CASE SERIES

W.W. IsHak , T. Saah, E. Rasyidi, M. Vasa, A. Ettekal, A. Fan

Primary Psychiatry. 2010;17(9):40-43

Factitious Disorder Case Series with Variations

of Psychological and Physical Symptoms
Waguih William IsHak, MD, Ernest Rasyidi, MD, Tammy Saah, MD, Monisha Vasa, MD, Amir
Ettekal, MD, and Alexander Fan, MD

ABSTRACT
FOCUS POINTS
In the clinical setting, factitious disorder is often mistaken for malin-
• Factitious disorder is the intentional production of symptoms
gering or somatoform disorders. Three cases of factitious disorder to assume the sick role in the absence of secondary gain.
with physical, psychological, and combined symptoms are reported. • Factitious disorder could present with physical, psychologi-
cal, or combined symptoms.
Comparing these patients may help facilitate identification of factitious
• Factitious disorders are commonly misdiagnosed with
disorder, especially with improving recognition in patients who are high medical conditions, somatoform disorders, or malingering.
utilizers of acute medical and psychiatric services. A high level of suspi- • Medical records from previous hospitalizations and health-
cion regarding the diagnosis of factitious disorder is needed, especially care providers are essential.
in cases with frequent utilizers of emergency room and inpatient ser- • Factitious disorder needs to be suspected in frequent acute care
utilizers with atypical presentations and negative results.
vices, atypical presentations, and negative diagnostic results.

INTRODUCTION tions in factitious disorders that contribute to the difficulty

The Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition-Text Revision,1 refined the diagnosis for fac-
titious disorder by providing three diagnostic criteria (Table
1).2 Studies indicate a .5% to .8% prevalence of factitious dis-
orders in hospital patients, with a prevalence of up to 6% to
8% on psychiatric units.2-5 However, patients with factitious
disorders are commonly misdiagnosed with medical condi-
tions, somatoform disorders, or malingering. Due to diagnos-
tic difficulties, only the most severe cases of factitious disorder
are diagnosed correctly. In other cases, factitious disorder may
be suspected but not diagnosed. The following three cases of
factitious disorder with disparate presentations are based on
the subtypes described in the DSM-IV-TR (Table 2).1 Patient
A presented with mainly physical symptoms. Patient B pre-
sented with physical and psychological symptoms. Patient C
presented with mainly psychological symptoms. The patients
presented depict the wide spectrum of severity and presenta-
of accurate diagnosis. The management of these cases also
demonstrates the diagnostic strategy needed for improving
diagnosis of factitious disorder.
FACTITIOUS DISORDER CASE REPORTS
Patient A: Factitious Disorder with
Predominantly Physical Signs and Symptoms
Patient A, a 27-year-old female, would often present to the
emergency department with vague complaints of abdominal
pain and bright red blood per rectum, which she stated was
typical for her Crohn’s disease. The patient also freely reported
a psychiatric history with multiple diagnoses, including bipolar
disorder, posttraumatic stress disorder (PTSD), obsessive-com-
pulsive disorder (OCD), panic disorder, a history of anorexia

Dr. IsHak is Director of Psychiatry Residency Training and Medical Student Education in Psychiatry at Cedars-Sinai Medical Center (CSMC) and Associate Clinical Professor of Psychiatry at the University of
California, Los Angeles (UCLA), the University of Southern California, and CSMC, all in Los Angeles, California. Dr. Rasyidi is the CSMC Psychiatry Chief Resident. Dr. Saah is former research physician volunteer
at CSMC and current psychiatry resident at Emory University in Atlanta, Georgia. Dr. Vasa is on medical staff at CSMC. Dr. Ettekal is Research Psychiatrist at California Clinical Trials in Glendale, California. Dr.
Fan is Associate Director of Inpatient Psychiatry at CSMC and Assistant Clinical Professor of Psychiatry at UCLA and CSMC.
Disclosures: Dr. IsHak receives grant support from the National Alliance for Research on Schizophrenia and Depression and Pfizer. Drs. Saah, Rasyidi, Vasa, Ettekal, and Fan report no affiliation with or financial
interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Waguih William IsHak, MD, FAPA, Cedars-Sinai Medical Center, Department of Psychiatry and Behavioral Neurosciences, 8730 Alden Dr, Thalians W-157, Los Angeles, CA
90048; Tel: 310-423-3515; Fax: 310-423-3947; E-mail: Waguih.IsHak@cshs.org.

