The Interplay of Factitious Disorder and Palliative Care Encounters: A Case Series

Abstract

Background:

Individuals with factitious disorders often suffer emotional pain, which motivates them to assume a “sick role” rather than experience the intensity of emotional distress. Such individuals may experience iatrogenic harm as a consequence of their psychological disorder. Their clinicians may develop strong negative emotions such as disgust and the health care system can accrue increased medical costs from diagnostic dilemmas. If the disorder remains unrecognized, the resulting tension can cause interdisciplinary team (IDT) conflicts and impact the effectiveness of care.

Methods:

In this article, we describe three cases of factitious behaviors, as either a comorbid illness or an underlying condition, that potentiate untoward health effects among patients seen by a palliative care team. We use these examples to illustrate common features of factious disorders, identify clinical pitfalls when caring for such patients, and offer care strategies for palliative care providers who may encounter such patients with increasing prevalence considering the larger national push to involve palliative care teams earlier in disease trajectories.

Introduction

Abnormal health care-seeking behaviors can be spectral in nature—from mere symptom exaggeration to willful deception.^1,2 Factitious disorders represent one aspect of this spectrum in which the deceptive behavior occurs even in the absence of obvious external rewards and is not explained better by another mental disorder.³ Factitious disorders affect all parties involved, including the treating clinicians. When clinicians suspect that a patient may be willfully fabricating an illness, trust in the clinician–patient relationship can be eroded. This can lead clinicians to wonder why patients engage in such behaviors and what personality profiles might coexist.^4,5 In addition, it has been postulated that deception may in fact be a social behavior and as such it is unlikely that clinicians will be able to determine reliably the contributory role of deception in each and every challenging clinical presentation.^6,7 Factitious disorders can lead to significant dissent within medical teams, and providers may consider more commonly identified conditions such as malingering or other personality disorders. Although the true incidence of factitious disorders is unknown, experts estimate that 0.8% to 1.3% of patients at a tertiary care center may suffer from it.^9,10 These numbers may underestimate the true prevalence of the disorder because more than two-thirds of patients may meet the criteria for other psychopathology.¹¹

The intent of this case review is to highlight the various ways emotional pain may manifest as factitious symptoms and potentiate untoward effects in clinical situations encountered by palliative care clinicians. Considering the mounting evidence showcasing the benefit of palliative care services¹² and the push to develop standardized protocols to expand palliative care services earlier in disease trajectories,¹³ palliative care clinicians will likely treat patients with factitious behaviors as either a comorbid illness or as the underlying reason for which they were referred.

Palliative care clinicians need to be aware of the main features of factitious disorders (Table 1)¹⁴ to avoid its potential adverse effects on patient care and team morale. In most patient care situations encountered by palliative care clinicians, a longitudinal relation that would facilitate diagnosis of specific somatoform behaviors and underlying motivations may not be possible. Therefore, this case series offers a process of clinical assessment and management when palliative care clinicians encounter patients with abnormal health care-seeking behaviors. It is beyond the scope of this article to develop a diagnostic framework for discerning factitious disorders from other somatoform type behaviors or personality disorders.

Table 1.

Factitious Disorder DSM-5 Criteria ¹⁴

Diagnostic criteria
Factitious disorder
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior in not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Case 1

A 67-year-old retired utility serviceman was followed by the inpatient palliative care consult service for psychological support in the setting of metastatic renal cell carcinoma that had progressed through all available targeted cancer treatment options. After being admitted to the hospital for abdominal pain, he developed rapid-onset, hypoactive delirium. His oncology team identified no organic cause for his delirium and attempts to manage his delirium were ineffective. His wife had a long history of depression and had been dependent on the patient “for almost everything” throughout their marriage. Medical staff noted that after the first day in the hospital, the patient's wife stopped visiting.

