AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

The term factitious disorder (FD) refers to the psychiatric condition in which an individual presents with an illness that is deliberately produced or falsified for the sole purpose of assuming the sick role. Patients with FD waste precious time and resources with lengthy and unnecessary tests at a high cost to the system. Moreover, patients with FD are among the most challenging and troublesome for busy clinicians and generate feelings of anger, frustration, or bewilderment. Physicians and staff generally expect patients to "behave like patients", and those with FD often violate key unwritten rules: (1) that patients should provide a reasonably honest history; (2) that symptoms should result from accident, injury, or chance; and (3) that patients hold the desire to recover and will cooperate with treatment toward that end.

Patients with FDs likely have been present throughout human history. Their appearance in the literature extends back to the time of the Roman physician Galen, who wrote about them in the second century. In the 1800s, the British physician Gavin described how some soldiers and seamen pretended illness to excite compassion or interest.

The modern history of FD began in 1951, when a clinician (Asher) described case reports of patients who habitually migrate from hospital to hospital, seeking admission through feigned symptoms while embellishing their personal history. He assigned the name Munchausen syndrome to this condition after Baron von Munchausen, a well-respected, retired German cavalry officer who had tales of his life stolen and parodied in a booklet in 1785. Persons with Munchausen syndrome were said to typically (1) exhibit numerous surgical scars, especially in the abdomen, (2) display a truculent or evasive manner, (3) provide a dramatic medical history of questionable veracity, and (4) attempt to conceal such documents as hospital discharge forms or insurance claims. Asher distinguished abdominal, hemorrhagic, and neurologic subtypes.

Since the publication of Asher's article, numerous reports of patients producing or falsifying almost every conceivable kind of illness have appeared in the literature. The type of patient described by Asher is now thought to represent a minority of cases of FD. The term Munchausen syndrome most appropriately refers to the subset of patients who have a chronic variant of FD with predominantly physical signs and symptoms. In practice, however, many still use the term Munchausen syndrome interchangeably with FD. In 1976, the term Munchausen syndrome by proxy entered the medical lexicon and came to describe cases in which an individual artificially produces illness in another person; typically a mother who produces illness in a young child.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) requires that the following 3 criteria be met for the diagnosis of FD: (1) intentional production or feigning of physical or psychological signs or symptoms, (2) motivation for the behavior is to assume the sick role, and (3) absence of external incentives for the behavior (eg, economic gain, avoiding legal responsibility, improving physical well-being, as in malingering).

The DSM-IV-TR recognizes the following 3 types of FD: (1) FD with predominantly psychological signs and symptoms, (2) FD with predominantly physical signs and symptoms, and (3) FD with combined psychological and physical signs and symptoms.

A fourth type, FD not otherwise specified, includes those disorders with factitious symptoms that do not meet the criteria for FD. The DSM-IV-TR places FD by proxy (ie, Munchausen syndrome by proxy) into this category, defining it as "the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care for the purpose of indirectly assuming the sick role." FD by proxy has yet to be recognized as an official separate category in the DSM-IV-TR. Appendix B of the DSM-IV-TR lists the following research criteria for FD by proxy.

• FD by proxy is the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care.
• The motivation for the perpetrator's behavior is to assume the sick role by proxy.
• External incentives for the behavior (such as economic gain) are absent.
• The behavior is not better accounted for by another mental disorder.

Pathophysiology

As with many psychiatric illnesses, the pathophysiology of FD is unclear. Case reports of abnormalities on MRIs of the brains of patients with chronic FD suggest that brain biology may play a role in some cases. In addition, some patients with FD have displayed abnormalities on psychological testing. Results of EEG studies have thus far been nonspecific.

