May 30, 2025 • 18 mins
⚕️ FREE MSRA PODCAST – Factitious Disorder
🎧 A high-yield breakdown of this complex psychiatric condition involving intentional symptom production – perfect for exam prep and clinical awareness.
🧠 Key Learning Points
📌 Definition
• A psychiatric disorder where a person deliberately produces or fakes symptoms to adopt the sick role, without external rewards like money or drugs.
• Also called Munchausen syndrome.
📌 Causes & Risk Factors
• Childhood trauma or abuse
• Personality traits: attention-seeking, impulsivity
• Prior serious illness or surgeries
• Working in healthcare
• Family history of mental illness
💡 Mnemonic: SICK ROLE – Self-harm, Illness exaggeration, Childhood trauma, Knowledge of medicine, Recurrent admissions, Overly dramatic, Lying, External gain absent
📌 Pathophysiology
• No specific biological mechanism
• Psychological drive for attention and care
• Possible link to unmet emotional needs or past trauma
📌 Symptoms
• Recurrent hospital visits
• Vague, inconsistent medical history
• Eagerness for invasive tests
• Multiple surgical scars
• Resistance to diagnosis or rapid transfers between providers
• Dramatic behaviour or knowledge of medical terms
📌 Differential Diagnosis
• Malingering – faking illness for external gain
• Somatic symptom disorder – symptoms without intentional deception
• Illness anxiety disorder – excessive worry without feigned symptoms
📌 Diagnosis
• Primarily clinical
• Requires detailed history, psychological assessment, medical records
• Use of DSM-5: Intentional symptom fabrication, without external reward
💡 Tip: Rule out true illness first; collaborate with psychiatry
📌 Management
• Multidisciplinary: psychiatry, psychology, medical team
• Cognitive behavioural therapy (CBT)
• Treat co-existing conditions (e.g. depression with SSRIs)
• Avoid unnecessary tests, maintain boundaries
• Build therapeutic trust – challenging but essential
📌 Complications
• Iatrogenic harm from unnecessary procedures
• Self-induced injuries
• Emotional distress and isolation
• Legal issues (e.g. fraud, child harm in Munchausen by proxy)
• Missed real diagnoses due to loss of clinical trust
📌 Prognosis
• Often chronic, difficult to treat
• Poor engagement with therapy is common
• Relapse risk is high
• Best outcomes with early intervention, strong psychological support
📎 More MSRA Resources for Factitious Disorder
📝 Revision Notes: https://www.passthemsra.com/topic/factitious-disorder-revision-notes/
🧠 Flashcards: https://www.passthemsra.com/topic/factitious-disorder-flashcards/
💬 Accordion Q&A Notes: https://www.passthemsra.com/topic/factitious-disorder-accordion-qa-notes/
🚀 Rapid Quiz: https://www.passthemsra.com/topic/factitious-disorder-rapid-quiz/
🎓 Full Course: https://www.passthemsra.com/courses/psychiatry-for-the-msra/
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
OK, imagine this, someone intentionally making themselves
sick, or you know, faking symptoms, maybe even having
unnecessary surgery. Right, and not for money or
getting out of something. Exactly.
Just to be sick. It's quite a baffling kind of
behaviour. It really makes you rethink why
people usually seek medical helpdoesn't.
(00:20):
It it does. And that complex, challenging
topic, that's what we're diving into today.
We're unpacking factitious disorder.
Also known, maybe more famously,as much.
Yeah, exactly. We've got some notes here that
really lay it all out piece by piece.
Covers the whole spectrum really, from the basic
definition right through to management and what the future
(00:41):
might hold for someone with it. So our mission, as always in
these deep dives, is to break down this information, give you
the key takeaways, the high yield stuff.
You know you're revising, you'rejust fascinated by this.
We'll guide you through the material, highlighting the
really crucial bits from these sources.
OK, we've. Got it all laid out.
Let's unpack this. Where do we start?
Definition I guess. What actually is fictitious
(01:02):
disorder? Well, what's fascinating here
and central is that it's a psychiatric disorder.
The person is intentionally producing or or feigning
physical or psychological symptoms in themselves.
OK, intentionally is the keywordthere.
They're actively doing this. It's not happening to them
involuntarily. Precisely.
And the notes are clear on the motivation.
(01:24):
It's about taking on that sick role, getting medical attention,
maybe sympathy. Right.
And that's different from malingering, isn't it?
Massively different, yeah. Malingering is faking for a
clear external gain, like avoiding work and in
compensation maybe drugs. OK, so with fictitious disorder
the gain is internal, it's the role itself.
(01:44):
The notes also mentioned things like pathological lying, maybe
moving between hospitals. Yeah, those behaviours
definitely fit the picture. Simulated illness, lying, that
sort of wandering between different doctors or hospitals.
