Emily, a 34-year-old nurse, is admitted with severe abdominal pain and recurrent episodes of hypoglycemia. Despite reporting intense pain, she appears unusually comfortable. She has a history of multiple hospitalizations for similar symptoms, but extensive workups have never identified a clear cause. Emily claims numerous drug allergies and refuses to share her past medical records. 

Factitious disorder (FD), previously known as Munchausen syndrome, describes a condition where individuals fabricate or induce medical or psychiatric symptoms without clear external incentives, such as financial gain or evading legal trouble. Unlike malingering, which is driven by tangible external benefits, FD stems from a psychological need to assume the sick role. This complicates its diagnosis and management, as many patients lack awareness of their underlying motivations (Lawlor A and Kirakowski J, Psychiatry Res 2014;218(1–2):209–218). 

FD affects approximately 1% of patients on medical floors, 0.5% in inpatient psychiatry, and 0.3% in inpatient neurology. About 70% of cases occur in women, many of whom are in fields related to health care (Bauer M and Boegner F, J Nerv Ment Dis 1996;184(5):281–288; Yates GP and Feldman MD, Gen Hosp Psychiatry 2016;41:20–28). But the true incidence of FD may be higher, as clinicians often hesitate to record such a diagnosis due to the potential of damaging patient rapport through false accusations. Another factor contributing to underdiagnosis is the complexity of the disorder—since it can mimic real medical conditions, it’s often difficult to rule out other diagnoses before concluding that the symptoms are factitious.

Recognizing FD

In Emily’s case, you note several red flags that suggest FD. The inconsistencies between her reported symptoms and objective findings, her extensive medical history with no clear diagnoses, and her reluctance to share medical records are all indicative. In addition, you observe that her symptoms seem to worsen in the presence of medical staff and improve rapidly once medical attention is provided.

FD is diagnosed based on the following DSM-5-TR criteria: 1) falsification of symptoms, 2) deceptive behavior, 3) absence of external incentives, and 4) exclusion of other mental disorders. Key indicators of FD include:

• Rapid symptom recovery after receiving medical attention
• Symptoms only appearing when medical staff are present
• Extensive hospital visits with vague or inconsistent medical histories
• Reluctance to share medical records
• Symptoms that do not align with typical disease presentations
• Numerous reported drug allergies
• Development of new symptoms as previous ones resolve

Diagnostic workup

Your workup will vary based on the patient’s presentation. For psychiatric symptoms, the diagnosis hinges on comparing the patient’s symptoms against known psychiatric disorders. In cases of alleged psychosis, for example, you might see symptoms that do not match with typical patterns in schizophrenia, like visual or tactile hallucinations but no auditory hallucinations or delusions. Don’t rely on a single atypical characteristic to diagnose FD—but when several unusual symptoms are present, an FD diagnosis becomes increasingly likely.

In medical presentations, access to objective test results is invaluable. Other typical presentations include chest pain, recurrent hypoglycemia, severe renal pain, and generalized skin lesions. Familiarity with these presentations can guide the choice of diagnostic tests. For a table of common medical conditions in FD, visit: www.thecarlatreport.com/diagnosingfd.

The medical team’s suspicions strengthen when Emily’s lab results show high insulin levels but low C-peptide levels, a combination that suggests she may be injecting herself with insulin. Normally, when the body produces insulin, it also produces C-peptide in equal amounts. So, when insulin levels are high but C-peptide is low, it’s a strong indication of exogenous insulin use.

Management strategies

Managing FD in patients like Emily requires a balance of empathy and firmness. Here are the steps for addressing FD:

1. Supportive confrontation

A “supportive confrontation” approach, where you discuss evidence of fabricated illness openly but nonjudgmentally with the patient, can be effective (Bass C and Halligan P, Lancet 2014;383(9926):1422–1432). To facilitate this, arrange a multidisciplinary team meeting with the patient that includes psychiatry, medical or surgical consultants, nursing staff, and security. Present the findings, such as an implausible history or inexplicable lab results, in a nonjudgmental manner. Invite the patient to share their perspective and thoughts on the information presented. This step will help you understand their viewpoint and can reveal underlying motivations that might be driving their behavior.

