Book Review

The Spectrum of Factitious Disorders

N Engl J Med 1996; 335:2003-2004December 26, 1996

Article

The Spectrum of Factitious Disorders
(Clinical Practice Series. No. 40.) Edited by Marc D. Feldman and Stuart J. Eisendrath. 229 pp. Washington, D.C., American Psychiatric Press, 1996. $36. ISBN: 0-88048-909-X

From 1783 to 1785, a woman named Kate Hudson plagued England's Nottingham General Hospital with visits prompted by the mysterious appearance of needles, nails, and pieces of bone beneath her skin. Her medical record, which may be the first recorded account of factitious disorder, reveals evidence of drug-seeking (laudanum), care-eliciting, and an array of surreptitious self-injuring behaviors (William Granger, Wonderful Museum, vol. 4. London: Alex. Hogg, 1803). Over the years, other factitious disorders were periodically described in the medical literature, but there was no broad interest in the phenomenon until 1951, when Richard Asher, in a flash of whimsy, connected it with the fabled liar Baron Munchausen.

To date, most information on factitious disorders has emerged from single case studies or letters to the editor, leaving the impression that they are uncommon or trivial. However, in the pages of the Journal James Jackson and I recently described 810 patients (“Habitually Wandering Patients,” 1994;331:1752-5) who accumulated 6266 hospital admissions in a single year, at a cost of $25 million. Although some of these admissions were necessary, we were able to show that the costs attributable to duplicity by patients were exceedingly high.

Now Feldman and Eisendrath have captured, in 11 brief chapters, the true dimensions of the problem of factitious disorders. In the opening chapter, Theodore Nadelson defines patients with such disorders as those who feign or produce their own disease, are aware of their role in the deception, and keep that role secret. He then sets the tone of the book by presenting a humane view of such patients that does not minimize their responsibility to society and the law. In the ensuing chapters, although multiple authorship produces some overlapping information and even some duplication of examples, the reader is rewarded with clear discussions of clinical, administrative, and ethical–legal problems.

Four especially useful chapters are devoted to factitious disorder by proxy, typically a form of child abuse in which a mother produces an illness, or the appearance of an illness, in her child. This diagnosis is currently confined to the speculative section of the diagnostic manual because its features have not been clearly established, and in a recent issue of Archives of Diseases in Childhood there has been a call to abandon the diagnosis in favor of describing exactly what has happened to the child. However, these four chapters will give the clinician sufficient tools for the task, because they discuss controversial and emotional issues with unusual wisdom. Anyone with a complex case will be inadequately prepared without this book, especially in a legal setting.

Another compelling chapter illustrates how patients may transfer their factitious disease to the legal arena. Legal professionals and law-enforcement officers, accustomed to the fabricated alibis of criminals and the exaggerated distress of plaintiffs, may be unprepared for the irrational deceptions that patients with factitious disorders introduce into their world. In case after case, this book demonstrates the seriousness of factitious disorders and their impact on family, friends, and practitioners in every medical specialty. This surprisingly comprehensive book is the first clinical guide to factitious disorders, and it is likely to remain for years the authoritative source in its field.

Loren Pankratz, Ph.D.
Oregon Health Sciences University, Portland, OR 97201