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When Munchausen Becomes Malingering: Factitious Disorders That Penetrate the Legal System

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When Munchausen Becomes Malingering: Factitious Disorders That Penetrate the Legal System When Munchausen Becomes Malingering: Factitious Disorders That Penetrate the Legal System Stuart J. Eisendrath, MD Psychiatrists and other physicians are usually familiar with factitious disorders, but attorneys and judges usually are not. Cases involving factitious disorders may enter the civil legal system in a number of ways and cause incorrect judgments, financial costs, and inappropriate medical care if these disorders are not identi- fied. Psychiatric consultants may play a key role in identifying these cases and educating legal personnel about factitious disorders. This article describes three cases in which persons with factitious disorders entered the civil litigation sys- tem. The role of the psychiatrist in these cases is discussed. Clues to the identi- fication of factitious disorders are described. The article also discusses the differentiation of factitious disorders from malingering and other forms of abnor- mal illness behavior, such as conversion, hypochondriasis, and somatization disorders. The concepts of primary and secondary gain in relationship to illness behaviors are elaborated. Factitious disorders are those conditions iar with factitious disorders from their in which individuals actively create signs medical training, many attorneys and or symptoms of physical or psychological judges have had not any exposure to such disease states.' Although there are numer- cases. As these cases appear to be devel- ous reports of factitious psychological oping more frequently in legal and other disorders,"-" there is controversy about nonmedical settings,' it is important for the legitimacy of the diagnosk6 This pa- these nonpsychiatrists to become aware per will limit its focus to factitious phys- of the factitious disorders in order to deal ical disorders and how they may enter the with cases appropriately. Considerable legal system in civil litigation. education may be necessary to inform Although most psychiatrists are famil- legal staff about factitious disorders be- cause the entity is so counterintuitive-no one expects an apparently reasonable per- Dr. Eisendrnth is affiliated with the Langley Porter Psy- chiatric Institute, University of California. San Fran- son to actively create a disease in him- or cisco. CA. Address correspondence to: Dr. S. Eisen- herself. Identification of factitious cases drath, 401 Parnass~lsAve., San Francisco, CA 94143- 0984. and early intervention may lead to cessa- Bull Am Acad Psychiatry Law, Vol. 24, No. 4, 1996 471 Eisendrath tion of costly litigation and more appro- arm against a metal shelf in a manufac- priate treatment. This article will discuss turing plant. He was taken to an emer- several illustrative cases of factitious dis- gency room and had a superficial lacera- orders and will also describe clues to their tion sutured and was given prophylactic detection. Finally, we will also examine tetanus toxoid and antibiotics. He then theoretical issues raised by these cases, developed signs of a wound infection and which differentiate factitious behavior saw an occupational medicine specialist from other abnormal illness behaviors who changed the antibiotic regimen. such as malingering. When this treatment failed to improve the Perhaps the most notorious factitious condition, the plaintiff was referred to an disorder is Munchausen syndrome by orthopedist. That physician performed an proxy, in which a mother creates illness incision and drainage and carefully doc- in her child.'. This condition is a form of umented the exploration of the wound. child abuse and is handled in the criminal Leaving the wound open to drain, the justice system. In adults, the most well- plaintiff had improved for several weeks, known factitious physical disorder is the but shortly before he was to go back to Munchausen syndrome. lo. ' ' As with suf- work, signs of infection recurred. The ferers of other factitious disorders, these orthopedic surgeon reopened the wound individuals may produce serious medical and discovered some foreign bodies in the problems, but in addition, travel widely, deeper layers of the tissues. Pathological appear to be highly sociopathic, and have examination suggested that the foreign a history of unceasing patienthood. Usu- bodies had been recently placed in the ally. these individuals are identifiable as tissue and had not been present at the time soon as any corroborative history is ob- of the original injury. tained. More difficult to diagnose are the Claiming dissatisfaction with his sur- individuals without an unceasing history geon, the plaintiff changed to a new or- of hospitalizations and medical treat- thopedist who immediately obtained an ments. These individuals may produce infectious disease consultation. These factitious physical disorders as a response physicians decided to try a new antibiotic to a stressful life situation that exceeds regimen. When this failed to heal the