This document discusses factitious disorders, including definitions, history, diagnosis and treatment options. Key points include: factitious disorder involves intentionally producing physical or psychological symptoms to receive medical care without external incentives; it was first included in the DSM-III in 1980 and subtypes have been revised in subsequent editions; diagnosis involves investigating medical histories and searching for evidence of self-induced symptoms; treatment includes continuous observation and monitoring medical records across providers.

1. FACTITIOUS DISORDERS
David Straker, D.O.
Steven Hyler, M.D.
Columbia University Medical Center
New York, NY

2. OVERVIEW
• Definition
• History
• Diagnosis and Treatment Options
• Evidence Based Data
• Novel Issues: Internet and Children
• Conclusions

3. DEFINITION
• The patient consciously (voluntarily) produces signs
and symptoms of an illness
• Intentional production
• It can be physical or psychological
• Primary goal  to receive medical, surgical or
psychiatric care
• No external incentive (no monetary gain)
• Primary gain to maintain the sick role

4. HISTORY
• DSM III
• DSM III-R
• DSM IV
• Other historical Issues

5. DSM III
• First entered DSM III in 1980
• FD patient assumes the “patient role”
• Filled the middle ground between hysterical disorders and
malingering
• Subtypes:
1) with psychological symptoms
2) with physical symptoms
3) chronic factitious disorder with physical symptoms
(Munchausen's syndrome)
4) atypical factitious disorder

6. DSM III-R
• Revised in 1987
• Assume the “sick role”
• Subtypes:
1) with psychological symptoms
2) with physical symptoms
3) factitious disorder not otherwise specified

7. DSM IV
• Revised in 1994
• Factitious disorder by proxy included
• DSM IV-TR has same criteria
• Subtypes
1) with psychological symptoms
2) with physical symptoms
3) factitious disorder not otherwise specified

8. OTHER HISTORICAL ISSUES
• 1951 - Munchausen’s syndrome coined by Richard Asher: a
more chronic, severe form of factitious disorder with multiple
hospitalizations, extending over years and where the patient
adopts a role of “patient” as a career
• 1983 - Paper by Reich and Gottfried: first paper to review
factitious disorders in the teaching hospital
• 1994 - Factitious Disorder by proxy introduced into DSM-IV.
Defined as the “deliberate production or feigning of physical
or psychological signs or symptoms in another person who is
under the individual’s care

9. DIAGNOSIS AND TREATMENT
• Contact prior treatment providers, family members
and friends to obtain parallel history
• Room and belonging searches to look for
paraphernalia used by the patient to create symptoms
may be helpful
• Cross-checking medical record numbers, social
security numbers and aliases also may be helpful
• Continuous observation (1:1 aid)

10. DIAGNOSIS AND TREATMENT
(continued)
• Laboratory Tests
1) c-reactive protein can detect exogenous insulin use in hypoglycemia
2) stool can be tested for phenolphthalein to evaluate for laxative abuse
3) lab tests can be done to check for exogenous epinephrine,
anticoagulants, thyroid hormone, and vanilla extract (VMA in
pheochromocytoma)
• Use of “blacklists” in emergency rooms ?
• Use of computerized medical record systems may be helpful
• Possible role of Dialectic Behavioral Therapy
(no reports in the literature)

11. EVIDENCE BASED DATA
• Limited to mostly anecdotal case reports
• No randomized controlled or clinical trials in
the past 7 years
• Two meta-analysis in the past 7 years
• Eighty-one review articles (in English), more
than half of which are on factitious disorder in
children and on Munchausen's by proxy
• Most review articles are case series

12. SELECT REVIEW ARTICLES
• Fliege et al (2002):
Factitious Disorders & Pathological self-harm
• Krahn et al (2003):
Factitious Disorders & physical symptoms

13. FACTITIOUS DISORDER AND
PATHOLOGICAL SELF HARM
• 7.5 percent of patients engaged in self-harm
• Three subtypes:
1) artefact (direct self harm): scratching,
burning, cutting, picking
2) self-induced (artificial disease): use of
medication or infectious substances
3) delegated self harm: such as amputation or
operation
• 15.1 % of patients engaged in all 3 behaviors
• Those who engaged in self harm were: more than 3 times as likely to have
a personality disorder and were generally younger, female, and single
Fliege et al 2002 (Germany)

14. FACTITIOUS DISORDERS
WITH PHYSICAL SYMPTOMS:
A RETROSPECTIVE EXAMINATION
• 21 year review of ninety-three patients
• Mean age 30.7 years old
• 72 % female, 90 % Caucasian
• 68.8 % employed, 47.3 % had health care training,
71.3 % were high school graduates
• 19.4 % left hospital AMA
• Approximately 20 % agreed to psychiatric treatment
Krahn et al 2003 (Mayo Clinic, USA)

15. NOVEL ISSUES IN
FACTITIOUS DISORDER
• Factitious Disorder via Internet
• Factitious Disorder in Children
• Factitious Disorder via phone / hoax calls

16. FACTITIOUS DISORDER
AND THE INTERNET
• Virtual chat rooms
• Support Groups
• Web sites
• M.A.M.A (Mothers Against Munchausen’s
Allegations) @ www.msbp.com

17. FACTITIOUS DISORDER
AND THE INTERNET (continued)
• Google search - Munchausen’s Syndrome:
250,000 sites
• Google search - Factitious Disorder: 31,500 sites
• Most popular sites: www.munchausen.com,
www.mbpexpert.com, and www.emedicine.com
• Barnes and Noble and Amazon web sites: 19 and 31
books respectively on factitious disorders

18. FACTITIOUS DISORDER
ON THE INTERNET
• More than 14 cases have been described
• Terms “Virtual Factitious Disorder” and
“Munchausen by Internet” coined by Marc D.
Feldman, MD in 1998 and 2000
• People who simplify the “real-life” process of
factitious disorder by carrying out their deceptions
online
• Person/patient jump from one support group to the
next; use different names and accounts; can pretend
to be the patient, son, mother, etc. to make the story
seem even more convincing

19. FACTITIOUS DISORDERS
IN CHILDREN
• Factitious Disorder by children (without
parental involvement)
• Factitious Disorder by Internet in Adolescents
• Factitious Disorder by proxy (via internet)
• Co-morbid Factitious Disorder and Factitious
Disorder by proxy

20. FACTITIOUS DISORDERS IN CHILDREN:
REVIEW ARTICLES
• Libow et al (2000): Review Article - 42 case reports
• Saez-de-Oscariz (2004): Review Article - 29 case
reports
• Most commonly reported falsified conditions were:
1) fevers
2) purpura
3) ketoacidosis
4) infections

21. FACTITIOUS DISORDER
IN THE 21ST
CENTURY
• Increasing availability of computer-based medical
records may help facilitate communication between
institutions and may help early recognition and
diagnosis
• Awareness of the use of the internet by such patients
may also help earlier detection and treatment
• Understanding that this is an illness that often starts
in childhood may help make clinicians aware that
early intervention and detection can prevent
chronicity of illness