You are on page 1of 6

Primary Psychiatry.

2009;16(1):61-66

FEATURE ARTICLE

Factitious Disorder in the Emergency Department
Jagoda Pasic, MD, PhD, Heidi Combs, MD, and Sharon Romm, MD

ABSTRACT
Factitious disorders can represent diagnostic and treatment dilemmas for all clinicians who come in contact with these perplexing patients. Presentations are unusual; symptoms may be incongruent with known diagnoses or match textbook descriptions. As demanding as it may be to care for such patients in the long term, it is equally challenging to assess a case in the initial emergency department where patients can present without historic data, demonstrate the ability to deceive, have unclear motivation, and exhibit puzzling symptoms. Missing a serious condition can be disastrous but there can also be sequelae of inadvertently ordered expensive and potentially harmful treatment. This article presents two patients who sought care in the psychiatric emergency services of a large, county hospital and discusses diagnostic and treatment issues. The authors propose psychological explanations for staff and clinicians’ reactions and suggest interventions useful in the emergency setting. The article emphasizes the necessity of caring for the patient in an ethical and appropriate manner and raises issues of risk management.

FOCUS POINTS
• The hallmark of factitious disorder is motivation to assume a sick role. • Deception is an integral part of factitious disorder. • Care providers must be attentive to their own responses to patients who might have the diagnosis of factitious disorder.

INTRODUCTION
Factitious disorders, classified as major mental illnesses by the American Psychiatric Association (APA),1 can represent diagnostic and treatment dilemmas for all who come in contact with these perplexing patients. Psychiatrists and medical prac-

titioners are confronted with individuals whose presentations are unusual, with symptoms either incongruent with known diagnostic categories or that match textbook descriptions with surprising precision. As demanding as it may be to care for such patients in the long term, it is equally challenging to assess a case in the initial, emergency treatment setting. Identifying factitious disorder is difficult in the emergency department where patients may present without available historic data, unclear motivation, and puzzling symptoms. The literature is a less helpful diagnostic aid than with other conditions. Because deception is integral, accurate epidemiologic data is unavailable2 and causes are equally puzzling.3 Missing a serious condition can be disastrous but there can also be sequelae of inadvertently ordered expensive and potentially harmful treatment.4 This article presents two patients, one with chiefly psychological symptoms and the second whose symptoms were predominantly physical, who sought care in the psychiatric emergency services of a large, county hospital. The authors discuss diagnostic and treatment issues, propose psychological explanations for staff and clinicians’ emotional reactions,57 and suggest interventions useful in the emergency setting.8

Dr. Pasic is associate professor of psychiatry in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and medical director of the Psychiatric Emergency Services at Harborview Medical Center in Seattle, Washington. Dr. Combs is clinical assistant professor and Dr. Romm is clinical associate professor in the Department of Psychiatry at Harborview Medical Center at the University of Washington. Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest. Please direct all correspondence to: Jagoda Pasic, MD, PhD, Associate Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, 325 Ninth Ave, Box 359896, Seattle, WA 98104-2499; Tel: 206-744-2377; Fax: 206-744-8615; E-mail: jpasic@u.washington.edu.

Primary Psychiatry

© MBL Communications

61

January 2009

J. Pasic, H. Combs, S. Romm

The authors also emphasize the necessity of caring for the patient in an ethical and appropriate manner and raise issues of risk management.9,10

CLINICAL CASE REPORTS
Case Report 1
Mr. X is a 28-year-old male who presented multiple times to the psychiatric emergency services of Seattle, Washington’s Harborview Medical Center; he had also sought care at local emergency rooms. He presented with bizarre behavior and confusion, though he showed no signs of internal preoccupation or responding to internal stimuli which would have be indicative of a true psychotic state. He was noted to be uncooperative during prior visits. Disorganized, he had been brought by ambulance at the request of the police. Medical and psychiatric history was unknown except for indication that in the past he had “lived in an institution.” Mr. X remained mute on questioning so, for considerations of safety, he was referred to the County Designated Mental Health Professionals for involuntary psychiatric admission; however, he was not detained due to insufficient evidence as required by Washington State Mental Health Law. Although discharged, the patient declined to leave the area. He also refused to walk although he had been previously observed to ambulate. When he left the hospital, he did so with the assistance of security officers. He yelled and spat throughout the discharge process, insisting there was “something seriously wrong.” A similar scenario had occurred in previous visits; on reluctant discharge from emergency services, he publicly disrobed, walked in front of a moving car, and jumped into a construction site, dangerous and bizarre behaviors that caused the police to return him to the emergency room.

