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Factitious Disorder in Children and Adolescents: A Retrospective Study

Received October 1, 2006; revised January 21, 2007; accepted January 29, 2007. From Charité–Universitätsmedizin Berlin, Dept. of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy. Send correspondence and reprint requests to Stefan Ehrlich, M.D., Charité–Universitätsmedizin Berlin, Campus Virchow-Klinikum, Klinik für Psychiatrie, Psychosomatik, und Psychotherapie des Kindes und Jugendalters, Augustenburger Platz 1, D-13353 Berlin, Germany. e-mail: stefan.ehrlich{at}charite.de
© 2008 The Academy of Psychosomatic Medicine

ABSTRACT

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BACKGROUND: Factitious disorder (FD) presumably manifests at an early age, but epidemiological and clinical data about pediatric FD are still lacking. OBJECTIVE: The authors sought to study prevalence data of FD among referrals to a child-and-adolescent consultation–liaison service (CLS). METHOD: Authors conducted a retrospective survey of FD on 1,684 patients who were referred to the CLS from 1992 to 2003 (Sample I) and 12,081 patients who were treated in a tertiary-care child health center from 2003 to 2005 (Sample II). RESULTS: In Sample I, FD occurred in 0.7% and, in Sample II, in 0.03% of the cases. CONCLUSION: The prevalence of pediatric FD among referrals to a CLS is similar to those found in studies of adults, and patients share many clinical characteristics.

INTRODUCTION

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In factitious disorder (FD), patients either intentionally produce or feign signs of medical or psychological disorders, or they misrepresent their histories. The motivation to assume the patient role, rather than to obtain an external reward, distinguishes FD from malingering. Malingering and FD both differ from somatoform disorders (e.g., somatization disorder, hypochondriasis, persistent somatoform pain disorder) and dissociative/conversion disorders in that the former are marked by active dissimulation, whereas the latter are prompted by unconscious conflicts and symptoms that are not intentionally produced.¹ In both diagnostic systems, ICD–10 and DSM–IV, the criteria for FD are nearly identical. Also, the DSM–IV emphasizes that the motivation for the behavior is to assume the patient role.^2,3 In contrast to deliberate self-harm, FD is indirect and is not acted-out overtly.⁴ Early and accurate diagnosis of FD protects the patient and may prevent costly and potentially harmful diagnostic and therapeutic procedures.⁵

Factitious illness may have a broad spectrum of presentations. In its milder forms, there may be only an exaggeration of physical symptoms. The most extreme and dramatic form is called Munchausen syndrome, first described by Asher.⁶ In 1951, she wrote:

Here is described a common syndrome, which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always traveled widely ("hospital hoppers"), and their stories, like those attributed to him, are both dramatic and untruthful.⁶

Patients with this syndrome create a complex disease picture, usually with a lengthy history, and visit many doctors and hospitals, undergo multiple dangerous procedures, but often leave suddenly and angrily.⁵

In the pediatrics literature, much attention has been paid to Munchausen syndrome by proxy. In Munchausen syndrome by proxy (MSBP), a perpetrator deliberately feigns or induces illness in a child for the purpose of fulfilling his own psychological needs. It must be differentiated from pediatric-condition falsification, which is done to effect some secondary gain. Both conditions represent severe forms of child abuse.⁷ However, there is considerably less awareness that medical and psychological symptoms can also be intentionally feigned or falsified by pediatric patients, themselves.

Precise prevalence data on FD are lacking in both the adult and pediatric literature. Patients simulating or feigning disease tend to be secretive and elusive. The histories those patients give are quite unreliable, and they often sign out against medical advice when they are about to be uncovered. Obtaining reliable data for research and prevalence studies has therefore been almost impossible.

Two studies in adult inpatients attempted to investigate the incidence of FD in a general-hospital setting.^8,9 In the first study, conducted by Sutherland and Rodin, 0.8% of 1,361 patients referred over a 3-year period to a consultation–liaison service (CLS) for psychiatric evaluation in Canada were diagnosed with FD. The second study found a similar incidence, 0.62%, over an 18-year period, using data from 15,000 patients evaluated by a psychiatric consultation service in a German teaching hospital.

