ORIGINAL PAPERS Feigned psychosisrevisited- a 20 year follow up of 10 patients

Martin Humphreys and Alan Ogilvie

Feigned , 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 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 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-RSchizophreniaSchizophreniaSchizophreniaAtypicalpsychosisManiaICD-10DSM-III-RUndifferentiatedschizophreniaUndifferentiatedschizophreniaUndifferentiatedschizophreniaBipolar

57SchizophreniaM termin-patient organicpsychosisUndifferentiatedschizophreniaParanoidschizophreniaDelusionaldisorderMania careSchizophrenia 51PersonalitydisorderM -1972SupportedaccommodationSchizophrenia

-PersonalitydisorderF -1975Bipolar

-1980Suicideillness

-1982Mania 42PersonalitydisorderF -1991Day disorder-ParanoidschizophreniaNonwithpsychosis-SchizophreniaBipolar hospitalReturned 51SchizophreniaF USASchizophreniato withpsychosisMild withpsychosisNilAtypicalpsychosisNilSchizophreniaSchizophreni-form

50PersonalityproblemF -1976SupportedaccommodationBipolardepressionNon

51PersonalityproblemF -1974Out-patientBipolarillness organicpsychosisModeratedepressionParanoidschizophreniaParanoidschizophrenia-OPCRITorganicpsychosisHebephrenicschizophreniaParanoidschizophreniaParanoidschizophreniaSchizophreniaSchizophreniaSchizophreniaBipolarwithpsychosisSchizophreniaSchizophreniaSchizophrenia

59PersonalityproblemM -1972Lostillness

upLongto follow 54SchizophreniaF termin-patient careSchizophrenia 54 PersonalityproblemClinical-1976Last disorderSubsequent -1987Indexadmission

Feigned psychosis revisited 667 ORIGINAL PAPERS

Findings classiflcatory systems but two had other diag noses, in one case 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 years. data there was apparent consistency between the Of the three patients who went on to be newly ultimate clinical diagnosis and that generated by diagnosed as suffering from a genuine schizo the objective instrument in each instance. In phrenic illness each has had numerous admis considering the concept of diagnosis it has been sions to hospital during the intervening period, held that such consistency and persistence over but always with the same diagnosis. One is now time, in keeping with the natural history of the living independently, taking long-term oral anti- disorder, substantiates the potential validity of psychotic medication and has regular contact the diagnostic entity. This would seem not to be with a community psychiatric nurse; another the case for "feigned psychosis". One of the lives at home, attends the out-patient department patients described here was lost to follow up. and receives intramuscular long acting medica Two more did not meet DSM-III-R criteria tion; and the third is in supported accommoda initially, but were ascribed diagnoses of mild tion, also being treated with a depot neuroleptic and moderate respectively at that preparation. time according to ICD-10. The remaining seven Two of the three patients who subsequently had evidence of a diagnosis of major affective attracted a diagnosis of affective disorder have disorder or schizophrenia stable over time and a had episodes of both hypomania and depression. natural history and response to treatment in Both had a family history strongly suggestive of keeping with this. serious mental illness. One of these two had no The fact that all these patients developed a contact with psychiatric services in the interven major psychiatric illness over the course of the ing 20 year period following the index admission follow up period is similar to the findings of Hay then presented with her first manic episode. The (1983), although the emergence of bipolar dis third patient in this group developed a depressive order in two cases is an outcome not previously illness two years after being admitted with what reported. It seems likely that so called feigned were thought to be simulated symptoms. The psychotic symptoms may indeed represent tran remaining patient attracted diagnoses of hypo- sient or more enduring phenomena, genuinely and depression, but on other occasions experienced and reported, which develop at some schizophrenia, during the time following his first later date into a more clearly defined and contact and before his suicide. recognisable pattern. On the basis of the present investigation it is not possible to determine how the patients Standardised diagnoses described in the study might have differed at the Only two patients did not fulfil criteria for OPCRIT time of their original presentation from other DSM-II1-R diagnosis at the Urne of their index psychotic patients. It is unclear why, when case admission, but all met ICD-10 criteria for some notes made at the time were sufficient to fulfill form of disorder at that point (Table 1). There standardised criteria for a psychotic disorder in were no follow up data available in one case where the majority of cases, symptoms were attributed the patient initially met criteria for mania with to feigning. There was evidence of some specific psychosis, but the remaining nine patients all motivating factor for the patient, in the form of fulfilled criteria for major mental illness when all social or domestic upheaval, in two of the cases subsequent episodes were included. Seven of included in the present study but only one faced a these had schizophrenia according to both criminal charge at the time of index admission.

