Introduction
Factitous Disorder (FD) is a diagnosis of exclusion,
hence posing a significant challenge to clinician
to diagnose one. Extensive investigation might be
done to search for a valid diagnosis, but due to
the nature of the disorder, which often involves
deception by the patient, investigations would
often be unfruitful. The prevalence of the illness is
unknown, possibly due to the deceptive nature, as
well as under-reported cases, where clinicians are
found to not record the Diagnosis and Statistical
Manual of Mental Disorders, 5th Edition, Text
Revision (DSM-V-TR).
Two types of FD are mentioned in the diagnosis
criteria: Imposed on self or imposed on another
(previously termed by proxy). The core features of
factitious disorder are the falsification of symptoms,
either medical or psychological, through identified deception, through exaggeration, fabrication,
simulation, or induction. Diagnostically, the need
to ascertain the motivation behind the deceptive
behavior is to differentiate between typical FD
and maligering: While malingering involves
a clear secondary gain, FD on the other hand
emphasizes more in identifying the falsification
acts (Table 1). Still, there is lack of clear evidence
of difference between them, and clinicians are still
struggling to be certain in their diagnosis [1]. The
lack of documented cases is because of only 50%
of patients received psychiatric evaluation [2].
There were also reported difficulty in reaching the
diagnosis due to many unnecessary interventions,
further complicating the clinical picture and
causing more harm to the patient [3].
Table 1. : Differences between Factitious Disorder and Malingering
| Factitious Disorder (F68.10/ F68.A) |
Malingering (Z76.5) |
| Classification (DSM-5-TR) |
Somatic symptoms and related disorders |
Other conditions that may be a focus of clinical attention |
| Mental Disorder (Bass et al, 2019) |
A mental disorder |
Not a mental disorder |
| Gender Prevalence (Udoetuk et al, 2020) |
Women>men |
Men>women |
| Behaviour (DSM -5-TR) |
Falsifying symptoms about themselves or others |
Falsifying symptoms about themselves |
| External incentives (Van Impelen et al., 2017) |
Lack of external incentive (assuming sick role/ internal incentive) |
Presence of external incentive (personal gain) |
| Motivation (Lipson, 2013) |
Unconscious |
Conscious |
| Cooperativeness in treatment (Lipson, 2013) |
Cooperative for procedure |
Less cooperative for procedure |
| Associated Personality Disorder (Lipson, 2013) |
Borderline Personality Disorder |
Antisocial Personality Disorder. |
The presented case will further discuss the
relationship between FD, depression, and poly-
pharmacy.
Case Presentation
Ms Volga was a 25-year-old local ethnic lady,
single and unemployed. She first presented to
our psychiatry outpatient clinic in June 2020,
following a referral from private sector.
Miss Volga started having abdominal pain since
her adolescent years. It mostly happened during
the period of menses. She described it as burning,
faint and colicky in nature, with a pain score of
9/10. It gradually worsened until 5 years ago
she decided to seek medical help, and she was
told to have Salmonella infection. Since then,
she was often preoccupied with the worry of
contamination, having intrusive thoughts, and
was having repetitive hand washing up to sixteen
times a day. She would feel relieved for a short
while after the compulsive handwashing, but the
intrusive thoughts would still recur afterwards.
1 year later, Ms Volga’s abdominal pain worsened
and became intolerable, especially during her
menses. She was brought to a clinic and treated
for dysmenorrhea and endometriosis. She was
started on hormonal therapy of oestradiol. She
finds the treatment ineffective, and started having
depressed mood, with occasional crying spells,
reduced energy most of the time, and difficulty
in concentrating in daily tasks. She was having
suicidal ideation due to intolerable pain. She got
admitted to general hospital after an episode of overdosing on paracetamol and flu medication in
2019. It was then she was referred to our psychiatry
outpatient clinic, for continuation of care.
Upon our initial assessment, Ms Volga complained
of her depression symptoms, and revealed that
she heard voices talking to her especially when
she was depressed, commanding and insulting
her. She feels worried and finds herself checking
for information on her illness online. She was
diagnosed Major Depressive Disorder (MDD)
and Obsessive-Compulsive Disorder (OCD),
and started on combination of antidepressant,
antipsychotic, and benzodiazepine.
After some time, we noted that Ms Volga would
frequently visit the clinic before her appointment
date, usually 1-2 days after a change in her
prescription by her clinician. She would request
for change of prescription again, at the same time
provided her list of medications she wished to try
or discontinue. If her wish were not complied,
she would return with physical complaints
which resembled the side effects of prescribed
medications. She also had occasions of visiting
other clinics to request for specific treatment
declined by us and brought their referral letters
back to us as proof. However, if her request were
granted, she showed rapid improvement, even
total resolution of her symptoms, which would
last for few weeks before she came to our clinic
and had new requests again.
