Factitious Disorders and Malingering

Perspective

Patients may present to the emergency department with symptoms that are simulated or intentionally produced. The reasons that cause this behavior define two distinct varieties: factitious disorders and malingering.

Factitious disorders are characterized by symptoms or signs that are intentionally produced or feigned by the patient in the absence of apparent external incentives.1,2 Factitious disorders have been present throughout history. In the second century, Galen described Roman patients inducing and feigning vomiting and rectal bleeding.³ Hector Gavin sought to categorize this behavior in 1834.³ These patients constitute approximately 1% of general psychiatric referrals, but this percentage is lower than that seen in emergency medicine because these patients rarely accept psychiatric treatment.^1,4 Of patients referred to infectious disease specialists for fever of unknown origin, 9.3% of the disorders are factitious.⁵ Between 5 and 20% of patients observed in epilepsy clinics have psychogenic seizures, and the number reaches 44% in some primary care settings.⁶ Among patients submitting kidney stones for analysis, up to 3.5% are fraudulent.⁷

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 Munchausen (1720-1797), a revered German military officer and noted raconteur who had his embellished life stories stolen and parodied in a 1785 pamphlet.³ The diagnosis applies to only 10 to 20% of patients with factitious disorders.^1,9 Other names applied include the “hospital hobo syndrome” (patients wander from hospital to hospital seeking admission), peregrinating (wandering) problem patients, hospital addict, polysurgical addiction, laparotomaphilia migrans, Kopenickades syndrome, Ahasuerus syndrome, and hospital vagrant.^4,10,11

Munchausen syndrome by proxy (MSBP), an especially pernicious variant that involves the simulation or production of factitious disease in children by a parent or caregiver, was first described in 1977.¹² There are approximately 1200 estimated new cases of MSBP per year in the United States.³ The condition excludes straightforward physical abuse or neglect and simple failure to thrive; mere lying to cover up physical abuse is not MSBP.^13,14 The key discriminator is motive: the mother is making the child ill so that she can vicariously assume the sick role with all its benefits. 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 of death are suffocation and poisoning.¹⁴ Permanent disfigurement or permanent impairment of function resulting directly from induced disease or indirectly from invasive procedures, multiple medications, or major surgery occurs in at least 8% of these children.^14,16 Other names applied include Polle’s syndrome (Polle was a child of Baron Munchausen who died mysteriously),^3,10 factitious disorder by proxy,¹⁷ pediatric condition falsification,¹⁸ and Meadow’s syndrome.²

Malingering is the simulation of disease by the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives, such as avoidance of military conscription or duty, avoidance of work, obtainment of financial compensation, evasion of criminal prosecution, obtainment of drugs, gaining of hospital admission (for the purpose of obtaining free room and board), or securing of better living conditions.2,19–21 The most common goal among such “patients” presenting to the emergency department is to obtain drugs, whereas in the office or clinic the gain is more commonly insurance payments or industrial injury settlements.²² Because of underreporting the true incidence of malingering is difficult to gauge, but estimates include a 1% incidence among mental health patients in civilian clinical practice, 5% in the military, and as high as 10 to 20% among patients presenting in a litigious context.²⁰ The most likely conditions to be feigned are mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain.²³

Clinical Features

Factitious Disorders

With a factitious disorder, the production of symptoms and signs is compulsive; the patient is unable to refrain from the behavior even when its risks are known. The behavior is voluntary only in the sense that it is deliberate and purposeful (intentional) but not in the sense that the acts can be fully controlled.² The underlying motivation for producing these deceptions, securing the sick role, is primarily unconscious.^9,24,25 Individuals who readily admit that they have produced their own injuries (e.g., self-mutilation) are not included in the category of factitious disorders.¹⁷ Presentations may be acute, in response to an identifiable recent psychosocial stress (termination of romantic relationship, threats to self-esteem), or a chronic life pattern, reflective of the way in which the person deals with life in general.²⁶ The symptoms involved may be either psychological or physical.

Psychological Symptoms

This disorder is the intentional production or feigning of psychological (often psychotic) symptoms suggestive of a mental disorder. Stimulants may be used to induce restlessness or insomnia; hallucinogens, to create altered levels of consciousness; and hypnotics, to produce lethargy. This psychological factitious condition is less common than factitious disorders with physical symptoms and is almost always superimposed on a severe personality disorder.2,17

Physical Symptoms

The intentional production of physical symptoms may take the form of fabricating of symptoms without signs (e.g., feigning abdominal pain), simulation of signs suggesting illness (e.g., fraudulent pyuria, induced anemia), self-inflicted conditions (e.g., the production of abscesses by injection of contaminated material under the skin), or genuine complications from the intentional misuse of medications (e.g., diuretics, hypoglycemic agents).²¹ These patients are predominantly unmarried women younger than 40 years. They typically accept their illness with few complaints and are generally well-educated, responsible workers or students with moral attitudes and otherwise conscientious behavior.^21,27,28 Many are in health care occupations, including nurses, aides, and physicians.

