Factitious Disorders in Everyday Clinical Practice

The pathological feigning of disease can be seen in all medical disciplines. It is associated with variegated symptom presentations, self-inflicted injuries, forced but unnecessary interventions, unusual and protracted recoveries, and frequent changes of treating physician. Factitious illness is often difficult to distinguish from functional or dissociative disorders on the one hand, and from malingering on the other. Many cases, even fatal ones, probably go unrecognized. The suspicion that a patient's problem may be, at least in part, factitious is subject to a strong taboo and generally rests on supportive rather than conclusive evidence. The danger of misdiagnosis and inappropriate treatment is high.

On the basis of a selective review of current literature, we summarize the phenomenology of factitious disorders and present concrete strategies for dealing with suspected factitious disorders.

Through the early recognition and assessment of clues and warning signs, the clinician will be able to judge whether a factitious disorder should be considered as a differential diagnosis, as a comorbid disturbance, or as the suspected main diagnosis. A stepwise, supportive confrontation of the patient with the facts, in which continued therapeutic contact is offered and no proofs or confessions are demanded, can help the patient set aside the sick role in favor of more functional objectives, while still saving face. In contrast, a tough confrontation without empathy may provoke even more elaborate manipulations or precipitate the abrupt discontinuation of care-seeking.

Even in the absence of systematic studies, which will probably remain difficult to carry out, it is clearly the case that feigned, falsified, and induced disorders are underappreciated and potentially dangerous differential diagnoses. If the entire treating team successfully maintains an alert, transparent, empathic, and coping-oriented therapeutic approach, the patient will, in the best case, be able to shed the pretense of disease. Above all, the timely recognition of the nature of the problem by the treating team can prevent further iatrogenic harm.