Her condition often fluctuated, with sometimes
varying complaints of psychotic-like symptoms
such as seeing vivid bizarre images, hearing
voices, and having the feels of everyone is talking
about her. She also had anger outburst with selfharming
behaviour, with repeated overdosing,
drinking poisons and cutting her forearms. For
those, she was sent to the emergency department
for acute treatment. Due to the increased severity
and bizarre nature of her illness, she was diagnosed
schizophrenia 5 months into her follow-up
treatment.
As Ms Volga repeatedly come to the clinic with
multiple complaints, her medications got revised
repeatedly, often resulted in the increment of
number and dosage of medications. Merely
after 3 years in our care, she had tried on most
antipsychotics, antidepressants, and mood
stabilizers. Her regime at one time consisted
of a combination of high dose oral Sertraline,
lithium, Asenapine, Intramuscular Paliperidone
Palmitate and regular Clonazepam. Despite such
adjustments, her condition still worsened, with
mixture of depressive, Obsessive Compulsive
Disorder (OCD) and psychotic symptoms. She
also suffered from medications side effect such as
weight gain, hyperprolactinemia, and tachycardia,
requiring addition of Propranolol. Psychological
intervention was unfruitful as she was not
cooperative to the therapy.
Results and Discussion
The difficulty of the managing the above case was
due to lack of cooperation from the patient’s main
caregiver-the mother. Patient’s mother would help
her to get the treatment she requested, pleading to
the treating doctors and refusing for any treatment
that may cause discomfort to them. When Ms
Volga’s condition worsened, the team has multiple
times advised for admission for monitoring, but
it was strongly refused. With many occasions of
difficult communications, eventually there was no
longer trust from both sides.
Her challenging behavior towards the clinicians
resembled of those with Borderline Personality
Disorder (BPD): Evident threats, anger outburst,
and irrational demands [4]. Despite having strong
suspicion, we failed to elicit any diagnostically
essential criteria which should be evident from
early adolescent, such as the affective instability,
interpersonal relationships, impulsivity, or identity
disturbances. Based on history provided by multiple sources, most of her changes happened in
her late adolescent, with none of usual predictive
factors such as childhood traumatic experience,
temperamental issue, and difficult parent
relationship [5].
There are many literatures that discuss the
resemblance between FD and Borderline
Personality Disorder (BPD). Goldstein wrote an
analysis report in 1998 based on twenty-nine cases
found over 10-year period in 1998. It was found
consistently that FD affects woman more than
man, with ratio of 2:1. There is more single than
married or divorced patients, which supports the
notion that they are doing poorly in interpersonal
relationships, pointing to the possibility of Axis
II diagnosis-especially BPD of nineteen reported
cases, 53% had a past or present diagnosis of
BPD. It was also reported that BPD shares similar
traits of self-destructive behavior with factitious
disorder [6]. Nadelson has proposed that adoption
of sick role in Munchausen’s Syndrome is
behavior of patients with BPD [7]. Based on all
this information, the team is still monitoring Ms
Volga for the possibility of the diagnosis.
The suspicion of Factitious Disorder arose, when,
as seen in the case [3]:
• Lack of response/improper response
is noted during treatment: Ms Volga’s
condition has not improved since she was
under treatment for 4 years, despite frequent
visits to the hospital. As we went through
her clinical notes, we noticed a pattern: Her
condition often fluctuates following certain
‘triggers’ in her life. For example, after a
switch in her medication, if it is her request
being granted, her psychosis and depression
symptoms would resolve rapidly in just 3
days after the changes made or, if it is her
request denied, her condition will continue to
worsen, resulting in anger outburst and selfharming
episodes at home of note, based on
a trial by Gallego et al., the response is only
evident between 8 to 16 weeks since the start
of treatment for patients with first episode
psychosis. Ms Volga’s rapid resolution of
symptoms is therefore unusual [8].
• Wax-and-waning of symptoms, vague or
unspecific complaints: There were times
that the team found Ms Volga to be highly
suggestible when reporting her symptoms.
During assessment, Ms Volga would answer
yes to most close ended questions about polypresence
of psychopathology, but there were
inconsistencies noted between her claims.
The context of her hallucination changed
frequently, with too much or too little detail of
her experiences. She couldn’t talk specifically
about what were the sequences of events, such
as her anger outbursts, her mood swings, and
the intrusive thoughts that she has experienced
for past 4 years. She also came with somatic
complaints, often resembled side effects of
her medications, and requested doctors to
make altercation to them. Still, she could not
specify the details. Even if she did, they did
not fit into the usual presentation of those
complaints.