The palliative care psychologist enlisted assistance from the staff palliative care physician for prognostication. The patient was determined to have short weeks to months to live because of the rapidly progressing cancer. While appearing confused and disoriented during the mental status evaluation, the patient followed one simple purposeful command: raising his right arm far above his head. The psychologist then engaged with the patient in a conversational manner when alone in the room and attempted to normalize his emotional reactions. After several minutes, the patient began to attend to the psychotherapy session and engaged in an active life review discussing how he had always cared for every facet of his wife's life. Through his life review, he was able to identify himself as a caring husband and cognitively reframe his wife's abandonment as her personal need to find another partner who could care for her as lovingly as he had for so many years. Although his wife never visited again, he did not demonstrate any further symptoms of delirium and died peacefully in an inpatient hospice.

The patient volitionally feigned delirium motivated by unconscious emotional pain: the pain of abandonment by his wife, the pain of leaving her alone and helpless, and the pain of realizing that he was replaceable despite his years of complete devotion to her needs. It was less distressing emotionally to feign delirium and disengage from the world than to face his unconscious fears. With intervention, he demonstrated little emotional distress after he came to terms with the circumstances that informed the psychological etiology of his factitious symptoms. Conversations during psychotherapy included normalizing the feigning of delirium as a way of avoiding the intense and overwhelming emotional pain.

Case 2

The palliative care consult service was asked to clarify treatment goals for a 59-year-old woman with multiple myeloma. Her electronic medical records (EMR) revealed an established behavioral pattern of seeking treatment for various conditions from multiple providers at different locations over many years. Her problem list in the EMR included more than 30 diagnoses, multiple hospitalizations, and frequent outpatient access to medical services.

Subsequent to the diagnosis of multiple myeloma, she experienced numerous unusual medication side effects and complications after procedures. She demonstrated poor insight into the seriousness of her cancer diagnosis. Her oncology providers expressed frustration that she had disrupted potentially effective cancer treatment by missing oncologic appointments and by misusing her medications. Compounding the issue, she often sought treatment for perceived side effects at outside institutions.

As her illness progressed, the patient continued to identify various unusual side effects to her cancer treatments and made frequent visits to the emergency department resulting in many hospitalizations, further reinforcing her “sick role.” On one such occasion, the patient presented to the emergency department with intense abdominal pain and was concerned about having a small bowel obstruction. Diagnostics ruled out anything abnormal but the patient continued to request further evaluation. A few days later during a psychotherapy session, the patient admitted that she had eaten some extremely spicy foods prior to going to the emergency department. The patient also admitted that she had purposefully avoided all types of foods prior. This information was not shared during emergency department interview or as an inpatient over the next several days. The patient was discharged with complete resolution of symptoms without any medical intervention.

Although she was receptive to psychotherapy, the patient was neither able to gain insight into her behaviors nor comprehend that her illness was life limiting. It is important to note that the patient had a special-needs adult son who had been adopted at 9 months of age and who required significant emotional and physical resources. In psychological sessions, the patient often discussed the difficulty and stress of caring for him. She described how her illnesses were impeding her ability to care for her son appropriately. She perceived herself as a loving and caring mother and her somatic preoccupation and feigning of symptoms allowed distraction from the guilt of not caring for her son. Scripting an alternative reality by volitionally feigning symptoms, manipulating treatments, and assuming the sick role was easier than experiencing the emotional pain of failure of motherhood.

Her husband of 35 years and her adult daughter were very supportive of her “lifelong health problems.” Although the patient was very appreciative of her medical care and conveyed her abundant requests in a pleasant manner, her interdisciplinary team (IDT) felt challenged managing her advanced illness in balance with her complicated psychological overlay. In particular, the medical team struggled with the appropriateness of her requests for further diagnostic work-up and therapeutics. As her functional status declined, the patient and her family continued to request invasive life-prolonging treatments including dialysis, which further distressed many inpatient care providers who felt that additional interventions were unwarranted. As she became moribund and lost decisional capacity, the palliative care team recommended a do-not-resuscitate order and a shift of goals toward comfort care as the best way to care for her. Her family eventually assented. She died comfortably in the hospital with her family acknowledging her bravery throughout her many illnesses.