The notes also give the other names you might hear.
Like Munchausen's. Munchausen's syndrome.
Yeah, or sometimes hospital addiction syndrome.
And it's named after Baron von Munchausen.
(02:05):
You know the guy famous for telling outrageous, untrue
stories? Oh OK, that makes sense.
The name reflects the deception involved.
It does, and the way it presentscan vary.
The notes say. Symptoms can be totally
simulated, faked, or someone might make a real illness they
have worse on purpose. Or even induce a disease,
actually make themselves sick. Yes, self induced illness is
(02:26):
part of it, and importantly, thenotes briefly touch on
Munchausen's by proxy. That's related but distinct.
It's where a caregiver fakes or causes illness in someone else,
like a child. OK, so right away, you see, this
is much deeper than just, you know, exaggerating a cough to
get a day off. It's a real psychological drive.
Which leads straight to the nextquestion.
Why? What causes someone to do this?
(02:49):
The notes call this the aetiology.
Yeah. What does the information say is
is going on underneath? What are the roots?
Well, the sources describe it ascomplex.
It's usually an interplay of different factors,
Psychological, social, environmental.
Not often, just one thing. And they list some specifics.
I think I saw childhood trauma mentioned.
That comes up quite significantly, yes.
(03:11):
Childhood trauma or abuse. Also certain personality traits
maybe being very attention seeking or needing a lot of
control. A need for control.
That's interesting and. Perhaps a deep desire for like
emotional connection or attention which they try to get
by being sick. Seeking connection through
illness? Wow.
(03:32):
It sounds almost like a, well, areally distorted coping
mechanism. It can seem that way.
Other things mentioned are maybehaving a background in
healthcare. Oh, so they'd have the knowledge
to fake things more convincingly?
Potentially, yeah. And just generally having
inadequate ways to cope with stress or emotions.
The notes even mentioned it might involve sort of reliving
past illnesses or even be a formof self punishment.
(03:54):
If we connect this to the biggerpicture, you can start to see
how a difficult past may be trauma, difficulty with
feelings. It could lead someone to find a
strange kind of safety or identity in being the patient.
Right now, related to causes arethe risk factors the notes look
at who might be more likely to develop this.
OK, so are there specific thingsthat make someone more
(04:16):
vulnerable according to the material?
A lot of overlap with the causes.
Naturally, childhood trauma and abuse are listed.
Again, a family history of mental illness or even
factitious disorder itself. And being in healthcare, that
comes up again too. Yes, working in Healthcare is
noted as a risk factor, again possibly linked to that
knowledge and access. Makes sense.
(04:36):
Opportunity meets vulnerability.Exactly.
Other risks mentioned are personality traits like
impulsivity, that need for attention again, having had lots
of hospital stays or surgeries in the past and just lacking
healthy coping strategies for life's difficulties.
The sources mentioned something about gender here too in the
risk factors section that it's more commonly observed in
(04:58):
females. Yes, noted as a risk factor.
We'll see how that contrasts a bit with the actual diagnosis
stats later on, which is interesting.
OK. Let's shift gear slightly.
Pathophysiology. Is there something physical
going on in the brain maybe? Yeah.
What did the notes say about thebiology of it?
Is there a specific pathway likein some other conditions?
Well, based strictly on the source material we have, it's
(05:21):
described mainly as a psychological disorder.
There aren't really specific known pathophysiological
processes driving it, not like, say, a neurological disease.
So the motivation is psychological, emotional needs
that drive for attention. We talked.
About. That seems to be the focus in
the notes, the need for attention, gratification from
the sick roll and the actions themselves, the feigning,
(05:44):
exaggerating, maybe self harm. These are described as conscious
behaviours. Conscious actions, even if the
underlying reasons are deep and complex.
Right. And then those are pretty clear
that these specific neurobiological mechanisms,
they're just not fully understood yet.
This raises an important question though, about that mind
body link. Even without a clear physical
(06:04):
cause in the usual sense, the mind is having a profound effect
on from the body, or at least the presentation.
Absolutely. It shows how powerful
psychological distress can be. Now if someone comes in with
confusing symptoms, doctors needto rule other things out.
Differential diagnosis. Right.
What else could look like this? How do they tell it apart?
The notes highlight three main things to differentiate it from
(06:26):
first malingering. We mentioned that earlier.
And the key difference there is.Motivation, malingering is
faking for obvious external gain, money, avoiding something,
drugs, that kind of thing. Got it.
External tangible reward in malingering.
Internal psychological reward infactitious disorder.
(06:47):
What? Else Second somatic symptom
disorder. Here the person has real
distressing physical symptoms, often without a clear medical
'cause they worry excessively about.
