Offering Hope and Help to the Victims of ARD Worldwide
1 Are You a Victim of...
This type of behavior has been found to exist in our realm, and given the nature of our own chronic suffering with Adhesion Related Disorder and desperation for approval and support, we too could fall into the category of victimization by a person, or persons, who exhibit "Munchausen by Internet"
Having spoken to Dr. Feldman, Bev Doucette feels
that this needs to be brought to the forefront for those who live life
with profound chronic illness.
Over nearly three years, from 1998 to 2000, a woman- let's call her Anna- posted to an online support group for people with mental illness.To the larger circle of readers, she acted mostly as friendly counselor. But to a select few, she e-mailed stories of escalating catastrophes.
The treatment for the support-group fakers is psychotherapy. The treatment for their victims is...another support group. Victims of Factitious Liars already has 42 members who post regularly about their own victimization and brainstorm about how to get publicity and funding to treat Munchausen. Cohen and Grabb are hoping to make a documentary on the Munchausen phenomenon and have recently received a substantial contribution from an individual donor.
2. Marked discrepancy between the person's claimed stress or disability and the objective findings
3. Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen
4. The presence of Antisocial Personality Disorder
Antisocial Personality Disorder (in the past referred to as "psychopathy" or "sociopathy") can raise concern about the possibility of malingering since deceitfulness is identified in the DSM-IV as a cardinal feature of this disorder.
There is another class of disorders that can be confused with malingering: Factitious Disorders. A Factitious Disorder is also characterized by "the intentional production of physical or psychological signs or symptoms" , but differs from malingering in that the motivation for the symptom production in Factitious Disorder is to assume the sick role rather than to obtain the external incentives which are the hallmark of malingering. A factitious disorder may involve a self-induced injury and tends to imply more genuine psychopathology than malingering since the "secondary gain" (external incentive) is absent or much less noticeable. Overholser traces the historical development of factitious disorder and suggests some ways of differentiating malingering and factitious disorders. He reports, for example, that most malingerers are seen on an outpatient basis while factitious disorder is often seen on an inpatient service, that malingerers seem "agreeable" while those with factitious illness are "belligerent" and that the primary source of motivation is "external" in malingerers and "internal" in those with factitious disorder. Overholser notes that another writer, Asher, first suggested this syndrome and named it in honor of Baron Hieronymus Karl Friederich von Munchausen, an 18th century nobleman noted for his ability to tell exaggerated stories. In 1968, Spiro defined a broader category of problems as "factitious illness", which includes Munchausen's Syndrome.
How often do plaintiffs fake or exaggerate emotional distress in personal injury suits. This figure is not known with certainty. Mental health professionals who study faking offer widely varying estimates of how often malingering occurs. In an article appearing in the journal OCCUPATIONAL HEALTH AND SAFETY, W. Donald Ross cites a Washington state survey which revealed that only one of one million claims were actually self-inflicted injuries being masqueraded as work injuries. He concluded that "True malingering is rare". G. G. Hay, in his review of the simulation of mental illness , estimated that five out of about 12,000 admissions to a South Manchester hospital were believed to be faking a psychosis, a rate of less than 1/20th of a percent. In a more recent study, Paul Lees-Haley found that only one of 64 personal injury claimants scored in the significant range on two different measures of malingering and he remarked upon "the large number of forensic patients who scored lower than one might imagine (on indices of faking) from a population that often is characterized as disturbed, making a cry for help, or exaggerating emotional distress" . Simon, in his 1995 book Posttraumatic Stress Disorder in Litigation, states that "The incidence of malingered psychiatric symptoms after injury is unknown". He cites estimates of occurrence of malingering by other experts that range from 1% to over 50%. Simon goes on to differentiate "pure malingering-the feigning of disease when it does not exist at all" from "partial malingering-the conscious exaggeration of existing symptoms or the fraudulent allegation that prior genuine symptoms are still present".
Various strategies have been suggested as aids in the detection of malingering. Huddleston, for example, recommended a technique to use with military men which involved depriving the soldier of books, tobacco and friends since this would often result in an improvement of faked symptoms. Other authors have suggested studying the eyes for signs of shiftiness or "wavering" In more recent times, drugs have been utilized to attempt to identify the faker. But, studies have shown that subjects can continue to deceive during amobarbital interviews. And, according to Hall and Pritchard, a hypnotic state does not guarantee against faking either.
