Factitious disorder কাকে বলে?
Factitious disorder হলো এমন একটি psychiatric disorder যেখানে ব্যক্তি ইচ্ছাকৃতভাবে অসুস্থতার লক্ষণ বানায়, exaggerate করে, test result manipulate করে, বা নিজেকে অসুস্থ করে তোলে, কিন্তু প্রধান উদ্দেশ্য টাকা/ছুটি/আইনি সুবিধা নয়—বরং “sick role” গ্রহণ করা, care/attention পাওয়া, hospital system-এর সঙ্গে যুক্ত থাকা। DSM-5-TR অনুযায়ী এটি Factitious disorder imposed on self অথবা Factitious disorder imposed on another হতে পারে; imposed on another হলে এটি child/elder abuse হিসেবে বিবেচ্য।
Malingering থেকে পার্থক্য: malingering-এ external gain থাকে—যেমন টাকা, চাকরি থেকে ছুটি, মামলা এড়ানো; Factitious disorder-এ external reward স্পষ্ট থাকে না। ICD-11 এটিকে malingering থেকে আলাদা করেছে।
Etiology / Cause — কারণগুলো
Factitious disorder-এর একক cause নেই; সাধারণত psychological vulnerability + trauma + personality pattern + medical-system exposure মিলে হয়।
- Childhood trauma / neglect / abuse: ছোটবেলায় অবহেলা, শারীরিক/মানসিক নির্যাতন, parental loss থাকলে পরবর্তীতে care পাওয়ার অস্বাভাবিক pattern তৈরি হতে পারে।
- Severe childhood illness বা frequent hospitalization: শিশু বয়সে দীর্ঘ অসুস্থতা থাকলে “illness identity” তৈরি হতে পারে।
- Personality disorder traits: বিশেষ করে borderline, dependent, narcissistic বা antisocial traits থাকতে পারে।
- Healthcare-related exposure: স্বাস্থ্যকর্মী, medical knowledge বেশি থাকা, বা পরিবারের কেউ স্বাস্থ্যসেবার সঙ্গে যুক্ত থাকলে symptoms convincingly fabricate করা সহজ হয়।
- Depression/anxiety/low self-esteem: অনেক ক্ষেত্রে comorbid depression/anxiety থাকে; medication এগুলো target করে, Factitious disorder নিজে নয়।
Clinical Features / Symptoms — লক্ষণগুলো
A. Core symptoms
- বারবার অসুস্থতার গল্প বলা, কিন্তু objective finding inconsistent।
- unexplained fever, bleeding, seizure-like episode, hypoglycaemia, diarrhoea, wound infection ইত্যাদি তৈরি করা।
- test result বা specimen manipulate করা—যেমন urine sample-এ blood/glucose মেশানো।
- বারবার hospital admission, multiple doctors/hospitals change করা।
- extensive medical knowledge দেখানো, কিন্তু history inconsistent।
- treatment failure বা “rare disease” claim করা।
- unnecessary surgery/procedure চাইতে পারে।
- family/previous records verify করতে না দেওয়া।
B. Common fabricated/induced presentations
| Presentation | কীভাবে তৈরি হতে পারে | Specific clue |
| Factitious fever | thermometer manipulation, contaminated sample | fever chart inconsistent, pulse-temperature mismatch |
| Factitious hypoglycaemia | insulin/sulfonylurea misuse | low glucose with abnormal insulin/C-peptide pattern |
| Factitious diarrhoea | laxative abuse | unexplained dehydration/electrolyte disturbance |
| Skin/wound lesion | self-inflicted wound, contamination | accessible body area, unusual healing pattern |
| Seizure-like episode | pseudoseizure-like presentation | EEG/video-EEG mismatch, atypical semiology |
| Bleeding/haematuria | blood contamination, anticoagulant misuse | inconsistent labs, abnormal coagulation/drug screen |
Clinically Diagnosis — কীভাবে diagnose করবেন
DSM-5-TR clinical criteria, simplified
- Falsification / induction: ব্যক্তি physical বা psychological signs/symptoms fabricate, exaggerate বা induce করে।
- Deceptive presentation: নিজেকে বা অন্যকে অসুস্থ/আহত/disabled হিসেবে present করে।
