Factitious Disorder Overview

Etiology

Although the exact etiology of FDIS remains unknown, several psychosocial factors frequently emerge among individuals with this diagnosis. A history of traumatic childhood experiences, early loss of a loved one, and feelings of abandonment appear common. By fabricating medical illnesses, many patients gain access to the attention and care from healthcare professionals that may have been absent in their formative years. Among the small number of patients who have acknowledged their diagnosis, many report a desire to feel important and to secure a sense of belonging through their assumed identity as a patient. The leading hypotheses regarding the pathogenesis of FDIS emphasize psychological mechanisms rather than biological ones.[2] Several theories have been proposed to explain this behavior, including:

• Many individuals diagnosed with this disorder have endured abuse, neglect, or instability during childhood. Feigning illness often provides a sense of control and helps fulfill unmet emotional needs. Adopting the patient role enables avoidance of personal responsibilities and escape from life’s failures.[2]
• Risky medical interventions sometimes serve as a form of self-punishment, driven by unresolved guilt from past experiences.[2]
• For others, the disorder may represent a coping mechanism for social isolation.[2]
• Some theorists suggest that increased medicalization of daily life and a cultural emphasis on victimhood have contributed to a rise in such cases.[2][9]
• A sense of achievement may also develop when patients succeed in misleading healthcare professionals or complicating the diagnostic process.[8]

According to DSM-5, FDIS shares key behavioral characteristics with substance use disorders, eating disorders, and impulse control disorders. In all of these conditions, persistent behavior occurs alongside intentional deception and significant efforts to conceal the conduct.[DSM5]

Epidemiology

FDIS has been identified in 1.3% of all hospitalized patients, with Munchausen syndrome accounting for approximately 10% of these cases.[1] Accurately determining the total number of individuals affected by factitious disorder remains challenging, as the diagnosis often proves difficult to confirm. The secretive and deceptive behavior that characterizes this disorder contributes to significant underdiagnosis. Additionally, the absence of a clearly defined threshold for the degree of deception required further complicates the diagnostic process.[10]

Patients suspected of having FDIS commonly deny the diagnosis when confronted and may react with hostility. Many choose to leave against medical advice and pursue treatment at another facility, complicating continuity of care. Several risk factors have been associated with this condition, including female gender, unmarried status, and employment within the healthcare field.[11] Onset typically occurs during early adulthood or middle age.[12]

Patients frequently seek care from dermatology and neurology specialists, as somatic symptoms offer a socially acceptable way to conceal underlying psychological distress.[8] This paradox places nonpsychiatric clinicians at the forefront of identifying a psychiatric condition.[9] Despite the relatively low prevalence, factitious disorder carries a high burden due to its association with significant morbidity, mortality, and increased healthcare costs.[1]

Pathophysiology

The pathophysiology of FDIS is primarily unknown, as no large-scale studies have been conducted on the condition. Psychosocial factors are widely acknowledged to have the most significant influence on the development of FDIS.

History and Physical

In the vast majority of cases, patients with FDIS present with somatic complaints that they attribute to legitimate medical conditions. Although the clinical presentation varies considerably, commonly reported symptoms include chest pain, abdominal pain, vomiting, diarrhea, anemia, hypoglycemia, infections, seizures, generalized weakness, headaches, vision loss, skin wounds, and joint pain.

Many patients with FDIS deliberately induce or worsen symptoms to maintain the appearance of illness. Methods used include ingesting spoiled food, injecting insulin to produce hypoglycemia, picking at the skin to create wounds, overdosing on medications, or intentionally avoiding prescribed treatments. In some cases, patients manipulate documentation by forging medical records or tampering with laboratory results.

Individuals with FDIS may also exploit existing benign medical abnormalities to support their fabricated illness. For example, a chronically abnormal electrocardiogram (ECG) can serve as a foundation for inventing related cardiac symptoms. Among sites of self-inflicted skin injury, the hand frequently becomes the target, often due to its accessibility and visibility during examination.[1]

Evaluation

In the majority of patients with FDIS, the presenting symptoms cannot be confirmed through laboratory or radiographic testing. Many patients take pride in portraying themselves as “medical mysteries,” often leaving physicians puzzled by conflicting clinical findings. Careful attention to inconsistencies, eg, a mismatch between reported symptoms and objective physical or laboratory results, can provide valuable diagnostic clues.