Frequency

United States

The prevalence of FD is unclear. Many authorities believe the condition is underdiagnosed because it involves willful deception, which may be missed by medical staff. Conversely, the prevalence of chronic FD may be overdiagnosed in some cases because the same patients with FD may migrate from hospital to hospital. The frequency of presentation of various factitious illnesses (eg, which factitious illnesses are most common) is unclear. However, most researchers agree that the prevalence of factitious psychological symptoms is much lower than the prevalence of factitious physical symptoms. Studies investigating the prevalence of FD have found the following:

• Of patients referred for evaluation of fever of unknown origin at the US National Institute for Allergy and Infectious Disease, 9.3% had FD.
• Of material submitted by patients as kidney stones, 2.6% was found to be nonphysiologic and probably fraudulent.

International

Whether the epidemiology of FD differs in countries other than the US is unclear.

• Of patients referred to the consultation-liaison service of a large teaching hospital in Toronto, 0.8% (10 of 1288) had FD.
• Of infants brought to a clinic in Australia because of serious illness, 1.5% were cases of FD by proxy.

Mortality/Morbidity

FD can result in morbidity and mortality from the patient's re-creation of actual medical conditions (eg, exogenous administration of insulin) or from the procedures undertaken by the physician to diagnose or treat the condition (eg, unnecessary cardiac catheterizations, surgeries). No studies have quantified the total estimated morbidity and mortality from FD.

Sex

Persons with FD are usually female and employed in medical fields such as nursing or medical technology. Working in the medical field provides knowledge of how disease might be produced artificially and provides access to equipment (eg, syringes, chemicals) with which to do so.

• Persons with chronic FD (ie, Munchausen syndrome) tend to be unmarried men who are estranged from their families.
• Perpetrators of FD by proxy are typically mothers who induce illness in their young children; however, sometimes fathers or others are responsible.

Age

Persons with FD tend to be women aged 20-40 years. Persons with chronic FD (ie, Munchausen syndrome) tend to be middle-aged men.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Patients may feign illness by means of a factitious history alone (eg, falsely claiming to have had a syncopal episode), by a factitious history plus the use of external agents that mimic disease (eg, adding exogenous blood to urine and claiming hematuria), or by a factitious history plus inducing an actual medical condition (eg, injecting bacteria to produce infection, ingesting CNS-active medications to induce psychiatric symptoms). Individuals with an actual medical condition may provide a fictitious history consistent with their condition (eg, epilepsy, pseudoseizures).

Detection of FD is typically slowed by the natural tendency among physicians to believe what patients say. Indeed, this tendency may be even greater because many patients with FD work in the health care field and are colleagues. The detection of FD among those who have an actual medical condition can be even more difficult.

• The presence of the following factors may raise the possibility that the illness is factitious:
• • Dramatic or atypical presentation
  • Vague and inconsistent details, although possibly plausible on the surface
  • Long medical record with multiple admissions at various hospitals in different cities
  • Knowledge of textbook descriptions of illness
  • Admission circumstances that do not conform to an identifiable medical or mental disorder
  • An unusual grasp of medical terminology
  • Employment in a medically related field
  • Pseudologia fantastica (ie, patients' uncontrollable lying characterized by the fantastic description of false events in their lives)
  • Presentation in the emergency department during times when obtaining old medical records is hampered or when experienced staff are less likely to be present (eg, holidays, late Friday afternoons)
• Other clues that may arise during the course of treatment include the following:
• • A patient who has few visitors despite giving a history of holding an important or prestigious job or a history that casts the patient in a heroic role
  • Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
  • Acceptance, with equanimity, of the discomfort and risk of surgery
  • Substance abuse, especially of prescribed analgesics and sedatives
  • Symptoms or behaviors only present when the patient is being observed
  • Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
  • Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
  • Giving approximate answers to questions (eg, a horse has 3 legs; 7 X 6 = 41), usually occurring in FD with predominantly psychological signs and symptoms (see Ganser Syndrome)

Physical

Suspicion of FD is raised when the patient has multiple surgical scars or a gridiron abdomen, indicating the chronic form of FD, or with evidence of self-induced physical signs.

