Factitious disorders, malingering and abuse

• Factitious disorder is the deliberate fabrication or induction of illness for an internal reason: the need to be a patient. When the deception is aimed at another person, usually a child, it is called factitious disorder imposed on another (FDIA), historically called Munchausen syndrome by proxy.
• Malingering is also deliberate, but the goal is external gain, such as money, time off work, compensation or avoiding legal consequences. The behaviour is conscious and stops being useful.
• Violence and abuse are far more common than factitious illness. About 1 in 3 women worldwide has experienced physical or sexual intimate partner or non-partner violence in her lifetime. ^[4]
• Elder abuse affects roughly 1 in 6 people over 60 in community settings. ^[5]
• Abuse is recognised by patterns, not by one test. A single bruise means little, but an injury pattern, an implausible history, a power imbalance and a vulnerable person together carry weight.
• Every suspected case needs two things: protecting the person at risk as soon as possible, and then sorting out health, legal and psychological support.

By the end of this page you should be able to:

1. Define factitious disorder imposed on self and on another, and distinguish both from malingering.
2. Describe the typical presentations, risk factors and epidemiology of factitious disorder and FDIA.
3. Recognise red flags for child, intimate partner, sexual and elder abuse in clinical encounters.
4. Ask, document and report concerns in line with safety, consent and child-protection duties.
5. Apply the WHO LIVES first-line support approach to a survivor who discloses violence. ^[7]
6. Explain the roles, content and audiences of APA's DSM-5-TR classification, WHO guidance and NICE PH50.
7. Plan basic, safe management and follow-up for each condition, including low-resource settings.

Factitious disorder sits in the group of somatic symptom and related disorders in DSM-5-TR (American Psychiatric Association, 2022). Its essential feature is the deliberate falsification of physical or psychological signs or symptoms in the absence of an obvious external reward. ^[2] The person is consciously deceiving others, but is driven by an internal need to occupy the sick role. Two subtypes are distinguished: factitious disorder imposed on self (FDIS), historically called Munchausen syndrome, and factitious disorder imposed on another (FDIA), historically called Munchausen syndrome by proxy. ^[1][2]

Munchausen syndrome is the severe, chronic, self-directed form, in which the person travels between hospitals, seeks invasive procedures and shows marked tolerance of procedures. ^[2] The term is now largely historical. Medical child abuse is the related clinical-legal term for harm caused by a caregiver fabricating or inducing illness in a child, whatever the caregiver's motive. ^[1]

Malingering is also deliberate, but the reason is external and practical: compensation, avoidance of work or legal consequences, drugs, shelter or sympathy. ^[3] The behaviour is conscious in both its production and its motivation, and it tends to resolve when the incentive disappears. In DSM-5-TR it is coded as malingering (V65.2). ^[3]

Abuse is a broad term for any act or omission within a relationship of trust that harms, distresses or controls another person. Intimate partner violence (IPV) is behaviour by a current or former partner that causes physical, sexual or psychological harm. It includes physical aggression, sexual coercion, psychological abuse and controlling behaviour. ^[4] Sexual violence is any sexual act or contact obtained by coercion, by any person and in any setting, and includes rape, attempted rape, unwanted touching and non-contact forms. ^[4] Elder abuse is a single or repeated act or failure to act, within a relationship of trust, that causes harm or distress to an older person. It includes physical, sexual, psychological and emotional abuse, financial and material abuse, abandonment, neglect, and serious loss of dignity or respect. ^[5]

Factitious disorder is estimated to be present in about 1.3% of all hospitalised patients, with Munchausen syndrome accounting for roughly 10% of those cases. ^[2] It can occur in any medical specialty, although reviews describe it as well documented in endocrinology, cardiology and dermatology. ^[2] Many patients work in or around health care, because access to symptoms, medical language and hospitals is easier for them. ^[1][2]

A systematic review of 455 perpetrators and 469 victims reported in 314 studies (published 1977-2024) collected from case reports and series found that:

