History

Fact Explanation
Physical symptoms of illness According to DSM-5, factitious disorders are a pattern of falsification of physical or psychological signs or symptoms, associated with identified deception. A patient with factitious disorders falsify medical and/or psychological impairment in themselves to appear as ill or impaired, even in the absence of obvious external rewards. [1] Symptoms maybe physiologically and medically explained manifestations of common diseases or they maybe bizarre symptoms unexplained even by extensive investigation. [2] Five levels of factitious disorders are recognized: 1)fictitious history 2) simulation, 3) exaggeration, 4) aggravation, and 5) self-induction of disease [3][4]
Psychological symptoms of illness Factitious disorders are characterized by long-term, persistent problems related to illness perception and identity. As with physical symptoms, any psychological symptom maybe associated in the presentation of factitious disorders and there maybe unexpected and unexplained symptoms along with a few symptoms specific to a certain disorder. According to DSM-5, the behavior should not be due to a delusional belief system or acute psychosis. and the behavior should not be better accounted for by another mental disorder, for it to be diagnosed as a factitious disorder. [1]
History of stressful life events Individuals with factitious disorders feign symptoms with the aim of assuming a sick role. This is a maladaptive coping strategy found especially in people with certain personality traits,such as anxious and borderline personalities to deal with psychological distress. Also sick role relieves the patients from responsibilities, thereby reducing stress and this coupled with the attention gained due to illness reinforce the symptoms. [3][4][5]
References
  1. DIMSDALE J, CREED F, DSM-V WORKGROUP ON SOMATIC SYMPTOM DISORDERS. The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV--a preliminary report. J Psychosom Res [online] 2009 Jun, 66(6):473-6 [viewed 01 June 2014] Available from: doi:10.1016/j.jpsychores.2009.03.005
  2. SINHA-DEB K, SARKAR S, SOOD M, KHANDELWAL SK. Wires in the body: a case of factitious disorder. Indian J Psychol Med [online] 2013 Apr, 35(2):209-11 [viewed 01 June 2014] Available from: doi:10.4103/0253-7176.116258
  3. KRAHN LE, LI H, O'CONNOR MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry [online] 2003 Jun, 160(6):1163-8 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12777276
  4. DAHALE AB, HATTI S, THIPPESWAMY H, CHATURVEDI SK. Factitious Disorder-Experience at a Neuropsychiatric Center in Southern India Indian J Psychol Med [online] 2014, 36(1):62-65 [viewed 01 June 2014] Available from: doi:10.4103/0253-7176.127253
  5. GORDON DK, SANSONE RA. A relationship between factitious disorder and borderline personality disorder. Innov Clin Neurosci [online] 2013 Nov, 10(11-12):11-3 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24563814

Examination

Fact Explanation
Mental State Examination: Appearance Appearance may vary widely depending on the symptoms.If a prominent sick role is projected, patient will appear to be ill, in discomfort or disabled. General appearance maybe neglected an unkempt. Movements maybe slow and appear to painful or difficult. But in the case of isolated or unique, bizarre and unexplained symptoms the patient may appear entirely normal.[1] [2]
Mental State Examination: Speech Will vary depending on the associated symptoms and disease/syndrome projected by the patient.
Mental State Examination: Mood Often the mood will be anxious or sometimes appear to be dysphoric (sad,hopeless, depressed ) due to illness and discomfort. Mood may be euthymic or angry as well depending on the symptoms. [1][4]
Mental State Examination: Thoughts Content of thoughts is largely centered around symptoms and illness. But thoughts must be devoid of any delusions for a diagnosis of factitious disorder to be made. Overvalued ideas and superstitious beliefs are common. [1]
Mental State Examination:Perception No abnormality of perception is present in factitious disorders, but a patient may feign abnormal perceptions as symptoms of psychiatric disease. [3]
Mental State Examination: Cognitive functions Cognitive functions are unaffected.[1]
Mental State Examination: Insight In most cases patients will seek repeated medical help but refuse to accept psychiatric opinion or treatment.[1]
References
  1. SINHA-DEB K, SARKAR S, SOOD M, KHANDELWAL SK. Wires in the body: a case of factitious disorder. Indian J Psychol Med [online] 2013 Apr, 35(2):209-11 [viewed 01 June 2014] Available from: doi:10.4103/0253-7176.116258
  2. KRAHN LE, LI H, O'CONNOR MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry [online] 2003 Jun, 160(6):1163-8 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12777276
  3. DIMSDALE J, CREED F, DSM-V WORKGROUP ON SOMATIC SYMPTOM DISORDERS. The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV--a preliminary report. J Psychosom Res [online] 2009 Jun, 66(6):473-6 [viewed 01 June 2014] Available from: doi:10.1016/j.jpsychores.2009.03.005
  4. DAHALE AB, HATTI S, THIPPESWAMY H, CHATURVEDI SK. Factitious Disorder-Experience at a Neuropsychiatric Center in Southern India Indian J Psychol Med [online] 2014, 36(1):62-65 [viewed 01 June 2014] Available from: doi:10.4103/0253-7176.127253