Modern psychology offers some behavioral cues which might be useful in detecting malingering. Freud suggested that liars make more "slips of the tongue" than those telling the truth. Others have suggested that liars blink their eyes more often than truth tellers, that liars' pupils are more dilated and DePaulo has said that nervous people and introverts are less successful as liars. But DePaulo goes on to say that many of these behaviors, which appear to be associated with level of anxiety, are not consistently associated with faking.
Several clinical strategies have been employed in an attempt to differentiate between the individual with a genuine psychological disorder and one who is faking or malingering. Among these are observation or videotaping of the suspected malingerer, a technique apparently employed by insurance companies, interviews without using psychological tests, a method sometimes used by psychiatrists, and formal psychological testing. Schretlen, in his excellent review of the use of psychological tests to identify malingering of sychological disorders, concludes that research supports psychological testing as a method of differentiating between genuine and feigned mental problems but research demonstrating that the psychiatric interview by itself can be used in this way is lacking.
Many psychological tests have been examined with respect to their ability to help identify malingering. Schretlen, in the same review article, mentions a few including the MMPI-2, the Rorschach test and the Bender Gestalt test. But there is controversy about the reliability and validity of the Rorschach and Bender Gestalt and some investigators feel this severely limits their usefulness in forensic settings.
The Minnesota Multiphasic Personality Inventory (MMPI-2) is "the most widely used and researched objective personality inventory". It may also be the psychological test most often used in the assessment of malingering of mental disorders. The MMPI, originally developed in the early 1940s by Hathaway and McKinley, was re-standardized in 1989, re-named the MMPI-2. The MMPI-2 consists of 567 true-false items which are grouped into Validity scales, which measure "test-taking attitudes", and Clinical scales which measure various aspects of personality and psychological symptoms. It has been referred to as the "gold standard" in the psychometric assessment of malingering.
The MMPI/MMPI-2 has been used in several different ways to detect malingering. Early on, Gough looked at ways the validity scales of the MMPI could be utilized to identify malingering. He reported in his 1950 study that the raw score on Validity Scale F minus the raw score on Validity Scale K (F-K) was quite useful in detecting "over reporting" profiles, those MMPI profiles in which examinees exaggerated their mental problems. Many studies of the usefulness of F minus K as a means of detecting malingering have subsequently been done and the consensus seems to be that this formula is accurate in distinguishing faked from normal profiles but is less accurate in distinguishing faked profiles from profiles of examinees with actual mental illness (Schretlen, 1988). Research continues into the best way to use the F minus K formula to measure faking.
Validity Scale F by itself has also been used to detect malingering. Berry and Baer looked at the combined data from more than 25 studies which examined how well MMPI validity scales could detect overreporting of psychological symptoms. The best indicator of faking was the F scale; F minus K was somewhat less effective. But investigators learned that random reporting (in addition to faking and real mental problems), also had the effect of elevating the F scale. A method was needed for differentiating between random responding and exaggeration of symptoms. With the re-standardization of the MMPI known as the "MMPI-2", VRIN (variable response inconsistency) and TRIN (true response inconsistency) were introduced. VRIN consists of special MMPI-2 items which can be used to rule out random responding. TRIN can be used to identify a different type of inconsistent responding.
As promising as some of these MMPI-2 Validity Scales are in the detection of malingered symptoms of mental disorders, efforts continue to improve their predictive power. For example, since much of the research database supporting the use of the MMPI-2 in personal injury work comes from scientific studies in medical and mental health outpatient settings, and from actual forensic assessments, more MMPI-2 data is needed from scientific studies of actual personal injury litigants. Research also continues into techniques that can improve the forensic psychologist's ability to understand personal injury litigants. For example, Paul Lees-Haley, who often publishes research studies of malingering, described a "credibility scale" for assessing personal injury claimants . Lees-Haley also combined existing MMPI-2 test items into a new "fake bad" scale for use, specifically, with personal injury claimants.
CONCLUSIONS: It is safe to say there is no method of detecting malingering
of emotional distress symptoms that is 100% accurate in all settings. Many
forensic psychologists believe, and I agree, that the best procedure currently
available for identifying faked symptoms of emotional distress in legal
settings is to use multiple sources of information. Good psychological
practice requires that these would include behavioral observations, psychodiagnostic
interviews, review of medical and psychological records, performance data
(such as school grades and work performance reviews) and psychological
test procedures specifically designed to measure faking. Gathering the
data needed for this kind of evaluation will ordinarily require several
meetings between the forensic psychologist and the lawyer's client. The
Validity scales of the MMPI-2 can be very powerful tools for assessing
the likelihood of faking in personal injury settings. But MMPI-2 test results
must be interpreted in combination with various other forms of data when
making such important judgments.
