Factitious Disorder: Then and Now
Factitious Disorder (sometimes called Munchausen Syndrome or Factitious Disorder Imposed on Self) is a condition in which someone presents with physical or mental illness for which no organic cause can be found. Motivations for this may be unclear, and the condition is associated with unusual behaviour such as falsifying medical records, self-harm, or creating fanciful histories.
Patients who present with Factitious Disorder are often well-versed in medical literature or have prior experience of hospitalisation and treatment. They may have some connection with medical practice or have prior clinical experience. As a result, their narratives and symptoms are often highly convincing and credible.
Factitious Disorder is distinct from Factitious Induced Illness (sometimes called Factitious Disorder Imposed on Another or Munchausen’s Syndrome by Proxy), in which a person fabricates the symptoms of an illness in another person, often a child or a dependent.
In this post we look at the definition and history of Factitious Disorder, as well as at the modern medico-legal considerations that it brings up.
Defining Factitious Disorder
A person with a Factitious Disorder does not fabricate their illness with the intention to malinger. This means that they do not report or induce their symptoms for personal gain. Rather, their intention (whether conscious or unconscious) is to attain the role of a patient. This is often referred to as their desire to attain a “sick role,” thereby establishing a kind of fabricated social contract in which “everyone must show the sick person kindness and forbearance.” In contrast to malingering, Factitious Disorder is considered a genuine mental disorder.
While patients who present with malingering or with Factitious Disorder both demonstrate intentional, feigned symptomatologies, they differ in why they fabricate their illness in the first place. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), in cases where a person’s symptoms are malingered, the “intention is motivated by external incentives, such as avoiding work or duty, evading responsibility, or obtaining financial gain.” In cases of Factitious Disorder, the fabrication is motivated by “internal incentives, such as seeking nurturance and sympathy for being ill.”
Although the majority of documented cases of Factitious Disorder concern feigned physical conditions, there have also been many examples of factitious mental illnesses, such as factitious obsessive compulsive disorder, factitious schizophrenia, and factitious post-traumatic stress disorder.
Factitious Disorder must be distinguished from Somatic Symptom Disorder, in which a patient genuinely experiences symptoms and does not intend to deceive, or Conversion Disorder, in which a patient presents with neurological symptoms (such as pain, numbness, paralysis, or fits) without any functional, organic cause.
As with all of these disorders, it is unclear what the causes of Factitious Disorder are, and they will typically vary on a case-by-case basis. Nevertheless, studies have shown that patients with Factitious Disorder may have suffered childhood abuse and have severe issues of abandonment. They may also have been victims of Factitious Induced Illness themselves, sparking a later pattern of fabrication. Their feigned symptoms often provide them with a “sense of control”, or offer them comfort from being the centre of attention among medical professionals and carers.
History and Terminology
Cases of malingering and feigned psychiatric disorders have a history extending back to at least Biblical times. Think of King David, for example, who “feigned madness… and let saliva run down his beard” in order to convince King Achish of Gath to set him free. In today’s terminology, we might think of this as an example of malingering, but it shows that, throughout history, cultures have been aware of and concerned about the deceptive power of feigned disorders.
It was not until the mid-twentieth century, however, that the act of fabricating itself became the subject of sustained clinical attention. In 1951, Richard Asher, a British Endocrinologist and Haematologist, highlighted a tendency among his patients to embellish or feign their symptoms. He referred to this tendency as “Munchausen’s Syndrome,” naming it after the fictional character Baron Munchausen, created by Rudolf Erich Raspe in the eighteenth century. This character was loosely based on the historical figure, Hieronymus Karl Freidrich, Freiherr von Münchhausen, a German baron who fought in the Russo-Turkish War (1735-1739) and who gained a reputation for telling impossible stories about his adventures. Asher wrote:
Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly the syndrome is respectfully dedicated to the Baron, and named after him.
It is unclear whether or not Asher was correct in thus asserting the widespread preponderance of Factitious Disorder and malingering (which, at the time, were not properly distinguished from one another). Recent studies have suggested that “approximately one-third of outpatients have symptoms that cannot be explained on the basis of a recognised ‘organic’ disease.” But it is often difficult to figure out whether or not those symptoms are being intentionally feigned. In an analysis of the prevalence of Factitious Disorder in clinical settings, it was found that 10 out of 1,288 patients who were referred to a psychiatric consultation service were diagnosed with Factitious Disorder (equivalent to 0.8%).
Irrespective of the question of prevalence, Asher’s terminology has been criticised in the years following his original diagnosis. It has often been observed that naming the disease after a humorous, fictional figure not only trivialises the real experience of patients who suffer from it, but also simply misrepresents what that experience involves. As the medical historian Jill Fisher notes, “the irony of the nomenclature is that the patients’ stories are unlike those of the Baron Munchausen because they are believable.” As mentioned above, those patients are often highly medically literate and are able to construct symptoms or narratives that are convincing enough to appear real.
While “Munchausen’s Syndrome” remains prevalent as an informal term, the American Psychiatric Association endorsed the term “Factitious Disorder Imposed on Self” in 2013, specifically distinguishing it from malingering and from other Somatic Symptom Disorders.
Medico-Legal Implications
As the definition of Factitious Disorder clearly shows, the patient is not trying to gain any external or material benefits and is not inflicting harm on another individual (as is the case for Factitious Induced Illness). Nevertheless, the disorder still has a number of very important implications with regards to the theory and practice of medico-legal work.
The first and perhaps most common area in which questions about Factitious Disorder arise is in relation to Personal Injury cases. In these cases, an Expert Witness may be asked to provide the Court with a judgment about whether a plaintiff’s illness is real, malingered, or factitious. An opinion will largely be based on a detailed professional assessment, as well as on whatever medical histories are available (bearing in mind that these too may be factitious or the result of malingering).