Case 3

A 53-year-old female was hospitalized for intense abdominal pain, which she attributed to an intestinal blockage. At the time of her admission, the patient requested a palliative care consult to assist with readmittance to home hospice for her “life-limiting multiple sclerosis.” She had been terminated from hospice a few weeks prior to hospital admission because of weight gain and improvement in functional status. During the consult, the palliative care team observed an orthotic ankle brace to “stabilize” three fractured bones and a large 3-inch binder of medical records that the patient indicated was for her to “refer” to when asked historical questions. She shared that she had significant cognitive deficits from the progression of the multiple sclerosis that clouded her memory, but then proceeded to describe a long history of medical interventions including surgeries, recurrent bladder infections from self-catheterizations, and other unusual medication side effects without consulting her medical binder. She asked for a physician's certification to renew home hospice care, noting, “It is the best care I have ever had. I am so depressed and I will not be able to cope without it.”

At the request of the palliative care team the primary team reviewed the patient's past medical work-up and providers learned that it did not support the diagnoses of a bone fracture or multiple sclerosis. She was eventually discharged home with a bowel regimen for constipation and a planned follow-up in the outpatient palliative care clinic. During the outpatient appointment, her adult daughters shared their exhaustion and fears regarding their mother's impending death, concurrent with the patient recounting her extensive medical history and her belief that she needed hospice care. The palliative care team carefully challenged the patient's diagnoses. Furthermore, they conveyed that she did not meet requirements for home hospice and was not dying. However, the patient remained focused on the need for further surgery and consultation for continuing abdominal problems throughout the session. The patient was receptive to a recommendation for a “goals of care” meeting with all of her providers and invited family members, as a way to determine what to do next. Unfortunately, other care providers did not recognize the need and the patient was lost to follow-up within the medical care system.

Discussion

These three cases illustrate challenges in identifying factitious behaviors, the variation in presentations, and the breadth of outcomes after palliative care encounters. Furthermore, these cases highlight that when palliative care providers encounter unexplained symptoms, a careful review of the patient's prognosis from the underlying medical condition and careful psychological assessment is warranted. Considering that delays in identification of factitious disorders can result in an inefficient medical evaluation, overutilization of medical resources, and the prescription of inappropriate medical therapies, clinicians should be aware of common behaviors that may suggest that a factitious disorder could be present (Table 1).¹⁴ In these three cases, the presence of a licensed psychologist as a member of the palliative care IDT was vital in identifying factitious behaviors and in coordinating medically appropriate care in an interdisciplinary fashion. By using appropriate interdisciplinary care strategies within the context of the disorder, the palliative care team was able to offer leadership designed to minimize IDT conflict.

In each of these cases, the patients had symptoms of an illness without the characteristic signs of the improperly identified illness. Through the scope of retrospective analysis, the first case provides an example of episodic factitious behavior that upon recognition was amenable to psychological intervention. Because nothing in the medical records or any prior encounters demonstrated behaviors associated with a factitious presentation, the clinical approach proved helpful.

A) Careful reassessment of the patient's underlying medical illness and prognosis

Knowing that the patient's prognosis was only weeks to months signified that the palliative care team would not have the luxury of longitudinal visits to fully discern whether the behaviors were a reflection of a factitious disorder or other mental health disorder—personality disorder, conversion disorder, etc. Subsequently, clinicians were able to focus medical and psychological interventions on the existential and psychological suffering.

B) Assessments of how deleterious the behaviors were for the patient's health situation

In this case, the patient developed the outward appearance of delirium—including fluctuating alertness, attention, and levels of confusion—without a medically identified etiology. One might speculate that the psychic pain of his wife's abandonment resulted in the unconscious behavior strategy of confusion and nonparticipation in the medical discussion and examination. Although the presentation of feigned delirium was volitional, the underlying motivation was to ameliorate the unconscious emotional pain of losing his wife. As such, it was less distressing to detach from the external world than to face abandonment. The consequence of this delirium-like presentation was temporarily harmful to the patient because he received unnecessary diagnostic work-up and pharmacologic therapies. More importantly, the delay in the recognition of the factitious symptoms led to a delay in appropriate psychological therapy and consequently lost days of quality life. One also may wonder if the patient's “delirium” resulted in less engagement with the patient and subsequently less emotional support from his health care providers. Although it can be challenging to quantify the degree of harm that may be accrued from the factious behavior and indeed scales have been devised to assist with this, in this case it was felt that the behaviors were leading to significant overall harm for the aforementioned reasons.¹⁵

C) Can the deleterious behaviors be ameliorated?

