Chapter 19: Factitious Disorder

Factitious disorder represents a psychiatric condition in which individuals deliberately produce, exaggerate, or fabricate symptoms of illness without external incentive such as financial gain or avoidance of responsibility. The defining feature distinguishing factitious disorder from malingering is the primary motivation to assume the sick role, often despite significant personal harm, medical complications, and social consequences. The chapter addresses two clinical presentations: factitious disorder imposed on self, where individuals deceive healthcare providers about their own health status, and factitious disorder imposed on another, previously termed Munchausen syndrome by proxy, which constitutes a form of abuse typically directed at children or vulnerable elders and carries legal reporting obligations. The historical foundation includes Asher's seminal 1951 description of Munchausen syndrome, characterized by chronic deception, frequent hospitalization, and peregrination across multiple medical facilities, along with pseudologia fantastica or habitual false storytelling. Epidemiological data suggests prevalence rates approaching one percent in general clinical populations, with higher rates in hospital settings, and many affected individuals possess healthcare backgrounds or training. Etiological understanding integrates psychodynamic frameworks emphasizing psychological needs for control and nurturing, behavioral reinforcement patterns that sustain illness behavior, and emerging neurobiological evidence from neuroimaging investigations. Diagnostic criteria outlined in the DSM-5 and ICD-11 emphasize intentional deception absent genuine external motivations, triggering clinical suspicion when patients present inconsistent medical histories, symptoms atypical for documented disease, disproportionate eagerness for invasive procedures, or deterioration following negative diagnostic testing. Management presents substantial clinical challenges including countertransference reactions, ethical tensions regarding appropriate surveillance and documentation, diagnostic uncertainty, and limited empirical treatment outcome research. Effective intervention requires interdisciplinary collaboration balancing patient protection with dependent safety, addressing underlying personality pathology, trauma histories, and comorbid psychiatric disorders while avoiding unnecessary iatrogenic harm through invasive medical procedures.