• Mental Status Examination: Patients with FD may vary in their presentation, and no findings have been shown to be pathognomonic. The following findings are possible:
• • Appearance may include physical findings described above.
  • Attitude may range from cooperative with assessment and treatment to evasive and vague regarding details.
  • Mood and affect may be brighter than what would be expected given the patient's medical condition.
  • Perceptual abnormalities, such as hallucinations and disturbances of thought process or thought content, and suicidality and/or homicidality, may be present with FD with predominantly psychological signs and symptoms. Patients having FD with predominantly physical signs and symptoms usually do not confess to thoughts of harming themselves or others, even when they have actually harmed themselves by deliberately inducing physical illness.
  • Cognitive functioning may be aberrant if the patient presents with Ganser syndrome.

Causes

• The causes of FD are not well defined. One psychodynamic explanation asserts that patients with FD, who often have a background of neglect or abandonment, are attempting to reenact unresolved early issues with parents. The following explanations are also possible:
• • Underlying masochistic tendencies
  • A need to be the center of attention and to feel important
  • A need to assume a dependent status and receive nurturance
  • A need to ease feelings of worthlessness or vulnerability
  • A need to feel superior to authority figures (eg, the physician) that is gratified by being able to deceive the physician
• Explanations offered for FD by proxy parallel those for FD, except that the parent is using the children to meet these needs. Thus, the child is used as a tool with which to recreate unresolved issues with parents and authority figures.
• • Alternatively, the mother is presumed to gain vicarious satisfaction of attention and nurturance needs that may be missing from her marriage through projective identification.
  • Another explanation asserts that the behavior stems from narcissism, sociopathy, and the desire to manipulate authority figures.
• The risk factors for developing FD remain largely unclear. Based on the histories of patients with FD, the following can be projected as characteristics that may predispose an individual to develop a factitious illness:
• • Presence of other mental disorders or medical conditions in childhood or adolescence that resulted in extensive medical attention
  • Holding a grudge against the medical profession or having had an important relationship with a physician in the past
  • Presence of a personality disorder, especially borderline, narcissistic, or antisocial personality disorder

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

FD appears in the differential diagnosis for many illnesses. Accordingly, FD must be distinguished from a true or real general medical condition or mental disorder, including those that are (1) due to accident or chance, (2) due to noncompliance with treatment, (3) iatrogenic, or (4) the result of attempted suicide, homicide, or self-mutilation.

FD must also be distinguished from the somatoform illnesses and malingering. FD has been believed to fall on a continuum between these illnesses.

Somatoform disorders include the following conditions:

• Somatization disorder (ie, multiple physical complaints over many years)
• Conversion disorder (ie, defects in sensory or motor functioning having a psychological origin)
• Hypochondriasis (ie, preoccupation with imagined disease or illness)
• Somatoform disorder not otherwise specified (eg, pseudocyesis)
• Pain disorder (ie, severe pain in which psychological factors have a strong component)
• Body dysmorphic disorder (ie, intense preoccupation with a real or imagined defect in appearance)

The differential diagnosis for FD by proxy includes the following possibilities:

• Real medical illnesses
• Overanxious parenting
• Normal variability between illnesses
• Illnesses resulting from discontinuation of medicines
• Malingering (by an older child)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The diagnosis of FD is typically made late, after other diagnostic possibilities have been exhausted. Laboratory studies can be especially helpful in facilitating the diagnosis of many physical illnesses as factitious.
• • For example, patients with hypoglycemia can be assessed for exogenous insulin injection by a finding of increased serum insulin/C-peptide ratio (>1.0) during a hypoglycemic episode.
  • Patients who complain of kidney stones can be asked to filter their urine for stones, and the submitted material can be tested for composition.
  • A tissue biopsy can be helpful in revealing the factitious nature of lesions in which foreign material has been injected to simulate naturally occurring disease.
• Because the range of factitious illnesses is limited only by the imagination of the perpetrator, listing all possible laboratory tests that might prove useful is impossible. However, suspicion that an illness is factitious should be conveyed to the pathologist, who may be helpful in identifying ways to confirm the diagnosis.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Provide medical care as needed to treat comorbid conditions and complications arising from induced illness.

