Defining Factitious Disorder

A factitious disorder is a condition in which a person acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms. Factitious disorder imposed on another is a condition in which a person deliberately produces, feigns, or exaggerates symptoms in a person in their care.

In factitious disorder imposed on the self, the affected person exaggerates or creates symptoms of illnesses in themselves to gain examination, treatment, attention, sympathy, and/or comfort from medical personnel. In some extreme cases, people suffering from this disorder are highly knowledgeable about the practice of medicine and are able to produce symptoms that result in lengthy and costly medical analyses, prolonged hospital stays, and unnecessary operations. The role of "patient" is a familiar and comforting one, and it is thought to fill a psychological need in people with this syndrome. 

In factitious disorder imposed on another, a caretaker (often a parent) ensures that a person in their care (such as their child, an older adult, or even a pet) will experience some medical affliction, therefore compelling the dependent to suffer treatment for a significant portion of their lives. Furthermore, a disease may actually be initiated in the dependent by the parent or guardian. There is growing consensus in the pediatric community that this disorder should be renamed "medical abuse" to highlight the harm caused by the deception and to make it less likely that a perpetrator can use a psychiatric defense when harm is done.

Physical exam of a child

A parent with factitious disorder imposed on another (formerly known as Münchausen syndrome by proxy) will deliberately produce, feign, or exaggerate symptoms in their child. With deception at its core, this behavior is a potentially lethal and frequently misunderstood form of child abuse.

These disorders are distinct from hypochondriasis and other somatic symptom and related disorders in that those with the latter do not intentionally produce their somatic symptoms (i.e., symptoms related to the body). They are also distinct from other psychiatric disorders such as malingering, in that factitious disorders do not fabricate symptoms for material gain such as financial compensation, absence from work, or access to drugs.

Münchausen Syndrome and Münchausen Syndrome By Proxy

Münchausen syndrome, a severe form of factitious disorder, was the first to be identified and was for a period used as the umbrella term for all such disorders. In the 5th edition of the DSM (DSM-5), Münchausen syndrome has officially been renamed "factitious disorder imposed on self". There is now considered to be a wide range of factitious disorders, and the label of Münchausen syndrome is reserved for the most severe form, where the simulation of disease is the central activity of the affected person's life. Münchausen syndrome is related to Münchausen syndrome by proxy, now known as "factitious disorder imposed on another"; this refers to the abuse of another person, typically a child, in order to seek attention or sympathy for the abuser. 

DSM-5 Diagnostic Criteria

The DSM-5 differentiates among two types of factitious disorder:

• Factitious disorder imposed on self (formerly Münchausen syndrome).
• Factitious disorder imposed on another (formerly Münchausen syndrome by proxy); this diagnosis is assigned to the perpetrator, while the victim may be assigned an abuse diagnosis such as child abuse. 

In order to be diagnosed with either of these forms of factitious disorder, the person must deliberately aim to deceive others by feigning or causing physical or mental symptoms, illness, or injury (in themselves or another). They must continue this deception over time, even with a lack of any apparent reward or benefit from their behavior. Factitious disorders should be distinguished from somatoform disorders, in which the patient is truly experiencing the symptoms and has no intention to deceive. In addition, the symptoms must not be attributed to another mental disorder (such as a psychotic disorder).

Etiology

Though the etiology of factitious disorders is not well understood, risk factors for developing the disorder include childhood traumas, growing up with parents/caretakers who were emotionally unavailable due to illness or emotional problems, a serious illness as a child, history of working in healthcare and/or failed aspirations to work in the medical field, personality disorders, and low self-esteem. Factitious disorders are more common in men and are often seen in young or middle-aged adults. 

Individuals with factitious disorder might be motivated either as a patient or by proxy as a caregiver to obtain attention, nurturance, sympathy, and leniency that often accompany the "sick role" and that are seen as not obtainable any other way. This is in contrast to malingering, in which the patient wishes to obtain external gains such as disability payments or to avoid an unpleasant situation, such as military duty. 

Treatment

Because there is uncertainty in treating suspected factitious disorders, some advocate that medical professionals or doctors first explicitly rule out the possibility that the patient has an early stage disease that is not yet clinically detectable in order to avoid under-treating real illness. If factitious disorder is determined, therapeutic and medical treatment may center on changing the person's behavior and, in the case of factitious disorder imposed on another, ensuring the safety of any dependents who are being unnecessarily subjected to medical treatment. Various types of psychotherapy, such as cognitive-behavioral therapy, may be used to help modify the patient's thinking or behavior; family therapy may also be used to address problematic family dynamics. If an underlying mood or personality disorder is detected, that disorder should be treated with the appropriate psychotherapy and/or medication.