Making a diagnosis and deciding on a treatment plan can be complicated enough. But a much more complex and troublesome situation emerges in those rare cases where symptoms are fabricated. This can lead a clinician down blind alleys of misdirection, sometimes with serious consequences for the patient or a loved one. In this offering, we’ll take a brief look at the increasing attention given to ‘factitious’ disorders, otherwise known as ‘fabricated or induced illness’ (FII).
Firstly, a quick breakdown of the terminology. If we take the BMJ best practice definition, ‘factitious’ disorders are “uncommon disorders in which the patient intentionally fabricates physical or psychological symptoms primarily for the purpose of deceiving healthcare providers and/or others. Patients are motivated primarily by a desire to assume the sick role, rather than by the hope to achieve external rewards”. Munchausen syndrome is an extreme form of a factitious disorder.
But there are sub-divisions, some of which are very troubling. ‘Factitious disorder imposed on self’ is the closest relative to Munchausen syndrome, and involves the patient fabricating physical or psychological symptoms.
Examples could include the patient falsely reporting physical symptoms such as headaches, chest pains or stomach aches, sometimes resulting in time-consuming tests and work-ups, and potentially risky surgical procedures. In the more extreme cases, patients will harm themselves, inject themselves with a dangerous substance to induce trauma, or even alter their own medical test results.
Examples of psychological symptoms reported by patients with a factitious disorder include claiming to see hallucinations, mimicking behaviour that would invite a diagnosis of schizophrenia, or claiming to hear voices. And some patients with this disorder fabricate both physical and psychological symptoms.
Of course, faking illness is nothing new – people have been doing it as far back as history goes. At the lower levels of this deception, it may be to avoid going to an event of some kind, or to gain some advantage, be it monetary or otherwise.
But for those with genuine factitious disorder, it is not to advance themselves in any material way, but rather to fulfil internal ‘gains’ such as attention-seeking, a need for validation, or as a stress-coping mechanism. It has been reported that some people with a factitious disorder do it simply because they enjoy confounding doctors.
As well as putting themselves at serious risk due to a plethora of unnecessary tests and procedures, these patients also place extra strain on already creaking healthcare systems.
Going down a darker road, there is ‘factitious disorder imposed on another’ (formerly known as Munchausen syndrome by proxy). The HSE defines this as when a parent or caregiver exaggerates or even causes symptoms of an illness in their child.
It stresses that the parents might not set out to deliberately deceive doctors, but their behaviour may still harm the child, such as subjecting them to unnecessary stress and medical tests, or even making the child believe they are ill. This type of child abuse falls into six categories: The mildest cases involve exaggerating a child’s symptoms or manipulating test results, while the most severe forms of FII imposed on another can include poisoning a child, or even smothering them.
Some of the other serious examples cited by the HSE include deliberately infecting a child’s wound, or not treating existing conditions so that they get worse.
On its website, the HSE provides a list of warning signs to consider if you suspect a parent or caregiver is abusing a child in this way. These include symptoms that only appear when the parent or carer is present; the parent or carer encouraging medical tests; a child not responding to treatment; and once a health issue is solved, another one quickly appears, among others.
Spotting a genuine factitious disorder is extremely complex. The DSM-5 recognises it as a disorder, but we are severely lacking in long-term and large-scale trials to better understand the phenomenon. A study from 2023 in StatPearls reported that factitious disorder often occurs in tandem with psychological illnesses such as depression, and it is important to treat these comorbidities, as they may have an impact on factitious tendencies.
At the moment, the only targeted treatment option seems to be psychotherapy, which may not be adequate when you consider the potential dangers and the
waste of precious healthcare resources caused by factitious disorders.
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