An orthopedic surgeon treating a patient, age 29, at a tertiary medical center asks a staff psychiatrist for advice. The patient—who has chronic bilateral knee infections—lives 350 miles away; her treatment-resistant disease has stymied and frustrated her local physicians. Her infections have persisted despite multiple courses of antibiotics and numerous surgical procedures.
Because of damage to the right knee joint, she cannot bear weight or walk. A registered nurse, she has been unable to work or care for her school-aged children for 2 years. The surgeon tells the psychiatrist that the patient denies psychiatric complaints beyond sadness over her inability to fulfill her responsibilities. She expresses a wish to recover and adamantly denies that she manipulates her wound or does anything to interfere with its healing. The medical/surgical team has noticed that while she is away from home receiving orthopedic care, her husband never visits or calls.
Cases such as the one described above are rare, but psychiatrists occasionally encounter patients with these baffling characteristics. When the patient’s disease fails to respond to treatment as expected—or progresses—members of the medical/psychiatric team need to ask themselves these questions:
- Are we dealing with a drug-resistant infection?
- Is the patient adhering fully with treatment?
- Does the patient do anything to perpetuate this disease process and wish to stay ill?
Asking this last question is difficult but necessary in certain situations. Most of us cannot imagine why a person would wish to remain sick. Why would someone be willing to endure pain and multiple hospital stays, remain isolated from family, and risk a permanent disability? Yet, an unknown number of people strive to appear unwell so that they can receive ongoing medical care.
What are factitious disorders?
Factitious disorders are psychiatric conditions in which patients deliberately portray themselves as ill. They may present with physical or psychological symptoms or both. Their objective is to assume the sick role—not to procure shelter, obtain financial assistance, avoid prison, etc., which would fall into other diagnoses such as malingering.
Table 1
DSM-IV DIAGNOSTIC CRITERIA FOR FACTITIOUS DISORDER
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| Types |
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| Source: DSM-IV-TR |
DSM-IV criteria are straightforward and inclusive (Table 1).1 They do not specify:
- the presence of medical and/or psychiatric disorders, which do not preclude the diagnosis
- reasons why a person may wish to assume the sick role.
The medical literature on factitious disorder includes many compelling case reports. However, the secretive nature of most patients with factitious complaints has made it difficult to conduct carefully designed community-based studies, prospective studies, or controlled randomized trials. Because research is scarce, much is unknown about who gets factitious disorder, what causes it, and how to treat it.
Differential diagnosis
Factitious disorder varies in severity. Among subtypes proposed by Folks et al (Table 2),2 patients in categories 3, 4, and 5—who produce physical illness—can potentially be identified by diagnostic testing.3 Patients in categories 1 and 2—who exaggerate physical symptoms and provide a false medical history—may be more difficult to detect.
In cases where patients exaggerate symptoms or fabricate histories, little objective information is typically available to the treating physicians. Medical records revealing multiple admissions or emergency room visits may be obtained from other institutions only if the patient gives permission. However, the patient often does not consent or the materials cannot be located.
Third-party payers’ pre-authorization procedures and utilization reviews may speak volumes about a patient’s search for health care. However, patients who are unemployed or estranged from spouses may lose insurance coverage over time. Government assistance programs such as Medicare and Medicaid provide care to many patients with these chronic problems and do not perform the same degree of utilization review.
Munchausen disorder—a variant of factitious disorder—is not recognized by DSM-IV. The term—while still used primarily by nonpsychiatrists—is generally viewed as outdated. The term is reserved for patients with the most severe and chronic form of factitious disorder.4 The few studies done of patients with this variant have not adequately examined the specificity and sensitivity of their core symptoms or other characteristics, such as production of a misleading medical condition, travel to multiple medical centers (peregrination), and the telling of tall tales (pseudologia fantastica).
Somatoform disorder. If physicians suspect that a patient’s illness is taking an unusual course, they may suspect a somatoform rather than factitious disorder. Patients with somatoform disorder do not intentionally produce their symptoms, whereas patients with factitious disorder deliberately try to appear ill. In both disorders, the underlying cause is unconscious.