CHAPTER 114 Factitious Disorders and Malingering Jag S. Heer 14,16 PERSPECTIVE children. Other names applied include Polle’s syndrome (Polle was a child of Baron Munchausen who died mysteriously),3,10 fac- Patients may present to the emergency department with symp- titious disorder by proxy,17 pediatric condition falsification,18 and toms that are simulated or intentionally produced. The reasons Meadow’s syndrome.2 that cause this behavior define two distinct varieties: factitious Malingering is the simulation of disease by the intentional pro- disorders and malingering. duction of false or grossly exaggerated physical or psychological Factitious disorders are characterized by symptoms or signs that symptoms, motivated by external incentives, such as avoidance of are intentionally produced or feigned by the patient in the absence military conscription or duty, avoidance of work, obtainment of of apparent external incentives.1,2 Factitious disorders have been financial compensation, evasion of criminal prosecution, obtain- present throughout history. In the second century, Galen described ment of drugs, gaining of hospital admission (for the purpose of Roman patients inducing and feigning vomiting and rectal bleed- obtaining free room and board), or securing of better living condi- ing.3 Hector Gavin sought to categorize this behavior in 1834.3 tions.2,19-21 The most common goal among such “patients” present- These patients constitute approximately 1% of general psychiatric ing to the emergency department is to obtain drugs, whereas in referrals, but this percentage is lower than that seen in emergency the office or clinic the gain is more commonly insurance payments medicine because these patients rarely accept psychiatric treat- or industrial injury settlements.22 Because of underreporting the ment.1,4 Of patients referred to infectious disease specialists for true incidence of malingering is difficult to gauge, but estimates fever of unknown origin, 9.3% of the disorders are factitious.5 include a 1% incidence among mental health patients in civilian Between 5 and 20% of patients observed in epilepsy clinics have clinical practice, 5% in the military, and as high as 10 to 20% psychogenic seizures, and the number reaches 44% in some among patients presenting in a litigious context.20 The most likely primary care settings.6 Among patients submitting kidney stones conditions to be feigned are mild head injury, fibromyalgia, for analysis, up to 3.5% are fraudulent.7 chronic fatigue syndrome, and chronic pain.23 Munchausen syndrome, the most dramatic and exasperating of the factitious disorders, was originally described in 1951.8 This fortunately rare syndrome takes its name from Baron Karl F. von CLINICAL FEATURES Munchausen (1720-1797), a revered German military officer and Factitious Disorders noted raconteur who had his embellished life stories stolen and parodied in a 1785 pamphlet.3 The diagnosis applies to only 10 to With a factitious disorder, the production of symptoms and signs 20% of patients with factitious disorders.1,9 Other names applied is compulsive; the patient is unable to refrain from the behavior include the “hospital hobo syndrome” (patients wander from hos- even when its risks are known. The behavior is voluntary only in pital to hospital seeking admission), peregrinating (wandering) the sense that it is deliberate and purposeful (intentional) but not problem patients, hospital addict, polysurgical addiction, laparo- in the sense that the acts can be fully controlled.2 The underlying tomaphilia migrans, Kopenickades syndrome, Ahasuerus syn- motivation for producing these deceptions, securing the sick role, drome, and hospital vagrant.4,10,11 is primarily unconscious.9,24,25 Individuals who readily admit that Munchausen syndrome by proxy (MSBP), an especially perni- they have produced their own injuries (e.g., self-mutilation) are cious variant that involves the simulation or production of facti- not included in the category of factitious disorders.17 Presenta- tious disease in children by a parent or caregiver, was first described tions may be acute, in response to an identifiable recent psycho- in 1977.12 There are approximately 1200 estimated new cases of social stress (termination of romantic relationship, threats to MSBP per year in the United States.3 The condition excludes self-esteem), or a chronic life pattern, reflective of the way in straightforward physical abuse or neglect and simple failure to which the person deals with life in general.26 The symptoms thrive; mere lying to cover up physical abuse is not MSBP.13,14 The involved may be either psychological or physical. key discriminator is motive: the mother is making the child ill so that she can vicariously assume the sick role