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A 20 Year Follow up of 10 Patients ORIGINAL PAPERS Feigned psychosisrevisited- a 20 year follow up of 10 patients Martin Humphreys and Alan Ogilvie Feigned psychosis, although rare, presents considerable throughout the intervening period (Slater, 1965). diagnostic problems in clinical psychiatric practice. This is in keeping with the suggestion that feigned Long-term follow up data are lacking. A retrospective psychosis may have its roots in genuine psychia case note study was undertaken of 10 patients tric disorder and that where the diagnosis has described in a previous paper, published in 1970, on been made actual illness may emerge later (Hay, the simulation of psychosis. The computerised 1983). diagnostic instrument OPCRIT was applied to both Shakespeare described how Edgar in King Lear index episode and lifetime occurrence of symptoms. feigned insanity and took on the guise of "Poor All 10 patients were found to have had a major Mad Tom". Paradoxically, since his madness was psychotic illness based on lifetime symptoms at 20 simulated, the detail of the account of Poor Tom's year follow-up by DSM-lll-R criteria. Eight had met such life and condition have been cited as evidence that criteria at the time of the initial episode. Diagnosis in Shakespeare must have been familiar with patients thought to be feigning psychotic symptoms chronic schizophrenia and that the illness, changes over time and major mental illness is likely to contrary to what had been suggested previously, emerge which may be schizophrenic or affective. The was indeed known in the sixteenth century (Bark, term feigned psychosis should be abandoned and more 1985). attention given to why symptoms are accepted as The simulation of mental illness had been used genuine in some cases but not others. as means of escape from prisoner of war camps in the First and Second World Wars (Reid, 1952; Jones, 1955) and featured in fictional writing Early accounts of feigned insanity included (Schneck. 1970). Samuel Fuller's film Shock observations relating to its detection by a lack of Corridor in which a journalist attempts to unravel the particular odour believed to attend the truly an unsolved murder in an asylum by feigning insane (Hill, 1814). So called "pretenders to insanity only to be overtaken by true mental madness" (Beck, 1829) were said to be found illness, was considered to be in such bad taste more commonly before the courts, and diagnosis that its screening was originally banned for 7 required identification of a specific motive such as years by the British Board of Censors. More attempts to avoid prosecution, conscription or recently media attention has focused upon the punishment. Ganser (1898) described three cases issue of serious offenders attempting to pervert of an hysterical twilight state in prisoners and the course of justice by the simulation of mental concluded that these were not the result of disorder. Szasz (1987) has explored the imitation malingering but true illness. Jung (1903) stressed of mental illness as well as the supposed what he considered to be the strong relationship deception involved in any apparent remedy and between criminality, "malingering", a term which cites Swift's reference in Gulliver's Travels to he left undefined, and "simulation", actions imaginary diseases and imaginary cures. intended to deliberately conceal inner healthi Modern diagnostic classifications include facti ness. He found only 11 malingerers among 8340 tious disorder with feigning of psychological admissions to hospital, but no fewer than nine of symptoms characterised by apparently obscure these patients had been investigated for or internal motivation and malingering associated convicted of a crime. Slater (1961) described with more obvious external stresses or incentives how the diagnosis of hysteria may be indicative (World Health Organization, 1992; American of the nature of the relationship between a Psychiatric Association, 1994). There remains particular doctor and patient at a specific time doubt nevertheless about the diagnostic legiti and in certain circumstances. He also found that macy of simulated mental illness (Jonas & Pope, there was frequently significant and serious 1985; Rogers et al 1989). Pope et al (1982) underlying physical or major psychiatric disorder emphasised the features often present in cases in such cases, sometimes only diagnosed accu of factitious psychosis, in particular the almost rately years after the original presentation despite universally poor outcome, but argued that their the presence of clear physical findings or signs findings in relation to a 4 to 7 year follow up 666 Psychiatric Bulletin (1996), 2O. 666-669 ORIGINAL PAPERS period suggested that the diagnosis remained feigned, rather than genuine, symptoms. Among