Differential Diagnoses

Fact Explanation
Malingering Malingering is the intentional production or feigning of either physical or psychological symptoms or disabilities motivated by external stresses or incentives. As this is done intentionally for personal gain this is not a psychiatric disorder.[1] [2]
Complex somatic symptom disorder (Somatization disorder in DSM-4) Patients have multiple recurrent and frequently changing physical symptoms involving one or more systems of the body, excessive concern and preoccupation with disease, with history of multiple medical consultations. The patients do not feign but experience the symptoms.[3]
Conversion disorder Like somatization disorder but with at least 1 or more deficits or symptoms affecting voluntary motor or sensory function that suggest a neurological or other general medical condition
Other medical or psychiatric conditions All other possibilities of medical or psychiatric conditions related to the symptoms, need to be excluded before a diagnosis of factitious disease is made.
References
  1. DAHALE AB, HATTI S, THIPPESWAMY H, CHATURVEDI SK. Factitious Disorder-Experience at a Neuropsychiatric Center in Southern India Indian J Psychol Med [online] 2014, 36(1):62-65 [viewed 01 June 2014] Available from: doi:10.4103/0253-7176.127253
  2. KRAHN LE, LI H, O'CONNOR MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry [online] 2003 Jun, 160(6):1163-8 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12777276
  3. DIMSDALE J, CREED F, DSM-V WORKGROUP ON SOMATIC SYMPTOM DISORDERS. The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV--a preliminary report. J Psychosom Res [online] 2009 Jun, 66(6):473-6 [viewed 01 June 2014] Available from: doi:10.1016/j.jpsychores.2009.03.005

Investigations - for Diagnosis

Fact Explanation
Relevant investigations depending on the symptoms All symptoms must be investigated as necessary starting from basic investigations to exclude the possibility of an alternative diagnosis. But the diagnosis of factitious disorder should be considered when history is suggestive, to avoid extensive, repeated and highly sophisticated investigation at great cost to patient and health sector.[1] [2][3]
References
  1. KRAHN LE, LI H, O'CONNOR MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry [online] 2003 Jun, 160(6):1163-8 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12777276
  2. SINHA-DEB K, SARKAR S, SOOD M, KHANDELWAL SK. Wires in the body: a case of factitious disorder. Indian J Psychol Med [online] 2013 Apr, 35(2):209-11 [viewed 01 June 2014] Available from: doi:10.4103/0253-7176.116258
  3. DAHALE AB, HATTI S, THIPPESWAMY H, CHATURVEDI SK. Factitious Disorder-Experience at a Neuropsychiatric Center in Southern India Indian J Psychol Med [online] 2014, 36(1):62-65 [viewed 01 June 2014] Available from: doi:10.4103/0253-7176.127253

Management - General Measures

Fact Explanation
Patient education Patients and family need to be educated about the disorder and given an explanation for its occurrence. Providing insight is needed for the compliance and success of all other aspects of management. [1]
Minimize harm Patients with factitious disorders have health seeking behavior to facilitate their sick role, and doctor shopping is quite common as a result. This can cause an economic and social burden for the patient and the family and this needs to be prevented by advising patient on the nature of the disorder.
Address underlying issues Anxiety and stress is often the underlying issues as well as personality disorders. These need to be addressed to convince the patient to give up the sick role. Help from family and friends need to be obtained to achieve this. [2]
Minimizing reinforcing and maintaining factors The sick role is reinforced and maintained by various factors such as relief from responsibilities, chores, and more attention from family and friends.[3]
References
  1. SINHA-DEB K, SARKAR S, SOOD M, KHANDELWAL SK. Wires in the body: a case of factitious disorder. Indian J Psychol Med [online] 2013 Apr, 35(2):209-11 [viewed 01 June 2014] Available from: doi:10.4103/0253-7176.116258
  2. GORDON DK, SANSONE RA. A relationship between factitious disorder and borderline personality disorder. Innov Clin Neurosci [online] 2013 Nov, 10(11-12):11-3 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24563814
  3. BASS C, HALLIGAN P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet [online] 2014 Apr 19, 383(9926):1422-32 [viewed 02 June 2014] Available from: doi:10.1016/S0140-6736(13)62186-8

Management - Specific Treatments

Fact Explanation
Pharmacotherapy Only for patients with other associated psychiatric disorders. [1]
Confrontational approach Patient is confronted with the fact that he/she is feigning the symptoms, while explaining the reason for it. [1][2]
Supportive cognitive behavioral therapy without confrontation Patient is not confronted with the truth but treated by Cognitive Behavioral Therapy while developing an empathetic relationship which induces the patient to change his maladaptive ways.[2]
References
  1. Ed. Marc D. Feldman and Stuart J. Eisendrath.The Spectrum of Factitious Disorders(Clinical practice). American Psychiatric Publishing.1996. [viewed on 02 June 2014] Available from http://www.appi.org/searchcenter/pages/SearchDetail.aspx?ItemId=8909#
  2. KRAHN LE, LI H, O'CONNOR MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry [online] 2003 Jun, 160(6):1163-8 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12777276