Them, but they aren't faking. Crucially, no.
According to the notes, there's no deliberate faking or
production of symptoms. The distress is genuine.
The belief they are ill is genuine, even if doctors can't
(07:09):
find the physical cause. OK, so somatic symptom disorder
isn't intentional deception, it's real distress about
symptoms. Exactly.
And the third one is illness anxiety disorder.
Used to be called hypochondriasis.
OK, worry about being sick. Yeah, excessive worry about
having or getting a serious illness, often based on
misinterpreting normal body stuff.
(07:29):
The anxiety itself is the main problem, not deliberately
creating symptoms. So based on these notes, that
intentional deception specifically to get into that
sick roll, that's the real dividing line for fictitious
disorder. That intentional production
seems to be the defining feature.
OK, let's talk epidemiology. How common is this?
Who tends to get it? I guess getting accurate numbers
(07:51):
is tough right if people are actively deceiving doctors?
You guessed it, the notes say. It's really challenging to pin
down the true prevalence becauseof that deceptive nature.
It often goes hidden or misdiagnosed.
Makes total sense. What estimates do they give?
They suggest it's relatively rare in the general population
but more common in healthcare settings, which fits with the
motivation. The estimates in clinical
(08:12):
populations vary, but the notes suggest maybe 1% to 5%.
And any particular places in healthcare where it's seen more
often? Yeah, higher rates noted in
psychiatric settings, emergency departments and specialties that
deal with complex or sort of vague symptoms, neurology,
dermatology, places like that. Fits the pattern.
Seeking help for various issues.And here's where it gets really
(08:34):
interesting. Remember the risk factors
possibly pointing more towards females?
Well, the epidemiology section in the notes actually says it's
more commonly diagnosed in malesoverall.
Oh really? That's unexpected.
It is, though it definitely happens in females too.
It's mainly seen in adults, typically aged 30 to 50, and
most reported cases seem to be in the white population.
(08:58):
That difference between potential risk factors and
actual diagnosed cases, that's quite telling.
Maybe about how it presents differently or gets identified
differently, or just how hard itis to diagnose accurately really
highlights that hidden aspect. It's a key point from the data
provided here. OK, clinical features.
What does this actually look like in practise?
(09:18):
What signs might make a doctor suspicious?
This is where it gets really specific.
What are the general signs? Generally things like vague or
atypical symptoms that don't quite fit a own disease pattern,
giving an inconsistent medical history, lots of hospital
visits, maybe surgeries, sometimes an unusual response to
treatments that should work. Resisting evaluation.
(09:38):
Yeah, resistance to evaluation can be a sign or conversely,
sometimes having surprisingly detailed medical knowledge and
like we said, seeking care from lots of different places that
doctor shopping. That seems like a classic flag,
and the notes had some really vivid examples, didn't they?
Some with dramatic names They. Did like feigning surgical
problems? The notes?
Let's call it laparotomophilia migraines.
(10:00):
Which means. Literally something like
migrating love of abdominal surgery paints a picture right?
Wow. Repeated unnecessary operations.
What else? Excessive bleeding termed
hemorrhagica, histrionica, strange fits, neurologica,
diabolica, even faking heart attacks.
Cardiopathia Fantastica. Those names really stick with
you. They emphasise how dramatic the
(10:22):
presentation can be. They do.
Other examples include inducing side effects from drugs, messing
with wound and healing so they don't get better, simulating gut
problems or breathing issues, self harm or malnutrition, even
using dyes to change skin colourto mimic something.
These examples show the sheer lengths someone might go to.
It's quite extreme. Definitely.
(10:43):
The notes also list other features to look out for.
A long history of unexplained illnesses, Those inconsistencies
we mentioned? Being weirdly willing to have
invasive tests, maybe being hostile or dramatic if
questioned, exaggerating or being dishonest in other parts
of life, Having lots of surgicalscars and sometimes despite
(11:04):
reporting severe symptoms, lacking the expected physical
signs and. There's even an online version
now, Munchausen by Internet. Yep, same underlying behaviour,
just playing out an online support groups or forums seeking
that sick role digitally. These examples, they really
stick with you, right? It makes it much more concrete
than just the definition they. Absolutely do.
So if a doctor suspects this, how do they actually actually
(11:24):
figure it out? What investigations are
involved? It sounds like a diagnostic
nightmare. The notes stress it needs a
really comprehensive assessment,detailed history, physical
exams, but crucially, psychological evaluations too.
So not just medical tests, you need mental health input.
Absolutely essential collaboration is key.
Doctors, psychologists, maybe even legal experts.
(11:48):
Sometimes the main goal is identifying those patterns of
deception, the inconsistencies. While still making sure you
don't miss a real illness. Exactly.
