Offering Hope and Help to the Victims of ARD Worldwide

 
 
Munchausen by Internet or "Factitious Disorder"
1 Are You a Victim of...
2 Manlingering vs Munchausen
3 Dr. Marc Feldman Factitious Disorder and More!
4 Factitious Disorder by Dr. David B. Adams
5 Dr. Marc Feldman M.D.  Factitious Disorder 
6 Factitious Means Contrived
7 Munchausen by Internet
8 Support Groups for Victims of Munchausen by Internet
9 Dr. Todd. S. Elwyn: Factitious Disorder
10 Editorian Playing Sick by Dr. Feldman
11 A Strang Case of Munchausen By Internet 
Are You a Victim of Munchausen by Internet:
 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.
"I consider adhesion-related disorders and false allegations of Munchausen syndrome in my book, "Playing Sick" (available through Amazon.com).  I provide quite a compelling story of a woman with scarring from endometriosis who was labelled a Munchausen patient and denied suitable treatment as a direct result.
On the other hand, I have a full chapter on "Munchausen by Internet" that you might well find of use; it provides direction for the steps to take if someone is misusing an online health-related support group."

Best,
Marc D. Feldman, M.D.

 

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.
For those who do not want to be victimized by such folks, however sick they may or may not be, Dr. Feldman has developed a series of cues for online detection.
Some warning signs are posts that copy textbook material or other online sites verbatim, and a series of dramatic declines followed by miraculous recoveries.
Be suspicious when the person makes fantastic claims, he says, resists telephone contact, or complains that the group is not supportive enough. Be very suspicious if a "friend" or family member posts for the sick person—displaying the same writing style and spelling errors.


Munchausen by Internet Breeds a Generation of Fakers
Cybersickness
by Francine Russo
June 27 - July 3, 2001


 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.
Her husband and two children had perished in a plane crash, she wrote. As a kid, her father had molested her, and she had suffered multiple personality disorder. Finally, she told her trusted-and trusting-confidants that she had just been diagnosed with leukemia.
Gwen Grabb, a psychotherapy intern and mother of three in Los Angeles, says the group believed Anna because she took on the role of helping others, revealing her own difficulties much later, and to an intimate audience. "She was very bright," recalls Grabb. "She was very supportive and kind. One day, she started telling me about `the crash,' what they found in the black box, how you could hear her daughter screaming. I had known her a year. I believed her."
But as the tales became more elaborate and grotesque, Grabb grew suspicious. Along with another group member- Pam Cohen, a bereavement counselor in the Mid-Atlantic region - she did some research and discovered Anna was making it up. It was a shock to all, but worse than that to Cohen. "It is like an emotional rape," she says.
People may have been upset over the online life and fatal cancer of the fictional Kaycee, whose creator admitted last month she'd invented the high school character for expressive purposes.
But that was geared to a general audience, however easily suckered. Pretenders like Anna hurt a much more vulnerable group- folks who may be seriously ill and are seeking help The Internet was made for such fakers, says Dr. Marc D. Feldman, a psychiatrist at the University of Alabama at Birmingham and an expert on Munchausen syndrome and factitious disorder.
People like these, he explains, suffer from a form of Munchausen, a condition in which they either feign illness or victimization, or actually induce illness or injury in order to gain sympathy and become the center of attention. With another variation, Munchausen by
proxy, caretakers seek these rewards by making their charges sick. Cyberspace has added a new twist-one Feldman labels Munchausen by Internet.
To credibly represent themselves as ill-often with obscure and dramatic maladies-
Munchausen sufferers often study medical literature, and even go so far as to poison themselves to simulate particular symptoms. "On the Internet," Feldman explains, "it's very easy to fake. All you have to do is click and you go to another disease site. You can become an expert on anything in 30 minutes by visiting Google."

By the time Feldman published his article "Munchausen by Internet" in the Southern Medical Journal in July of last year, he'd already studied over 20 cases of cyberMunch. "The incidence is increasing rapidly," he reports.
Feldman runs his own site, and provides a link to another started this year by Cohen, (Victims of Factitious Liars). Cohen says the people who congregate at her site feel betrayed, but they understand the fakers are seriously troubled.
The irony in these Munchausen cases is that those pretending to be ill really are sick, but they rarely go to the right kind of doctor.
When confronted on the Web, they often disappear. In person, they may show some contrition even though they resist treatment. One of Dr. Feldman's first Munchausen patients was a profoundly depressed young woman who was feigning terminal breast cancer.