Primary Psychiatry 40 © MBL Communications Inc. September 2010

 Factitious Disorder Case Series with Variations of Psychological and Physical Symptoms
nervosa, and Asperger’s syndrome, as well as a history of sui-
cide attempts and self-injurious behaviors. The patient had
a stable income through state disability and lived in a com-
fortable home with her parents in an affluent neighborhood.
Psychiatric consultation was requested on her third admission
to the medical center and after 13 previous presentations to
the emergency department. At that point she had undergone
extensive diagnostic testing, including computed tomography
scans, upper gastrointestinal (GI) endoscopy with small bowel
follow through, colonoscopy, and biopsies, all of which had
been unsuccessful in finding the cause of GI bleeding. She was
transferred to the inpatient psychiatric hospital for complaints
of depressed mood and her diagnosis was refined to PTSD
and borderline personality disorder. During hospitalization, a
nurse found the patient in the bathroom one night inserting a
toothbrush into her rectum, producing the bloody stools that
she had been complaining of for the past several days. When
confronted, the patient articulated that she desired the atten-
tion that came with her medical work-ups and that it instilled
a sense of control over her environment. This behavior was
different from previous suicide attempts in that there was no
intent to die. It was also distinct from her self-injurious behav-
iors which were performed openly and freely admitted to. As
for the discrepancy between reported psychiatric diagnoses and
those at time of discharge, this was due to diagnostic errors on
the part of previous treatment teams, not due to misrepresenta-
tion by the patient. The patient thus met criteria for factitious
disorder with predominantly physical symptoms.
Patient B: Factitious Disorder with Combined
Psychological and Physical Signs and Symptoms
Patient B, a 52-year-old female with bipolar depression,
was admitted to the inpatient unit for the fifth time in 6
months after presenting with suicidality and depressed mood.
The patient stated that she had been diagnosed with OCD,
PTSD, and attention-deficit/hyperactivity disorder. She also
stated that she was blind and had a guide dog. During hospi-
talization, she consistently reported that her depression and
suicidality were worsening. However, observations showed
TABLE 1
DSM-IV-TR DIAGNOSTIC CRITERIA FOR FACTITIOUS DISORDER1
A. Intentional production or feigning of physical or psychological signs or
symptoms.
B. The motivation for the behavior is to assume the sick role.
C. Absence of external incentives for the behavior (such as economic gain,
avoiding legal responsibility, or improving physical well-being, as in
malingering).
DSM-IV-TR=Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision.
IsHak WW, Rasyidi E, Saah T, et al. Primary Psychiatry. Vol 17, No 9. 2010.
Primary Psychiatry
that the patient joked, laughed, and regaled others with far-
fetched stories. She ate and slept well, and ambulated without
difficulty. It also became increasingly obvious that Patient
B was not blind. She was observed reading, looking in the
mirror, and dialing numbers from her phone book. In daily
sessions, inconsistencies were noted in her elaborate recol-
lections of traumas. The management plan consisted of per-
forming a diagnostic work-up including medical, neurologic,
and neuropsychological evaluations, in addition to a trial of
citalopram 40 mg PO and lamotrigine 200 mg PO, both at
bedtime, as well as psychotherapy. Ophthalmology and neu-
rology consults did not reveal any visual loss. The psychologi-
cal and neuropsychological testing confirmed suspicions about
the presence of significant antisocial, narcissistic, and border-
line personality traits, and showed intact neuro-cognitive
functioning. Additional information confirmed the patient’s
tendency to move from hospital to hospital, leave against
medical advice, and express inconsistent medical and psychi-
atric complaints, which gave evidence to the diagnosis of a
factitious disorder. The most important two differential diag-
noses were conversion disorder and malingering. Conversion
disorder was ruled out because the patient was shown to have
intact vision on medical consultations. Regarding malinger-
ing, there were no specific secondary gains as she had a stable
housing and financial situation. It became clear that Patient
B was intentionally producing both physical (blindness) and
psychological (worsening of depression) symptoms in order
to assume the sick role. She was informed of the diagnostic
possibility of factitious disorder with combined psychological
and physical signs and symptoms, and was recommended for
continuation of both psychotherapy and pharmacotherapy.
TABLE 2
DSM-IV-TR TYPES OF FACTITIOUS DISORDER1
Type Description
Factitious disorder with pre- If psychological signs and symptoms pre-
dominantly psychological signs dominate in the clinical presentation.
and symptoms
Factitious disorder with pre- If physical signs and symptoms predomi-
dominantly physical signs and nate in the clinical presentation.
symptoms
Factitious disorder with com- If both psychological and physical signs
bined psychological and physi- and symptoms are present but neither
cal signs and symptoms predominates in the clinical presentation.
Authors’ Note: The DSM-5 taskforce has recommended, in 2010, an additional
subtype entitled: Factitious disorder imposed on another (previously, factitious
