Patients with factitious disorder may falsely claim to have had an episode of major symptoms. Some others may have a false history and also manage to manipulate assessing instruments like a thermometer. They may also add external agents to mimic the symptoms of disease. For example, a patient may add blood to urine and claim to have hematuria. Cases are also available where a patient induces a medical condition like injecting bacteria to develop an infection or take CNS-active medication to feign psychiatric disorders. Those who have an actual medical condition like epilepsy may claim to have fictitious episodes which is consistent with their condition. Medical history is often very dramatic and inconsistent.

Medical history of the patient, reported by the patient, may be very exhaustive and exaggerated. They often do not have any medical records to support their claims. They may even deny access to relatives and friends. There are some cases where patient denies having an extensive medical history even when they have ample evidences like scars and marks on physical examination. Self-inflicted physical signs may also be present in different parts of the body. Many physical inconsistencies may be noted like absence of signs of dehydration in a patient claiming to have persistent diarrhea and vomiting. Neuropsychological problems may not be consistent with the diagnostic category. Symptoms presented may be atypical. For example, those feigning dementia may show both recent and remote memory atrophy.

• Malingering

  Abstract Malingering is the intentional fabrication of medical symptoms for the purpose of external gain. [ncbi.nlm.nih.gov]

  Malingering or factitious disorder is the faking or intentional exaggerating of symptoms of a psychiatric illness. [forensicpanel.com]

• Pain

  This article describes a patient who presented with pain complaints to numerous doctors. [ncbi.nlm.nih.gov]

  SSD commonly involves multiple complaints, such as headaches, dizziness, chest pain, abdominal pain, and limb pain. If the only complaint is pain, it is categorized as SSD with Predominant Pain. [intropsych.com]

  […] than pain One sexual symptom other than pain One pseudoneurologic symptom Chronic, recurring, and/or stable Frequent visits, therapeutic relationship with provider, active listening, avoidance of excessive or invasive treatments, focus on management [accessmedicine.mhmedical.com]

  Now, as a college student, Jane sometimes makes up severe pain in her chest or abdomen. When she pretends to be in pain, her roommate takes her to the campus infirmary, where the doctors and nurses take care of her. [study.com]

• Fever

  Factitious fever is extremely challenging to diagnose in patients with complicated chronic medical problems, and represents as much as 10% of fevers of unknown origin. [ncbi.nlm.nih.gov]

  Factitious fever represents 1–10% of FUO cases [ 2, 3 ]. The most comprehensive review of factitious fevers, published in 1979, included 32 cases [ 3 ]. [bmcresnotes.biomedcentral.com]

  Frequently a patient's history contains reports of sexual abuse, growing up in an orphanage or an early death of a close relative. 4 Clinical significance Fever of unknown etiology and impaired wound healing are the most frequent ailments that make patients [flexikon.doccheck.com]

  Or they may report symptoms that could result from many different disorders, such as blood in their urine, diarrhea, or fever. [msdmanuals.com]

• Fever of Unknown Origin

  Factitious fever is extremely challenging to diagnose in patients with complicated chronic medical problems, and represents as much as 10% of fevers of unknown origin. [ncbi.nlm.nih.gov]

  […] of unknown origin. [bmcresnotes.biomedcentral.com]

  […] of unknown origin in prospective studies 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 [unboundmedicine.com]

  The highest incidence was reported by neurologists and dermatologists. [ 5 ] Studies suggest that up to 9% of hospitalised patients have a factitious disorder. [ 6 ] 9.3% of patients presenting with fever of unknown origin were found in one study to be [patient.info]

  For example, in a patient with factitious fever, any diagnosis which would normally be considered for fever of unknown origin should initially be on the differential. [clinicaladvisor.com]

• Epilepsy

  […] combined physical AND psychological symptoms Factitious disorder with predominantly physical signs Factitious disorder with predominantly physical signs and symptoms Factitious psychosis Factitious skin disease Piblokto Self-induced non-photosensitive epilepsy [icd9data.com]

  The "thyroid carcinoma" proved to be a benign nodule, there was no definite evidence for epilepsy (the EEG presented non-specific abnormalities and he never had seizures while in hospital). [priory.com]

