Factitious DisorderMANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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564 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Acute anxiety Acute psychosis Agitation-behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Dementia and behavioral crisis Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp49

Immediate priorities

›Life-threatening presentations from self-induced illness

›Factitious hypoglycemia from exogenous insulin

›Blood glucose < 3.0 mmol/l requiring immediate IV dextrose

›50% dextrose 50 ml IV bolus; continuous dextrose infusion if refractory

›Factitious sepsis from self-inoculation

›Broad-spectrum antibiotics within 1 hour of septic shock recognition

›IV access assessment for self-contaminated lines requiring removal

›Factitious hemorrhage or coagulopathy

›INR > 4.0 from surreptitious warfarin ingestion

›Vitamin K 10 mg IV; 4-factor PCC for life-threatening bleed

›Factitious overdose or drug ingestion

›Cardioactive substance ingestion: digoxin, beta-blockers, calcium channel blockers

›Continuous cardiac monitoring; targeted reversal agents

Stabilization and monitoring

›Acute resuscitation targets

›MAP >= 65 mmHg

›Norepinephrine if vasopressor needed after 30 ml/kg IV crystalloid

›SpO2 >= 92%

›Supplemental oxygen titration

›Blood glucose 4.0 to 10.0 mmol/l

›Recheck glucose every 30 minutes until stable

›Temperature < 38.3 degrees C after source control measures

›Monitoring bundle for suspected self-induced illness

›Continuous cardiac monitor

›QT prolongation from ingested substances

›Arrhythmia from electrolyte disturbances

›IV access site integrity

02History/hx64

Presentation pattern

›Core symptom complex

›Dramatic, vague, or textbook-perfect symptom reporting

›Symptoms shift when initial workup is negative

›Magnitude of reported symptoms exceeds objective pathology

›Symptom variability

›Exacerbations preceding scheduled discharge

›Symptom resolution when unobserved

›Polysymptomatic complaint across multiple organ systems

›Neurological, GI, dermatological, endocrine, hematological most common

›Infectious presentations: recurrent abscesses, fevers of unknown origin

Hospital utilization history

›Pattern of excessive healthcare use

›Prior hospitalizations at multiple institutions

›Resistance to allowing access to outside records

›Inconsistencies between reported history and medical records

›Extensive surgical history

›Multiple operations often at different institutions

›Classic Munchausen: gridiron abdomen appearance

›Number of treating physicians and facilities visited

›Hospital-hopping pattern highly suggestive

›Prior diagnoses of factitious disorder at other facilities

Risk factors

›Demographic and occupational risk factors

›Female sex: 66 to 90% of cases in most published series

›Age 25 to 40 years at presentation; mean approximately 34 years

›Healthcare profession or training: up to 50 to 67% of patients

›Nurse, medical assistant, or laboratory technician most common

›Direct IV access present: central lines or implanted ports in approximately 67%

›Psychiatric and psychosocial risk factors

›Past psychiatric history present in approximately 92% of cohort cases

›Personality disorder, especially borderline personality disorder

›Depressive disorder present in approximately 42% of cases

›History of childhood trauma or adversity in approximately 69%

›Abuse, neglect, parental divorce, prolonged early hospitalization

›Family psychiatric history present in approximately 78%

›Substance use disorder comorbidity

Key alarm features

›High-risk self-induced presentations

›Self-induced sepsis via injection of fecal material or saliva into IV lines

›Surreptitious ingestion of insulin, warfarin, thyroid hormone

›Self-induced wounds failing to heal despite appropriate treatment

›Factitious GI bleeding leading to unnecessary endoscopy or transfusion

›Factitious respiratory distress prompting intubation

›Case series documented more than 60 ED visits for unfounded respiratory distress

