Factitious Disorder

Factitious disorder is characterized by the falsification of physical or psychological signs/symptoms, or induction of injury or disease, associated with identified deception, in the absence of obvious external rewards. [1] It is an underdiagnosed condition with significant iatrogenic morbidity and mortality, presenting across all medical specialties. [2]

• Key HPI questions: Explore the timeline, onset, and progression of symptoms; ask about prior hospitalizations, surgeries, and number of different hospitals visited [3]
• Symptom characterization: Symptoms are often dramatic, vague, or textbook-perfect; may shift when initial workup is negative; the magnitude of symptoms consistently exceeds objective pathology [3]
• Timing/triggers: Exacerbations often occur just before scheduled discharge or when attention from staff wanes [3]
• Associated symptoms: Patients may report symptoms across multiple organ systems over time; endocrinological, cardiological, dermatological, and neurological presentations are most common [4]
• Important negatives: Inconsistencies between reported history and medical records; resistance to allowing access to outside records or collateral contacts [3]

• Self-induced sepsis (e.g., injection of fecal material or saliva into IV lines) [1]
• Surreptitious ingestion of insulin, warfarin, thyroid hormone, or other medications causing life-threatening lab derangements [1][5]
• Self-induced wounds that fail to heal despite appropriate treatment, with atypical organisms on culture [3]
• Factitious GI bleeding leading to unnecessary endoscopy, surgery, or transfusion [6]
• Factitious respiratory distress prompting intubation — one case series documented >60 ED visits with unfounded respiratory distress [7]
• ICU admissions for feigned or induced illness occurred in ~18% of one case series [8]
• Suicide risk: Case reports of completed suicide exist; deceptive behavior does not preclude serious psychopathology [3]

• Commonly self-administered substances to induce illness: Insulin (factitious hypoglycemia), warfarin/anticoagulants (factitious bleeding), thyroid hormone, laxatives, diuretics, sympathomimetics [1][5]
• Medications to be cautious with: Opioids — patients may seek or obtain opiates (especially meperidine/morphine) when not clinically indicated [3]
• No specific pharmacotherapy has demonstrated efficacy for factitious disorder itself; a systematic review found no significant difference in outcomes with psychiatric medication vs. without [9]
• Treat comorbid psychiatric conditions: Depression (present in ~42% of cases), anxiety, and personality disorders should be managed with standard pharmacotherapy when identified [4][10]

• Not a primary consideration in factitious disorder management
• Be aware of factitious purging behaviors (laxative abuse, induced vomiting) that may cause electrolyte derangements requiring correction
• Patients inducing factitious malnutrition or failure to thrive may require nutritional rehabilitation

• Conduct a thorough ROS but be alert to overly positive or dramatic responses across multiple systems
• High-yield systems to review: Neurological (seizures, syncope, weakness), GI (bleeding, vomiting), dermatological (non-healing wounds), endocrine (hypoglycemia, thyrotoxicosis), hematological (bleeding, anemia), infectious (recurrent abscesses, fevers of unknown origin) [4]
• Ask about psychiatric symptoms: Depression, suicidal ideation, anxiety, prior self-harm
• Screen for substance use disorders — high rates of comorbid substance abuse [3]

• Collateral is critical: Obtain outside medical records from other institutions; patients frequently resist this, which itself is a red flag [3]
• Contact prior treating physicians when possible — a history of similar presentations at multiple hospitals is highly suggestive [3]
• Family psychiatric history: Present in ~78% of cases [10]
• Childhood adversity: History of abuse, neglect, parental divorce, enmeshment, or early prolonged illness/hospitalization is extremely common [3][10]
• Family dynamic issues were identifiable in 100% of patients in one retrospective cohort [10]
• Consider factitious disorder imposed on another (Munchausen by proxy) if the patient has dependents [3]

• Female sex (~66–90% in most series) [3-4][10]
• Age 25–40 years at presentation (mean ~34 years) [3-4][11]
• Healthcare profession or training — up to 50–67% of patients [3][10-11]
• Direct IV access (e.g., central lines, ports) — present in ~67% [10]
• Past psychiatric history — 92% in one cohort [10]
• History of childhood trauma/adversity — 69% [10]
• Personality disorder (especially borderline) and depression [3-4]
• Substance use disorders [3]
• Prior hospitalization for medical or psychiatric illness in early adulthood [1]
• Higher income quartiles and private insurance were associated with FDIS coding in a large US inpatient database [12]

• Malingering: Intentional symptom production for external gain (financial, legal, avoiding work); factitious disorder lacks obvious external reward [1]
• Somatic symptom disorder: Genuine distress about somatic symptoms without deception or falsification [1]
• Functional neurological symptom disorder (conversion disorder): Neurological symptoms inconsistent with pathophysiology but without intentional deception [1]
• Borderline personality disorder: Self-harm may occur but is not associated with deception to assume the sick role [1]
• True medical illness: Comorbid genuine disease is common and does not exclude factitious disorder [1]
• Delusional disorder: Fixed false beliefs about illness without conscious deception [1]
• Substance use disorder: May mimic or coexist with factitious presentations