Dr. Marc Feldman's Munchausen Syndrome, Malingering, Factitious Disorder, & Munchausen by Proxy Page
Skip to Factitious Disorders & Munchausen Syndrome.
***Dr. Feldman's newest book, PLAYING SICK,
is NOW AVAILABLE for order at a big discount. It covers all the topics
dealt with on this page. Find it at Amazon.com by searching for "Playing
I am a psychiatrist and author from Birmingham,
Alabama. MUNCHAUSEN SYNDROME is the most severe and chronic form of my
area of specialty, the FACTITIOUS DISORDERS. I am an expert in MALINGERING
as well (in which people do the same thing, but for external gain such
as narcotics). Factitious disorders are well-recognized among psychiatrists,
but they have not received the attention--or advocacy among consumers,
families, and professionals--that have greeted more common ailments such
as depression. However, factitious disorders can be every bit as disabling
and further public and professional education are vital.
· In "MUNCHAUSEN SYNDROME BY PROXY" (MSBP), an individual makes another person sick in order to accrue the same gains--but this time vicariously. This is a form of abuse in which children are the usual victims.
FACTITIOUS DISORDERS, INCLUDING MUNCHAUSEN
Atlanta Medical Psychology
Factitious is not synonymous with fictitious. Factitious is not the same as the act of malingering. Malingering does not constitute a mental disorder; factitious disorder does constitute impaired psychological functioning. Factitious Disorder involves voluntary amplification or production of physical and psychological symptoms due to internal motivation, an unconscious need to maintain oneself in the role of patient.
Factitious disorders are considered mental disorders and fall within the province of those psychological conflicts which warrant treatment. For complex reasons, the patient suffering from factitious disorder needs to be perceived as injured or ill in order to meet underlying, chiefly unconscious, needs.
Patients with factitious disorder will willfully submit to painful, dehumanizing and even dangerous diagnostic and therapeutic procedures in order to meet these unconscious needs. In medical clinics, it is not unusual to find patients who have undergone multiple invasive procedures designed to treat conditions or disease processes which were found not to exist.
By contrast, patients who are malingering are consciously aware of not only their acts but also of their motives. They feign symptoms in order to secure financial remuneration, to avoid demands made upon them, to escape responsibility or to deliberately control the behavior of others.
Patients with factitious disorders will present with psychological and/or physical complaints and will work vigorously to maintain themselves in the patient role and to secure the attention, affection and special considerations our society affords those who are validly ill.
There are clinical reports of mothers who have harmed their own children in order to secure for themselves the role of life-saver and/or life protector. This vicarious living-through the patient role created for their victimized children is also a form of factitious disorder.
· E-Mail: (for patients and referral sources
· Telephone: 404.252.6454
Factitious Disorders (and more!)
"An umbrella term for any psychological or psychiatric disorder the
symptoms of which are voluntarily produced; factitious disorders are feigned
and the disabilities displayed are simulated. Usually, however, this classification
does not include malingering, in which the illness is claimed for a particular
purpose; in a factitious disorder there seems to be no obvious aim other
than to play the 'patient role.' These disorders are often classified by
patterns of symptoms and referred to
The Penguin Dictionary of Psychology, © Arthur S. Reber
And more! (not necessarily "factitious", but one wonders....)
In my archives of over 100,000 e-mails, I have a lot of gems of alt. med. weirdness, deceit, libel, etc. I intend to occasionally post some of them here. The archives of the Dr Clark list contain some real doozies!
I'll start with some of the tamer ones, believe-it-or-not! The worst ones (in "The Bolen Files"**) may well see the light of day at some "appropriate" time . . . . ! (** Many thanks to those who continually supply me with copies of Bolen e-mails which they have received or run across.)
The following mail from the Dr Clark list speaks for itself. I take no responsibility for the ideas presented here. . . . ;-) Normally I would protect the author by disguising the source, but since the author made it a condition not to do so . . . !
Now just how many red flags (quack ideas) can you count? Copy the following
to an e-mail in HTML format and mark the red flags with red. Count them
and send me
the mail with your comments! I'll just start with a few examples below,
but some of them may be as links.
