Evidence-Based Reviews

Factitious illness: A 3-step consultation-liaison approach

Current Psychiatry. 2007 April;6(4):54-58

References

1. Stern T. Malingering, factitious illness, and somatization. In: Hyman S, ed. Manual of psychiatric emergencies. Boston: Little, Brown, and Co; 1988;23:217-25.-

2. Turner J, Reid S. Munchausen’s syndrome. Lancet. 2002;359:346-9.

3. Popli A, Prakash S, Dewan M. Factitious disorders with psychological symptoms. J Clin Psychiatry 1992;53:9.-

4. Huffman J, Stern T. The diagnosis and treatment of Munchausen’s syndrome. Gen Hosp Psychiatry 2003;25:358-63.

5. Asher R. Munchausen’s syndrome. Lancet 1951;1:339-41.

6. Steinwender C, Hofmann R, Kypta A, Leisch F. Recurrent symptomatic bradycardia due to secret ingestion of beta-blockers—a rare manifestation of cardiac Munchausen syndrome. Wien Klon Wochenschr 2005;117(18):647-50.

7. Bretz S, Richards J. Munchausen syndrome presenting acutely in the emergency department. J Emerg Med 2000;18(4):417-20.

8. Hopkins R, Harrington C, Poppas A. Munchausen syndrome simulating acute aortic dissection. Ann Thorac Surg 2006;81(4):1497-99.

9. Salvo M, Pinna A, Milia P, Carta F. Ocular Munchausen syndrome resulting in bilateral blindness. Eur J Ophthalmol 2006;16(4):654-56.

10. Highland K, Flume P. A “story” of a woman with cystic fibrosis. Chest 2002;121(5):1704-7.

11. Stretton J. Munchausen syndrome. Lancet 1951;1:474.-

12. Stern T. Munchausen’s syndrome revisited. Psychosomatics 1980;21(4):329-36.

13. Stern T. Factitious disorders. In: Hyman S, Jenike M, eds. Manual of clinical problems in psychiatry Boston: Little, Brown, and Co; 1990;21:190-4.

14. Greenacre P. The imposter. Psychoanal Q 1958;27:359-82.

15. Cramer B, Gershberg M, Stern M. Munchausen syndrome. Arch Gen Psychiatry 1971;24:573-8.

16. Ford C. The Munchausen syndrome: a report of four new cases and a review of psychodynamic considerations. Psychiatry Med 1973;4:31-45.

17. Bursten B. On Munchausen’s syndrome. Arch Gen Psychiatry 1965;13:261-8.

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19. Gregory RJ, Jindal S. Factitious disorder on an inpatient psychiatry ward. Am J Orthopsychiatry 2006;76(1):31-6.

Psychiatric evaluation. Physicians should think of factitious psychiatric illness when:

a patient’s behavior is notably different when he believes he is being directly observed and when he believes he is alone³
psychiatric symptoms do not readily fit into diagnostic categories (such as a vague mix of memory loss, suicidal thoughts, and psychosis)
the patient is suggestible or provides a diffusely positive review of systems (for example, he may report additional symptoms after having observed other patients).

Clinical Point

The emergency department often is these patients’ gateway; they arrive in the evening or on weekends when less experienced staff are on call

When evaluating a patient with suspected factitious psychiatric symptoms, perform a comprehensive psychiatric evaluation to identify an Axis I or II disorder. Rule out possibilities such as dementia associated with complaints of memory loss, psychosis associated with reports of hallucinations, or affective symptoms or Axis II pathology associated with thoughts of suicide. Patients with factitious disorder often have an underlying psychiatric illness such as a personality disorder, but the Axis II disorder does not fully explain the presenting complaint.

The psychiatric presentations of Munchausen syndrome can be especially complicated, as they are usually associated with less objective evidence than are medical presentations (Box).^4-10 Clarity of the history and diagnosis may be in the eye of the beholder.

Admission characteristics

Somatic complaints. Chaos often surrounds the hospitalized patient with factitious illness. The ED commonly is their gateway, and they tend to arrive in the evening or on weekends when less experienced staff are on call.¹¹

Box

Factitious disorder:
Presentation severity ranges up to Munchausen syndrome

Munchausen syndrome—a particularly severe factitious illness—is characterized by peregrination, recurrent presentations, and pseudologia fantastica (stories that seem outrageously exaggerated).⁴ In 1951, Asher named this syndrome for Baron von Münchhausen, an 18th century Prussian officer who wandered from city to city creating tall tales about his life.⁵

Munchausen by proxy, in which a parent is responsible for producing illness in a child, may lead to extensive medical evaluations and treatment.

After more than 50 years, factitious illness continues to draw scientific and clinical attention. A search of PubMed over the last 10 years found nearly 500 citations. Presentations included:

symptomatic bradycardia caused by beta-blocker ingestion⁶
refractory hypoglycemia caused by surreptitious insulin injections⁷
false reports of aortic dissection⁸
recurrent episodes of self-harm including bilateral blindness from ocular trauma⁹
fabricated sweat chloride test results in a patient claiming to have cystic fibrosis.¹⁰

Because the patients’ somatic complaints predominate, the ED physician must complete a full evaluation, even if aspects of the history are inconsistent. Patients tend to appeal to physicians’ nurturing qualities in an attempt to have them provide care and attention.¹²

Escalating demands. During the hospital stay, patients with factitious illness may make repeated requests for care, which may escalate into demands if their needs are not met.¹³ At this point, staff often start to experience negative countertransference reactions. As medical tests reveal little to no evidence of an organic basis for their symptoms and no cohesive psychiatric diagnosis is reached, patients may complain of misdiagnosis and mistreatment.¹³

Patients usually leave before psychiatric consultation can be obtained, and the underlying suffering that led to their factitious complaints remains unaddressed. Typically, patients are lost to follow-up until the next presentation at another hospital, where the process begins again.

What motivates patients?

The motivation behind factitious presentations can be bewildering. Asher’s paper on Munchausen syndrome described several possible reasons for patients’ behavior, such as desire to be the center of attention, holding a grudge against the medical profession, drug seeking, looking for shelter, and running from police.⁵ This list, however, includes correlates of secondary gain, which with today’s psychiatric nomenclature would lead to a diagnosis of malingering.

Psychological factors. Some clinicians have tried to address underlying psychiatric factors, but data on evaluation and management are limited because these patients usually eschew psychiatric examination. Although the patient is voluntarily producing the symptoms, unconscious psychological factors are at play and are an essential part of the picture.¹⁴

When assessed, patients appear to have lived rootless lives with few attachments, which may have been the result of sadistic and unsatisfying relationships with authority figures of their youth.^15,16 Their grandiosity and distortion of the truth suggest a narcissistic need to overcome feelings of incompetence or impotence.¹⁷ Their ambivalent relationship to hospitals and physicians may reflect a need for caretaking, arising from early relationships and past caretakers.

Lastly, there is a component of masochism; this makes some individuals (erroneously) believe that if you don’t inflict pain you don’t care about them.¹³

Factitious illness: A 3-step consultation-liaison approach

References

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