You have to rigorously rule out genuine medical or other
psychiatric conditions first. The diagnosis itself uses
criteria from the DSM 5, the standard manual.
It's classified as fictitious disorder.
And Munchausen's is seen. As often as a more severe,
(12:10):
chronic form of fictitious disorder, both fall into the
category of somatic symptom and related disorders in the DSM.
Five the notes had some important tips for clinicians,
too, didn't they? When they suspect.
This yes like try to minimise unnecessary invasive tests.
Once suspicion is high, be awarepatients might tamper with
samples or records. Look carefully for
inconsistencies. But, and this is crucial,
(12:33):
remember that someone with factitious disorder can also
develop a real medical problems.This raises an important
question. How do you walk that line?
Balancing suspicion with the duty to investigate potential
real illness, especially if the person has this history.
That sounds incredibly difficultfor doctors.
It's a massive challenge in clinical practise.
(12:54):
Which brings us neatly to management.
How do you treat this once it's identified?
Can't be easy. No, the notes are clear.
Management is difficult. It needs that multidisciplinary
team approach. The core is psychological
intervention. Psychotherapy, things like CBT.
Exactly. Psychotherapy, especially
cognitive behavioural therapy, is key.
(13:14):
The focus isn't on treating the fixed symptoms, obviously, but
on the underlying psychological distress.
Addressing the why behind the behaviour.
Precisely helping the person understand and manage the
unresolved conflicts or unmet needs driving it.
Collaboration again. Medical teams, mental health,
social support. Sometimes hospitalisation is
needed, especially if there's a risk of self harm.
(13:36):
Building trust must be incredibly hard though, given
the deception involved. Hugely challenging, the notes
highlight the need to try and build a therapeutic alliance,
offer support but also set really clear boundaries about
the deceptive behaviour. And there's some other points
about management. Yes, balancing investigating
potential real illness versus addressing the pathological need
(13:57):
to be sick. If the diagnosis is clear,
confronting the patient might beneeded, but sympathetically
while being ready for denial or anger.
Psychiatric treatment is vital, especially if trauma is
involved. Treating other issues like
depression maybe with SSR is canhelp.
And crucially, not dismissing real symptoms just because of
the history. Absolutely vital, never deny
(14:19):
genuine care needs. The notes also mentioned
practical things like hospital record systems and how universal
electronic records might help spot patterns of doctor shopping
earlier. What's fascinating here is the
whole treatment goal shifts. It's not about fixing a physical
problem, but about healing the underlying psychological pain
that's manifesting in this really unusual way.
(14:40):
It requires a totally different mindset.
So what about the prognosis? The long term outlook.
Given how hard it sounds to get people into treatment and keep
them there, I imagine the outlook isn't always great.
The notes reflect that prognosisis often difficult to determine,
mainly because people with factitious disorder can be very
resistant to the psychological help they need.
(15:01):
So it depends on the individual whether they engage.
Very much so. Influencing factors include how
severe it is, the person's willingness for therapy, what
the underlying issues are, and how much social support they
have. So improvement is possible.
It is with the right intervention, but the notes warn
that it can often be a chronic condition and relapse is common.
(15:23):
Really addressing those deep underlying psychological issues
is key for any chance of long term recovery.
The notes added some more sobering points on prognosis,
too. They did, mentioning a lack of
big follow up studies or well tested treatments suggesting
it's still a difficult area and really significantly an
increased risk of harm or even death for the person from the
(15:44):
self harm, the unnecessary procedures causing
complications, what doctors calliatrogenic harm, or from
withholding important information about what they've
done or their real health status.
Wow, so the behaviour aimed at getting care can actually lead
to serious physical danger? Exactly.
And that final point under prognosis is stark.
(16:06):
If someone has a known history of this, they can lose
credibility. So even if they later develop a
real illness, they might struggle to be believed.
That last point is particularly stark.
Their history literally puts them at risk even when they're
genuinely sick. It's a terrible Catch 22.
Which leads right into complications.
What are the negative consequences?
Well, unnecessary medical procedures and self harm.
(16:29):
We've covered those. They seem like the biggest ones.
Definitely primary complications.
Also, the financial cost to healthcare systems from all
these investigations and treatments.
And the impact on relationships,the doctors, family.
Huge impact. Strained relationships with
healthcare providers due to the broken trust.
Potential legal issues if fraud is involved, like getting drugs
(16:49):
illicitly, and it damages trust and credibility in their
personal life too. So the fallout is really
wide-ranging, yes. The notes reiterate the risk
from self induced harm, the emotional distress the person
experiences because the underlying pain is real even if
the symptoms aren't, and again, the crucial need for
psychological support. If we connect this to the bigger
(17:10):
picture, you really see how thisisn't just some medical oddity,
it's a serious condition with profound negative impacts on the
individual, the healthcare system, their whole life.
