Factitious disorder
Diagnostic Foundations of Factitious Disorder
Factitious disorder is a complex and often misunderstood mental disorder characterized by the intentional falsification, induction, or exaggeration of physical or psychological symptoms in the absence of obvious external incentives. Unlike malingering, in which deception is motivated by tangible external gains such as financial compensation, avoidance of legal responsibility, or access to resources, factitious disorder involves deception driven by internal psychological motivations (American Psychiatric Association, 2013). In factitious disorder, deception persists even when external rewards are minimal or absent and may continue despite high personal cost. While external gains may occasionally be present in factitious disorder, they are insufficient to explain the behavior (Rogers, 2004).
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), factitious disorder is classified under Somatic Symptom and Related Disorders (American Psychiatric Association, 2013). The core diagnostic feature is the intentional production or feigning of symptoms, combined with the presentation of oneself or another person as ill, impaired, or injured. Crucially, the deceptive behavior occurs mostly in the absence of external rewards, situating the disorder closer to others that involve identity formation, attachment needs, and emotional regulation.
The DSM-5 distinguishes two principal forms: 1) factitious disorder imposed on self and 2) factitious disorder imposed on another. In factitious disorder imposed on self, individuals deliberately fabricate, exaggerate, or induce symptoms in themselves. This may include falsifying medical histories, manipulating diagnostic tests, exaggerating genuine conditions, or directly causing illness or injury, for example, by ingesting toxic substances or interfering with wound healing (American Psychiatric Association, 2013; Bass & Halligan, 2014). Individuals often present repeatedly to healthcare services and may appear unusually knowledgeable about medical terminology, procedures, and hospital routines.
Factitious disorder imposed on another, historically referred to as Munchausen syndrome by proxy, involves the deliberate falsification or induction of illness in another individual, most commonly a child under the person’s care. In this form, the perpetrator assumes the role of a concerned and attentive caregiver while covertly causing or fabricating symptoms in the dependent person (American Psychiatric Association, 2013). The DSM-5 explicitly recognizes this behavior as a form of abuse.
Epidemiological data on factitious disorder are limited, in part because the condition is difficult to detect and often deliberately concealed. Prevalence estimates vary widely, and the disorder is widely regarded as underdiagnosed (Bass & Halligan, 2014). Clinical reports suggest that factitious disorder imposed on self is more frequently identified in women, particularly in hospital settings, although cases occur across genders and age groups. Factitious disorder imposed on another is most often identified in caregivers, especially mothers, though this pattern may reflect detection and reporting biases rather than true prevalence differences (Sheridan, 2003).
The etiology of factitious disorder remains poorly understood, and no single explanatory model has been conclusively established. Psychological accounts emphasize the role of unmet emotional needs, identity disturbance, attachment pathology, and maladaptive coping strategies. Many individuals appear to derive psychological gratification from assuming the sick role or, in the imposed-on-another form, from occupying the role of the devoted and heroic caregiver (Bass & Glaser, 2014). Histories of trauma, neglect, or early illness have been reported in some cases, suggesting that illness may become central to identity and interpersonal connection.
Diagnosing factitious disorder poses significant clinical challenges. The diagnosis is often considered only after extensive medical evaluation fails to explain the clinical presentation or when inconsistencies, implausible histories, or evidence of symptom manipulation emerge (American Psychiatric Association, 2013). Differentiating factitious disorder from malingering, somatic symptom disorder, illness anxiety disorder, and genuine medical conditions requires careful assessment. Although intentional deception is a defining feature, it is rarely directly observable and must be inferred from behavioral patterns over time.
The consequences of factitious disorder can be severe. Individuals may undergo unnecessary and invasive medical procedures, experience iatrogenic harm, and place substantial strain on healthcare systems. In cases of factitious disorder imposed on another, the physical and psychological harm to the victim can be profound, and in some cases, life-threatening (Sheridan, 2003).
Despite its seriousness, factitious disorder remains a diagnosis that many clinicians hesitate to make, often because of concerns about confrontation, stigma, or damage to the therapeutic relationship. However, avoiding the diagnosis may perpetuate harm and delay appropriate intervention.
Case Reports on Factitious Disorder Imposed on Self
Yates and Feldman (2016) conducted a comprehensive systematic review to address a major gap in the clinical understanding of factitious disorder imposed on self: the absence of a sufficiently large, systematically analyzed sample describing the demographic and clinical profiles of affected patients. The authors aimed to synthesize all eligible adult case reports of factitious disorder imposed on self with physical symptoms published in the scientific literature to identify patterns across cases and across medical specialties.
