How to Recognize Factitious Disorder

When I was already in training to become a medical psychologist, I had a supervisor who was highly skilled on this topic. I had the opportunity to observe him clinically interviewing Munchausen by proxy abusers, victims and family members. My first patient under his supervision was a child victim who I ended up treating for eight years. This supervisor also introduced me to other experts who, decades later, I remain connected to via the American Professional Society on the Abuse of Children (APSAC).

Although case reports of neuroimaging have described brain abnormalities in factitious disorder (for example, white matter lesions disseminated bilaterally, moderate bilateral frontotemporal cortical atrophy, mild cerebellar atrophy, hyperperfusion of the right thalamus), it is unclear if these findings represent causes for the disorder, sequelae, neither, or both.

Likewise, limited data available via neuropsychological testing suggests dysfunction in the right hemisphere, but conclusions are not possible at this time. Those with factitious disorders often report a history of early losses via death, sickness, or abandonment; disrupted attachments or other traumas; gratifying (reinforcing) experiences related to the sick role; and a desire for attention. However, accounts of past loss or trauma sometimes differ from information gathered from family members. For some, abnormal illness behaviors begin in childhood, perhaps as a way of coping with stress. It can be intergenerational, but that is not always the case.

Yes, some individuals report that they found the attention and care they received while ill or injured to drive subsequent behavior. This experience can happen as a child, teen or adult. However, it might not be a singular episode. Having a genuine chronic illness or condition can place a vulnerable person at higher risk for developing a factitious disorder.

The most common comorbidity is a personality disorder. Some hypothesize that the sick role behavior associated with factitious disorder may be a means of establishing or stabilizing one's identity, maintaining relationships with others, and addressing emotional dysregulation and unmet needs. Chronic illness and/or hospitalization may provide factitious disordered individuals with psychological benefits that are otherwise unavailable in more conventional social settings such as in the workplace. These benefits can include a clear role and sense of importance and belonging, and concern and acceptance by others. Other comorbidities, present in at least 20 per cent of published cases, include Post-Traumatic Stress Disorder, Somatic Symptoms Disorders, Substance Use Disorders, depression and learning disorders. About half have engaged in self-destructive or self-injurious behavious. Finally, over half of those who have abusively falsified illness or injury in another have also falsified illness or injury in themselves.

By definition, factitious disorder behavior is conscious and deliberate. However, insight about the harm associated with the behavior is frequently lacking. One can think of the analogy of a substance abuser who very deliberately does what they feel they need to do in order to obtain their substance of choice and do not appreciate (or cannot bear to acknowledge) the harm their deceptive behaviors cause to loved ones. 

One abuser once explained to me that she knew she was poisoning her child to cause extreme vomiting and had to hide that fact, but she ignored the danger in order to experience the psychological benefits of being in the hospital with her child. With an obviously high level of denial, she considered her behavior relatively safe since she thought of her child as not genuinely ill and since she controlled the amount of poison given. The clear suffering of her violently ill child did not elicit empathy or remorse when she was craving the attention she received during hospitalizations. Thus, factitious disordered individuals need strong psychological support to face the consequences of their behavior and assistance in breaking through their denial. Some will be impervious to any psychoeducation or intervention attempts.

Accurate prevalence data is not available. However, case reports and clinical experience demonstrate that mental illness, developmental disorders and psychological conditions/behaviors are falsified by some with factitious disorders. In fact, there are no disorders or conditions that cannot be falsified. A short article on Munchausen by proxy in educational and mental health settings can be found in this special issue: https://docs.wixstatic.com/ugd/4700a8_ae2c9d0878e145c6bd118933d641f21f.pdf

Those who acknowledge illness falsification are far more likely to benefit from treatment. Treatment includes efforts to increase awareness and to reduce the risk of relapse via the acquisition of strengthened skills and support. The ACCEPTS model can be used as a framework for psychotherapy with the abuser and family members. This acronym stands for acknowledgment of the behavior, coping skills, empathy for the victim(s), parenting skills, taking charge of one’s recovery, and social support. Specific psychotherapy modalities that can be helpful include narrative therapy, Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), parenting skills and parent-child interaction therapy. 

Medication may effectively target comorbidities such as depression. Indicators of successful treatment include: 

(a) admitting to the behavior, including specific details

(b) experiencing an appropriate emotional response to the harm caused to others

(c) developing better coping skills and a relapse prevention plan

(d) demonstrating the ability to refrain from illness falsification over a significant period of time

If the individual does not take any responsibility for the illness falsification within six to 12 months of the start of therapy, this is a poor prognostic indicator.

Some child victims need permanent protection from the abuser. Careful monitoring is needed if the child has continued contact with the abuser, especially if the abuser has not made meaningful progress in psychotherapy. The general clinical approach to the child victim is to use a rehabilitation model in order to maximize normal functioning (physical, social, academic and so on) and health, to support the acquisition of developmental milestones and to assist the victim in developing a sense of self that is not based on falsified medical problems. 

Outcomes for the child victims appear to be improved if they receive focused psychotherapy. Common psychotherapy themes include denial of abuse, anger, enmeshment, attachment, dominance versus self-efficacy in relationships, control over one’s body, sick-role behavior, iatrogenic post-traumatic stress disorder, self-esteem, defining family relationships and grief. Older youth who are adequately prepared and equipped may benefit from a facilitated review of their own medical records and/or discussions with their abuser, paediatrician or others. A psychotherapist is usually the facilitator of these experiences. Clinical and case management practice guidelines are available for free fromthe American Professional Society on the Abuse of Children (APSAC) at www.apsac.org/_files/ugd/4700a8_47be1e8b569a428dad3e41fd366e2f4f.pdf

There are several ways in which social media and the internet in general have changed the behavior of those with a factitious disorder as well as the investigations of such individuals. The internet has made it easy to search for information and the means to fabricate, simulate or induce illness. Thus, the need to have medical training or experience in order to successfully mislead a clinician is reduced. 

Social media is a platform that allows one to garner a wider audience to gain sympathy, attention and direct support. However, investigators can also track this behavior, including social media accounts, fundraising efforts, news stories, comments and reviews, involvement in online support groups, online sales and businesses and legal cases and actions, and seek confirmation of history provided (such as professional licenses, employment and so on). Further, officers of the law can obtain a search warrant to examine search histories. See a short article on the influence of electronic and internet advances on Munchausen by proxy in this special issue: https://docs.wixstatic.com/ugd/4700a8_ae2c9d0878e145c6bd118933d641f21f.pdf

If you are concerned that someone is abusing another by falsifying illness or disability, you can report it to the appropriate abuse hotline (child abuse, dependent adult or elder abuse, animal cruelty and so on). If you are concerned that someone is falsifying illness or disability in themselves, you can share that information with the person directly, with his or her treating clinicians, and/or to friends/ family who may want to work with you to supportively intervene. You might want to think of it similarly to an intervention with someone with a substance abuse disorder. They are likely to deny their problem, but some individuals might be open to help if close friends and family are united and provide the needed support.