A very complex picture with significant human consequences.
Well, that brings us towards theend of this deep dive into the
material on fictitious disorder.We've looked at that core idea,
(17:31):
intentional fanning to be sick. Explore the complex
psychological roots, seeing how incredibly difficult it is to
spot. And discuss the challenges
around management and the often difficult prognosis.
We've tried to pull out the key information from these notes
give you that high yield understanding.
Hopefully it helps make this complex condition a bit clearer.
We hope so. Synthesising this kind of
(17:52):
material quickly is what these deep dives are all about.
Absolutely, and think you better.
All the deception, the internal drive of the risks, the ethical
tightrope for clinicians, it leaves you with a lot to Mull
over. It really does.
And perhaps a final thought, given how convincing this can be
and the risk of missing real illness later on, how do
(18:15):
healthcare systems get better atnavigating this?
How do you balance that necessary vigilance with the
fundamental need to trust and care for patients?
That balance, yeah, that feels like the ongoing critical
challenge. Yeah.
If you were using this for revision or just want to find
out more, there are resources available.
Yeah definitely check out pastthemsra.com and also frames
sra.com. Both have great resources for
(18:36):
medical learning and revision. A massive thank you for joining
us on this deep dive today. We hope exploring factitious
disorder through these notes hasbeen genuinely inside for you.
OK, imagine this, someone intentionally making themselves
sick, or you know, faking symptoms, maybe even having
unnecessary surgery. Right, and not for money or
getting out of something. Exactly.
Just to be sick. It's quite a baffling kind of
behaviour. It really makes you rethink why
people usually seek medical helpdoesn't.
(00:20):
It it does. And that complex, challenging
topic, that's what we're diving into today.
We're unpacking factitious disorder.
Also known, maybe more famously,as much.
Yeah, exactly. We've got some notes here that
really lay it all out piece by piece.
Covers the whole spectrum really, from the basic
definition right through to management and what the future
(00:41):
might hold for someone with it. So our mission, as always in
these deep dives, is to break down this information, give you
the key takeaways, the high yield stuff.
You know you're revising, you'rejust fascinated by this.
We'll guide you through the material, highlighting the
really crucial bits from these sources.
OK, we've. Got it all laid out.
Let's unpack this. Where do we start?
Definition I guess. What actually is fictitious
(01:02):
disorder? Well, what's fascinating here
and central is that it's a psychiatric disorder.
The person is intentionally producing or or feigning
physical or psychological symptoms in themselves.
OK, intentionally is the keywordthere.
They're actively doing this. It's not happening to them
involuntarily. Precisely.
And the notes are clear on the motivation.
(01:24):
It's about taking on that sick role, getting medical attention,
maybe sympathy. Right.
And that's different from malingering, isn't it?
Massively different, yeah. Malingering is faking for a
clear external gain, like avoiding work and in
compensation maybe drugs. OK, so with fictitious disorder
the gain is internal, it's the role itself.
(01:44):
The notes also mentioned things like pathological lying, maybe
moving between hospitals. Yeah, those behaviours
definitely fit the picture. Simulated illness, lying, that
sort of wandering between different doctors or hospitals.
The notes also give the other names you might hear.
Like Munchausen's. Munchausen's syndrome.
Yeah, or sometimes hospital addiction syndrome.
And it's named after Baron von Munchausen.
(02:05):
You know the guy famous for telling outrageous, untrue
stories? Oh OK, that makes sense.
The name reflects the deception involved.
It does, and the way it presentscan vary.
The notes say. Symptoms can be totally
simulated, faked, or someone might make a real illness they
have worse on purpose. Or even induce a disease,
actually make themselves sick. Yes, self induced illness is
(02:26):
part of it, and importantly, thenotes briefly touch on
Munchausen's by proxy. That's related but distinct.
It's where a caregiver fakes or causes illness in someone else,
like a child. OK, so right away, you see, this
is much deeper than just, you know, exaggerating a cough to
get a day off. It's a real psychological drive.
Which leads straight to the nextquestion.
Why? What causes someone to do this?
(02:49):
The notes call this the aetiology.
Yeah. What does the information say is
is going on underneath? What are the roots?
Well, the sources describe it ascomplex.
It's usually an interplay of different factors,
Psychological, social, environmental.
Not often, just one thing. And they list some specifics.
I think I saw childhood trauma mentioned.
That comes up quite significantly, yes.
(03:11):
Childhood trauma or abuse. Also certain personality traits
maybe being very attention seeking or needing a lot of
control. A need for control.