disorder by proxy was published in Appendix B of the DSM-IV-TR1 as a proposed
disorder for further study). Publication of the DSM-5 is expected in 2013.
DSM-IV-TR=Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision.
DSM-5=Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
IsHak WW, Rasyidi E, Saah T, et al. Primary Psychiatry. Vol 17, No 9. 2010.
41 © MBL Communications Inc. September 2010
 W.W. IsHak , T. Saah, E. Rasyidi, M. Vasa, A. Ettekal, A. Fan
Patient C: Factitious Disorder with Predominantly
Psychological Signs and Symptoms
Patient C, a 38-year-old male, presented complaining of a
3–4-month history of depressed mood, poor energy, difficulty
sleeping, poor appetite, psychomotor retardation, increasing
hopelessness, and suicidal ideation with a plan to walk into
traffic. Once on the inpatient wards, the patient remained
compliant with his medications; however, no change in mood
was seen. Throughout his stay, Patient C demonstrated, on a
consistent basis, a discrepancy between what he stated to staff
and what was observed on the wards. The patient consistently
reported depressed mood and suicidality, but was observed to
be euthymic, in good spirits, and carousing with the other
patients. The patient’s stay was also significant for two suicide
attempts both with low lethality and high possibility of rescue.
Elaborate stories regarding the death of his best friend, as well
as his previous married life, employment status, and relations
with his family, were for the most part later repudiated by the
patient’s father. Eventually, the patient was so disruptive to
the inpatient milieu that he was placed in seclusion. Within
a few hours he arranged to be picked up by a friend and was
successful in finding a place to stay. Before being discharged,
the patient admitted to never being suicidal and that the two
suicide attempts had both been feigned. The treatment team
noticed that the patient had traits of antisocial, narcissistic,
borderline, and histrionic personality disorders. The likeli-
hood of malingering was low because the patient had stable
income and was offered numerous housing options, which
he refused. The treatment team concluded that this patient
was willing to assume the sick role, by intentionally manifest-
ing psychological symptoms, to gain the social interaction of
being in a psychiatric unit.
DISCUSSION
Although factitious disorders have been formally recog-
nized for >30 years, diagnostic criteria have evolved signifi-
cantly since the recognition of the disorder. From the DSM-II6
through the DSM-III7 and DSM-III-R,8 factitious disorders
had no clear inclusion or exclusion criteria for diagnosis.9 The
advent of the DSM-IV10 and DSM-IV-TR11 advanced the diag-
nosis of factitious disorder by defining three diagnostic criteria:
A) intentional production of physical or psychological signs
or symptoms, B) motivation to assume the sick role, and C)
absence of external incentives or secondary gain.1,12-14 Criterion
A differentiates factitious disorder from somatoform disorders
by requiring the intentional production of signs or symptoms.
Criterion C differentiates factitious disorder from malingering
by eliminating the presence of secondary gains for the patient.15
It is also important to note that while patient cases B and
C were also clear examples of pseudologia fantastica, where
Primary Psychiatry
embellished truth and colorful fantasies are presented as fact in
order to gain the interest of the listener, this phenomenon is
neither pathognomonic nor necessary under our current nosol-
ogy for the diagnosis of factitious disorder.14
The three cases presented elucidate several effective diag-
nostic strategies. With Patient A, psychiatric consultation
led to psychiatric hospitalization and a careful review of the
medical and psychiatric history. The treating psychiatrist had
thoughtful discussions with the patient’s other doctors, which
confirmed her history of high health services, utilization, and
a lack of evidence for a medical etiology. The close observation
of the psychiatric nursing staff then caught the patient in an act
of self-injury. With Patient B, the treating psychiatrist also had
a thorough diagnostic plan, which included consultation with
the neurology, medicine, ophthalmology, and neuropsycho-
logical testing services. Nursing observations on the inpatient
psychiatric unit revealed that the patient did not have the visual
or depressive symptoms that she claimed to have. The treat-
ing psychiatrist was also able to obtain valuable medical and
psychiatric history from collateral sources to confirm a pattern
of multiple hospitalizations, inconsistent medical and psychi-
atric presentations, and hospital discharges against medical
advice. With Patient C, nursing observations also found that
the patient’s behavior on the psychiatric unit were inconsistent
with his reported symptoms. The treating psychiatrist was able
to obtain collateral history from the patient’s father, which
confirmed that the patient had falsified his symptoms and psy-
chiatric history to gain admission to the psychiatric unit.
The growing literature on factitious disorder indicates that
patients have certain common traits. Understanding these traits
may help in accurate diagnosis and management. Some studies
have found that factitious disorder patients often have work
experience in healthcare fields. They can use their medical
knowledge to deceive and confuse the treatment team in their