• Psychiatric care
• • Patients with FD must be evaluated fully and assessed for comorbid axis I and axis II diagnoses. By treating axis I disorders, improvement or resolution of factitious behavior may also occur.
  • Pharmacotherapy must be monitored carefully to prevent patients from perpetuating self-destructive behavior. Medications to treat the symptoms of personality disorders, such as selective serotonin reuptake inhibitors (SSRIs) to reduce impulsivity, may be of benefit.
  • Psychotherapy should focus on establishing and maintaining a relationship with the patient. Supportive psychotherapy may help contain the symptoms of FD.
  • Family therapy may help families to better understand patients and their need for attention.
  • Cognitive-behavioral therapy may prove difficult when patients are unable to form a collaborative team with the treatment provider; patients with comorbid antisocial personality disorder may be especially difficult.

Surgical Care

Provide surgical care as needed to treat comorbid conditions and complications arising from induced illness.

Consultations

• Psychiatrists
• • Obtaining a psychiatric consultation is recommended when the practitioner believes an illness may be factitious.
  • Health care providers should work as a team, together with nursing, social work, and legal personnel.
  • The patient should be gently confronted with the team's suspicions in a supportive manner that focuses on the patient's psychological distress as the source of illness.
  • Psychiatric treatment should be offered to the patient.
  • The patient with FD will probably try to split the team, and this is a danger for the psychiatric consultant who attempts to establish a therapeutic relationship with the patient. Accordingly, some authorities feel that therapy should not be attempted with patients who have FD unless they can make a good-faith showing of desire for therapy.
  • Patients who are confronted typically deny that they have manufactured disease, although a few will admit it.
  • Patients with the chronic form of FD typically become angry and discharge themselves from the hospital to try to perpetuate their illness elsewhere.
  • A small percentage of patients with FD will consent to psychiatric treatment.
• Where FD by proxy is suspected, the law requires physicians to notify the authorities and to initiate steps for the immediate protection of the child.
• • Protection may involve removal of the child from the home, at least until the situation can be completely assessed.
  • Once protective measures are in place, the mother should be confronted with the evidence. She will almost certainly deny the charge and will attempt to remove the child from the hospital.
  • Criminal prosecution of the perpetrator may also be necessary.
  • Evaluation should not be limited to the child involved but should also include his or her siblings.
  • Psychotherapy should be offered to the mother, the affected children, and the family.
  • Pharmacotherapy may be appropriate when the mother has comorbid axis I or axis II conditions that are amenable to treatment.
  • The family requires careful long-term monitoring, especially because of the danger that the mother could move her family and seek to perpetrate such behavior in a new location.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

There is a lack of evidence to support the efficacy of any particular pharmacological intervention in treating FD. However, pharmacologic therapy for concurrent psychiatric diagnoses is indicated.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Further inpatient care may be required if patients relapse. This includes the treatment of any medical or surgical conditions as well as psychiatric hospitalization when necessary.

Further Outpatient Care

• Close psychiatric follow-up care and monitoring in the outpatient setting is indicated to prevent relapse. Close medical follow-up care may also be necessary, depending on the condition.

Transfer

• Transfer from the medical floor to an inpatient psychiatric department is indicated if patients agree to treatment. In rare cases, involuntary hospitalization may be possible if the patient's health is jeopardized severely by continued production of factitious illness (eg, the patient has already lost a kidney because of FD and is in danger of losing another).

Deterrence/Prevention

• Deterrence and prevention involve clear documentation of patients with a known history of FD, although it does not involve blacklisting.