That's interesting and. Perhaps a deep desire for like
emotional connection or attention which they try to get
by being sick. Seeking connection through
illness? Wow.
(03:32):
It sounds almost like a, well, areally distorted coping
mechanism. It can seem that way.
Other things mentioned are maybehaving a background in
healthcare. Oh, so they'd have the knowledge
to fake things more convincingly?
Potentially, yeah. And just generally having
inadequate ways to cope with stress or emotions.
The notes even mentioned it might involve sort of reliving
past illnesses or even be a formof self punishment.
(03:54):
If we connect this to the biggerpicture, you can start to see
how a difficult past may be trauma, difficulty with
feelings. It could lead someone to find a
strange kind of safety or identity in being the patient.
Right now, related to causes arethe risk factors the notes look
at who might be more likely to develop this.
OK, so are there specific thingsthat make someone more
(04:16):
vulnerable according to the material?
A lot of overlap with the causes.
Naturally, childhood trauma and abuse are listed.
Again, a family history of mental illness or even
factitious disorder itself. And being in healthcare, that
comes up again too. Yes, working in Healthcare is
noted as a risk factor, again possibly linked to that
knowledge and access. Makes sense.
(04:36):
Opportunity meets vulnerability.Exactly.
Other risks mentioned are personality traits like
impulsivity, that need for attention again, having had lots
of hospital stays or surgeries in the past and just lacking
healthy coping strategies for life's difficulties.
The sources mentioned something about gender here too in the
risk factors section that it's more commonly observed in
(04:58):
females. Yes, noted as a risk factor.
We'll see how that contrasts a bit with the actual diagnosis
stats later on, which is interesting.
OK. Let's shift gear slightly.
Pathophysiology. Is there something physical
going on in the brain maybe? Yeah.
What did the notes say about thebiology of it?
Is there a specific pathway likein some other conditions?
Well, based strictly on the source material we have, it's
(05:21):
described mainly as a psychological disorder.
There aren't really specific known pathophysiological
processes driving it, not like, say, a neurological disease.
So the motivation is psychological, emotional needs
that drive for attention. We talked.
About. That seems to be the focus in
the notes, the need for attention, gratification from
the sick roll and the actions themselves, the feigning,
(05:44):
exaggerating, maybe self harm. These are described as conscious
behaviours. Conscious actions, even if the
underlying reasons are deep and complex.
Right. And then those are pretty clear
that these specific neurobiological mechanisms,
they're just not fully understood yet.
This raises an important question though, about that mind
body link. Even without a clear physical
(06:04):
cause in the usual sense, the mind is having a profound effect
on from the body, or at least the presentation.
Absolutely. It shows how powerful
psychological distress can be. Now if someone comes in with
confusing symptoms, doctors needto rule other things out.
Differential diagnosis. Right.
What else could look like this? How do they tell it apart?
The notes highlight three main things to differentiate it from
(06:26):
first malingering. We mentioned that earlier.
And the key difference there is.Motivation, malingering is
faking for obvious external gain, money, avoiding something,
drugs, that kind of thing. Got it.
External tangible reward in malingering.
Internal psychological reward infactitious disorder.
(06:47):
What? Else Second somatic symptom
disorder. Here the person has real
distressing physical symptoms, often without a clear medical
'cause they worry excessively about.
Them, but they aren't faking. Crucially, no.
According to the notes, there's no deliberate faking or
production of symptoms. The distress is genuine.
The belief they are ill is genuine, even if doctors can't
(07:09):
find the physical cause. OK, so somatic symptom disorder
isn't intentional deception, it's real distress about
symptoms. Exactly.
And the third one is illness anxiety disorder.
Used to be called hypochondriasis.
OK, worry about being sick. Yeah, excessive worry about
having or getting a serious illness, often based on
misinterpreting normal body stuff.
(07:29):
The anxiety itself is the main problem, not deliberately
creating symptoms. So based on these notes, that
intentional deception specifically to get into that
sick roll, that's the real dividing line for fictitious
disorder. That intentional production
seems to be the defining feature.
OK, let's talk epidemiology. How common is this?
Who tends to get it? I guess getting accurate numbers
(07:51):
is tough right if people are actively deceiving doctors?
You guessed it, the notes say. It's really challenging to pin
down the true prevalence becauseof that deceptive nature.
It often goes hidden or misdiagnosed.
Makes total sense. What estimates do they give?
They suggest it's relatively rare in the general population
but more common in healthcare settings, which fits with the
motivation. The estimates in clinical
(08:12):
populations vary, but the notes suggest maybe 1% to 5%.
And any particular places in healthcare where it's seen more
often? Yeah, higher rates noted in
psychiatric settings, emergency departments and specialties that
deal with complex or sort of vague symptoms, neurology,
dermatology, places like that. Fits the pattern.
