Factitious Disorder: DSM-5-TR Diagnostic Criteria and Management
Core Diagnostic Criteria
Factitious disorder is diagnosed when a patient intentionally produces or feigns physical or psychological symptoms to assume the sick role, without any external incentive such as financial gain or avoiding legal responsibility. 1
The DSM-5-TR requires all of the following criteria:
- Falsification of symptoms or signs: The patient deliberately fabricates physical or psychological symptoms, or intentionally induces injury or disease 2, 3
- Deceptive presentation: The individual presents themselves to others as ill, impaired, or injured 4
- Absence of external rewards: The behavior occurs even when obvious external incentives (financial compensation, avoiding work, obtaining drugs) are absent—this distinguishes factitious disorder from malingering 1
- Not better explained by another disorder: The behavior is not better accounted for by another mental disorder such as delusional disorder or psychotic disorder 2
Subtypes and Specifiers
The DSM-5-TR recognizes two primary presentations:
- Factitious disorder imposed on self: The individual falsifies their own illness 5, 4
- Factitious disorder imposed on another (previously "Munchausen syndrome by proxy"): The individual falsifies illness in another person, typically a dependent 4
Munchausen syndrome is a severe subtype of factitious disorder imposed on self, characterized by:
- Predominantly male presentation (unlike typical factitious disorder) 5
- Dramatic, wandering presentation across multiple healthcare facilities ("peregrination") 5, 4
- Extensive medical knowledge and willingness to undergo invasive procedures 4
- More severe course and poorer prognosis 5
Typical Clinical Presentation
Patient Characteristics
The stereotypical profile of a young female healthcare worker represents only a subset of patients; factitious disorder affects individuals across diverse demographics 5. Key features include:
- Multiple hospitalizations with extensive, unnecessary diagnostic workups 2
- Vague, inconsistent symptoms that do not follow typical disease patterns 1
- Symptoms that fluctuate or worsen when the patient knows they are being observed 1
- Extensive medical knowledge disproportionate to their stated background 4
- Resistance to psychiatric evaluation or abrupt discharge when confronted 2
- History of seeking care from multiple providers or facilities ("doctor shopping") 5, 4
Common Symptom Presentations
Factitious disorder can mimic virtually any medical condition across all specialties 5, 4:
- Neurologic symptoms (seizures, paralysis, sensory deficits) 1
- Gastrointestinal complaints (abdominal pain, vomiting, diarrhea) 1
- Dermatologic lesions (self-inflicted wounds that fail to heal) 4
- Hematologic abnormalities (self-induced bleeding, anemia) 4
- Infectious presentations (fever, wound infections through contamination) 4
- Psychiatric symptoms (hallucinations, suicidal ideation) 2
Critical Differential Diagnosis
The most important distinction is between factitious disorder and malingering—both involve intentional symptom production, but malingering is motivated by clear external gain (money, avoiding prosecution, obtaining drugs), whereas factitious disorder is driven solely by the psychological need to assume the sick role. 1
Other key differentials:
- Somatic symptom disorder: Symptoms are NOT intentionally produced; the patient genuinely experiences distress from symptoms they believe are real 1
- Illness anxiety disorder: Preoccupation with having a serious illness without significant somatic symptoms 1
- Conversion disorder: Neurological symptoms are not intentionally produced and occur unconsciously 1
- Obsessive-compulsive disorder: Intrusive thoughts about causing harm are ego-dystonic and provoke anxiety, not deliberately enacted 6
- Psychotic disorders: Delusions about illness are fixed false beliefs, not conscious fabrications 2
Diagnostic Approach
Positive Evidence to Seek
Rather than diagnosis by exclusion, actively look for:
- Direct observation of symptom fabrication (tampering with specimens, self-injury, medication manipulation) 5, 4
- Discrepancies between reported symptoms and objective findings 5
- Inconsistent medical history across different providers 4
- Symptoms that resolve when the patient is unaware of observation 1
- Evidence of self-harm or intentional contamination of wounds 4
- Possession of medical equipment or medications not prescribed to them 4
Common Pitfalls
- Premature confrontation often leads to patient elopement and continuation of behavior at another facility 2, 5
- Assuming all unexplained symptoms are factitious risks missing genuine medical conditions 5
- Failure to document objective evidence before making the diagnosis 4
- Overlooking psychiatric comorbidities (personality disorders, depression, trauma history) that are present in the majority of cases 2, 7, 5
Management Strategy
Immediate Safety Considerations
The first priority is preventing iatrogenic harm from unnecessary procedures, medications, or surgeries. 2, 5
- Avoid invasive testing unless absolutely medically indicated 5
- Coordinate care through a single primary provider to prevent "doctor shopping" 4
- Document all objective findings meticulously 4
- Assess for suicidality—death can occur from complications of self-induced illness, iatrogenic harm, or suicide 5
Confrontation Approach
When confronting the patient, adopt a non-aggressive, empathetic, face-saving approach rather than accusatory language. 5, 4
Recommended framework:
- Present objective evidence in a neutral, non-judgmental manner 5
- Frame the discussion around concern for the patient's wellbeing 2, 5
- Offer psychiatric consultation as a collaborative next step, not as punishment 2, 4
- Avoid using terms like "lying" or "faking"—instead describe "a need to be in the sick role" 2
- Anticipate denial and have a plan for ongoing engagement 5
Psychiatric Treatment
Psychotherapy with a multidisciplinary team is the primary treatment modality, though evidence for efficacy is limited. 2, 7
Treatment components:
- Psychodynamic psychotherapy addressing early trauma, attachment disruptions, and maladaptive coping patterns 7
- Cognitive-behavioral approaches targeting the reinforcement cycle of assuming the sick role 2
- Treatment of comorbid conditions (depression, anxiety, personality disorders) which are present in the majority of cases 2, 7, 5
- Harm reduction approach when complete cessation is not achievable—minimize medical interventions while maintaining therapeutic alliance 5
Countertransference Management
Healthcare providers commonly experience:
- Anger and feelings of betrayal when deception is discovered 7
- Desire to punish or abandon the patient 7
- Difficulty maintaining empathy for someone who "wastes resources" 2
Recognize that factitious disorder represents severe psychopathology rooted in early trauma and interpersonal dysfunction—not willful manipulation for entertainment. 7
Prognosis and Long-Term Outlook
The prognosis is generally poor, particularly in the short and medium term, with high rates of recidivism and continued healthcare-seeking behavior. 5
Prognostic factors:
- Munchausen syndrome subtype has worse outcomes than other presentations 5
- Presence of personality disorders (common comorbidity) predicts poorer response to treatment 7
- Early intervention before extensive iatrogenic harm may improve outcomes, though evidence is limited 2
- Mortality is rare but possible from self-induced illness, procedural complications, or suicide 5
Psychopathological Understanding
The underlying psychology involves:
- Early attachment trauma and disrupted caregiver relationships leading to maladaptive help-seeking 7
- Pathological need for attention and care that can only be met through the sick role 7
- Identity conflicts where the patient's sense of self is organized around being ill 2
- Masochistic gratification from self-harm and medical procedures 2
- Aggression and desire for dominance over healthcare providers through deception 7