DISEASE OR DECEPTION? THE MYSTERY OF FACTITIOUS
Jenny (a pseudonym) was one of those "invisible"
people we all know and overlook each day. A secretary for a manufacturing
company, Jenny was as a diligent employee, but one who hadn't developed
many friends at work. Nevertheless, she seemed to find all the companionship
she needed in her relationship with her live-in boyfriend. Week in and
week out, her world seemed never to change, and yet she seemed satisfied.
Then one day everything, suddenly and quietly, fell apart.
In Jenny's case, the ruse of cancer came crashing
down when the leaders of the breast cancer support group discovered that
she had lied about her medical care. Referred for psychiatric care, Jenny
revealed feelings of overwhelming depression, and this deep depression
had fueled her factitious behavior. Treated with antidepressant medication
and psychotherapy, Jenny ended her illness portrayals and moved on--decisively--with
her life. She has never resorted to factitious illness again.
People with Factitious Disorder (FD) are not pretending to be sick in order to gain benefits external to the disorder, for example, to get insurance money. Thus they differ from malingerers, who are dishonest but do not have a mental disorder. People with FD are such expert liars that the syndrome has been called "Munchausen syndrome" in honor of a German baron who was a famous liar. In this respect FD patients share characteristics with people who have Antisocial Personality Disorder
People with FD are willing and eager to pay for their symptoms by having unnecessary tests, treatments, and operations. They may become expert in producing the symptoms of disorders, expert enough in many cases to con physicians and surgeons into treating them or operating on them for nonexistent maladies, or mental health professionals into treating them for imaginary disorders. The person with FD thus appears to the outsider to share characteristics with masochists, in that they arrange to cause pain to themselves. Maxmen and Ward1 report that one person with FD had over 420 documented hospitalizations. Further, they note that the state of Washington saved $100,000 per patient per year by installing a tracking system that identified patients with FD and prevented them from being repeatedly admitted to hospitals for treatment.
Patients with FD vehemently deny that they are faking symptoms, and they do not seek, or willingly accept, treatment from mental health professionals. Nevertheless, Maxmen and Ward1 warn examiners not to assume that there are no physical problems co-occurring with the FD. Also, they suggest that the patients be kept in the hospital and placed in long-term treatment with a mental health professional, despite the small likelihood that the FD will be cured. If a child is being victimized by a parent who concocts symptoms for the child, the child should be protected through admission to the hospital. In these cases, the diagnosis given to the parent is Munchausen Syndrome by Proxy, a type of child abuse.
Read a book on the subject:
Munchausen by Internet
The Internet is a medium of choice for millions of people who need health-related information. Medical websites have multiplied exponentially over the past several years. Thousands of virtual support groups have sprung up for those suffering from particular illnesses. Whether formatted as chat rooms, as newsgroups, or in other ways, they offer patients and families the chance to share their hopes, fears, and knowledge with others experiencing life as they are. These online groups can counter isolation and serve as bastions of understanding, deep concern, and even affection.
For decades, physicians have known about so-called factitious disorder,
better known in its severe form as Munchausen syndrome (Feldman & Ford,
1995). Here, people willfully fake or produce illness to command attention,
obtain lenience, act out anger, or control others. Though feeling well,
they may bound into hospitals, crying out or clutching their chests with
dramatic flair. Once admitted, they send the staff on one medical goose
chase after another. If suspicions are raised or the ruse is uncovered,
they quickly move on to a new hospital, town, state, or in the worst cases
— country. Like traveling performers, they simply play their role again.
I coined the terms "virtual factitious disorder" (Feldman, Bibby, &
Crites, 199 and "Munchausen
by Internet" (Feldman, 2000) to refer to people who simplify this "real-life"
process by carrying out their deceptions online. Instead of seeking care
at numerous hospitals, they gain new audiences merely by clicking from
one support group to another. Under the guise of illness, they can also
join multiple groups simultaneously. Using different names and accounts,
they can even sign on to one group as a stricken patient, his frantic mother,
and his distraught son all to make the ruse utterly convincing.
Detection of False Claims
For decades, physicians have known about so-called factitious disorder, better known in its severe form as Munchausen syndrome (Feldman & Ford, 1995). Here, people willfully fake or produce illness to command attention, obtain lenience, act out anger, or control others. Though feeling well, they may bound into hospitals, crying out or clutching their chests with dramatic flair. Once admitted, they send the staff on one medical goose chase after another. If suspicions are raised or the ruse is uncovered, they quickly move on to a new hospital, town, state, or in the worst cases — country
Like traveling performers, they simply play their role again. I coined the terms "virtual factitious disorder" (Feldman, Bibby, & Crites, 199 and "Munchausen by Internet" (Feldman, 2000) to refer to people who simplify this "real-life" process by carrying out their deceptions online. Instead of seeking care at numerous hospitals, they gain new audiences merely by clicking from one support group to another. Under the guise of illness, they can also join multiple groups simultaneously. Using different names and accounts, they can even sign on to one group as a stricken patient, his frantic mother, and his distraught son all to make the ruse utterly convincing.