• Refusal of a formal assessment: Patients
with FD are often found to be refusing formal
assessment. This may because of the fear of
going through a formal assessment, knowing
that their deception effort could be exposed.
For Ms Volga, she requested for financial
aid in the past, but refused to be assessed by
Occupational Therapists despite the need,
and she refused to provide any reason to her
refusal.
• Gain: Although we found no evidence of
secondary gain which suggests malingering,
Ms Volga did receive much attention from
her mother since she fell ‘ill’. We suspect
the presence of primary gain, which was the
attention given during her sick role. Thus,
bringing the suspicion of Factitious disorder.
The diagnosis is further supported by an
assessment of MMPI-2-RF, conducted by clinical
psychologist. It was reported as there are multiple
domains of with score invalid in their validity
scales, suggestive of over reporting. In a recent
meta-analysis, it is found that MMPI-2-RF is
highly effective in detecting feigning of mental
disorders. The Fp-r in newly revised MMPI-2-RF
maintains its effectiveness in capturing feigned
psychopathology with very high specificity.
Another aspect that needs addressing in this case
poly-pharmacy, which is a common phenomenon
observed in psychiatric treatment. Based on
a recent cohort by Stassen, it is known to be
associated with 60% of treatment in patients in
schizophrenia as well as depressive disorders.
For Ms Volga, poly-pharmacy is one of the main
consequences, stemming from repeated visits
to different clinicians with differing point of
view. She was prescribed four different classes of psychotropic at a time, with most of them are
on high or maximum doses. Based on National
Association of State Mental Health Programme
Directors (NASMHPD) (NASMHPD Technical
Report, 2001), poly-pharmacy is divided into five
groups [9]:
• Same-class poly-pharmacy: Use of more
than one medication of the same class (e.g.,
use of two antipsychotics in patients with
schizophrenia).
• Multi-class poly-pharmacy: It is the use
of full therapeutic doses of more than one
medication from different classes for the
same symptom cluster (e.g., use of lithium
and second generation antipsychotic, such as
olanzapine, for treatment of bipolar disorder).
• Adjunctive poly-pharmacy: Use of one
medication to treat side effects caused by
another medication of a different class
(e.g. usage of trihexyphenidyl to treat
extrapyramidal syndromes caused by
antipsychotics).
• Augmentation poly-pharmacy: It refers
to the use of one medication at a lower than
normal dose along with another medication
from a different class in full therapeutic dose
for the same symptom cluster (e.g. addition of
low dose haloperidol in a patient responding
partially to risperidone); or the addition of a
medication that would not be used alone for
the same symptom cluster (e.g. augmentation
of antidepressants with lithium or thyroid
hormone).
• Total poly-pharmacy: It is the total count of
medications used in a patient, or total drug
load.
The usage of multiple medications has known to
alter the nature of the medicines, including the
therapeutic effects, side effect profiles as well as
the dosage requirements [10]. Despite the known
side effects, psychiatrists still highly adopt polypharmacy.
The reasons are mostly associated
with the lack of response to mono-therapy despite
multiple switching attempts, to compensate for
the side effect of an existing drug, or as preference
based on experience of the treating clinician
[10,11].
It is important to remind ourselves that although
many literatures do not advocate for polypresence pharmacy, it does have supporting evidence of
effectiveness in combination of certain drugs
but none of them are proved superior to another.
There is also a lack of conclusive evidence of the
superiority of poly-pharmacy than mono-therapy
[12-14].
In Miss Volga’s situation, we are concerned
of her medication regime as she was showing
physiological and psychological changes since
the addition of her medicines [15-17]. As we
look back on her clinical notes, her depression
symptoms worsened with increment of her
medication, along with the presence of emotional
and cognition dampening, this can be a side effect
of psychotropic, especially antipsychotics [18].
Through a recent systemic review by Sirinoot,
poly-pharmacy is associated with increased drugrelated
problems and risk of depression. However,
it is often difficult to ascertain the diagnosis of
major depressive disorder due to the possibility of
patient exaggerating or simulating the symptoms
to prolong the sick role [19-22].
Conclusion
The diagnosis of Factitious Disorder should be
based on continuous observation, inconsistencies
of reported symptoms, with evidence from
multiple agencies such as psychiatrist, clinical
psychologist, and occupational therapist. Polypharmacy
may be a direct consequence to patient
with FD, but more research is needed in terms
of their relationship. We also emphasize the
weight of a diagnosis of great disability such as
schizophrenia would imply an opportunity of sick
role adaptation for FD patients.
Notes on Patient Consent
Patient and her mother have given consent for the
team to produce this case report.
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Citation: Late detection of Factitious Disorder- Munchaussenâ??s Syndrome with feigned schizophrenia ASEAN Journal
of Psychiatry, Vol. 25 (1) January, 2024; 1-6.
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