›ICU admissions for induced illness in approximately 18% of one case series

›Psychiatric alarm features

›Suicidal ideation: case reports of completed suicide exist

›Deceptive behavior does not preclude serious underlying psychopathology

›Active self-harm separate from factitious illness behavior

Symptom timeline and triggers

›Temporal pattern clues

›Symptom onset or worsening after staff attention decreases

›Rapid resolution when patient believes they are unobserved

›Recurrence of identical presentation pattern across multiple admissions

›Substance exposure history

›Access to insulin, anticoagulants, thyroid medications, laxatives, diuretics

›Sympathomimetic exposure causing tachycardia or hypertension

›Opioid-seeking behavior not supported by clinical findings

Collateral history

›External records and contacts

›Outside medical records from other institutions

›Resistance to record release itself a red flag

›Prior treating physicians when contactable

›Similar presentations at multiple hospitals highly suggestive

›Family members or caregivers as informants

›Family dynamic issues identifiable in 100% of one retrospective cohort

›Factitious disorder imposed on another screening

›Patient has dependents: children, elderly relatives, or individuals with disabilities

›Caregiver-mediated illness induction must be excluded

03Physical Exam/exam44

Vital signs

›Hemodynamic assessment

›Tachycardia from sympathomimetic ingestion or induced sepsis

›Heart rate > 100 bpm may be factitious or genuine complication

›Hypoglycemia signs

›Diaphoresis, pallor, tremor

›Fever pattern

›Thermometer manipulation: oral thermometer rubbed against surfaces

›Temperature inconsistent with other clinical findings

Skin and wound examination

›Self-inflicted wound characteristics

›Location in accessible body areas (arms, thighs, anterior torso)

›Geometric or linear wound patterns atypical of spontaneous pathology

›Unusual wound distribution

›Non-healing despite appropriate wound care and antibiotics

›Ligature and edema findings

›Circumferential edema suggesting intermittent ligature application

›Demarcation line at ligature site

›Dermatological mimicry

›Self-applied caustic agents causing skin lesions

›Dermatitis artefacta pattern

IV access and injection sites

›Central line and port examination

›Signs of unauthorized access or manipulation

›Injection site trauma beyond expected use

›Track marks suggesting repeated self-injection

›Peripheral IV sites

›Bruising pattern inconsistent with routine IV attempts

04Differential Diagnosis/ddx38

Psychiatric mimics

›Malingering

›ICD-10 Z76.5

›Intentional symptom production for identifiable external reward

›Financial gain, avoiding legal consequences, avoiding military service

›Distinguishing feature: obvious external incentive present; absent in factitious disorder

›Somatic symptom disorder

›ICD-10 F45.1

›Genuine distress about somatic symptoms without intentional deception

›Distinguishing feature: no fabrication or deliberate induction of symptoms

›Illness anxiety disorder

›ICD-10 F45.21

›Persistent fear of having serious illness despite reassurance

›No symptom fabrication; genuine health preoccupation

Neurological mimics

›Functional neurological symptom disorder

›ICD-10 F44.4 through F44.7

›Neurological symptoms inconsistent with pathophysiology without intentional deception

›Distinguishing feature: Hoover sign and other positive functional signs; no identified deception

›Conversion disorder

›Subtype of functional neurological symptom disorder

›Triggered by psychological stressor; not willful

Psychiatric comorbidities not excluders

›Borderline personality disorder

›ICD-10 F60.3

›Self-harm may occur without deception to assume sick role

›May coexist with factitious disorder

›Delusional disorder with somatic delusions

05Laboratory Tests/lt41

Metabolic and glucose studies

›Blood glucose

›First-line test when factitious hypoglycemia suspected

›Insulin 0.5 nmol/l or greater with C-peptide < 0.6 nmol/l confirms exogenous insulin

›Sulfonylurea screen if C-peptide not suppressed with hypoglycemia

›Rules out oral hypoglycemic agent ingestion

›Electrolytes panel

›Unexplained hypokalemia suggests laxative or diuretic abuse

›Potassium < 3.0 mmol/l with metabolic alkalosis classic pattern

›Metabolic alkalosis with low urinary chloride: vomiting induction pattern

›Hypernatremia or hyponatremia from fluid or salt manipulation

Endocrine studies

›Thyroid function tests

›Suppressed TSH with elevated T3 and T4: exogenous thyroid hormone ingestion

›Low thyroglobulin with elevated T4 distinguishes exogenous from endogenous hyperthyroidism