Further investigations have come from several subspecialties: At the National Institute of Allergy and Infectious Diseases, the study of 343 patients with prolonged fever of unknown origin found 9% of the cases to have factitious fever and self-induced infections;¹⁰ however, other authors reported lower prevalence rates (2.2% and 3.5%).^11,12 FDs appearing as neurological syndromes were investigated in a Department of Neurology, yielding a prevalence rate of 0.3%,¹³ and in a Department of Neurosurgery, yielding a prevalence rate of 0.003%.¹⁴ Pope et al.¹⁵ identified a cohort of 9 patients (4.1%) with factitious psychotic symptoms from among 219 patients consecutively admitted to a research ward for psychotic disorders,¹⁵ but Bhugra found only 0.5% with factitious psychiatric disorder in a psychiatric hospital.¹⁶ Results of these studies showed that women outnumber men in non-Munchausen types of FD, whereas more adult men than women present with Munchausen syndrome. FD with physical signs and symptoms was more frequent than FD with solely psychological symptoms. The overall prevalence rate of FD in adults treated in hospitals and independent practice was estimated to be 1.3%.¹⁷

Although FD often begins at an early age,^8,18 to this date, only case studies and one extensive review on the population of children and adolescents have been published.¹⁹ The aim of this study was both to determine the prevalence of FD in pediatric patients referred to a Child and Adolescent Psychiatry CLS, and to determine clinical and psychological characteristics of pediatric FD.

METHOD

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This study was approved by the hospital’s Institutional Review Board.

Two retrospective surveys of FD were conducted on 6- to 18-year-old patients in a large, multidisciplinary tertiary-care child health center that held approximately 265 beds.

Sample I: Referrals to the CLS
Sample I consisted of 1,684 patients who were referred to a Child and Adolescent Psychiatry CLS from 1992 to 2003. The CLS is part of the Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, which consists of two inpatient units, a daytime clinic, and an interdisciplinary outpatient clinic. Information regarding these patients was obtained from comprehensive database forms that are completed routinely on all patients referred to our department. These forms were completed by Child and Adolescent Psychiatry residents and psychologists after the cases had been reviewed by the attending-physician staff. They have been entered into an electronic database and contain information regarding demographics, patient and family history, psychopathology, somatic and psychiatric diagnoses following ICD–10 criteria, and treatment.²⁰ To increase the sensitivity in this study, we also included six subjects in whom FD was only suspected at the time of treatment. In all identified cases, all available full-length, paper-based hospital charts from all departments of the university hospital were reviewed in order to confirm the diagnosis of FD according to ICD–10 criteria and to retrieve longitudinal information regarding the disease course. Patients were included if their physical and psychological signs or symptoms were judged to be intentionally produced, and their motivation was to assume the "sick role." If external incentives were present or medical records revealed a plausible medical explanation for the symptoms, patients were excluded. Also, a clinically experienced second rater, blind to the results of the original analysis, independently reviewed all medical records. Intensive chart review gave enough evidence to confirm a diagnosis of FD in all cases but one, in which a diagnosis of FD was originally established or suspected by the consulting physician. Interrater reliability, expressed as specific agreement, was 0.92.²¹ The ICD–10 research-criteria study²² found an interrater agreement of only 54% for the diagnosis FD.

Sample II: All Pediatric Patients
Sample II consisted of 12,081 patients, who were treated in any of the inpatient units of the tertiary-care child health center. Information on these patients was retrieved from a center-wide database containing only basic variables such as age, gender, and diagnosis.

We also investigated (with SPSS 11.0) the frequencies of other diagnoses and diagnostic groups in the above-described patient populations. The SPSS Syntax program allowed for several diagnoses for each patient, but prevalence was calculated on the basis of number of patients.

RESULTS

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Using our electronic database, in Sample I, we identified 15 patients who had received a diagnosis of FD. Full-length, paper-based hospital charts from all departments of the university hospital were available in 13 cases. After extensive chart review, the case of a 15-year-old girl showing signs of overt self-harm, but no signs of FD, was excluded. Thus, our final sample consisted of 12 patients with FD resulting in a prevalence of 0.71% among all referrals. However, one of the patients was originally referred to our department by a judge. Table 1 shows the frequency of FD as compared with the frequencies of all other psychiatric disorders in Sample I. Somatoform disorders (14.7%) and dissociative disorders (6.2%) were much more prevalent than FD. "Reaction to severe stress/adjustment disorders" (19.7%) was the most common diagnostic category.

