Approach
Research to determine the effectiveness of any specific management techniques for factitious disorders is lacking.[25] The relative merits of confrontational and non-confrontational approaches have been debated, with a general consensus that direct, accusatory interventions are likely to result in more resistance from the patient, patients leaving the hospital against medical advice, or threats of legal action.[3]
When a case of factitious disorder is suspected, but not yet confirmed, the first principle should be to do no harm. Risky interventions or diagnostic procedures, such as surgeries, should be avoided unless absolutely necessary. To the extent possible, treatments should be based on objective data rather than exclusively on patient report. Potentially addictive substances should be avoided when treating pain or psychiatric symptoms. Although it is best to identify one person as the primary provider to the patient, a multi-disciplinary team should be involved. This should include consulting ethics and legal services early.[25] Psychiatric evaluation is warranted in most cases to assess for comorbid psychiatric illness and evaluate suicide risk.
Treatment of urgent conditions
If a patient has induced objective findings, such as infection or hypoglycaemia, these conditions must be treated as is medically indicated. To prevent a patient from sabotaging treatment, it may be necessary to provide supervision for the patient during this initial therapy.
Presenting the suspected diagnosis to the patient
When addressing concerns about a diagnosis of factitious disorder with the patient, the discussion should be non-punitive and supportive, respecting the dignity of the patient. Theoretically, this may increase the likelihood that the patient will engage in treatment with a mental health provider to address the factitious behaviour. The physician might tell the patient that there is some concern that the illness may be factitious but that adequate treatment has been provided in any case.[3] Although patients presenting with factitious illness are likely to provoke anger and frustration in the treating team, it is important to remain calm and supportive in clinical interactions.
Referral for follow-up treatment
When the diagnosis of factitious disorder is discussed with the patient, many will leave the hospital against medical advice and will not be amenable to follow-up treatment. For those who either admit to feigning illness or are open to treatment, the long-term strategy aims towards changing behaviour so that it does not recur. Follow-up treatment with psychotherapy has been discussed in multiple case series and case reports but has not been studied prospectively.[25] Approaches have included psychoanalytic psychotherapy, cognitive behavioural therapy, and supportive therapy in both inpatient and outpatient settings, sometimes augmented with medications appropriate to treat any comorbid psychiatric illness. Although case reports have documented some treatment success with therapy, most patients are unlikely to engage in treatment. Some authors have suggested the establishment of centralised reporting registries to aid in the development of evidence-based treatments.[25] This approach must be balanced with respect for protected health information and relevant laws.
Management of factitious disorder imposed on another (previously factitious disorder by proxy)
When factitious disorder imposed on another (previously factitious disorder by proxy) is suspected, it is essential to remember that these cases are instances of abuse and must be reported to the appropriate authorities, such as child protective services, adult protective services, or the police.[26] The institution's risk-management department or attorney should be consulted to help guide reporting and documentation. The main concern is the safety of the people involved.[27]
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