He hospitalized her and successfully treated her with psychotherapy and drugs. "We tell them we'll give them treatment for their emotional illness," Feldman explains, "that they don't need to be ill to see a doctor anymore."
Getting them proper treatment could prevent a lot of harm. Off-line, by some estimates, people with Munchausen and similar disorders consume as much as $20 billion annually in unnecessary medical procedures.
Those taken in by online Munchausen sufferers are often homebound. For them, the Internet is a lifeline to the outside world.. "To discover that their love and nurturing have been misdirected is like being taunted with their own illness," Feldman says. "It's devastating."
Diane Hamilton, a librarian in Cape May, New Jersey, and a migraine sufferer, brought one such case to Dr. Feldman's attention. From 1998 to 1999, a visitor posted to a long-standing migraine support group on Usenet.
He claimed to be a 15-year-old medical student. Not only did he have migraines, he said, but he also had a seizure disorder and hemophilia.
At first he won great love and approval from the group. Then his stories become more and more incredible.
His mother was deaf and his father was alcoholic and abusive. He had to skateboard three miles a day to get the bus to medical school, and he had a nightclub job as a drummer. When group members began to question his stories more and more aggressively, his "mother" signed on to say how their doubt might plunge the boy into another episode of depression. Finally, as he was met with increasing skepticism, both the "teen" and his "mother" disappeared from the site, having victimized a vulnerable group.. "Some of them had such bad migraines they had to be on Social Security disability," says Hamilton. "Others had them from head traumas from accidents. Many had been on drugs for years with no relief."
After their encounter with the fake poster, the group never recovered. It split into factions of believers and doubters, its spirit of trust and caring broken.
An even more bizarre case involved the 1997 duping of a Web-based fan club for the musical Rent. Many of the members had met while waiting on line for tickets in New York, and for them the club became a support network. Catherine Skidmore, a 26-year-old technology consultant in New York, was one of those taken in a student claiming to suffer from a fatal liver and nerve disease. 
"She showed up once with an IV shunt taped in her arm," Skidmore recalled. "And she'd go to the cast members and try to get sympathy." In this way, the woman was able to meet and have dinner with Rent stars Anthony Rapp and Gwen Stewart. When she returned to Chicago,
the group started getting e-mail from a "friend" of the woman's. The messages were full of medical jargon and day-by-day accounts of the "sick" person's condition as she slipped into a coma. "I had lost a friend who didn't tell me she was dying," says Skidmore. "So I wrote to her and said I didn't want her to be alone."
Skidmore and others in the group prayed, sent messages, and bought tickets to fly to Chicago. But whenever they were about to leave, the friend, who refused to give the name of the hospital, would write that Rachel had miraculously recovered.

Eventually, these Lazarus-like revivals aroused suspicion. Group members uncovered the hoax by calling all the hospitals in Chicago. Rapp's boyfriend, Josh Safran, was one of the fraud detectors. "I can't believe the lengths she went to. Her e-mails were very medically proficient. And everybody's lives were so messed up. It was total drama." Although Safran was skeptical early on, he hesitated to mention his doubts. "If she turned out to be sick after this, we were horrible people."

The people who perpetrate these hoaxes don't usually consider the ways they're harming others. One former Munchausen patient, a 40-year-old computer technician on the West Coast, used to hurt herself and pretend she'd been the victim of an attack or accident. "I called them 'scenarios,'" she explains. "When I'd do something to attract the paramedics and police, I got an adrenaline rush. I believe I got addicted to it. At the time, it didn't occur to me I was hurting anyone but myself."

For those who do not want to be victimized by such folks, however sick they may or may not be, Dr. Feldman has developed a series of cues for online detection. Some warning signs are posts that copy textbook material or other online sites verbatim, and a series of dramatic declines followed by miraculous recoveries. Be suspicious when the person makes fantastic claims, he says, resists telephone contact, or complains that the group is not supportive enough. Be very suspicious if a "friend" or family member posts for the sick person-displaying the same writing style and spelling errors.

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.

Paradoxically, one of the issues Cohen and Grabb must confront is that a member on their own site could be lying. "Look for inconsistencies in the story over time," Cohen advises her group. "If you become suspicious, e-mail me and let me know. For the most part, we have to take what people say at face value. But let's all be aware that we could get used and get emotionally attached to someone who is an online liar."


Manlingering vs Munchausen

Beverly J. Doucette: August 2004:
This is interesting to read as it validates the existence of this disorder and ways in which one might recognize it in someone. 

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" , Stuart J. Clayman, Ph.D.
http://www.psych9.com/Articles/Identifying_Faked_or_Exaggerat/identifying_faked_or_exaggerat.html
Identifying Faked or Exaggerated Symptoms of
Emotional Distress in Personal Injury Suits

Stuart J. Clayman, Ph.D.

