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Psychiatric-Mental Health Nursing

21.3 Factitious Disorder

Psychiatric-Mental Health Nursing21.3 Factitious Disorder

Learning Objectives

By the end of this section, you will be able to:

  • Discuss the DSM-5-TR diagnosis relative to factitious disorder
  • Identify risk factors for factitious disorder
  • Give examples of client symptoms and behaviors associated with factitious disorder
  • Describe stress responses of clients due to types of factitious disorder
  • Plan nursing and collaborative care for clients seeking treatment for factitious disorder

Factitious disorder and its counterpart, factitious disorder imposed on another, involve individuals who feign illness or intentionally make others believe they are sick. Factitious disorder, also known as Munchausen syndrome (named after Baron von Munchausen, a German military officer who was a “teller of tall tales”), is characterized by a desire for attention and validation through self-inflicted illness. Meanwhile, factitious disorder imposed on another, formerly known as Munchausen by proxy, involves caregivers who fabricate or induce illness in another person, often their own child. This part of the chapter delves into the psychology behind these behaviors, covers assessment skills to identify factitious behavior, and touches upon the ethical challenges that arise in providing care for individuals with these disorders.

Medical Diagnosis

The mental health condition in which individuals intentionally and consciously fabricate or induce physical or psychological symptoms in themselves or another is called factitious disorder. The primary motivation behind this behavior is to assume the role of a client or caregiver and receive medical attention, sympathy, or support. The defining feature of factitious disorder is the conscious fabrication or induction of symptoms with no external incentives, such as financial gain. There are two main types of factitious disorder (Carnahan & Jha, 2023; Cleveland Clinic, 2021). Factitious disorder imposed on self involves individuals who purposely exaggerate, simulate, or self-inflict physical or psychological symptoms to assume the sick role. They may go to great lengths to deceive medical professionals, including faking or inducing symptoms, manipulating medical tests, or even undergoing unnecessary medical procedures. The underlying motive is to obtain medical care, attention, and validation for their concerns. The condition in which an individual intentionally causes illness or symptoms in another person under their care, often a dependent, such as a child, older parent, or other vulnerable individual, even a pet, is called factitious disorder imposed on another (FDIA). The person with factitious disorder imposed on another may falsify symptoms, tamper with medical tests, administer medications or substances, or engage in other deceptive behaviors to make the dependent appear, become, or remain sick. The motivation may be to gain attention, sympathy, or a sense of control in the caregiver role, or even to obtain controlled substances.

Risk Factors for Factitious Disorder

The risk factors for factitious disorder are multifactorial but center around a history of childhood trauma as well as attention-seeking behavior. Known risk factors are limited because obtaining reliable data is difficult due to the nature of factitious disorder.

Psychosocial Risk Factors

Adverse experiences during childhood, such as abuse, neglect, or significant disruptions in attachment, have been associated with an increased risk of developing factitious disorder. These adverse experiences can impact an individual’s emotional development, self-esteem, and coping mechanisms, potentially leading to the development of maladaptive behaviors to gain attention or control.

Individuals with factitious disorder often have a strong need for attention and validation. They may feel a sense of emptiness, insecurity, or low self-worth and use the fabricated symptoms or illness as a way to receive the attention and care they desire. If the individual has experienced positive reinforcement, such as sympathy or validation for displaying symptoms or illness behavior, they may be more likely to develop factitious disorder.

Certain personality traits may increase the susceptibility to developing factitious disorder. Individuals with histrionic personality traits, for example, may have a strong need for attention, drama, and a desire to be the center of attention. Other characteristics, such as narcissistic traits or borderline personality disorder, may also play a role in seeking attention and validation through the fabrication of symptoms. Difficulties in regulating and expressing emotions can also contribute to the development of factitious disorder as can depression and poor self-esteem. Individuals may use the fabrication of symptoms or illness as a way to cope with unresolved emotional pain, distress, or to avoid other challenging life situations.

Behavioral Risk Factors

Behavioral risk factors for factitious disorder refer to specific behaviors or patterns of behavior that may increase the likelihood of developing or maintaining the disorder, such as:

  • childhood trauma, such as emotional, physical, or sexual abuse
  • a serious illness during childhood
  • the loss of a loved one through death, illness, or abandonment
  • past experiences during a time of sickness and the attention it brought
  • the desire to be associated with doctors or medical centers
  • work in the health-care field (Mayo Clinic, 2019)

Some individuals who assume the caregiver role for someone with a genuine illness or disability may develop factitious disorder imposed on another as a way to maintain their involvement in the medical system, gain attention, or fulfill a need for control. This may occur when the individual feels threatened by the improvement or recovery of the person for whom they are caring.

