Factitious disorder: recognition and AU general practice management

A condition defined by deception

Factitious disorder (FD) sits at an uncomfortable intersection of psychiatry, ethics, and medico-legal obligation. The core feature — intentional falsification of illness — makes it unlike most presentations in general practice, where the GP’s default posture of trusting the patient’s account serves well. In factitious disorder, that posture enables ongoing harm.

Understanding factitious disorder requires distinguishing it clearly from two conditions it is often confused with: malingering (intentional deception motivated by external reward — money, drugs, legal avoidance) and somatic symptom disorder (genuine, distressing physical symptoms without conscious fabrication). Getting this distinction right shapes everything that follows in management.

The stakes rise sharply when a child is the victim. Factitious disorder imposed on another (FDIA) — formerly termed Munchausen syndrome by proxy — is not simply a psychiatric condition of the perpetrator: it is a form of serious child abuse with a reported mortality of 6–10% in identified cases, and GPs across Australia carry statutory obligations that activate on reasonable suspicion alone.

A. Core clinical — the AU general-practice framework

Definitions

Factitious disorder imposed on self (DSM-5-TR F68.10) — intentional falsification, fabrication, induction, exaggeration, or aggravation of physical or psychological symptoms in order to assume the sick role, in the absence of obvious external incentive. The deceptive behaviour is present even when no external reward is apparent.

Factitious disorder imposed on another (FDIA) (DSM-5-TR F68.10 with “imposed on another” specifier) — the same process, but carried out by one person upon another, typically a dependent child. The psychiatric diagnosis is given to the perpetrator, not the victim. The acts inflicted on the victim are separately classified as child abuse.

Malingering is not a mental disorder in DSM-5-TR — it is a condition that may be a focus of clinical attention (Z-code). The distinction from factitious disorder is the external incentive: financial compensation, avoiding prosecution, obtaining controlled substances. In practice this distinction is sometimes difficult, and the two can coexist.

Epidemiology

True prevalence of FD is unknown because concealment is intrinsic to the condition. Estimates suggest approximately 1% of liaison-psychiatry referrals and up to 0.6–3% of medical inpatients in specialty cohorts. Yates and Bass (2017) estimated FDIA incidence at 0.4–2 per 100,000 children per year in pooled international data. Perpetrators are approximately 95% biological mothers, and healthcare training is over-represented among perpetrators (14–30% of cases in published series).

Pattern recognition — red flags

For FD imposed on self:

• Inconsistencies between successive history-takings, with collateral history from family or prior treaters, and between history and objective findings
• Pseudologia fantastica — elaborate, partially-true autobiographical narrative with dramatic or pitiable elements
• Peregrination — wandering between hospitals, specialists, and states; reluctance to allow contact with previous treaters
• Eagerness for invasive investigation or surgery (unusual contrast to typical patient ambivalence about procedures)
• Symptoms that worsen when discharge is mentioned, or that resolve dramatically on admission
• Sabotage of treatment — tampering with IV lines, contaminating wounds, manipulating thermometers
• Healthcare or nursing background, or disproportionate medical literacy at initial presentation
• Laboratory evidence of self-induced disease — see below

For FDIA:

• Child’s illness occurs only when the nominated carer is present; resolves on separation
• Symptoms reported by the carer are unwitnessed by any other person
• Child has an extensive medical file with multiple diagnoses across multiple providers
• Carer is disproportionately knowledgeable about the child’s condition and encourages further investigation or surgery
• Sibling history of unexplained illness or unexplained death
• Carer shows flat or incongruent affect during the child’s procedures, or conversely theatrical concern
• Child’s school attendance is markedly limited; prolonged hospital admissions

Investigations

The investigative goal is confirmation of fabrication — not an extended diagnostic cascade. Once FD is suspected, the principle is to stop the diagnostic juggernaut, not extend it.

Key targeted investigations:

• Factitious hypoglycaemia — paired serum insulin + C-peptide + sulphonylurea screen during a hypoglycaemic episode. Exogenous insulin gives high insulin with suppressed C-peptide; sulphonylurea misuse gives high insulin + high C-peptide + positive drug screen (eTG Endocrinology)
• Factitious thyrotoxicosis — suppressed TSH + high T4 + low thyroglobulin (endogenous hyperthyroidism elevates thyroglobulin)
• Factitious coagulopathy — warfarin/superwarfarin assay; mixing studies; specific factor levels
• Real-time prescription monitoring — SafeScript (Vic/NSW), QScript (Qld), ScriptCheckSA, ScriptCheckWA, Tas RTPM — to identify multi-prescriber controlled-drug patterns

My Health Record review with patient consent can reveal historical admissions and diagnoses across providers.

