Hypochondriasis. Patients with hypochondriasis are obsessed with concerns that they have an illness. Their worries may compel them to seek out examinations and diagnostic tests. Unlike patients with factitious disorder, these patients do not deliberately provide information or manufacture symptoms to create the appearance of a medical disorder.
Malingering. Patients who malinger may engage in deceitful behaviors that can include creating a misleading impression about a medical or psychiatric illness. Being a patient, however, is not their objective. They may be seeking disability payments, insurance settlements, shelter, or food.
Patient evaluation
Patients suspected of factitious disorder merit a thorough medical and psychiatric evaluation, guided by their presenting symptoms. They commonly have comorbid psychiatric disorders (Table 3), which medical/surgical team members and the psychiatrist need to identify before considering a diagnosis of factitious disorder.
Because invasive tests such as angiography, colonoscopy, biopsies, or exploratory surgery are required to exclude some underlying medical processes, the treatment team must take care not to cause harm. The expected benefits of diagnostic testing must be balanced against the risks of an iatrogenic event.
Table 2
FIVE PROPOSED SUBTYPES OF FACTITIOUS DISORDER
| Characteristic | Examples |
|---|---|
| May be most difficult to detect | |
| 1. Exaggerates physical symptoms 2. Provides a false medical history | An epileptic patient has a seizure while EEG is normal Describes a fictitious history of cancer |
| Can potentially be identified by diagnostic testing | |
| 3. Simulates physical symptoms 4. Modifies physiology to create physical signs 5. Induces physical illness | Puts gravel into urine sample Exerts oneself before vital signs test to elevate blood pressure Injects foreign material into a surgical wound to slow healing |
| Source: Adapted from Folks et al.2 | |
Relatively little is known about how to diagnose a factitious process coexisting with a genuine medical disorder. For example, a patient with well-documented chronic inflammatory disease may easily exaggerate pain and diarrhea to facilitate hospital admission.
To confront or not to confront?
Some patients may relish the patient role for a time—such as while being evaluated for a presumed opportunistic infection—but may not consent to more definitive tests—such as HIV testing. They may demand discharge while they still may be harming themselves, such as by injecting foreign material. The patient may plan to find another health care provider and continue the maladaptive behavior.
If you suspected that our case patient was playing a role in perpetuating her chronic knee infections, would you confront her with the evidence? The answer is unclear, but some experts argue against confrontation.5 Once a patient believes that the medical team suspects a factitious process, he or she may no longer wish to cooperate, even if the diagnostic evaluation is incomplete. Patients often become more guarded about what they reveal after they are confronted. They may become more careful to hide evidence of wound tampering (e.g., syringes) and hesitant to discuss emotional issues (e.g., estranged relationships, feeling overwhelmed by work and home duties).
Case reports suggest that patients who simulate symptoms, modify their physiology, or induce physical illness are at high risk of morbidity and mortality. For example, one report described a patient who underwent two cardiopulmonary resuscitations because of torsades de pointes triggered by hypokalemia related to covert laxative use.6 Physicians must manage these cases carefully to reduce patient risk. In rare cases where a patient’s behavior becomes life-threatening, admission to a psychiatric unit—even involuntarily—may be necessary.
Collaborating with the patient
A comprehensive treatment approach is optimal for patients with factitious disorder. All the patient’s objective medical disorders should be addressed in systematically and with empathy. Treating a co-existing medical disorder may help the physician gain the patient’s trust, which in turn can help keep treatment options open.
Some patients have been known to exaggerate their physical symptoms because they feel they have a serious, undiagnosed medical problem. They feel that their assessment has been cursory and that they need to compel the physician to do a more thorough evaluation in order to identify the true underlying problem. Although no research supports this observation, these patients may be reassured when their physicians carefully evaluate their medical problems.
Eisendrath5 recommends that the treatment team take time to get to know the patient and convey that this attention is devoted to the person, not just the medical illness. This approach may increase the likelihood of learning about psychosocial issues the person may be trying to resolve by taking the patient role. Patients also may be more willing to complete the evaluation and adhere to recommended treatment, although these outcomes are not guaranteed.
Table 3
DISORDERS KNOWN TO CO-EXIST WITH FACTITIOUS DISORDER
| Disorder | Possible issue |
|---|---|
| Medical | Coexisting medical disease |
| Delusional | Somatic delusions |
| Depressive | Somatic complaints, dependency on staff |
| Chemical dependency | Prescription drug abuse |
| Eating disorders | Persistent vomiting, weight loss |
| Obsessive-compulsive disorder | Somatic obsessions |
| Hypochondriasis | Conviction one is unwell |
| Pain disorders | Pain complaints |
| Malingering | Seeking shelter in hospital |
| Source: Adapted from Folks et al. Somatoform disorders, factitious disorders, and malingering. | |
| In: Stoudemire A, Fogel B, Greenberg D, eds. Psychiatric care of the medical patient (2nd ed). New York: Oxford University Press, 2000:458-75. | |