Factitious Disorders and Malingering
Lucy A. Epstein
Theodore A. Stern
Few situations are as perplexing and frustrating to the emergency department (ED) physician as caring for the patient who deliberately creates his or her symptoms, as occurs in factitious disorders or malingering. Patients with factitious illness create medical or psychiatric symptoms for primary gain, defined by the desire for the “sick role” (1). Patients who malinger feign symptoms for secondary gain, which is often material reward (such as disability payments) (1). These situations are particularly challenging because they violate an unspoken, but assumed, contract of trust between doctor and patient. These disorders are diagnoses of exclusion; each presentation mandates a full medical evaluation. They can arise in the context of true medical illness (e.g., a patient with chronic pain may also malinger to obtain opiates) and can result in significant physical injury (e.g., by deliberate self-harm) (2). The cornerstone of safe management in the ED involves ruling out medical emergencies, offering psychiatric assistance when indicated, setting clear limits of care, thoroughly documenting the process of evaluation and management, and managing intense countertransference reactions toward these patients.
PRESENTING CLINICAL FEATURES
Factitious Illness
CASE
A 25-year-old man is flown via med-flight to a tertiary care center from a community hospital, where he had told staff that he had Ehlers-Danlos syndrome and was having an aortic dissection. Upon arrival to the ED, he clutches his chest, states that he is in severe pain, insists to the surgical team that he needs immediate surgery, and hands the staff a set of chest radiographs, which he states is from a prior evaluation. After he is told that his vital signs, physical exam, repeat chest radiograph, and chest computerized tomographic scan are unremarkable, he refuses to sign a release to obtain old medical records and leaves against medical advice, insisting that the ED physicians are incompetent.
Presentations can vary widely, including an inconsistent history, falsified laboratory results, or deliberate self-injury (3). Any organ system can be involved, and the results can be life threatening (e.g., a patient who surreptitiously injects insulin and develops profound hypoglycemia [4]). Table 25.1 lists selected examples from the literature. A patient may also present with psychiatric complaints, such as false reports of suicidal ideation, homicidal ideation, or psychosis (5,6). Munchausen syndrome, characterized by peregrination, pseudologia phantastica (embellishment of tales regarding symptoms), and feigning of illness, is a particularly severe form of factitious illness (7). It was named after Baron von Munchausen, an 18th century Prussian officer who wandered from tavern to tavern, recounting tall tales of his exploits (8). Emergency psychiatrists who work with pedia-tric patients should also be on the alert for Munchausen syndrome by proxy, a condition in which a caregiver generates a factitious illness in his or her child.
TABLE 25.1 Selected Presentations of Factitious Illness | ||||||||||
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Unfortunately, it is difficult to estimate the true incidence of factitious illness. Presentations often go unrecognized, and physicians may be
hesitant to document the diagnosis in the official medical record (8,9). Anecdotal evidence has suggested that the prototypical patient is young and female (and may have had some training in health care), but highly variable demographics have been noted (2,9). Patients commonly present to emergency settings, where the physician who treats them may not be familiar with their recurrent reports of symptoms. They may present late at night, when the ED is likely to be staffed with fewer (and perhaps less experienced) personnel (10). Such patients may present with a narrative that contains detailed medical terminology that unravels under close examination (9,10,11,12). Moreover, they are often vague and evasive. They may have had an extensive history of medical procedures (with scars to prove it) and may seem oddly undaunted by the prospect of painful or invasive procedures (10). They appear to lead itinerant lives, with few close contacts and little social support (10).
hesitant to document the diagnosis in the official medical record (8,9). Anecdotal evidence has suggested that the prototypical patient is young and female (and may have had some training in health care), but highly variable demographics have been noted (2,9). Patients commonly present to emergency settings, where the physician who treats them may not be familiar with their recurrent reports of symptoms. They may present late at night, when the ED is likely to be staffed with fewer (and perhaps less experienced) personnel (10). Such patients may present with a narrative that contains detailed medical terminology that unravels under close examination (9,10,11,12). Moreover, they are often vague and evasive. They may have had an extensive history of medical procedures (with scars to prove it) and may seem oddly undaunted by the prospect of painful or invasive procedures (10). They appear to lead itinerant lives, with few close contacts and little social support (10).
Malingering
CASE
A 37-year-old woman presents to the ED with anxiety, stating that her clonazepam prescription had been stolen. She provides a vague story that does not correspond with the information provided in the electronic medical record. The record makes note of several visits to her primary care provider (PCP) requesting early refills for multiple “lost” prescriptions. When the psychiatrist mentions her visits to her PCP, the patient’s eyes widen and she says, “You mean you can see what I have said to other doctors?” She then adds, “Never mind, I have to go” and quickly terminates the encounter.
Malingering is neither an axis I nor an axis II psychiatric disorder. However, it can be a common reason for psychiatric consultation when the patient’s complaint appears inconsistent with medical or psychiatric illness (8). Typical features of malingering include a vague and unverifiable history, a history of medicolegal involvement, and symptoms that do not correlate with objective findings (10). Unlike the patient with factitious illness, a patient who is malingering may be uncooperative with objective tests or invasive procedures and may leave before such tests are undertaken. Malingering is associated with antisocial personality disorder (characterized by a lack of empathy, by lying, and by a flagrant disregard for social norms) and with substance dependence (10).
IMMEDIATE INTERVENTIONS FOR ACUTE PRESENTATIONS
As with all other patients who present with somatic symptoms, it is essential to rule out acute and serious illness. Thus, all medical and psychiatric symptoms need to be fully investigated, with particular attention paid to ruling out life-threatening causes of symptoms (such as myocardial infarction or pulmonary embolism).
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