Second edition

07.qxd 3/10/08 9:35 AM Page 302
302 Other major syndromes
7.8 MALINGERING AND FACTITIOUS ILLNESS
Both malingering (LoPiccolo et al. 1999) and factitious illness
(Krahn et al. 2003) are characterized by the intentional
feigning of illness; they are distinguished from one
another by the motive underlying this behavior. In malingering
the motive is readily understandable, as for example
when someone complains of a ‘bad back’ to get out of work
or to obtain narcotics. In factitious illness, however, the
motive is a little more obscure, in that the goal of these
individuals is merely to be a patient in the hospital, and to
assume, as it were, the ‘sick role’.
Before making a diagnosis of malingering or factitious
illness, one must be reasonably certain that there is no true
underlying illness that could reasonably account for the
individual’s complaints. Furthermore, one must also distinguish
malingering and factitious illness from conversion
disorder, Briquet’s syndrome, and hypochondriasis; these
differential possibilities are distinguished by the lack of any
associated intentionality and by the lack of any recognizable
‘goal’. Thus, in the case of ‘paralysis’, the malingerer
and the individual with factitious illness both consciously
and intentionally feign weakness, with the goal, respectively,
of either an understandable gain (e.g., winning a
lawsuit) or of simply being a patient on the neurologic
ward. By contrast, in the case of, say, conversion disorder,
the ‘paralysis’ simply appears, without any planning or
intention on the part of the patient, and persists despite
there being no advantage to the patient.
Malingering
Some malingerers may limit their dissimulation to simply
voicing more or less convincing complaints. Others may
take advantage of an actual illness, and embellish their
symptoms out of all proportion to the actual underlying
disease or condition. Some may go so far as to actually
stage an accident or inflict a wound and then go on to exaggerate
their effects. Falsification of medical records may
also occur.
Neurologic, psychiatric, and rheumatologic illnesses are
often chosen as models. Malingerers may complain of
headaches, anesthesia, paralysis, ‘whiplash’, and pain, especially
low back pain. Depression, post-traumatic stress disorder,
and psychosis may also be feigned. A peculiar form
of malingering may be seen in prisoners awaiting trial or
sentencing, known as the ‘Ganser syndrome’ (Carney et al.
1987; Tsoi 1973). Also known as the ‘nonsense syndrome’,
this is characterized by ‘nonsense’ responses to questions,
which are always just off the mark or past the point. For
example, if the individual is asked to add 5 plus 3, he may
respond ‘7’; with coaching and encouragement he may give
other responses, such as ‘6’ or ‘9’, but never the correct one.
In a similar vein, if asked how many legs a horse has, the
response may be ‘3’. Typically, although these individuals
appear confused and dazed, they are generally able to find
their way around the jail and to do those things that are necessary
to maintain a certain degree of comfort and safety.
All in all, these individuals are acting out the ‘popular’ conception
of ‘insanity’, and once the trial is over, or the sentence
imposed, this ‘insanity’ clears up quickly.
Several features may alert the physician to the possibility
of malingering. First, look for obvious gains should the
individual be certified as ‘ill’, such as obtaining insurance
payments or narcotics, or winning a lawsuit. Second, be
alert to inconsistencies in the clinical presentation. In this
regard, when neurologic complaints are heard, the diagnostic
tips discussed in the Section 7.7 for conversion disorder
may be kept in mind. Third, be suspicious when patients
are uncooperative with treatment, or when the offering of a
good prognosis is met with thinly veiled hostility.
In doubtful cases, obtaining collateral history may be
very helpful. For example, if, on interviewing the spouse of
an individual who complains of incapacitating back pain,
one gathers a history that the ‘patient’ spends his weekends
playing volleyball, the diagnostic evaluation is essentially
complete. Laboratory testing may be helpful, as for example
neuroimaging in cases of feigned paralysis; however,
most malingerers tend to feign illnesses that lack distinctive
laboratory findings.
What the physician should do, once it becomes clear
that malingering is present, is not clear. Some advocate a
simple, but non-judgmental, discussion of the facts, and
indeed some malingerers may respond favorably to this.
Most, however, will not and indeed may become even
more demanding or hostile. Regardless of what approach is
taken, however, it is important to ‘do no harm’, and in this
regard, one should not prescribe narcotics, certify nonexistent
illnesses, or do anything else that reinforces the
patient’s deception.
Factitious illness
The illnesses feigned here tend to be severe, as might be
expected, given that the goal of the dissimulation is admission
to the hospital. Typically, the patient arrives at the
emergency room with a very convincing presentation (Reich
and Gottfried 1983). Some may complain of several episodes
of severe chest pain, suggesting crescendo angina. Others
may report having had a ‘seizure’, and even bite their tongue
to make the picture more convincing. Others may swallow
blood and then vomit, thus simulating hematemesis,
whereas others may hold the blood in their mouths and then
cough, producing a picture of hemoptysis. A urine specimen
may be contaminated with feldspar to mimic renal calculi,
or with feces to suggest a severe urinary tract infection. More
malignantly, feces may be injected to create a septic picture.
Laxatives may be taken to induce diarrhea, furosemide to
create hypokalemia, myelosuppressants to mimic aplastic
anemia, thyroid hormone to produce hyperthyroidism, and
either insulin or oral antidiabetic agents to produce hypoglycemia
and raise the question of an insulinoma; in this last