The difficulty with this process is that an Expert Witness may be asked to provide an opinion on whether a person has a Factitious Disorder or not, when in reality the person will likely present with a spectrum of overlapping symptoms that might be motivated by any number of different factors. Fortunately, the final determination of this is the responsibility of the Court!
Symptoms may be the result of mental disorders, but they could also be caused by characterological dispositions, contextual influences, attempts to malinger, and more. Often, medical professionals will provide the court with a range of possible scenarios for the Court to make its determination, as it is not necessarily possible to decide whether or not a plaintiff’s actions definitively suggest a pattern of lying and malingering, rather than an identifiable disorder.
Another scenario in which Factitious Disorder might be relevant to legal proceedings stems from the fact that a patient with a genuine Factitious Disorder will often be willing to undergo significant diagnostic procedures, such as biopsies and surgeries. Moreover, they will also often be placed on “unnecessary” courses of medication. This puts the patient at physical risk, but it also puts doctors at legal risk for carrying out superfluous procedures. Indeed, in one case reported from 1986, a patient underwent treatment for a factitious case of cancer and subsequently attempted to sue her doctors for the damage that the course of treatment caused her. Note that this shows that, while the intentions of a person with a Factitious Disorder may not initially be directed towards personal gain (that would be malingering), they may well provoke a legal situation in which the patient sues for damages. In other words, the harm caused by unnecessary procedures may in turn provoke the patient to make a claim against their doctors.
This fact was relevant to another case from 1971, in which a woman with Factitious Disorder presented with such convincing bouts of Hypoglycemia that doctors surgically removed her pancreas. As a result, the patient went on to suffer from Diabetes for the remainder of her life. The doctors responsible were investigated for failing to uphold a duty of care, but the court ruled in this case that medical professionals are not liable for treating a patient with fabricated symptoms as long as the doctors act in a way that would have been appropriate had the symptoms been real. In other words, the doctors were not held responsible for having been “tricked” into carrying out procedures that they otherwise would have performed.
This ruling is also relevant to issues of mental capacity, which can themselves be raised in relation to cases of Factitious Disorder. This is because patients with Factitious Disorder may not be considered able to give informed consent to the treatments they receive. The problem is that these patients often appear entirely rational and lucid—indeed, they may be better informed than most other patients. This can sometimes dissuade medical professionals from the need to conduct an assessment of the patient’s mental state or their mental capacity. Thus far, however, there does not seem to have been any case in which a medical professional has been held liable for neglecting to assess the mental capacity of a person with a Factitious Disorder.
In another medico-legal scenario arising in relation to Factitious Disorder, the roles between plaintiff and defendant are reversed. This occurs when a patient with a Factitious Disorder is considered civilly (or in some cases even criminally) liable for fraud. In some states in America, for example, it is illegal to pretend to be ill or to impersonate a patient. As a result, in Arizona in 1995, a woman was prosecuted for having “presented a contrived history to various medical, psychiatric, and dental practitioners and facilities to obtain unwarranted care.” Her behaviour was deemed to be “factitious” but nevertheless “carefully planned” and by no means “irresistible.” Though her intentions were not manifestly to secure money or gain, the services rendered by the hospitals for treating her fabricated symptoms were calculated to have cost $106,997, for which she was ordered to pay total restitution. Though this is obviously more significant in insurance-based healthcare systems such as the one that exists in the United States, it nonetheless carries moral and legal implications that are relevant to the UK.
Indeed, in the UK as well as in the United States, a person can be liable for fabricating their medical history in order to receive substances such as drugs or medication. Again, this is not the same as malingering, since Factitious Disorder very commonly presents with issues of substance abuse. A person may not be actively seeking to defraud the healthcare system in order to obtain drugs illegally, but their Factitious Disorder may implicate them in such acts.
Finally, medico-legal scholars have also considered the somewhat paradoxical scenario of whether a Factitious Disorder itself could be considered a litigable harm. In other words, they have wondered whether it might be possible for someone to allege that another party caused their Factitious Disorder through malice or negligence. There have been a few cases in which such a possibility could be considered relevant, but the details have always been fairly ambiguous. In one 2014 case, for example, a claimant made the argument that they would have had compensable, psychological pain, if their diagnosis of Factitious Disorder had been confirmed. As the diagnosis was not confirmed, however, it remains impossible to know whether or not the court would have accepted that argument as legitimate (Harvey v. Colvin, 2014). There does not seem to be any documented case of a plaintiff successfully suing after being diagnosed with Factitious Disorder as a result of the malicious or negligent acts of another. As James C. Hamilton and Kathryn A. K. Kouchi (2018) note, it is still commonly accepted that Factitious Disorder has its roots in “long-standing characterological problems that are likely to have been caused by adverse childhood experiences.” There seems to be little evidence to suggest that it can be induced by later physical or psychological trauma.
Conclusion
All of these scenarios highlight complex and ongoing areas of research. Clearly, Factitious Disorder is, by its very nature, difficult to recognise, assess, and diagnose. It brings into question many of the issues that are central to making legal decisions, such as consciousness, understanding, awareness, and intent. It seems unlikely that it will be possible to establish objective mechanisms to test whether symptoms are the result of a Factitious Disorder or malingering, meaning that both medical and legal professionals will have to try and remain comfortable with the ambiguities and nuances of each individual case.
This post is provided for general information purposes and is not intended to cover every aspect of the topics with which it deals. It does not constitute medical, legal, or professional advice, nor is it necessarily an endorsement of the views of Professor Elliott, the U.K. Centre for Medico-Legal Studies, its employees, or its affiliates. Though we aim to ensure that all information is accurate at the time of posting, we make no representations, warranties or guarantees, whether express or implied, that the content in the post is complete or up to date.