The authors compiled information from 372 studies, including 455 individual cases. The findings challenge several long-standing assumptions about factitious disorder imposed on self. Approximately two-thirds of cases involved female patients, with a mean age at presentation of just over 34 years. This finding contradicts earlier claims of male predominance, as reflected in earlier diagnostic manuals. Notably, a striking proportion of patients—over half of those for whom occupation was reported—claimed employment in healthcare or laboratory professions, with nursing being the most common. The authors discuss whether this reflects a genuine association or publication bias, noting that healthcare professionals may be more adept at fabricating illness convincingly and thus more likely to appear in published case reports.
The review revealed considerable heterogeneity in how factitious disorder presents. Patients were found across a wide range of medical specialties, with endocrinology, cardiology, dermatology, and gastroenterology being particularly common. Importantly, the majority of patients did not merely simulate or falsely report symptoms; many actively induced illness or injury in themselves. Common methods included insulin abuse to induce hypoglycemia, self-bloodletting to cause anemia, and deliberate infection or wound manipulation.
Psychiatric comorbidity was inconsistently reported. Among cases with available information, depression was the most frequently reported diagnosis, while personality disorders were less common than often assumed in the literature. Suicidal ideation or prior suicide attempts were reported in only a minority of cases. At the same time, the high prevalence of illness induction underscores the substantial risk of serious injury or death.
The review also examined factors that lead clinicians to diagnose factitious disorder. The most common trigger was a presentation unsupported by objective clinical findings. Other important indicators included extensive prior healthcare use, atypical or improbable illness courses, treatment failure, unusual patient behavior, and evidence of fabrication.
In discussing their findings, Yates and Feldman emphasize that factitious disorder cannot be understood through a single clinical stereotype. Instead, it is a heterogeneous condition shaped by patient characteristics, available medical technologies, and specialty-specific diagnostic practices. They argue that patients with factitious disorder often exploit protocol-driven pathways to admission and take advantage of widely available medical knowledge, including information obtained from the internet.
Patterns in Factitious Disorder Imposed on Self.
Factitious disorder often remains hidden for long periods because it does not present as a single, easily identifiable symptom or behavior. Instead, it tends to emerge through patterns that unfold over time, across situations, and sometimes across institutions. Recognizing these patterns does not require specialized diagnostic expertise, but it does require attention to inconsistencies, escalation, and the broader context in which illness claims arise.
None of the signs described below, as defined in the DSM-5 (American Psychiatric Association, 2013), is definitive on its own; they become meaningful when they cluster or persist.
One of the most common concerning patterns involves a mismatch between reported symptoms and objective findings. Individuals may describe severe, unusual, or dramatic symptoms that are not supported by clinical examinations, test results, or observed functioning. This does not mean that all unexplained symptoms indicate deception—many genuine medical conditions are difficult to diagnose—but repeated discrepancies over time may raise concern, particularly when new symptoms appear as older ones are ruled out.
Another frequently noted pattern is an atypical course of illness. Conditions may follow an unpredictable or medically implausible trajectory, with symptoms appearing suddenly, worsening unexpectedly, or failing to respond to treatments that would ordinarily be effective. In some cases, improvement is brief or nonexistent, even with extensive interventions. The illness narrative may seem unusually complex, involving multiple diagnoses, rare conditions, or shifting explanations that adapt to new information.
Escalation is also a key feature. When previous explanations or complaints are questioned or resolved, new symptoms may emerge that are more severe, harder to verify, or associated with greater risk. This escalation can include the development of symptoms that require invasive procedures, emergency interventions, or hospital admissions. Research based on large collections of case reports suggests that active induction of illness or injury—rather than simple exaggeration—is more common than previously assumed (Yates & Feldman, 2016).
A pattern of extensive engagement with healthcare systems is another potential warning sign. Individuals may have a long history of consultations, hospitalizations, or procedures across multiple settings. They may seek care from numerous providers or institutions, sometimes presenting incomplete or inconsistent medical histories. This pattern can be difficult to detect because it often spans years and locations, and because each new encounter may appear legitimate when viewed in isolation.