Licensed Psychologist
181-4 Lake Shore Road
Brighton, MA 02135
Tel: (617) 782-8355
Fax: (617) 254-9053
E-mail: docstu@psych9.com

Psychologists have long been interested in the effect that rewards and punishments have on human behavior. Because huge rewards are potentially available in personal injury suits, the forensic psychologist understands that a personal injury litigant might try to engage in "impression management" during the psychological exam and carefully assesses the likelihood this has occurred. A personal injury litigant may, for example, exaggerate or minimize symptoms and impairments in order to obtain certain goals. This article discusses some aspects of symptom exaggeration and how it can be measured. Symptom minimization or denial of psychological symptoms can also be seen in certain types of personal injuries and will be the subject of another article. 

"Malingering" is the term psychologists and other mental health professionals use to describe "the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution or obtaining drugs" . The individual engaging in malingering is thought to be consciously aware that he or she does not have the physical or mental illness that is being presented. 

    There should be a strong suspicion of malingering if any two or more of the following are identified:
    1. Medicologal context of presentation (e.g. the person is referred by an attorney to the clinician for examination) 
    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 Factitious Disorder and More!

    http://ourworld.compuserve.com/homepages/Marc_Feldman_2/

       

      Dr. Marc Feldman's Munchausen Syndrome, Malingering, Factitious Disorder, & Munchausen by Proxy Page

      Skip to Factitious Disorders & Munchausen Syndrome. 
      Skip to Munchausen Syndrome by Proxy. 
      Skip to Obtain Books on the Subject, Including Dr. Feldman's New Book for the General Public, PLAYING SICK. 
      Skip to The Munchausen Tales. 
      Skip to Dr. Feldman's Non-Munchausen Book, "Stranger Than Fiction: When Our Minds Betray Us." 
      ATTORNEYS ONLY: Click to visit Dr. Feldman's site only for attorneys. 



      ***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 Sick"*** 
      Dr. Feldman can vouch only for the material in the links below that he has personally written. He appreciates hearing about individuals' experiences with the phenomena discussed on this page, but cannot always respond. His email address is mdf@myself.com. 



      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. 
      People with factitious disorders feign, exaggerate, or actually self-induce illnesses. Their aim? To assume the status of "patient," and thereby to win attention, nurturance, and lenience that they feel unable to obtain in any other way. Unlike individuals who "malinger," people with factitious disorders are not primarily seeking external gains such as disability payments or narcotic drugs--though they may receive them nonetheless. 
       
       
       

      · 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 SYNDROME
       

      Click for a brief overview article on the subject, "Disease or Deception? The Mystery of Factitious Disorders."

      Click for another one-page article about factitious disorders (note that treatment through long-term hospitalization is very controversial).

      Click for a medical dictionary entry on Munchausen syndrome.

      Click for the Merck Manual entry on Munchausen syndrome.

      Click for a woman's first-hand account of factitious disorder.

      Click for a brief 2002 article about Munchausen syndrome.

      Click for a site devoted to factitious psychological disorders.

      Click for a case of factitious bereavement.

      Click for an academic article about Munchausen syndrome and MSBP by Internet.

      Click for a brief article about so-called Munchausen by Internet.

      Click for a longer article from a major newspaper about Munchausen by Internet.

      Click for a report about children and adolescents with factitious disorder.

      Click for an article illustrating the international dimensions of factitious disorders.

      Click for an article about a recovered Munchausen patient.

      Click for a first-hand account about a Munchausen patient (skip to section headed "A Case of 'Munchausen'").

      Click for a brief article about factitious Cushing's syndrome.

      Click for a case report of a factitious clotting disorder.

      Click for an abstract about factitious dental problems.

      Click for an abstract about the use of aliases in factitious disorder.



      Factitious Disorder by Dr. David B. Adams

      Factitious Disorder
      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.


      http://www.psychological.com/factitious_disorders.htm

      Atlanta Medical Psychology 
      The clinical practice of Dr. David B. Adams is located in The Medical Quarters in the northside of Atlanta at the junction of Scottish Rite, Northside and Saint Joseph's Hospitals. Dr. Adams consults to occupational medicine, surgeons, nurse case managers, insurers and employers regarding the psychological impact of work-related injury and the role of psychological factors in short- and long-term disability.

      FACTITIOUS

      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 only).

      · Questions from the general public must be submitted through the Discussion Group

      · Telephone: 404.252.6454

      Mail: 
      Atlanta Medical Psychology
      The Medical Quarters - Suite 251, 
      5555 Peachtree-Dunwoody Rd, N.E., 
      Atlanta, GA 30342-1703



      Dr. Marc Feldman M.D.  Factitious Disorder

      Factitious Disorders (and more!)

      Disease or Deception? The Mystery of Factitious Disorders - Marc D. Feldman, M.D.