Several additional indicators often support the suspicion of FDIS. These include a history of numerous hospitalizations, willingness to undergo high-risk medical procedures, repeated surgical interventions, inconsistent or shifting narratives, resistance to psychiatric evaluation, and extensive diagnostic workups with minimal therapeutic response. For example, anemia that fails to improve after blood transfusion or a symptom pattern that the patient can inexplicably predict may suggest factitious behavior.[13][14][11][15]

Patients with FDIS often resist requests to obtain previous medical records and frequently avoid disclosing prior care.[2] During hospitalization, few visitors typically appear, and the patient’s condition may decline as the discharge date approaches.[2] Obtaining external medical records becomes essential, not only to identify discrepancies in the current presentation but also to uncover any prior diagnosis of FDIS.

Treatment / Management

The diagnosis of FDIS falls under the criteria outlined in the DSM-5. Diagnostic confirmation requires clear evidence that the patient intentionally and falsely presents symptoms of a psychiatric or general medical condition, without any indication of malingering. The behavior must occur independently of other psychiatric or medical disorders, eg, schizophrenia or delusional disorder.

Direct confrontation regarding suspected FDIS rarely leads to acknowledgment of the illness. More often, patients respond with denial, hostility, or defensive behavior. Reactions may include becoming visibly upset, threatening legal action, leaving against medical advice, or seeking care at a different hospital. A more effective strategy involves approaching the patient with empathy and support rather than confrontation. Psychiatric consultation remains essential, even when met with resistance, to evaluate for underlying or comorbid psychiatric disorders.

Psychotherapy serves as the primary treatment for FDIS, although most patients decline participation. An admission of the disorder is not required for therapy to proceed, and very few patients ever acknowledge the diagnosis. In some cases, cognitive-behavioral therapy focused on unresolved childhood trauma may offer benefits.

Experts often recommend an interprofessional approach to care. Involvement from nurses, psychiatrists, primary care clinicians, therapists, and family members can enhance therapeutic engagement.[10] Many advocate for a nonconfrontational, relationship-building approach once the diagnosis becomes evident. This method may reduce factitious behavior and allow for concurrent treatment of psychiatric comorbidities with greater success.[16](B2)

Management should always include careful attention to coexisting psychiatric conditions. Studies suggest that some individuals with FDIS tend to “age out” of the disorder by their fourth decade of life, similar to patterns observed in personality disorders.[1] A concurrent diagnosis of depression, particularly when treatable, may indicate a more favorable prognosis.[1](B3)

Differential Diagnosis

When evaluating a patient for factitious disorder, clinicians must carefully consider other potential etiologies that may resemble the condition. Malingering, conversion disorder, and borderline personality disorder are the most likely conditions to have overlapping clinical features.

Malingering

Malingering involves the conscious fabrication or exaggeration of symptoms to achieve secondary gain. Differentiating malingering from factitious disorder presents a significant challenge, as determining a patient’s underlying motivation can prove difficult. Ruling out external incentives, eg, financial compensation, avoidance of work, evasion of legal consequences, or exemption from military duty, remains essential when malingering is a possibility.[17]

Conversion Disorder and Somatic Symptom Disorder

Conversion disorder and somatic symptom disorder, both rooted in subconscious processes, can also mimic factitious disorder. These conditions lack intentional deception and require a different diagnostic and therapeutic approach. In contrast, diagnosing factitious disorder demands objective evidence of intentional falsification or induction of symptoms.[17]

Borderline Personality Disorder 

Patients with borderline personality disorder frequently exhibit deceptive behaviors and engage in self-injury. Unlike individuals with factitious disorder, however, those with borderline traits often acknowledge their self-harming actions. Clinicians should also remain aware of the high rate of comorbidity between borderline personality disorder and factitious disorder, as both may coexist in the same individual.[17]

Prognosis

Although definitive evidence for the most effective intervention remains limited, the overall prognosis for FDIS tends to be poor. Most patients refuse to acknowledge their maladaptive behaviors, which significantly hinders engagement in treatment. Individuals with comorbid conditions, including substance use disorders, anxiety, or depressive disorders, often experience better long-term outcomes compared to those with coexisting personality disorders.

Confrontation rarely leads to productive results, as most patients deny their actions and decline treatment. Among those who begin therapy, dropout rates remain high. Despite these challenges, patients who consistently participate in long-term psychotherapy demonstrate more favorable outcomes, suggesting that sustained therapeutic engagement may improve prognosis over time.[18]

Complications

FDIS does not follow a benign course and carries significant risks of morbidity and mortality. Patients frequently engage in behaviors that result in potentially life-threatening self-injury and often undergo high-risk medical procedures without clinical necessity. These actions not only endanger their health but also place a substantial financial burden on the healthcare system, with associated costs reaching hundreds of thousands of dollars per patient.[19]

Beyond the physical and economic consequences, the disorder inflicts considerable emotional distress. Both patients and their families often experience ongoing psychological suffering, driven by the chronic nature of the illness and the complexities involved in its recognition and management.[1]