Somatic Symptom and Related Disorders: Factitious Disorders

Factitious disorders imposed on the self or another are some of the most challenging conditions clinicians face. They involve the conscious falsification of signs or symptoms of illness. They range from mild severity to life-threatening. For factitious disorders imposed on the self, the lack of sufficient external rewards differentiates factitious disorders from malingering although both may be present at times. Munchausen’s syndrome, although making up the minority of cases with factitious disorder imposed on the self, represents the most severe form and features a persistent lifestyle of illness with patients wandering from hospital to hospital and exaggerated histories. To make a diagnosis of factitious disorder, collateral information from family or previous caregivers is often extremely helpful. Psychological factors that appear to play a role in the etiology of the disorder include wishes to stay in a dependent role (i.e., the sick role), desires to act out angry or guilty feelings, and eagerness to maintain relationships with high-status healthcare professionals. Treatment of factitious disorders incorporates several key goals. One is to avoid doing harm to the patient and to prevent the patient from doing harm to him/herself. Treatment of comorbid disorders is often quite helpful. There are several psychological approaches. One is to make a nonpunitive confrontation – “we know you are doing this to yourself and we take it as your cry for help.” Then the patient is referred for ongoing psychiatric care. A second approach involves offering the patient a face-saving route to relinquishing their behavior without having to admit the factitious origin. With either of these approaches, it is important that the patient has an ongoing relationship with a primary caregiver who sees the patient at regular intervals and coordinates interventions to avoid harming the patient. In factitious disorder imposed on another, one person creates illness in another, typically an infant or child. Hence this condition involves child abuse and involvement of appropriate legal and social agencies. Treatment requires at least temporary separation of the child from the abuser and psychiatric intervention to ameliorate the morbidity of these children. In some instances, psychotherapy with the abuser has been helpful as well.