Clinical Pearls & Morning Reports

Posted by Carla Rothaus

Published April 26, 2023


How does factitious disorder differ from malingering?

Factitious disorder may be suspected when a patient has been to multiple health care facilities, has an inconsistent medical history, does not allow access to collateral information from family and friends, and has symptoms that are not responding as expected to standard treatments. Read the NEJM Case Records of the Massachusetts General Hospital here.

Clinical Pearls

Q: What are some of the characteristics of people with factitious disorder?

A: Factitious disorder is rare and is more common in female patients, health care workers, and patients with a history of trauma or major mental illness. Most patients feign symptoms of a medical illness, often a preexisting medical condition, although deliberate falsification of a psychiatric illness can occur. The deception can involve exaggeration or invention of symptoms, induction of illness through ingestion or injection of substances, falsification of studies and medical records, or exacerbation of genuine medical findings through deliberate nonadherence to treatment. Abdominal pain and seizures are among the symptoms that are most commonly reported by patients with factitious disorder. There is often a history of childhood illness; illness in family members is also common.

Q: What kinds of information can help to make the diagnosis of factitious disorder?

A: To make the diagnosis, it is imperative to obtain evidence of falsification of illness, whether through direct observation, the review of medical records for inconsistencies, the discovery of tampering with laboratory tests or medical records, or confrontation of the patient. If there is clinical concern about factitious disorder, continuous observation with a 1:1 sitter is recommended, along with meticulous exploration of any additional records, including controlled-substance databases and insurance or pharmacy records. Such records may reveal not only overt deception but also some other factors associated with the syndrome, including frequent use of health care services, peregrination (movement across multiple health care facilities, sometimes in multiple states or countries), inconsistencies in basic demographic data, or a history of describing grandiose “tall tales” about previous achievements (pseudologia fantastica).

Morning Report Questions

Q: How does factitious disorder differ from malingering?

A: Deliberate and purposeful deception is the key finding in both factitious disorder and malingering, and it helps to differentiate these syndromes from other conditions that may be associated with similar presentations, including delusional disorder, conversion disorder, somatic symptom disorder, or borderline personality disorder. The presence of a clear external benefit — for example, access to controlled substances, securing shelter, financial gain, or avoidance of work, responsibility, or criminal prosecution — is indicative of malingering. The absence of a clear benefit, in which the feigning of symptoms appears to be motivated by the patient’s desire for attention or to reinforce experiences related to a sick role, is indicative of factitious disorder.

Q: Do patients with factitious disorder tend to accept their diagnosis and accept treatment when confronted by medical personnel?

A: Although psychiatric treatment is often warranted, especially for patients with a preexisting history of trauma, more than 60% of patients with factitious disorder decline follow-up. As many as 77% of patients with factitious disorder do not admit that they have feigned illness even when presented with objective evidence, and most disengage from providers after such confrontation. There are no recommended specific pharmacologic interventions; individual therapy has been shown to benefit motivated patients. Ultimately, the prognosis is poor, given the increased morbidity and mortality related to feigning illness or undergoing unnecessary medical or surgical interventions.

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