• 95.3% of victims were children or adolescents, with a mean age of 5.58 years and a median of 3 years. ^[1]
• 56.5% of victims were male. ^[1]
• 92.75% of perpetrators were female, with a mean age of 29.48 years. ^[1]
• 19.56% of perpetrators had a medical background. ^[1]
• The condition is rare in absolute terms, with reported prevalence estimates from 0.002% to 0.53%, and it is likely to be under-recognised. ^[1]
• Published case series describe the condition as responsible for about 6% to 10% of deaths among affected children. ^[1]
• In the same review, 14.5% of victims ended up in foster care or the care of social services, and 29.67% of perpetrators were accused of a crime. ^[1]

Malingering is common in settings where there is a tangible reward. Reported prevalence ranges from about 7.4% in non-forensic assessments to 16% to 53% in forensic assessments. ^[3] These figures come from medicolegal and compensation settings, and the context matters far more than the headline number.

Worldwide, about 1 in 3 women (31.6%) has been subjected to physical or sexual violence by an intimate partner, or non-partner sexual violence, in her lifetime; this is roughly 840 million women and girls. ^[4] About 25.8% of women aged 15 to 49 in a relationship have experienced physical or sexual violence from a partner at least once. ^[4] An estimated 8% of women over 15 have experienced non-partner sexual violence. ^[4] Over the last 20 years the average annual decline in IPV has been only 0.2%, so the "1 in 3" figure has barely moved. ^[4] The regions with the highest prevalence are Oceania (37%), sub-Saharan Africa (32%) and southern Asia (31%). ^[4] More than 1 in 5 ever-partnered girls aged 15 to 19 has already experienced physical or sexual violence from an intimate partner. ^[4]

In 2023, an average of 140 women and girls a day were killed by a partner or another family member. ^[4]

Over a year, about 1 in 6 people (15.7%) aged 60 or older in community settings experiences some form of abuse. ^[5] In institutions such as nursing homes, 64.2% of staff report perpetrating some form of abuse in the past year. ^[5] Ageing populations mean the global number of victims is expected to grow to roughly 320 million by 2050, even if the proportion stays the same. ^[5] Table 1 gives the prevalence by type of abuse in community settings, with proxy and staff reports.

The internal drive is usually the sick role itself: attention, care, rescue from stress or an identity built around being unwell. ^[2] Risk factors described in case series include:

• psychiatric or medical conditions in childhood or adolescence that attracted marked attention from family or doctors. ^[2]
• personality disorder, especially borderline, narcissistic or antisocial. ^[2]
• employment or training in a health-care sector. ^[1][2]
• female sex, often 30 to 40 years of age. ^[2]
• dissatisfaction with, or dependence on, medical care. ^[2]
• childhood trauma, neglect, emotional deprivation or early loss of a significant person. ^[2]
• a family history of serious illness, which may have introduced the person to the benefits of the sick role. ^[2]

No structural or functional brain abnormality has been identified for factitious disorder. ^[2]

The perpetrator (usually female, often a parent) introduces or lies about illness in a dependent person, usually a young child, in order to obtain medical and secondary benefits and to occupy the role of needed caregiver. ^[1] The motivation is primary psychological gain, not a clear external reward. ^[1] About 19.6% have a health-care background, and many have physical or psychological problems themselves. ^[1]

Malingering arises where there is a clear incentive and a loose link between symptoms and objective findings. Typical contexts are compensation claims, criminal or civil litigation, military service, disability assessments and drug seeking. ^[3] It is more common in people with substance misuse and antisocial traits, and is slightly more common in men than in women. ^[2]

Violence is driven by interacting factors at individual, family, community and societal level. Risk is raised by gender inequality, norms that support male authority, poverty and unemployment, alcohol and drug use, a history of child maltreatment or witnessing violence, controlling behaviour, and power imbalance. ^[4] Women with disabilities and adolescents are at particularly high risk. ^[4]

For elder abuse, individual risk factors for victimisation include functional dependence, poor health, cognitive impairment, poor mental health and low income. Perpetrators are more likely to be mentally ill or substance-dependent, or financially dependent on the older person. ^[5]

