Both involve intentional symptom production; factitious is motivated by the sick role, malingering by external incentive (only factitious is a mental disorder).
Also known as: factitious disorder, Munchausen, malingering, factitious imposed on another
Overview
Factitious Disorder (DSM-5-TR): falsification of physical or psychological signs/symptoms, or induction of injury or disease, associated with identified deception; the individual presents themselves (or another — Factitious Disorder Imposed on Another, formerly Munchausen by proxy) as ill, impaired, or injured; the deceptive behavior is evident even in the absence of obvious external rewards; not better explained by another mental disorder. Malingering: intentional production or gross exaggeration of physical/psychological symptoms motivated by external incentives (disability, drugs, avoiding work, military duty, criminal prosecution). Malingering is a V/Z-code, NOT a mental disorder.
Epidemiology
Factitious disorder estimated at ~1% of inpatient consultations; likely underrecognized. Factitious imposed on another disproportionately involves female caregivers and pediatric victims. Malingering more common in forensic, disability, and substance-seeking contexts; base rate varies widely (5-30% depending on setting).
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Question 1PsychiatryMedium
A 34-year-old nurse is admitted for the fourth time in six months for episodes of confusion and diaphoresis, and each admission has documented a serum glucose in the 30s mg/dL. She is eager to undergo additional testing and asks repeatedly about exploratory procedures, but becomes evasive and refuses to consent when the team requests records from the three other hospitals where she has been treated. During this admission, a fingerstick glucose is normal whenever a staff member remains in the room. Workup during a hypoglycemic episode shows an elevated serum insulin with a suppressed C-peptide, and a nurse later finds an insulin pen and used syringes in her bag. There is no pending litigation, disability claim, or other external incentive. Which of the following is the most likely diagnosis?
AMalingering of induced hypoglycemia
BFactitious disorder imposed on self
CFactitious disorder imposed on another
DIllness anxiety disorder, care-seeking
Reveal answer & full explanation
Correct answer: B — Factitious disorder imposed on self
AMalingering of induced hypoglycemia
BFactitious disorder imposed on self✓
CFactitious disorder imposed on another
DIllness anxiety disorder, care-seeking
Why Factitious disorder imposed on self is correct
The patient consciously falsifies illness: she self-administers exogenous insulin, proven by the lab pattern of elevated serum insulin with a suppressed C-peptide (an outside insulin source raises measured insulin while shutting off endogenous secretion). The insulin pen and used syringes confirm she is inducing the hypoglycemia.
Classic factitious red flags are all present: a healthcare background, recurrent admissions across multiple institutions, eagerness for invasive procedures, symptoms that normalize when she is observed, and refusal to let the team contact prior caregivers.
The decisive feature is the ABSENCE of any external incentive. Per DSM-5-TR, deception with falsification or induction of illness occurring without an obvious external reward defines factitious disorder; the motive is the intrapsychic need to assume the sick role.
Why the others are wrong
Malingering of induced hypoglycemia is the deliberate production of symptoms for an EXTERNAL incentive (disability, drugs, avoiding work, legal benefit). The stem explicitly states there is no litigation, disability claim, or other external gain, so the watershed feature for malingering is absent.
Factitious disorder imposed on another requires that illness be falsified or induced in a victim, such as a child or a patient under her care, who is then presented for treatment; here she is injecting herself and presenting herself, so the sick role she assumes is her own.
Illness anxiety disorder, care-seeking is preoccupation with having or acquiring a serious illness with minimal or no actual somatic symptoms; there is no fabrication or self-induction of physical findings.
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Factitious disorder: motivation is intrapsychic — to assume the sick role — and behavior is consciously produced but reflects pathologic need for care/attention. Mechanism is poorly understood but linked to early attachment disturbance and dysfunctional coping. Malingering is not a psychiatric disorder; it is a conscious choice for tangible gain.
Differential diagnosis
Somatic symptom disorder — Symptoms NOT intentionally produced; distress is the core feature
Conversion disorder — Symptoms NOT intentionally produced; incompatibility with neurologic disease
Illness anxiety disorder — Preoccupation with illness; no fabrication of signs
True medical illness — Always reconsider before labeling — fabrication and real disease can coexist
Delusional disorder, somatic type — Fixed false belief without conscious deception
Diagnostic workup
Diagnostic criteria
Factitious: deception with falsification or induction; presents self/other as ill; behavior evident even without external reward; not better explained by another disorder. Malingering: intentional symptom production for external incentive — coded as V65.2 / Z76.5 (not a mental disorder).
Labs
Targeted testing based on presentation
Toxicology / drug levels when surreptitious medication suspected
Urine sulfonylurea or insulin/C-peptide levels in unexplained hypoglycemia
Coagulation studies and warfarin/heparin assays in unexplained bleeding
Diagnostic algorithm
Feature
Somatic Symptom / Conversion
Factitious Disorder
Malingering
Symptom production
Not intentional
Intentional (conscious)
Intentional (conscious)
Motivation
Distress, illness anxiety
Sick role (intrapsychic)
External incentive (tangible gain)
Mental disorder?
Yes
Yes
No (V/Z code)
Response to confrontation
Defensive but persists
Often denies, moves on
May abandon symptoms when incentive removed
Treatment
CBT, SSRI, primary care continuity
Long-term psychotherapy, non-confrontational
Not a treatment target; address incentive
Differentiating non-intentional somatic disorders, factitious disorder, and malingering — symptom production and motivation are the key axes.
Complications
Iatrogenic harm from unnecessary procedures, medications, surgeries
Death in FDIA victims — case fatality reported up to 6-9%
Healthcare team distress, legal exposure
Loss of trust between patient and clinicians
Missed real disease when label applied prematurely
PANCE pearls
External incentive is the watershed: present = malingering; absent = factitious.
Malingering is NOT a psychiatric diagnosis (V/Z code); factitious disorder IS.
Munchausen syndrome (historical term) ≈ chronic, severe factitious disorder with pseudologia fantastica and peregrination.
Factitious Disorder Imposed on Another (FDIA) is a form of child abuse — mandatory reporting is required.
Do not confront aggressively — collaborative, multidisciplinary planning produces better outcomes.
Always reconsider organic disease — fabrication does not exclude coexisting real pathology.
References
DSM-5-TR — American Psychiatric Association. DSM-5-TR. 2022.
AAP 2007 — Stirling J Jr; AAP Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics 2007;119:1026-30.
Bass 2014 — Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet 2014;383(9926):1422-32.
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