and caused respiratory difficulty. Surgeons removed this with a rigid endoscope. After evaluation by psychiatry, he was deemed neither suicidal nor homicidal and was discharged. Within 24 hours, he presented to an affiliated hospital with a razor blade in his esophagus. Psychiatric evaluation was repeated and this time he was detained by the County Designated Mental Professionals as a danger to himself.

DISCUSSION
Factitious disorder is classified as a major mental illness by the APA.1 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, offers three diagnostic criteria for this condition (Table 1), including the intentional production of physical or psychological symptoms; the motivation to assume the sick role; and the absence of external incentives for this behavior. The condition can present with either physical or psychological symptoms by themselves or by a combination of the two. Variants exist and are classified as factitious disorder not otherwise specified. Munchausen’s syndrome, a chronic variant, most often presents with numerous physical symptoms. It was first described by Asher2 in 1951, who identified patients traveling from hospital to hospital to dramatically offer their complaints. Munchausen’s syndrome by proxy3 is another version of the disease in which a person, typically a parent, intentionally creates symptoms in their child so enabling the adult to identify with the sick role.

PREVALENCE AND ETIOLOGY
Because of difficulty in diagnosing the disorder and deception is a prominent componant, accurate epidemiologic data is absent and long-term follow-up is almost impossible to obtain.4 Estimated prevalence rates vary from 0.1% in an Italian community study5 of 2,363 people to 9.3% of referrals of fever of unknown origin to the National Institute
TABLE 1

Case Report 2
Mr. Y is a 38-year-old male with an esophageal stricture previously dilated on several occasions. He presented to the emergency department because he was experiencing difficulty swallowing. His history included ingestion of objects such as tacks and safety pins, behaviors which lacked obvious external incentives. On the current occasion, a computed axial tomography scan showed the presence of a coin in his esophagus which was subsequently removed by endoscopy. His postoperative course was complicated by intentional ingestion of a pulse oximeter which had lodged in his cervical esophagus
Primary Psychiatry © MBL Communications

DSM-IV DIAGNOSIS OF FACTITIOUS DISORDER1
A. Intentional production or feigning of physical and/or psychological signs or symptoms. B. Motivation for behavior is to assume sick role. C. External incentives for behaviors (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent.
DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Pasic J, Combs H, Romm S. Primary Psychiatry. Vol 16, No 1. 2009.

62

January 2009

Factitious Disorder in the Emergency Department

for Allergy and Infectious Disease. Causes are equally puzzling. One theory is that the condition develops as a result of stressful life events such as early loss and abandonment. The resulting use of the medical arena to enact life’s dramas allows them to gain control over situations where previously there was none.6

the emergency setting with physical complaints is entitled to medical screening for acute illness and stabilization. Similarly, a thorough psychiatric evaluation is warranted for a patient with psychological symptoms.

DEMOGRAPHICS
The majority presenting with what ultimately proves to be factitious disorder are women 20–40 years of age, often employed in the medical field as nurses, medical technicians, or other health-related jobs. Common presenting conditions are self-induced wounds or infections and simulated disease states.7,8

