A 17-year-old female came to clinic with a history of 4 episodes over the past month of saying she didn’t feel well, falling to the floor, shaking of her hands and face and then after a period of time would be responsive. The episodes lasted an unknown period of time but less than 2 minutes. She would be normal after them within 5-10 minutes. They occurred when she was doing something like cooking, but had not been standing for long periods of time nor was exercising. She had no loss of bowel or bladder control and those around her say she was unresponsive to her name. She denied trying to diet, taking medications or drugs, and reported normal sleeping. She denied any recent abnormal events or stress. During the office visit, she had one of these episodes and during it she had a pulse of ~90 beats/minutes and steady, pulse oximeter was 100%, she had tremulousness of her arms, hands and face, but none of her lower extremities and did not have jerking. Her eyes had tremulousness when the examiner opened them but saw normal pupils and reactivity. She was responsive to name within 20 seconds, and fully alert within 90 seconds. The past medical history was positive for depression and she was taking an anti-depressant. There were stimulant medications in the home for another sibling. The family history was negative for seizures or other neurological problems, or cardiac problems. They denied any early or unexplained deaths. There was diabetes in the family. The review of systems was negative.
The pertinent physical exam showed a healthy appearing female with normal vital signs with weight in the 75% and height in the 90%. Her examination was otherwise unremarkable. The diagnosis of an unexplained episode that possibly was a seizure, but did not appear to be syncopal. The patient’s clinical course showed she was sent to the emergency room for further evaluation and was admitted overnight. Laboratory testing was normal as was an electroencephalogram and the cardiac monitoring during the hospitalization showed no abnormalities. The health care personnel did not know what these episodes represented. She was diagnosed with “abnormal behavior” and was to followup with her primary doctor who was also managing her mental health.
Factitious disorder (FD) is when patients fabricate illness in themselves or another person without obvious gain. FD has had other terminology and in the past has been called Munchausen Syndrome (if FD in themselves) or Munchausen Syndrome by proxy or FD by proxy (if FD being perpetuated in another person). The current DSM-V terminology is FD imposed on self or FD imposed on another. Malingering (sometimes referred to as simulation) is similar but those that fabricate illness or medical need have an obvious external reward such as gaining access to public social service benefits, free hospital room and board, or evading military service. Malingering does not have a DSM-V designation but has a “V” code for criteria to consider in making other diagnoses. Intentionality is the key difference here between FD and malingering.
FD can be very difficult to diagnose and treat as the motivations for the FD are often obscure, the patients deny the problem and often doctor- or hospital-shop so no continuity or pattern is established to make the diagnoses or help with treatment. It is underdiagnosed and less likely to be reported unless severe injury or death are outcomes. Costs to the health system can be enormous because of diagnostic and treatment procedures and hospitalizations, and patients put themselves at iatrogenic risk. Fortunately fatalities reported in the adult literature are rare, but this is not true in at least one systematic review of the pediatric literature.
A systematic literature review of FD in the adult (> 18 year old) population, identified 455 cases, with 66% being female, younger age (mean 32 years) and of the professions identified 47% were in healthcare particularly nursing. FD have co-morbid conditions as well and this study identified depression (42%), personality disorder (17%), substance abuse (15%) and anxiety (15%). Suicidal thoughts or attempts were reported in 14%. Common reasons for diagnosing FD were past health care use, atypical presentation, treatment failure, investigations or evidence of fabrication. Most patients (59%) in this study “…elected to induce illness or injury in themselves instead of attempting only to simulate (19%) or falsely report (22%) a medical problem.”
FD imposed on another can be medical child abuse. In a systematic literature review of perpetrators of medical child abuse, they nearly always the victim’s mother (96%) and almost all female (98%). They also were young with a mean age of 27.6 years and 46% were in the health professions. Common co-morbidities were FD imposed on self (31%), personality disorder (19%) and depression (14%). There was also a strong history of childhood maltreatment (30%).
“The variety of methods available to these patients [to feign an illness] is limited in principle only by their level of dedication, imagination and medical knowledge.” “The wealth of medical knowledge now available on the Internet may enable patients lacking a background in healthcare to present with complex medical problems. It is seldom possible to diagnose FD with conviction….”
In adult FD patients, many patients present with signs and symptoms for protocol-driven admissions such as retrosternal chest pain, or use common medications such as insulin, anticoagulants and thyroid hormones to induce illness and change blood chemistries so there is “objective evidence” of disease. Using hallucinogens to alter perception, hypnotics to include lethargy, or stimulants to produce insomnia and irritability occur. In adult patients the most common presentations were (parentheses indicates number of cases out of 455):
- Recurrent hypoglycemia – 31
- Retrosternal chest pain – 29
- Severe renal pain – 13
- General dermatological lesions, induced – 10
- Cushing syndrome symptoms – 9
- Anemia, induced – 9
- Thyrotoxicosis, induced – 8
- Asthma, simulated episodes – 8
- Breast dermatological lesions, induced – 7
- Sepsis, induced – 7
- Chronic pain reported – 7
- Severe diarrhea, induced – 6
- Keratoconjunctivities, induced – 6
The cases in the pediatric population most likely differ as children may not be as sophisticated as adults in planning and carrying out FD or mimicking of them, nor may have access to various medications.
In this author’s experience, ill-defined episodes of potential seizures, syncope or vertigo, and chronic pain are fairly common and may represent organic disease or potentially a FD.
Combinations of various signs or symptoms may raise the issue that FD may be part of, or the cause of, and can include:
- Atypical presentation
- Symptoms present only when individual is observed
- Atypical behavior in the hospital or clinic (e.g. arguing with personnel, disobedience of hospital rules)
- Unusual understanding of hospital/medical terminology and routines
- Multiple evaluations/treatments in the past without results
- Few outside visitors during hospitalization
- Intense relationships with other patients or healthcare providers
- Developing symptoms of other patients
- Worsening of symptoms after discharge from hospital
- Evidence of traveling to multiple institutions
- Pseudologia fantastic (pathological liar)
Patients with rare or difficult to diagnose organic disease can also have strange or abnormal symptoms which may require careful monitoring and evaluation to also diagnose. There can be an important, and difficult balance between monitoring of symptoms for organic disease and more evaluation in a patient with potential FD.
Questions for Further Discussion
1. How are FD and seizures similar and different?
2. How are FD and syncope similar and different?
3. If FD is considered, how could this diagnosis be made and what potential therapy is available if the patient was willing?
- Age: Teenager
To Learn More
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Yates GP, Feldman MD. Factitious disorder: a systematic review of 455 cases in the professional literature. General Hospital Psychiatry. 2016;41:20-28. doi:10.1016/j.genhosppsych.2016.05.002
de Sousa D, Kanomata EY, Feldman RJ, Maluf A. Munchausen syndrome and Munchausen syndrome by proxy: a narrative review. Einstein (Sao Paulo). 2017;15(4):516-521. doi:10.1590/S1679-45082017MD3746
Yates G, Bass C. The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) – A systematic review of 796 cases. Child Abuse Negl. 2017;72:45-53. doi:10.1016/j.chiabu.2017.07.008
Tozzo P, Picozzi M, Caenazzo L. Munchausen Syndrome by Proxy: balancing ethical and clinical challenges for healthcare professionals. Clin Ter. 2018;169(3):e129-e134. doi:10.7417/T.2018.2067
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa