Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

Table 19–2. Methods of Factitious Symptom Production, Suggestive Signs, and Confirmatory Tests by Systems ( Continued )

Method of Factitious Symptom Manufacture

Symptom

Signs Suggestive of Factitiousness

Test for Factitious Method

Pulmonary Asthma

Tape interfering with pulse oximeters Intractable hypoxia

Lung biopsy

Inhalation of irritant (talc) Ingestion of allergens Manipulation of sweat test Ingestion of anticoagulants Cough abrasion of lung Self-induced trauma to respiratory tract

Intractable status asthmaticus

Serum salicylate level

Cystic fibrosis

Normal x-rays

Sweat potassium

Normal examination/lack of clubbing Normal bronchoscopy/lack of blood

Hemoptysis

Respiratory failure

Incongruous arterial blood gas Marked hypocapnia

Rheumatologic Arthritis

Insertion of metal fragments in joints

X-rays Synovial aspirate analysis

Lupus

Feigned history/borderline positive ANA Injection of contaminants to create purpura

Repeat serum autoimmune tests negative Repeat serum tests Normal complement in active flare

Vasculitis

Tissue biopsy of lesions reveals foreign material Corneal examination/conjunctival biopsy

Ophthalmologic Conjunctivitis

Instillation of foreign substance

Purulent discharge purposely left on skin and eyelashes Severity of discharge greater than severity of redness Severity of swelling less than severity of redness Mainly inferior conjunctival involvement Cornea uninvolved

Anisocoria

Instillation of atropine eye drops

HPLC, high-performance liquid chromatography; UPEP, urine protein electrophoresis; ACTH, adrenocorticotropic hormone; ANA, antinuclear antibody.

Table 19–3. Clues That Should Trigger Suspicion of Factitious Disorder 1. The patient has sought treatment at various different hospitals or clinics 2. The patient is an inconsistent, selective, or misleading informant; they resist allowing the treatment team access to outside sources of information 3. The course of the illness is atypical and does not follow the natural history of the presumed disease 4. A remarkable number of tests, consultations, and medical and surgical treatments have been done to little or no avail 5. The magnitude of symptoms consistently exceeds objective pathology, or symptoms have proved to be exaggerated by the patient 6. Some findings are discovered to have been self-induced or at least worsened through self-manipulation 7. The patient might eagerly agree to or request invasive medical procedures or surgery 8. Physical evidence of a factitious cause might be discovered during the course of treatment 9. The patient predicts deteriorations, or there are exacerbations shortly before their scheduled discharge 10. A diagnosis of factitious disorder has been explicitly considered by at least one health care professional 11. The patient is noncompliant with diagnostic or treatment recommendations or is disruptive on the unit 12. Evidence from laboratory or other tests disputes information provided by the patient 13. The patient has a history of work in the health care field 14. The patient engages in gratuitous, self-aggrandizing lying 15. While seeking medical or surgical intervention, the patient opposes psychiatric assessment

Table 19–3 lists clues that should trigger suspicion of factitious disorder. Factitious disorder should be suspected whenever medical signs or symptoms defy conventional medical understanding or when they do not respond to usual medical treatment—for example, when a wound refuses to heal or when test results show a pattern incon sistent with usual disease presentation. Factitious disorder patients may also demonstrate an exceptional eagerness to undergo invasive or extensive testing. They may deny access to collateral sources of information, refuse to sign releases of information, and refuse to give contact information for family, friends, or former physicians. An extensive medical history, evidence of multiple surgeries, and reports of multiple drug allergies are also clues for the astute clinician. These patients often have jobs in the medical profession, have few visitors, and have been known to forecast the progression of their symptoms. They may supply falsified transcripts, test results, medical records, photos, personal documents, and physician reports. There are even cases of patients bringing in pictures and x-rays of pathologic condi tions downloaded from the internet and purported to be their own. Simply considering factitious disorder is the first important step toward diagnosis. Subsequently, information supporting the diagnosis should be collected. A review of past medical records is mandatory and may reveal inconsistencies. Collateral information from family, friends, or other health care providers may likewise show inconsisten cies. Ward clerks may be the first to notice waxing and waning levels of distress depending on when the patient thinks clinicians are observing. The collection of laboratory specimens under close observation can minimize contamination or manipulation of samples. Laboratory val ues can provide diagnostic clues, as when microbiology reports reveal unusual pathogens or polymicrobial findings without apparent cause.

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