- External reward নেই: money, legal benefit, job leave—এগুলো প্রধান motive নয়।
- Better explanation নেই: malingering, delusional disorder, somatic symptom disorder, conversion disorder ইত্যাদি দিয়ে ভালোভাবে explain হয় না।
Clinical diagnosis করার practical steps
- Non-judgmental history: সরাসরি “আপনি মিথ্যা বলছেন” বলা যাবে না। এতে patient doctor-shopping বাড়াতে পারে।
- Old record collect: previous admission, surgery, lab reports, prescription, discharge summary cross-check।
- Collateral history: family/caregiver থেকে history নিন—patient consent থাকলে।
- Pattern identify: recurrent unexplained illness + inconsistent objective findings + multiple hospital visits।
- Rule out true disease first: Factitious disorder diagnosis দেওয়ার আগে organic disease exclude করা জরুরি।
- Psychiatric assessment: depression, anxiety, trauma, personality disorder, self-harm risk, substance misuse assess করুন।
- One primary clinician model: একাধিক doctor না বদলে একজন coordinated physician + psychiatrist follow-up রাখুন।
Investigations — specific কী কী করবেন
Investigation diagnosis confirm করার জন্য নয়; বরং true disease exclude এবং fabrication/induction pattern detect করার জন্য।
Baseline investigations
- CBC with differential
- ESR/CRP
- RBS/FBS, HbA1c
- Urea, creatinine, electrolytes
- LFT
- TSH/free T4
- Urinalysis + urine microscopy
- Pregnancy test, if relevant
- ECG before QT-prolonging psychotropics
- Toxicology/drug screen, if suspicion থাকে
- Previous medical record review — খুব গুরুত্বপূর্ণ
Symptom-specific investigations
| Suspected presentation | Specific test |
| Hypoglycaemia | Plasma glucose, insulin, C-peptide, sulfonylurea screen |
| Fever/sepsis claim | Blood culture, urine culture, CRP/procalcitonin; line/wound contamination check |
| Bleeding | PT/INR, aPTT, platelet count, fibrinogen, anticoagulant screen |
| Diarrhoea | Stool R/E, stool osmotic gap, laxative screen where available |
| Thyrotoxicosis claim | TSH, free T4, free T3, thyroglobulin; exogenous thyroxine suspicion |
| Seizure-like episode | Video-EEG, serum prolactin/CK only supportive, not diagnostic |
| Skin lesion | Dermatology review, wound culture, lesion accessibility pattern |
| Psychiatric comorbidity | PHQ-9, GAD-7, suicide/self-harm assessment, personality assessment |
Differential Diagnosis
| Disorder | পার্থক্য |
| Malingering | clear external gain থাকে |
| Somatic symptom disorder | symptom নিয়ে excessive anxiety থাকে, deception থাকে না |
| Illness anxiety disorder | অসুখ হওয়ার ভয়; intentional fabrication নয় |
| Conversion disorder / functional neurological disorder | neurological symptom থাকে, কিন্তু deliberate falsification নয় |
| Delusional disorder, somatic type | fixed false belief থাকে; deception নয় |
| Borderline personality disorder | self-harm/instability থাকতে পারে; Factitious behaviour comorbid হতে পারে |
| Substance misuse | drug-induced symptoms mimic করতে পারে |
| True rare disease | সবসময় exclude করতে হবে |
Management / Treatment — guideline-based
1. Core treatment: psychotherapy + coordinated care
Factitious disorder-এর treatment challenging; robust evidence কম। Systematic review অনুযায়ী কোনো single management method-এর strong evidence নেই; psychotherapy, supportive approach, এবং coordinated care সবচেয়ে practical approach।
Non-pharmacological management
- Supportive psychotherapy: shame/guilt না বাড়িয়ে distress, loneliness, emotional need address করা।
- CBT: illness behaviour, attention-seeking cycle, maladaptive belief modify করা।
- DBT skills: emotional dysregulation, self-harm tendency, impulsivity থাকলে useful।
- Trauma-focused therapy: childhood trauma/PTSD থাকলে।
- Family therapy: family reinforcement কমানো, healthy support তৈরি।
- Single clinician contract: unnecessary tests/procedures কমাতে one physician + psychiatrist coordination।
- Avoid aggressive confrontation: direct accusation করলে patient treatment abandon করতে পারে।
- Safety plan: self-harm, poisoning, insulin misuse, anticoagulant misuse থাকলে urgent safety management।
- Factitious disorder imposed on another: victim separation, safeguarding, medico-legal reporting, paediatric/psychiatric/social service involvement জরুরি।
Pharmacological treatment — point আকারে
Important: Factitious disorder-এর core symptom-এর জন্য কোনো approved specific drug নেই। Medicine ব্যবহার হবে comorbid depression, anxiety, OCD, insomnia, bipolarity, psychosis, severe agitation থাকলে। Mayo Clinic-ও উল্লেখ করে medicines mainly comorbid depression/anxiety-এর জন্য ব্যবহৃত হয়।
বাংলাদেশে available brand examples সহ medication table
Brand availability সময়/এলাকা/stock অনুযায়ী বদলাতে পারে; prescription দেওয়ার আগে DGDA/registered pharmacy source verify করা উচিত। নিচের brand examples Bangladesh drug databases/company pages-এ listed।
| Generic | কেন ব্যবহার করবেন | Adult dose & duration | Bangladesh brand examples with mg | Major side effects | Major interactions |
| Sertraline | Comorbid depression, GAD, panic, OCD/PTSD symptoms; first-line SSRI option | Start 25 mg OD 1 week, then 50 mg OD; increase by 50 mg weekly; max 200 mg/day. Continue usually 6–12 months after remission, then taper. BNF dosing supports 25→50 mg titration. | Repose 25/50/100 mg, Zosert 25/50 mg, Seronex 25/50/100 mg, Chear 25/50 mg, Andep 25/50 mg, Setra 50 mg | Nausea, diarrhoea, insomnia/somnolence, sexual dysfunction, tremor, hyponatraemia, serotonin syndrome, initial anxiety | MAOI/linezolid/methylene blue contraindicated; tramadol, triptan, other SSRI/SNRI → serotonin syndrome; NSAID/aspirin/warfarin → bleeding risk |
| Escitalopram | Depression/anxiety prominent হলে; less activating SSRI | Start 5–10 mg OD; usual 10 mg OD; max 20 mg/day; elderly/hepatic impairment usually max 10 mg. BNF: adult initially 10 mg, maintenance 5–20 mg. | Nexito 5/10/20 mg, Oxapro 5/10 mg, S-Citapram 5/10 mg, Citalex 5/10 mg, Escilex 5/10/20 mg, Esipram 5/10 mg, Citalam 5/10 mg | Nausea, headache, insomnia, sexual dysfunction, QT prolongation, hyponatraemia | MAOI contraindicated; QT-prolonging drugs/macrolide/fluoroquinolone/antipsychotic caution; NSAID/warfarin bleeding risk |
| Fluoxetine | Depression/OCD with low energy, hypersomnia; long half-life helpful if adherence poor | Start 10–20 mg morning, usual 20 mg/day; increase up to 60 mg/day if needed. BNF: adult initially 20 mg daily, up to 60 mg. | Prolert 20 mg capsule; 20 mg/5 ml suspension, Prodep 20 mg capsule, Seren 20 mg capsule | Insomnia, anxiety, GI upset, sexual dysfunction, weight change, serotonin syndrome | MAOI contraindicated; because long half-life, MAOI start করতে হলে 5-week washout দরকার; CYP2D6 interactions—TCA, antipsychotic, metoprolol, tamoxifen caution |
| Mirtazapine | Depression + insomnia + poor appetite/weight loss থাকলে | Start 15 mg HS, range 15–45 mg HS. BNF: 15–30 mg at bedtime initially, up to 45 mg. | Mitaprex 7.5/15/30 mg, Mitadip 7.5/15/30 mg, Mirzalux 15/30 mg, Mitrazin 7.5/15/30 mg, Mirtaz 7.5/15/30 mg, Rejoy 7.5/15/30 mg, Resant 15 mg | Sedation, weight gain, increased appetite, dry mouth, constipation, dizziness; rare neutropenia | Alcohol/benzodiazepine/opioid → sedation/respiratory depression; MAOI contraindicated; other serotonergic drugs caution |
| Clonazepam | Severe acute panic/anxiety/insomnia হলে short-term only; dependence risk থাকায় routine নয় | 0.25–0.5 mg HS or BID short term; usually ≤2–4 weeks, taper slowly. Panic/seizure indications recognised; serious sedation/respiratory risk with CNS depressants. | Clonatril 0.25/0.5/1/2 mg, Clonium 0.5/1/2 mg, Cloron 0.5/1/2 mg; drops 2.5 mg/ml, Lonazep 0.5/2 mg; MD 0.5/1/2 mg, Leptic ODT 0.25/0.5 mg, Clonapex 0.5/1 mg, Clonepam 0.5 mg | Drowsiness, ataxia, cognitive slowing, falls, paradoxical disinhibition, tolerance, dependence, withdrawal seizure | Alcohol, opioids, sedatives, antihistamines, antipsychotics → severe sedation/respiratory depression; avoid in substance use disorder |
| Quetiapine | Only if comorbid psychosis, bipolar disorder, severe agitation, or specialist-indicated insomnia; not first-line for FD | Dose depends on indication. For bipolar depression, titration often 50→100→200→300 mg HS by day 4; psychosis/bipolar mania specialist titration. BNF provides titration guidance and max up to 800 mg/day depending indication. | Qmax 25/100 mg; XR 50/200/300 mg, Quiet 25/100 mg; XR 50/200/300/400 mg, Qutipin 25/100 mg; SR 50/200/300 mg, Queta 25/100 mg; XR 50/200/300/400 mg, Qutap 25/100 mg, Seropin 25/100 mg, Seroquet 25/100 mg; ER 50/200 mg, Tiapine 25/100 mg; XR 50/200/300/400 mg | Sedation, orthostatic hypotension, weight gain, dyslipidaemia, hyperglycaemia, QT prolongation, EPS rare, NMS rare | CYP3A4 inhibitors—clarithromycin, ketoconazole, ritonavir ↑level; carbamazepine/phenytoin ↓level; alcohol/sedatives ↑sedation; QT-prolonging drugs caution |
Drug monitoring
- SSRI start করলে first 1–2 weeks anxiety/suicidal ideation monitor।
- Baseline and follow-up: weight, BP, sleep, sexual side effect, sodium if elderly/diuretic।
- Quetiapine হলে: weight/BMI, fasting glucose/HbA1c, lipid profile, BP, ECG if cardiac risk।
- Benzodiazepine হলে: dependence, misuse, sedation, driving risk, respiratory disease check।
- Any self-induced poisoning/insulin/anticoagulant misuse থাকলে inpatient safety monitoring দরকার।
Prevention — কীভাবে প্রতিরোধ/relapse কমাবেন
- Early recognition: repeated unexplained illness + inconsistent record দেখলে early psychiatry liaison।
- One hospital/one physician plan: multiple unnecessary tests/procedures কমানো।
- Non-punitive communication: patient-কে shame না দিয়ে “stress-body connection” model ব্যবহার।
- Regular scheduled follow-up: crisis হলে emergency admission নয়, বরং structured outpatient visit।
- Family education: excessive attention বা reinforcement কমানো, কিন্তু abandonment নয়।
