Vol 36 Issue 1 Jan-Mar 2014
62 Indian Journal of Psychological Medicine | Jan - Mar 2014 | Vol 36 | Issue 1
Factitious Disorder-Experience at a
Neuropsychiatric Center in Southern India
Ajit Bhalchandra Dahale, Shivananda Hatti, Harish Thippeswamy, Santosh Kumar Chaturvedi
Factitious disorder (FD; pathomimia), which has
been described as both disease and deception,
presents to the clinician as one of the most
challenging conditions in medical experience.
Patients who present with the symptoms of this
disorder are considered to have a “sick role” seeking
as the motivation for feigning the illness. FD is
distinguished from malingering by this “sick role”
seeking in contrast to external incentives acting as
the motivating factor in the latter.
Categorized as an Axis I DSM IV condition, it is
diagnosed when there is an intentional production or
feigning of physical or psychological signs or symptoms
where the incentive is to assume the sick role and
external incentives for the behavior are absent. In
DSM IV, four subtypes of FD are mentioned – FD
with predominantly psychological signs and symptoms,
FD with primarily physical signs and symptoms,
FD with combined physical and psychological signs
and symptoms, and FD not otherwise specified. In
the expanded International Statistical Classification
10 (ICD-10), FD (F68.1) is defined as repeated
and consistent feigning of symptoms with obscure
motivation for the behavior and is best interpreted as a
disorder of illness behavior and the sick role. Another
related condition is “FD by proxy,” which was described
initially by Meadow as “the deliberate production or
feigning of physical or psychological symptoms or signs
in another person who is under that individual’s care,”
Objective: Factitious disorder is amongst the more intriguing but less-studied psychological disorders. Studies
from different parts of the world have reported of varying prevalence rates. Here, we try to study the prevalence
of factitious disorder in a specific sample of patients attending a neuropsychiatric center in India. Materials
and Methods: We did a retrospective review of our institute’s database for cases with a diagnosis of factitious
disorder in the 10-year duration from 2001 to 2010. We reviewed the available clinical and socio-demographic
data. Results: Of the 81,176 patients seen in the 10-year duration, only 8 patients had been assigned the
diagnosis of factitious disorder, leading to a prevalence rate of 0.985 per 10,000 patients in this sample. Most
of the patients were lost to follow-up; hence. Conclusion: Factitious disorder remains highly underdiagnosed in
developing countries like India. Mental health professionals need to be more aware and inquisitive about this
particular disorder, so that they do not miss the diagnosis.
Key words: Factitious disorder, India, psychological symptoms
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Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
Address for correspondence: Dr. Harish Thippeswamy
Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore - 560 029, Karnataka, India.
Dahale, et al.: Factitious disorder-Southern India
Indian Journal of Psychological Medicine | Jan - Mar 2014 | Vol 36 | Issue 1
and is commonly perpetrated by mothers against infants
or young children.
Literature regarding FD is limited to a few case reports
or small case series. Interestingly, there has also been
a case report on concurrent presence of FD and FD
by proxy. Another newer concept or problem in this
field is “Munchausen by Internet,” where a person
may post false stories of his illness on internet forums
to gain attention.
The diagnosis of FD has controversies regarding the
criteria and its empirical content. Patients with FD
have an unusually long, rich, and changing historical
and clinical profile. So also, FD has high chances of
occurrence of medico-legal issues. FD appears to be
relatively common in specialty medical settings rather
than psychiatric setting – yet, it often goes unrecognized
and undiagnosed. Since FD can be difficult to detect,
its prevalence may be underestimated.