valid. In contrast Hay (1983) identified a group of the other nine patients there was said to be no prior six patients who fulfilled his study criteria for history to suggest psychosis although a consistent simulation, those discharged over a 10 year pattern of various degrees of disturbance of period with a diagnosis of feigned psychosis or personality was described in each. From the details remembered by the responsible doctor as having contained in the original paper we were able to feigned psychotic illness, all but one of whom identify 10 of these 12 patients and examine their later developed some form of genuine disorder. case notes. Clinical diagnosis and demographic In the present paper we review the original data were recorded from the time of the previously diagnosis and describe the outcome for 10 reported episode and also any diagnoses made patients who presented with what were appar subsequently. The computerised instrument OP- ently simulated psychotic symptoms more than CRIT (McGuffln et al 1991), which generates 20 years ago. diagnoses according to a number of classificatory systems from case note, clinical or other defined sources of information, was applied for each index The study admission and then all subsequently recorded Ritson & Forrest (1970) described 12 patients data. admitted to a psychiatric hospital who were Table 1 shows the original diagnosis for each apparently simulating symptoms of psychosis. In patient at the time of the index admission, the three cases a diagnosis of schizophrenia had current clinical situation, the OPCRIT ICD-10 already been made, although for each of these and DSM-III-R diagnoses relating to case note patients the presentation at the time of the episode information from the time of the index admission described was considered to be characterised by and from analysis of subsequent data. Table 1. Original and subsequent diagnoses for each patient, and their current clinical situations Index clinical diagnosis - diagnosis - OPCRIT Patientdiagnosis12345678910M Sex Age outcomeLong ICD-10Non DSM-III-RSchizophreniaSchizophreniaSchizophreniaAtypicalpsychosisManiaDSM-III-RUndifferentiatedschizophreniaUndifferentiatedschizophreniaUndifferentiatedschizophreniaBipolarICD-10 SchizophreniaM57 in-patientterm organicpsychosisUndifferentiatedschizophreniaParanoidschizophreniaDelusionaldisorderMania careSchizophrenia PersonalitydisorderM51 -1972SupportedaccommodationSchizophrenia PersonalitydisorderF- -1975Bipolar -1980Suicideillness 1982Mania- PersonalitydisorderF42 1991Day- disorder-ParanoidschizophreniaNonwithpsychosis-SchizophreniaBipolar hospitalReturned SchizophreniaF51 USASchizophreniato withpsychosisMild withpsychosisNilAtypicalpsychosisNilSchizophreniaSchizophreni-form PersonalityproblemF50 -1976SupportedaccommodationBipolardepressionNon PersonalityproblemF51 -1974Out-patientBipolarillness organicpsychosisModeratedepressionParanoidschizophreniaParanoidschizophrenia-OPCRITorganicpsychosisHebephrenicschizophreniaParanoidschizophreniaParanoidschizophreniaSchizophreniaSchizophreniaSchizophreniaBipolarwithpsychosisSchizophreniaSchizophreniaSchizophrenia PersonalityproblemM59 -1972Lostillness upLongto follow SchizophreniaF54 in-patientterm careSchizophrenia 54 PersonalityproblemClinical-1976Last disorderSubsequent -1987Indexadmission Feigned psychosis revisited 667 ORIGINAL PAPERS Findings classiflcatory systems but two had other diag noses, in one case bipolar disorder by both ICD- CÃ-infcaÃ-diagnoses and outcome 10 and DSM-III-R criteria, and in the other, Of the three patients said to have had a prior non-organic psychosis and bipolar disorder schizophrenic illness but feigned symptoms, two respectively. are now in long term in-patient hospital care with a clinical diagnosis of schizophrenia. The other patient has returned to her country of birth but OPCRIT suggested the presence of an affective illness at the time of the index presentation rather Comment than schizophrenia. All of the remaining seven This study is unusual in that it allowed a follow patients have subsequently attracted a clinical up period of at least 20 years for all those diagnosis of either schizophrenia (n=3), a major concerned. The finding that in most cases affective illness (n=3), or in one case, both of these sufficient signs and symptoms were recorded at at different times in the past. The period which the time of the initial presentation to meet elapsed between the index admission with appar operational criteria for a major disorder by ently feigned symptoms and the ultimate diag OPCRIT diagnosis is of particular interest. nosis of a manic depressive or schizophrenic Despite the obvious limitations of such a illness ranged from 7 months to in excess of 20 retrospective study based only upon case note
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