Behaviors and Symptoms of Factitious Disorder

Individuals with factitious disorder engage in deceptive behaviors to fabricate or induce symptoms. They may exaggerate existing symptoms, simulate new symptoms, or tamper with medical tests to maintain the appearance of illness. Deception and manipulation become habitual and central to their behaviors, serving as a means to assume the sick role and receive attention or care. Individuals with factitious disorder tend to be resistant to disclosing the truth about their fabricated symptoms. They may be evasive or provide inconsistent information during medical evaluations, making it challenging for health-care providers to reach an accurate diagnosis. This reluctance to reveal the truth perpetuates the cycle of deception and maintains their identity as a client.

Individuals with factitious disorder may establish a close relationship with health-care professionals, seeking their approval, validation, and attention. They may exhibit ingratiating behaviors, such as excessive praise, flattery, or compliance, to maintain a favorable rapport with medical staff. This behavior is aimed at reinforcing the perception of being a cooperative and deserving client.

Individuals with factitious disorder may persist in their deceptive behaviors despite negative consequences, such as repeated medical evaluations, exposure to unnecessary treatments or procedures, financial strain, or difficult relationships with health-care providers and loved ones. Their desire for attention and validation overrides concerns about the potential harm caused by their actions.

It is important to note that factitious disorder is different from malingering, where individuals feign symptoms for external incentives, such as financial compensation or avoiding legal responsibilities. Individuals with factitious disorder feign symptoms for intrinsic incentives, such as attention and validation from health-care providers or others.

The symptoms of factitious disorder can vary depending on the individual and the specific presentation of the disorder. Some individuals with factitious disorder go beyond fabrication and actually induce physical or psychological symptoms in themselves. They may engage in self-harm or self-poisoning, deliberately manipulate their body to create physical signs of illness or injury, or intentionally cause themselves pain or discomfort.

Individuals with factitious disorder often possess wide-ranging knowledge of medical conditions, procedures, and treatments. They may acquire this knowledge through personal experience, professional background in health care, or extensive research. This knowledge enables them to present their symptoms convincingly, manipulate medical professionals, and navigate the health-care system to their advantage.

Stress Responses

Stress responses are broken down into those experienced by clients with factitious disorder and those diagnosed and involved with factitious disorder imposed on another; they can vary widely.

Stress Responses in Factitious Disorder

Maintaining a facade of illness and deception can negatively affect relationships with family, friends, and health-care providers. Loved ones may become frustrated, confused, or even distrustful as they try to understand the motivations behind the client’s behavior. Health-care providers may also feel frustrated or deceived, which can impact the quality of care and support they provide. Individuals with factitious disorder may isolate themselves or become alienated from others due to the complexities and secrecy surrounding their condition. They may fear discovery or judgment, leading to social withdrawal and a sense of isolation. This isolation can exacerbate feelings of loneliness and reinforce the cycle of seeking medical attention as a primary source of social interaction.

The extensive medical attention sought by individuals with factitious disorder can result in frequent absences from work, loss of employment, or financial strain. Hospitalizations, medical tests, and treatments can disrupt employment stability and financial security. Additionally, the financial burden of unnecessary medical expenses can accumulate over time.

Factitious disorder is often associated with underlying psychological distress. The motivations behind the disorder may be rooted in unresolved emotional pain, trauma, low self-esteem, or a need for control or validation. These underlying psychological issues can contribute to ongoing distress, self-doubt, and a diminished sense of self-worth if left untreated.

Stress Responses in Factitious Disorder Imposed on Another

Factitious disorder imposed on another is a serious form of factitious disorder that can have profound and devastating effects on the lives of both the victim and the perpetrator. Here’s how factitious disorder imposed on another affects the lives of clients and others involved:

Impact on the victim includes the following (Cleveland Clinic, 2021):

  • Physical and emotional harm: The victim, usually a child or vulnerable adult, is subjected to unnecessary medical procedures, treatments, and interventions. This can cause physical harm, pain, and distress, potentially leading to long-term health complications.
  • Medical trauma: Repeated medical evaluations, hospitalizations, and invasive procedures can lead to medical trauma for the victim. They may develop a fear or aversion to medical settings and procedures, which can have lasting psychological and emotional consequences.
  • Disrupted development: Factitious disorder imposed on another can disrupt a child’s physical, emotional, and social development. It may compromise their normal developmental milestones, and they may experience delays in education, socialization, and overall growth.

Impact on the perpetrator includes the following:

  • Legal consequences: Perpetrators of factitious disorder imposed on another can face legal repercussions for their actions. They may be charged with child abuse, neglect, or other criminal offenses, like battery. Legal interventions, child protective services, and court proceedings may be involved to ensure the safety and well-being of the victim.
  • Loss of trust and relationships: Factitious disorder imposed on another can lead to a breakdown of trust and relationships for the perpetrator. Friends, family members, employers, and health-care providers may become aware of the deception and may distance themselves from the individual. The perpetrator may face significant social isolation and stigmatization.