›Cortisol and ACTH

›Factitious Cushing syndrome from exogenous steroid ingestion

›24-hour urinary free cortisol suppressed; serum ACTH low

Coagulation studies

›Coagulation panel

›Unexplained elevated INR: surreptitious warfarin ingestion

›INR response to vitamin K administration confirms warfarin

›Factor assays if mixed deficiency pattern

›Mixing study: INR correction suggests factor deficiency versus inhibitor

Hematology

›Complete blood count

›Anemia from factitious hemorrhage or laxative-induced malabsorption

›Leukocytosis from induced sepsis

06Diagnostic Tests/dt53

Scoring Systems

›DSM-5 Criteria for Factitious Disorder Imposed on Self (F68.10)

›Criterion A: Falsification of physical or psychological signs, symptoms, or induction of injury or disease with identified deception

›Criterion B: Individual presents self as ill, impaired, or injured

›Criterion C: Deceptive behavior present even without obvious external rewards

›Criterion D: Not better explained by another mental disorder such as delusional disorder

›Severity stratification

›Single episode: one documented episode

›Recurrent episodes: two or more episodes of falsification or induction

›Chronic: persistent pattern over years across multiple institutions

›Diagnostic confidence framework

›Direct evidence of falsification found in only approximately 20% of cases

›Most common diagnostic clues: normal or inconclusive investigations in 69%

›Atypical clinical presentation in 59% of identified cases

›Evocative patient behavior in 33% of identified cases

›Performance validity testing

›Symptom validity tests detect deceptive reporting in neuropsychological presentations

›Below-chance performance on forced-choice tests confirms volitional failure

›Useful adjunct when neurological fabrication is suspected

MRI

›Role of MRI in factitious disorder evaluation

›No specific MRI finding diagnoses factitious disorder

›Brain MRI indicated if factitious neurological disorder causes are being excluded

›Structural lesion must be ruled out before functional diagnosis assigned

›Spine MRI if myelopathic factitious presentation suspected

›Pattern recognition on MRI

›Normal MRI with profound reported deficits supports functional etiology

›Factitious demyelinating lesion injection not reported; standard MS workup applies

07Disposition/dispo31

Admission criteria

›Medical admission indications

›Active medical emergency from self-induced illness

›Septic shock, hemorrhage, severe hypoglycemia, overdose

›Severe electrolyte derangement requiring IV correction

›Diagnostic uncertainty requiring monitored inpatient observation

›Need for monitored environment to prevent ongoing self-harm

›Psychiatric admission indications

›Active suicidal ideation or intent

›Active self-harm risk beyond factitious illness behavior

›Need for urgent psychiatric stabilization

›Voluntary psychiatric admission for treatment engagement

ICU admission criteria

›ICU-level indications

›Hemodynamic instability requiring vasopressor support

›Respiratory failure requiring mechanical ventilation

›Severe metabolic derangement with end-organ dysfunction

›Cardiac monitoring for ingested cardioactive substances

Observation indications

›Criteria for observation stay

›Suspected ongoing self-induction requiring supervised environment

›Awaiting collateral records or psychiatric consultation

›Medical stability uncertain within 24 hours

Discharge criteria

›Safe discharge requirements

›Medical stability with no acute self-induced complications

›Psychiatric safety assessment completed by psychiatry service

›Outpatient follow-up arranged with primary care within 1 to 2 weeks

08Treatment/t68

Acute medical management

›Factitious hypoglycemia protocol

›50% dextrose 50 ml IV bolus for blood glucose < 3.0 mmol/l with symptoms

›Recheck glucose in 15 minutes

›Continuous dextrose 10% infusion if recurrent hypoglycemia

›Octreotide 50 mcg subcutaneous every 8 hours if sulfonylurea ingestion confirmed