Complications

• Complications may arise from the induction of factitious illness or arise iatrogenically from the workup or treatment for the condition, in addition to producing high health care costs.

Prognosis

• Chronic FD appears to follow an unremitting course. Treatment may transiently ameliorate symptoms but does not appear to last.
• Patients with simple FD follow a more variable course. Some who seek treatment may be able to overcome their illness. In any event, simple FD appears to have some tendency to remit in the fourth decade of life.

Patient Education

• The patient confronted with staff suspicions that the illness is factitious may be unreceptive to attempts at patient education. Still, education should be attempted in the same gentle and supportive manner with which the patient is confronted. If the patient gives permission, educating family members about the patient's condition may also be helpful. Education as to risks of noncompliance with treatment recommendations is also important, ethically and legally, because the patient may wish to sign out against medical advice.
• • Convey empathy for the patient's distress that has led to the feigning or intentional production of illness.
  • Inform the patient that his or her distress may improve with treatment.
  • Point out that without treatment, the patient may again seek hospitalization.
  • Emphasize that each episode of producing or feigning illness can result in significant morbidity or even mortality for the patient through the production of illness or the undergoing of unnecessary tests or treatments.
• If the patient is receptive to psychiatric treatment, patient education may be an important component of psychotherapy. Information from this article or other sources may be used to help the patient understand more about his or her illness, including the presumed origins of factitious behavior and the importance of regular follow-up care with the psychiatrist.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• A patient with FD is entitled to the same rights to privacy and confidentiality of information as any other patient.
• • Although patients with FD waste valuable resources, notifying other hospitals of patients with FD or circulating a blacklist of such patients likely violates the physician's ethical and legal duties; therefore, this practice should be discouraged. Keep in mind that patients with FD can and do litigate.
  • Searching a patient's belongings for items used in perpetrating factitious illness without permission likely violates the patient's privacy unless the search is conducted with the patient's consent. Consent can sometimes be gained however, by revealing to the patient that one has suspicions that the illness is factitious and then asking for permission to search. Patients may insist they have nothing to hide and allow the search.
  • The use of video cameras to monitor patient behavior, if already in routine use to monitor patients' rooms (eg, in some critical care wards) would not appear to violate privacy considerations. The covert operation of cameras for the specific purpose of catching the patient with FD is a more controversial method that is sometimes used.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Aduan RP, Fauci AS, Dale DC, et al. Factitious fever and self-induced infection: a report of 32 cases and review of the literature. Ann Intern Med. Feb 1979;90(2):230-42. [Medline].
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association;2000.
• Asher R. Munchausen's Syndrome. Lancet. 1951;1:339-41.
• Awadallah N, Vaughan A, Franco K, et al. Munchausen by proxy: a case, chart series, and literature review of older victims. Child Abuse Negl. Aug 2005;29(8):931-41. [Medline].
• Banerjee A. Factitious disorders presenting as acute emergencies. Postgrad Med J. Feb 1994;70(820):68-73. [Medline].
