socio - cultural factors are important in the epidemiology and psychopathology of various psychiatric disorders12 including factitious ones .
they have an influence on the pathways to seeking medical help.3 in addition , illness behavior has cultural overtones in arab patients.4 factitious disorders are characterized by physical , and psychological signs or symptoms that are intentionally produced with no external incentives to feign illness.5 these disorders have been reported from various cultures.67 a distinction should be made between factitious disorders and malingering . in the latter , the patient produces symptoms with an obvious goal . in factitious disorders , the motivation to be a patient is vague and obscure .
munchausen 's syndrome , in its classic description , is an uncommon subtype of factitious disorder which has received great attention.78 this syndrome is the earliest description of a factitious disorder with predominantly physical signs and symptoms .
although factitious disorders are common among males , recent reviews indicated a preponderance of female patients.9 the probable judgement that a particular symptom is produced intentionally is made both by direct evidence and with the exclusion of other causes of the symptoms . almost in all reported cases of factitious disorders with physical symptoms ,
however , many such patients have been described as having underlying masochistic , borderline or dependent personality traits.9 although the prognosis is usually poor , patients who have adequate psychosocial support with less severe personality pathology can do better . in this article ,
a 45-year - old , illiterate , saudi housewife was referred from a medical ward for psychiatric consultation . during her stay in the medical ward ,
she was investigated for skin lesions distributed mainly on the abdomen and both thighs , but not on her back or other areas of the body inaccessible to the hand .
her case history revealed that two years prior to her current psychiatric consultation , she was hospitalized for vague abdominal pain , but all investigations were normal .
after discharge from the hospital , she consulted a traditional healer who treated her by cauterization . during the following two years
, she presented with recurrent skin lesions on the abdomen , arms and both thighs .
her illness had created marital discord but there was no family history of mental illness .
the examination of the mental state did not show any major disorder . during her stay in the psychiatric ward for observation ,
evidence of intentional production of skin lesions on healed sites and on new areas was reported .
when confronted with evidence of their factitious nature , she denied doing herself any harm .
the judgement that the skin lesions were produced intentionally was made by direct evidence from the staff in the ward and by excluding other causes of these lesions .
she was discharged from the psychiatric ward after three months and given a follow - up appointment in the psychiatric clinic but she never showed up .
a 39-year - old , single , illiterate and unemployed saudi male presented with dramatic severe abdominal pain .
he was vague and inconsistent when questioned in detail about the nature of the pain .
when all of the investigations proved negative , he started to complain of chest pain .
his past history showed that he had been admitted to different general hospitals in saudi arabia , some of which were far from his hometown .
the information received from some of these hospitals showed that repeated medical and surgical consultations , including extensive investigations , did not reveal any physical disorder .
in addition , psychiatric assessment showed no evidence of mental disorders either . during his stay in the psychiatric unit , he presented with acute renal pain , hematuria and evidence of self - induced blood tinged stool .
on confronting the patient about the factitious nature of his complaints after organic causes had been ruled out , he became angry and discharged himself .
two months later , he presented to the hospital in a deaf - mute state but left the hospital when again confronted . similarly
, he did not benefit from traditional healers whom he had visited many times , on the advice of his relatives .
one of the essential clinical features of the above two cases is the intentional production of physical symptoms .
the first case is that of factitious dermatosis , the second is of chronic physical symptoms associated with multiple hospitalizations .
the first case of dermatitis artefacta was preceded by cauterization from a traditional healer which might have acted as a predisposing factor .
the second case is similar in presentation to other classic cases of munchausen 's syndrome10 described in several cultures .
it is important for clinicians to remember that with factitious disorder there could be some real physical illnesses that need appropriate management.11 the behavior of these two patients has cultural dimensions . to travel
, females in the saudi culture need  mahram  ( a person whom they can not legally marry ) who might not always be available.12 this requirement restricts their travel creates an important feature of what was known as wandering type of munchausen 's syndrome.13 in females , the type of munchausen 's syndrome that is characterized by less severe psychopathology , a higher functioning level and less frequent factitious behavior is classified as non - prototypical.14 this classification seems to be justified as revealed in case 1 , though it has recently been criticized8 because the criteria for classification are not applicable in a good number of factitious disorder cases .
new modern hospitals are common in saudi arabia . for submissive female and male patients , falling sick
this might be incorporated into the psychopathology of factitious disorders in saudi culture . in spite of socio - cultural factors , it is clear that doctors awareness and acceptance of the possibility of factitious disorders is a prerequisite to making the diagnosis .
once factitious disorder is diagnosed , it is important to confront the patient but remain supportive .
confrontation should be carefully planned . in saudi culture , it would be inappropriate to inform the relatives that the patient is feigning the symptoms , since this may precipitate psychotic breakdown of the patient .
interestingly , both patients consulted traditional healers during their factitious behavior . although consulting traditional healers could be explained partially by the religious background of the saudi culture ,
it is interesting that in spite of the modern treatment available in saudi arabia , patients including those with factitious disorder , still consult traditional healers with their somatic and psychological symptoms .
 factitious disorders are characterized by physical or psychological manifestations that are intentionally produced or feigned with no apparent external incentives in order to assume the sick role . 
 these disorders are rarely reported or may be under - reported in saudi patients . 
 we describe here two male and female saudi cases of such disorders . both presented predominantly with features of munchausen 's syndrome . 
 like most psychiatric patients both had sought help from traditional healers prior to their reporting to the hospitals . 
 inspite of the socio - cultural factors , it is clear that doctors awareness and acceptance of the possibility of factitious disorders is a prerequisite to making the diagnosis . 