Behavioral patterns surrounding illness can also be informative. Some individuals display an unusual degree of familiarity with medical terminology, procedures, or institutional routines. Others appear unusually eager for tests, treatments, or procedures, even when these carry risk or discomfort. At the same time, there may be resistance to sharing information between providers or reluctance to authorize access to prior medical records, which can limit continuity and oversight.
The social and interpersonal context of illness is another important dimension. Illness may become central to personal identity, daily structure, or relationships. Attention, care, and concern from others may appear closely tied to symptom presentation, with distress intensifying when that attention wanes. In some cases, illness narratives cast the individual consistently in the role of a victim of medical mystery, misfortune, or systemic failure. While such narratives can also arise in genuine chronic illness, their persistence and dramatic framing may warrant attention when combined with other warning signs.
Factitious Disorder Imposed on Another
In situations involving factitious disorder imposed on another, patterns extend beyond the individual claiming illness to include a dependent person presented as ill. Symptoms may occur only in the presence of a particular caregiver or improve when that person is absent. Medical findings may be inconsistent, unexplained, or repeatedly contradicted by observations across different contexts. The caregiver may appear exceptionally attentive, knowledgeable, and invested in the sick role, while also resisting alternative explanations or independent observation (American Psychiatric Association, 2013).
Many of the features described—unexplained symptoms, treatment-resistant conditions, and repeated consultations—are common in genuine illness and psychological distress. Factitious disorder becomes a consideration only when such features accumulate, intensify, and interact in ways that are difficult to reconcile with known medical or psychological processes.
Distinguishing Factitious Disorder from Other Conditions
Understanding factitious disorder requires careful attention to what distinguishes it from other psychological, medical, and contextual explanations for unusual or harmful presentations of illness. Because factitious disorder involves intentional falsification or induction of illness, its identification depends less on the presence of specific symptoms and more on understanding motivation, behavior patterns, and context over time. Many conditions can superficially resemble factitious disorder, and some may lead to equally serious harm without involving deception. In factitious disorder, symptoms are knowingly fabricated, exaggerated, or induced, even though the individual may have limited insight into why they engage in such behavior (American Psychiatric Association, 2013). By contrast, in several other conditions, illness presentations may be inaccurate, exaggerated, or persistent without deliberate intent to mislead.
1) Psychotic Disorders. One important distinction concerns psychotic disorders, particularly delusional disorder with somatic themes. Individuals experiencing psychosis may sincerely believe they or another person are ill, even in the absence of objective evidence. In such cases, reports of extreme or implausible symptoms may occur, but they stem from fixed false beliefs rather than intentional deception. The defining difference lies in conviction: psychotic individuals believe the symptoms are real, whereas in factitious disorder the symptoms are purposefully misrepresented, even if insight into motivation is poor. Reports of bizarre bodily processes or persecutory explanations are more characteristic of psychosis than of factitious disorder (American Psychiatric Association, 2013).
2) Somatic Symptom Disorder. Somatic symptom disorder presents another challenge. Individuals with this condition experience genuine distress related to physical symptoms that may be medically unexplained or disproportionate to the findings. Their suffering is real, and their reports are not intentionally false. Somatic symptom disorder may co-occur with factitious disorder, further complicating interpretation, but the presence of preoccupation alone does not justify a factitious diagnosis (American Psychiatric Association, 2013).
3) Anxiety-Related Conditions. Anxiety-related conditions, especially illness anxiety disorder, also warrant consideration. Excessive health anxiety can lead to repeated medical consultations, insistence on testing, and heightened focus on bodily sensations. This pattern may appear similar to factitious disorder, particularly when reassurance fails to reduce concern. However, in illness anxiety disorder, the individual does not deliberately falsify symptoms. The behavior is driven by fear and misinterpretation rather than deception. Similarly, caregivers with intense anxiety may over-medicalize a child out of fear of harm, not because they are fabricating illness.
4) Vulnerable Child Syndrome. Vulnerable Child Syndrome is a pattern in which caregivers perceive a child as fragile following an early medical crisis and subsequently engage in excessive monitoring and treatment-seeking (Allen et al., 2004). Although this can expose a child to unnecessary interventions, it does not involve intentional falsification. Distinguishing this syndrome from factitious disorder imposed on another can be particularly difficult, especially when early medical trauma is present. The distinction becomes critical when there is evidence of symptom induction or deliberate misrepresentation.