  Those who have an actual medical condition like epilepsy may claim to have fictitious episodes which is consistent with their condition. Medical history is often very dramatic and inconsistent. [symptoma.com]

  Serum prolactin in epilepsy and hysteria.. Br Med J. 1987;2:1682-1684. Bye AM, Nunan J. Video EEG analysis of non-ictal events in children. Clin Exp Neurol. 1992;29:92-98. French J. Pseudoseizures in the era of video-electroencephalogram monitoring. [nzma.org.nz]

• Dyspnea

  The morning of hospital day five, the patient developed acute chest pain, dyspnea, mild hypotension, and hypoxia. Intravenous fluid and oxygen supplementation were administered. [bmcresnotes.biomedcentral.com]

• Abdominal Pain

  Six weeks later she presented with worsening abdominal pain. [karger.com]

  Case Study: Factitious Disorder A young woman comes to the hospital seeking treatment for abdominal pain. Preliminary workups reveal that there is no cyst or obstruction, no infection, and no apparent reason for the pain. [luxury.rehabs.com]

  Symptoms and Signs Patients with factitious disorder imposed on self may complain of or simulate physical symptoms that suggest certain disorders (eg, abdominal pain suggesting an acute surgical abdomen, hematemesis). [merckmanuals.com]

• Chronic Diarrhea

  FACTITIOUS DIARRHEA DUE TO SURREPTITIOUS INGESTION OF LAXATIVES: A PROTOTYPE OF FACTITIOUS DISORDERS In 1980, we reported on 27 patients with intractable diarrhea who had been referred to us by other gastroenterologists because the etiology of their chronic [ncbi.nlm.nih.gov]

• Muscle Spasm

  Along with symptoms like abdominal pain, headaches or muscle spasms, the patient displays mental symptoms like depression, anxiety or paranoia. Munchausen’s syndrome. [futuresofpalmbeach.com]

• Antisocial Personality Disorder

  However, people who adopt malingering behaviors often have a diagnosable mental illness called antisocial personality disorder. [elementsbehavioralhealth.com]

  Somatization disorder epidi? Almost exclusively a femal disorder.... (before age of 30 and present for years) Males can have it but it is highly co-morbid with antisocial personality disorder and alcoholism. [quizlet.com]

  […] with doctors, or of grudges against them.Present diagnosis of borderline, narcissistic, or antisocial personality disorder. 13. [slideshare.net]

  Cognitive-behavioral therapy may prove difficult when patients are unable to form a collaborative team, such as with comorbid antisocial personality disorder. [psychnet-uk.com]

  Factors that may increase your risk of factitious disorder include: Having a personality disorder, such as antisocial personality disorder or borderline personality disorder Having severe problems during childhood such as psychiatric problems Being hospitalized [health.cvs.com]

• Denial

  By relinquishing the denial of death-directed tendencies, the therapist is able to establish normality, reality and structure, and is thus in a position to exert a stabilizing effect, initially on her- or himself, but frequently also on the patient, for [ncbi.nlm.nih.gov]

  This form of treatment can be unsuccessful if the family is uncooperative or displays signs of denial and/or antisocial disorder. Psychotherapy is another method used to treat the disorder. [en.wikipedia.org]

  However, the diagnosis of this syndrome seems unlikely as the patient herein reported has had discordant characteristics from other cases with levodopa-seeking and taking behavior: report of frequent untolerable effects with levodopa and denial of use [scielo.br]

• Psychiatric Symptoms

  We report a 6-year follow-up for a patient with Factitious Disorder who first reported neurological then psychiatric symptoms, and investigate the cost of his detected hospitalizations. [ncbi.nlm.nih.gov]

  The outcome of our patient was poor as expected by the presence of comorbidity of severe motor complications and psychiatric symptoms, including depressive, anxiety and factitious symptoms, and refusal of psychiatric support. [scielo.br]

  In FD with psychiatric symptoms, patients may occasionally use psychoactive medications in order to feign the symptoms. [prognosisapp.com]