their usual coping strategies.I2 Because of wound, the orthopedist decided to place this uncommon reaction, others may not the plaintiff's arm in a cast to investigate be aware of. or even suspect, the facti- the possibility that the plaintiff was inter- tious etiology. fering with the healing process. After sev- eral weeks, the cast was removed and the Case 1 wound had essentially healed. Two days Mr. B. a 32-year-old African-American later, however. the wound appeared to be male, filed suit against several physicians swelling with infection. Antibiotics were who had treated him for an arm wound. changed again and the arm was again Allegedly, he injured the arm in a work- placed in a cast. When the cast was re- related incident in which he scraped his moved. the wound had almost completely 472 Bull Am Acad Psychiatry Law, Vol. 24, No. 4, 1996 When Munchausen Becomes Malingering healed. The orthopedist raised the idea of they had been due to friends shifting the plaintiff interfering with the healing blame to him. There was no overt evi- process, but the plaintiff vehemently de- dence of psychosis. affective disorder. or nied any manipulation of the wound and cognitive disturbance. He acknowledged changed physicians. Eventiially. this pat- that the arm injury had occurred shortly tern was replicated with five other physi- after his wife had given birth to their only cians and the plaintiff underwent multiple child. The plaintiff noted that this event surgical debridements of his arm wound, had been stressful. but added that he did which had not healed over a four-year not have much time to worry about his period. Over the course of treatment, sig- new infant because he had been preoccu- nificant amounts of muscle and nerve tis- pied with his own injury. sue were removed. Most recent investiga- Mr. B denied having had any psychiat- tions showed evidence of osteomyelitis in ric treatment. Several of the doctors he the deepest areas of the wound and am- had seen for his wound had suggested that putation was being considered as the only he see psychiatrists for consultations, but means of obtaining a cure. The plaintiff he had refused. saying his only problem remained on total disability and began was his ongoing infection. His wife had litigation against all of the physicians ex- separated from him on several occasions. cept for his current ones. reportedly due to her difficulties caring Defense attorneys asked a psychiatric for both an infant and a disabled spouse. consultant to review the case because Nonetheless. he denied any current mar- medical records had raised the question of ital difficulties. the plaintiff manipulating his wound. The The consultant concluded that Mr. B consultant reviewed medical records ex- had a factitious disorder that at times tending into the patient's teenage years. shifted into malingering. Some of Mr. B's These records documented 12 injuries to arm illjuries had not been associated with the patient's arms over the prior 10 years. any apparent gain. but half of them were Most. but not all, of these had been asso- related to obtaining disability payments. ciated with periods of one month of dis- The arm wound that led to the malprac- ability for industry-related incidents. His tice litigation may not originally have records noted a history of adolescent be- been produced factitiously. but it clearly havioral problems that eventuated in his was perpetuated in that manner. The con- being sent to a juvenile detention center sultant speculated that the wound may for grand theft and one conviction for have represented the plaintiff's attempt to robbery as an adult. His work history was obtain support and attention from his wife marked by a lack of continuity; he had when this was threatened with the birth of held all jobs for less than one year. a child. Eventually. the perpetuation of The consultant performed a psychiatric the wound appeared to be aimed at finan- examination during which the plaintiff cial gain via the litigation. The plaintiff's minimized any responsibility for the past history of sociopathic behavior crimes he had been convicted of. saying strengthened the likelihood of malinger- Bull Am Acad Psychiatry Law, Vol. 24, No. 4, 1996 473 Eisendrath ing. The extent of his injury and the ac- with her. At the urgings of several tual disability he suffered suggested that friends, she began litigation against the Mr. B had features of both factitious dis- hotel where the injury occurred, claiming order and malingering. After the consul- security was inadequate. tant was deposed by the plaintiff's coun- As part of the litigation process. her sel with the foregoing assessment. the attorney obtained a psychiatric evaluation plaintiff and his attorney decided to with- of her to assess the level of depression draw his lawsuit. that was present and what treatment might be necessary. The psychiatric con- Case 2 sultant reviewed her medical records ex- Ms. A was a 35-year-old Caucasian tending into her teenage years. One key female who claimed that she had been finding was that she had been hospital- injured in a parking lot of a luxury hotel.
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