Prevalence of FD varies depending on the type of the
patient population studied, study setting, and even
clinician’s index of suspicion. A community study from
Italy reported the prevalence to be 0.1%, whereas
it was 9.3% in referrals to the National Institute for
Allergy and Infectious Disease with fever of unknown
origin (FUO) lasting over 1 year. Prevalence of FD
in neurology inpatients was reported to be 0.3% in a
German study. Prevalence in psychiatry inpatients
also varies from 0.5 to 8%.[11,12] Among psychiatry
referrals in a general hospital, one study found 10
patients to be diagnosed with FD among 1288 referrals,
making the prevalence 0.78% [Table 1]. There are
very few reports of FD from developing countries, such
as the study regarding FUO in Argentina that reported
four cases of FD amongst 113 cases of FUO and the
case reports from other countries.
After a thorough search in Medline, PubMed,
Embase, Medknow databases, we came across a few
case reports from India of varied presentations like
factitious schizophrenia, multiple physical and sexual
complaints, and oliguria, whereas detailed case
series and long-term studies are yet to be reported.
The age of onset for FD is generally before 30 years.
FD is generally seen more commonly among females,
especially those who are associated with healthcare
field. A retrospective study of 93 patients of FD at the
Mayo Clinic showed that 42% patients were female
Comorbid existence of FD with other psychiatric
Although it is clear that people with FD have a higher
rate of comorbid psychiatric disorders, feigning of
symptoms itself should be an evidence for psychological
distress: “While an act of malingering may be
considered adaptive, by definition, a diagnosis of a
Factitious Disorder always implies psychopathology . . .”
(APA, 1980: 285). Diagnosis of comorbid problems
in people with FD is a contentious issue. DSM Axis I
disorders – depression and anxiety disorders have been
reported, but the data are scanty.
Practical difficulties in the diagnosis of psychiatric
disorders in people with FD include factors such as
Varied presentations in different medical specialities,
lesser index of suspicion in specialists, presentation in
emergency settings where one cannot afford to wait
for being investigated extensively to avoid untoward
happenings, and lack of thorough knowledge about the
symptoms and disease in one who is presenting.
This study from a neuropsychiatric center aims at
reviewing the database for the clinical details of
patients with diagnosis of FD from the year 2001 to
2010. It aims to provide information which would be
useful in increasing the awareness and understanding
about FD at a neuropsychiatric center in a developing
MATERIALS AND METHODS
This study describes the nature of psychiatric diagnoses
and treatment in patients who were identified to have
FD at a neuropsychiatric center in southern India
during the 10-year period between 2001 and 2010. The
institute for patient care and academic pursuit in
mental health and neurosciences. The institute is a
referral center for patients from all over India. It has
a daily psychiatry outpatient turnover of more than
followed by a more detailed evaluation. Postgraduate
trainees from the disciplines of psychiatry, psychiatric
social work, and psychology do the detailed
evaluation and discuss with a consultant psychiatrist.
A diagnosis is made if the condition of the patient
Table 1: Prevalence of factitious disorder
Type of study
Community study (Italy)
Neurology inpatients (Germany)
General hospital patients referred to psychiatry (UK)
Patients with FUO referred to NIAID
Prevalence of FD (%)
Dahale, et al.: Factitious disorder-Southern India
64 Indian Journal of Psychological Medicine | Jan - Mar 2014 | Vol 36 | Issue 1
fulfills the criteria as per ICD-10. The details are
entered into computerized database after appropriate
coding of each case record. Using this computer
database, we identified all individuals with FD
between the years 2001 and 2010. Detailed data
on clinical characteristics was available for five
patients. The hospital records were reviewed by two
psychiatrists. The study was a retrospective chart-
based review and there were no individual patient
identifiers involved in the analysis and reporting.
Consent was provided at the time of registration for
services by each individual.
During the above-mentioned period, 81,176 (52,364
men and 28,812 women) patients were assessed. FD
was diagnosed in only eight patients. Prevalence of
diagnosed FD is, therefore, 0.985 per 10,000 patients
in this sample. Detailed data on clinical characteristics
was available for five patients. Age of the patients
diagnosed with FD ranged from 16 to 40 years. Of all
these patients, one had history of chronic depression
and two had history suggestive of sub-syndromal
depressive symptoms. Personality problems were
diagnosed in three patients, of whom two had anxious
avoidant personality traits and another patient had
histrionic personality disorder. Psychosocial issues like
interpersonal problems with in-laws, over-involved
parents, and self-medication were present in three
patients. Also, one patient had history of dermatitis
Schonlein purpura. No patient came for even a single
follow-up. The socio-demographic and clinical details
of the cases are presented in Table 2.