PSYCHODYNAMICS ASSOCIATED WITH DIAGNOSIS AND TREATMENT
Countertransference, or feelings evoked in the treator, poses problems for both patient and provider. Patients who feign illness to gain privileges afforded those in the sick role stir up strong negative reactions. Clinicians and staff respond with despair, anger, and frustration. Patients are pejoratively labeled “chronic complainers,” “difficult,” and “frequent flyers,” because they repeatedly seek healthcare services. Staff reaction may be so strong that they lose ability to respond with empathy.12 Countertransference complicates treatment. Clinicians may harbor a conviction that all patients with factitious disorder are untreatable, causing the patient to feel not only incurable but worthless. Anger, fear, aversion or disgust undermines a therapeutic alliance. The inherent drama of factitious behaviors can create inappropriate levity, titillation, or gossip, reflecting the provider’s underlying rage caused by the patient’s manipulation of his peers and practitioners. Providers, in turn, may treat the patient or referring physician with undue harshness.13 If feelings go unrecognized, there is the potential danger of missing a diagnosis of an accompanying condition or that the care provider’s anger or resignation will mobilize the patient’s resistance.13,14 Furthermore, clinicians may over-identify with the patients, who often are healthcare providers themselves, which can interfere with diagnosis and appropriate treatment. Groves12 identified four subtypes of difficult patients. (Table 2) These descriptions can promote insight into patient behavior and clinician response. Case Report 1 may, at first, be seen as a malingerer, but on closer scrutiny can be identified as a “manipulative help-rejecter.” Case Report 2 is identified as “self-destructive denier” in combination with “dependant clinger.”

MAKING THE CORRECT DIAGNOSIS
Accurate diagnosis is difficult. There are no specific tests to aid in assessment. Clinical acumen is vital. The patient may tell a story that seems almost unbelievable; laboratory finding may be inconsistent; and there may be inexplicable gaps in the record or the patient may refuse to allow gathering of historic data. In spite of the impulse to collect as much information as possible, regulations regarding privacy and confidentiality must be respected.9 Differential diagnosis can be perplexing. Diagnostic boundaries blur between factitious disorder, the somatoform disorders where symptoms are unconsciously generated, and malingering with its accompanying external incentives. Foremost, a genuine organic etiology of the condition must be eliminated.10 Unlike the outpatient setting where patients, after exhaustive medical work-up, are referred to a psychiatrist who diagnoses factitious disorder, several visits to an emergency department may take place before this occurs. According to one study11 of psychiatrists providing emergency services at an urban general hospital, 13% of patients were suspected of feigning symptoms. Emergency room providers are familiar with homeless or substance-abusing patients who produce symptoms to obtain food and shelter. These individuals evoke frustration and negative reactions from the staff. However, malingerers, unlike those with factitious disorder, intentionally produce or feign symptoms by which to benefit such as economic gain in the form of disability payment or the avoidance of legal responsibility.1 Assumption of the sick role is benefit enough for those with factitious disorder. Because factitious disorders are often diagnoses of exclusion, an individual presenting in
Primary Psychiatry © MBL Communications

PROVIDING NECESSARY MEDICAL OR SURGICAL CARE
Surgeons are used to operating on patients for truly emergent reasons, sometimes even without obtaining consent as an urgent intervention. However, with patients who deliberately create pathology, surgeons may feel less inclined to intervene.

63

January 2009

J. Pasic, H. Combs, S. Romm

In such cases, psychiatry consultation can be a great resource. Helpful techniques include assessment of danger to self and/or decisional capacity, validation of the surgical team’s concerns, setting limits for the patient, and maintaining a safe setting which can include assigning a constant observer or placing the patient in a room monitored by camera. The challenge comes with a surgical team reluctant to operate because of concern that self-injurious behavior will continue. This did not occur when Case Report 2 required urgent surgical intervention because of risk of airway obstruction. In Case Report 2, the patient exhibited disturbing behavior necessitating the involvement of more than one discipline, ie, emergency medicine, psychiatry, and otorhinolaryngology. The initial assessment was conducted by the emergency medical physician who deemed necessary the consultation for dysphagia. Because a history of self-injury and swallowing objects was noted, referral to psychiatry was also made. The psychiatrist found the patient not suicidal so recommended neither hospitalization nor involuntary detention.