Impact on family and support systems includes the following:

  • Family dynamics: Factitious disorder imposed on another can severely disrupt family dynamics and relationships. Other family members may be unaware of the deception or may become complicit in it, leading to strained relationships and conflicts within the family.
  • Emotional distress: Family members who discover the truth may experience significant emotional distress, ranging from shock and disbelief to guilt, anger, and betrayal. The revelation of such abuse can have a profound and lasting impact on their emotional well-being.
  • Need for support and healing: The entire family may require therapeutic support and counseling to heal from the trauma and to rebuild trust and healthy relationships. Support systems, including mental health professionals and support groups, can play a vital role in facilitating the healing process.

Nursing Care

Building trust and rapport with the client is a crucial first step in the care of the client with factitious disorder, even though the client’s behaviors may seem deceptive. Nurses should create a nonjudgmental and empathetic environment where clients feel safe discussing their concerns, while still setting clear boundaries and limits with the client. Nurses are cautioned to remain aware of personal involvement.

The goal of treatment is to replace maladaptive attention-seeking behavior with positive behaviors. Treatment usually involves long-term psychotherapy. Nurses can offer stress coping skills as alternatives to expression of illness symptoms.

Psychosocial Considerations

Client Empowerment

In this scenario, the nurse builds trust with a client with factitious disorder while still maintaining clear boundaries.

Nurse: Good morning, AJ, how was your night?

Client: Another sleepless eight hours! I guess I just don’t deserve a good night’s sleep!

Nurse: You don’t deserve it?

Client: Well, I can’t catch a break in any part of my life, why would sleep be any different?

Nurse: (using silence and active listening)

Client: Hey nurse, you said you were here to help me, right? Like get the doctor to give me something at bedtime? Or maybe you could, you know, just get me something?

Nurse: Sounds like this is a problem for you, is that accurate?

Client: Yes, it is! If you’re not going to help me, just say so.

Nurse: AJ, I support your concern. Let’s review the plan we discussed together. We talked about some relaxation techniques. You had some suggestions.

Client: Oh, yeah, I was going to try meditation . . .

Nursing Assessment

Begin by gathering a thorough medical history, including past hospitalizations, surgeries, and treatments. Pay attention to inconsistencies or discrepancies in their reported medical history and observe any discrepancies between reported symptoms and medical findings. Inquire about their health-care-seeking behaviors, including frequent visits to different health-care providers or hospitals. In factitious disorder imposed on another, the abuser is the client. This disorder is a form of maltreatment toward a child, adult, or elder. The recipient of actions by the abuser may also experience mental illness due to the abuse.

Observe the client’s behavior and physical presentation during the assessment. Note any indications of intentionally induced symptoms or fabrication of symptoms. Be attentive to any evidence of self-harm or manipulation of medical devices or test results. Assess the client’s mental health status, including any history of personality disorders, past trauma, or emotional distress. Evaluate their understanding of the mind-body connection and their motivations for seeking medical attention. Observe for any signs of secondary gain, such as attention-seeking behavior or a desire to assume the “sick role.”

Collaborate with other health-care professionals, such as psychiatrists or social workers, to gather additional information and perspectives. Seek collateral information from family members, friends, or previous health-care providers to validate or refute the client’s reported medical history and behaviors.

Throughout the assessment, maintain a professional and nonjudgmental approach. Document all observations and findings accurately and objectively. Clients may sometimes withhold information, lack trust, or be fearful. Some clients will pause the assessment and ask the nurse’s opinion on past or present treatment options, choices in their care, or for the nurse to provide a diagnosis. The nurse should respond to the client’s questions by acknowledging their feelings and educating the client on the treatment process. The nurse can reflect upon the client’s own words, such as, “You mentioned you have a therapist you like,” or, “You shared with me that your Dad offered you a place to live.” This identifies the client’s strengths and encourages the client’s participation.

Approaches to Treating Factitious Disorders

According to Weber (2023), a multidisciplinary approach is most effective when treating factitious disorder. Nurses should engage in collaboration with psychiatrists and primary care providers, social service professionals, and therapists. The client’s family members are included. A multidisciplinary approach allows for comprehensive assessment, coordinated treatment planning, and ongoing support for the client. Regular communication and information sharing are vital to ensuring a consistent and integrated approach to care.

