Book Review

Patient or Pretender: Inside the Strange World of Factitious Disorders

N Engl J Med 1994; 330:297January 27, 1994

Article

Patient or Pretender: Inside the Strange World of Factitious Disorders
By Marc D. Feldman and Charles V. Ford, with Toni Reinhold. 223 pp. New York, John Wiley, 1993. $19.95. ISBN: 0-471-58080-5

Among the many bizarre and incredible conditions that can develop in human beings, factitious illnesses (of which Munchausen syndrome is the ultimate form) are unequaled. The very mind-set of a physician -- caring, trusting, and eager to help -- is diametrically opposed to that of the patient with a factitious illness -- deceiving, lying, and eagerly undergoing diagnostic and surgical procedures for no apparent reason. The mixture is as natural as oil and water.

Feldman and Ford help us to understand these disorders. There is a natural three-step progression among physicians faced with such a patient. First is the unparalleled rage experienced by a physician the first time he or she is duped (the authors, perhaps accurately, equate the experience with mental rape). This rage is compounded by guilt created by hatred for the patient. It is often the first time a doctor has experienced negative emotion toward a patient; doctors are not used to hatred. In the second step, physicians recognize the patient's pathetic pathologic behavior and, although not understanding or condoning it, rapidly diagnose it and sometimes even admire the patient's tenacity, bravado, and ingenuity. Now, rather than rage at being duped, physicians will proudly discuss (and perhaps embellish) these medical tall tales with their colleagues. The third step is the clinical and scientific study of such patients and the treatment of these complex illnesses. Patient or Pretender gets to a point midway between the second and third steps.

The authors, both psychiatrists, have undoubtedly been manipulated and maligned by patients with factitious disorders but have probably not been duped to the same extent as primary care physicians. Nearly all patients with factitious illnesses enter the medical system by perverting some medical or surgical catastrophe and only later are referred to psychiatrists. The authors explain as best they can the pathophysiology of such patients: the pathetic, yet intelligent, person with a borderline personality disorder seeking a nurturing environment. Rather than be healthy nobodies at home, these patients prefer to be stars in the hospital.

The first third of the book recounts tales of such deception, using detailed psychological and psychiatric techniques that “explain” patients' needs and points of view and thus help the practitioner gain a clearer view of the mental mechanics of such patients. Unfortunately, the middle third of the book continues on in the same way, with the presentation of case after case. The book ends with excellent chapters on Munchausen syndrome-by-proxy, an outstanding chapter on the feelings of the duped care giver (I could have used this during my own first step in dealing with patients with factitious disorders), and two sound chapters on the legal and ethical issues universally stirred up by such encounters and on methods of confronting and treating these high-maintenance patients.

Why and how are doctors and nurses duped? Feldman and Ford echo the experience of others. Most health care professionals do not want to consider the possibility of deception and may not even include factitious illness in the differential diagnosis. Experienced consultants, however, always consider factitious illness in the differential diagnosis. Rather than diagnose factitious diseases by exclusion, the experienced physician will be aware of signs of perfidy, including the fantastic tales offered by these patients, their demanding manner and uncanny ability to disrupt an entire ward, inconsistencies in their stories, incredibly minute details of medical illness coupled with an incomplete knowledge of medical terminology, and sometimes a prompt escape from the ward when they feel that practitioners are on to their deception.

The style of the book is clear, yet very informal, somewhat like a Reader's Digest medical article. Physicians may tire of the constant parenthetical explanations of what a biopsy or a hematologist is, but this very feature will make the book more useful to other health care providers.

Overall, the book makes for easy, pleasant, and interesting reading. It is not a reference book, but an account of the rich experience of two psychiatrists. Psychologists, social workers, nurses, and members of the legal profession would gain immensely from reading it. Physicians dealing with patients who have these disorders are strongly advised to read this book, especially the final four chapters, the value of which will easily justify its relatively low price.

Craig S. Kitchens, M.D.
University of Florida, Gainesville, FL 32602