         Factitious disorder

      "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
      accordingly; e.g., factitious disorder with psychological symptoms (also called pseudopsychosis); factitious disorder with physical symptoms (also called M?nchhausen syndrome). Distinguish from somatoform disorder where the symptoms are not produced 'voluntarily' and are not under the control of the individual." 

          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 DISORDER
      Marc D. Feldman, M.D.

      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. 
      Jenny's boyfriend announced he was leaving her: he had fallen in love with another woman and was moving out. Horrified and adrift, with no one to call on for comfort, Jenny chose a remarkable way out of her loneliness. She mobilized an instant support network by showing up at work one day and announcing, "I've just been diagnosed with breast cancer. And it's too late. It's terminal." 
      It was also a lie. Jenny had found a remarkable and desperate way to mobilize an instant support network of sympathetic co-workers. Eventually she enrolled in a breast cancer support group, shaved her head to mimic the effects of chemotherapy, and dieted to lose 50 pounds all to keep the illusion alive. 
      Jenny was suffering not only from a broken heart, but from an emotional ailment called "factitious disorder." People with factitious disorder feign or actually induce illness in themselves, typically to garner the nurturance of others. In bizarre cases called "Munchausen syndrome by proxy," they even falsify illness in another person (such as their own children) in order to garner attention and sympathy for themselves as the heroic caregiver. 
      Desperate? Of course. Yet more common than you might think. Experts estimate that one percent of hospitalized patients are faking their ailments. The medical bills in one case alone amounted to $6 million. Clearly factitious disorders are sapping an already-burdened health care system. 
      They also defy the imagination. Patients have bled themselves into anemia and then showed up at a doctor's office stating they haven't a clue about how they became so ill. Others have secretly taken laxatives to induce diarrhea, or mimicked seizures so convincingly that neurologists hospitalized them on the spot. 
      The good news: this phenomenon is finally coming out of the closet. In recent months, newspapers, magazines, and TV news programs have all described cases of factitious disorder, helping both health professionals and the general public to become aware. At the same time, factitious disorder patients are recognizing that, twisted as their behavior may seem even to themselves, help is available. 

      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. 
      The first step for factitious disorder patients is to realize they cannot go it alone. Though this is a hurdle they inevitably find intimidating, they simply must reach out to a therapist. The therapist can help them realize why the feigned illnesses began in the first place: why had the need for sympathy become so intense? The therapist can also discover underlying emotional problems--as in Jenny's case--that must be treated at once, and also provide the very caring these patients had previously had to go to extremes to elicit. Finally, the therapist can help teach the patient ways to get needs met without resorting to self-defeating, and even literally self-destructive, actions. 
      Families who suspect that a loved one has factitious disorder are invariably hungry for education about it. Consulting with a knowledgeable professional or reading about the disorder are important steps to take before they actually confront the patient. Heavy-handed, punitive confrontation doesn't work. Instead, we now know that factitious disorder is among the trickiest of psychological ailments to address, and intervention must be informed, carefully planned, and, above all, humane. 
      5/30/98 
      Marc D. Feldman, M.D is the co-author of "Patient or Pretender: Inside the Strange World of Factitious Disorders" (1994) and co-editor of "The Spectrum of Factitious Disorders" (1996).



      Factitious Means Contrived

      Healthinmind/Mental Health Disorders

      http://www.healthinmind.com/english/factittxt.htm

      Factitious Disorders
      "Factitious" literally means "contrived," and the meaning could hardly be more apt. People with factitious disorder are great con men or con women, although what they obtain through their conning most people would far rather not have. They fake either mental disorders or physical disorders - two specific types of factitious disorder - or a mixture of the two, which qualifies them for the third classification, Facititious Disorder With Combined Psychological and Physical Signs and Symptoms. Finally, there is the usual "Not Otherwise Specified" category, which includes people who concoct symptoms in others, typically children, so that the concocter can assume the sick role by proxy.

      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:
      Patient or Pretender:  Inside the Strange World of Factitious Disorders by Marc D. Feldman, Charles V. Ford
      Marc D. Feldman, M.D. is the co-author of "Patient or Pretender: Inside the Strange World of Factitious Disorders" (1994) and co-editor of "The Spectrum of Factitious Disorders" (1996). 



      Munchausen by Internet

      by Marc D. Feldman
      Online Support for People with Illness 
       
       

      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.
       
       

      Clues to Detection of False Claims
      Online Support for People with Illness

      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.