Diagnosis of FD seems to be infrequent in the general
psychiatric setup in India. Only eight individuals had a
diagnosis after screening over 80,000 cases seen in the
center over a 10-year period. Prevalence of diagnosed FD
is, therefore, 0.985 per 10,000 patients in this sample,
which is on lower side when compared to 0.5-8%
reported in other studies. Judging by the projected
prevalence of FD in the population and the higher
prevalence of mental health problems, perhaps this is
with psychological symptoms would have undergone
evaluation here. It is possible that people who attracted
the diagnoses of FD are the individuals in whom
the presentation was typical and severe. Four of the
patients presented with anxiety symptoms, suggesting
the need to observe for anxiety symptoms in suspected
cases of FD. Three individuals in this sample also had
personality disorder or traits. Perhaps, persons with
physical symptoms as FD present to medical or surgical
settings, whereas those with psychological, emotional,
and behavioral factitious symptoms seek psychiatric
Thus, it is important for the psychiatrists to take a
detailed history of previous admissions and treatment,
along with investigation reports while assessing
individuals with FD. The second issue is authenticity
of the reports as the patients can change the name
be careful before making any diagnosis. In this patient
subtype, there is, however, a high use of psychotropic
medications and this reflects a symptom-focused
Table 2: Demographic and clinical details of cases
Poor concentration, anxiety,
worrying of illness
Bleeding nose on multiple
Bleeding spots in
Stopped all medicines
Citalopram 20 mg/d,
Carbamazepine 600 mg/d
Depressive symptoms Histrionic
behavior traits EUPD traits
Fluoxetine 20 mg
Chronic depression AAPD
AAPD traitsDepressive symptoms,
IPR issues present
No follow-upNo follow-up No follow-upAbsconded No follow-up
Total number may be more than six as some features may be present in more than one patient AAPD – Anxious avoidant personality disorder; AIB –
Abnormal illness behavior; EUPD – Emotionally unstable personality disorder; GAD – Generalized anxiety disorder; HSP – Henoch – Schonlein purpura;
IPR – Interpersonal relationship; OCD – Obsessive compulsive disorder; PD – Personality disorder; SSRI – Selective serotonin reuptake inhibitor
Dahale, et al.: Factitious disorder-Southern India Download full-text
Indian Journal of Psychological Medicine | Jan - Mar 2014 | Vol 36 | Issue 1
Individuals in this sample received counselling with a
psycho-educational focus that included information
on the nature of FD and its relation to the problems
that they had presented with. Most of the patients
did not turn up for follow-up after discharge, whereas
one patient absconded when doctors tried to confront
the patient with the diagnosis and management plan.
to diagnose the FD and no clear guidelines are available
to confront, precautionary methods need to be taken
to avoid untoward outcomes like absconding and
denial for follow-up. Perhaps, the improvement in
the awareness of the nature of the problem among
the patients as well as the relatives may lead to better
coping strategies and minimize the reliance on the
There is a need for improving the awareness of FD
among mental health professionals as well as general
practitioners, as the disorder can be very challenging
to the health care professionals. While the assessment
and management of FD is integrated in the practice
of professionals who specialize in mental health, this
is not the case for general practitioners. There is a
need to build a multidisciplinary approach in the
management of the disorder, as well as for improving
the ongoing support with self-support groups, supported
employment and carer support.
This study has the limitations of being based on a
by a psychiatric trainee and a consultant psychiatrist
before the diagnosis was made. Information gathered
using a semi-structured interview was recorded in the
case notes and diagnoses were made according to the
ICD-10 criteria. These measures ameliorated some of
the disadvantages of the retrospective design.