Key distinguishing feature: Factitious disorder requires identified deception in the absence of obvious external rewards. [1]

• Extensive surgical history with multiple operations, often at different institutions [3]
• Unexpectedly large number of childhood illnesses and hospitalizations [3]
• History of non-healing wounds, recurrent infections, or unexplained lab abnormalities
• Prior psychiatric diagnoses (depression, personality disorders, PTSD) [4][10]
• Previous episodes of factitious behavior at other facilities [8]
• Substance abuse history [3]

• Vital signs: May be normal or abnormal depending on method of illness induction (e.g., tachycardia from sympathomimetics, hypoglycemia from insulin)
• Skin: Look for self-inflicted wounds in accessible areas (often geometric, linear, or in unusual distributions); wounds that fail to heal despite appropriate care; evidence of ligatures causing edema [3]
• Abdomen: Multiple surgical scars ("gridiron abdomen" in classic Munchausen syndrome)
• IV access sites: Examine for signs of self-injection, track marks, or manipulation of central lines [10]
• Concealed devices: Search for hidden syringes, catheters, ligatures, or medications [3]
• Neurological exam: Inconsistencies between reported deficits and observed function; non-anatomical patterns

• Discrepant or inexplicable lab results are often the first clue to diagnosis [5][11]
• Toxicology/drug screening: Screen for surreptitious drug ingestion (insulin, warfarin, thyroid hormone, laxatives, diuretics) [5]
• Insulin and C-peptide levels: Factitious hypoglycemia shows high insulin with low C-peptide (exogenous insulin) [5]
• Sulfonylurea screen if hypoglycemia is present
• Coagulation studies: Unexplained coagulopathy may indicate warfarin ingestion
• Electrolytes: Unexplained hypokalemia (laxative/diuretic abuse), metabolic alkalosis
• Urine studies: Specimen tampering (e.g., adding blood to urine); consider observed specimen collection [1][5]
• Wound cultures: Atypical organisms (fecal flora) in wound infections suggest self-inoculation [3]
• Sample integrity: Laboratory staff should be alerted to highly variable results or extreme abnormalities inconsistent with the broader clinical picture [5]

• No specific imaging diagnoses factitious disorder
• Imaging is often obtained extensively and unnecessarily as part of the workup for fabricated symptoms — a hallmark of the disorder [3]
• Review prior imaging records for pattern of excessive, unrevealing studies across multiple institutions
• Imaging may be needed to evaluate complications of self-induced injury (e.g., abscess from self-injection, bowel perforation from ingested foreign bodies)
• When to stop imaging: When clinical suspicion for factitious disorder is high and objective findings do not support the reported symptoms

• Performance validity tests (PVTs) and symptom validity tests (SVTs): Emerging tools for detecting deceptive behavior, particularly in neuropsychological presentations [13]
• Covert video surveillance: Controversial and legally complex; has been used in inpatient settings to document self-injurious behavior, but requires institutional legal and ethics review
• Observed specimen collection: When sample tampering is suspected
• Medical record review across institutions: Often the single most valuable diagnostic tool — reveals patterns of hospital-hopping, inconsistent histories, and prior diagnoses of factitious disorder [3][8]
• Pharmacy database review: Identify patterns of medication-seeking across providers

• Indicated when: Factitious ingestion of cardioactive substances is suspected (e.g., digoxin, beta-blockers, calcium channel blockers, sympathomimetics)
• Factitious arrhythmias: Patients may ingest substances to induce tachycardia, bradycardia, or QT prolongation
• Electrolyte-related ECG changes: Hypokalemia from laxative/diuretic abuse may cause U waves, ST depression, or arrhythmias

DSM-5 Diagnostic Criteria (F68.10 — Factitious Disorder Imposed on Self): [1]

• A. Falsification of physical or psychological signs/symptoms, or induction of injury/disease, with identified deception
• B. Individual presents as ill, impaired, or injured
• C. Deceptive behavior present even without obvious external rewards
• D. Not better explained by another mental disorder (e.g., delusional disorder)

Severity stratification

• Mild: Symptom fabrication/exaggeration without self-induced injury
• Moderate: Self-induced illness requiring medical treatment
• Severe: Life-threatening self-induced conditions (sepsis, hypoglycemia, hemorrhage) requiring ICU care [7-8]

Diagnosis is typically based on indirect evidence — direct evidence of falsification is found in only ~20% of cases. [8] The most common diagnostic clues are normal/inconclusive investigations (69%), atypical presentation (59%), and evocative patient behavior (33%). [8]

Initial stabilization

• Treat any acute medical consequences of self-induced illness (hypoglycemia, sepsis, hemorrhage, overdose) per standard protocols
• Remove access to means of self-harm (IV lines, sharps, medications) when safe to do so

Supportive confrontation (preferred approach): [2-3]

• Collect firm evidence of fabrication before confrontation
• Involve psychiatry early — ideally before confrontation
• Confrontation should be non-judgmental, non-punitive, conducted by ≥2 staff members
• Emphasize the patient as someone who needs help; assure continued care
• Do not demand confession or proof — allow face-saving
• Document thoroughly