        LESSONS
      Perhaps the most important lesson is that, while most people visiting support groups are honest, all members must balance empathy with circumspection. Group members should be especially careful about basing their own health care decisions on uncorroborated information supplied in groups. When Munchausen by Internet seems likely, it is best to have a small number of established members gently, empathically, and privately question the author of the dubious posts. Even though the typical response is vehement denial regardless of the strength of the evidence, the author typically will eventually disappear from the group. Remaining members may need to enlist help in processing their feelings, ending any bickering or blaming, and refocusing the group on its original laudable goal.

      References: Feldman, M.D. (2000): Munchausen by Internet: detecting factitious illness and crisis on the Internet. Southern Journal of Medicine, 93, 669-672
      Feldman, M.D., Bibby, M., Crites, S.D. (199  :
      "Virtual" factitious disorders and Munchausen
      by proxy. Western Journal of Medicine, 168, 537-539
      Feldman, M.D., Ford, C.V. (1995): Patient or Pretender: Inside the Strange World of Factitious Disorders. New York, John Wiley & Sons




      Support Groups for Victims of Munchausen by Internet

      http://www.healthcentral.com/News/NewsFullText.cfm?ID=38731&storytype=ReutersNews

                    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.

      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.
      For those who do not want to be victimized by such folks, however sick they may or may not be, Dr. Feldman has developed a series of cues for online detection.
      Some warning signs are posts that copy textbook material or other online sites verbatim, and a series of dramatic declines followed by miraculous recoveries.
      Be suspicious when the person makes fantastic claims, he says, resists telephone contact, or complains that the group is not supportive enough. Be very suspicious if a "friend" or family member posts for the sick person—displaying the same writing tyle and spelling errors.

      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
      http://www.healthcentral.com/News/NewsFullText.cfm?ID=38731&storytype=ReutersNews

      Victims of factitious liars
      http://health.groups.yahoo.com/group/victimsoffactitiousliars/

      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 truthisbest@yahoo.com. Please describe briefly how you were duped and why you would like to join. 

      Thank you in advance.

      Post message: SurvivingAfterBetrayal@yahoogroups.com
      Subscribe: SurvivingAfterBetrayal-subscribe@yahoogroups.com
      Unsubscribe: SurvivingAfterBetrayal-unsubscribe@yahoogroups.com
      List owner: SurvivingAfterBetrayal-owner@yahoogroups.com





      Dr. Todd. S. Elwyn: Factitious Disorder


      Synonyms and related keywords: Munchausen syndrome, Munchausen's syndrome, Munchausen syndrome by proxy, Munchausen's syndrome by proxy, FD, factitious illness, pseudologia fantastica, Ganser syndrome, narcissism, sociopathy, somatoform illnesses, malingering, somatization disorder, conversion disorder, hypochondriasis, pseudocyesis, pain disorder, body dysmorphic disorder, major depression, delusional disorder, somatic delusions

        AUTHOR INFORMATION  Section 1 of 10 

      Author: Todd 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, John A Burns School of Medicine, University of Hawaii 
      Todd S Elwyn, MD, is a member of the following medical societies: American College of Legal Medicine, American Medical Association, American Psychiatric Association, and Phi Beta Kappa

      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 

        INTRODUCTION  Section 2 of 10 
      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 care. 
      · The motivation for the perpetrator’s behavior is to assume the sick role by proxy. 
      · External incentives for the behavior (such as economic gain) are absent.
      · The behavior is not better accounted for by another mental disorder.

      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. 
      Frequency:

      • In the US: The prevalence of FD is unclear. Many authorities believe the condition is underdiagnosed because it involves willful deception, which may be missed by medical staff. Conversely, the prevalence of chronic FD may be overdiagnosed in some cases because the same patients with FD may migrate from hospital to hospital. The frequency of presentation of various factitious illnesses (eg, which factitious illnesses are most common) is unclear. However, most researchers agree that the prevalence of factitious psychological symptoms is much lower than the prevalence of factitious physical symptoms. Studies investigating the prevalence of FD have found the following: 
      • Of patients referred for evaluation of fever of unknown origin at the US National Institute for Allergy and Infectious Disease, 9.3% had FD. 
      • Of material submitted by patients as kidney stones, 2.6% was found to be nonphysiologic and probably fraudulent. 
      • Internationally: Whether the epidemiology of FD differs in countries other than the US is unclear. 
      • Of patients referred to the consultation-liaison service of a large teaching hospital in Toronto, 0.8% (10 of 128  had FD. 
      • Of infants brought to a clinic in Australia because of serious illness, 1.5% were cases of FD by proxy.
      Mortality/Morbidity: FD can result in morbidity and mortality from the patient's re-creation of actual medical conditions (eg, exogenous administration of insulin) or from the procedures undertaken by the physician to diagnose or treat the condition (eg, unnecessary cardiac catheterizations, surgeries). No studies have quantified the total estimated morbidity and mortality from FD. 
      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 presence of the following factors may raise the possibility that the illness is factitious:o Dramatic or atypical presentation 
        • Vague and inconsistent details, although possibly plausible on the surfaceo Long medical record with multiple admissions at various hospitals in different cities 
        • Knowledge of textbook descriptions of illness 
        • Admission circumstances that do not conform to an identifiable medical or mental disorder 
        • An unusual grasp of medical terminology 
        • Employment in a medically related field 
        • Pseudologia fantastica (ie, patients’ uncontrollable lying characterized by the fantastic description of false events in their lives) 
        • Presentation in the emergency department during times when obtaining old medical records is hampered or when experienced staff are less likely to be present (eg, holidays, late Friday afternoons)
      • Other clues that may arise during the course of treatment include the following:
        • A patient who has few visitors despite giving a history of holding an important or prestigious job or one that casts the patient in a heroic role
        • Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
        • Acceptance, with equanimity, of the discomfort and risk of surgery
        • Substance abuse, especially of prescribed analgesics and sedatives 
        • Symptoms or behaviors only present when the patient is being observed 
        • Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
        • Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
        • Giving approximate answers to questions (eg, a horse has 3 legs; 7 X 6 = 41), usually occurring in FD with predominantly psychological signs and symptoms (see Ganser Syndrome)
      Physical: Suspicion of FD is raised when the patient has multiple surgical scars or a gridiron abdomen, indicating the chronic form of FD, or with evidence of self-induced physical signs. 
      • Mental Status Examination: Patients with FD may vary in their presentation, and no findings have been shown to be pathognomonic. The following findings are possible:
        • Appearance may include physical findings described above.
        • Attitude may range from cooperative with assessment and treatment to evasive and vague regarding details. 
        • Mood and affect may be brighter than what would be expected given the patient's medical condition.
        • Perceptual abnormalities, such as hallucinations and disturbances of thought process or thought content, and suicidality and/or homicidality, may be present with FD with predominantly psychological signs and symptoms. Patients having FD with predominantly physical signs and symptoms usually do not confess to thoughts of harming themselves or others, even when they have actually harmed themselves by deliberately inducing physical illness.
        • Cognitive functioning may be aberrant if the patient presents with Ganser syndrome.
    • Causes: 

    • · 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:
      • Underlying masochistic tendencieso A need to be the center of attention and to feel important 
      • A need to assume a dependent status and receive nurturance
      • A need to ease feelings of worthlessness or vulnerability
      • A need to feel superior to authority figures (eg, the physician) that is gratified by being able to deceive the physician
    • Explanations offered for FD by proxy parallel those for FD, except that the parent is using the children to meet these needs. Thus, the child is used as a tool with which to recreate unresolved issues with parents and authority figures.
      • Alternatively, the mother is presumed to gain vicarious satisfaction of attention and nurturance needs that may be missing from her marriage through projective identification.
      • Another explanation asserts that the behavior stems from narcissism, sociopathy, and the desire to manipulate authority figures.
    • The risk factors for developing FD remain largely unclear. Based on the histories of patients with FD, the following can be projected as characteristics that may predispose an individual to develop a factitious illness:
      • Presence of other mental disorders or medical conditions in childhood or adolescence that resulted in extensive medical attention
      • Holding a grudge against the medical profession or having had an important relationship with a physician in the past
      • Presence of a personality disorder, especially borderline, narcissistic, or antisocial personality disorder 
    DIFFERENTIALS  Section 4 of 10 
      Delusional Disorder 
      Depression
      Schizophrenia 

      Other Problems to be Considered: 
      FD appears in the differential diagnosis for many illnesses. Accordingly, FD must be distinguished from true or real general medical conditions or mental disorders, including those that are (1) due to accident or chance, (2) due to noncompliance with treatment, (3) iatrogenic, or (4) the result of attempted suicide, homicide, or self-mutilation.

      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: 

    • Somatization disorder (ie, multiple physical complaints over many years)
    • Conversion disorder (ie, defects in sensory or motor functioning having a psychological origin)
    • Hypochondriasis (ie, preoccupation with imagined disease or illness)
    • Somatoform disorder not otherwise specified (eg, pseudocyesis)
    • Pain disorder (ie, severe pain in which psychological factors have a strong component)
    • Body dysmorphic disorder (ie, intense preoccupation with a real or imagined defect in appearance)
    With somatoform disorders, the production of the symptoms of illness is not intentional, and the motivation for illness is unconscious. In FD, symptoms are produced intentionally but for unconscious reasons. In malingering, symptom production is intentional and conscious to achieve an external incentive beyond assuming the sick role (eg, evading the police, obtaining compensation, getting a bed for the night). In practice, determining whether an external incentive exists is sometimes difficult.

