Patient will present as → a 35-year-old female with c/o palpitations and chest pain for 2 days. She reports that she had been sweating with nausea and vomiting. She reports that she “checked her pulse which was about 156.” She denies any personal or family history of heart disease or anxiety disorders. She rated her chest pain as 10/10, “which radiates down my left arm and up my jaw.” ECG reads normal sinus rhythm. Troponin, CK-MB, and other labs were normal. When she was told that her labs were normal, she flopped onto the bed and started “seizing.” She stated, “I am seizing. Why won’t you help me?” When the ER PA called her out, she got angry and left against medical advice.
Key Points:
Factitious disorder imposed on self (Munchausen syndrome)
- The patient falsifies physical or psychological symptoms or induces injury or disease to themselves
- The patient's deceptive behavior occurs in the absence of external rewards
Factitious Disorder Imposed on Another (Munchausen syndrome by proxy)
- When in another person (e.g., a child) it is termed factitious disorder imposed on another (Munchausen syndrome by proxy)
DSM-5 Diagnostic Criteria
Factitious Disorder Imposed on Self
- Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
- The individual presents himself or herself to others as ill, impaired, or injured.
- The deceptive behavior is evident even in the absence of obvious external rewards.
- The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
Specify: Single episode, recurrent episodes (two or more events of falsification of illness and/or induction of injury)
Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy)
- Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.
- The individual presents another individual (victim) to others as ill, impaired, or injured.
- The deceptive behavior is evident even in the absence of obvious external rewards.
- The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
Note: The perpetrator, not the victim, receives this diagnosis.
Conjoint confrontation by the PCP and the psychiatrist.
- Overt disclosure using therapies such as biofeedback, self-hypnosis, and double-blind therapy (where a patient is told that there are possible diagnoses of their illness: one organic and the other factitious disorder).
- In factitious disorder imposed on another (e.g., in a child)
- Children must be removed by child protective services
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Question 1 |
A 9-year-old boy is brought to the emergency room with shortness of breath. His mother reports that his symptoms began two days ago and that this is the first time that her son has ever been sick. On exam, he is pale, diaphoretic, and lethargic, and his glucose is found to be 20 mg/dL. When looking up the patient's chart, the physician finds that the patient has been brought into the emergency room four times in the past year with the same symptoms, and his C-peptide levels at all visits have been low. After administration of glucose, what is the most appropriate next step?
Discharge to home with follow-up at with an endocrinologist Hint: The patient's C-peptide levels are low, and therefore this presentation is unlikely to be due to overproduction of endogenous insulin.
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Refer the patient's mother to a psychiatrist Hint: Although the patient's mother may benefit from therapy, the providers must first protect the patient from further harm.
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Contact the patient's outpatient pediatrician for follow-up diabetes testing Hint: This patient has low, not high glucose. Although the outpatient pediatrician should be involved in the case, the patient does not need follow-up testing for diabetes. | |
Contact the hospital ethics board Hint: Since this is a case of very likely child abuse, the hospital ethics board does not need to be involved. | |
Contact child protective services |
Question 1 Explanation:
This clinical presentation is most consistent with Factitious disorder imposed on another (Munchausen syndrome by proxy). This is considered a form of child abuse, and providers should contact child protective services in suspected cases. Factitious disorder imposed on another is a psychiatric condition in which a patient consciously reports false symptoms, or induces symptoms, with the goal of playing the "sick role." Patients may inflict significant self-harm in the process of creating symptoms, such as injecting insulin or swallowing food that is known to be contaminated
Question 2 |
A 32-year-old nursing assistant presents to the emergency department with severe abdominal pain and bloody diarrhea. She reports a history of Crohn's disease diagnosed at multiple hospitals. Review of records from five different health systems reveals inconsistent histories and numerous negative workups. She was hospitalized last year for hypoglycemia while working in an endocrinology clinic. Her mother died when she was 8 years old. Which factor most strongly increases her risk for factitious disorder?
Female gender Hint: While females have slightly higher rates, gender alone is a weaker risk factor than healthcare occupation | |
Age between 30-40 years Hint: Typical onset is third/fourth decade, but age is less predictive than occupational exposure | |
History of early parental loss Hint: Associated with factitious disorder but less specific than healthcare employment | |
Current employment as a healthcare worker | |
Previous hospitalization for medical illness Hint: Can trigger factitious disorder but isn't as strong as occupational risk |
Question 2 Explanation:
This patient presents with multiple red flags for factitious disorder, and among the listed options, being a healthcare worker (past or present) is the most significant risk factor. Healthcare workers have knowledge of medical conditions and access to medical supplies, enabling sophisticated illness simulation. They understand which symptoms to report and how to manipulate tests. This patient's hypoglycemia while working in endocrinology (where insulin access is likely) and inconsistent histories across multiple hospitals strongly suggest factitious behavior. While other factors like female gender, age <40, and early parental loss are associated with factitious disorder, healthcare employment provides both the means and knowledge for illness falsification. Studies consistently identify healthcare workers as a high-risk group, as they can create convincing presentations and know how to avoid detection. The combination of medical knowledge and opportunity makes this the strongest single risk factor.
Question 3 |
A 28-year-old woman is admitted for evaluation of recurrent seizures unresponsive to multiple anticonvulsants. Video EEG monitoring captures three "seizures" with normal electrical activity throughout. When alone, she was observed placing a syringe in her bedside drawer. Her serum phenytoin level is undetectable despite documented administration. She eagerly agrees to invasive testing. What is the most appropriate next diagnostic step?
Confront her immediately about the suspicious findings Hint: Premature confrontation typically results in denial and departure AMA; evidence should be gathered first | |
Order psychiatric consultation while continuing medical workup Hint: Appropriate but secondary to gathering objective evidence through records | |
Search her room and belongings for evidence Hint: May be done but less comprehensive than full record review | |
Obtain serum and urine toxicology screening Hint: Useful but limited compared to pattern analysis from multiple records | |
Contact previous healthcare facilities for records |
Question 3 Explanation:
The most appropriate next step is obtaining records from previous healthcare facilities, which often provides definitive evidence of factitious disorder through pattern recognition and inconsistencies. This patient shows multiple indicators: pseudoseizures on video EEG, hidden syringe, undetectable anticonvulsant levels despite witnessed administration, and eagerness for invasive procedures. Before confronting the patient (which often leads to departure AMA), comprehensive medical record analysis is crucial. Creating a chronological table of healthcare contacts reveals patterns of factitious behavior, inconsistent histories, and previous episodes. Records may show multiple negative workups, doctor shopping, aliases, or prior factitious disorder diagnoses. This systematic approach provides objective evidence while maintaining therapeutic rapport. Electronic medical records make finding previous encounters easier, even with aliases if birth date/SSN match. This evidence-gathering protects both patient and clinician while avoiding premature confrontation.
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