Factitious Disorder

Factitious Disorder 

Factitious disorder refers to a patient’s deliberate deception of others in order to appear ill, impaired, or injured. Individuals with factitious disorder either falsify signs or symptoms of an illness (e.g., manipulating laboratory samples) or actually induce injury or disease (e.g., injecting themselves with a microbe or poison). The primary aim is thought to be assumption of the “sick role,” which for individuals with factitious disorder serves a psychological, often unconscious, purpose (“primary gain”).

In the DSM-V, factitious disorder is divided into factitious disorder imposed on the self and factitious disorder imposed on another.

This article addresses only factitious disorder imposed on the self. Factitious disorder is categorized as a “somatic symptom and related disorder,” alongside conversion disorder, somatic symptom disorder, and illness anxiety disorder.

These illnesses, along with malingering, are important considerations in differential diagnosis.

Unlike the other conditions, factitious disorder is not motivated by typical “secondary gain” (e.g., disability benefits, controlled substances, legal damages, or other beneficial consequences for the patient.)

The hallmark is conscious deception, which can take the form of simulation of symptoms, falsification of data, or self-injury in order to assume the patient role.

When portraying a physical disorder, the individual may seek examination and treatment including invasive diagnostic testing or surgery. Factitious disorder can also occur when patients feign symptoms of a psychiatric illness.

The term Munchausen syndrome was formerly synonymous with factitious disorder imposed on the self, while Munchausen syndrome by proxy was synonymous with factitious disorder imposed on another.

The Munchausen term is no longer in official use by the DSM-V, but it is sometimes used by psychiatrists to describe a severe variant of factitious disorder characterized by exaggerated lying (pseudologia fantastica), sociopathy, and geographic wandering (peregrinating) from hospital to hospital.

F68.10Intentional production or feigning of symptoms or disabilities, either physical or psychological (factitious disorder)
300.19Factitious disorder

Epidemiology & Demographics

Incidence (In U.S.)

The overall incidence is unknown. The incidence of factitious disorder among clinical encounters is probably about 1%.

Prevalence (In U.S.)

Unknown. Estimates range between 0.1% and 2%.

Predominant Gender

More common in women by 3:1 ratio. Psychiatric symptom variant and the severe variant sometimes called Munchausen syndrome may be more common in men.

Predominant Age

30 to 40 yr of age

Peak Incidence

30 to 40 yr of age


No genetic predisposition known

Physical Findings & Clinical Presentation

  • •The patient may appear inconsistent or their statements may differ from what is documented in their medical record.
  • •They may be resistant to allowing providers to obtain outside records or communicate with other treaters.
  • •The clinical picture may be atypical for the natural history of a portrayed disease (e.g., an infection that does not respond to multiple courses of appropriate antibiotics).
  • •Tests, consultations, and medical and surgical treatments may be performed without any improvement in symptoms.
  • •The presentation may be acute and dramatic, in excess of what might be expected.
  • •The patient may predict deterioration or report exacerbation just before scheduled discharge.
  • •They may oppose psychiatric consultation when offered.


  • •The etiology is unknown, but predisposing factors include a history of significant childhood illness or trauma, such as having witnessed violence and physical, emotional, or sexual abuse.
  • •Personality disorders appear to be highly comorbid.


Factitious disorder is a diagnosis of exclusion. It requires demonstrating that the individual is taking surreptitious actions to misinterpret, simulate, or cause signs or symptoms of illness or injury in the absence of any obvious external reward.

Early diagnosis is helpful to prevent extensive and unnecessary testing and treatment, which can cause iatrogenic injury.

Suspicion may be raised when there is direct observation of fabrication, signs or symptoms that contradict laboratory testing, nonphysiologic response to treatment, circumstantial observations suggesting fabrication (e.g., syringes noted in a patient’s handbag), recurrent patterns of illness exacerbation, or failure to follow the expected natural history of disease. 

The below info describes clues that increase the likelihood of subtle forms of factitious disease.

Clues That Increase the Likelihood of Subtle Forms of Factitious Disease

From Feldman M et al: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016, Elsevier.