It is crucial to address any underlying psychiatric conditions, such as personality disorders or trauma-related disorders, that may contribute to the development or maintenance of factitious disorder. Treating co-occurring mental health conditions can help improve overall well-being and decrease the motivation for engaging in deceptive behaviors. Psychotherapy, particularly CBT, can be especially beneficial in treating factitious disorder. CBT aims to address the underlying psychological factors and motivations that drive behavior. It helps clients identify and modify unhelpful thoughts, beliefs, and behaviors associated with factitious disorder. Therapy can also focus on developing healthier coping mechanisms and addressing underlying emotional distress or trauma.

Providing a supportive and nonjudgmental environment is also critical when treating factitious disorder. Nurses can play a key role in building trust, establishing therapeutic relationships, and demonstrating empathy toward the client. By creating a safe space for open communication, clients may feel more comfortable sharing their motivations and experiences, which can aid in treatment progress.

Nurses can also assist by providing education about factitious disorder to help clients gain insight into their behavior and understand the potential consequences of their actions. By increasing their knowledge and awareness, clients may be more motivated to engage in treatment and make positive changes. Education can also be extended to family members or caregivers to help them better understand the condition and provide appropriate support.

As discussed in Mood Disorders and Suicide, potential for self-harm is part of the mental health assessment. Client safety is a high priority in nursing care of clients with factitious disorder, or factitious disorder imposed on another. Social and Emotional Concerns presents the legal responsibility of the nurse, as a mandatory reporter, to report suspected or known abuse and neglect.

Setting clear boundaries and limits is essential in managing factitious disorder. Health-care providers must establish guidelines for appropriate care and interventions, such as planning with the client which topics to be discussed during therapy sessions or nursing interactions. Consistent monitoring, strict adherence to protocols, and verifying information can help prevent unnecessary procedures or treatments, and assist to resolve factitious behavior.

Psychosocial Considerations

Factitious Disorder Imposed on Another

Nursing care for factitious disorder imposed on another is a highly complex and challenging situation. It involves a caregiver, typically a parent, intentionally fabricating or causing illness in a child or other dependent person to assume the sick role and seek medical attention. Here are some important considerations for nursing care in these cases:

  • Recognize the signs: Nurses should be vigilant in recognizing the signs and symptoms of factitious disorder imposed on another. These may include inconsistent or unexplained medical presentations, failure to respond to treatment, unusual symptoms, and a history of multiple hospitalizations or medical interventions.
  • Protect the victim: The primary focus in these cases is to ensure the safety and well-being of the victim. If there are concerns of abuse or neglect, follow appropriate reporting protocols and involve the appropriate protective services.
  • Collaborate with the health-care team: Work closely with the health-care team, including physicians and advanced practice providers, child protection specialists, social workers, and psychologists, to develop a comprehensive approach to care. Collaboration and regular communication are crucial for the welfare of the vulnerable party and the effectiveness of interventions.
  • Gather information: Obtain information from multiple sources, such as previous medical records, other health-care providers, and school personnel, to gain a comprehensive understanding of the victim’s medical history and potential discrepancies or inconsistencies.
  • Document carefully: Maintain accurate and detailed documentation of all assessments, interventions, and observations. This documentation is essential for the continuity of care, legal purposes, and the well-being of the victim.
  • Focus on the victim’s needs: Provide appropriate medical care and support for the victim’s genuine health needs while avoiding unnecessary interventions related to fabricated or induced symptoms. The victim’s well-being should always be the top priority.
  • Monitor and observe: Continuously monitor the victim’s condition and response to treatment. Be vigilant for any signs of the caregiver’s interference or manipulation of medical information or treatment.
  • Educate and support the family: Provide education and support to family members, including the caregiver, to help them understand the disorder and its consequences. Offer resources for psychological support and therapy to address underlying psychological factors.
  • Promote safety and security: Create a safe and supportive environment for the victim and the family. Ensure that appropriate security measures are in place to prevent further harm or manipulation.
  • Ethical considerations: Recognize and address the ethical dilemmas that arise in caring for child victims. Balancing the provision of appropriate care, protecting the victim’s well-being, and addressing legal and ethical considerations can be complex. Consult with the health-care team, follow institutional protocols, and seek guidance from ethics committees as needed.
  • Legal and child protection involvement: Cooperate with legal authorities and child or adult protection agencies. Provide accurate and objective information to aid in the investigation and protection of the victim.
  • Ongoing assessment and support: Nursing care for factitious disorder imposed on another requires ongoing assessment and vigilance. Continuously evaluate the victim’s progress, collaborate with the health-care team, and provide support for the victim and family during and after interventions.

It is important to note that nursing care for factitious disorder imposed on another is highly complex and requires a multidisciplinary approach. The primary goal is to protect the victim from harm and provide appropriate care while addressing the underlying psychological factors contributing to the caregiver’s behavior.

(Zaky, 2015)


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