Definition and DSM-5 criteria
Factitious disorder is the intentional falsification or induction of physical or psychological signs or symptoms associated with identified deception, in the absence of obvious external rewards (distinguishing it from malingering, where there is a tangible gain such as money or avoiding school). DSM-5 recognises two presentations: imposed on self and imposed on another.
Factitious disorder imposed on self — DSM-5 criteria:
- Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
- The individual presents themselves to others as ill, impaired or injured.
- The deceptive behaviour is evident even in the absence of obvious external rewards.
- Not better explained by another mental disorder (e.g. delusional disorder, another psychotic disorder).
Factitious disorder imposed on another (formerly Munchausen syndrome by proxy) has identical criteria except the individual presents another person — the victim — as ill. Crucially, the diagnosis is assigned to the perpetrator, not the victim; the child receives a child-abuse diagnosis (caregiver-fabricated illness / medical child abuse).
Clinical features
In paediatric practice, the most consequential form is factitious disorder imposed on another, a form of medical child abuse. The perpetrator — usually a parent, most often the mother — fabricates history, falsifies records or samples, simulates signs, or actively induces illness (e.g. suffocation, poisoning, contaminating lines or specimens). The child is subjected to repeated, often invasive and harmful, investigations and treatments. An older child may also present with self-imposed factitious symptoms.
Diagnosis
Diagnosis hinges on objective evidence of deception, not on inferring motive. Document discrepancies, preserve records and specimens, and gather collateral history. Separating the suspected perpetrator from the child (observed admission, supervised contact) and seeing whether the “illness” resolves can be diagnostically and protectively decisive — but must be done within a formal safeguarding process, never as a covert ad-hoc test.
See the full criteria: Factitious Disorder
Red flags — safeguarding and medical child abuse
- Signs/symptoms that occur only in the caregiver’s presence and resolve in their absence
- History incongruent with examination, investigations, or independent observation
- Rare, recurrent or unexplained illness that defies a unifying diagnosis despite extensive work-up
- A caregiver who insists on invasive tests, resists reassurance, or seems oddly comfortable with the sick role / multiple providers (doctor-shopping)
- Tampered samples, inconsistent biochemistry, or induced injury (apnoea, sepsis, bleeding, electrolyte disturbance)
- Sibling with unexplained illness or death
- Any reasonable suspicion mandates child-protection referral — do not confront the caregiver alone or first
Management overview
When factitious disorder imposed on another is suspected, the child’s safety is paramount: this is child abuse, and the response is a safeguarding pathway, not a covert solo investigation. Escalate early to the named child-protection lead, social services and, where indicated, police; convene a multidisciplinary strategy meeting; and meticulously document objective findings. Do not confront the suspected perpetrator before protective measures are in place, as this can escalate risk to the child.
For factitious disorder imposed on self (typically an older adolescent), the approach is non-punitive and validating of the underlying distress — avoid direct accusation, which usually ruptures the relationship and prompts flight to another provider. Engage mental-health services to address the often-severe underlying psychopathology, minimise iatrogenic harm from unnecessary procedures, and coordinate care through a single team. Prognosis is guarded; the immediate goals are protection and harm reduction.
References
- American Psychiatric Association. DSM-5-TR. 2022.
- Yates G, Bass C. Perpetrators of medical child abuse: systematic review. Child Abuse Negl. 2017;72:45–53.
- Flaherty EG, et al; AAP. Caregiver-Fabricated Illness in a Child. Pediatrics. 2013;132(3):590–597.
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.