  • Predominantly women
  • Previous experience in the medical field, which provides an unusual grasp of terminology and access to medical supplies
  • Multiple surgeries, multiple procedures
  • Inexplicable laboratory test results
  • Inconsistency and implausibility of certain aspects of the history
  • Visits to three or more medical centers previously for the same symptoms, or to a nationally known referral center such as the Mayo Clinic or Cleveland Clinic, despite residing far away
  • History of substance abuse or prior psychiatric disorder
  • Vagueness in regard to details of past history and/or reluctance to allow release of previous medical records

Differential Diagnosis

  • •All medical or psychiatric condition(s) related to the symptoms being portrayed.
  • •Malingering: The deceptive presentation of an illness in malingering may be indistinguishable from factitious disorder, but malingering is motivated consciously by secondary gain, while factitious disorder is motivated by an often-unconscious desire to assume the “sick role.” Factitious disorder is almost never self-advantageous; in fact, patients with factitious disorder put themselves at grave risk of harm.
  • •Somatic symptom disorder: This disorder is characterized by excessive thoughts, feelings, or behaviors related to a physical symptom that is not well explained physiologically. The patient may appear unduly preoccupied and may be motivated by the “sick role,” but is not deceptive.
  • •Conversion disorder: This disorder is characterized by altered voluntary motor or sensory function impairment that is not related to a known neurologic cause. It does not involve deception.
  • •Delusional disorder, somatic type: This disorder can present with symptoms that are discrepant with objective evidence. The patient may dramatically emphasize symptoms to gain the attention of a medical professional, but they are not deceptive.
  • •Self-injurious behavior: This can be seen in a number of psychiatric conditions such as borderline personality disorder. Patients generally describe self-injuring as a way to regulate painful emotions, and it is not motivated by a desire to occupy the “sick role.”


  • •Dictated by the presenting complaints. A reasonable index of suspicion when presentation is not consistent with known pathology.
  • •Methods that have been used to bolster or confirm a suspicion of self-induced or factitious disease are summarized as below

Methods That Have Been Used to Bolster or Confirm a Suspicion of Self-Induced or Factitious Disease

From Feldman M et al: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016, Elsevier.

  • Review old medical records and discuss case with previous doctors and family members if appropriate. Identify discrepancies and inconsistencies, and estimate influence of gain derived from the sick role. Inquire about psychosomatic illness, previous psychiatric treatment, suicide attempts, stress in the patient’s life, childhood abuse, marital/sexual problems, eating disorders, and so on. A forensic consultant with access to multiple records can be uniquely helpful in identifying conflicting stories.
  • Review previous biopsy slides, looking for foreign body material in wounds, melanosis coli, and other clues, as appropriate for the patient’s symptoms.
  • Obtain a psychiatric evaluation to help determine whether the patient has a personality disorder or psychiatric disease, absence of which would argue against factitious disease. Psychiatrists should not attempt initially to discover the underlying unconscious motivation that may have impelled the patient to assume the sick role.
  • If symptoms and signs may be explained by surreptitious ingestion of medications and poisons, obtain appropriate medication and toxicology screens. Consider obtaining a urine test for diuretics even in the absence of renal or electrolyte disorders. Evaluate results of such screens in light of the sensitivity and specificity of the tests employed.
  • Test biological fluids collected under direct observation and compare results with fluids collected privately by the patient. For example, compare fecal material obtained at “unprepped” sigmoidoscopy with fecal material submitted by the patient.
  • Have nursing staff observe the patient to detect tampering behavior.
  • Search the patient’s personal belongings.
  • Conduct covert videotape surveillance.

Laboratory Tests

  • •Laboratory testing often reveals inconsistencies.
  • •Laboratory abnormalities may reflect the underlying factitious behavior (e.g., hypokalemia in an individual surreptitiously taking furosemide or a clean urine sample obtained by straight catheterization in someone complaining of hematuria who had tampered with self-provided urine).


Nonpharmacologic Therapy

Two approaches may be considered by the primary physician:

  • •Nonpunitive diagnostic disclosure by the primary physician and a psychiatrist in collaboration. This is sometimes called “confrontation,” but it is not adversarial. A supportive stance should be maintained and an offer for ongoing support and follow-up made. The below summarizes consensus opinions on the treatment of factitious disease.
  • •Avoid overt confrontation with patient but provide him or her with a face-saving way to recover. For example, a therapeutic double bind would involve saying, “There are two possibilities here: One is that you have a medical problem that should respond to the next intervention we do, or two, you have a factitious disorder. The outcome will give us the answer.”
  • •Severe cases may be virtually impossible to treat except to avoid further invasive intervention.