TREATMENT: EMERGENCY ROOM INTERVENTIONS BEYOND MEDICAL INTERVENTIONS
The literature on reports on emergency room treatment of factitious disorder patients is limited. Outside of clear-cut emergent medical procedures or medication administration, interventions with factitious disorder patients are problematic at best and carry the risk for iatrogenic harm at worst.
TABLE 2

GROVES’ CLASSIFICATION OF THE HATEFUL PATIENT12
1. Dependent clingers escalate from mild and appropriate requests for reassurance to repeated, impassioned cries for explanation, affection, and all forms of attention imaginable. Can lead to sense of weary aversion toward patient. 2. Entitled demanders use intimidation, devaluation, and guilt-induction to place doctor in role of inexhaustible supply depot. Can evoke fear and then counter-attack when they achieve their requests. 3. Manipulative help-rejecters appear to have quenchless need for emotional suppliers and appear to feel that no regimen will help. They use their symptoms as an admission ticket to a relationship that cannot be surrendered as long as symptoms exist. In the provider, they evoke feelings of guilt and inadequacy. 4. Self-destructive deniers display unconsciously self-destructive behaviors. They evoke all above negative feelings as well as malice and at times the provider harbors the secret wish that the patient should die.
Pasic J, Combs H, Romm S. Primary Psychiatry. Vol 16, No 1. 2009.

The authors of this article have found recommendations in the literature for office treatment and suggest that they may be adapted for use in the emergency room. Either a confrontational or non-confrontational approach has been tried by the primary physician or in conjunction with a psychiatrist.15 Reich and Gottfried9 studied 12 patients with factitious disorder confronted with their behaviors. Although it has been reported that psychosis can occur,16 none became suicidal or psychotic using this approach yet only one patient acknowledged his conduct.9 If the patient feels humiliated and exposed by confrontation, no matter how sensitively handled, proceeding with any therapy is difficult. Hollender and Hersh15 advocate the non-confrontational approach. They recommend that the consulting psychiatrist avoid the role of prosecutor and try to help the patient understand behaviors identified by the primary physician. Another technique that can be employed to allow narcissistically vulnerable patients to relinquish symptoms without threat of exposure and humiliation was developed by Eisendrath.17 He originated a “double-bind” approach. The patient is informed that his failure to respond to the next offered treatment will prove the illness is faked. The patient can simultaneously make his recovery and save face. This approach is based on the hypothesis that confrontation fails because symptoms of factitious disorder serve as an important psychological defense and can be relinquished only in an atmosphere of safety.18 There is an absence of robust research supporting the effectiveness of any management technique for factitious disorder. Eastwood and Bisson5 reviewed treatment outcomes in 32 case reports and 13 case series. They found no significant difference between confrontational and non-confrontational approaches, between treatment with psychotherapy compared to treatment with none, and with the addition or avoidance of medications. They concluded that long-term management plans which include consistent care and a holistic approach are beneficial, a model difficult to achieve in an acute hospital setting. The authors5 suggest that various strategies may be helpful but there is no definitive way to help select a particular management plan. Of note is a report of two cases ending in suicide, a reminder of the necessity of vigilance.5 One management goal is to modify patient’s often unrealistic expectations of the medical profession. The clinician should offer encouragement to cope with symptoms rather than expect a cure19 and acknowledge that the patient is manifesting physical symptoms for psychic distress. It is this distress that must be identified and treated. It is not unreasonable to refer the patient to psychotherapy, a treatment that may be interpersonal or psychoanalytically

Primary Psychiatry

© MBL Communications

64

January 2009

Factitious Disorder in the Emergency Department

oriented.20-23 Realistically, a referral to therapy by an emergency room provider may be immediately rejected by the patient for emotional or financial reasons.

SYSTEM INTERVENTIONS
While there are no evidence-based studies to suggest interventions in the emergency department, in the case of suspected or presumed factitious disorder, the authors of this article recommend the creation of a care plan, the consideration of psychiatric consultation, and, if possible, the assignment of the same provider on repeated emergency room visits (Table 3).

