Dying to Be Ill
The Book Brigade talks to psychiatrist Marc Feldman.
Posted June 28, 2018
All humans need the attention and support of others. Some go to unusual lengths to get it—by feigning a medical illness. Some go so far as to use their children or pets as proxies.
What led you to write a book about fake disorders?
I have been fascinated by factitious disorder (FD)—better known as Munchausen syndrome—since I encountered my first FD patient more than 25 years ago. The patient was a self-professed “terminal breast cancer patient” who had told everyone at her workplace that she had metastatic cancer, all in the pursuit of attention and sympathy that she felt unable to get in any other way. She finally confessed after the leaders of her breast cancer support group developed suspicions and confirmed that she had never seen any of the doctors she claimed were treating her. They referred her to me for an emergency psychiatric appointment, and I admitted her to the hospital, where treatment was effective. My report of this befuddling case in a medical journal led to an unexpected book deal, and I published my first book on the subject in 1993. I have since written three other books on the subject and remain dedicated to these patients.
Is this a common problem? Is it increasing or changing in any way?
The American Psychiatric Association says that around one percent of all patients admitted to general hospitals are feigning, exaggerating, or self-inducing their illnesses. That makes it uncommon, but still with important public health implications, considering the costs of the misguided treatments of these patients. With the advent of “Munchausen by Internet” (MBI), people are using social media to make false claims of illness and accrue emotional gratification as a result. Because of the easy access to the Internet by patients with deep unmet psychological needs, I think MBI is making the overall phenomenon more common.
How do you get to be an expert in factitious disorders?
I became an expert by trying to read most of the professional literature on the subject, and talking and meeting with other experts. In 1996, I set up my first Munchausen.com website, and have received innumerable comments and inquiries from affected patients, family members, and professionals since then. The patients and families have been the best source of learning, and I do my best to help them as much as I can.
What are some of the kinds of ways people feign or even intentionally create illness?
Perhaps the most common mechanism is to falsely report signs and symptoms. For instance, a person—as I have described already—may falsely report cancer or other serious disease. Others go further and enact medical signs such as seizures, which some can fake convincingly. They might have an authentic ailment—such as a small laceration—that they deliberately worsen to force more medical treatment, or inject themselves with bacteria to create a condition that is literally life-threatening. The range of medically deceptive behaviors is limited only by people’s motivation, knowledge, and creativity.
Why would a parent shave a child’s head to tell others that the child is suffering from cancer?
This is called “Munchausen by proxy,” though it is increasingly being called “medical child abuse” (MCA), which is a term that laypeople can understand more easily. The motivations for MCA are often similar to those in FD—a misguided search for sympathy and nurturance. Unlike FD, however, MCA usually involves victimizing a child, who is helpless to resist the abuse. Thus, it is a recognized form of maltreatment and is obviously against the law. However, such cases seem not to be prosecuted as often as they should be.
Munchausen by animal proxy! It’s astonishing. Please describe it and how it shows up.
In Munchausen by animal proxy (MBAP), the victim of the medical deceptions is a pet—usually a dog, cat, or horse. MBAP involves a human caregiver’s faking or inducing illness in the pet, and then soliciting sympathy and veterinary attention as if he or she has no idea why and how the pet became sick. It is a form of animal maltreatment, but is probably rarely recognized. Veterinarians seem not to receive any training on the subject, so I decided to devote a full chapter to the subject in my book.
Is there a pattern to the kind of illnesses that people fake?
The illnesses most people fake are serious, dramatic, and attention-grabbing. In the original 1951 description of Munchausen syndrome, Dr. Richard Asher described people who collapsed in “pain,” had apparent vomiting of blood, and so on. These are the sorts of ailments that will lead to priority care, whether in an emergency department, doctor’s office, or hospital. Other patients opt for apparently chronic, disabling illnesses that will get them attention for a long period of time. Sometimes they carry out their deceptions for so long that those around them begin to wonder how they are able to survive despite such serious medical conditions, and that might be the first clue that FD is afoot.
Are there specific psychological qualities that lead people to falsely insist they have a medical illness?
A majority of these patients have personality disorders that lead them to behave in ways that are ultimately self-destructive. Clearly, lying about illness always has the potential to backfire and alienate those who have been deceived, but the patients lack more effective coping mechanisms to get their needs met.
Using a child to bear the burden of a parent’s illness is bad enough—but to use a child to bear the burden of a fake illness seems unimaginable—and a form of child abuse. What is going on in such cases?
It is not generally illegal to “steal” someone’s attention and sympathy by faking illness in oneself, but it is always illegal to use another person’s body to do so. MCA perpetrators treat their children, or other victims, as “objects” to be manipulated for their own gain, rather than individuals to love and for whom to care. Like FD patients, they tend to have serious personality disorders and lack appropriate ways to cope, so they resort to desperate and abusive behaviors.
Why do people feign illness? Is it a severe form of needing attention in a culturally sanctioned way?
Most people are able to get the love and concern that they seek without being duplicitous in any way, but those who are medically deceptive misuse the reactions others have to their appearing ill. We all know that, if we are ill, others will generally provide increased attention and lenience, but we also seek to get well as quickly as possible. These FD patients warp the sick role, in that they lie about their apparent illnesses.
What kind of pain are such people experiencing?
These patients are experiencing the kind of pain that comes to those who feel isolated, distant, unappreciated, and unloved. They become desperate for emotional—and sometimes tangible—support, and this desperation drives many FD patients.
What would need to happen in the world for people not to feign illness?
The world is one in which there is relatively little unconditional love. All too often, our getting emotional re-ueling is contingent on our doing something to obtain it—such as achieving on a task, at home, at work. For some people, FD is a bit of a shortcut to get that validation, and—as a mental disorder—people have to take self-preserving actions (e.g., getting treatment) that the world cannot automatically provide.
How as a physician do you maintain empathy for such patients?
Since my first experience with a medically deceptive patient, I have felt strong empathy for all of these patients. I realize that they are in emotional pain to some degree—and often to a very substantial degree. This realization facilitates my understanding of these patients and ability to work well with them.
Are there early clues—before you run every possible test on a patient—that an illness might be factitious?
In my articles and books, I provide many clues to detection that can reduce the doctor’s self-perceived need to perform unnecessary tests and even unwarranted diagnostic procedures and surgeries. Among them are realizing that inconsistencies between what the patient says and what he or she has told others about the symptoms (as documented in the medical records or relayed by family members and friends) can be vital. Also, symptoms that do not match the patient’s physical appearance, or patient reports that make little objective sense, can be powerful clues.
How do you approach treatment of a factitious illness?
My new book provides unprecedented insights from actual patients about the interventions that have helped them the most in turning their backs on FD. The whole area of treatment is complicated, and so I would refer anyone interested in receiving or providing help to read Dying to be Ill.
What do you consider the single most important message you are delivering in your book?
My most important message is that the public, like health care professionals, needs to be aware of medical deception in all its forms. There are few resources for patients, providers, family members, law enforcement, and others, and I have consistently sought during my career to address this persistent deficiency.
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