Factitious Disorders are characterised by physical or psychological symptoms intentionally produced or simulated with the purpose of assuming the role of a person who is sick. An evaluation of the ‘intention’ of a certain symptom is made by collecting direct evidence and through the exclusion of other causes. Factitious Disorders are differentiated from acts of simulation, in which symptoms are always produced intentionally, but have a purpose related to environmental circumstances (e.g., the symptoms are produced to avoid legal obligations, being subjected to tests or my develop so as to eventually procure some kind of economic advantage). Simulation or malingering can be considered a normal adaptive behaviour in certain circumstances, while on the contrary in the Factitious Disorders the motivation lies in the psychological need to assume the role of a person who is ill, as revealed by the absence of external incentives that might motivate such behaviour.

In the literary world there have been numerous cases of simulated illness. For example, in Conan Doyle’s short story The Adventure of the Dying Detective, a malingering Sherlock Holmes pretends he has been infected by a contagious and lethal disease originating in Sumatra, as such a ruse appears to be the only way to get his rival to offer a full confession to a crime. In Dostoevsky’s The Brothers Karamazov, the evil Smerdiakov simulates epileptic seizures, however in this case with homicidal intent. Factitious Disorders are also commonly referred to as the Munchausen Syndrome. After years serving in the cavalry and now living in retirement on his family estate, Baron Munchausen (1720-1797) enjoyed entertaining his friends with tales in which he attributed to himself a series of extraordinary exploits. The term Munchausen Syndrome was first used in 1951 in the British medical journal The Lancet to refer to situations characterised by repeated hospital admissions for the treatment of apparently acute illnesses. Patients would provide a plausible explanation for their predicament and for the cause itself, however this would be subsequently found to be entirely false.

The DSM IV defines the syndrome as the Chronic Factitious Disorder with predominant physical signs and symptoms. It should be noted that the Factitious Disorders have a number of common characteristics:

• they are difficult to suspect and diagnose;
• they are usually identified in an attempt to exclude a disease which is being simulated;
• they are the cause of considerable expense in terms of diagnostic costs, medical examinations, specialist consultancy and the length of procedures;
• these patients seem to resist being referred for psychiatric therapy, which, in turn, in any case tends not to provide encouraging results and does not preclude or offer protection against highly frequent relapses;
• the disorders can result in lengthy and complex legal proceedings, especially in cases of simulated violence;
• they can simulate violence or cause the death of the patient, although such occurrences are rare;
• such patients induce feelings of indignation, irritation and a loss of esteem on the part of care-givers;
• affected patients often involve family members, health-care providers (general practitioners, specialists, lab technicians, anatomopathologists and nurses) and social workers or voluntary staff etc;
• factitious Disorders can be sometimes engendered in a patient by another person (usually a mother who influences a son or daughter), thereby creating a pathological condition known as the Munchausen Syndrome by proxy or Polle Syndrome.

The clinical history invented by the person is usually credible and plausible, however details provided are almost always vague and inconsistent. The narrative produced by a patient when anamnesis is taken may contain tales of heroic deeds. These patients also often bring with them copious clinical documentation that may refer to multiple surgical interventions, almost as if they were intent on challenging the physician’s ability. The age of onset is normally during early adulthood. During hospitalization these patients are typically and particularly fussy, demanding, hostile and constantly seek attention. In turn, they generally receive very few visitors. A common feature of the Factitious Disorders is the patients’ never-ending desire to be examined and even submitted to quite uncomfortable medical tests, as if they were afflicted by a desire to harm themselves.

Munchausen Syndrome by Proxy. In such cases the disorder is engendered in another person. It may occur for example that, driven by a desire to be at the centre of attention, a mother may decide her daughter has a (non-existent) disease and then force her to take medicines and submit to continuous medical examinations, eventually succeeding in affecting her health in quite a substantial manner. >>> (Dissociative Disorders)

Bibliographical references:

Asher R. Munchausen syndrome. Lancet, 1951; 1: 339.