Core features & definitions

• Factitious disorder imposed on self: falsification of symptoms or induction of injury on oneself to assume the sick role; behaviour persists despite absence of external rewards and may involve elaborate deceptions.
• Factitious disorder imposed on another (caregiver‑perpetrated): caregiver deliberately produces or fabricates symptoms in a dependent person (child, elderly, disabled) to gain attention or sympathy.
• Different from malingering (external incentives such as financial gain or avoidance of responsibility) and from somatic symptom disorder (symptoms not intentionally produced).

Why it matters — risks & harms

• Unnecessary investigations, repeated hospitalisations, iatrogenic injuries, invasive procedures, and even death in severe cases of imposed illness.
• Psychosocial harm: disruption of family functioning, legal consequences, and long‑term psychological morbidity for victims.
• Complex clinical and legal responsibilities for clinicians—including safeguarding, forensic documentation and multidisciplinary coordination.

Red flags and warning features

• Unexplained or atypical course, symptoms incongruent with investigations, symptoms that only occur when caregiver present, extensive medical history with multiple providers, eagerness for invasive tests, and inconsistent collateral histories.
• Discrepancy between reported and observed symptoms, symptoms that worsen despite treatment, or evidence of tampering with samples/lines/medication.

Assessment checklist

1. Document meticulously: timelines, observed behaviours, inconsistencies, collateral information (past records, other clinicians), and photographic/recorded evidence where ethically and legally permitted.
2. Maintain a non‑accusatory clinical stance—prioritise patient safety (or dependent’s safety) and avoid confrontational language that may precipitate flight or escalation.
3. In suspected imposed illness, involve safeguarding teams early (child protection, adult safeguarding), paediatrics, social services and legal advisors as required by local protocols.
4. Use careful diagnostic formulation: consider underlying psychiatric comorbidity in the perpetrator (personality disorder, factitious psychopathology) and in the victim (trauma, attachment issues).

Immediate management priorities

• Ensure safety of the potential victim: consider separating the caregiver from the vulnerable person when immediate harm suspected—follow local safeguarding/legal processes.
• Limit unnecessary invasive procedures and investigations where appropriate, but balance this with the need to rule out organic disease—decisions should be multidisciplinary.
• Preserve therapeutic relationships carefully: use neutral language, avoid direct accusation in front of the patient/victim, and plan disclosure thoughtfully with safeguarding and legal teams if required.

Treatment approaches

• Psychiatric care for the affected individual: victims may need trauma‑informed psychotherapy, medical follow‑up for iatrogenic harm and social support; involve child/adult psychiatry where needed.
• Treatment for the perpetrator (when engaged): complex and often challenging—psychotherapy focusing on personality pathology, motivation, and underlying needs; engage forensic psychiatry or specialist services when available.
• Multidisciplinary interventions: coordination between medical, mental health, social services, legal and safeguarding teams to create an action plan that minimises harm and addresses legal responsibilities.

Legal, ethical & documentation considerations

• Document facts, observations and dates carefully—avoid speculative language. Maintain chain of custody for any physical evidence and follow local policies for reporting to child protection or law enforcement when needed.
• Consider confidentiality limits—duty to protect vulnerable persons may require breach of confidentiality and reporting; consult legal/safeguarding colleagues before disclosure where possible.
• Preserve sample integrity and photographic evidence when permissible and follow institutional protocols for forensic documentation.

Practical tips for clinicians

• Keep detailed, objective records; use interdisciplinary case conferences; involve safeguarding and legal teams early; avoid public confrontation; prioritise victim safety.
• Engage forensic, psychiatric and social care services when indicated; provide follow‑up and rehabilitation for victims and offer psychiatric care for perpetrators when feasible under legal frameworks.