There are no systematic or controlled treatment studies in patients with factitious disorders. This is hardly surprising, as the patient's primary motive is deception, and the doctor's is to understand or unmask these motives, usually leading to rapid discharge from hospital after deception has been exposed. Furthermore, once the diagnosis is established, the doctor-patient relationship may have become irreparably damaged: negative emotions in the doctor may need to be dealt with before any consideration can be given to 'engaging' the patient in any therapeutic endeavour. Ethical and legal issues may also intrude (see below) and affect management. Although psychotropic medications have been used, the main treatment is psychological, using either confrontational or non-confrontational strategies.

Confrontational approaches

This process is easier if the physician has tangible evidence of fabrication, for example catheters, or medication used in the patient's deception. It is also desirable to have the psychiatrist present when the physician confronts the patient. The approach during confrontation and thereafter should be non-punitive and supportive, stressing continuity of care, and that the patient is a sick person who needs help. This approach was adopted in perhaps the largest published series of patients with factitious disorder treated systematically.(5) Thirty-three patients were 'confronted' with objects found in their room or with clinical data showing that their conditions were factitious. Only 12 (36 per cent) patients acknowledged the truth; the remaining 21 continued to deny that they played any role in creating their disorders. No confronted patient developed serious psychological disturbance or became suicidal, or discharged themselves against medical advice. Four of the most chronic cases became asymptomatic. Most, however, greeted the idea with either overt hostility or passivity and covert negativism.

Non-confrontational strategies

These approaches, advocated by Eisendrath and Feder, (29 are less concerned with the origin of the illness and more with shaping future behaviours. Face-saving is a key element, and it is important for the patient to subsequently explain their 'recoveries' without admitting that their original problems were psychiatric.

One strategy is the therapeutic 'double-bind'. In this approach the patient is presented with two choices: prove that his or her disorder is not factitious by responding to a relatively minor and benign medical intervention, or prove that the disorder is factitious by failing to respond. For example, a woman was offered the double-bind for a wound that had failed to heal in 4 years despite numerous surgical closures. Following this strategy the plastic surgeon told her that her wound should respond to a skin grafting procedure. If it did not, it would mean that her disorder was factitious in origin. The graft took place, and there was no recurrence of infection at

2-year follow-up.(20> This approach has also been used with some success in the rehabilitation of three patients with factitious motor disorders. (21) The strategy was successful in providing patients with a face-saving legitimization of both their illnesses and recoveries.

Another face-saving approach uses 'inexact interpretations', i.e. suggesting a relationship between certain events or stressors, for example being abandoned, and emergence of factitious symptoms. It involves presenting a brief formulation of the problem to the patient, stopping short of overtly identifying the factitious origin. By avoiding confrontation the doctor makes it safe for the patient to relinquish the symptom with a feeling of control. Regrettably, none of these non-confrontational techniques have been evaluated in a systematic fashion.

Systemic interventions

Patients with factitious disorders can create havoc on medical and surgical wards. They often elicit negative and hostile emotions in general hospital staff, especially after the deception has been exposed. The psychiatrist can help staff members to vent and reduce the anger they experience when a factitious diagnosis is confirmed, and also help the staff to understand the likely mechanisms underlying the factitious behaviour. These issues are often best addressed at a multidisciplinary staff meeting. The major task of this group, which should include a member of the hospital medico-legal department as well as the patient's family doctor, is to develop practical treatment guidelines and to discuss the complex legal and ethical issues raised with factitious physical disorders. Some of these issues are discussed in the next section.

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