Consensus Opinions on the Treatment of Factitious Disease

From Feldman M et al: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016, Elsevier.

  • Achievement of insight should not be the principal early goal of treatment, because it can weaken the patient’s defenses.
  • One person should have primary responsibility for patient management.
  • There should be a comprehensive psychiatric evaluation of the patient, including assessment for suicide risk.
  • All members of a multidisciplinary team should be aware of the psychiatric assessment and treatment plan.
  • The treatment plan should be individualized.
  • Comorbid illness should be treated appropriately.
  • If confrontational techniques are used, they should be nonpunitive and supportive.

Features of Supportive Confrontation

From Feldman M et al: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016, Elsevier.

  • Tell the patient what you suspect without outright accusation.
  • Support the diagnosis of factitious disease with facts.
  • Provide empathetic and face-saving comments. ∗“Maybe you didn’t know what you were taking—this medication could cause you to be sick”; “Maybe you took it in your sleep”; “What you did was a cry for help, and we understand”; “We realize you must be in great distress”; “We want to continue to take care of you.”
  • Avoid probing to uncover the patient’s underlying feelings and motivations. ‡Later it may be decided to break this promise in patients with potentially fatal factitious disease, such as patients who are creating sepsis by injecting contaminated material into their bodies. This promise should only be broken after consultation and consensus opinion have been obtained by an ethics committee, legal personnel, and others, as described in the text., †This is done to minimize disruption of essential emotional defenses.
  • Assure the patient that the physician will not release the diagnosis to others without the patient’s permission unless required to do so by law. 
  • Ensure that the staff demonstrates continued acceptance of the patient.
  • Encourage psychiatric help, but do not force the issue.

Acute General Rx

  • •First, do no harm. If factitious disorder is confirmed, avoid unnecessary testing, treatment, consultation (other than psychiatric), or other intervention which carries risk of iatrogenic harm.
  • •Obtain psychiatric assistance on a liaison basis, even if the psychiatrist will not evaluate the patient.
  • •Diagnostic disclosure is not aimed at obtaining a confession, and only a small minority of patients will acknowledge their deception. The treating physician should nonpunitively hold the conviction that the truth is already known, and efforts by the patient to prove legitimate illness should be countered with reassurance of the patient’s physical health and sincere offers to connect the patient with psychiatric help.
  • •Treatment of comorbid psychiatric disorders may be most helpful in the acute setting. Reduction of burden of comorbid illness with medications and/or psychotherapy may ameliorate the factitious behavior.
  • •Where applicable, multidisciplinary staff meetings can be useful to process feelings about the patient and about being deceived. Collaboration is important.

Chronic Rx

  • •Psychotherapy is the standard of care for factitious disorder, although evidence of its effectiveness is limited, and specific protocols are not developed. The therapeutic approach is similar to that for personality disorders, emphasizing both the nurturing relationship and the development of coping skills.
  • •There is no evidence that psychiatric medications such as antidepressants or antipsychotics are beneficial in cases without comorbid mood or psychotic disorders.
  • •Consistent relationships with treating physicians are generally recommended even if “treatment” is being firmly limited.
  • •Establishment of a central reporting register has been proposed to aid development of evidence-based guidelines.


  • •The prognosis is poor, with recovery infrequent.
  • •After being confronted with their behavior, some patients may cease factitious behavior, but they may also seek other physicians or hospitals and repeat their deception.
  • •The majority of patients refuse or do not follow up with psychiatric treatment.


Always obtain psychiatric referral. Additionally, litigation is common, especially if the patient feels humiliated when receiving a diagnosis of factitious disorder. Involvement of hospital counsel (risk management) and ethics consultation is often appropriate.

 Pearls & Considerations

  • •Think of factitious disorder whenever there is an unexplained medical course that continues to repeat itself despite appropriate treatment; when presentations appear dramatic but details are vague or inconsistent; or when patients have obtained extensive consultation from other professionals but resist permission to obtain outside records or collaborate.
  • •Factitious disorder is not a form of malingering. The deliberate deception seen in factitious disorder is motivated by the patient’s psychological need to occupy the “sick role.”
  • •Patients may have a history of working in the health care field.
  • •Patients may put themselves at grave risk of iatrogenic harm, and the most important treatment objective is the prevention of morbidity associated with unnecessary testing and treatment.
  • •Obtain psychiatric assistance whether or not you ask the patient to meet directly with the psychiatrist.


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