Factitious disease: clinical lessons from case studies at Baylor University Medical Center

Abstract

Factitious disease is defined as the intentional production (or feigning) of disease in oneself to relieve emotional distress by assuming the role of a sick person. Although the self-induction of disease is a conscious act, the underlying motivation is usually unconscious. It has been estimated that 3% to 5% of physician-patient encounters involve factitious disease. This article presents 6 case studies from Baylor University Medical Center that highlight various clinical aspects of factitious disease. Patients with factitious diseases are extremely difficult to recognize because they do not appear different from patients with authentic causes of similar symptoms, because their psychiatric abnormalities are not appreciated, and because doctors and nurses have alowindex of suspicion. Since patients with factitious disease present a false medicalhistory, their physicians prescribe unnecessary procedures and therapies that may result in iatrogenic disease. In many cases, damage to these patients from doctors' actions exceeds the harm resulting from the patients' self-induced illness. The clues that should suggest factitious disease, the diagnostic roles of the clinician and a consulting psychiatrist, and the ethical conflicts that confront doctors taking care of such patients are discussed. To help keep factitious disease in clinical perspective, one of the case studies involves the antithesis of factitious disease, where a patient was mistakenly diagnosed as having psychogenic pain when in fact the symptoms were caused by an overlooked physical disease. Better knowledge of the clinical features of factitious disease might have prevented the disastrous outcome.

Figure 1

The histologic appearance of melanosis coli, showing pigment-laden macrophages between the crypts in the lamina propria. The pigment is probably lipofuscin released by damaged epithelial cells. This is highly suggestive of long-term anthraquinone use. The effect is reversible within 1 year of discontinuing anthraquinone ingestion. The pigment-laden macrophages may be present histologically even when the endoscopic appearance of mucosa is normal. Hematoxylineosin stain, ×120. Reproduced with permission from reference .

Figure 2

Proposed pathogenesis for factitious disease. Adapted from references and .

Figure 3

Mesenteric artery occlusion caused by extensive atherosclerosis. (a) The mucosal surface of a segment of jejunum showing ischemic necrosis and two small perforations. (b) Anterior external aspect of the aorta showing takeoff of patent celiac artery (top) and totally occluded superior mesenteric artery (tip of the pen), located 1 cm below the celiac artery.