Dying to be Ill

True Stories of Medical Deception

Marc D. Feldman, Gregory P. Yates

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351663533
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Most of us can recall a time when we pretended to be sick to reap the benefits that go along with illness. By playing sick, we gained sympathy, care, and attention, and were excused from our responsibilities. Though doing so on occasion is considered normal, there are those who carry their deceptions to the extreme. In this book, Dr. Marc Feldman describes people's strange motivations to fabricate or induce illness or injury to satisfy deep emotional needs. Doctors, family members, and friends are lured into a costly, frustrating, and potentially deadly web of deceit. From the mother who shaves her child's head and tells her community he has cancer, to the co-worker who suffers from a string of incomprehensible "tragedies, " to the false epilepsy victim who monopolizes her online support group, "disease forgery" is ever-present in the media and in many people's lives. In Dying to be Ill: True Stories of Medical Deception, Dr. Feldman, with the assistance of Gregory Yates, has chronicled this fascinating world as well as the paths to healing. With insight developed from 25 years of hands-on experience, Dying to be Ill is sure to stand as a classic in the field.

Chapter 1
Illness and Illusion

An Overview of Medical Deception

God hath given you one face, and you make yourself another.

Hamlet, William Shakespeare (1564–1616)

Almost everyone can admit to having embellished an illness to get sympathy from a loved one, or to having fantasized about how other people would react if they were diagnosed with a terminal disease. Factitious disorder is an exaggerated outgrowth of these relatively normal experiences, and this is what makes it at once frightening and familiar.¹ Does this kind of behavior, normal at it seems, qualify as “factitious disorder”? What about “nervous” stomach aches or “tension” headaches? Where does factitious disorder start, and where does it stop? Is it something new in medicine? Those are just some of the concerns of this chapter.

The lives of factitious patients revolve around disease, illness, and sickness. More precisely: these patients fabricate disease and illness in order to reap the rewards of the sick role, which include entitlement to support from others, exemption from social obligations, and a general state of being in need of help, or deserving of special allowances. This is the major difference between factitious disorder and the nervous stomach or the headache that means “not tonight.” We will return to the idea of the sick role a few times in this book.

It is through illness behavior that factitious patients draw attention to themselves, and by means of disease fabrication that they secure it. If their disease claim is unconvincing, it may fail to be taken seriously, or be regarded with suspicion.

Everyone needs attention. Some people get it through telling jokes, helping others, boasting, or being brave. Factitious disorder patients draw attention to themselves by being (or appearing to be) sick. If convincing enough, this deception can become a career.

The Discovery of Factitious Disorder

Factitious disease is not a discovery of modern medicine. Historical records show that patients like those discussed in this book have been around for centuries, if not millennia. They were undoubtedly known to the physicians of ancient Rome. Among the more obscure works of prominent physician and surgeon Galen of Pergamon (c. AD 130–c. AD 210) can be found a tract with a striking title: How to Detect Those Who Feign Disease. It opens as follows:

Persons feign disease for many reasons.… To the medical practitioner, certainly, it belongs to distinguish and discriminate [diseases] which are purposely produced by external applications, from those which have their origins in the complaints of the body itself.²

Galen writes of Romans who repeatedly bit the inside of their cheeks, so that they would have “the power, whenever they pleased, toward the end of a cough, to spit blood … as if it came from the chest or abdomen.” Exactly the same technique has been documented in cases reported in the last decade, and I have witnessed patients do this myself. One of Galen’s more ingenious fraudsters rubbed a poisonous plant (thapsia, “deadly carrots”) onto his leg to cause swelling—all the while claiming he was in agony. Although Galen insisted that there were “many reasons” for the deceptive behaviors he described, psychiatric motives would not be considered until the 19th century.

In the fourth volume of the Edinburgh Medical and Surgical Journal, we find some outraged “Remarks on the Difference between the Infectious Opthalmia, and that produced by the Artful Application of Irritating Substances to the Eyes,” written in 1808 by one John Vetch, an English military surgeon. While posted to a barracks in Kent, Vetch had happened upon:

A system, which has existed among the men of the 28th regiment of foot [soldiers], of producing, by the application of irritating substances to their eyes, such a degree of ocular inflammation, as not only to exempt them from their duty, but even with the ultimate view of being discharged from the service.³

These shirkers of the 28th had, through their acts, blackened the name of all patients with inflammation of the eye by instilling in surgeons the “hasty belief that there exists no other than a factitious ophthalmia.” By 1833, “factitious” could be found in the Cyclopaedia of Practical Medicine,⁴ which, along with Vetch’s early work, was referenced extensively in an essay by the Scottish physician Hector Gavin.

Gavin’s essay, Feigned and Factitious Diseases of Soldiers and Seamen,⁵ had in 1835 secured him a prestigious award at the University of Edinburgh. The subject matter was of pressing concern to the British armed forces abroad:

Soldiers and sailors feigning disease are commonly designated as malingerers or skulkers … I need scarcely say, how well it is known how seriously, during the late prolonged wars, the service both of the army and navy suffered from such impostures being oftentimes successful, and how onerously the pension list was burthened by men quite unworthy of its advantages.

