Individuals may intentionally produce or feign psychological (often psychotic) symptoms suggestive of a mental disorder. Stimulants may be used to induce restlessness or insomnia; hallucinogens, to create altered levels of consciousness; and hypnotics, to produce lethargy. This psychological factitious condition is less common than factitious disorders with physical symptoms and is almost always superimposed on a severe personality disorder. ^{, ,}

The intentional production of physical symptoms may take the form of fabricating symptoms without signs (e.g., feigning abdominal pain), simulation of signs suggesting illness (e.g., fraudulent pyuria, induced anemia), self-inflicted conditions (e.g., the production of abscesses by injection of contaminated material under the skin), or genuine complications from the intentional misuse of medications (e.g., hypoglycemic agents). These patients are predominantly unmarried women younger than 40 years old. They typically accept their illness with few complaints and are generally well-educated, responsible workers or students with moral attitudes and otherwise conscientious behavior. A majority of individuals with factitious disorder are employed in health care settings, including laboratory technicians, nurses, and physicians. There is an increased rate of personality disorders and depression among individuals with factitious disorder. ^,

These patients are willing to undergo incredible hardship, limb amputation, organ loss, and even death to perpetuate the masquerade. Although multiple hospitalizations often lead to iatrogenic physical conditions, such as postoperative pain syndromes and drug addictions, patients continue to seek hospitalization for its own sake. They typically have a fragile and fragmented self-image and are susceptible to psychotic and suicidal episodes. Interactions with the health care system and relationships with caregivers provide the needed structure that stabilizes the patient’s sense of self. Some patients are driven by the conviction that they have a real but as yet undiscovered illness. Consequently, artificial symptoms are contrived to convince the physician to continue a search for the elusive disease process. Factitious illness behavior has also emerged on the internet. “Virtual support groups” offering person-to-person communications through chat rooms or websites have been perpetrated by individuals, under the pretense of illness or personal crisis, for the purpose of extracting attention or sympathy, acting out anger, or exercising control over others.

The uncommon patient with true Munchausen syndrome has a prolonged pattern of “medical imposture,” usually years in duration. The diagnosis may be delayed several years. The average age at presentation is 34 years, and the syndrome is most commonly found in women. Patients’ entire adult lives may consist of trying to gain admission to hospitals and then resisting discharge. The majority of patients work in the health care field. ^{, ,} The quest for repeated hospitalizations often takes these patients to numerous and widespread cities and states.

These individuals see themselves as important people, or at least related to such persons, and their life events are depicted as exceptional. They possess extensive knowledge of medical terminology. There is frequently a history of genuine disease, and the individual may exhibit objective physical findings.

The symptoms presented are “limited only by the person’s medical knowledge, sophistication, and imagination.” Common presentations are those that most reliably result in admission to the hospital, such as abdominal pain, self-injection of a foreign substance, feculent urine, bleeding disorders, hemoptysis, paroxysmal headaches, seizures, shortness of breath, asthma with respiratory failure, chronic pain, acute cardiovascular symptoms (e.g., chest pain, induced hypertension, and syncope), renal colic and spurious urolithiasis, fever of unknown origin, and profound hypoglycemia. Some self-induced conditions are highly injurious or even lethal.

The patient usually presents during evenings or on weekends so as to minimize accessibility to psychiatric consultants, personal physicians, and past medical records. In teaching institutions, these patients often present in July, shortly after the change in resident house officers. They relate their history in a precise, dramatic, even intriguing fashion, embellished with flourishes of pathologic lying and self-aggrandizement. Pseudologia fantastica, or pathologic lying, is a distinctive peculiarity of such patients. In a chronic, often lifelong behavior pattern, the patient typically takes a central and heroic role in these tales, which may function as a way to act out fantasy. The history quickly becomes vague and inconsistent, however, when the patient is questioned in detail about medical contacts. Attempts to manage the complaint on an outpatient basis are adamantly resisted. Once admitted, the patient initially appeals to the physician’s qualities of nurturance and omnipotence, lavishing praise on the caregivers. Behavior rapidly evolves, however, as the patient creates havoc on the ward by insisting on excessive attention while ignoring both hospital rules and the prescribed therapeutic regimen. When the hoax is uncovered and the patient confronted, fear of rejection may abruptly change into rage against the treating physician, closely followed by departure from the hospital against medical advice.

Ninety-eight percent of perpetrators are biological mothers who come from all socioeconomic groups. ^{, ,} Many have a background in health professions or social work, or a past history of psychiatric treatment, marital problems, or suicide attempts. Depression, anxiety, and somatization are common, but overt psychotic behavior by the mother is atypical. Perpetrators of FDIA are skilled in manipulating health care workers and child protection services. They are pleasant, socially adept, cooperative, and appreciative of good medical care. They often display a peculiar eagerness to have invasive procedures performed on their child. They often prefer to stay in the hospital with their child, cultivate unusually close relationships with hospital staff, and thrive on staff attention. This affable relationship with the medical team rapidly changes to excessive anger and denial when the perpetrator is confronted with suspicions. ^,

Most of these mothers have had an abusive experience early in life, and they use the health care system as a means to satisfy personal nurturing demands. They often cannot distinguish their needs from the child’s and satisfy their own needs first. They derive a sense of purpose from the medical and nursing attention gained when their children are in the hospital. Alternatively, the behavior may enable the mothers to escape from their own physical or psychological illnesses, marital difficulties, or social problems.

Victims of FDIA are equally male and female children. The proper diagnosis for the victims of FDIA is the coding for confirmed or suspected child physical abuse (995.4) and the appropriate injury code. ^, The child or vulnerable adult may also suffer physical or psychological consequences of unnecessary medical procedures. The mean age at diagnosis is 40 months, and the mean duration from the onset of signs and symptoms to diagnosis is 15 months. ^, A known physical illness that explains part of the symptoms is common among these children. Most have a history of significant failure to thrive and have been hospitalized in more than one institution. Delays in many areas of performance and learning, difficulty with family relationships, attention deficit disorder, or clinical depression may coexist. Some of these victims may have factitious disorder later in life or even PTSD. Elders may also be victims of FDIA, although this is uncommon.