  The patient's symptoms are unusual or unbelievable. The patient has a large number of symptoms that belong to several different psychiatric disorders. [minddisorders.com]

• Aggressive Behavior

  All patients had similar, characteristic psychopathological features including self-discharge, aggressive behavior, pseudologia phantastica, and hospital wandering. [ncbi.nlm.nih.gov]

• Type A Personality

  People with factitious disorders seem to derive some type of personal gratification from playing the role of a sick person. They may enjoy being comforted by family members, observed by doctors and coddled by nurses. [futuresofpalmbeach.com]

• Seizure

  She also simulated arrhythmias, seizures and unconsciousness. Her symptoms had previously led to comprehensive cardiological, neurological and endocrinological evaluations and treatment in at least three different countries in two continents. [ncbi.nlm.nih.gov]

  Seizure d/o Head injuries Tumors of CNS Frontal lobe lesions Acute encephalitis Delirium Stroke Multiple sclerosis What is factitious disorder? Intentional production or feigning of physical or psychological sxs WITHOUT an EXTERNAL INCENTIVE. [quizlet.com]

  Patient’s may experience seizures (i.e. ‘pseudoseizures’), weakness, non-responsiveness, numbness, and even vision loss. [shortwhitecoats.com]

  They may feign illness—e.g., by faking a seizure or acting as if they have multiple personalities. They may falsify lab results—e.g., by adding blood or protein to a urine specimen. [munchausen.com]

  There are, to be sure, cognitive or mental disorders that divest the accused from responsibility for their actions, such as the completely undiagnosed situation of an epileptic who has his or her first seizure while driving a car, crashing his vehicle [duhaime.org]

• Stroke

  It looks like a stroke, but isn’t. It is usually triggered by stress and most patients spontaneously recover. [stomponstep1.com]

  […] number insuffi- cient to meet criteria Some of above symptoms and/or vague somato- form complaints such as fatigue for at least 6 mo >6 mo Same as above Conversion disorder no Onset after acute stress Pseudoneurologic symptom or symptom complex such as stroke-like [accessmedicine.mhmedical.com]

  Seizure d/o Head injuries Tumors of CNS Frontal lobe lesions Acute encephalitis Delirium Stroke Multiple sclerosis What is factitious disorder? Intentional production or feigning of physical or psychological sxs WITHOUT an EXTERNAL INCENTIVE. [quizlet.com]

  Nor did she experience the stroke, two heart attacks, three heart operations, or two instances of flatlining on operating tables that she claimed to have endured. [bridgestorecovery.com]

• Clumsiness

  Physical presentations include vomiting, diarrhea, respiratory arrest, asthma, seizure, recurrent conjunctivitis, clumsiness, syncope, fever, infection, bleeding, failure to thrive, or electrolytic disturbance. [emedicine.medscape.com]

Patients with factitious disorder may mislead the physician and force him to depart from the standard practices of diagnosis. They may force the physician to forgo the usual diagnostic procedures. Testing and procedures should be decided only after confirmatory and differential diagnosis. Care should be taken to avoid repeating a test based on the false history.

Laboratory studies are effective in providing ample evidence to prove that a particular disease is factitious. If a patient is using exogenous insulin injections, abnormal serum insulin-to-C-peptide ratio can give the right indication of deception [9]. Likewise, tissue biopsy helps to identify self-inflicted lesions to simulate symptoms of a naturally occurring disease. In most of the cases, test results will not be in lieu with the claimed disease. But, in general it is difficult to present a comprehensive list of all the tests that would be helpful in collecting evidence for factitious diseases. But, once suspicion is raised, laboratory tests can be used effectively in finding the external agent or the false claim behind the condition [10].

Similarly, many diagnostic imaging techniques may be useful in proving the medical deception, particularly in those cases where the patient feigns an established problem that can be imaged. Differential diagnosis include malingering, borderline personality disorder, somatic symptom disorder, and conversion disorder.