Seeking help for various issues.And here's where it gets really
(08:34):
interesting. Remember the risk factors
possibly pointing more towards females?
Well, the epidemiology section in the notes actually says it's
more commonly diagnosed in malesoverall.
Oh really? That's unexpected.
It is, though it definitely happens in females too.
It's mainly seen in adults, typically aged 30 to 50, and
most reported cases seem to be in the white population.
(08:58):
That difference between potential risk factors and
actual diagnosed cases, that's quite telling.
Maybe about how it presents differently or gets identified
differently, or just how hard itis to diagnose accurately really
highlights that hidden aspect. It's a key point from the data
provided here. OK, clinical features.
What does this actually look like in practise?
(09:18):
What signs might make a doctor suspicious?
This is where it gets really specific.
What are the general signs? Generally things like vague or
atypical symptoms that don't quite fit a own disease pattern,
giving an inconsistent medical history, lots of hospital
visits, maybe surgeries, sometimes an unusual response to
treatments that should work. Resisting evaluation.
(09:38):
Yeah, resistance to evaluation can be a sign or conversely,
sometimes having surprisingly detailed medical knowledge and
like we said, seeking care from lots of different places that
doctor shopping. That seems like a classic flag,
and the notes had some really vivid examples, didn't they?
Some with dramatic names They. Did like feigning surgical
problems? The notes?
Let's call it laparotomophilia migraines.
(10:00):
Which means. Literally something like
migrating love of abdominal surgery paints a picture right?
Wow. Repeated unnecessary operations.
What else? Excessive bleeding termed
hemorrhagica, histrionica, strange fits, neurologica,
diabolica, even faking heart attacks.
Cardiopathia Fantastica. Those names really stick with
you. They emphasise how dramatic the
(10:22):
presentation can be. They do.
Other examples include inducing side effects from drugs, messing
with wound and healing so they don't get better, simulating gut
problems or breathing issues, self harm or malnutrition, even
using dyes to change skin colourto mimic something.
These examples show the sheer lengths someone might go to.
It's quite extreme. Definitely.
(10:43):
The notes also list other features to look out for.
A long history of unexplained illnesses, Those inconsistencies
we mentioned? Being weirdly willing to have
invasive tests, maybe being hostile or dramatic if
questioned, exaggerating or being dishonest in other parts
of life, Having lots of surgicalscars and sometimes despite
(11:04):
reporting severe symptoms, lacking the expected physical
signs and. There's even an online version
now, Munchausen by Internet. Yep, same underlying behaviour,
just playing out an online support groups or forums seeking
that sick role digitally. These examples, they really
stick with you, right? It makes it much more concrete
than just the definition they. Absolutely do.
So if a doctor suspects this, how do they actually actually
(11:24):
figure it out? What investigations are
involved? It sounds like a diagnostic
nightmare. The notes stress it needs a
really comprehensive assessment,detailed history, physical
exams, but crucially, psychological evaluations too.
So not just medical tests, you need mental health input.
Absolutely essential collaboration is key.
Doctors, psychologists, maybe even legal experts.
(11:48):
Sometimes the main goal is identifying those patterns of
deception, the inconsistencies. While still making sure you
don't miss a real illness. Exactly.
You have to rigorously rule out genuine medical or other
psychiatric conditions first. The diagnosis itself uses
criteria from the DSM 5, the standard manual.
It's classified as fictitious disorder.
And Munchausen's is seen. As often as a more severe,
(12:10):
chronic form of fictitious disorder, both fall into the
category of somatic symptom and related disorders in the DSM.
Five the notes had some important tips for clinicians,
too, didn't they? When they suspect.
This yes like try to minimise unnecessary invasive tests.
Once suspicion is high, be awarepatients might tamper with
samples or records. Look carefully for
inconsistencies. But, and this is crucial,
(12:33):
remember that someone with factitious disorder can also
develop a real medical problems.This raises an important
question. How do you walk that line?
Balancing suspicion with the duty to investigate potential
real illness, especially if the person has this history.
That sounds incredibly difficultfor doctors.
It's a massive challenge in clinical practise.
(12:54):
Which brings us neatly to management.
How do you treat this once it's identified?
Can't be easy. No, the notes are clear.
Management is difficult. It needs that multidisciplinary
team approach. The core is psychological
intervention. Psychotherapy, things like CBT.
Exactly. Psychotherapy, especially
cognitive behavioural therapy, is key.
(13:14):
The focus isn't on treating the fixed symptoms, obviously, but
on the underlying psychological distress.
Addressing the why behind the behaviour.
Precisely helping the person understand and manage the
unresolved conflicts or unmet needs driving it.