Humility is essential: Bass and Halligan (Lancet, 2014) document numerous cases of genuine rare disease (pheochromocytoma, porphyria, autoimmune encephalitis) that were incorrectly labelled factitious disorder. Do not eliminate real disease from consideration.

Management — FD imposed on self

Per Eastwood and Bisson (BJPsych, 2008) and RACGP guidance:

• Coordinate care — single GP, single hospital where possible; share information across providers under duty-of-care principles
• Avoid further invasive investigation once FD is reasonably established; document the rationale; offer continuing care rather than angry discharge
• Non-confrontational communication — face-saving reframing that allows the patient to step down from the sick role without explicit admission: “These symptoms can sometimes be a body’s way of communicating distress that doesn’t have other words. I’d like us to focus on the emotional side alongside the physical, and meet regularly to help you feel better overall.”
• Treat comorbidity — depression with SSRI per eTG; borderline personality disorder with dialectical behaviour therapy (DBT); trauma history with phased trauma-focused therapy; substance use; eating disorder
• Medico-legal vigilance — contemporaneous factual documentation; involve a second clinician in diagnosis where possible; FD patients disproportionately make AHPRA complaints

B. Evidence and controversies

Direct confrontation

Krahn et al. (Am J Psychiatry, 2003) reviewed a large case series and found the majority of patients denied the diagnosis following confrontation, terminated the therapeutic relationship, and re-presented elsewhere. Some decompensated with suicidal ideation. Outcomes were worse in the confrontation group. The evidence for non-confrontational, face-saving approaches is more supportive, though no randomised trial exists.

Covert video surveillance (CVS) in FDIA

Southall et al. (BMJ, 1997) demonstrated that CVS captured active abuse (suffocation, poisoning) in a series of 39 cases, supporting its diagnostic role where other evidence is incomplete. Ethical concerns — privacy, continued harm during the surveillance window, evidence admissibility — have led most Australian paediatric units to require multidisciplinary ethics and legal review before CVS. CVS is not a first-line GP intervention; it requires a coordinated institutional framework.

Reporting threshold

RCPCH (2021), AAP (2007), and AIFS mandatory-reporting guidance all converge on early reporting at the level of reasonable suspicion, rather than deferring until certainty. The false-positive harm (family stress from an incorrect notification) must be weighed against the false-negative harm (ongoing abuse of a child). Given the 6–10% mortality in identified FDIA cases, the balance strongly supports earlier reporting.

DBT for comorbid BPD

DBT has strong randomised evidence for borderline personality disorder — Linehan et al. (Arch Gen Psychiatry, 2006) and a 2020 Cochrane review confirm its efficacy. Since FD frequently occurs on a background of borderline personality pathology, DBT is the best-supported psychiatric intervention to offer as adjunct treatment, targeting emotion regulation and crisis survival — skills that indirectly reduce sick-role behaviour.

C. FDIA — Australian mandatory reporting and child protection

In every Australian state and territory, general practitioners are mandatory reporters of suspected child abuse, including FDIA. The trigger threshold is “reasonable belief” or “reasonable suspicion” — not proof.

State and territory contacts:

• Victoria — Child Protection 13 12 78
• New South Wales — Child Protection Helpline 132 111
• Queensland — Child Safety Services 1800 811 810
• South Australia — Child Abuse Report Line 13 14 78
• Western Australia — Child Protection 1800 622 258
• Tasmania — Strong Families Safe Kids 1800 000 123
• Northern Territory — Child Abuse Hotline 1800 700 250
• ACT — Child and Youth Protection Services 1300 556 729

Statutory immunity for good-faith reports applies under child protection legislation in each jurisdiction. You are protected from liability for a report made in good faith, even if FDIA is not ultimately substantiated.

Do not confront the carer before reporting. Premature confrontation may cause abrupt discharge against medical advice and escalating harm to the child. Let child protection services lead the investigation. Assess siblings — siblings of FDIA victims are at high risk and must be included in the child protection notification.

D. Australian operations

MBS items

Long GP attendances (item 36 or 44) are appropriate — FD presentations frequently run long. Mental Health Care Plan (items 2715 / 2717) enables psychology referral for DBT or CBT; offer at every contact even when previously declined, document the offer and refusal. Better Access psychology (items 80000–80020) up to 10 individual sessions per calendar year.