No robust medical data are available to support the effectiveness of any specific management strategy for factitious disorders. However, some experts believe that the key to successful management (meaning at least harm reduction) is engagement with the patient in the diagnosis and psychotherapy.¹⁶ Only after the psychologist's diagnosis of factious disorder with psychological features and engagement with the patient about the psychological factors that may have contributed to the behaviors was the patient able to participate in the important human interactions required for a more peaceful death. Indeed there is published evidence to suggest that some factitious disorders can be episodic and situation specific rather than a pervasive clinical state. Although prospective studies are rare (likely because many patients are lost to follow up) and the course of factitious disorders is uncertain, this case highlights that factitious behaviors can be variable in presentation.¹⁶ In this case an attempt of a therapeutic intervention and subsequent observation as to whether the deleterious behavior subsided, proved to be clinically constructive.

The second case demonstrates a long-standing pattern of behaviors that ultimately interfered with the patient's ability to understand the severity of her terminal illness. These behaviors included manipulations of self that allowed her to seek medical attention and assume the sick role.⁵ These behaviors correspond to the accounts of patients with factitious disorders in which they deceive medical professionals in order to maintain the sick role and to obtain attention. Unfortunately, the patient's behaviors continued after her myeloma diagnosis and her cancer-defined “sick role” was firmly established. In addition to creating diagnostic dilemmas, these behaviors ultimately sabotaged her ability to receive optimal and timely antineoplastic care.

Ironically, she spent much of her life seeking attention from the medical community prior to her cancer diagnosis. Yet despite having been diagnosed with a bona fide serious illness, the factitious symptoms persisted. In a sense, the hospital became a safe haven from these emotional stressors of her life: for her it was easier to feign sickness in hospital than to deal with the emotional and physical burden of caring for her son at home as her disease progressed. Meanwhile, her hematologic malignancy team often expressed a broad range of emotions in trying to care for her—from frustration, to anger, to consternation—citing her inconsistencies in presentation as the source of their frustrations. Of note, the patient's family exhibited very limited distress throughout her illness. Perhaps this observation can be attributed to continuous positive reinforcement from the patient and from care providers.

For our palliative care team, an important “take home” point from her case was that behaviors unusual to care providers are not always unusual to family members. Ultimately, the palliative care team recognized that they were not able to ameliorate the patient's behaviors considering their chronic and refractory nature. Instead, the focus of the palliative care consult team shifted more towards attenuating care provider distress. To this end, the palliative care team reminded the primary team that the patient's factitious symptoms were manifestations of her own emotional pain and not intended to impact them personally. It was important to recognize that this patient's motivations remain unconscious, although the behavioral presentation was conscious. Furthermore, the palliative care team outlined care strategies (Table 2) that were designed to minimize harm, enable boundary setting, and prevent the communication of mixed messages by the various care teams.

Table 2.

Interdisciplinary Treatment Strategies

• Verify past medical history and diagnostic results

• Maintain consistent and firm boundaries across all care providers

• Minimize multiple care providers in the room for daily care

• Ask family to leave the room when providing nursing-based care to minimize family distress and/or misunderstandings

• Provide consistent, concrete, and direct instructions during care

• Rotate nursing staff on a regular basis to minimize provider distress

• Designate certain providers (limit number) to share medical information and recommendations with patient and family

• Concrete and consistent information and recommendations should be given by these designated providers

• Document each encounter to facilitate cohesive consistent communication among all care providers

• Provide psychological education to all treatment teams regarding the psychological factors affecting behaviors, reactions, and decisions of patient and family

• Frequent care conferences may be appropriate (without patient and family)

Unlike the first two cases, the patient in the third case did not have a known terminal diagnosis when the palliative care team was consulted. Rather, it was the diagnostic quagmire and request for hospice that prompted the referral. With her request for hospice recertification, the patient's presenting symptoms and reported diagnoses were recognized as the fodder for secondary gain. Hence, this case demonstrates the variability in which factitious disorders can present. It also demonstrates that at times, factitious disorders can mimic or overlap with other somatic symptoms and related disorders (Table 3).¹⁴

Table 3.

