The treatment of factitious physical disorders has developed significantly over the past several decades. Shortly after Asher identified the Munchausen syndrome in the early 1950s, other physicians began to report numerous cases of the disorder. Many physicians began to develop the idea of a “blacklist” to allow hospital emergency rooms to rapidly identify and exclude these patients. Because of problems with confidentiality, ethics, and the possibility of real disease, blacklists never really emerged as a major tool in managing factitious disorders.
Some psychiatrists began treating factitious disorder with various medication trials. In describing the treatment of factitious disorder in one patient, Fras and Coughlin noted the onset of psychotic thinking that responded to phenothiazine. As a consequence, Fras and Coughlin called for avoidance of “triumphant confrontation” and advocated judicious use of antipsychotic medication. More recently, Prior and Gordon used pimozide effectively in one patient, after reasoning that the individual’s factitious disorder bore some similarity to hypochondriacal delusions.
Earle and Folks (1986) suggested that affective disorders can play a role in some factitious disorders. Merrin et al. (1986) noted the onset of a factitious episode following a loss or separation. When a disorder such as major depression is present, it usually bodes well for the treatability of the factitious disorder. Antidepressants may be extremely effective in these patients.
Most factitious disorder patients need psychological interventions. Hollender and Hersh (1970) developed a noteworthy strategy for the primary physician and psychiatrist to conjointly deal with the factitious patient. To prevent the psychiatrist from being seen as a prosecutor by the patient, they advocate a joint confrontation of the patient. In this nonpunitive confrontation, the primary physician would inform the patient about the factitious disorder diagnosis and the findings that led to this assessment. Following this, the physician might say, “We know you have been feeling stressed to have to use this way of coping.” The psychiatrist would then interpret the patient’s factitious behavior as a cry for help; psychiatric treatment would be offered to provide the patient a more adaptive way of coping with his or her stressors.
Other physicians have taken this approach and attempted to “close the circle” around the patient with vigorous confrontation and transfer of the patient into intensive psychiatric treatment. Some patients have benefited from intensive psychoanalytically oriented psychotherapy. These therapies use the factitious physical symptoms as metaphorical communications from the patient, with less emphasis on detecting the origin of the symptom .
Clinical experience, however, has suggested that although Hollender and Hersh’s (1970) approach has some merit, it is not effective for many patients. Most factitious disorder patients will not admit the factitious nature of their disorder, even if presented with incontrovertible evidence. For example, in one of the larger case series reported, P. Reich and Gottfried (1983) noted that fewer than one-sixth of the patients admitted the factitious etiology following confrontation, and only a fraction of those patients appeared to have benefited from the confrontation in long-term follow-up. Many patients will interpret the confrontation as a source of humiliation and seek another physician and hospital setting.
Behavioral and Psychotherapeutic Strategies
Because of the difficulties involved with the confrontational approach, several physicians have suggested avoiding confrontation in favor of using strategies that allow the patient to relinquish the factitious symptom in a face-saving way. For example, Klonoff et al. (1983-1984) advocated a behavioral approach. Her staff provided biofeedback as a face-saving technique to allow a patient to gain control over factitious pseudoepileptic seizures. The staff also positively reinforced healthy behavior. Similarly, Solyom and Solyom (1990) used a behavioral approach in treating factitious paraplegia. The physicians did not argue with the patient about the origins of the paraplegia but accepted it as needing treatment. They removed positive reinforcements for the factitious behavior and gave negative reinforcement in the form of painful faradic massages to stimulate movement in the paralyzed limbs. They advised the patient that the duration of the massage would be extended if the treatment did not work. The patient responded dramatically to these efforts by walking soon after the beginning of treatment.
In a unique approach, Schwartz et al. (1993) reversed the usual reinforcements of hospitalization. The intervention consisted of permanently admitting to the hospital a factitious disorder patient who had been repeatedly hospitalized and allowing the patient passes for leaving the hospital instead of repeatedly discharging the patient. This technique resulted in markedly reduced hospital stays for the patient in the follow-up period. The patient had less need for illness behavior with the guarantee of a permanent bed. However, many hospitals today may find it difficult to have the administrative flexibility this particular nonconfrontational intervention requires.
Eisendrath (1989) suggested other nonconfrontational approaches, including inexact interpretations, therapeutic double binds, and face-saving techniques. Inexact interpretations consist of making an interpretation that is partially correct but incomplete. The interpretation to the patient captures much of the psychodynamics of the patient’s disorder without identifying the factitious nature of the patient’s disorder. For example, one woman who was guilt ridden as a consequence of childhood sexual abuse developed abdominal pain without an identifiable organic etiology whenever her romantic relationships became sexual. During an inpatient evaluation of the pain, a psychiatric consultant was asked to evaluate her. While the evaluation was under way, her current boyfriend asked her to marry him. That night she developed unexplained septicemia, as she had on two prior hospitalizations. The psychiatric consultant suggested to her that she might feel a need to punish herself when good things, such as the engagement, happened in her life. The patient readily agreed with the interpretation and 2 days later revealed that, because of her guilty feelings, she had injected a foreign substance intravenously after her boyfriend proposed. She then entered outpatient psychotherapy that was successful in helping her to tolerate intimate relationships with less guilt.
A therapeutic double bind is another tool that the psychiatrist can use with factitious disorder patients. In this approach, the patient is not confronted directly with the diagnosis of a factitious etiology. Instead, the patient is offered another medical intervention, such as a new medication or minor procedure (e.g., a split-thickness graft for a wound that has not healed). The offer includes a bind, however. The patient is told that the differential diagnosis for the condition includes a factitious etiology and that the physicians will believe the disorder is factitious if the medical technique does not prove effective. The patient then faces a choice of relinquishing the factitious disorder or admitting it. Many patients with this choice will choose to become “healed” following the procedure or new medication rather than be labeled factitious.
Other face-saving techniques that the psychiatric consultant can use include hypnosis and biofeedback. For example, for patients with wounds that do not heal, learning hypnosis to improve blood flow and tissue oxygenation may be helpful. Biofeedback to reduce muscle spasm, increase blood flow, and enhance relaxation can similarly be an effective technique to use with patients. Many patients will accept these “procedures” much more readily than overt psychotherapy and will feel comfortable discussing significant psychological issues during these sessions. All of these techniques offer the patient the opportunity to relinquish the factitious symptom without having to endure the humiliation of public acknowledgment of the etiology of the disorder. The expectations appropriate for these techniques must be kept in mind: the goal is not personality reconstruction but symptomatic improvement.
The use of nonconfrontational techniques has limitations. Some patients may be producing such a life-threatening disorder that there is no time to try any of the nonconfrontational approaches. In these cases, authoritative interventions are called for. For example, one woman with an aplastic anemia was being seen in psychiatric consultation for evaluation of depression and a possible factitious etiology for her anemia. The patient’s white blood cell and platelet counts were at life-threateningly low levels. Soon after the psychiatric consultation was initiated, a friend of the patient revealed information indicating that the patient’s disorder was caused by the patient’s self-administration of chemotherapy drugs. Because of the urgency of her medical situation, and fearing that she might still be taking the drugs while in the hospital, the hematologist and psychiatrist confronted her and a room search was carried out with her permission. There was no time to try a nonconfrontational approach without endangering her life.
Revision date: July 5, 2011
Last revised: by Jorge P. Ribeiro, MD