Based on experience with two dozen cases of Munchausen by Internet, I have arrived at a list of clues to the detection of factititous Internet claims. The most important follow:
1. the posts consistently duplicate material in other posts, in books, or on health-related websites;
2. the characteristics of the supposed illness emerge as caricatures;
3. near-fatal bouts of illness alternate with miraculous recoveries;
4. claims are fantastic, contradicted by subsequent posts, or flatly disproved;
5. there are continual dramatic events in the person's life, especially when other group members have become the focus of attention;
6. there is feigned blitheness about crises (e.g., going into septic shock) that will predictably attract immediate attention;
7. others apparently posting on behalf of the individual (e.g., family members, friends) have identical patterns of writing.
Support Groups for Victims of Munchausen by Internet
Some online support group users fake illness
July 27, 2000
NEW YORK (Reuters Health) - Online support groups can offer an emotional lift to people suffering from a range of illnesses. But they can also attract healthy interlopers looking for attention rather than support, one psychiatrist says.
Although most people who participate in Internet support groups are genuine, sometimes "our heart strings can be tugged for malicious reasons," Dr. Marc D. Feldman of the University of Alabama at Birmingham told Reuters Health.
In the July issue of the Southern Medical Journal, he reports on four cases of what amounts to a "virtual" version of the mental illness Munchausen syndrome. People with Munchausen syndrome feign illness in order to undergo medical treatment. In the case of people who target online support groups, the goal is to be the center of the group's attention.
Online support groups allow people to post messages to each other, sometimes seeking or offering advice but more often simply sharing their experiences. Feldman said he was alerted to the problem of support group imposters by messages to his own Web site on Munchausen syndrome and related conditions.
Because people go into online support groups "with unabashed trust," he said, they are often devastated to find out that a member was dishonest. While Feldman does not want to discourage people from turning to virtual support groups, he said the public should be aware that a "tiny fringe element" misuses the groups.
In one case Feldman describes in his report, a woman claiming to have a baby with cystic fibrosis posted messages to a parents' support group and eventually informed members that her daughter had died. Another mother, however, realized the woman's posts were full of inaccuracies on the illness and its treatment. She alerted other members, and the suspicious woman's posts ended abruptly.
Inaccurate or inconsistent posts are a key warning sign that a support group member may be less than genuine, according to Feldman.
"We also find that they have extreme deteriorations (in their health) followed by miraculous recoveries that just don't ring true," Feldman said.
Besides the emotional toll imposters exact, he noted, some offer group members medical advice that is at best misleading and at worst "dangerous."
The treatment for the support-group fakers is psychotherapy!
The treatment for their victims is...another support group. Victims
of Factitious Liars already has 42 members who post regularly about their
own victimization and brainstorm about how to get publicity and funding
to treat Munchausen.
This type of behavior has been found to exist in our realm, and given
the nature of our own chronic suffering with Adhesion Related Disorder
and desperation for approval and support, we too could fall into the category
of victimization by a person, or persons, who exhibit
Victims of factitious liars
This is a group for people who haven been affected by adults with Factitious Disorder, formerly known as Munchausen Syndrome. If you have been affected by someone with this illness and would like to join this group please write a brief letter to email@example.com. Please describe briefly how you were duped and why you would like to join.
Thank you in advance.