Somatic Symptoms and Other Related Disorders

Somatic symptom disorder	Multiple distressing health symptoms that significantly disrupt daily life
Illness anxiety disorder	Preoccupation with acquiring or having a serious illness
Conversion disorder	Neurologic symptoms exhibited without a known etiology
Psychological factors affecting medical conditions	Behaviors/attitudes negatively affect a known medical illness
Factitious disorder	Psychological or physical symptoms falsified for no particular reason

Note: malingering is not a mental health disorder.

The presentation of somatic symptoms can be very fluid. Because patients often do not present with clear diagnostic specificity, there can be significant disagreement among care staff whether the underlying psychological disorder is more emblematic of somatic symptom, conversion disorder, factitious disorder, or in some circumstances malingering. In many cases, it may be more important for medical care providers to recognize that the patient's creation of physical symptoms is used as psychological strategy to mask and cope with the intensity of emotional pain, rather than to spend much of their focus discerning the specific diagnosis within the somatic symptom and related disorders spectrum.

Of particular interest in case three was the patient's recent perceived exacerbation of multiple sclerosis symptomatology incident to her second divorce and the resultant loss of her long-term, “well-compensated” employment. One could also argue that more than a robust home-care package, hospice allowed her to maintain her identity as a sick person. Unfortunately, this case also illustrates how the breakdown in communication between health care professionals (and health care systems) and the missed diagnosis of a severe mental disorder may have contributed to patient harm. Published accounts may suggest that confronting patients about the possible presence of factitious behaviors can be associated with improved outcomes if done via a multidisciplinary team that emphasizes elements of medical and psychological support.¹⁶ This was attempted in this case but was not executed because of lack of patient and clinician buy-in. It is likely that this patient eventually sought care and additional interventions at a different health care system when she did not attain the medical outcome she was seeking.

Approach to factitious disorders for palliative care providers

With the hope of improved symptom management and support, palliative medicine practitioners are often consulted to care for patients with distressing symptoms. Often at the time of consult, the primary practitioner already has utilized commonly accepted approaches to complex symptoms and disease processes without sufficient result. It is not uncommon that palliative care providers are consulted when the symptoms are distressing not only for the patient, but also for the requesting practitioner. When patients are not improving with therapies as expected, providers and staff can experience second thoughts, tension, and self-doubt. If unresolved over time, these tensions can manifest interdisciplinary conflict and changes in practice behaviors.

After a reasonable diagnostic work-up and trial of therapy, it is necessary to reconsider underlying etiologies and differentials. Practitioners must reexamine the data, including the physical and behavioral responses to therapy. If expected responses to treatment are not seen, or if the patient (or the treating team) exhibit red-flag warning signs (Table 4), the broadened differential must include consideration of abnormal health care-seeking behaviors such as factitious disorders. Mental health professionals experienced with these complex presentations (i.e., psychologists, advance practice psychiatric nurses, or psychiatrists) can provide clinical identification, help modify team approaches accordingly, and recommend a schema that allows for maintaining therapeutic relationships.

Table 4.

Red Flags

• Patient behaviors inconsistent with reported or observed symptoms

• No clear objective findings no matter how many and how extensive the diagnostics

• Staff conflicts

• Fellows, residents, and students conflicted

• Intradisciplinary conflicts

• Interdisciplinary conflicts

• Spending far more time than usual on one patient

• Change one's methods or standards of practice

• Question own beliefs, values, and professional abilities

• Role of consultant becomes blurred

• Boundaries become blurred

Conclusion

As providers, we must remain vigilant when these challenging cases present and not allow ourselves to “wash our hands” and in essence abandon such patients as a result of our own discomfort or frustration. Frequently, when significant countertransference is present, provider's distress clouds the ability to identify patients' underlying psychic distress and to seek an appropriate mental health referral. However, as demonstrated in these three cases, the assumption that these cases may be identified solely on our own distress is erroneous as many of these patients are pleasant and outwardly engaging. Most notably is case 1: without a psychologist to identify this disorder we worry this would have been missed and appropriate interventions denied the patient.