• Benbadis SR. The problem of psychogenic symptoms: is the psychiatric community in denial?. Epilepsy Behav. Feb 2005;6(1):9-14. [Medline].
• Bergethon PR. Factitious ventricular tachycardia. Ann Intern Med. Oct 1987;107(4):593-4. [Medline].
• Bools C. Factitious illness by proxy. Munchausen syndrome by proxy. Br J Psychiatry. Sep 1996;169(3):268-75. [Medline].
• Cramer B, Gershberg MR, Stern M. Munchausen syndrome. Its relationship to malingering, hysteria, and the physician-patient relationship. Arch Gen Psychiatry. Jun 1971;24(6):573-8. [Medline].
• Eisendrath SJ, McNiel DE. Factitious physical disorders, litigation, and mortality. Psychosomatics. Jul-Aug 2004;45(4):350-3. [Medline].
• Feldman MD, Eisendrath SJ, eds. The Spectrum of Factitious Disorders. Washington DC:. American Psychiatric Press;1996.
• Feldman MD. Playing Sick?; Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York, NY: Routledge:. 2004.
• Fenelon G, Mahieux F, Roullet E, Guillard A. Munchausen''s syndrome and abnormalities on magnetic resonance imaging of the brain. BMJ. Apr 27 1991;302(6783):996-7. [Medline].
• Folks DG. Munchausen''s syndrome and other factitious disorders. Neurol Clin. May 1995;13(2):267-81. [Medline].
• Folks DG, Freeman AM 3rd. Munchausen''s syndrome and other factitious illness. Psychiatr Clin North Am. Jun 1985;8(2):263-78. [Medline].
• Ford CV, Feldman MD. Factitious disorders and malingering. In: Textbook of Consultation-Liason Psychiatry. The American Psychiatric Press. 1996:533-544.
• Huffman JC, Stern TA. The diagnosis and treatment of Munchausen' s syndrome. Gen Hosp Psychiat. Sep-Oct 2003;25(5):358-363.
• Justus PG, Kreutziger SS, Kitchens CS. Probing the dynamics of Munchausen''s syndrome. Detailed analysis of a case. Ann Intern Med. Jul 1980;93(1):120-7. [Medline].
• Kass FC. Identification of persons with Munchausen''s syndrome: ethical problems. Gen Hosp Psychiatry. Jul 1985;7(3):195-200. [Medline].
• Keiser HR. Surreptitious self-administration of epinephrine resulting in ''pheochromocytoma''. JAMA. Sep 18 1991;266(11):1553-5. [Medline].
• Kooiman CG. Neglected phenomena in factitious illness: a case study and review of literature. Compr Psychiatry. Nov-Dec 1987;28(6):499-507. [Medline].
• Krahn LE, Li H, O''Connor MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry. Jun 2003;160(6):1163-8. [Medline].
• Lebowitz MR, Blumenthal SA. The molar ratio of insulin to C-peptide. An aid to the diagnosis of hypoglycemia due to surreptitious (or inadvertent) insulin administration. Arch Intern Med. Mar 8 1993;153(5):650-5. [Medline].
• McBride A. Quite sane: the true syndrome of Baron Munchausen and a case report of Ophthalmic Munchausen syndrome. Psychiatric Bulletin. 1992;16:432-4.
• Meadow R. Munchausen syndrome by proxy. Arch Dis Child. Feb 1982;57(2):92-8. [Medline].
• Mitchell CC, Frank MJ. Pseudobradycardia during Holter monitoring. The electronic Munchausen syndrome?. JAMA. Jul 23 1982;248(4):469-70. [Medline].
• Newmark N, Adityanjee, Kay J. Pseudologia fantastica and factitious disorder: review of the literature and a case report. Compr Psychiatry. Mar-Apr 1999;40(2):89-95. [Medline].
• Roberts I, Cohen H, Reeves WG. Characterisation of antibodies to insulin to help diagnose factitious hypoglycaemia. Br Med J (Clin Res Ed). May 11 1985;290(6479):1391-2. [Medline].
• Rogers R, Bagby RM, Rector N. Diagnostic legitimacy of factitious disorder with psychological symptoms. Am J Psychiatry. Oct 1989;146(10):1312-4. [Medline].
• Stern TA, Cremens CM. Factitious pheochromocytoma. One patient history and literature review. Psychosomatics. May-Jun 1998;39(3):283-7. [Medline].
• Taylor S, Hyler SE. Update on factitious disorders. Int J Psychiatry Med. 1993;23(1):81-94. [Medline].
• Wallach J. Laboratory diagnosis of factitious disorders. Arch Intern Med. Aug 8 1994;154(15):1690-6. [Medline].
• Wise MG, Ford CV. Factitious disorders. Prim Care. Jun 1999;26(2):315-26. [Medline].

Article Last Updated: Apr 13, 2006