›Reduces insulin secretion; prevents recurrent hypoglycemia

›Glucagon 1 mg IM as alternative if IV access unavailable

›Factitious coagulopathy from warfarin

›Vitamin K 10 mg IV for INR > 4.0 without life-threatening bleed

›Repeat INR in 6 hours

›4-factor PCC 25 to 50 units/kg IV for life-threatening hemorrhage

›Fresh frozen plasma 15 ml/kg if PCC unavailable

›INR monitoring every 6 to 12 hours until stable

›Factitious sepsis management

›Blood cultures before antibiotic initiation

›Broad-spectrum antibiotics within 1 hour of septic shock recognition

›Piperacillin-tazobactam 4.5 g IV every 6 hours

›Vancomycin 25 to 30 mg/kg IV loading dose for MRSA coverage

›Source control: remove suspected contaminated IV lines

›Replace peripheral and central access at new sites

›De-escalate antibiotics based on culture and sensitivity results

Thyrotoxicosis from exogenous thyroid hormone

›Propranolol 40 to 80 mg oral every 6 hours for symptomatic control

›Target heart rate < 90 bpm

›IV propranolol 0.5 to 1 mg over 10 minutes for severe tachycardia

›Withhold exogenous thyroid hormone; TSH and thyroid function normalize within 4 to 8 weeks

Electrolyte correction

›Hypokalemia from laxative or diuretic abuse

›Potassium replacement 40 mmol oral per dose if tolerating oral intake

›IV potassium chloride 10 to 20 mmol/hour via central access for severe hypokalemia

›Maximum 20 mmol/hour peripherally

›Continuous cardiac monitoring during IV repletion

›Correct underlying cause: stop diuretics and laxatives if possible

›Metabolic alkalosis from vomiting induction

›Normal saline 1 to 2 litres IV for volume-responsive alkalosis

›Acetazolamide 250 to 500 mg oral or IV if refractory

›Monitor chloride, potassium, and bicarbonate every 6 to 8 hours

Psychiatric and behavioral management

›Confrontation strategy

›Collect firm evidence of fabrication before confrontation

›Involve psychiatry before confrontation if possible

›Confrontation conducted by at least 2 staff members

›Non-judgmental and non-punitive approach

›Emphasize patient as needing help; assure continued care regardless of diagnosis

›Do not demand confession; allow face-saving reframing

›Document confrontation discussion and patient response thoroughly

›No specific pharmacotherapy proven effective for factitious disorder itself

›Systematic review found no significant difference in outcomes with versus without psychiatric medication

›Treat comorbid depression: selective serotonin reuptake inhibitor first-line

›Sertraline 50 mg oral daily; titrate to 100 to 200 mg daily as tolerated

›Fluoxetine 20 mg oral daily as alternative

›Treat comorbid anxiety disorder with SSRI or SNRI

›Borderline personality disorder: dialectical behavior therapy referral; avoid excessive benzodiazepines

›Long-term psychotherapy

›Cognitive behavioral therapy or psychodynamic therapy recommended

›Patient engagement is poor: approximately 12% agree to psychiatric treatment at confrontation

›Frame follow-up as ongoing support, not punishment

Harm reduction measures

›Care coordination strategy

›Designate single primary care provider for all care coordination

›Reduces hospital-shopping and redundant investigations

›Limit unnecessary testing and procedures

›Multidisciplinary review of all planned investigations

›Establish clear care boundaries while maintaining therapeutic alliance

›IV access management

›Peripheral IV only when central line manipulation is a concern

›Supervised IV access when self-injection suspected

›Remove and replace contaminated lines at new sites

›Medication administration

›Supervised oral medication administration when ingestion tampering suspected

›Nurse-administered medications with direct observation

›Lock access to bedside medication supplies

09Special Populations/sp58

Pregnancy

›Factitious disorder in pregnancy

›Presentations include factitious preeclampsia, factitious fetal distress, self-induced preterm labor

