Factitious Disorders and Malingering

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. Factitious disorders have been present throughout history. In the second century, Galen described Roman patients inducing and feigning vomiting and rectal bleeding. Hector Gavin sought to categorize this behavior in 1834. 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. Of patients referred to infectious disease specialists for fever of unknown origin, 9.3% of the disorders are factitious. Between 5 and 20% of patients observed in epilepsy clinics have psychogenic seizures, and the number reaches 44% in some primary care settings. Among patients submitting kidney stones for analysis, up to 3.5% are fraudulent. Munchausen syndrome, the most dramatic and exasperating of the factitious disorders, was originally described in 1951. 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. The diagnosis applies to only 10 to 20% of patients with factitious disorders. 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. 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. There are approximately 1200 estimated new cases of MSBP per year in the United States. The condition excludes straightforward physical abuse or neglect and simple failure to thrive; mere lying to cover up physical abuse is not MSBP. 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%. Children who die are generally younger than 3 years, and the most frequent causes of death are suffocation and poisoning. 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. Other names applied include Polle’s syndrome (Polle was a child of Baron Munchausen who died mysteriously), factitious disorder by proxy, pediatric condition falsification, and Meadow’s syndrome. 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. 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. 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. The most likely conditions to be feigned are mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain.