Factitious Physical Disorders, Litigation, and Mortality

Abstract

Received Oct. 7, 2003; revision received Feb. 10, 2004; accepted March 10, 2004. From the Langley Porter Psychiatric Hospital and Clinics, University of California, San Francisco. Address reprint requests to Dr. Eisendrath, Langley Porter Psychiatric Hospital and Clinics, University of California, 401 Parnassus Ave., San Francisco, CA 94143-0984; stuarte@lppi.ucsf.edu (e-mail). Copyright 2004 The Academy of Psychosomatic Medicine. This case report describes four patients who died of factors directly related to factitious physical disorder and whose cases involved civil litigation. The causes of death varied among the patients and included massive aspiration pneumonia, cardiac arrest, opioid overdose, and septic shock. We discuss how individuals with factitious disorder may enter the legal system through the process of civil litigation. This entry into the legal system, in which monetary gain plays a significant role, illustrates that the boundary between malingering and factitious disorder can be permeable. Nonetheless, individuals with factitious physical disorder have a strong tendency toward self-injurious behavior that may eventually result in death. In the case series of 20 patients from which these four patients were drawn, four (20%) patients died as a direct result of factitious disease. This mortality rate should serve as a warning sign to physicians who provide care for these patients that they are dealing with a potentially fatal disease. Factitious physical disorders are those in which an individual consciously creates signs or symptoms of disease. The individual may create the signs or symptoms using a fictitious history, a simulation of disease, or by the actual production of disease states. These cases can be quite vexing for physicians and caregivers because they violate the basic patient-doctor contract. In this contract, patients are allowed to remain in the sick role with the expectation that they want to get out of that role as soon as possible. The patient with factitious disorder violates the contract by seeking to remain in the sick role as a primary goal. DSMIV established the following criteria for a diagnosis of factitious disorder: