Version June 2024
| Symptom | Laboratory test | Comments |
| Cardiovascular | ||
| Angina | Definitive test: coronary angiography. Also consider: stress test, ECG, echocardiogram for wall motion abnormalities. | History of prior myocardial infarction or cardiac bypass does NOT exclude factitious presentation – may represent the patient fabricating prior symptoms. |
| Arrhythmia | Consider indirect dysrhythmia though manipulated electrolytes (Mg, K). Supervise telemetry lead placement to avoid manipulation. Digitalis, beta-blockers and calcium channel blockers can be measured in serum. | Arrhythmias have also been reported in patients with surreptitious laxative or thyroxine abuse (see below). |
| Aortic dissection | In patients reportedly unable to receive CT aortogram with contrast or MRI, consider transthoracic echocardiogram. | Patient's goal may be thoracotomy. Patients have reported an allergy to radiography contrast prohibiting CT imaging. Also allergy to gadolinium or shrapnel residue in their body prohibiting MRI. |
| Hypotension | Serum assays for beta-blockers and calcium channel blockers. Electrochemiluminescence assays detect atenolol and metoprolol in urine samples. | Capillary electrophoresis with electrochemiluminescence detection – assays developed to detect doping in sports. |
| Hypertension | Serum or urine assay for pseudoephedrine. Pheochromocytoma can also be simulated. | Valsalva maneuver may be used by the patient during BP measurement to produce transient HTN. |
| Dermatologic | ||
| Cheilitis granulomatosa | Liver and lymph node biopsies may show histiocytes that contain polyvinylpyrrolidone (PVP) suggesting self-inoculation. | PVP, a polymer, is used in hair sprays, skin care products, fruit juices. |
| Dermatitis artefacta, cheilitis, subcutaneous emphysema | Punch biopsy with histopathology – may reveal evidence of mechanical trauma with areas of necrosis and extravasation of RBCs. Imaging or skin exam can note needle tracks for subcutaneous air. | |
| Erythematous lesion, pemphigus | Apply alcohol to lesion. Direct immunofluorescence. | |
| Herpes zoster | Negative viral PCR. | |
| Onychodystrophy | Microscopy. | Nail file to replicate symptoms. |
| Scabies | Scabies PCR, microscopy. | |
| Endocrine | ||
| Cushing's syndrome | High-pressure liquid chromatography (HPLC) used to distinguish exogenous versus endogenous glucocorticoids. Cortisol and corticosterone are co-secreted, so both should be checked since corticosterone will not be elevated if cortisol is surreptitiously added to urine samples. | Surreptitious addition of hydrocortisone requires measurement of upstream metabolites to check for evidence of suppressed pituitary secretion of ACTH. |
| Hyperaldosteronism | Glycyrrhizic acid can be detected in serum. | The ingestion of black liquorice has gained particular notoriety on the internet. The sweetener used to make licorice, glycyrrhizic acid can lead to treatment-resistant hypokalemia, metabolic alkalosis and hypernatremia. |
| Hyperthyroidism | TSH, T3, free T4, thyroglobulin, and thyroid autoantibody. Some recommend 24 h radioiodine uptake testing. During thyroid storm factitious hyperthyroidism is the only etiology in which TSH will be low. | Some herbal medications contain thyroid hormones. Serum thyroglobulin may less useful as 10 to 20% of people have anti-thyroglobulin antibodies that may affect thyroglobulin measurement. |
| Hypoglycemia | Serum insulin, C-peptide, and proinsulin levels, assays for metformin, meglitinides, sulfonylureas. Novel incretin analogue exenatide and amylin analogue pramlintide not routinely included in hypoglycemic drug screens. Also consider manipulation of testing strips. | Urine can be more sensitive than serum and may remain positive for a longer period. Anti-insulin antibodies no longer useful as more human recombinant insulin is used. Also C-peptide is cleared renally and will be elevated in renal failure. |
| Pheochromocytoma | Serum chromogranin A useful to identify true pheochromocytoma. Meta-iodobenzylguanidine nuclear scan is probably the gold standard. Vanillylmandelic acid (VMA) should not be used for suspected factitious pheochromocytoma because vanilla extract or foods high in vanillin can elevate VMA. | Agents to mimic pheochromocytoma symptoms include self-administration of epinephrine, metaraminol, and isoproterenol. Patients can use the Valsalva maneuver to produce a symptom pattern suggestive of pheochromocytoma. |
| Gastrointestinal | ||
| Diarrhea | Surreptitious addition of water to stools detected by measuring fecal fluid osmolality – if less than 290 mosm/kg, water or hypotonic solution may have been added to stool. Consider 3-day stool collection for 200 g/day volume check. Urine screen for phenolphthaleins, anthraquinones, and bisacodyl plus stool screen for magnesium and phosphate. | Urine and stool "laxative abuse" screens often need to be performed multiple times due to intermittent laxative use by patients and low sensitivity of the tests. |
| Gastrointestinal (GI) bleeding | Factitious bleeding suggested when nasogastric tube shows blood but no cause found on esophagogastroduodenoscopy. Colonoscopy is less sensitive to elucidate lower GI bleeding. The "single-stripe" sign on colonoscopy may indicate non-steroidal anti-inflammatory abuse, which can be detected on high performance liquid chromatography (HPLC). | Ingestion of salicylates can also cause factitious lower GI bleeds. Radiolabelling only useful in a patient injecting themselves with blood they had obtained from transfusions in-hospital; discovered when rectal blood was found not to be radiolabelled after a radio-isotope injection. |
| Nausea/vomiting | When produced by ipecac consumption, measure serum or urine emetine levels (detectable by HPLC). Elevated creatine kinase, leukocytosis, and transaminitis also associated with ipecac toxicity. After vomiting episodes, clinicians should see low serum potassium, low chloride after acute vomiting or prolonged episodes of vomiting. | Excess ipecac induces myopathic toxicity including skeletal muscle weakness and hypotonia and cardiomyopathy with dysrhythmias, T-wave abnormalities, and prolonged QT interval. |
| Pseudo-obstruction | Detect loperamide or another motility slowing agent by HPLC of blood or stool. | |
| Gynecology and obstetrics | ||
| False ectopic pregnancy | Self-injection of human chorionic gonadotropin (hCG) has been reported. This led to a negative urine beta-hCG and negative ultrasound. Also subsequent serum beta-hCG levels were widely varying. | |
| Vaginal discharge | Typically the fluids have an inconsistent pH or the vaginal wall shows evidence of trauma/abrasion in patients denying intercourse or instrumentation. | |
| Hematologic | ||
| Anemia/bleeding | Examination may show evidence of venipuncture or instrumentation, particularly of orifices or the genital-urinary tract or gastrointestinal tract on endoscopy. | |
| Anticoagulation | For patients not known to be on warfarin, administer vitamin K, and then re-check PT/INR. Warfarin can be assayed directly but warfarin derivatives such as the rodenticide brodifacoum require use of HPLC. For patients on warfarin, there can be "false-resistance" to warfarin that requires extensive clinical input and attention. This must be cautiously approached as genetics can play a large role. If vitamin K and plasma warfarin levels are irregular, consider genetic testing if there is no indication of factitious behavior. Prolonged PTT but normal reptilase time suggest presence of heparin. Another test is to add protamine sulphate or an ion-exchange resin to the blood sample which will indicate the presence of exogenous heparin. | The most common hematologic factitious disorder is surreptitious anticoagulation abuse. |
| Aplastic anemia | This has been provoked by the ingestion of alkylating agents such as busulfan or other chemotherapy agents. | |
| Sickle cell disease | Confirmation with hemoglobin electrophoresis. | Important for patients not known to local clinicians. |
| Thrombocytopenia/ITP (also see rheumatologic-purpura) | Purpura and ITP feigned by quinidine ingestion – check serum quinidine level. Isolated thrombocytopenia has been caused by quinine ingestion. | |
| Infectious diseases | ||
| Bacteremia | Polymicrobial bacteremia or unusual organisms in blood cultures should raise suspicion. | Case reports note stool flora, pet flora as most common exogenous material. |
| Fever | Directly observed temperature measurement using electronic thermometer. | Ensure no recent ingestion of hot beverages, warm wax or wet cotton in ears. In 1979, 9% of patients presenting to an NIH study on fever of unknown origin were found to be suffering from factitious disorder. |
| HIV/AIDS | Repeat HIV ELISA and Western blot, check viral load for acute HIV. | Patient with normal CD4 count and undetectable viral load can claim suppression with anti-retrovirals. But antibody should still be positive. |
| Wounds | Apply fluorescein or tetracycline to wound, then examine hands/nails for fluorescence. | Non-healing wounds will heal when casted, but this can be circumvented by patients. Substances introduced into wounds include: human/animal feces, household toxins, aquarium water, foreign bodies, milk and others. |
| Neurologic | ||
| Movement disorders | EMG and EEG reveal inconsistent amplitude patterns in factitious tremors and myoclonus. | Dopaminergic drugs including antipsychotics may be taken to induce Parkinsonian symptoms. |
| Multiple sclerosis | MRI brain demonstrating at least 2 different regions of white matter change. CSF with mild lymphocytosis, oligoclonal bands in IgG region. | CSF protein electrophoresis is 90% sensitive in pts with active MS symptoms. |
| Non-epileptiform seizures | Serum prolactin level at baseline (near onset of epileptiform activity) then 20 minutes later. However this can be normal in partial-seizures and elevated in epilepsy. Video EEG useful but this can miss frontal lobe seizures which have movements that can suggest factitious behavior such as pelvic thrusting and cycling movements. | One estimate suggests that 15 to 30% of the patients presenting to epilepsy clinics with refractory epilepsy are psychogenic in nature. Most of these patients are unlikely to have factitious disorder. |
| Nephrologic/urologic | ||
| Diuretic abuse/Bartter syndrome | Urine assays can detect furosemide, torsemide, and hydrochlorothiazide. HPLC can detect furosemide and other diuretics. | Bartter syndrome is a rare inherited defect in the ascending loop of Henle, there are at least 6 reports of factitious presentations of this condition. |
| Goodpastures syndrome | See hematuria and hemoptysis sections. | One patient appeared in 3 different peer reviewed articles. |
| Hematuria | Direct observation of urine collection to ensure blood or iodine not added to sample. Three tube test to rule out urethral trauma – first tube should have most RBCs if self-inflicted urethral trauma is the source of blood. Hematuria can be simulated by introducing foreign bodies such as paper clips or safety pins. This can be detected on x-ray or with direct cystoscopy. Air in the bladder on imaging is also indicative of self-manipulation. | Reports suggests that 0.6 to 3% of patients presenting with hematuria have tampered with urine samples to produce false positive tests. |
| Nephrolithiasis | Microscopic exam, infrared spectrophotometry, crystallography, x-ray diffraction to characterize crystals suspected to be non-physiologic. | 3.5% of stones submitted by patients were found to be artefacts (not all were factitious). One case report of subcutaneously implanted metal in abdomen at level of ureter mimicking stone on plain film in patient who claimed IV contrast allergy. |
| Proteinuria | Surreptitious protein addition to urine or bladder detectable by urine protein electrophoresis revealing abnormal alpha and beta globulin fractions. Egg albumin antibody can be used if this is suspected. | Normal serum protein, albumin, creatinine, and BUN levels should raise suspicion in a patient with proteinuria. |
| Oncology | ||
| Cancer | Manipulation of records. Multiple case reports of patients claiming to bring records of disease and diagnosis at remote or foreign institutions requiring treatment. Contact the document's authors/institution. If they are not available, police can be asked to assist verification. At least one report of a patient obtaining sample medical reports off of the internet. | Multiple cases of prophylactic mastectomy for falsely claiming a strong family history of breast cancer. |
| Ophthalmology | ||
| Mydriasis | Homatropine drops detected by identification of homatropine in tears. | |
| Other presentations | Successful techniques for investigating these injuries include pH testing to detect acidic and alkali chemicals and imaging and skin exam to look for evidence of traumatic puncture to introduce air or foreign body materials. | Other ophthalmic presentations include the insertion of foreign body crystals, fungal endophthalmitis, self-induced anterior scleritis, and reports of factious conjunctivitis, primarily by inserting dental plaque as an irritant. |
| Otolaryngology | ||
| Airway and swallowing difficulties | Videoflouroscopy can be useful as well as surface EMG techniques. | |
| Pulmonary | ||
| Asthma | Lung biopsy specimen analyzed by x-ray energy-dispersive spectroscopy showed talc crystals. Chronic ingestion of aspirin in patients with known salicylate sensitivities. | Clear tape has been used to fool pulse oximeters. |
| Cystic fibrosis | Sweat chloride test, but exam should show digital clubbing and abnormal x-rays. In one case the sweat chloride test was manipulated and the patient discovered by evaluation of the sweat potassium. | |
| Hemoptysis | Fiberoptic bronchoscopies that don't show even a minute trace of blood in the oral cavity, glottic area or tracheobronchial tree during a presentation of "active hemoptysis" should elicit a possibility of factitious hemoptysis. In that case examine the nares, palate and posterior tongue for evidence of self-induced trauma. Also consider ingestion of anti-clotting agents and cough abrasion of the lung. | A patient received 25+ admissions to more than 14 hospitals and at least 16 bronchoscopy investigations, all of which were negative. |
| Respiratory failure | Arterial blood gas measurements should demonstrate incongruities. | At least 10 reported cases of factitious patients receiving intubation for respiratory failure. |
| Rheumatologic | ||
| Arthritis | Insertion of metal fragments into joint detected by diffraction radiology or microscopic analysis of synovial aspirate. | |
| Lupus | Feigned usually by symptomatic history +/– borderline elevation in ANA; repeat serum ANA, anti-dsDNA, anti-Smith antibodies. Seronegative lupus can occur however. Note that in an active flair complement CH50, C3 and C4 levels should be low. | |
| Vasculitis (also see hematologic – thrombocytopenia, and nephrologic-Goodpastures) | Tissue biopsy of lesions may reveal foreign material (saliva, talcum powder) injected to create purpuric lesions. | |
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