RISK ASSESSMENT
Patients with factitious disorder engage in behaviors endangering themselves. Researchers24,25 propose three types of self-harm, including direct self-harm such as self-inflicted burns; self-created disease, including symptoms produced by the application of noxious agents, such as self-inflicted hypoglycemia (Case Report 1 best fits this category); and indirect or delegated harm, which includes damage or health risks created by medical interventions provoked by the patient. In such cases, the medical staff is “delegated” to carry out a procedure due to feigned symptoms or manipulated findings as exemplified by Case Report 2. In Case Report 1, the patient engaged in behavior that put himself at risk of serious harm (eg, jumping from a high place; inviting being hit by a car) and created his own disease. In Case Report 2, the otolaryngology team initially hesitated to operate on this patient using a procedure that by itself has potential for an adverse outcome. Controversy may exist around the question of whether patients with feigned
TABLE 3

symptoms or illness should have the same kind of treatment administered to patients with “legitimate” symptoms or diseases. However, it is the physician’s ethical duty to provide adequate care if a patient’s symptoms pose a risk of serious harm if left without intervention. The two patients received care that met community standards. In Case Report 1, an evaluation for involuntary psychiatric treatment was indicated due to self-harm behaviors, and in Case Report 2 surgery was required for foreign body removal to prevent bleeding, infection, and perforation. While hospitalization would rarely be appropriate for cases of malingering, it may be indicated for patients with factitious disorders when there is an acute medical issue or a psychiatric issue that poses imminent risk of harm to self, or the patient’s symptoms are causing grave disability. Factitious disorders are rarely associated with risk of harm to others except in cases of Munchausen’s by proxy; hence, hospitalization on this ground is not indicated.

RISK MANAGEMENT
Tempting as it may be to dismiss patients in the emergency department who are suspected of factitious disorder, stabilization must be provided according to the Emergency Medical Treatment and Active Labor Act (Social Security Act: Sections 1866 and 1867). An individual suspected of factitious disorder has the same rights as any patient, ie, the right to reasonable care, respect, privacy, safety, and confidentiality.26 The clinician must adequately document physical and psychological findings and include positive and negative laboratory results. If confusion is an issue, decisional capacity must be established. If the standard of care is ignored, clinicians are vulnerable for risk management review and possible litigation. Patients with factitious disorder may refuse treatment because of anger and humiliation; they may leave against medical advice or consider themselves wronged, feelings that can motivate them to sue. While no physician is immune to a lawsuit, abiding by federally mandated regulations, adhering to the standard of care, and keeping accurate documentation are the best protective measures.

SYSTEM INTERVENTIONS
1. Create a care plan in the patient record to identify medical and/or psychiatric concerns and recommendations for follow up. Highlighting an alert to future providers to refer to this care plan may help reduce unnecessary referrals, tests, and treatments. 2. Consider psychiatric consultation. This consultant can offer assistance to the patient and to the care provider. Psychiatrists help the team identify countertransference issues, important in achieving an effective and productive relationship with the patient. 3. Assign the same provider to work with the patient if possible. This reduces treatment redundancy, a situation potentially reinforcing of undesired behaviors. Most beneficial if the patient accepts a referral to a primary care provider.
Pasic J, Combs H, Romm S. Primary Psychiatry. Vol 16, No 1. 2009.

CONCLUSION
From personal experiences combined with a literature review, the authors of this article conclude the following. First, in spite of provider reaction, a thorough medical and psychiatric assessment should be performed on patients whether or not they are suspected of having a factitious disorder. Serious acute problems must not be overlooked. Second, every effort must be made

Primary Psychiatry

© MBL Communications

65

January 2009

J. Pasic, H. Combs, S. Romm

to engage the patient in care in the acute setting to help with immediate assessment and to encourage appropriate follow-up. Third, although there is absence of robust support for any treatment, there is some evidence for trying either a confrontational or non-confrontational approach or Eisendrath’s “double-bind” technique.5,8,15,18 Fourth, hospitalization or consideration for involuntary detainment is strongly recommended when there is potential for the patient harming him or herself or when the patient lacks decisional capacity. Fifth, creation of a care plan, easily accessible in the medical record, gives the opportunity for consistent, informed assessment and treatment. Last, all involved with patient care must accurately and neutrally provide thorough documentation to minimize legal risk for the provider and accomplish good patient care. PP