›Self-induced preterm labor via rupture of membranes or uterine manipulation

›Consult maternal-fetal medicine and psychiatry concurrently

›Fetal safety considerations

›Exogenous insulin causes fetal hypoglycemia

›Monitor fetal heart rate pattern; fetal glucose parallel to maternal

›Warfarin is teratogenic and fetal anticoagulant

›Vitamin K and 4-factor PCC for maternal bleeding; warfarin contraindicated in second and third trimester

›Sepsis-related preterm labor risk

›Tocolysis contraindicated in frank chorioamnionitis

›Factitious disorder imposed on another by pregnant person

›Self-report of fetal movement cessation or fabricated biophysical profile findings

›Fetal non-stress test and ultrasound for objective fetal assessment

›Mandatory reporting consideration if fetal safety is at risk

›Psychotropic medication safety in pregnancy

›SSRIs generally considered compatible; sertraline preferred based on neonatal safety data

›Avoid benzodiazepines in first trimester; short-term use acceptable if urgent

›Antipsychotics reserved for acute agitation; olanzapine or quetiapine preferred

Geriatric

›Age-specific presentation differences

›Factitious disorder less common in older adults but recognized

›Caregiver-mediated factitious presentations more common than self-induction in elderly

›Elder abuse overlap: factitious disorder imposed on another must be considered

›Diagnostic challenges in older adults

›Multiple genuine comorbidities increase clinical complexity

›Polypharmacy creates legitimate opportunity for surreptitious drug ingestion

10Background/b57

Epidemiology

›Prevalence and incidence data

›True prevalence underestimated due to diagnostic difficulty and patient mobility

›Estimated 0.6 to 3% of referrals to general hospital psychiatric services

›Large US National Inpatient Sample 2017 to 2021 study documents consistent hospital burden

›Higher income quartiles and private insurance associated with FDIS coding

›Iatrogenic morbidity and mortality significant across all medical specialties

›Demographic distribution

›Female sex predominance: 66 to 90% in most published series

›Mean age of presentation approximately 34 years; range 25 to 40 years

›Healthcare profession or training in up to 67% of patients

›ICU admission rate approximately 18% in one multi-center case series

›Healthcare utilization burden

›Median number of hospitalizations before diagnosis: 4 to 10 in retrospective series

›Unnecessary procedures and surgeries account for major iatrogenic harm

›Mortality from self-induced illness and suicide risk is real and documented

Pathophysiology

›Psychological mechanisms

›Psychological need to assume the sick role without external incentive

›Core DSM-5 diagnostic criterion distinguishing factitious disorder from malingering

›Attachment and identity: illness as identity and means of obtaining care and attention

›Early childhood adversity: trauma, abuse, and prolonged illness creating illness schema

›Childhood adversity identified in approximately 69% of patients

›Borderline personality features: identity disturbance, impulsivity, and emotional dysregulation

›Methods of illness induction

›Symptom fabrication: verbal reporting of false symptoms without objective findings

›Medical record falsification: altering laboratory results or clinical notes

›Specimen tampering: adding blood to urine; substituting samples

›Self-induced physical illness

›Self-injection of fecal material, saliva, or contaminants causing sepsis

›Exogenous substance ingestion: insulin, warfarin, thyroid hormone, laxatives, diuretics

›Self-inflicted wounds: caustic agents, ligatures, sharp objects

›Foreign body insertion causing obstruction or infection

›Neurobiology

›No established neurobiological mechanism unique to factitious disorder

›Overlap with impulse control and compulsive behavior disorders proposed

›Comorbid depression alters reward processing and reinforcement of illness behavior

Therapeutic Considerations

›Evidence base for treatment

›No randomized controlled trials for specific factitious disorder treatments

›Systematic review by Eastwood and Bisson found insufficient evidence to recommend specific intervention

›Multidisciplinary team approach associated with improved outcomes in case series

›Confrontation approaches

›Supportive confrontation preferred over direct confrontation

›Non-punitive; face-saving; continued care assured

›Non-confrontational approach: address psychological needs without formal accusation

