotional, physical or sexual abuse
• A serious illness during childhood
• A relative with a serious illness 
• A poor sense of identity or self-esteem
• Loss of a loved one through death, illness or abandonment early in life 
• Unfulfilled desire to be a doctor or other health professional 
• Work in the health care field 
• Personality disorders

Factitious disorder is considered rare, but it's not known how many people have the disorder. Some people use fake names to avoid detection, some visit many different hospitals and doctors, and some are never found out — all of which make it difficult to make a reliable estimate.

COMPLICATIONS

People with factitious disorder are willing to risk their lives to be seen as sick. They frequently have other mental disorders as well. As a result, they face many possible complications, including:

• Injury or death from self-inflicted medical conditions
• Severe health problems from unnecessary surgery or other procedures 
• Loss of organs or limbs from unnecessary surgery
• Alcohol or other substance abuse
• Significant problems in daily life, relationships and work 

PREPARING FOR YOUR APPOINTMENT

A person with factitious disorder is likely to first receive care for this condition when a health care provider raises concerns that psychological problems may be a factor in the illness. If your loved one has symptoms that suggest factitious disorder, his or her provider may contact you in advance to talk about your loved one's health history.

If you think a loved one may have factitious disorder, contact his or her provider and start the conversation yourself. Here's some information to help you get ready for that talk.

What you can do

To get prepared, make a note of:

• Your loved one's health history in as much detail as possible. Try to include as much as you can about the health complaints, diagnoses, medical treatments and procedures your loved one has had. If you have the names and contact information for the health care professionals or facilities that provided care, have those on hand.
• Any current behaviors or circumstances you observe that cause you to be concerned that your loved one may have factitious disorder.
• Key points from your loved one's personal history, including abuse or other trauma that occurred during childhood and any significant recent losses.
• Medications your loved one is currently taking, including supplements and over-the-counter and prescription drugs, and the dosages.
• Your questions for the health care provider so that you can make the most of your discussion.

For factitious disorder, some questions to ask the doctor include:

• What is likely causing my loved one's symptoms or condition?
• Are there other possible causes?
• How will you determine the diagnosis?
• Is this condition likely temporary or long lasting?
• What treatments are recommended for this disorder?
• How much do you expect treatment could improve the symptoms?
• How will you monitor my loved one's well-being over time?
• Do you think family therapy will be helpful in this case?
• What next steps should we take?

What to expect from the doctor

The doctor is likely to ask you a number of questions, including:

• What injuries or illnesses has your loved one recently complained of?
• What injuries or illnesses has he or she been treated for in the past?
• Has your loved one been diagnosed with any specific medical problem?
• What treatments has he or she had, including drugs and surgery?
• How often has your loved one changed doctors or hospitals in the past?
• Have any medical care providers, friends or family had concerns that your loved one may be causing or contributing to his or her illness?
• How have your loved one's symptoms affected his or her career and personal relationships?
• Do you know if he or she ever had a self-inflicted injury or attempted suicide?
• Do you know if your loved one was abused or neglected as a child?
• Did he or she suffer any other trauma, such as a serious illness or loss of a parent, during childhood?
• What else makes you suspect that your loved one may have factitious disorder?
• Have you talked to your loved one about your concerns?

TESTS AND DIAGNOSIS

Diagnosing factitious disorder is often extremely difficult. People with factitious disorder are experts at faking many different diseases and conditions. And often they do have real and even life-threatening medical conditions, even though these conditions may be self-inflicted.

The person's use of multiple health care providers and hospitals, the use of a fake name, and privacy and confidentiality regulations may make gathering information about previous medical experiences difficult or even impossible.

A health care provider may suspect factitious disorder when:

• The person's medical history doesn't make sense
• No believable reason exists for the presence of an illness or injury
• The illness does not follow the usual course
• There is a lack of healing for no apparent reason, despite appropriate treatment
• There are contradictory or inconsistent symptoms or lab test results
• The person is caught in the act of lying or causing his or her injury

To help determine if someone has factitious disorder, mental health providers conduct a detailed interview and run tests for possible physical problems.

To be diagnosed with factitious disorder, a person must meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. The DSM criteria for factitious disorder (previously, when severe, called Munchausen syndrome) include:

• Making up physical or psychological signs or symptoms or causing injury or disease with the deliberate intention to deceive
• Pretending to be sick or injured or to be having problems functioning
• Continuing with the deception, even without receiving any visible benefit or reward
• Behavior is not better explained by another mental disorder, such as a delusional disorder or another psychotic disorder

The DSM criteria for factitious disorder imposed on another (previously called Munchausen syndrome by proxy) include:

• Making up physical or psychological signs or symptoms or causing injury or disease in another person with the intention to deceive
• Presenting another person to others as sick, injured or having problems functioning
• Continuing with the deception, even without receiving any visible benefit or reward
• Behavior is not better explained by another mental disorder

TREATMENTS AND DRUGS

Treatment of factitious disorder is often difficult, and there are no standard therapies. Because people with factitious disorder want to be in the sick role, they're often unwilling to seek treatment for the disorder. However, if approached in a gentle, non-judgmental way, a person with factitious disorder may agree to be treated by a mental health provider.

Direct accusations of factitious disorder may make the affected person angry and defensive, causing him or her to abruptly end a relationship with a health care provider or hospital and seek treatment elsewhere. So the health care provider may try to create an \"out\" that spares your loved one the humiliation of admitting to faking symptoms.

For example, the health care provider may reassure your loved one that not having an explanation for medical symptoms is stressful and suggest that the stress may, in fact, be responsible for some physical complaints. Or, the provider may ask your loved one to agree that, if the next one or two medical treatments don't work, they'll explore together the idea that there may be a psychological cause for the illness. Either way, the provider will try to steer your loved one toward care with a mental health provider.

Treatment often focuses on managing the condition, rather than trying to cure it. Treatment generally includes talk therapy (psychotherapy) and behavior counseling. If possible, family therapy also may be suggested.

Medications may be used to treat other mental disorders that also are present, such as depression or anxiety. In severe cases, temporary psychiatric hospitalization may be necessary.

LIFESTYLE AND HOME REMEDIES

In addition to professional treatment, these tips may help people who have factitious disorder:

• Stick to your treatment plan. Attend therapy appointments and take any medications as directed. If you feel an urge to harm yourself or cause yourself to become ill, talk honestly to your therapist or primary care doctor for better ways to cope with your emotions.
• Have a medical gatekeeper. Have one trusted primary health care provider to manage your medical care, rather than visiting numerous providers, specialists and surgeons.
• Remember the risks. Remind yourself that you could face permanent injury or even death each time you hurt yourself or have a risky test or surgery needlessly.
• Don't run. Resist urges to find a new health care provider or to flee to a new town where medical professionals aren't aware of your background. Your therapist can help you overcome these powerful urges.
• Connect with someone. Many people with factitious disorder lack friendships and other relationships. Try to find someone you're able to confide in, share enjoyable times with and offer your own support to.