Psychiatric management

• No specific pharmacotherapy has proven efficacy for factitious disorder itself [9]
• Treat comorbid depression, anxiety, PTSD, and personality disorders with appropriate medications
• Long-term psychotherapy is recommended (CBT, psychodynamic therapy), though engagement is poor [9][14]
• A multidisciplinary team approach with medical and psychological support yields improved outcomes [3]

Harm reduction

• Designate a single primary care provider to coordinate all care
• Limit unnecessary testing and procedures
• Establish clear boundaries around care while maintaining therapeutic alliance

Admission criteria

• Active medical emergency from self-induced illness (sepsis, hemorrhage, overdose, severe metabolic derangement)
• Acute suicidal ideation or self-harm risk
• Need for psychiatric stabilization
• Diagnostic uncertainty requiring monitored observation

Discharge criteria

• Medical stability with no acute self-induced complications
• Psychiatric safety assessment completed
• Outpatient follow-up arranged (PCP + psychiatry)

Observation indications

• Suspected ongoing self-induction of illness requiring monitored environment
• Awaiting collateral records or psychiatric consultation

Specialist consultation triggers

• Psychiatry/C-L psychiatry: All suspected cases [7]
• Ethics committee: Complex cases involving confrontation, surveillance, or healthcare worker patients
• Legal/risk management: If the patient is a healthcare worker, or if factitious disorder imposed on another is suspected (mandatory reporting may apply) [3]
• Child protective services: If the patient has dependents and factitious disorder imposed on another is a concern [3]

• Follow-up timing: PCP within 1–2 weeks; psychiatry within 1–2 weeks if engaged
• Coordinate care: Notify PCP of diagnosis; establish a single point of medical contact to reduce hospital-shopping [14]
• Symptoms requiring immediate reassessment: Fever, signs of infection, bleeding, altered mental status, suicidal ideation, or any new acute medical complaint
• Patient counseling: Frame follow-up as ongoing support, not punishment; emphasize that care will continue regardless of diagnosis
• Expected course: Recovery from chronic factitious disorder is rare; ~75% of patients are confronted but only ~17% acknowledge self-induced illness; ~12% agree to psychiatric treatment. Many patients leave AMA or seek care elsewhere after diagnosis is raised [3]
• Prognosis: Associated with substantial morbidity, mortality, and healthcare costs; suicide risk is real and should not be dismissed [3]

1. Diagnostic and Statistical Manual of Mental Disorders. — Dilip V. Jeste, Jeffrey A. Lieberman, David Fassler, et al American Psychiatric Association (2022). 2022.

2. Factitious Disorders in Everyday Clinical Practice. — Hausteiner-Wiehle C, Hungerer S. Deutsches Arzteblatt International. 2020.

3. Factitious Disorders and Malingering: Challenges for Clinical Assessment and Management. — Bass C, Halligan P. Lancet. 2014.

4. Factitious Disorder: A Systematic Review of 455 Cases in the Professional Literature. — Yates GP, Feldman MD. General Hospital Psychiatry. 2016.

5. Munchausen Syndrome and Factitious Disorder: The Role of the Laboratory in Its Detection and Diagnosis. — Kinns H, Housley D, Freedman DB. Annals of Clinical Biochemistry. 2013.

6. Factitious Gastrointestinal Bleeding: A Case Series and Review. — Mullarkey M, Wilcox CM, Edwards AL. The American Journal of the Medical Sciences. 2021.

7. Consultation-Liaison Case Conference: A Case of Factitious Disorder Imposed on Self. — Margolis M, Wong TL, Shmuts R, Taylor JB. Journal of the Academy of Consultation-Liaison Psychiatry. 2023.

8. A Descriptive, Retrospective Case Series of Patients With Factitious Disorder Imposed on Self. — Bérar A, Bouzillé G, Jego P, Allain JS. BMC Psychiatry. 2021.

9. Management of Factitious Disorders: A Systematic Review. — Eastwood S, Bisson JI. Psychotherapy and Psychosomatics. 2008.

10. Clinical, Demographic, Psychological, and Behavioral Features of Factitious Disorder: A Retrospective Analysis. — Jimenez XF, Nkanginieme N, Dhand N, Karafa M, Salerno K. General Hospital Psychiatry. 2019.

11. Patients Who Strive to Be Ill: Factitious Disorder With Physical Symptoms. — Krahn LE, Li H, O'Connor MK. The American Journal of Psychiatry. 2003.

12. Factitious Disorder and Malingering in General Hospitals in the United States: A Retrospective Analysis of the National Inpatient Sample 2017-2021. — Punko D, Onyeaka H, O'Sullivan I, et al. Journal of Psychosomatic Research. 2026.

13. The Other Face of Illness-Deception: Diagnostic Criteria for Factitious Disorder With Proposed Standards for Clinical Practice and Research. — Chafetz MD, Bauer RM, Haley PS. The Clinical Neuropsychologist. 2020.

14. Munchausen Syndrome. — Prabhu A, Abaid B, Sarai S, Sumner R, Lippmann S. Southern Medical Journal. 2020.