›Useful when evidence is insufficient for direct confrontation

›Direct confrontation: reserved for cases with definitive evidence

›Risk of immediate AMA departure; approximately 75% confronted but only 17% acknowledge self-induced illness

›Prognosis and outcomes

›Recovery from chronic factitious disorder is rare without sustained psychiatric engagement

›Approximately 12% of confronted patients agree to psychiatric treatment

›Many patients leave AMA or seek care elsewhere after diagnosis is raised

›Suicide risk is real and should not be dismissed even when behavior appears manipulative

›Long-term medical harm from invasive procedures and unnecessary treatments

›Care coordination principles

›Single primary care coordinator reduces fragmentation and hospital-shopping

›Electronic health record flagging for pattern recognition across encounters

›Pharmacy database review to identify medication-seeking across providers

›Regular multidisciplinary case conferences to align management approach

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge instructions for Factitious Disorder

›You were treated for a medical condition that required attention to your health and safety

›Your care team has arranged follow-up appointments to support your wellbeing

›Primary care provider follow-up within 1 to 2 weeks of discharge

›Psychiatry or mental health follow-up within 1 to 2 weeks if arranged

›Medications after discharge

›Take all prescribed medications exactly as directed

›Do not take medications that were not prescribed to you

›Bring a complete medication list to all follow-up appointments

›Warning signs requiring return to emergency department

›Fever above 38.5 degrees C or chills suggesting infection

›Dizziness, sweating, shaking, or confusion suggesting low blood sugar

›Unusual or excessive bleeding or bruising

›Severe abdominal pain or vomiting

›Altered mental status or loss of consciousness

›Any thoughts of harming yourself or others

›New wounds, skin changes, or symptoms that were not present at discharge

›Mental health support resources

›Contact your psychiatry outpatient team if distress increases before appointment

›Crisis line available 24 hours: local crisis resources as applicable

›Emergency department is available at any time for urgent medical or mental health needs

›General wellness guidance

›Regular meals and hydration to maintain stable blood sugar

›Avoid alcohol and non-prescribed substances

›Maintain all scheduled follow-up appointments

12References/r36

Guidelines and key sources

›DSM-5-TR Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision

›American Psychiatric Association 2022

›Diagnostic criteria for Factitious Disorder Imposed on Self F68.10 and Factitious Disorder Imposed on Another F68.A

›Yates GP, Feldman MD. Factitious Disorder: A Systematic Review of 455 Cases in the Professional Literature

›General Hospital Psychiatry 2016

›PMID 27302720

›Largest systematic review; diagnostic clues, ICU admission rates, confrontation outcomes

›Hausteiner-Wiehle C, Hungerer S. Factitious Disorders in Everyday Clinical Practice

›Deutsches Arzteblatt International 2020

›PMID 32897184

›Clinical detection, laboratory clues, and management framework

›Bass C, Halligan P. Factitious Disorders and Malingering: Challenges for Clinical Assessment and Management

›Lancet 2014

›PMID 24612861

›Malingering versus factitious disorder distinction; assessment strategies

›Eastwood S, Bisson JI. Management of Factitious Disorders: A Systematic Review

›Psychotherapy and Psychosomatics 2008

›PMID 18418027

›Evidence base for psychiatric treatment; no RCT evidence for specific intervention

›Jimenez XF, Nkanginieme N, Dhand N, Karafa M, Salerno K. Clinical, Demographic, Psychological, and Behavioral Features of Factitious Disorder

›General Hospital Psychiatry 2019

›PMID 30777298

›Kinns H, Housley D, Freedman DB. Munchausen Syndrome and Factitious Disorder: The Role of the Laboratory

›Annals of Clinical Biochemistry 2013

›PMID 23592802

›Laboratory detection of specimen tampering and surreptitious substance ingestion

›Punko D, Onyeaka H, O'Sullivan I, et al. Factitious Disorder and Malingering in General Hospitals in the United States

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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