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TABLE 1. Frequencies of Diagnosis Among Patients Referred to the Consultation–Liaison Service (Sample I)

For the time period 2003–2005, diagnostic data on all inpatients age 6 to 18 who were admitted to the tertiary-care child health center were available (Sample II). Only 4 of 12,081 patients (0.03%) received the diagnosis of FD, but 0.89% of all patients were diagnosed with somatoform disorders, and 0.10% with dissociative disorders.

In the following presentation, we will consider the clinical and psychological characteristics of the patients with FD in Sample I: 9 of the 12 identified patients were girls, and only 1 of them was younger than 14 years (Table 2). The mean hospitalization rate was 6.6, and the duration of the falsifications varied between 0.5 and 9 years. Some of the patients presented with several symptoms (Table 3), but the most frequently produced symptoms pertained to the skin (33%; exanthema, eczema, edema). In summary, 8 patients (66%) primarily falsified illness through simulation (i.e., false reporting of symptoms, contaminating lab samples) whereas only 4 youths (33%) produced symptoms (that is, any action that affects the patient’s body). Four patients (Patients #5, #6, #8, #10) continued to visit numerous hospitals, thus fulfilling the criteria for the more severe form of FD: Munchausen syndrome.^5,6

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TABLE 2. Demographic and Clinical Characteristics of Patients With Pediatric Factitious Disorder Referred to Child and Adolescent Psychiatry Consultation–Liaison Service (Sample I)

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TABLE 3. List of Patients With Pediatric Factitious Disorder Referred to Child and Adolescent Psychiatry Consultation–Liaison Service (Sample I)

Comorbid ICD–10 Axis I disorders were found in five patients. Diagnoses included attention-deficit hyperactivity disorder (Patient #7), anxiety and depressive disorder (Patient #5), and anorexia nervosa (Patient #9). However, incipient personality disorder (Patients #4, #6, #9) was the most frequent diagnosis. IQ was mostly average (eight patients), but three patients (#1, #10, #11) were measured or clinically judged to have below-average IQ (<85). In addition to FD, overtly acted-out self-harm was found in five patients, and three patients had a history of suicide attempt.

Half of the patients had witnessed severe somatic illness within their immediate family, and more than one-third had personally experienced severe or chronic illness. Psychiatric illness in 1st- or 2nd-degree relatives was found in 42% of the cases. In each of those cases, alcohol abuse or dependence was reported. However, histories on biological parents were incomplete (N=9) because of the high rate of adoption and foster care. In addition to foster care and adoption (50% of the patients), suspected or confirmed sexual or physical child abuse was very common (42%). Previous MBPS was suspected in two cases (Patients #7 and #11).

Because of the feigned or produced symptoms, five patients received unnecessary radiological workup, and six patients underwent invasive procedures such as skin biopsies (N=3) and surgery (e.g., diagnostic laparoscopy, adenectomy, appendectomy, and arytenoidectomy). Radiological work-up, in most patients, consisted of several x-rays, and two patients received scintigraphies and CAT scans. Four patients were also treated unnecessarily with systemic medications for their factitious symptoms. Prescribed drugs included sex steroids, glucocorticoids, heparin, antibiotics, and anticonvulsants.

A striking 75% of the patients admitted to their manipulations when confronted. Patients who either admitted to their manipulations or did not were not significantly different regarding age. Only two patients rejected psychotherapy (Patients #3 and #10), whereas eight patients underwent voluntary inpatient psychiatric treatment (Table 2).

Follow-up was available for seven patients (58%) because they returned to the hospital. Time until follow-up ranged between 1 and 8 years (mean: 2.3; standard deviation [SD]: 2.8 years). Three patients, one of whom underwent a short course of outpatient psychotherapy (Patient #8), one of whom had completed inpatient Child and Adolescent Psychiatry (CAP) treatment (Patient #11), and one of whom had eloped from involuntary inpatient CAP treatment (Patient #10); presented to other departments of the hospital with similar symptoms. Hence, 3 of 7 patients obviously resumed their factitious behavior. Three patients received a second or third course of psychiatric inpatient treatment; one, because of several suicide attempts (Patient #5), one because of deteriorating anorexia nervosa (Patient #5), and one because of polytoxicomania (Patient #1). Only one of the patients for whom follow-up was available seemed to improve (Patient #4). She kept regular appointments at the metabolic outpatient clinic, and laboratory results indicated an acceptable compliance with her phenylketonuria management.

