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Factitious illness: A 3-step consultation-liaison approach

Current Psychiatry. 2007 April;06(04):54-58
April 1, 2007|Psychiatry
Lucy A. Epstein, MD;Theodore A. Stern, MD
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Lucy A. Epstein, MD
Clinical Fellow, Department of Psychiatry, Massachusetts General Hospital

Theodore A. Stern, MD
Chief, Psychiatric Consultation Service, Massachusetts General Hospital, Professor of Psychiatry, Harvard Medical School, Boston, MA

Make the diagnosis when it is present; rule it out when it is not.

Treatment challenges

Because patients with factitious disorder are not easily studied, no particular treatment is well-supported in the literature. Approaches that have been reported include preventing patients from being re-admitted to medical facilities, admitting patients for psychiatric treatment, and providing outpatient therapies such as individual psychodynamic psychotherapy, behavioral modification, and group psychotherapy.18

Other management strategies suggested in the literature include:

  • reframing cognitive distortions
  • drawing up a set of realistic hospitalization goals (with a written contract)
  • maximizing the therapeutic alliance
  • avoiding team splitting
  • minimizing iatrogenic harm.19
Whatever the treatment, educate the medical staff about this complex disorder (Table 2), including the hazards of premature and unsubstantiated interventions or painful procedures. Also help them manage countertransference reactions. Provide an outlet for the staff’s intense emotions, and help them place such emotions into a therapeutic context.

Table 2

Recommended care for a patient with factitious illness

Fully investigate all medical and psychiatric complaints, especially if physical safety is threatened
Maintain a healthy skepticism about unusual or illogical presentations while attempting to preserve an empathic connection with the patient
Be aware of countertransference reactions, as they may provide valuable insight about the underlying cause of the patient’s symptoms
Realize that psychiatric symptoms and medical presentations fall on a continuum from conscious to unconscious; at times there may be a mix of motivations
Report all findings nonjudgmentally, both to the patient and in medical documentation
Confront patients? The efficacy and style of confronting patients with factitious illness have been hotly debated. Although no consensus has emerged, an empathic, nonthreatening confrontation may help the patient accept much-needed psychiatric care.13

Nevertheless, prepare the physician for the patient to respond to confrontation with denial and resistance because he or she feels exposed and humiliated. If the physician makes it clear that ongoing medical care will still be available—even if the symptoms are fabricated—the patient may be more willing to accept psychiatric treatment.13

Related resources

  • Barsky AJ, Stern TA, Greenberg DB, Cassem NH. Functional somatic symptoms and somatoform disorders. In: Stern TA, Fricchione GL, Cassem NH, et al, eds. The Massachusetts General Hospital handbook of general hospital psychiatry 5th ed. Philadelphia: Mosby/Elsevier; 2004:269-91.
  • Elwyn TS, Ahmed I. Factitious disorder. EMedicine from WebMD. Last updated April 13, 2006. www.emedicine.com/med/topic3125.htm.

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