Clinical Findings
Physical factitious disorders can take many forms, limited only by human imagination. Individuals have been known to create signs or symptoms of virtually every disease entity. Patients with factitious disorder have created abnormalities such as hypokalemia, anemia, hyperamylasuria, and hypoglycemia. Conditions including acquired immunodeficiency syndrome (AIDS), bleeding disorders, cancer, limb edema/reflex sympathetic dystrophy, shoulder-hand syndrome, and skin conditions have been feigned. Individuals with factitious disorders are generally considered to produce signs and symptoms on three possible levels: 1) fictitious history (e.g., a patient claims to have migraine headaches when in fact he or she has no headache), 2) simulation of disease (e.g., adding drops of blood to a urine specimen to simulate hematuria), or 3) actual creation of a pathophysiological state (e.g., injecting bacteria to create an infection).

The identification and appropriate treatment of factitious disorders are particularly important because these patients can consume vast quantities of expensive services. Clearly these patients are a major financial strain on the health care system.

The best known variant of factitious disorder is Munchausen syndrome. In this condition, the individual pursues an unceasing lifestyle of patienthood. The individual wanders geographically and has sociopathic tendencies (e.g., lying, impostorship). Asher (1951) was the first to label these patients as having Munchausen syndrome because they often told incredible stories (pseudologia fantastica) with dramatic symptoms reminiscent of the Baron von Munchausen children’s stories. It is important to note, however, that most factitious disorder patients do not fit the criteria for Munchausen syndrome. P. Reich and Gottfried (1983) and Kapfhammer et al. (1998) reported that up to 90% of factitious disorder patients do not have the Munchausen syndrome variant. This 90% have stable homes, families, and jobs. This differentiation is important because Munchausen syndrome patients are refractory to psychiatric interventions to which other factitious disorder patients may readily respond. With Munchausen syndrome patients, the main intervention is to try to avoid the potential harm of invasive medical procedures and the tremendous expenses incurred. Goldstein (1998) emphasized the importance of differentiating between factitious disorders in patients having reactions to acute stressors and chronic patterns of behavior.

Epidemiology
Typically, at least 50% of Munchausen syndrome patients are male, whereas patients with other categories of factitious disorders are predominantly female. The usual age at onset for identification of factitious disorders is in the 20s or 30s. Often, however, precursors of factitious disorders (e.g., illness amplification, false stories) may be seen in the childhood histories of these patients. In addition, factitious disorder patients often have had traumatic childhood illnesses or childhood illnesses that produced some benefit, such as increased caregiver concern (in the form of medical care) when this was lacking in the patient’s home.

Comorbid psychiatric diagnoses in factitious disorder patients run a wide spectrum. Munchausen syndrome patients have most commonly been considered to have a serious personality disorder, often with borderline features, sociopathic features, or both. Other factitious disorder patients may have less personality disturbance and may have concurrent Axis I disorders (e.g., major depression or adjustment disorders) that make them much more amenable to treatment.

The true incidence of factitious physical disorders is unknown. Clearly the spectrum of severity is very broad, ranging from a child temporarily feigning illness to the adult patient who injects insulin to mimic an insulinoma. Some authors have suggested that the occurrence of factitious disorder may be greater than expected by most physicians. In Aduan et al.‘s study of fevers of unknown origin at the National Institutes of Health, 9.6% of the cases were identified as factitious. Knockaert et al. reported that in a general hospital setting, 3.5% of the cases of fevers of unknown origin were factitious, a rate higher than that of drug-related fevers. Similarly, Gault et al. (1988) noted that approximately 3% of kidney stones submitted by patients were artifactual. J. D. Reich and Hanno reported that 0.6% of renal colic is due to factitious etiologies.

One issue that tends to make factitious disorder underrecognized is that physicians may not suspect it very readily. Most physicians do not expect their patients to deceive them, a tendency that can contribute to the fact that it often takes 6-10 years before a condition is identified as factitious in origin. In many cases, once the consultant makes the diagnosis, the primary physician is quite surprised and may even refuse to believe the diagnosis despite compelling evidence.

Diagnosis and Differential Diagnosis
One clue to the diagnosis of physical factitious disorders is a history of unexplained or inconsistent medical findings. Fevers without an appropriate increase in pulse rate represent one example. Other clues include the patient’s appearing socially isolated, with few friends or family members visiting him or her in the hospital, despite his or her serious medical problem, or the patient’s failure to respond to appropriate medical treatment. Especially when these findings occur in someone who has either worked in or is related to someone who has worked in the health field, the physician should have a high index of suspicion for a factitious disorder. Obtaining collateral information from family and previous physicians and hospitals is crucial.

The differential diagnosis for a case in which a factitious disorder diagnosis is being considered is quite broad. Rare medical diseases that might explain an unusual set of findings need to be considered. The physician also should review the possibility of other forms of abnormal illness-affirming behavior. Factitious disorder patients consciously produce signs or symptoms but generally do so for unconscious motivations, similar to phobic patients, who consciously avoid a phobic object but do not know why; malingering patients consciously produce signs or symptoms but know that they are doing so to achieve an external gain; and patients with conversion disorder, somatization disorder, or hypochondriasis produce their illness-affirming behavior without knowing they are doing so or their motivation for doing so. These differential diagnoses are outlined in

Table 62-2.

Theories of Etiology
Several major psychodynamic themes are common to factitious disorder patients. One is that of mastery or control gained through the factitious disorder. For example, an adult who was traumatized by a medical illness in childhood may recreate an illness that he or she can control entirely, unlike the illness he or she experienced in childhood. When such a factitious disorder patient is creating his or her disease, the physician caring for the patient is often more worried about the illness than about the patient. A second common theme is that of masochism. Some patients feel a compulsion to suffer as atonement for various forbidden feelings, such as anger or sexual excitement. A third frequent theme is that of dependency gratification. Many factitious disorder patients experienced significant deprivation in their childhoods that left them with unfulfilled cravings for attention and care; they then act out those needs in the medical setting. A fourth theme involves patients who were physically or sexually abused as children; these patients attempt to master their trauma by reenacting the abuse with physicians who unknowingly step into the symbolic role of abusive parent. Fifth, some factitious disorder patients’ deceit serves as an expression of rage toward the symbolic parental figure, as patients exult in outwitting the physician. A sixth common theme is that the factitious behavior serves as a defense against a loss that has occurred. Finally, Spivak et al. (1994) noted that the factitious disorder patient might be attempting to prevent psychosis by using the behavior as an external support structure to organize the self.