REFERENCES
1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:471-472. 2. Asher R. Munchausen’s syndrome. Lancet. 1951;1(6650):339-341. 3. Meadow R. Munchausen syndrome by proxy. The hinterland of child abuse. Lancet. 1977;2(8033):343-345. 4. Fehnel CR, Brewer EJ. Munchausen’s syndrome with 20-year follow-up. Am J Psychiatry. 2006;163(3):547. 5. Eastwood S, Bisson JI. Management of factitious disorders: a systematic review. Psychother Psychosom. 2008;77(4):209-218. 6. Jones RM. Factitious disorders. In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry. 6th ed. Baltimore, MD: Williams & Wilkins; 1995:1271-1279.

7. Lipsitt DR. Factitious disorder and Munchausen syndrome. In: UpToDate. Schwenk TL, ed. UpToDate. Waltham, MA: 2008. Available at: www.uptodate.com. Accessed December 3, 2008. 8. Eisendrath S. Current overview of factitious physical disorders. In: Feldman MD, Eisendrath SJ, eds. The Spectrum of Factitious Disorders. Washington, DC: American Psychiatric Association Press; 1996:195-213. 9. Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med. 1983;99(2):240-247. 10. Wise MG, Ford CV. Factitious disorders. Prim Care. 1999;26(2):315-326. 11. Yates BD, Nordquist CR, Schultz-Ross RA. Feigned psychiatric symptoms in the emergency room. Psychiatr Serv. 1996;47(9):998-1000. 12. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887. 13. Willenberg H. Countertransference in factitious disorder. Psychother Psychosom. 1994;62(12):129-134. 14. Nadelson T. Victim, victimizer: interaction in the psychotherapy of borderline patients. Int J Psychoanal Psychother. 1976;5:115-129. 15. Hollender MH, Hersh SP. Impossible consultation made possible. Arch Gen Psychiatry. 1970;23(4):343-345. 16. Fras I, Coughlin BE. The treatment of factitial disease. Psychosomatics. 1971;12(2):117-122. 17. Eisendrath SJ. Factitious physical disorders: treatment without confrontation. Psychosomatics. 1989;30(4):383-387. 18. Weiss J. The integration of defences. Int J Psychoanal. 1967;48(4):520-524. 19. Bass C, May S. Chronic multiple functional somatic symptoms. BMJ. 2002;325(7359):323-326. 20. Schoenfeld H, Margolin J, Baum S. Munchausen syndrome as a suicide equivalent: abolition of syndrome by psychotherapy. Am J Psychother. 1987;41(4):604-612. 21. Tucker LE, Hayes JR, Viteri AL, Liebermann TR. Factitial bleeding: successful management with psychotherapy. Dig Dis Sci. 1979;24(7):570-572. 22. Mayo JP Jr, Haggerty JJ Jr. Long-term psychotherapy of Munchausen syndrome. Am J Psychother. 1984;38(4):571-578. 23. Spivak H, Rodin G, Sutherland A. The psychology of factitious disorders. A reconsideration. Psychosomatics. 1994;35(1):25-34. 24. Willenberg H, Eckhardt A, Freyberger H, Sachsse, U, Gast U. Self-destructive behavior: classification, and basic documentation. Psychotherapeut. 1997;42:211-217. 25. Fliege H, Scholler G, Rose M, Willenberg H, Klapp BF. Factitious disorder and pathological self-harm in a hospital population: an interdisciplinary challenge. Gen Hosp Psychiatry. 2002;24(3):164-171. 26. Medical-Legal Survival: A Risk Management Guide for Physicians. Oak Brook, IL: University Health System Consortium; 2007.

Primary Psychiatry

© MBL Communications

66

January 2009