Factitious Disorders in Children and Adolescents

Dear Editor:

In their excellent article in the March issue of Psychiatry 2006, Jaghab et al.¹ review the understudied subject of factitious disorders, including Munchausen syndrome, in children and adolescents. They also offer a new case report involving a 15-year-old boy who engaged in a panoply of medical deceptions to obtain hospitalization with its attendant attention, care, and concern. This boy was lost to follow-up but may have obtained admission to additional inpatient facilities. I would like to supplement their article with a second previously-unreported case for whom 12 years of follow-up is available.

Case report. Ms. A, now age 20, first falsified symptoms at age 8 to “get attention and nurture,” to “feel special,” and to “exert some control over life.” Her life seemed in disarray because of her parents' recent separation and subsequent divorce. Since an even earlier age, Ms. A had found herself envious of the care that people with serious conditions, including her diabetic father, received. Remaining with her mother, whom Ms. A perceived as relishing the role of caretaker and thus unwittingly encouraging symptoms, Ms. A repeatedly reported false flu-like symptoms lasting a day to a week that included nausea and headaches. She sometimes applied heat to thermometers to appear feverish or used her fingers to induce vomiting as a way to support the deceptions. The frequency of such illnesses compromised their believability, however, and so at the age of 13 the patient began to report intractable migraines instead. She modeled her migraines on the authentic ones of her new stepmother. Innumerable doctor visits ensued, with medications prescribed or dosages increased and many referrals to specialists made. The subjective nature of pain—the fact that the experience of pain cannot easily be refuted—led to tacit acceptance of the migraines as valid. At age 17, the patient went off to college, where her general confidence and sense of independence increased, resulting in her gradually abandoning her symptoms. However, in a pattern reflective of malingering (also mentioned by Jaghab, et al.), Ms. A resumed her fallacious complaints of migraines to get days off from her job. Recently, she confessed to her parents that many of her childhood symptoms were enacted, a report they accepted with equanimity, but Ms. A. has insisted to her parents that the migraine reports have always been accurate.

Pseudologia fantastica, or the telling of gratuitous lies that nevertheless are engaging, had been evident since an early age and continues in Ms. A. She found that her lies could “manipulate authority figures.” They included false claims that her grandfather had died, that her mother had cancer, and that she had become pregnant but had a miscarriage. She describes the lying as almost compulsive, adding that she deplores her own pattern of misleading others but feels unable to stop. That said, she currently feels in better control of her tales of illness and personal tragedy but fears that the impulse to enlarge upon them will return.

Discussion. Ms. A appears to have borderline personality traits, as many factitious disorder patients do,² but has not received a formal diagnosis of borderline personality disorder. Her current status is compromised by alcohol abuse and an unhealthy romantic relationship. Still, she is insightful about her 12-year history of factitious illness behavior and is generally motivated for positive change, though not currently receiving psychiatric or psychological care. As noted, her case adds to an important, expanding literature on the expression of factitious disorder in children and adolescents.

With regards,
Marc D. Feldman, MD
Department of Psychiatry and Behavioral Medicine University of Alabama Tuscaloosa, Alabama mdf@myself.com