2. Explaining the illness 

Discuss with the patient why feigning of symptoms is the most likely explanation, and explain that further inpatient care is not indicated and could even be harmful by leading to unnecessary tests, procedures, or medications. Offer outpatient follow-up with counseling to address underlying psychological issues.

3. Documentation 

We recommend completing notes and documentation prior to the confrontation in case of a discharge involving threats, strong emotions, and security personnel. This ensures that all relevant information is accurately recorded and provides an objective basis for defending the health care team’s actions and decisions in the event of a contentious discharge. Consider involving the hospital’s legal team, particularly if the patient is a health care worker, as a diagnosis of FD may impact their future employment and require additional reporting to licensing boards. Following the meeting, be sure to update your documentation to reflect the details of the confrontation and any subsequent discussions. 

You and the care team meet with Emily to discuss her diagnosis. You tell her, “Emily, we’ve taken a close look at your medical history and the results from your tests. We’ve noticed some inconsistencies that don’t quite match with any known medical conditions. It’s possible that stress or other psychological factors might be contributing to your symptoms. Our aim is to support you and help you feel better. We’d like to involve our psychiatric team to explore these possibilities together and find the best approach for your care. This way, we can make sure you’re getting the right kind of help and treatment.” 

Differential diagnosis

The differential diagnosis for FD includes several psychiatric disorders.

Malingering

This disorder occurs when a patient fabricates symptoms for clear external incentives, like financial compensation or evasion of criminal charges.

Factitious disorder imposed on another

Previously known as Munchausen syndrome by proxy, this disorder involves a caregiver fabricating or inducing symptoms in someone else, typically a child or dependent adult, driven by a need for attention or sympathy. The caregiver might give misleading medical histories, tamper with tests, or induce symptoms. In these cases, the treatment team must protect the victim by reporting to legal authorities or protective services.

Somatic symptom disorder

In this disorder, patients experience physical symptoms along with significant, disproportionate anxiety about their health, even when medical evaluations show no underlying disease or cause that matches the intensity of their distress. The symptoms and distress are authentic and not intentionally produced.

Functional neurological symptom disorder (conversion disorder)

This disorder involves neurological symptoms (like paralysis, blindness, or seizures) that cannot be explained by a medical evaluation. The symptoms are a response to psychological stressors, and as with somatic symptom disorder, they are not consciously or intentionally produced.

Antisocial personality disorder

This disorder is characterized by a disregard for the rights of others and a pattern of deceit and manipulation. While individuals with antisocial personality disorder might feign illness, it is typically for external gains, such as financial benefits or avoiding legal consequences, rather than a need to be seen as ill.

Borderline personality disorder

Individuals with this disorder typically exhibit impulsivity, unstable relationships, and self-damaging behaviors, which can sometimes include inducing or faking illness as a cry for help or to manipulate others. However, the intent behind these actions is not solely to assume a sick role but often to manage emotional pain or to seek care in dysfunctional ways. Borderline personality disorder is often comorbid with FD (Yates and Feldman, 2016).

Prognosis

The prognosis for FD is generally poor due to low treatment adherence. Less than 20% of patients acknowledge their behavior and engage in psychiatric treatment (Bass and Halligan, 2014). However, a study of individuals in online support groups for FD found that about one-fifth were successful at reducing their symptoms with various strategies, like participating in therapy and learning to communicate their needs (Lawlor and Kirakowski, 2014).

Carlat Verdict

FD is a complex, often under- diagnosed condition that requires careful, empathetic handling. Patients often go to great lengths to induce or fabricate medical symptoms, putting themselves at risk of genuine harm. Engage patients in frank but nonjudgmental dialogue to best manage this condition.