These patients are willing to undergo incredible hardship, limb amputation, organ loss, and even death to perpetuate the masquerade.²¹ Although multiple hospitalizations often lead to iatrogenic physical conditions, such as postoperative pain syndromes and drug addictions, patients continue to crave hospitalization for its own sake. They typically have a fragile and fragmented self-image and are susceptible to psychotic and even suicidal episodes.²⁷ Interactions with the health care system and relationships with caregivers provide the needed structure that stabilizes the patient’s sense of self. The hospital may be perceived as a refuge, sanctuary, or womblike environment.^4,21,24,29 Some patients are apparently driven by the conviction that they have a real but as yet undiscovered illness. Consequently, artificial symptoms are contrived to convince the physician to continue a search for the elusive disease process.²¹ Factitious illness behavior has even emerged on the Internet. “Virtual support groups” offering person-to-person communications through chat rooms and bulletin boards have been perpetrated by individuals, under the pretense of illness or personal crisis, for the purpose of extracting attention or sympathy, acting out anger, or exercising control over others.³⁰

There has been increasing recognition of factitious illness produced by children (distinct from the MSBP described later). These children, ranging in age from 8 to 18 years, are typically “bland, flat and indifferent during their extensive medical interventions . . . depressed, socially isolated and often obese.”³¹ Among the most common presentations are fever without clear etiology, diabetic ketoacidosis, purpura, and recurrent infections. The prognosis is good if identification and psychotherapeutic intervention can be carried out at a young age.³¹

Munchausen Syndrome

The uncommon patient with true Munchausen syndrome has a prolonged pattern of “medical imposture,” usually years in duration. The behavior usually begins before the age of 20 years and is diagnosed between the ages of 35 and 39 years. Twice as many men as women are affected.4,32 Patients’ entire adult lives may consist of trying to gain admission to hospitals and then steadfastly resisting discharge. Their career of imposture usually lasts about 9 years but has continued unabated for as long as 50 years.⁴ The quest for repeated hospitalizations often takes these patients to numerous and widespread cities, states, and countries.²

These individuals see themselves as important people, or at least related to such persons, and their life events are depicted as exceptional.³² They possess extensive knowledge of medical terminology. There is frequently a history of genuine disease, and the individual may exhibit objective physical findings.²⁷

The symptoms presented are “limited only by the person’s medical knowledge, sophistication, and imagination.”² The alleged illnesses involved have been termed dilemma diagnoses in that investigators rarely can totally rule out the disorder, clarify the cause, or prove that it did not exist at one time.⁴ Common presentations are those that most reliably result in admission to the hospital, such as abdominal pain, self-injection of a foreign substance,^10,11 feculent urine, bleeding disorders, hemoptysis, paroxysmal headaches, seizures, shortness of breath, asthma with respiratory failure,^4,33 chronic pain,²⁵ acute cardiovascular symptoms (e.g., chest pain, induced hypertension and syncope),³² renal colic and spurious urolithiasis,⁷ fever of unknown origin (hyperpyrexia figmentatica),^5,11 profound hypoglycemia, and coma with anisocoria.³⁴ Some self-induced conditions are highly injurious or even lethal.¹⁰

The patient usually presents during evenings or on weekends so as to minimize accessibility to psychiatric consultants, personal physicians, and past medical records.11,27 In teaching institutions these patients often present in July, shortly after the change in resident house officers.⁴ They relate their history in a precise, dramatic, even intriguing fashion, embellished with flourishes of pathologic lying and self-aggrandizement. Pseudologia fantastica, or pathologic lying, is a distinctive peculiarity of these patients. In a chronic, often lifelong behavior pattern, the patient typically takes a central and heroic role in these tales, which may function as a way to act out fantasy.³⁵ The history quickly becomes vague and inconsistent, however, when the patient is questioned in detail about medical contacts.^2,29 Attempts to manage the complaint on an outpatient basis are adamantly resisted.²⁵ Once admitted, the patient initially appeals to the physician’s qualities of nurturance and omnipotence, lavishing praise on the caregivers. Behavior rapidly evolves, however, as the patient creates havoc on the ward by insisting on excessive attention while ignoring both hospital rules and the prescribed therapeutic regimen.² When the hoax is uncovered and the patient confronted, fear of rejection abruptly changes into rage against the treating physician, closely followed by departure from the hospital against medical advice.^10,11,25

Munchausen Syndrome by Proxy

The diagnosis of MSBP depends on specific criteria (Box 114-1).¹⁴ The presenting complaints typically evade definitive diagnosis and are refractory to conventional therapy for no apparent reason.¹⁴ The symptoms are usually more than five in number, presented in a confused picture; they are unusual or serious and, by design, unverifiable. They invariably occur when the mother is alone with the child or otherwise unobserved.³⁶ In 72 to 95% of cases, simulation or production of illness occurs while the victim is hospitalized.¹⁴

BOX 114-1 Criteria for the Diagnosis of Munchausen Syndrome by Proxy