5) Medical Conditions. Finally, it is essential to acknowledge that genuine medical conditions, including rare diseases, can initially appear implausible or inconsistent. History contains numerous examples of misattributed deception later proven to be true illness. This underscores the need for humility and caution. Factitious disorder should never be inferred solely from diagnostic uncertainty or clinician frustration.
Report of Cases of Factitious Disorder Imposed on Self
Case 1 (https://www.thescottishsun.co.uk/fabulous/15441433/lied-about-being-sick-for-decades/)
This case concerns a self-reported, long-term pattern of factitious behavior. The individual was identified as a 49-year-old artist from Calgary who described decades of faking illness to obtain attention and care from others. From as early as age four, she engaged in behaviors intended to simulate serious medical conditions — including pretending to faint, inducing injuries, and fabricating symptoms such as seizures. Over the years, she was repeatedly admitted to medical facilities under false pretenses. She later acknowledged the behavior as part of a lifelong pattern of deception driven by emotional and psychological needs rather than external incentives.
In adulthood, amid periods of stress and trauma, she engaged in increasingly dangerous acts, including intentionally harming herself to appear ill. At one point, she was even airlifted to a hospital after faking a seizure. After years of such behavior and numerous unnecessary medical interventions, she eventually disclosed her deceptions to a psychiatrist, leading to a formal diagnosis of factitious disorder. She later pursued treatment, including therapy and medication, and wrote a memoir about her experience to raise awareness of the condition.
This case reports on a phenomenon sometimes described as Munchausen by Internet, a contemporary expression of factitious disorder imposed on self. The reporting highlights situations in which individuals feign serious illnesses or medical crises online to gain sympathy, emotional support, and attention from virtual communities. These narratives often develop in health-related forums or social media groups where others share genuine experiences of illness.
Although the specific individuals are not named in the reporting, the examples discussed involve users who repeatedly post dramatic claims of grave disease or misfortune that ultimately prove to be fabrications. Their behavior consumes significant emotional energy and support from other participants and can undermine the trust and functioning of online support groups. The presentation of fabricated medical conditions in online forums is recognized as a form of factitious disorder imposed on self when viewed through a psychiatric lens, and news coverage has highlighted the psychological and social impacts of such behavior.
Report of Cases of Factitious Disorder Imposed on Another
This case was reported in the Australian news and involved a mother who deliberately poisoned her two-year-old child, leading to repeated hospitalizations. According to court records, the child presented multiple times with unexplained medical emergencies that were eventually traced to the administration of insulin without medical indication. The child experienced life-threatening hypoglycemic episodes that required urgent medical intervention.
During legal proceedings, expert testimony suggested that the mother’s behavior was consistent with Factitious Disorder Imposed on Another. The report emphasized that the mother appeared attentive and concerned during hospital visits while covertly causing harm. The child’s condition improved after separation from the caregiver, reinforcing the conclusion that the illness episodes were not spontaneous.
Case 4 (https://time.com/5553735/the-act-hulu-true-story/)
This case, widely reported in international news and later explored in documentaries and dramatizations, involved a mother who fabricated and exaggerated her daughter's medical conditions for years. The child was portrayed as suffering from numerous serious illnesses, including neurological impairments and chronic physical disabilities, leading to extensive medical interventions, including surgeries, medication regimens, and the use of mobility aids.
Over time, the daughter’s identity became organized around illness, dependence, and disability. Authorities ultimately determined that the caregiver had systematically deceived medical professionals and induced unnecessary treatments, behavior consistent with Factitious Disorder Imposed on Another.
Case 5 (https://pubmed.ncbi.nlm.nih.gov/36532908/)
In this clinical case report, researchers describe a rare case of Factitious Disorder Imposed on Another in an adult patient with a complex combination of medical and psychiatric conditions. The victim had a history of diabetes, substance use disorder, and schizoaffective disorder and relied on a caregiver who was responsible for aspects of their daily care and medical decision-making.
Over time, the caregiver was found to be falsifying symptoms and medical information about the adult patient, creating narratives of illness that were inconsistent with medical findings. The report highlights the medicolegal and ethical challenges clinicians faced in recognizing and documenting Factitious Disorder Imposed on Another in an adult victim, where underlying physical and mental health comorbidities complicated the picture.