Post message: SurvivingAfterBetrayal@yahoogroups.com
Dr. Todd. S. Elwyn: Factitious Disorder
AUTHOR INFORMATION Section 1 of 10
S Elwyn, MD, Staff Physician, Department of Psychiatry, University
of Hawaii Coauthor(s): Iqbal
Ahmed, MD, Program Director, General and Geriatric Psychiatry Residency
Programs, Vice Chair for Education, Professor, Department of Psychiatry,
A Burns School of Medicine, University of Hawaii
Editor(s): Sarah C Aronson, MD, Associate Professor, Departments of Psychiatry and Medicine, University Hospitals of Cleveland; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories; Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry, Assistant Professor, Department of Medicine, Froedtert Hospital, Medical College of Wisconsin; and Stephen Soreff, MD, Director of Quality Improvement, President of Education Initiatives, HMA Behavioral Health, Inc
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography
Background: Few patients are more challenging and troublesome to busy clinicians than those with factitious illnesses. The term factitious disorder (FD) refers to any illness deliberately produced or falsified for the sole purpose of assuming the sick role. Patients waste valuable time and resources with lengthy and unnecessary tests and procedures at a cost, according to one estimate, of $40 million per year. Moreover, patients with FD often generate feelings of anger, frustration, or bewilderment in the physician. These patients violate the following unwritten rules of being a patient 1) patients should provide a reasonably honest history; (2) symptoms result from accident, injury, or chance; and (3) patients hold the desire to recover and cooperate with treatment toward that end.
FDs likely have always been present throughout history and have appeared in the literature since the time of the Roman physician Galen, who wrote about them in the second century. In the 1800s, the British physician Gavin described how some soldiers and seamen pretended illness to excite compassion or interest.
The modern history of FD begins in 1951, when Asher described case reports of patients who habitually migrate from hospital to hospital, seeking admission through feigned symptoms while embellishing their personal history. He assigned the name Munchausen syndrome to this condition after Baron von Munchausen, a well-respected, retired German cavalry officer who had tales of his life stolen and parodied in a booklet in 1785. Persons with Munchausen syndrome were said to typically (1) exhibit numerous surgical scars, especially abdominal surgical scars, (2) display a truculent or evasive manner, (3) provide a dramatic medical history of questionable veracity, and (4) attempt to conceal such documents as hospital discharge forms or insurance claims. Asher distinguished abdominal, hemorrhagic, and neurologic subtypes.
Since the publication of Asher's article, numerous reports of patients producing or falsifying almost every conceivable kind of illness have appeared in the literature. The type of patient described by Asher is now thought to represent a minority of cases of FD. The term Munchausen syndrome most appropriately refers to the subset of patients who have a chronic variant of FD with predominantly physical signs and symptoms. In practice, however, many still use the term Munchausen syndrome interchangeably with FD. In 1976, the term Munchausen syndrome by proxy entered the medical lexicon and came to describe cases in which an individual artificially produces illness in another person, typically a mother who produces illness in a young child.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) requires that the following 3 criteria be met for the diagnosis of FD 1) intentional production or feigning of physical or psychological signs or symptoms, (2) motivation for the behavior is to assume the sick role, and (3) absence of external incentives for the behavior (eg, economic gain, avoiding legal responsibility, improving physical well-being, as in malingering).
The DSM-IV recognizes the following 3 types of FD 1) FD with predominantly psychological signs and symptoms, (2) FD with predominantly physical signs and symptoms, and (3) FD with combined psychological and physical signs and symptoms.
A fourth type, FD not otherwise specified, includes those disorders with factitious symptoms that do not meet the criteria for FD. The DSM-IV places FD by proxy (ie, Munchausen syndrome by proxy) into this category, defining it as "the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care for the purpose of indirectly assuming the sick role." FD by proxy has yet to be recognized as an official separate category in the DSM-IV. Appendix B of the DSM-IV lists the following research criteria for FD by proxy.
· FD by proxy is the intentional production or feigning of physical
or psychological signs or symptoms in another person who is under the individual’s
Pathophysiology: As with many psychiatric illnesses, the pathophysiology
of FD is unclear. Case reports of abnormalities on MRIs of the brains of
patients with chronic FD suggest that brain biology may play a role in
some cases. In addition, some patients with FD have displayed abnormalities
on psychological testing. Results of EEG studies have thus far been nonspecific.
Sex: Persons with FD are usually female and employed in medical fields such as nursing or medical technology. Working in the medical field provides knowledge of how disease might be produced artificially and provides access to equipment (eg, syringes, chemicals) with which to do so.
· Persons with chronic FD (ie, Munchausen syndrome) tend to be unmarried men who are estranged from their families.
· Perpetrators of FD by proxy are typically mothers who induce illness in their young children; however, sometimes fathers or others are responsible.
Age: Persons with FD tend to be women aged 20-40 years. Persons with chronic FD (ie, Munchausen syndrome) tend to be middle-aged men.
