Fabrication or Fact? Navigating Ethical and Clinical Challenges in Diagnosing Factitious Disorder

Background: Factitious disorder (FD) is a complex psychiatric condition characterized by deliberate falsification or induction of symptoms to assume the role of a patient, driven by internal psychological needs rather than external rewards. Despite its rarity, FD poses significant diagnostic and ethical challenges in clinical practice. Methods: This paper explores the nuances of diagnosing and managing FD through two contrasting case studies, underscoring the risks of both overdiagnosis and underdiagnosis. Results: The first case details a patient with a history of multiple hospitalizations and symptom exaggeration, ultimately revealing a clear pattern of factitious behavior. Despite accumulating evidence, clinicians hesitated to assign the FD diagnosis due to ethical concerns and fear of damaging the therapeutic relationship. This avoidance resulted in repeated iatrogenic harm, violation of ethical principles such as non-maleficence, and delayed psychiatric intervention. In contrast, the second case describes a patient who was prematurely labeled with FD in the absence of sufficient evidence, leading to delayed care for a genuine medical condition and a breakdown in trust with the healthcare system. Conclusion: These cases highlight the need for a deliberate, evidence-based, and ethically sound approach when considering a diagnosis of FD. Clinicians must balance the imperative to avoid harm with the duty to promote patient well-being through honest communication and appropriate treatment. Non-confrontational approaches, while preserving rapport, may inadvertently reinforce deceptive behaviors or delay psychiatric care for patients with FD. Ultimately, diagnosing FD responsibly requires clear evidence to support clinical suspicion, awareness of unconscious bias, and the use of standardized communication strategies to ensure that patients receive compassionate and appropriate care.