    The differential diagnosis for FD by proxy includes the following possibilities:

    • Real medical illnesses
    • Overanxious parenting
    • Normal variability between illnesses
    • Illnesses resulting from discontinuation of medicines
    • Malingering (by an older child)   Patients with other psychiatric diagnoses can also present with somatic preoccupation that is not supported by findings from physical examination, laboratory testing, or imaging. 
    Patients with major depression with psychotic features and delusional disorder (somatoform type) can present with somatic delusions. Associated features of these conditions should facilitate the differential diagnosis. 

      WORKUP  Section 5 of 10 

    Lab Studies: 

    • The diagnosis of FD is typically made late, after other diagnostic possibilities have been exhausted. Laboratory studies can be especially helpful in facilitating the diagnosis of many physical illnesses as factitious.
      • For example, patients with hypoglycemia can be assessed for exogenous insulin injection by a finding of increased serum insulin/C-peptide ratio (>1.0) during a hypoglycemic episode.
      • Similarly, patients who complain of kidney stones can be asked to filter their urine for stones, and the submitted material can be tested for composition.
      • A tissue biopsy can be helpful in revealing the factitious nature of lesions in which foreign material has been injected to simulate naturally occurring disease.
    • Because the range of factitious illnesses is limited only by the imagination of the perpetrator, listing all possible laboratory tests that might prove useful is impossible. However, suspicion that an illness is factitious should be conveyed to the pathologist, who may be helpful in identifying ways to confirm the diagnosis. 

    •  

       
       


      TREATMENT  Section 6 of 10 

      Medical Care: Provide medical care as needed to treat comorbid conditions and complications arising from induced illness. 

    • Psychiatric care
      • Patients with FD must be evaluated fully and assessed for comorbid axis I and axis II diagnoses. By treating axis I disorders, improvement or resolution of factitious behavior may also occur.
      • Pharmacotherapy must be monitored carefully to prevent patients from perpetuating self-destructive behavior. Medications to treat the symptoms of personality disorders, such as selective serotonin reuptake inhibitors (SSRIs) to reduce impulsivity, may be of benefit.
      • Psychotherapy should focus on establishing and maintaining a relationship with the patient. Supportive psychotherapy may help contain the symptoms of FD. 
      • Family therapy may help families to better understand patients and their need for attention.
      • Cognitive-behavioral therapy may prove difficult when patients are unable to form a collaborative team, such as with comorbid antisocial personality disorder.
    Surgical Care: Provide surgical care as needed to treat comorbid conditions and complications arising from induced illness. 
    Consultations:
    • Psychiatrists
      • Obtaining a psychiatric consultation is recommended when the practitioner believes an illness is possibly factitious. 
      • Health care providers should work as a team, together with nursing, social work, and legal personnel. 
      • The patient should be gently confronted with the team’s suspicions in a supportive manner that focuses on the patient’s psychological distress as the source of illness. 
      • Psychiatric treatment should be offered to the patient. 
      • The patient with FD will probably try to split the team, and this is a danger for the psychiatric consultant who attempts to establish a therapeutic relationship with the patient. Accordingly, some authorities feel that therapy should not be attempted with patients who have FD unless they can make a good-faith showing of desire for therapy. 
      • Patients who are confronted typically deny that they have manufactured disease, although a few admit it. 
      • Patients with the chronic form of FD typically become angry and discharge themselves from the hospital to try to perpetuate their illness elsewhere. 
      • A few patients with FD consent to psychiatric treatment.
    • Where FD by proxy is suspected, the law requires physicians to notify the authorities and to initiate steps for the immediate protection of the child.
      • Protection may involve removal of the child from the home, at least until the situation can be completely assessed. 
      • Once protective measures are in place, the mother should be confronted with the evidence. She will almost certainly deny the charge and will attempt to remove the child from the hospital.
      • Criminal prosecution of the perpetrator may also be necessary. 
      • Evaluation should not be limited to the child involved but should also include his or her siblings.
      • Psychotherapy should be offered to the mother, the affected children, and the family.
      • Pharmacotherapy may be appropriate when the mother has comorbid axis I or axis II conditions that are amenable to treatment.
      • The family requires careful long-term monitoring, especially because of the danger that the mother could move her family and seek to perpetrate such behavior in a new location. Advertisement


      MEDICATION  Section 7 of 10 

      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 

    Further Inpatient Care:
    • Further inpatient care may be required if patients relapse. This includes treatment of any medical or surgical conditions and psychiatric hospitalization when necessary.
    Further Outpatient Care: 
    • Close psychiatric follow-up care and monitoring in the outpatient setting is indicated to prevent relapse. Close medical follow-up care may also be necessary, depending on the condition.