CLINICAL Section 3 of 10
History: Patients may feign illness by means of a factitious history alone (eg, falsely claiming to have had a syncopal episode), by a factitious history plus the use of external agents that mimic disease (eg, adding exogenous blood to urine and claiming hematuria), or by a factitious history plus inducing an actual medical condition (eg, injecting bacteria to produce infection, ingesting CNS-active medications to induce psychiatric symptoms). Detection of FD is typically slowed by the natural tendency among physicians to believe what patients say. Indeed, this tendency may be even greater because many patients with FD work in the health care field and are colleagues.
· The causes of FD are not well defined. One psychodynamic explanation asserts that patients with FD, who often have a background of neglect or abandonment, are attempting to reenact unresolved early issues with parents. The following explanations are also possible:
Other Problems to be Considered:
FD must also be distinguished from the somatoform illnesses and malingering. FD has been believed to fall on a continuum between these illnesses.
Somatoform disorders include the following conditions:
The differential diagnosis for FD by proxy includes the following possibilities:
WORKUP Section 5 of 10
TREATMENT Section 6 of 10
Medical Care: Provide medical care as needed to treat comorbid conditions and complications arising from induced illness.
No medications are shown to be efficacious in treating FD per se. However, pharmacologic therapy for concurrent psychiatric diagnoses is indicated.
FOLLOW-UP Section 8 of 10
Marc D. Feldman, M.D.
Playing Sick?: Untangling the Web of Munchausen Syndrome,
Munchausen by Proxy, Malingering,and Factitious Disorder
Psychiatrist Marc Feldman describes patients' strange motivations, from malingerers who invent chronic back pain to avoid work to mothers who demand major abdominal surgery for their healthy children because they derive perverse pleasure from medical attention. Self-induced bleeding, fake fevers, and even a bogus asthma attack so convincing that doctors rush the patient to ICU are the stock in trade of patients with these disorders. Practitioners are deeply disturbed by these patients, angry about the time and resources they consume but nervous about confronting them with the truth.
Based on years of research and clinical practice, Playing Sick? provides
the clues that can help practitioners and family members recognize these
disorders, avoid invasive procedures, and sort out the motives that drive
people to hurt themselves and deceive others. With insight and years of
hands-on experience, Feldman shows how to get these emotionally ill patients
the psychiatric help they need.
Awhile back, I was planning to go home to Hawaii for the holidays. The owner of one of my mailing lists lived in Hawaii, and I wanted to get together with him while I was there. He said he was a doctor, so I decided to find out what hospital he worked at, to see if it was convenient to where I would be staying. I didn't want to admit to him that I didn't remember which hospital he worked at, so I looked up his e-mail address, figuring it might be connected to his work. It sounded like it might be a professional domain, but it wasn't. Instead, it resolved to MailCity (a free e-mail provider, like Hotmail). Okay, fine. I went to the AMA website, which lists every doctor in the U.S., whether they are members of the AMA or not. But there was no doctor by his name licensed to practice in Hawaii. In fact, according to Google there was no one with his last name at all, anywhere in the world.
Okay, maybe he wasn't using his real name to post online. That's not unusual. But then he posted a photo of himself to the list. And it looked so fake. It looked like a yearbook photo, scanned in, with the eyes and hair visibly Photo shopped to match his description. And it was very awkwardly cropped - probably to disguise the fact that it was a photo of a boy in an ordinary white shirt, rather than a picture of a doctor in a white coat. And then I remembered that his "friend," a person on the list who claimed to know him in real life, was a digital artist.
I started to think back. A lot of the things this person had said in the past struck me as being, well, unlikely. He claimed to be half Japanese and half German, yet had blue-green eyes and jet-black hair. That is extremely improbable. White/Asian marriages are common in Hawaii, and the kids invariably have brown eyes and brown hair. It's close to impossible for someone who is half-Japanese to have blue eyes. Dark eyes are dominant, and most Japanese have no recessive genes for blue eyes, as dark-eyed Caucasians might.
Then there was his extreme defensiveness, if he thought anyone was questioning his expertise. He'd say things like "I know better than you, I'm a doctor." That struck a wrong note, because, in my experience, people who really do have credentials don't feel the need to flaunt them that way. The more you learn, the more you realize how little you really know.
Most tellingly, there was the fact that his life was so dramatic. That's a key sign of what some have dubbed "Munchausen by Internet." His mother died of cancer when he was a child. His father abused him. He was raped in his apartment, and then again, in the parking lot of the hospital where he supposedly worked. He threatened to kill himself if he didn't pass his exams. His cousin was hit by a car on his birthday. Despite the fact that a few days before Christmas the cousin was on death's door, he recovered enough that he was home by Christmas. His friend donated bone marrow to two people (when I've been in the database for ten years, and haven't been called once). He saved a Russian mail-order bride from a botched abortion. And much more. Taken all together, it just didn't seem likely.