668 Humphreys & Ogilvie ORIGINAL PAPERS

All of those who had not previously attracted a HAY,G. G. (1983) Feigned psychosis - a review of the simulation of mental illness. British Journal of clinical diagnosis of schizophrenia were said to . 143, 8-10. have had personality problems or a personality HILL,G. N. (1814) An Essay on the Prevention and Cure of disorder. This may be strongly associated with Insanity with Observations and Rules for the Detection of the notion that an individual is in control and Pretenders to Madness. London. entirely responsible for their actions and might JONAS.J. M. & POPE, H. G. (1985) The dissimulating disorders: a single diagnostic entity? Comprehensive diminish the significance of symptoms otherwise Psychiatry. 26. 58-62. recognised as genuine (Lewis&Appleby, 1988). It JONES,E.H. (1955) The Road to En-Dor.London: Pan Books. is also noteworthy that although on occasion the JUNG.C.G. (1903) On simulated Insanity. In Collected works content of psychotic symptoms may be under ofC. G.Jung Vol I. (1957). London: Routledge and Kegan standable in psychodynamic terms, the diagnos Paul. tic importance of their presence remains. LEWIS,G. & APPLEBY.L.(1988) : the The long-term outcome findings presented from patients psychiatrists dislike. British Journal of Psychiatry. 153, 44-49. this study lend further weight to the viewthat the McGuFFiN, P., FARMER.A. E. & HARVEY.I. (1991) A utmost caution must be exercised in regard to the polydiagnostic application of operational criteria in suggestion that psychotic symptoms might be studies of psychotic Illness: development and reliability simulated, or at least that they may have little of the OPCRTTsystem. Anchiues of General Psychiatry. significance in terms of the future development of 48, 764-770. POPE,H. G., JONAS,J. M. & JONES,B. (1982) Factitious the clinical picture, especially at the time of first psychosis: phenomenology, family history and long term presentation to psychiatric services. The subse outcome of nine patients. American Journal of quent onset of a more clearly recognisable major Psychiatry. 139. 1480-1483. mental illness remains likely.The evidence for the REID,P. R. (1952) The Colditz Story. London: Hodder & diagnosis of feigned psychosis may be no more Stoughton. RITSON.B.& FORREST.A.(1970)The simulation ofpsychosis: objective than the absence of the odour described a contemporary presentation. British Journal of Medical by Hill (1814) and lead to the same potential for Psychology. 43. 31-37. clinical error as the diagnosis of hysteria (Slater, ROGERS.R.,BAGBY.R.M. & RECTOR.N.(1989) Diagnostic 1965). In our opinion the term should be legitimacy of with psychological abandoned. It might be better to make a detailed symptoms. American Journal of Psychiatry. 146. 1312- description of the reported phenomena in terms 1314. SCHNECK,J. N. (1970) Pseudo malingering and Leonid of "atypical symptoms" and to keep an open mind Andreyev's The Dilemma. Psychiatric Quarterly. 44, about their significance and any future diagnosis 49-54. regardless of what treatment might be deemed SCOTT.P.D. (1965) Commentary on Shorers translation of appropriate at the time (Scott, 1965). The Ganser . British Journal of Criminology.5, 127-131. SLATER.E.(1961) "Hysteria 311" 35th Maudsley Lecture. Journal of Mental Science. 1O7, 359-381. Acknowledgement —¿(1965)Diagnosis of "Hysteria." British MedicalJournal. 1, We are grateful to Dr Bruce Ritson for encoura 1395-1399. ging us to undertake this study. SZASZ,T. S. (1987) Insanity - The Idea and Its Consequences. NewYork:Wiley. WORLDHEALTHORGANIZATION(1992)The Tenth Revisionof the International Classiflcation of Diseases and Related References Health Problems (ICD-10). Geneva: WHO. AMERICANPSYCHIATRICASSOCIATION(1994)Diagnostic and Statistical Manual of Mental Disorders (4th édition) (DSM-IV). Washington, DC: APA. Martin Humphreys*, Lecturer in Forensic BARK,N. M. (1985) Did Shakespeare know schizophrenia? Psychiatry, Department of Psychiatry, Royal The case of Poor Mad Tom In King Lear. British Journal of Edinburgh Hospital, Morningside Park, Psychiatry. 146. 436-138. Edinburgh EH 10 5HF: Alan Ogilvie. Clinical BECK, T. R. (1829) Elements of Medical Jurisprudence. Edinburgh: Londman Rees. Scientist, MRC Brain Metabolism Unit, Royai GANSER.S. J. (1898) lieber einen eigenartigen hystrlschen Edinburgh Hospital Daemmerzustand. ArchÃ-nJürPsychiatrie und Nerven Krankheiten. 3O. 633. (Translated by SHORER. C. E. (1965) British Journal of Criminology. 5, 120.) •¿Correspondence

Feigned psychosis revisited.