The illness is real to the person in the sense that it governs behaviour, but the symptoms are manufactured. Methods include exaggeration, fabrication, simulation and direct induction, such as ingestion of medicines or interference with tests. ^[2] Deterioration can be striking: people with Munchausen syndrome may move from genuine health to repeated harm, and in the most extreme self-directed cases, repeated induction leads to deep ulceration or loss of a limb. ^[2]

Presentation is shaped by the goal. Symptoms are often vague, disabling and inconsistent with known disease, while the person refuses tests that do not support the claim and loses interest in treatment once the goal is secured. ^[2]

Abuse is not a disease mechanism but a pattern of harm. In FDIA, the harm reaches the victim through medical care itself: unnecessary tests, procedures, medicines and hospitalisations. ^[1] In IPV, harm occurs through physical, sexual, psychological and controlling behaviour, sometimes leading to homicide. ^[4] In elder abuse, harm arises through physical, emotional, financial and neglectful acts, aggravated by dependence and isolation. ^[5] Sexual violence produces trauma, infection, pregnancy, pain and long-term psychiatric morbidity. ^[4]

No sign is specific, but the likelihood rises when several of the following are present: ^[2]

• a young woman, often a health-care worker, who speaks medical language fluently.
• dramatic, vague or inconsistent history.
• multiple admissions to different hospitals across a wide area.
• many treatment interventions, complications, and unexplained "resistant" illness.
• paradoxical enthusiasm for invasive tests and procedures, including surgery.
• appropriate mood, with belle indifférence (an odd calm about dramatic symptoms).
• mental state suggesting borderline, narcissistic or antisocial traits, or depression.
• self-harm or suicide attempts in the background.

The condition is most often recognised late, after exhaustive medical work-up and avoidable harm. ^[2]

• the dependent person's symptoms are unusual, severe or unexplained, and occur only in the presence of the caregiver. ^[1]
• repeated presentations with complex illness that does not respond to treatment. ^[1]
• tests or specimens that do not fit the clinical picture, or are tampered with. ^[1]
• a caregiver who is highly knowledgeable, emotionally invested in treatment and eager for procedures. ^[1]
• a long, wandering medical story across hospitals and cities. ^[2]
• improvement or resolution when victim and perpetrator are separated. ^[1]

• antisocial traits, substance misuse or a clear gain (money, leave, drugs, housing). ^[2][3]
• vague, changing or exaggerated symptoms. ^[2]
• refusal or avoidance of investigations and treatment that would not help the claim. ^[2]
• symptoms that disappear when the incentive ends. ^[2]
• examination and imaging that do not match the claimed disability. ^[3]

Many women present with general health complaints rather than a disclosure. Common indicators include: ^[4]

• injuries inconsistent with the explanation, or repeated "accidents".
• chronic pain, headaches, fatigue, sleep disturbance, depression and anxiety.
• genital, pelvic or sexual symptoms, repeated STI or pregnancy-related problems.
• a partner who controls appointments, answers for the patient or never leaves her alone.
• delay in seeking help, or explanation that does not fit the injury.

Violence against women causes miscarriage, preterm delivery, low birth weight and stillbirth in pregnancy. ^[4]

Survivors may present acutely or remotely. Features include genital or anal injury or pain, bleeding, STI symptoms, pregnancy, fear, shame, depression and post-traumatic symptoms. ^[4] The 2023 violence against women estimates state that 8% of women over 15 have experienced non-partner sexual violence, so this is not rare. ^[4] The examiner moves slowly, explains each step, obtains consent and documents observations using the person's own words.

Risk is highest when the older person is dependent or has cognitive or physical impairment. Warning signs include: ^[5]

• unexplained bruises, burns, fractures or malnutrition.
• poor hygiene, missed medicines, untreated ulcers or dehydration.
• financial irregularities, missing money or unusual transactions.
• fear, anxiety, withdrawal or a too-controlling carer.
• injuries at different stages of healing.
• a carer with substance misuse, mental illness or financial dependence.