Collaboration again. Medical teams, mental health,
social support. Sometimes hospitalisation is
needed, especially if there's a risk of self harm.
(13:36):
Building trust must be incredibly hard though, given
the deception involved. Hugely challenging, the notes
highlight the need to try and build a therapeutic alliance,
offer support but also set really clear boundaries about
the deceptive behaviour. And there's some other points
about management. Yes, balancing investigating
potential real illness versus addressing the pathological need
(13:57):
to be sick. If the diagnosis is clear,
confronting the patient might beneeded, but sympathetically
while being ready for denial or anger.
Psychiatric treatment is vital, especially if trauma is
involved. Treating other issues like
depression maybe with SSR is canhelp.
And crucially, not dismissing real symptoms just because of
the history. Absolutely vital, never deny
(14:19):
genuine care needs. The notes also mentioned
practical things like hospital record systems and how universal
electronic records might help spot patterns of doctor shopping
earlier. What's fascinating here is the
whole treatment goal shifts. It's not about fixing a physical
problem, but about healing the underlying psychological pain
that's manifesting in this really unusual way.
(14:40):
It requires a totally different mindset.
So what about the prognosis? The long term outlook.
Given how hard it sounds to get people into treatment and keep
them there, I imagine the outlook isn't always great.
The notes reflect that prognosisis often difficult to determine,
mainly because people with factitious disorder can be very
resistant to the psychological help they need.
(15:01):
So it depends on the individual whether they engage.
Very much so. Influencing factors include how
severe it is, the person's willingness for therapy, what
the underlying issues are, and how much social support they
have. So improvement is possible.
It is with the right intervention, but the notes warn
that it can often be a chronic condition and relapse is common.
(15:23):
Really addressing those deep underlying psychological issues
is key for any chance of long term recovery.
The notes added some more sobering points on prognosis,
too. They did, mentioning a lack of
big follow up studies or well tested treatments suggesting
it's still a difficult area and really significantly an
increased risk of harm or even death for the person from the
(15:44):
self harm, the unnecessary procedures causing
complications, what doctors calliatrogenic harm, or from
withholding important information about what they've
done or their real health status.
Wow, so the behaviour aimed at getting care can actually lead
to serious physical danger? Exactly.
And that final point under prognosis is stark.
(16:06):
If someone has a known history of this, they can lose
credibility. So even if they later develop a
real illness, they might struggle to be believed.
That last point is particularly stark.
Their history literally puts them at risk even when they're
genuinely sick. It's a terrible Catch 22.
Which leads right into complications.
What are the negative consequences?
Well, unnecessary medical procedures and self harm.
(16:29):
We've covered those. They seem like the biggest ones.
Definitely primary complications.
Also, the financial cost to healthcare systems from all
these investigations and treatments.
And the impact on relationships,the doctors, family.
Huge impact. Strained relationships with
healthcare providers due to the broken trust.
Potential legal issues if fraud is involved, like getting drugs
(16:49):
illicitly, and it damages trust and credibility in their
personal life too. So the fallout is really
wide-ranging, yes. The notes reiterate the risk
from self induced harm, the emotional distress the person
experiences because the underlying pain is real even if
the symptoms aren't, and again, the crucial need for
psychological support. If we connect this to the bigger
(17:10):
picture, you really see how thisisn't just some medical oddity,
it's a serious condition with profound negative impacts on the
individual, the healthcare system, their whole life.
A very complex picture with significant human consequences.
Well, that brings us towards theend of this deep dive into the
material on fictitious disorder.We've looked at that core idea,
(17:31):
intentional fanning to be sick. Explore the complex
psychological roots, seeing how incredibly difficult it is to
spot. And discuss the challenges
around management and the often difficult prognosis.
We've tried to pull out the key information from these notes
give you that high yield understanding.
Hopefully it helps make this complex condition a bit clearer.
We hope so. Synthesising this kind of
(17:52):
material quickly is what these deep dives are all about.
Absolutely, and think you better.
All the deception, the internal drive of the risks, the ethical
tightrope for clinicians, it leaves you with a lot to Mull
over. It really does.
And perhaps a final thought, given how convincing this can be
and the risk of missing real illness later on, how do
(18:15):
healthcare systems get better atnavigating this?
How do you balance that necessary vigilance with the
fundamental need to trust and care for patients?
That balance, yeah, that feels like the ongoing critical
challenge. Yeah.
If you were using this for revision or just want to find
out more, there are resources available.
Yeah definitely check out pastthemsra.com and also frames
sra.com. Both have great resources for
(18:36):
medical learning and revision. A massive thank you for joining
us on this deep dive today. We hope exploring factitious
disorder through these notes hasbeen genuinely inside for you.
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