DISCUSSION

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To our knowledge, this is the first systematic survey investigating FD in pediatric patients referred to a Child and Adolescent Psychiatry consultation–liaison service and among inpatients in a large multidisciplinary tertiary-care child health center. Among 1,684 patients who were referred to a Child and Adolescent Psychiatry CLS over a 12-year period, 0.7% were correctly diagnosed with FD. Thus, the prevalence of FD in pediatric patients seems to be only slightly lower than the prevalence among adult patients seen in the frame of psychiatric CLS. The prevalence of FD among all patients age 6–18 who reported to the tertiary-care child health center between 2003 and 2005 was much lower (0.03%). Somatoform disorders and dissociative disorders were much more common among children and adolescents in both samples. Nonetheless, the true prevalence of FD in children and adolescents is almost impossible to estimate. In the first place, data on the prevalence in the general population are still lacking. Furthermore, not only the overlap of FD with deliberate self-harm, but also the possibility of MBPS in pediatric patients renders the diagnosis delicate for the clinician. Finally, the clinician might be more inclined to diagnose illness falsification as somatization to avoid unpleasant confrontations.

Although it may be upsetting to suspect a patient of violation of the basic patient–doctor contract, which is based on mutual trust, it seems necessary to maintain an index of suspicion for factitious causes of medical and psychiatric diagnoses, even in children and adolescents. A high proportion of patients in this study either received unnecessary medication or underwent radiological work-up and invasive procedures. Similar to the findings by Libow,¹⁹ on average, more than 2 years went by before the deceptions were discovered. In order to avoid iatrogenic harm, an interdisciplinary effort by a treatment team is necessary to uncover factitious components of illness.

Similar to adults and in line with the existing case studies in children and adolescents,¹⁹ the vast majority of pediatric patients with FD were girls (75%); but Munchausen syndrome was also more prevalent in girls (3:1). Most patients (67%) falsified illness through simulation or by describing a fictitious history and symptomatology (Pseudologia fantastica). This form of FD is considered to constitute a milder form, as compared with the fabrication of verifiable abnormalities.²³ Somewhat surprising is the lack of factitious fever due to thermometer manipulation in our study. However, studies focusing on fever of unknown origin might lead to a skewed conclusion about the frequency of this condition.¹⁰

Previous reports on adult patients suggest that patients with FD often have backgrounds in medically-related fields or caring professions.^8,9 In this study, only one patient was enrolled in a nurse apprenticeship. However, for the rest of the children and youth, the high rate of early experience with illness or with a close relative’s serious illness may have constituted a risk factor.

In addition to the review of available case studies of FD in pediatric patients, in this study we also investigated psychiatric comorbidity and biographical and familial risk factors. Just as in adult patients with FD,^5,9 a high proportion of our patients suffered from comorbid psychiatric illness, especially, incipient personality disorder, additional overtly acted-out self-harm, and suicidality. The frequent overlap between overtly acted-out self-harm and FD is consistent with several reports by other authors.⁴ Kapfhammer et al.⁸ also found a high incidence of traumatic events, for instance, placement in a foster home, physical and sexual abuse, early losses, and neglect in the biography of adult patients with FD. This coincides with our results, which show that 42% of the patients were likely to be victims of child abuse, and 50% lived in foster care or with adoptive parents. A positive family history of psychiatric illness, especially alcoholism, seems to constitute an additional risk factor.

In some cases, FD is likely to be transmitted from parents to their children. Noeker²⁴ differentiates two different pathways: 1) parents can train children to fabricate symptoms or support a child’s manipulations;²⁵ or 2) children who falsify illness might have been victims of MSBP in the past.²⁶ In our study, we found signs of a history of MSBP in two cases: one patient’s brother reportedly died of sudden infant death syndrome, which may in fact represent manifestations of MSBP.²⁷ In at least one case, the mother had substantially facilitated her daughter’s fabrications. Thus, abusive parents may serve as role models, teaching their offspring to produce symptoms on their own.