In children, suspect abuse when injuries do not match development, when there are repeated or serious injuries, when histories change, or when a child is unusually frightened. The same principle applies to suspected FDIA: unexplained, treatment-resistant, dramatic illness that occurs only with one caregiver. NICE emphasises referring children when there are grounds to suspect harm and sharing information without consent when children's safety is at risk. ^[6]

The examination must be safe, respectful and private. Do not raise abuse or mental health content when the potential perpetrator is in the room. ^[6]

• Safety first: separate the person from the person suspected of harming them, where possible. ^[6]
• Consent and confidentiality: explain what you can keep confidential and when you must share information to protect someone. ^[6]
• Record observations in the person's own words, with injuries described by site, size, shape and age, photographs and diagrams where available.
• Avoid premature confrontation in suspected factitious disorder, because it usually leads to denial and departure, while offering psychiatric support. ^[2]
• Standardise mental state examination, looking for depression, anxiety, PTSD, substance misuse, personality traits and cognitive function. ^[2]
• Document negative findings as well as positive ones, and gather records from other hospitals and general practice.

There is no single test that proves factitious disorder, malingering or most forms of abuse. Diagnosis is clinical, supported by records, consistency and sometimes observation.

• Factitious disorder: diagnosis rests on evidence of deliberate deception in the absence of obvious external gain, after organic and psychiatric causes are considered. Repeated unexplained admissions, normal results after extensive work-up, and evidence of induction (for example an unusual substance or an artifact in a test) all point toward it. ^[1][2] Liaison psychiatry and a multidisciplinary review of records are usually needed. ^[2]
• FDIA: multidisciplinary assessment, separate histories, review of medical records, targeted observations and, where lawful, covert video surveillance or separation of caregiver and child. ^[1] Child protection procedures must be activated from the start. ^[6]
• Malingering: assess for objective gain, inconsistency between claimed and observed function, and incentive-specific behaviour. It remains a diagnosis of exclusion with medicolegal implications, and should be recorded with care and fairness. ^[3]
• IPV: clinical enquiry in services where disclosure is more likely (antenatal, postnatal, sexual health, mental health, substance use, paediatric and vulnerable-adult services), rather than routine universal screening of asymptomatic women. ^[6] Validated tools exist but should be matched to local protocols.
• Elder abuse: assess cognition, function, nutrition, skin, medicines and finances; involve adult safeguarding services and, where necessary, adult protective services. ^[5]
• Sexual violence: medical assessment for injuries, STI prophylaxis, emergency contraception and pregnancy testing, preservation of forensic evidence and documentation. ^[4]

There is no pharmacological treatment for factitious disorder itself, and no anti-factitious "first-line" drug. ^[2] Management is psychiatric and relational:

• Recognise and protect: stop unnecessary investigations and procedures; avoid excessive medicalisation. ^[2]
• Multidisciplinary care: involve liaison psychiatry, primary care, and, where children are involved, child protection services and social work from the outset. ^[1][2]
• Engagement: a calm, non-punitive approach is more productive than confrontation; the evidence for forced confrontation is weak, and it usually drives the person away. ^[2]
• Treat comorbidity: depression, anxiety, trauma and personality disorder features are common and respond to standard, guideline-based treatments. ^[2]
• Therapy: psychotherapy (particularly therapies addressing self-regulation, identity and trauma) may help in a long-term relationship, although evidence is limited. ^[2]
• Safety planning: most patients should be considered at high risk of self-injury. ^[2]
• Legal and social steps: where a child is at risk, child protection law overrides confidentiality. ^[6]

Named framework used: the APA DSM-5-TR classification and its two subtypes (factitious disorder imposed on self; factitious disorder imposed on another). ^[1][2]

There is no psychiatric treatment for malingering, which is not a psychiatric disorder. ^[3] Careful, objective documentation, clear communication about findings, and independent functional assessment are the mainstays. ^[2][3] The clinician should:

• describe exactly what is observed and what is not consistent.
• avoid moralising language.
• treat any genuine illness that is present.
• avert unnecessary intervention, while retaining duty of care.
• refer for assessment and rehabilitation as appropriate.

