What is the appropriate treatment approach for a patient with suspected fictitious disorder (Factitious Disorder), involving fabricated illness for attention and sympathy?

Treatment Approach for Factitious Disorder

Initial Recognition and Diagnostic Confirmation

The appropriate treatment approach for factitious disorder centers on early recognition through systematic evaluation of warning signs, followed by supportive, non-confrontational engagement that maintains therapeutic alliance while preventing iatrogenic harm. 1, 2

Key Diagnostic Indicators to Identify

• Multiple prior medical encounters with extensive diagnostic testing that fails to identify organic pathology, often across different facilities ("doctor shopping") 3, 4
• Healthcare or laboratory profession background (reported in 26.8% of cases), which provides knowledge to fabricate convincing symptoms 5
• Vague, poorly described complaints that lack specific anatomic localization or clear temporal patterns, with symptoms fluctuating with activity or stress 1, 3
• Unusual or protracted recoveries from procedures, self-inflicted injuries, and frequent changes of treating physicians 2
• Absence of material gain (distinguishes from malingering) and symptoms are intentionally produced (distinguishes from somatic symptom disorder) 1, 3

Stepwise Management Algorithm

Step 1: Team-Based Assessment and Documentation

• Conduct multidisciplinary team review involving medical, surgical, and psychiatry services to evaluate the pattern of care-seeking behavior 4, 6
• Perform detailed chronological analysis of medical records across all available facilities to identify patterns of deception, simulation, or self-induced illness 4
• Document specific inconsistencies between reported symptoms, objective findings, and observed behaviors without premature confrontation 2
• Screen for psychiatric comorbidity, particularly depression (present in 41.8% of cases) and personality disorders (16.5% of cases), as these require concurrent treatment 5

Step 2: Prevent Iatrogenic Harm

• Avoid exhaustive investigation and unnecessary invasive procedures once factitious disorder is suspected 1
• Limit access to controlled substances and monitor for misuse of anxiety medications or opiates 1
• Coordinate care through a single primary provider to prevent fragmented care and "doctor shopping" 2, 4
• Implement transparent documentation accessible to the entire treating team to maintain consistency in approach 2

Step 3: Supportive Confrontation Strategy

Use a dignity-sparing, stepwise confrontation approach rather than demanding proof or confession, as harsh confrontation may precipitate abrupt discontinuation of care or escalation of manipulative behaviors. 2, 6

• Initiate conversation with empathy: "We've noticed some patterns in your medical care that concern us, and we want to help you in the most effective way possible" 2
• Present objective findings without accusatory language: "The test results don't match what we would expect given your symptoms" 2, 6
• Offer continued therapeutic contact: "We remain committed to your care and want to work with you to address what's really troubling you" 2, 7
• Frame the sick role as maladaptive: "Sometimes people develop patterns of seeking medical care that don't actually help them feel better or improve their quality of life" 2
• Provide face-saving exit: "We can work together to find better ways to address your needs for support and attention" 2, 7

Step 4: Psychiatric Intervention and Psychotherapy

• Consult psychiatry early when factitious disorder is suspected, rather than waiting until after multiple failed medical interventions 4, 7
• Initiate individual outpatient psychotherapy focused on addressing the underlying psychological need to be nurtured and cared for 7
• Consider cognitive-behavioral therapy principles to help patients identify and challenge maladaptive patterns of care-seeking behavior 1
• Address comorbid depression aggressively when present, as depressive symptoms are the most common psychiatric comorbidity 5
• Monitor for suicidal ideation and self-harm risk, particularly during the confrontation and early treatment phases 7

Step 5: Long-Term Management Structure

• Establish scheduled follow-ups with primary care at regular intervals to provide legitimate medical attention and reduce emergency presentations 2, 7
• Create psychiatric advanced directives where jurisdictions permit, to guide treatment during periods of symptom escalation 1
• Involve family members when appropriate, providing psychoeducation about the disorder while maintaining patient confidentiality 1
• Develop crisis management plan with clear criteria for when to seek emergency care versus scheduled appointments 1

Critical Pitfalls to Avoid

• Do not delay psychiatric consultation when factitious disorder is suspected—early intervention prevents irreversible morbidity and iatrogenic harm 4
• Do not perform "locker searches" or other confrontational investigative techniques without ethics consultation, as this damages therapeutic alliance 1
• Do not discharge the patient abruptly after diagnosis, as this may lead to escalation of dangerous behaviors or death at another facility 4
• Do not assume all symptoms are fabricated—patients with factitious disorder can develop genuine medical conditions requiring appropriate treatment 1
• Do not attribute symptoms to "normal aging" or anxiety without systematic evaluation for factitious patterns 1

Prognosis and Outcomes

• Early recognition and psychiatric intervention can lead to resolution of factitious behaviors, with 72% of patients showing improvement after appropriate psychiatric treatment 1
• Unrecognized cases carry significant mortality risk, with deaths occurring from complications of self-induced illness or unnecessary medical procedures 2, 4
• Healthcare profession background and female gender (66.2% of cases) are the most common demographic features, though factitious disorder occurs across all populations 5