Description

• Factitious disorder is a mental disorder manifested by an abnormal need for a sick role. Patients appear ill because they are feigning, exaggerating, or inducing symptoms. They are aware that they are not ill; they are aware that their symptoms are not real but will deny this. Factitious disorder is divided into two subtypes: “imposed on self” and “imposed on another.”
• May come to light when a disease history is stated in absence of symptoms, when symptom patterns are puzzling, or when there are nonhealing or unremitting symptoms despite repeated adequate and correct treatments
• In factitious disorder imposed on another (previously known as Münchausen by proxy), an individual falsifies or induces illness in another person to vicariously accrue emotional payoffs, including sympathy, admiration, and/or feelings of power over care providers. Children are the usual victims, and the mother is the usual perpetrator. The updated term for this activity is medical child abuse or, per the American Academy of Pediatrics (2013), “caregiver fabricated illness.”
• Types of factitious disorder:
  • Factitious disorder with predominantly physical signs and symptoms
    • Typically simulates one physical disease
  • Factitious disorder with predominantly psychological signs and symptoms
    • These patients mimic the behavior of people with mental illnesses, claiming they are hearing voices or having visual hallucinations. In Ganser syndrome, patients may also give wrong answers to simple questions to support the image that they are mentally ill.
  • A previous term for factitious disorder imposed on self is Münchausen syndrome. This term is sometimes used by clinicians to describe an “extreme form” of factitious disorder in which patients spend much of their lives seeking medical care from different providers and hospitals (changing hospitals when treatment is refused) and are willing to undergo painful procedures and surgeries to maintain their sick role; named after an 18th-century nobleman who told tall tales
  • A newer manifestation of this is Münchausen by Internet—a person can present him or herself to chat groups, claiming to be affected by the illness on which the chat group focuses.

Epidemiology

Incidence
Estimates vary on the incidence of medical child abuse. In the United States, an estimated 200 new cases of serious abuse are expected to be uncovered yearly.

Prevalence

• Factitious disorder with predominantly physical signs and symptoms: up to 5% of patient–physician encounters may be due to a “factitious production of symptoms” (1)[B] but hard to estimate due to the secretive nature of the disorder; identified as the probable cause of 3–9% of fevers of unknown origin in prospective studies
• It is estimated that between 0.02% and 0.9% of all referrals to medical specialists may be cases of factitious disorder, rather than medical illnesses (2)[C].

Etiology and Pathophysiology

• The psychological basis is thought to be an unresolved sense of deprivation from childhood that, in a time of stress in adulthood, leads to a false claim of medical illness in order to get care. In Münchausen, this behavior is chronic.
• Personality predisposition and shaping may be factors, evident in the high degree of deceitfulness, seeming lack of remorse, disregard for safety, inability to manage work and interpersonal situations, and unwillingness to conform to social norms.

Risk Factors

• Abuse/deprivation in childhood
• Childhood traumas, including hospitalizations
• Growing up with ill or emotionally unavailable caretakers
• Experience as health care professional
• Most “imposed on another” presentations involve a mother inducing symptoms in a child. Siblings of children known to have suffered this type of abuse are also at grave risk.

Commonly Associated Conditions

• History of many medical procedures
• Litigiousness
• Substance abuse
• Suicide attempts
• Psychiatric comorbid conditions, including adjustment disorder, borderline personality disorder, depression, somatoform disorder, eating disorders, and delusional disorder
• Transgenerational transmission of trauma
• In medical child abuse: Siblings of the currently affected child may have been improperly diagnosed with rare, intractable conditions or may even have died.
• In medical child abuse: intrapsychic, social, economic benefit seeking, unresolved separation issues
• In factitious disorder and medical child abuse, “doctor shopping” presenting to different doctors in different hospitals in an attempt to avoid detection of falsified illness