Treatment modalities are classified into acute and long-term methods. Once the diagnosis is confirmed, attempt should be made to involve the patient in the treatment. Techniques are used to reduce confrontation by using inexact interpretations, therapeutic double blinds and other methods to involve the patient. Patient’s emotional distress should be considered as the source of illness and psychiatric treatment should be offered to the patient. Care should be taken to offer standard care until the patient is fully diagnosed. Comorbid conditions and complications from induced illness should be treated.

Psychotherapy tries to establish a relationship with the patient. Families should be involved to achieve a better understanding of the issue. Those with chronic and severe factitious disorder are at increased risk of danger for themselves. There are no known specialized and proven inpatient or outpatient programs for preventing these. Pharmacological interventions are not known to have any special effect in treating this disorder, but if a concurrent psychiatric disorder is present, pharmacological therapy may be recommended. Surgery is needed only if comorbid conditions require one. Thus, caution should be placed before deciding on surgery for a patient with factitious disorder. Activities of the patients should be limited to a short space so as to not let them spend their time alone. Allowing them increased space or infrequent checks may give them time and space to tamper or self-induce symptoms of illness.

Chronic and severe forms of factitious disorder are progressive and often have a poor prognosis. There is no effective therapy available for this disorder and many of the patients are not willing to undergo any form of therapy. Those with mild form of factitious disorder have a fair prognosis. Many are able to overcome the disease. Presence of associated mental disorder like depression is a good prognostic factor. Morbidity and mortality is increased by feigning actual medical conditions like external administration of insulin. Manipulations of one’s own body like self-inflicted injuries, and ingestion of toxins also act as negative prognostic factor. Unintended accidents like adverse medical reactions, allergies and complications from surgery and other procedures also cause considerable issues.

The actual etiological factor of the disorder is not clearly defined yet. It is difficult to conduct a comprehensive research on these patients as they tend to be very elusive. The assumption of illness is a conscious effort from the patient but the reason for doing so is not conscious. There are several hypotheses regarding the actual reason for the behavior. Some assume that feigning illness is used as a defensive mechanism against sexual and aggressive impulses. Some others hypothesize that these patients undergo multiple procedures and examinations as a self-punishment. More recent works suggest that the characteristic behavior of the patients is a way to establish a ‘sense of self’ to others so that they get unconditional concern and sympathy. They feel that this helps them to get a sense of importance which is difficult in an otherwise normal routine and social contexts.
Case studies on patients with factitious disorder show that many of them had experienced severe illness as a child or had a close relative who experienced chronic illness. This made them assume the advantages of being sick or taking up a sick role. It is often found to start after a stressful event [3]. The major risk factors that predispose a person to feign a disease include:

• Having severe illness for mental disorder during childhood
• Presence of borderline disorder like antisocial personality disorder

Epidemiological research on factitious disorder is negligible. One of the major reasons for lack of adequate data is that patients with this disorder are not honest about their medical deceptions. Further, the number of cases recorded may be an overestimation as these patients often migrate from hospital to hospital. In US, prevalence of this disorder is reported to be in the range of 0.2-1% [4]. In Germany, one-year prevalence of the condition was around 1.3%. Factitious disorder was found to be more common among women in the age group of 20-40 years. Middle aged men had more chronic form of this disorder [5]. Children had more of factitious disorder imposed on self [6].

Studies also show that white people are more affected by factitious disorder, but it is still not clear whether race is a significant risk factor in the development of this disorder. Many studies showed that people with this disorder were mostly from the medical field who had the knowledge of how to feign the disease symptom and to develop it artificially using equipment to which they have access.

Just like the etiology of the disease, pathophysiology is also not clearly defined. Brain defect or dysfunction is not reported to be associated with the development. One of the theories regarding the pathogenesis report an unconscious motivation and conscious deception [7]. Deprivation or trauma in early life may cause the patient to subconsciously learn that illness is a way to relieve emotional stress. Thus later in the life, the patient feigns illness to avoid emotional distress. Focusing on the physical illness that he/she assumes helps to avoid the painful emotions [8]. The diseases and symptoms feigned may vary with the patients. IQ of these patients is usually normal. Rarely some of them have symptoms of psychosis. In most of cases, patients look forward to the tangible emotions of sympathy, warmth, and nurturance.