As the reach of palliative care consult services continues to expand^13,17,18 and the call for palliative care providers to be involved earlier in the trajectory of illness increases,¹⁸ it is likely that palliative care providers will encounter patients with factitious behaviors with greater frequency. Considering the psychological dimensions of the condition, such patients may request goals of care that may be in contrast with the best interests of their medical situation. Hence, palliative care consult teams need not only be able to recognize a dying patient, but possess an ability to determine when a patient is not dying, even if the patient's expressed goals of care may be comfort. By doing so, palliative care providers are in a unique position to positively impact the care provided to patients with factitious disorders, especially if the palliative care team is able to direct the patient toward more appropriate psychological therapies. For our consult team, the presence of a trained psychologist as a member of our IDT was crucial in the identification of factitious symptoms and the construction of the appropriate care plans.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

Vranceanu

, Barsky

, Ring

: Psychosocial aspects of disabling pain. J Bone Joint Surg Am, 2009; 91:2014–2018.

Halligan

, Bass

, Oakley

: Wilful deception as illness behavior. In: Halligan

, Bass

, Oakley

(eds.): Malingering and Illness Deception. Oxford: Oxford University Press, 2003, pp. 3–28.

Berry

, Nelson

: DSM-5 and malingering: A modest proposal. Psychol Inj Law, 2010; 3:295–303.

Sutherland

, Rodin

: Factitious disorders in a general hospital setting: Clinical features and a review of the literature. Psychosomatics, 1990; 31:392–399.

Pankratz

: Patients Who Deceive: Assessment and Risk in Providing Health Care and Financial Benefits. Springfield IL: Charles Thomas, 1998.

Vrij

: Detecting Lies and Deceit. Pitfalls and Opportunities, 2nd edition. Chiechester: John Wiley, 2008.

Bass

, Halligan

: Factitious disorders and malingering: Challenges for clinical assessment and management. Lancet, 2014; 383:1422–1432.

Drob

, Meehan

, Waxman

: Clinical and conceptual problems in the attribution of malingering in forensic evaluations. J Am Acad Psychiatry Law, 2009; 37:98–106.

Sutherland

, Rodin

: Factitious disorders in a general hospital setting: Clinical features and a review of the literature. Psychosomatics, 1990; 31:392–399.

10.

O'Shea

: Factitious disorders: The Baron legacy. Int J Psychiatry Clin Pract, 2003; 7:33–39.

11.

Bass

, Murphy

: Somatoform and personality disorders: Syndromal comorbidity and overlapping developmental pathways. J Psychosom Res, 1995; 39:403–427.

12.

Mahony

, Blank

, Zallman

, Selwyn

: The benefits of a hospital-based inpatient palliative care consultation service: Preliminary outcome data. J Palliat Med, 2005; 8:1033–1039.

13.

Kelly

, Meier

: Palliative care—A shifting paradigm. N Engl J Med, 2010; 363:781–782.

14.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth edition. Arlington, VA: American Psychiatric Association, 2013, pp. 324–326.

15.

Rief

, Ihle

, Pilger

: A new approach to assess illness behavior. J Psychom Res, 2003; 54:405–414.

16.

Mahondas

, Bewley

, Taylor

: Dermatitis artefacta and artefactual skin disease: The need for a psycho dermatology multi-disciplinary team to treat a difficult condition. Br J Dermatol, 2013; 169:600–606.

17.

Palliative care programs continue rapid growth in US hospitals: Becoming standard practice throughout the country [press release]. New York: Center to Advance Palliative Care; April 5, 2010.

18.

Weissman

, Meier

: Operational features for hospital palliative care programs: Consensus recommendations. J Palliat Med, 2008; 11:1189–1194.