with all its benefits. Psychological Symptoms The mortality rate from MSBP is 9 to 31%.14,15 Children who die are generally younger than 3 years, and the most frequent causes This disorder is the intentional production or feigning of psycho- of death are suffocation and poisoning.14 Permanent disfigure- logical (often psychotic) symptoms suggestive of a mental disor- ment or permanent impairment of function resulting directly der. Stimulants may be used to induce restlessness or insomnia; from induced disease or indirectly from invasive procedures, mul- hallucinogens, to create altered levels of consciousness; and hyp- tiple medications, or major surgery occurs in at least 8% of these notics, to produce lethargy. This psychological factitious condition 1487 1488 PART III ◆ Medicine and Surgery / Section Eight • Psychiatric and Behavioral Disorders is less common than factitious disorders with physical symptoms The symptoms presented are “limited only by the person’s and is almost always superimposed on a severe personality medical knowledge, sophistication, and imagination.”2 The alleged disorder.2,17 illnesses involved have been termed dilemma diagnoses in that investigators rarely can totally rule out the disorder, clarify the 4 Physical Symptoms cause, or prove that it did not exist at one time. Common pre- sentations are those that most reliably result in admission to the The intentional production of physical symptoms may take the hospital, such as abdominal pain, self-injection of a foreign sub- form of fabricating of symptoms without signs (e.g., feigning stance,10,11 feculent urine, bleeding disorders, hemoptysis, parox- abdominal pain), simulation of signs suggesting illness (e.g., ysmal headaches, seizures, shortness of breath, asthma with fraudulent pyuria, induced anemia), self-inflicted conditions (e.g., respiratory failure,4,33 chronic pain,25 acute cardiovascular symp- the production of abscesses by injection of contaminated material toms (e.g., chest pain, induced hypertension and syncope),32 renal under the skin), or genuine complications from the intentional colic and spurious urolithiasis,7 fever of unknown origin (hyper- misuse of medications (e.g., diuretics, hypoglycemic agents).21 pyrexia figmentatica),5,11 profound hypoglycemia, and coma with These patients are predominantly unmarried women younger anisocoria.34 Some self-induced conditions are highly injurious or than 40 years. They typically accept their illness with few com- even lethal.10 plaints and are generally well-educated, responsible workers or The patient usually presents during evenings or on weekends so students with moral attitudes and otherwise conscientious behav- as to minimize accessibility to psychiatric consultants, personal ior.21,27,28 Many are in health care occupations, including nurses, physicians, and past medical records.11,27 In teaching institutions aides, and physicians. these patients often present in July, shortly after the change in These patients are willing to undergo incredible hardship, limb resident house officers.4 They relate their history in a precise, amputation, organ loss, and even death to perpetuate the mas- dramatic, even intriguing fashion, embellished with flourishes of querade.21 Although multiple hospitalizations often lead to iatro- pathologic lying and self-aggrandizement. Pseudologia fantastica, genic physical conditions, such as postoperative pain syndromes or pathologic lying, is a distinctive peculiarity of these patients. In and drug addictions, patients continue to crave hospitalization a chronic, often lifelong behavior pattern, the patient typically for its own sake. They typically have a fragile and fragmented takes a central and heroic role in these tales, which may function self-image and are susceptible to psychotic and even suicidal epi- as a way to act out fantasy.35 The history quickly becomes vague sodes.27 Interactions with the health care system and relationships and inconsistent, however, when the patient is questioned in detail with caregivers provide the needed structure that stabilizes the about medical contacts.2,29 Attempts to manage the complaint on patient’s sense of self. The hospital may be perceived as a refuge, an outpatient basis are adamantly resisted.25 Once admitted, the sanctuary, or womblike environment.4,21,24,29 Some patients are patient initially appeals to the physician’s qualities of nurturance apparently driven by the conviction that they have a real but as and omnipotence, lavishing praise on the caregivers. Behavior yet undiscovered illness. Consequently, artificial symptoms are rapidly evolves, however, as the patient creates havoc on the ward contrived to convince the physician to continue a search for the by insisting on excessive attention