(007) When the Labs Don’t Add Up: A Case of Factitious Disorder Diagnosis and Management

Abstract:

Background: Factitious disorder (FD) requires evidence that the patient is provoking symptoms. Convincing symptoms with rare objective evidence make diagnosis challenging; C-L psychiatrists frequently assist with care (Jimenez 2020).

Case: Ms. H is a 33-year-old with diagnoses including postural tachycardia syndrome (PoTS), epilepsy, iron deficiency anemia, and generalized anxiety disorder. She was admitted for hypotension, syncope, and acute kidney injury in the setting of reported nausea, vomiting and diarrhea. She was hospitalized one month prior for the same and diagnosed with digoxin toxicity, resulting in discontinuation. On admission, she had a detectable digoxin level (1.2) despite reported discontinuation; digoxin level was 0.4 (0.8-2.0 ng/mL) one week before presentation. Her level increased (1.3) the following day despite fluid resuscitation, indicating she was still taking digoxin; toxicology stated alternative explanations were unlikely. Other inconsistencies included reported epilepsy with undetectable levetiracetam levels despite reported adherence, reported thalassemia with negative electrophoresis, reported PoTS without objective data, and anemia of unclear etiology.

On psychiatric consultation, she endorsed anxiety in the context of illness and denied acute psychosocial stressors. The patient had several factors that increased concern for FD including medical work, receiving healthcare in multiple states, and eagerness to undergo medical interventions. Ms. H was diagnosed with FD but not confronted with the diagnosis. The medical record now includes the FD diagnosis and toxicology’s recommendations for specific labs when she re-presents with symptoms.

Discussion: There is a dearth of evidence to support any one FD management strategy (Eastwood 2008); the approach taken here includes careful record documentation and avoidance of confrontation, keeping Ms. H engaged in outpatient care and reducing unnecessary hospitalizations. She continues to see her PCP weekly, unusual in that many patients are lost to follow-up (Bass 2014). Cardiac FD presentations are more likely falsely reported or feigned, rather than induced (Yates 2016). It is rare to have objective data for FD, as was available here with digoxin levels.

Implication: Although more research is needed, a non-confrontational strategy with coordination between healthcare teams may represent an effective approach to caring for FD patients. C-L psychiatrists play an important role in working developing effective management strategies across the spectrum of care.

References:

Bass, C., Halligan, P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet, 2014, 383: 1422–1432.

Eastwood, S., Bisson, J.I. Management of factitious disorders: a systematic review. Psychother. Psychosom., 2008, 77: 209–218.

Jimenez, X.F., Nkanginieme, N., Dhand, N., Karafa, M., Salerno, K. Clinical, demographic, psychological, and behavioral features of factitious disorder: A retrospective analysis. Gen. Hosp. Psychiatry, 2020, 62: 93–95.

Yates, G.P., Feldman, M.D. Factitious disorder: a systematic review of 455 cases in the professional literature. Gen. Hosp. Psychiatry, 2016, 41: 20–28.