The literature is divided as to the treatment of FD. Some authors recommend confrontation by the primary physician and the consulting psychiatrist after the diagnosis is secured. In one study, only 1 of 10 confronted adult patients acknowledged self-inducing symptoms, and only 2 accepted ongoing psychiatric treatment.⁹ However, Libow reported that only 5 of 23 pediatric patients described in case studies denied their intentional falsifications when confronted.¹⁹ Our survey strongly supports these findings in children and adolescents, although we were unable to confirm that pediatric patients who admit to their deeds are significantly younger than those who do not. The mean age of the patients in our study (15.99 [2.06]) did not significantly differ from those described in the other case studies. As opposed to adults,⁹ an astonishingly high proportion of the patients in our study (75%) underwent inpatient psychiatric treatment. All but one of these patients did so on a voluntary basis. However, particularly in the case of children, where the questionable involvement of parental figures is a concern, legal interventions to ensure patient safety and treatment may be required. Conclusive empirical data on the treatment of FD is still lacking, but a nonconfrontational approach, which improves patient compliance, is currently widely accepted.²⁸ These strategies include use of inexact interpretations of psychological defenses, therapeutic use of a double bind, and use of techniques that allow the patient to give up the factitious symptoms without losing face.²⁹ Limit-setting for the protection of both the physician and patient and close supervision are essential in the management of patients who falsify illness. The goal is not to invalidate the patient’s symptoms but, rather, to create a rapport and allow psychiatric follow-up to take place.

Longitudinal data on FD are scarce in the adult literature and anecdotal in children and adolescents. Professional confidentiality usually makes it difficult to obtain information from other hospitals without the patient’s consent. Even within the same institution, the procedural difficulties around recovering previous reports on a patient can present an obstacle to prompt diagnosis of FD. In this study, we retrieved follow-up data on more than half of the patients. These data demonstrated that even young patients often have a chronic course of disease or at least require repeated psychiatric inpatient treatment. However, the retrospective nature of this study might skew our data, since patients with a chronic disease course are more prone to seek out medical attention. Thus, according to the hospital charts, only one subject had an effective outcome. It remains an open question whether the frequent personal contact of this patient with the same caring physician at the metabolic outpatient clinic contributed to this success.

Limitations
The findings of this retrospective study should be considered in light of the following limitations: First, as described above, FD is rarely recognized, and, with the current criteria and the lack of appropriate testing instruments, the diagnosis is difficult. Unfortunately, because full-length medical records were missing, two cases had to be excluded. Second, the structure of our multidisciplinary tertiary-care child health center changed over time, and the number of consultation–liaison patients increased as a result of improved resources. Third, there is also the possibility that the pediatricians did not consult CLS even when FD was suspected or when patients left the hospital before psychiatric evaluation could be performed. Therefore, the actual incidence of FD in children and adolescents is likely to be higher than estimated in this study. Fourth, depending on developmental stage, some children may feign illness rather than overtly harming themselves. Finally, since follow-up was not carried out prospectively, the proportion of FD in pediatric patients with a favorable long-term outcome is difficult to estimate.

Implications
Although the true prevalence of pediatric FD can only be estimated, our study shows that the prevalence of FD in patients referred to psychiatric consultation–liaison services is only slightly lower in pediatric patients than in adults. Pediatric and adult patients with FD share many of the same clinical characteristics. They are usually girls/women; they suffer from multiple psychiatric comorbidities; they have been acquainted with somatic illness; and they have had to put up with multiple familial and biographical risk factors. Iatrogenic harm is a common consequence. In contrast to adult FD,^8,9 feigning seems to be more frequent than the actual fabrication of symptoms. The most apparent difference is that children and adolescents are more inclined to admit to their fabrications and accept psychotherapy. Hence, physicians should always include FD in their differential diagnosis when confronted with unexplainable symptoms or implausible histories. In this manner, counterproductive and costly referrals, with risk of invasive procedures, can be prevented. Beyond conventional medical testing, an interdisciplinary effort by a treatment team is necessary to use the opportunity for early psychiatric treatment.

ACKNOWLEDGMENTS

 
We thank Mary Traester and Matthew Weston for assistance with manuscript preparation.

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Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Ehrlich, S. Articles by Lehmkuhl, U. Search for Related Content PubMed Citation Articles by Ehrlich, S. Articles by Lehmkuhl, U. Child/Adolescent Psychiatry Miscellaneous Childhood Disorders

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