It can be estimated using prevalence figures available from
other countries that India has about 1.3 million people
unfortunately remain undiagnosed and may be subjected
to extensive medical investigations. Although there
are some case reports on FD, there is still a paucity of
research. This is a retrospective study based on screening
of all adults seen in the outpatient clinic of a tertiary
institution over a 10-year period. Only eight individuals
have been diagnosed as having FD in this time-frame,
and a review of their clinical features and management
indicates the use of psychotropic medications based
approach for comorbidity and symptomatic treatment.
The findings from this study point to the need for further
research in this area. A prospective design with structured
assessment would yield further valuable information.
The authors would like to thank all the units of the
1. Feldman MD, Eisendrath SJ. The spectrum of factitious
disorders. Washington (DC): American Psychiatric Press; 1996.
American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders. Washington: American
Psychiatric Association; 1994.
World Health Organization: The ICD-10 Classification of Mental
and Behavioral Disorders: Clinical descriptions and diagnostic
guidelines. Geneva: World Health Organization; 1992.
Meadow R. Munchausen syndrome by proxy. The hinterland
of child abuse. Lancet 1977;2:343-5.
Feldman MD, Rosenquist PB, Bond JP . Concurrent factitious
disorder and factitious disorder by proxy. Double jeopardy.
Gen Hosp Psychiatry 1997;19:24-8.
Feldman MD. Munchausen by Internet: Detecting
factitious illness and crisis on the Internet. South Med J
Turner MA. Factitious disorders: Reformulating the DSM-IV
criteria. Psychosomatics 2006;47:23-32.
Faravelli C, Abrardi L, Bartolozzi D, Cecchi C, Cosci F,
D’Adamo D, et al. The Sesto Fiorentino study: Point and
one-year prevalences of psychiatric disorders in an Italian
community sample using clinical interviewers. Psychother
Aduan RP , Fauci AS, Dale DC, Herzberg JH, Wolff SM. Factitious
fever and self-induced infection: A report of 32 cases and
review of the literature. Ann Intern Med 1979;90:230-42.
10. Bauer M, Boegner F. Neurological syndromes in factitious
disorder. J Nerv Ment Dis 1996;184:281-8.
11. Catalina ML, Gomez Macias V, De Cos A. Prevalence
of factitious disorder with psychological symptoms in
hospitalized patients. Actas Esp Psiquiatr 2008;36:345-9.
12. Bhugra D. Psychiatric Munchausen’s syndrome.
Literature review with case reports. Acta Psychiatr Scand
13. Sutherland AJ, Rodin GM. Factitious disorders in a general
hospital setting: Clinical features and a review of the
literature. Psychosomatics 1990;31:392-9.
14. Chantada G, Casak S, Plata JD, Pociecha J, Bologna R.
Children with fever of unknown origin in Argentina: An
analysis of 113 cases. Pediatr Infect Dis J 1994;13:260-3.
15. Grover S, Kumar S, Mattoo SK, Painuly NP , Bhateja G,
Kaur R. Factitious schizophrenia. Indian J Psychiatry
16. Sharma I, Ancharaz V, Azmi SA, Chugh S, Ram D. Factitious
disorder-a case report. Indian J Psychiatry 1990;32:285-6.
17. Mishra PB, Shyangwa P , Khandelwal SK, Kalra OP . Factitious
disorder with oligoanuria: A case report. Indian J Psychiatry
18. Krahn LE, Li H, O’Connor MK. Patients who strive to
be ill: Factitious disorder with physical symptoms. Am
J Psychiatry 2003;160:1163-8.
How to cite this article: Dahale AB, Hatti S, Thippeswamy H, Chaturvedi
SK. Factitious disorder-experience at a neuropsychiatric center in Southern
India. Indian J Psychol Med 2014;36:62-5.
Source of Support: Nil, Conflict of Interest: None.