Particular considerations over criminal cases involving multiple victims
The following cases involve caregivers (nurses) who deliberately harmed or killed patients in their care. In psychiatry, such acts may overlap with extreme forms of fabricated or induced illness or reflect severe psychopathology (e.g., personality disorder, sadistic behavior), but not all meet the strict DSM-5 definition of Factitious Disorder Imposed on Another. This condition requires intentional deception about illness status without external gains. In some of these cases, the motives reported are complex (e.g., reducing workload, thrill, power, etc.).
Case 1 (https://www.cbsnews.com/news/nurse-life-sentence-murder-10-patients-germany/)
This case was widely reported in major news outlets as involving a palliative care nurse in Germany who was sentenced to life imprisonment for intentionally killing 10 elderly patients and attempting to murder 27 others. According to court reports, the unnamed male nurse worked at a hospital near Aachen and used lethal doses of sedatives and painkillers (including morphine and midazolam) to induce death or life-threatening conditions in patients. Prosecutors described his motive as a desire to reduce his workload during night shifts, and they characterized his actions as performed “without enthusiasm” and with “a lack of empathy.”
The crimes occurred over several months, and exhumations were ordered to identify additional potential victims. The court found the acts carried “particular severity of guilt,” leaving open the possibility of extended incarceration beyond the standard minimum for life convictions in Germany.
Case 2 (https://people.com/resuscitation-rambo-nurse-killed-dozens-patients-11863441)
Niels Högel was a former intensive care nurse who became one of the most prolific caregiver murderers in modern history. Known in news reporting as the “Resuscitation Rambo,” Högel initially gained a reputation for dramatic resuscitations before later investigations revealed that he had repeatedly induced cardiac arrests in patients by administering unauthorized and harmful medications to later appear to save them.
He worked primarily in hospitals in northern Germany, where investigators found that death rates surged whenever he was on duty. After a colleague witnessed a suspicious injection in 2005, authorities launched an investigation. Subsequent exhumations and record reviews revealed that Högel was responsible for at least 85 patient deaths, though the true total is believed to be higher, with some estimates placing it well over 100. He was convicted and sentenced to life in prison, and the case drew extensive international media coverage because it exposed catastrophic failures in hospital oversight and misuse of caregiver authority.
In Spain, a nursing assistant at a public hospital was convicted and sentenced to 20 years in prison for murdering elderly patients by injecting air into their veins, causing fatal embolisms. The court rejected accidental explanations after forensic analysis showed large amounts of injected air, concluding the acts were intentional. The victims were elderly and vulnerable, and the nurse used her position and access to inflict lethal harm.
Reported in international news, this case concerns a former British neonatal nurse who was convicted of murdering seven babies and attempting to murder eight more while working in a hospital’s neonatal unit between 2015 and 2016. According to Reuters, she was found guilty at trial and sentenced to life imprisonment with a whole-life order.
In 2025, a group of medical experts publicly challenged the medical evidence used in her conviction, arguing that some of the deaths may have been due to natural causes or treatment failures rather than deliberate harm, and they submitted their findings to a review commission. Despite these challenges, British courts have upheld her conviction, and a public statutory inquiry continues to examine the systemic circumstances that allowed the deaths to occur.
References
Allen, E. C., Manuel, J. C., Legault, C., Naughton, M. J., Pivor, C., & O’Shea, T. M. (2004). Perception of child vulnerability among mothers of former premature infants. Pediatrics, 113 (2), 267–273. https://doi.org/10.1542/peds.113.2.267
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
Bass, C., & Glaser, D. (2014). Early recognition and management of fabricated or induced illness in children. The Lancet, 383(9926), 1412–1421. https://doi.org/10.1016/S0140-6736(13)62183-2
Bass, C., & Halligan, P. (2014). Factitious disorders and malingering: Challenges for clinical assessment and management. The Lancet, 383(9926), 1422–1432. https://doi.org/10.1016/S0140-6736(13)62186-8
Rogers, R. (2004). Clinical assessment of malingering and deception (3rd ed.). Guilford Press.
Sheridan M. S. (2003). The deceit continues: an updated literature review of Munchausen Syndrome by Proxy. Child Abuse & Neglect, 27(4), 431–451. https://doi.org/10.1016/s0145-2134(03)00030-9
Yates, G. P., & Feldman, M. D. (2016). Factitious disorder: A systematic review of 455 cases in the professional literature. General Hospital Psychiatry, 41, 20–28. https://doi.org/10.1016/j.genhosppsych.2016.05.002