In medicolegal contexts, follow local rules on disclosure and independence of the expert. ^[3]

The WHO guidance for intimate partner and sexual violence is centred on the health-care provider as the likely first professional contact. ^[4][7] WHO places care and support, including safety planning and survivor-centred management, at the centre; local law determines whether reporting to police is compulsory, and where reporting is required the woman should be told before any disclosure. ^[7][8] Universal screening of asymptomatic women is also not recommended: instead, clinical enquiry is advised when indicators are present or the situation is clinically appropriate. ^[6][7][8]

First-line support is remembered as LIVES: ^[7]

• Listen closely, with empathy, without judgement.
• Inquire about her needs and concerns.
• Validate: acknowledge her experience, and say plainly that violence is not her fault.
• Enhance safety: discuss a safety plan.
• Support: help her connect to information, services and social support.

Other steps include treating injuries, providing emergency contraception and STI prophylaxis after sexual assault, offering pregnancy testing, and referring for mental health care, all according to local protocols. ^[4][7]

NICE PH50 gives a structured, four-level training model for professionals working with domestic violence and abuse, and recommends that maternity, sexual health, mental health, substance misuse and child and vulnerable-adult services ask about abuse as part of routine good practice. ^[6] It also explains how to create an environment that makes disclosure possible: visible information and helpline numbers, privacy, and safe reception arrangements. ^[6]

Management of suspected elder abuse is multidisciplinary: assess acute safety, cognition and function, nutrition and medicines; involve adult safeguarding or protective services; mobilise family, social care and legal support where indicated. ^[5] Promising approaches include caregiver interventions that relieve burden, money-management programmes, helplines, emergency shelters and multidisciplinary teams. ^[5] Clinicians should also know local reporting law, which varies. ^[5][6]

Survivor-centred, trauma-informed care: first-line support with LIVES, informed consent, medical treatment of injuries, STI prophylaxis, emergency contraception, pregnancy testing, forensic documentation where appropriate and consented, and referral for mental health and legal support. ^[7] Forensic swabs and specimens should be taken as early as possible: collection is useful within 5 days, and after 7 days there is usually nothing to collect. ^[8] Do not pressure a person to report to the police; offer the option and respect the choice. ^[7]

• Domestic violence information sharing: distinguish adult-only situations from those in which children are involved. Information may be shared without consent when children's safety is at risk. ^[6]
• Children: refer using local child-protection pathways and always discuss with the safeguarding lead where there is uncertainty. ^[6]
• Elder and vulnerable adults: follow local adult-safeguarding law and, where relevant, adult protective services. ^[5][6]
• Domestic violence: follow NICE PH50's pathway for disclosure, risk assessment and referral, and MARAC processes for high-risk cases where these exist. ^[6]

• Physical harm: unnecessary operations, medications, infections and loss of tissue or limbs in factitious disorder; brain injury, disability and death in abuse. ^[1][2][4]
• Mortality: FDIA is responsible for roughly 6% to 10% of deaths among affected children in published case series. ^[1] In 2023, 140 women and girls died, on average, each day from partner or family violence. ^[4]
• Psychological sequelae: anxiety, depression, PTSD, self-harm, personality disruption and long-term attachment problems. ^[1][2][4]
• Social and legal harm: family breakdown, criminal charges, loss of employment, and stigmatisation of genuine patients after a false accusation of malingering. ^[1][3]
• Health-system harm: wasted resources and erosion of trust between patients and clinicians. ^[2][3]

• Factitious disorder is usually chronic and relapsing; many people leave care before a stable therapeutic relationship is possible. ^[2]
• FDIA has a high risk of recurrence and of serious harm; victims may have long-term physical and neurocognitive sequelae, and the experience can affect a further generation. ^[1]
• Malingering tends to resolve when the incentive resolves, but disability status and legal proceedings can prolong it. ^[3]
• IPV currently shows very little global improvement: the average annual decline is about 0.2%. ^[4]
• Elder abuse is predicted to increase in numbers as populations age, even though its proportion may remain the same. ^[5]