At this point, you're probably thinking I'm a complete idiot for not catching on earlier. Especially since I've run into this kind of faker before. But in fandom, there's a tendency to trust. To take people at face value. It's different if you're selling on eBay, or vetting potential dates on Match.com. Then, you're cautious, because you know people are trying to get something from you. But a Munchausen's sufferer wants only your attention, so it often doesn't occur to you to be suspicious. I realized that some of the things the "doctor" was saying were improbable, but I thought he was just exaggerating. It didn't occur to me that it was all completely made up.
One of the reasons the ruse was so successful was the clever use of sock puppets. He seemed to have a lot of real-life friends, who surely would have said something if he wasn't on the up-and-up. They posted from different e-mail addresses, and seemed to have different styles. (One was supposedly Japanese, and used broken English.)
But after that obviously faked photo was posted, I decided to check the headers. Though his female friend and male cousin had different e-mail addresses and supposedly lived in different countries, their posts originated from the same source. They were, I was sure, the same person. Now I knew why, during online chats, one of them would always have to leave just before another of them arrived.
So who was real? The doctor,the friend, or the cousin? The list had an official web site and domain name, so I looked up who the official owner was. It was the friend. The doctor and cousin were the sock-puppets. I had been talking to fictional characters for the past three years.
It seemed so bizarre I could hardly credit it. And yet, there was no other explanation. It was an extreme case of Munchausen syndrome: a psychological problem where people pretend to be ill (or claim their children or friends are ill) in order to garner sympathy and attention.
I had run across these Internet fakers several times before, though nothing as long or elaborate as this. When I first got online, I "met" a young woman who claimed to be a vet, and offered me all kinds of advice about my cat and my tropical fish. She got cancer, slowly declined, then died. We wanted to send flowers, and maybe attend the funeral, and got her ISP to contact her family for us. To our shock, her parents said there was no funeral. She wasn't dead, she wasn't even sick. At least not physically. She'd pulled this kind of "pretend death" several times before, and was in therapy, but every time life got stressful, she'd do it again.
And the Internet is the ideal place for a Munchausen sufferer. With the click of a button, you can find out all kinds of information, to help you pose as anyone you want. People don't expect to see you in person or even talk to you except by e-mail, making deception easier. And often, mailing lists, message boards, etc., will give unqualified support to their members.
So what did I do? Nothing, at first. It was weird, but didn't seem all that harmful. In fandom, people often play role-playing games, or post under pseuds. This just seemed like an extreme exaggeration of something that's commonly accepted in fandom. And I didn't want to make trouble on the list. So I didn't say anything to anyone. I tried not to reply to the doctor's and cousin's posts, only to the friend's. I wanted to encourage her to be herself. I thought that might persuade her to give up the lies and the sock puppets.
Of course, that was futile. She was an amazingly talented person: good at art, writing, technology, language, etc. She could have been a star of fandom if she weren't always pretending to be someone else. But it wasn't enough. It never is, for Munchausen's sufferers. Just as an anorectic can never be thin enough, a Munchausen's sufferer can never get enough attention.
Five months later, I decided I couldn't keep quiet any longer. The "doctor" announced that he had cancer, and was likely to die. That was too much; people were getting really upset, and for no reason. It wasn't right for people to be losing sleep over this drama. He didn't have cancer, and he wasn't dying...because he didn't exist.
I e-mailed the co-moderator of the list with my suspicions. I was very nervous about how she would react, but she agreed with me. She'd suspected the same thing for a long time. She posted a message exposing the deception to the list, and I supported her. We were both kicked off, of course. I also forwarded the warning to a related list. Not everyone there was pleased at the disruption, but I felt it was my duty to warn people. I had previously encouraged people, many of them newbies, to join the first list, not realizing it was an invitation to The Twilight Zone.
For similar reasons, I'm posting the bizarre story here. Munchausen's by Internet is extremely common in fandom - far more common than most people realize. Here are the warning signs (borrowed from Marc Feldman's article):
To these I will add one more:
I thought long and hard about posting this article. Revealing how I
figured out the fakery might actually help Munchausen's sufferers carry
out their fraud. But no matter how careful they are, they can't hide the
most telling clue:
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