Clinical Vignette
Patient: "Ms. P," 33-year-old nurse, presenting to a new hospital with apparent sepsis after a central line infection — her 4th such admission at different hospitals in 14 months.
Chief Concern: Emergency physician: "This patient presented with fever, rigors, and positive blood cultures from an indwelling central line. She was initially treated for sepsis. However, upon contacting her previous hospitals, we discovered she has been admitted 3 times in the past 14 months at 3 different hospitals for similar infections. The infectious disease consultant notes that the organisms isolated are unusual skin flora, consistent with direct inoculation. The patient has medical knowledge (nurse) and has resisted removal of her central line."
History of Present Illness: Ms. P's medical record reconstruction reveals: hospitalization 1 (14 months ago): central line infection, polymicrobial (skin flora), treated with IV antibiotics, discharged. Hospitalization 2 (9 months ago, different hospital): central line infection, same unusual organism pattern, treated. Hospitalization 3 (5 months ago, third hospital): central line infection again, infectious disease noted 'unusual recurrence pattern.' Current admission (4th hospital): same presentation. Key findings: (1) all infections occurred in the CENTRAL LINE (port of entry she has access to), (2) organisms are consistent with direct inoculation (skin flora introduced into the line), (3) she is a nurse with knowledge of sterile technique AND how to introduce organisms, (4) she resists central line removal (insists she needs it for 'another condition'), (5) she presents to DIFFERENT hospitals, preventing pattern recognition, (6) she is knowledgeable about medical terminology and details, (7) she displays a calm, almost pleased demeanor during hospitalizations, (8) she does NOT have an external incentive (not seeking disability, not avoiding legal issues, not seeking opioids). When confronted with the pattern, she initially denied but then stated: 'Being in the hospital is the only time people take care of me. When I'm admitted, I'm the patient and everything revolves around me.'
Past Psychiatric History: No diagnosed psychiatric condition. History of childhood emotional neglect (parents 'never paid attention to me unless I was sick').
Mental Status Exam: Composed, cooperative. Uses medical terminology fluently. Detailed knowledge of her 'medical conditions.' When asked about the infection pattern, initially defensive, then tearful: described childhood where illness was the only time parents showed attention. Affect flat when discussing deception, tearful when discussing loneliness. No psychotic symptoms. No external incentive identified.
Step 1: Factitious Disorder DSM-5-TR Criteria
Criterion A: Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
Intentional inoculation of central line with organisms (induction of disease). Identified deception: presenting to multiple hospitals to prevent detection, misrepresenting medical history. MET — induction of disease with deception.
Criterion B: The individual presents herself to others as ill, impaired, or injured.
Presents to ERs with genuine (self-induced) sepsis. Maintains 'patient' role. Identified as medically ill. MET.
Criterion C: The deceptive behavior is evident even in the absence of obvious external rewards.
No external incentive: not seeking disability, compensation, opioids, or avoidance of responsibilities. Internal motivation: 'Being in the hospital is the only time people take care of me.' MET — NO EXTERNAL INCENTIVE.
Criterion D: NOT better explained by another mental disorder (such as delusional disorder or another psychotic disorder).
No psychotic symptoms. She knows she is inducing the illness (intact reality testing). Not delusional. MET.
SUBTYPE: Imposed on self (formerly 'Munchausen syndrome').
Imposing illness on herself, not on another person. IMPOSED ON SELF.
Step 2: Factitious Disorder vs. Malingering
| Feature | Factitious Disorder | Malingering | This Patient |
|---|---|---|---|
| Motivation | INTERNAL: assume 'sick role,' receive care, attention | EXTERNAL: financial gain, avoid legal consequences, obtain medications | Factitious: 'only time people take care of me' |
| DSM classification | Mental disorder | V-code (not a mental disorder) | Mental disorder |
| Awareness | Aware of deception (intentional symptom production) | Aware of deception (intentional symptom production) | Aware |
| Goal | Patient status, nurturance | Tangible reward | Patient status and nurturance |
| Treatment | Psychiatric treatment indicated | No psychiatric treatment (motivational/legal issue) | Psychiatric treatment indicated |
Clinical Challenge
Factitious disorder is one of the most challenging diagnoses because the patient actively deceives the treatment team. Detection often requires cross-institutional communication (as in this case) and a high index of suspicion. Ms. P's nursing knowledge facilitated both the symptom production and the medical deception.
Diagnostic Formulation
Diagnostic Conclusion
Factitious Disorder Imposed on Self, with Recurrent Episodes (F68.10): All DSM-5-TR criteria met. Recurrent pattern (4 episodes over 14 months). Self-induced central line infections. Internal motivation (assume sick role). Treatment: (1) Non-confrontational therapeutic engagement (direct confrontation often leads to discharge and re-presentation elsewhere). (2) Psychotherapy focused on underlying attachment needs and childhood neglect. (3) Limit-setting: remove unnecessary medical hardware (central line), consolidate care with one treatment team. (4) Coordinate care across institutions (flag medical record). (5) Address underlying core deficit: chronic emotional neglect creating a need for caregiving that is only met through illness.
Teaching Points
- The critical distinction between Factitious Disorder and Malingering is MOTIVATION. Factitious Disorder involves INTERNAL motivation (desire to assume the sick role, receive care, be nurtured). Malingering involves EXTERNAL motivation (financial gain, avoiding legal consequences, obtaining drugs). Both involve intentional symptom production, but only Factitious Disorder is classified as a mental disorder.
- Factitious Disorder Imposed on Another (formerly 'Munchausen by proxy') involves fabricating or inducing illness in another person (typically a parent inducing illness in a child). This is a form of CHILD ABUSE and requires mandatory reporting. The DSM-5-TR diagnosis is assigned to the PERPETRATOR, not the victim.
- Healthcare professionals (nurses, physicians, paramedics) are overrepresented among factitious disorder patients because they possess the medical knowledge necessary to produce convincing symptoms and evade detection. Ms. P's nursing knowledge allowed her to introduce organisms into her central line and present with genuine sepsis.
- Detection of factitious disorder often requires communication across institutions. Patients frequently present to different hospitals ('hospital shopping') to prevent pattern recognition. Ms. P visited 4 different hospitals. Integrated medical record systems and cross-facility communication are the primary detection mechanisms.
- The underlying psychopathology in factitious disorder often involves early attachment disruption or childhood emotional neglect. Ms. P's statement ('the only time people take care of me') and her history of childhood neglect suggest that illness behavior is a learned strategy for receiving the nurturance that was absent in early life.