• Universal but sensitive awareness: train all staff who meet patients to recognise abuse and factitious behaviour. NICE PH50 proposes four levels of training (front-desk to specialist advocacy) plus pre-qualifying training and continuing professional development for all health and social care professionals. ^[6]
• IPV: display information about support, protect privacy in consultation rooms and reception spaces, and take clinical enquiry opportunities in high-yield services. ^[6]
• Factitious disorder: maintain vigilance, review records across hospitals, use multidisciplinary discussion and avoid unnecessary intervention. ^[1][2]
• Malingering: document objectively, treat genuine conditions and avoid harmful, futile investigation. ^[2][3]
• Elder abuse: support carers, offer money-management help, provide helplines and emergency shelter, and remove isolation by involving multidisciplinary teams. ^[5]
• WHO's wider priorities for ending violence against women are gender equality, legislation, funded services and evidence, all of which apply to the abuse spectrum. ^[4][7]

• Pregnancy: pregnant women experiencing IPV have higher risks of under-use of antenatal care, substance misuse, miscarriage, preterm delivery, low birth weight and stillbirth. Make private space available, offer LIVES support and refer. ^[4]
• Children: FDIA is mainly a condition of young children; average victim age is about 5.6 years, and the majority are male. ^[1] Safeguarding law must take priority over confidentiality. ^[6]
• Older adults: abuse risk rises with cognitive impairment, dependence, poor health and isolation. ^[5]
• People with disabilities: heightened risk due to dependence and discrimination; involve trusted, independent advocates. ^[4]
• Health-care workers with factitious disorder: the diagnosis should lead to support and treatment, not simply dismissal, while protecting patients from harm. ^[2]

• A single private question and a safe room are more important than advanced technology.
• Use the LIVES approach for any disclosure. ^[7]
• NICE PH50-level lists of helplines and referral pathways are helpful where computerised systems are weak. ^[6]
• In elder abuse, basic assessment (nutrition, skin, medicines, money, cognition) and mobilising community and family support can be done without advanced tests. ^[5]
• Where child or adult safeguarding services are limited, build on maternal-and-child health and primary care networks for early detection. ^[6]

The most important differentials for factitious disorder are somatic symptom disorder, illness anxiety, conversion disorder, malingering, borderline and narcissistic personality disorders. ^[2] Somatic symptom and illness-anxiety presentations arise from unconscious processes; the person is not deliberately deceiving. ^[2] Functional neurological disorder also arises unconsciously. ^[2] Malingering always carries an external reason and usually responds to reward. Abuse differs because the harm is inflicted on someone rather than self-reported, and recognition comes from the pattern rather than the test.

• Factitious disorder is deliberate but internally motivated; malingering is deliberate and externally motivated. ^[2][3]
• FDIA most often affects young children and is associated with serious harm and a significant fatality risk. ^[1]
• There is no specific drug for factitious disorder or malingering; management is psychiatric, multidisciplinary and focused on safety. ^[2]
• About 1 in 3 women worldwide has experienced physical or sexual intimate partner or non-partner violence. ^[4]
• IPV is asked about with clinical enquiry, not with routine universal screening of asymptomatic women. ^[6][7]
• WHO guidance centres the health-care provider as first contact, uses first-line support (LIVES) and respects the woman's decision whether to involve police; local law governs any compulsory reporting. ^[7][8]
• First-line support for survivors is LIVES: listen, inquire, validate, enhance safety, support. ^[7]
• Elder abuse affects about 1 in 6 people over 60 in the community and is far more common in institutions. ^[5]
• Recognition of abuse depends on patterns, inconsistency and context rather than on a single test.
• NICE PH50 supplies four levels of training and routines for disclosure, risk assessment and information sharing. ^[6]
• Children's safety overrides confidentiality where safeguarding law applies. ^[6]
• In low-resource settings, privacy, a single question and a referral pathway are usually the highest-yield interventions.

Child abuse and neglect; sexual assault assessment and care; personality disorders and defence mechanisms; substance use disorders; delirium; dementia; major depressive disorder; post-traumatic stress disorder.