Factitious Disorder: Detection, Diagnosis, and Forensic Implications

CASE VIGNETTE
Over a period of 2 decades, a 44-year-old woman self-induced labor and delivery in 5 consecutive pregnancies by rupturing her own amniotic sac with a fingernail or cervical manipulation or misappropriating and self-administering prostaglandin suppositories from the hospital unit on which she worked as a nurse. Preterm deliveries resulted in fetal demise in 1 case and in neonatal intensive care treatment for 2 of the offspring. One of the surviving children has cerebral palsy attributable to the mother's factitious illness behavior, which represents MBP maltreatment. The patient sought attention and care through the ruses, which were never uncovered by her obstetrical and gynecological caregivers. Indeed, she underwent an unnecessary hysterectomy because of the illusion of heavy menstrual bleeding actually produced by autophlebotomy, with placement of the blood in the vagina. In addition to the MBP, the patient sought—and seeks—misguided medical treatment for herself as part of her self- directed factitious disorder.²

Testing and procedures can be repeated unnecessarily by physicians who succumb to the patient's entreaties for additional intervention. Rather than being considered in the differential, factitious disorder is often not considered as a possibility; as a result, it is seriously underdiagnosed. In some tertiary care settings sensitive to the issue of medical deception, the reported prevalence has been as high as 9.3% among patients with fever of unknown origin.³ In a prospective study on a psychiatric unit, the incidence was 6%.⁴ Still, the broader range of somatoform disorders, those mind-body disorders that occur at the intersection of disease and illness, are much more common. In a health care system in which psychological distress is undervalued (and underreimbursed), somatic symptoms become the admission ticket for getting help and assuming the sick role.⁵ Although illnesses (subjectively experienced) often do not have an underlying disease (pathophysiologically understood), medical evaluation and treatment start with the communication of perceived distress by the patient (Table 3).^6,7

It should be noted that somatoform disorders should be distinguished from psychophysiological disordersin which psychological factors (eg, stress) produce physiological changes in the body (eg, elevated blood pressure).