There are no definite methods for preventing the development of this disorder. Patients are also not motivated to work towards reducing the morbidity associated with the false illness. If a patient is known to have this disorder, it should be clearly documented. Physicians should try to assess the psychological problems of a patient who have repeated medical complaints and have an extensive medical history.

Factitious disorder is a psychiatric condition in which a patient feigns symptoms and/or signs of a disease or illness for assuming the role of a sick person. This was first reported by Richard Asher in 1951 who recorded case histories of patients who sought hospital admissions by feigning symptoms [1]. Factitious disorder is categorized into two types [2]:

• Factitious disorder imposed on self or Munchausen syndrome
• Factitious disorder imposed on another

This is characterized by strange actions in which the patient tries to provide an honest history of the disease. Unlike malingering, factitious disorder does not have an attractive incentive. This disorder can be distinguished from somatic symptoms by the fact that the patient behaves deceptively to mislead the physician for the purpose of assuming sick role. Symptoms of illness or an injury is often self-inflicted. Factitious illness may be severe and chronic and the patient may be ready to move from one hospital to another, or even from one country to another in search of a suitable audience. They even seek multiple treatment modalities like surgeries and procedures. This may be life threatening in some cases. In milder forms of this disorder, only slight exaggeration of symptoms are present. The motivating factor for feigning illness may be different in different people.

Factitious disorder is a psychiatric condition in which a patient feigns the presence of a physical or mental illness. They may deliberately create symptoms or exaggerate the history to be a sick person. They often hurt themselves or alter a test result to make symptoms and approach physician for treatment. They do not have any clear external gains in feigning any disease. Most of them are ready to undergo painful and expensive tests to get enough attention and sympathy from others. It is often associated with severe emotional distress, and hence factitious disorder is considered as a mental disorder. Many of these patients may have other personality disorders.

The most common sign of this disorder include an extensive and inconsistent history of the problem as reported by the patient. Feigned symptoms does not respond to standard treatment procedures and most often become severe once the treatment is started. There may be many physical signs of earlier treatments like scars. New symptoms of the claimed disease often appear once a diagnostic test fails. They will have history of seeking treatment in many hospitals and clinics without any response. They often deny any association with friends or relatives and refuse to allow physicians to meet or talk to any of the relatives.

The first step in the treatment of this disease is to alter the behavior of the patient. This is possible with the help of psychotherapy. Family therapy includes the family in the treatment so as to have a better understanding of the issue.

1. Asher R. Munchausen's Syndrome. Lancet. 1951;1:339-341.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013:324-6.
3. Wedel KR. A therapeutic confrontation approach to treating patients with factitious illness. Social Work. 1971;16(2):69–73.
4. Fliege H, Grimm A, Eckhardt-Henn A, Gieler U, Martin K, Klapp BF. Frequency of ICD-10 factitious disorder: survey of senior hospital consultants and physicians in private practice. Psychosomatics. 2007;48(1):60-4.
5. Krahn LE, Li H, O'Connor MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry. 2003;160(6):1163-8.
6. Peebles R, Sabella C, Franco K, Goldfarb J. Factitious disorder and malingering in adolescent girls: case series and literature review. Clin Pediatr (Phila). 2005;44(3):237-43.
7. Lipsitt DR. Introduction. In: Feldman MD, Eisendrath SJ, editors. The Spectrum of Factitious Disorders. Washington, DC: American Psychiatric Press Inc; 1996. pp. xix–xxviii.
8. Eisendrath SJ. Current overview of factitious physical disorders. In: Feldman MD, Eisendrath SJ, editors. The Spectrum of Factitious Disorders. Washington, DC: American Psychiatric Press; 1996. pp. 21–36.
9. Lebowitz MR, Blumenthal SA. The molar ratio of insulin to C-peptide. An aid to the diagnosis of hypoglycemia due to surreptitious (or inadvertent) insulin administration. Arch Intern Med. 8 1993;153(5):650-5.
10. Wallach J. Laboratory diagnosis of factitious disorders. Arch Intern Med. 1994;154(15):1690-6.