Factitious illness: A 3-step consultation-liaison approach

Ms. J, age 33, arrives at the emergency department (ED) complaining of chest pain and shortness of breath—symptoms she says are similar to those she had during episodes of pulmonary embolism. Routine laboratory workup, including chest CT and ultrasound of the lower extremities, indicate a very low likelihood of PE, but she insists that she be admitted.

On the medical floor, nursing staff note that Ms. J appears short of breath only when directly observed. Medical records reveal multiple visits to other hospitals with repeated requests for admission. When gently confronted, she maintains she will die
if she is not treated.

Has your hospital’s medical staff ever been puzzled by a patient’s inconsistent presentation or unsettled by a concern that he or she was not being straightforward with them? Have they suspected that a patient such as Ms. J may be voluntarily producing his or her symptoms?

This article suggests a 3-step approach by which the consultation-liaison psychiatrist can help medical staff identify and manage patients with factitious illness.

Cardinal features

In factitious illness, the patient’s symptoms are:

• under voluntary control and consciously produced
  
• not a direct result of a medical or psychiatric condition
  
• produced to assume the sick role (not to accrue secondary gain—a core feature of malingering).
  

CASE: Self-inflicted injury

Ms. H, age 50, surprises even the most seasoned clinicians when she presents to the ED with brain parenchyma herniating from an open wound in her skull. She denies having picked at her scalp and does not endorse a history of obsessive-compulsive disorder or trichotillomania.

On the medical floor, however, she is seen picking at the wound, which leaves blood on her protective mittens. Surgical repair is repeatedly attempted, and her case is complicated by chronic infections and a nonhealing wound.

Clinical presentation

Factitious disorder presents 3 diagnostic and treatment challenges for a hospital’s medical staff:

• To recognize and treat (even self-inflicted) serious medical conditions that can be life-threatening.
  
• To orchestrate appropriate diagnostic evaluation. (Remember that factitious illness is a diagnosis of exclusion.)
  
• To handle countertransference reactions to patients that can be intense; physicians may experience anger, frustration, resignation, and hatred.
  

CASE: ‘Suicidal’ but not depressed

Mr. B, age 48, presents to the ED with thoughts of suicide and profoundly depressed mood. On examination, however, he does not appear depressed. He repeatedly requests food, cigarettes, and assistance in finding shelter, which lead to concern that his main goal is secondary gain. However, because Mr. B has a history of serious suicide attempts—including some while an inpatient—the ED physician is reluctant to dismiss his complaints and unsure about how to proceed.

3-step diagnostic approach

Treating factitious illness is predicated upon making the correct diagnosis, which requires the medical team to investigate and gather data from collateral sources, such as outside hospital medical records and other providers. The diagnostic process can be summarized in 3 steps:

Step 1. Determine whether the patient has an identifiable medical or psychiatric problem that could explain the symptoms.

Step 2. Determine whether the symptoms are consciously or unconsciously produced. Somatoform disorders—such as conversion disorder and somatization disorder, for example—are thought to result from processes outside the patient’s control.

Step 3. Distinguish if the motivation is to obtain the sick role (consider factitious illness) or if material benefits are the goal (consider malingering). Both motivations may be operative in a given patient.

Table 1

Medical clues to a patient with factitious illness