Multidisciplinary case conferencing (items 132 / 133) is particularly useful for FDIA cases requiring coordination between hospital, psychiatry, child protection, and GP. GP psychiatric assessment and management plan (items 291 / 293) supports a consultant psychiatrist providing specialist opinion to guide ongoing GP-led care.

PBS

SSRIs and SNRIs (sertraline, fluoxetine, escitalopram, venlafaxine) — PBS General Schedule per eTG Psychotropic. Mood stabilisers (lamotrigine, valproate, lithium) — PBS Authority for bipolar. Avoid benzodiazepines and opioids in FD — these create dependence and disinhibition risks, and their prescription histories are easily detected via real-time prescription monitoring.

Medico-legal notes

Patients with factitious disorder disproportionately make AHPRA complaints and pursue litigation. RACGP guidance on complaints emphasises contemporaneous, factual, objective documentation. Sign workers’ compensation, insurance, and TAC certificates only for conditions you can defend objectively. Refer to an independent medical examiner where external pressure exists to certify incapacity that is not clinically supported.

E. Special populations

Children (FDIA victims). Mortality 6–10% in identified cases. Morbidity from repeated unnecessary procedures, missed schooling, and iatrogenic harm from treatments prescribed for fabricated conditions is substantial in survivors. Older children may collude with the carer’s fabrications, creating a complex dual presentation. Child-protection assessment by a paediatric child-protection specialist is essential.

Elderly and dependent adults. FDIA involving an elderly person with reduced decision-making capacity is recognised in DSM-5-TR and ICD-11. Mandatory reporting frameworks vary by jurisdiction — refer to Compass elder abuse reporting guidance and state-specific frameworks. The threshold for police or Public Advocate referral is low where decisional capacity is impaired.

Culturally and linguistically diverse patients. Assertive advocacy by a carer for a sick child may be misinterpreted as FDIA in the context of cultural differences in carer engagement styles. Apply cultural safety principles (RACGP cultural safety framework); use a professional interpreter; consult with a cultural liaison before concluding the presentation is factitious.

Patients with genuine rare disease. The most important safeguard against false diagnosis: always maintain a real-disease differential. Before concluding a presentation is factitious, ensure a reasonable investigative effort has been made to exclude pheochromocytoma, porphyria, mast cell activation syndrome, systemic lupus, paroxysmal hypoglycaemia, and autoimmune encephalitis in presentations that might fit.

When to escalate

Escalate immediately when:

• Suspected FDIA in a child — notify child protection services immediately; do not wait for a case conference
• Any time child or dependent-adult safety is acutely at risk — concurrent child protection notification and paediatric referral
• Suicidality — FD carries a substantial suicide risk in some cohorts; any expression of suicidal ideation requires urgent risk assessment and safety planning per RACGP suicidality guidance

Refer routinely to:

• Liaison psychiatry or consultant psychiatrist for FD confirmed or highly suspected in the inpatient setting
• DBT-trained clinical psychologist via Better Access where patient engagement is possible
• Beyond Blue (1300 22 4636) and Lifeline (13 11 14) as accessible crisis supports for comorbid depression/anxiety

What this article is and is not

This article is educational material for patients and carers seeking to understand factitious disorder. It draws on RACGP, RANZCP, eTG, and RCPCH 2021 guidance.

It is not a substitute for a personal clinical assessment by a GP, psychiatrist, or child-protection clinician. If you have concerns about a child’s welfare, contact the relevant state child protection service directly — you do not need to be certain.

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Sources cited

• RACGP — Abuse and violence guidelines
• eTG complete — Psychotropic
• AMH — Australian Medicines Handbook
• RANZCP
• AIFS — Mandatory reporting of child abuse
• RCPCH 2021 — Perplexing presentations / FII
• Bass C, Halligan P. Factitious disorders. Lancet 2014
• Eastwood S, Bisson JI. Management of factitious disorders. BJPsych 2008
• Krahn LE et al. Am J Psychiatry 2003
• Yates G, Bass C. BJPsych Advances 2017
• Linehan MM et al. DBT for BPD. Arch Gen Psychiatry 2006
• Cochrane — DBT for borderline personality disorder 2020
• Southall DP et al. Covert video surveillance. BMJ 1997
• HealthDirect
• Beyond Blue
• Lifeline
• Compass — elder abuse