- Access restriction: harmful medicines—insulin, anticoagulant, laxative, sedatives—unsupervised access কমানো।
- Comorbidity treat: depression/anxiety/personality disorder/trauma properly treat করলে relapse কমতে পারে।
- FDIA prevention: child/elder/vulnerable person involved হলে immediate safeguarding, multidisciplinary team, medico-legal reporting।
Real clinical example
একজন ২৮ বছর বয়সী patient বারবার “fever + sepsis” নিয়ে ভর্তি হচ্ছে। Blood culture কখনো unusual organism দেখায়, কখনো negative; fever mainly nurse না থাকলে বাড়ে; line infection repeated; previous hospital records দিতে চায় না। Work-up-এ true immunodeficiency পাওয়া গেল না। এখানে diagnosis shortcut হবে:
Repeated unexplained illness + inconsistent objective finding + hospital hopping + evidence of manipulation + no external gain = Factitious disorder suspect.
Overview / Summary
Factitious disorder হলো intentional falsification/induction of illness without obvious external gain. Diagnosis clinical, কিন্তু true medical illness exclude করা আবশ্যক। Core treatment psychotherapy, supportive non-accusatory approach, coordinated care, and safety planning. Medicine Factitious disorder cure করে না; comorbid depression/anxiety/insomnia/psychosis থাকলে SSRI, mirtazapine, short-term clonazepam, or quetiapine specialist indication অনুযায়ী ব্যবহার করা যায়।
Actionable Plan / Steps
- Organic disease rule out করুন—baseline + symptom-specific investigations।
- Previous records এবং collateral history collect করুন।
- Patient-কে blame না করে single clinician + psychiatry liaison follow-up দিন।
- Self-harm/poisoning/FDIA risk থাকলে urgent safety intervention।
- Comorbid depression/anxiety থাকলে SSRI first-line বিবেচনা; insomnia/appetite issue থাকলে mirtazapine; benzodiazepine only short-term।
- Unnecessary investigations/surgery avoid করতে written care plan করুন।
Reference List — Textbook + Guideline + DOI
Textbooks
- Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s Synopsis of Psychiatry, 12th ed. Somatic Symptom and Related Disorders chapter.
- Gelder M, Andreasen N, Lopez-Ibor J, Geddes J. New Oxford Textbook of Psychiatry, 3rd ed. Somatic symptom and factitious disorders section.
- American Psychiatric Association. DSM-5-TR: Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision, 2022.
Guidelines / authoritative clinical sources
- WHO. ICD-11 Clinical Descriptions and Diagnostic Requirements for Mental, Behavioural and Neurodevelopmental Disorders, 2024.
- NICE. Depression in adults: treatment and management, NG222, 2022.
- NICE/BNF. Sertraline, escitalopram, fluoxetine, mirtazapine, quetiapine dosing references.
Peer-reviewed journals with DOI
- Eastwood S, Bisson JI. Management of Factitious Disorders: A Systematic Review. Psychotherapy and Psychosomatics. 2008;77(4):209–218. DOI: 10.1159/000126072.
- Hausteiner-Wiehle C, Hungerer S. Factitious Disorders in Everyday Clinical Practice. Deutsches Ärzteblatt International. 2020;117(26):452–459. DOI: 10.3238/arztebl.2020.0452.
- Liu RK, Green J, Newton R. A scoping review of treatment for Factitious disorder imposed on self. Psychiatry Research Communications. 2025;5:100216. DOI: 10.1016/j.psycom.2025.100216
Md.Rafiqul Islam Lipu,Date:-22-05-2026,Time:-1-05-33 Pm