Similar to my previous post on the role of civil commitment and catatonia, I’d like to share my thoughts on what little is known about Factitious Disorder and civil commitment.

There is not much to say, in brief. In fact, many writers can find a lot to say about the other interesting clinical features of Factitious Disorder. That includes me. I wrote the chapter on factitious disorder and malingering in the book I and my former University of Iowa psychiatry department chairperson, Robert G. Robinson, co-edited (Amos, 2010).

The gist of the definition of this disorder is that patients lie about medical or psychiatric symptoms to health care providers to adopt the sick role presumably because they crave attention, especially from doctors. It is distinguished from malingering by not defining malingering as a disorder and identifying external incentives as the major reason to fake medical or psychiatric illness, e.g., escaping penalties or obligations such as incarceration or military service, or obtaining entitlements.

In the DSM-5 it was placed in the Somatic Symptom Disorder Category:

• Factitious Disorder Imposed on Self
  • A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, assoc. w/identified deception
  • B. Presenting oneself to others as ill, impaired, injured
  • C. Deceptive behavior evident even in absence of obvious external rewards
  • D. Not better accounted for by another mental d/o like delusional d/o or other psychosis

It can be further specified into single or recurrent episodes. There is also another category, Factitious disorder imposed on another (by proxy in DSM-IV).

Regarding civil commitment, obtaining an order can sometimes be difficult when the standard in a jurisdiction is imminent danger to self, or when judges require a treatment plan for a disorder for which there is little evidence of consistently effective treatment— (Eastwood, S. and J.I. Bisson, Management of Factitious Disorders: A Systematic Review. Psychotherapy and Psychosomatics, 2008. 77(4): p. 209-218.)

The legal climate is further complicated by patients with the disorder who have filed malpractice lawsuits against the doctors who failed to recognized their factitious behavior. Patients have been sued for false claims to insurance companies.

A recently published case report (which makes up the majority of papers published about the disorder) mentions the Eastwood and Bisson review (see above), which indicated that 60% of these patients either refused or failed to appear for psychiatric follow-up. Civil commitment is limited to those with imminent suicide risk, clear evidence of danger to others, or inability to provide for basic self-care needs (Sinha A, Smolik T. Striving to Die: Medical, Legal, and Ethical Dilemmas Behind Factitious Disorder. Cureus. 2021 Feb 9;13(2): e13243. doi: 10.7759/cureus.13243. PMID: 33585147; PMCID: PMC7872498.)

Patients with factitious disorder can self-induce illness in ways that result in severe disfigurement or death, often from unnecessary medical interventions. And they have successfully sued physicians who unwittingly caused iatrogenic harm for failing to recognize their disorder—despite denying the true nature of their feigned illnesses in the first place early on. The cost of their excessive health utilization has been estimated to run in the millions of dollars. Their subterfuge can also result in the physician ignoring genuine disease.

General management principles involved include:

• Assess severity, potential for imminent life or limb threat
• Thoroughly document evidence
• Involve hospital administration/attorneys/ethicists early
• Psychiatric consultation early
• Treat depression, psychosis, addiction
• Confrontational v. nonconfrontational approaches

One published case report described obtaining a commitment order based on the patient’s demonstrated dangerousness from self-induced illness (Johnson, 2000). Another case report described “house arrest” as the intervention (Elmore, 2005). Yet another report discussed an interesting non-coercive “Hospital Management” approach which used “paradoxical free access to the hospital with a designated permanent bed on a medical ward for 1 year—which was apparently successful (Schwarz, 1993). The list of successfully treated patients under court order is short and the likelihood of sustained recovery is probably low.

The civil commitment approach is confrontational and there are proponents for a nonconfrontational approach because it’s difficult to get a court order for involuntary psychiatric hospitalization and often, once a patient with Factitious Disorder is admitted to a locked psychiatric ward, the self-induced illness behavior often simply stops. And there are supporters for the development of a “therapeutic discharge” plan in which hospital administration and clinical staff collaborate to conduct a safe discharge:

• Consider involving hospital administration and all health care personnel in a therapeutic discharge plan if it can be done safely
  • Taylor, J. B., S. R. Beach and N. Kontos (2017). “The therapeutic discharge: An approach to dealing with deceptive patients.” Gen Hosp Psychiatry 46: 74-78.
  • Kontos, N., J. B. Taylor and S. R. Beach (2018). “The therapeutic discharge II: An approach to documentation in the setting of feigned suicidal ideation.” Gen Hosp Psychiatry 51: 30-35.
  • Beach, S. R., et al. (2017). “Teaching Psychiatric Trainees to “Think Dirty”: Uncovering Hidden Motivations and Deception.” Psychosomatics 58(5): 474-482.

References

Amos, J. (2010). Managing factitious disorder and malingering. In E. b. Robinson, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry (pp. 82-88). New York: Cambridge University Press.

Elmore, J. L. (2005). Munchausen Syndrome: An Endless Search for Self, Managed by House Arrest and Mandated Treatment. Annals of Emergency Medicine, 561-563.

Johnson, B. R. (2000). Suspected Munchausen’s Syndrome and Civil Commitment. J Am Acad Psychiatry Law, 74-76.

Schwarz, K. M., et al (1993). Hospital Management of a Patient With Intractable Factitious Disorder. Psychosomatics, 265.