He also emphasized the importance of factitious diseases in the private practice of medicine as he described a subgroup of women "who assume the semblance of disease for some inexplicable cause" (5).
Patients with factitious diseases are extremely difficult to recognize because they do not appear different from patients with authentic causes of similar symptoms, because their psychiatric abnormalities are not appreciated, and because doctors and nurses have a low index of suspicion.
On Feigned and Factitious Diseases, Chiefly of Soldiers and Seamen; on the Means Used to Simulate or Produce Them, and on the Best Modes of Discovering Imposters; Being the Prize Essay in the Class of Military Surgery, in the University of Edinburgh Session, 1835-6, with Additions.
It has been estimated that up to 5% of physician-patient encounters may involve factitious diseases (15).
Psychiatrists have studied a small number of patients with various factitious diseases and have proposed the model that is depicted in Figure 2.
The benefits and risks of confrontation have been analyzed by Reich and Gottfried (18), who reviewed 41 cases of various types of factitious disease from a single institution.
Parenthetically, it is interesting to note that factitious disease often begins shortly after a stressful event (32, 33).
First, patients with subtle forms of factitious disease don't appear different from other patients with similar symptoms caused by authentic disease (20, 26, 34, 35), and the psychiatric abnormalities they have are not recognized by their doctors (36).
Therefore, as with many other factitious diseases, physicians must use clinical evidence from multiple sources to establish a diagnosis of surreptitious laxative ingestion, rather than rely primarily on laboratory tests.
False-negative tests, particularly for senna, may delay the diagnosis of factitious disease for years and contribute to complications from unnecessary or inappropriate medical or surgical therapy and overutilization of healthcare resources.
As with other forms of factitious disease, diagnosis of surreptitious laxative ingestion is difficult and often delayed for many years (3, 7-12).