search for an accurate diagnosis. Factitious disorder patients
are fearful of abandonment and highly sensitive to rejection.16
They usually have comorbid Axis I and II diagnoses. They use
the hospital setting to find support, safety, and social relation-
ships that they cannot obtain otherwise. Confronted with their
falsification of history and intentional production of symptoms,
factitious disorder patients have increased risk of self-harm and
exacerbation of psychiatric disorders. They become extremely
difficult to manage as the therapeutic rapport is broken.
From the three patients presented and a review of the
literature, several recommendations to facilitate the accurate
diagnosis and proper management of factitious disorder
patients have been provided. In cases in which factitious
disorder is suspected, always ask the patient for permission
to obtain medical records from previous hospitalizations and
healthcare providers. After Patient A had been caught in the
act of producing her physical symptoms, she conceded con-
sent. However, even in situations where patients are caught
42 © MBL Communications Inc. September 2010
 Factitious Disorder Case Series with Variations of Psychological and Physical Symptoms
“red-handed,” there may be an impressive level of denial with
patients going so far as to assert that events never actually
took place. With Patients B and C, consent was obtained by
explaining to the patients that access to sufficient informa-
tion was necessary in providing appropriate treatment. Again,
there may be scenarios where patients balk at this proposal.
Refusal by the patient of a well-presented, reasonable request
should make the treating physician suspicious of a non-medi-
cal diagnosis. Similarly, the treating physician should also
ask the patient for permission to collect history from col-
lateral sources such as family members, spouses, and friends.
A refusal by the patient may indicate a fear of discovering a
falsification. In a hospital, the treating physician should ask
the nursing staff to closely monitor a patient suspected of
factitious disorder. Close observation can reveal a patient’s
surreptitious production of clinical signs. The treating physi-
cian should also seek consultations from specialists in other
fields to exclude a medical etiology for the patient’s signs
and symptoms. In a psychiatric unit, the treatment team,
including nurses and therapists, needs to be reminded to set
appropriate limits and boundaries for suspected factitious
disorder patients. These limits and boundaries may decrease
the social and psychological gains that a patient may want
from a hospitalization.
CONCLUSION
The dearth of information available on factitious disorder
and the difficulty in obtaining epidemiologic and diagnostic
information should not preclude the possibility of more
accurate diagnosis and better management. Large descriptive
and longitudinal studies with adequate diagnostic work-ups,
including medical, neurologic, neuropsychological, and per-
Primary Psychiatry
sonality testing evaluations, are needed in order to develop
a clear understanding of factitious disorders. Unfortunately,
such studies are very difficult to undertake in a patient
population that is adverse to discovery. Nonetheless, facti-
tious disorder should be considered in patients with atypical
presentations and negative diagnostic results who are high
utilizers of acute care facilities such as the emergency room
and inpatient services. PP
REFERENCES
1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American
Psychiatric Association; 2000:513-516.
2. Hamilton JC, Feldman MD, Janata JW. The A, B, C’s of factitious disorder: a 220 response to Turner.
Medscape J Med. 2009;11(1):27.
3. Catalina ML, Gómez Macias V, de Cos A. Prevalence of factitious disorder with psychological symptoms in
hospitalized patients. Actas Esp Psiquiatr. 2008;36(6):345-349.
4. Sutherland AJ, Rodin GM. Factitious disorders in a general hospital setting: clinical features and a review
of the literature. Psychosomatics. 1990;31(4):392-399.
5. Gregory RJ, Jindal S. Factitious disorder on an inpatient psychiatry ward. Am J Orthopsychiatry.
2006;76(1):31-36.
6. Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. Washington, DC: American Psychiatric
Association; 1968.
7. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric
Association; 1980.
8. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed rev. Washington, DC: American Psychiatric
Association; 1987.
9. Rogers R, Bagby RM, Rector N. Diagnostic legitimacy of factitious disorder with psychological symptoms.
Am J Psychiatry. 1989;146(10):1312-1314.
10. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric
Association; 1994.
11. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American
Psychiatric Association; 2000.
12. Krahn LE, Li H, O’Connor MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am
J Psychiatry. 2003;160(6):1163-1168.
13. Dike CC, Baranoski M, Griffith EE. Pathological lying revisited. J Am Acad Psychiatry Law. 2005;33(3):342-349.
14. Turner MA. Factitious disorders: reformulating the DSM-IV criteria. Psychosomatics. 2006;47(1):23-32.
15. Drob SL, Meehan KB, Waxman SE. Clinical and conceptual problems in the attribution of malingering in
forensic evaluations. J Am Acad Psychiatry Law. 2009;37(1):98-106.
16. Feldman MD. Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy,
Malingering, and Factitious Disorder. New York, NY: Brunner–Routledge; 2004.
43 © MBL Communications Inc. September 2010