    •  
    Transfer:
    • Transfer from the medical floor to an inpatient psychiatric department is indicated if patients agree to treatment. In rare cases, involuntary hospitalization may be possible if the patient's health is jeopardized severely by continued production of factitious illness (eg, the patient has already lost a kidney because of FD and is in danger of losing another).
    Deterrence/Prevention:
  • Deterrence and prevention involve clear documentation of patients with a known history of FD, although it does not involve blacklisting.
    Complications:
  • Complications may arise from the induction of factitious illness or arise iatrogenically from the workup or treatment for the condition, in addition to producing high health care costs.

  •  

     
     
     
     
     

    Prognosis: 

  • Chronic FD appears to follow an unremitting course. Treatment may transiently ameliorate symptoms but does not appear to last.
  • Patients with simple FD follow a more variable course. Some of those who seek treatment may be able to overcome their illness. In any event, simple FD appears to remit in the fourth decade of life.

  •  

     
     
     

    Patient Education:

  • The patient confronted with staff suspicions that the illness is factitious may be unreceptive to attempts at patient education. Still, education should be attempted in the same gentle and supportive manner with which the patient is confronted. If the patient has given permission, educating family members about the patient's condition may also be helpful. Education as to risks of noncompliance with treatment recommendations is also important, ethically and legally, because the patient may wish to sign out against medical advice.
  • Education
    • Convey empathy for the patient's distress that has led to the feigning or intentional production of illness. 
    • Inform the patient that his or her distress may improve with treatment. 
    • Point out that without treatment, the patient may again seek hospitalization. 
    • Emphasize that each episode of producing or feigning illness can result in significant morbidity or even mortality for the patient through the production of illness or the undergoing of unnecessary tests or treatments.
  • If the patient is receptive to psychiatric treatment, patient education may be an important component of psychotherapy. Information from this article or other sources may be used to help the patient understand more about his or her illness, including the presumed origins of factitious behavior and the importance of regular follow-up care with the psychiatrist.
    •  


      Editorian Playing Sick
      by Dr. Feldman

      "Munchausen by Internet"

    I consider adhesion-related disorders and false allegations of Munchausen syndrome in my book, "Playing Sick" (available through Amazon.com).  I provide quite a compelling story of a woman with scarring from endometriosis who was labelled a Munchausen patient and denied suitable treatment as a direct result.  On the other hand, I have a full chapter on "Munchausen by Internet" that you might well find of use; it provides direction for the steps to take if someone is misusing an online health-related support group.
       
    Best,
    Marc D. Feldman, M.D.
     

    Playing Sick?: Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering,and Factitious Disorder
    by Marc D. Feldman

    Editorial Reviews
    Book Info
    Taken from cases from real patients, text addresses the impact of phony illnesses, factitious disorders, and Munchausen syndrome on patients and caregivers. Provides clues for helping practitioners and family members for recognizing these disorders, avoid invasive procedures, and sort out possible motives. DNLM: Munchausen Syndrome. 

    Book Description
    When a person fakes illness or injury to satisfy emotional needs, doctors and family members are lured into a costly, frustrating, and potentially deadly web of deceit.
    Taken from bizarre cases of real patients, Playing Sick? is the first book to chronicle the devastating impact of phony illnesses--factitious disorders and Munchausen syndrome--on patients and caregivers alike.

    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. 


    http://paris-kim.com/potholes/munch.htm

    A Strange Case of Munchausen
    by Internet

    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): 

    • The posts consistently duplicate material in other posts, in books, or on health-related websites. 
    • The characteristics of the supposed illness emerge as caricatures. 
    • Near-fatal bouts of illness alternate with miraculous recoveries. 
    • Claims are fantastic, contradicted by subsequent posts, or flatly disproved. 
    • There are continual dramatic events in the person's life, especially when other group members have become the focus of attention. 
    • There is feigned blitheness about crises (e.g., going into septic shock) that will predictably attract immediate attention. 
    Others apparently are posting on behalf of the individual (e.g., family members, friends) have identical patterns of writing.

    To these I will add one more: 

    • When dramatic announcements are made (threats of suicide, claims of rape, etc.) that would normally elicit much concern, the reaction from others is much less than you would expect. 


    In my experience, if you suspect someone is faking, others do, too. But often, the only sign they give is not replying to the faker's posts. In this case, I thought I was the only one who suspected. But I found out later that the perpetrator had been in trouble on other lists for fakery, even been kicked off one. Some people had recognized what was going on years before I had, and had left the list in disgust because they got sick of the constant B.S.

    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:
    the constant, and constantly escalating, drama. That will always be the giveaway.



     
     
       
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