Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

raised. The wide spectrum of this disorder should be kept in mind when considering course and prognosis. At one end of the spectrum, factitious illness behavior could be considered within the normal range, as when a patient magnifies his symptoms to seek reassurance from a physician or when a patient lies about completing her antibi otic course for cellulitis in order to maintain positive regard. Further along the spectrum, factitious illness behavior becomes a maladap tive coping mechanism but not a chronic pattern of deception. These less pernicious cases may respond to a clinician’s sensitive inquiry into the precipitants to factitious behavior and coaching the patient to find more adaptive solutions. Concurrent mood, anxiety, or substance abuse disorders bode a better prognosis; comorbid personality disor ders, especially antisocial personality disorder, bode a poorer prog nosis. According to some experts, many factitious disorders remit around the age of 40 years, corresponding to the age of remission for many with borderline personality disorder. Unfortunately, Munchau sen syndrome tends to have an unremitting, refractory course and is associated with substantial morbidity and mortality. After efforts to engage a patient in treatment fail, management should be directed toward harm reduction rather than cure. In Sutherland and Rodin’s series of ten patients diagnosed on a psychiatric consultation service with factitious disorder, only one out of nine patients confronted with the diagnoses admitted to fac titious behavior, and only one engaged in psychiatric treatment. In Krahn’s series, only one in six of confronted patients admitted to factitious behavior, and only 12% agreed to psychiatric treatment. These studies would seem to support the contention that confronta tion is unlikely to helpfully engage a patient. However, in Reich and Gottfried’s series of factitious disorder patients, of 33 confronted with the diagnosis, the majority improved, including four chronic cases (only 13 ever acknowledged their role). A “supportive confrontation” conceptualization may help to frame the interaction as an attempt to ally with the patient’s and provider’s common goals when the will ingness of the patient to engage in rehabilitation is perceived to be favorable. In more resistant patients, nonconfrontational approaches may permit the patient to save face while maintaining the therapeu tic relationship. At times, confrontation is unavoidable, as in cases when “therapeutic discharge” is required to prevent further harm and mischief from occurring when a patient is refusing to leave. It should be remembered that this population is at high risk of self-injurious behavior when attempting to confront factitious behavior, and plans for preventing self-harm should be in place prior to the confrontation. The course of factitious disorder is usually intermittent: Isolated events and frequently recurring/unremitting episodes are less com mon. Onset is usually in early adulthood, often after hospitalization for a medical condition or a mental disorder. In individuals with recurrent episodes of falsification or signs and symptoms of illness and/or induction of injury, this pattern of successive deceptive inter actions with medical personnel may become lifelong. Once clinicians recognize a factitious physical disorder, they should be alert to the possibility of patient-initiated litigation to defend the “realness” of their self-induced illness. Litigation often fulfills the same psychodynamic motivations that led to the original factitious illness behavior. Actions brought against clinicians may provide an additional outlet for the patient’s anger, as well as provide an increased level of care or attention. Litigation may be initiated by the patient’s family, who may not understand that the patient’s illness is self-inflicted. Litigation may be a marker for increased risk of death. In a study of 20 factitious disorder patients with concurrent lawsuits, 4 cases ended in death.

Factitious Disorder Imposed on Another When considering the differential diagnosis of this disorder, in addition to the considerations for factitious disorder imposed on self, clinicians should keep in mind the wide range of behavior among normal parents who seek medical care for their children. Again, according to Meadow, “exaggeration and mild deception are part of everyday behavior.” The possibility of factitious disor der and malingering by children themselves should be considered, especially in older children and teenagers. Approximately 14% of victims of factitious disorder imposed on another were found to be in collusion with the perpetrator. Other by-proxy possibilities should also be considered because children may manifest psychopatholo gies of their parents. For example, in hypochondriasis by proxy, a hypochondriac mother preoccupied with her child’s health may repetitively seek pediatric care leading to unnecessary procedures and iatrogenic illness for the child. In anorexia nervosa by proxy, an anorexic mother may restrict her child’s food due to fears of excessive weight in her child. A mother with malingering by proxy may put her child through multiple evaluations to maintain disabil ity or welfare payments. A paranoid father with a history of psy chosis feared that his son was being poisoned by breast milk and insisted that the emergency room check his son’s hair for mercury. It is important to remember that putting a child through unnecessary tests or treatments which can cause harm is medical child abuse, regardless of the perpetrator’s motives. Other by-proxy syndromes described in the literature include mas querade syndrome (in which illness fabrication results in the child’s increasing dependency on the mother), mothering to death (in which the child is confined to a sick role as if the child were ill while avoid ing physicians and agencies), extreme illness exaggeration (in which a parent exaggerates their child’s symptoms in an effort to increase a pediatrician’s attention to the child), and achievement by proxy (as in youth sports). Gaslighting is a nonmedical term used to indicate when a person induces another to doubt their own sanity through psycho logical manipulation, even to the point of being hospitalized. It may be a form of malingering by proxy when external incentives are present. DISCUSSION Mr. R was finally diagnosed with factitious disorder imposed on self based on his deceptive behavior (giving a false name and history) in the service of simulating disease (feigned grief and amnesia). Mr. R admitted that he had acted deceptively, making this a conscious, willful act, although he never articulated his motivation. His life history contained fantasti cal elements, and he tended toward embellishment and confabulation ( pseudologia fantastica ). No clear material gain was ever established. This case serves as a cautionary tale against assuming that decep tive behavior implies a lack of organic pathology. Mr. R had an isch emic stroke and evidence of prior strokes causing organic cognitive and memory impairment, but he also gave a false identity. The available information makes it impossible to determine whether Mr. R’s previous amnestic episodes during times of stress were real; one may rightly wonder what effect his old temporal lobe stroke had on his memory and whether it played any role in his deceptive behavior.

COURSE AND PROGNOSIS Factitious Disorder Imposed on Self

Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of this content is prohibited. The course of factitious disorder is difficult to determine, as many patients drop out of treatment once a factitious disorder has been In general, psychological presentations of factitious disor der imposed on self have a poor prognosis comparable to that of