These “impostures” consisted of diseases that were simulated, exaggerated or aggravated, but also diseases that Gavin called “factitious.” By this, he meant what we might now call an induced condition: “wholly produced by the patient, or with his concurrence.” These factitious complaints vexed Gavin most of all, because many of the men who produced them did so with peculiar intentions. They aimed, he thought:

To obtain the ease and comforts of an hospital [sic], &c.; –sometimes, though rarely, to bring blame or punishment on an individual whom they dislike; … – to excite compassion or interest. …

Motives such as these were born, he felt, not from a wish to be discharged or excused from service, but a “perversion of reason”—more “a consequence of insanity, than a rational attempt of a man to improve his future prospects.” To demonstrate this, Gavin pointed to the case of a serviceman who cut his Achilles tendon:

With a razor, and prevented as much as he could its reunion, who bore an excellent character, had served twenty-six years, and might have been discharged with a good pension when he pleased.

More perplexing than the self-mutilation of this soldier is Gavin’s willingness to associate him with a “factitious injury.” “Factitious”⁶ was, at this time, a word with implications that were beneath a man of “excellent character.” The first written use of the word was to lambast the “exceeding frauds” of several cardinals of the Roman Catholic Church, as part of a treatise composed by the theologian Richard Crakanthorpe in 1631:

None of them … deserve any credit, for among their writings are inserted many suppositious and factitious tracts … the author of [one] was not only an impostor, but a heretic.⁷

When “factitious” was adopted as a medical term, this condemnation came along with it. Just as Crakanthorpe’s cardinals blasphemed the authority of the Church, so did malingerers “blaspheme” the authority of the doctor.

Gavin was willing to diagnose this man of “excellent character” with a factitious problem because the case was, as far as he knew, exceptional. The soldier had no need to maim himself to escape the army or seek more comfort. In the main, he judged, deceit was evidence of poor character, and the presence of madness had no bearing on this. In fact, Gavin observed that the insanity in his patients was often intermingled with “an unaccountable gratification in deceiving … officers, comrades, and surgeon” (as we continue to see today).

Sadly, Gavin died in a shooting accident in 1855, and little was written about his research in the century that followed. Dermatologists, however, came to similar conclusions of their own about deceitful patients (who had not gone away) and continued to use a variant of the word factitious in their scholarship. Indeed, as early as 1901, we see an entry for “dermatitis factitia” in Hardaway’s Clinical Manual of Skin Diseases, accompanied by the definition: “feigned [skin] eruptions, or eruptions that have been artificially produced.”⁸

Early dermatologists did not consider these feigned eruptions to be rare. Dr. Norman Walker, a skin specialist at the Royal Infirmary in Edinburgh (where Gavin had once practiced) gave a lecture in 1910 on “dermatitis artefacta” (factitious skin lesions) induced with corrosive acid. “I have seen quite a number [of these lesions],” Walker explained, “quite often in girls who seem to have abso lutely no reason for doing such a thing.”⁹ The assumption among Walker’s contemporaries was that the lesions were produced by patients who were mentally unwell in some way.

A few decades later, consensus among dermatologists created a formal diagnostic category for factitious skin disease in the sixth revision of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD–6). The authors appropriated several names in use by dermatologists: “dermatitis artefacta,” “dermatitis factitita,” “dermatitis ficta,” and “neurotic excoriation” (708.4). The first edition of the American Psychiatric Asso ciation’s Diagnostic and Statistical Manual of Mental Disorders (DSM), published in 1952, made no mention of these diagnoses. Few psychiatrists at this time concerned themselves with factitious disease—fewer still, factitious dermatoses.

One notable exception was Dr. Karl Menninger, an influential American psychiatrist with an interest in disorders of aggression. In 1934, Menninger wrote about a series of hospital patients in whom he had discovered a pathological need “to submit to surgical procedures.”¹⁰ So strong was this compulsion that one patient had demanded the removal of her kidney. Menninger branded these individuals polysurgical addicts and warned his readers of their willingness to hoodwink surgeons into performing unneeded operations. The clinical picture was markedly similar to Gavin’s, although the word “factitious” was not used this time.

Menninger was fascinated by the self-destructiveness of these patients. He maintained that their behavior was primarily a method of coping with deeply repressed suicidal urges. The work of Sigmund Freud had influenced him greatly, and he was among the first psychiatrists in the U.S. to incorporate Freud’s theory of the unconscious into his practice. Menninger interpreted polysurgical addiction as a transformation of an unconscious wish to die into a conscious feeling of aggression toward a particular body part. In this sense, the disorder was a mechanism for survival: better to lose a kidney than to die outright. Enlisting a surgeon enabled these patients to disavow their suicidal impulses, which they would be forced to acknowledge if they mutilated themselves. Secondary motivations included some of the factors noted by Gavin—especially the “ease and comforts of a hospital”— but Menninger saw these as opportunistic goals, to be pursued after hospitalization.

Further cases of polysurgical addiction were reported in the medical literature (and continue to be), but that diagnosis, like dermatitis artefacta, was relevant only to a narrow band of health professionals. It was only after 1951 that clinicians of all specialties started to take an interest in factitious disease and the patients who presented with it.

In 1951, the term “Munchausen’s syndrome” appeared in The Lancet.¹¹ The article was written by Richard Asher, a physician with a reputation for medical controversy. For years, Asher had attacked “accepted wisdoms” in healthcare, penning several influential articles that are still taught to medical students today. In “Munchausen’s syndrome,” Asher described three simulated abdominal emergencies, each involving dramatic—and entirely false—claims of severe abdominal pain and bloody vomit, as well as a voluminous history of admissions to London hospitals.

Asher didn’t use the word “factitious” for these patients, but he felt much the same way as Gavin about them. Their schemes were uniformly “senseless,” produced by a “psychological kink” of some sort, and deserving of recognition as a psychiatric phenomenon. Otherwise, they would continue to be diagnosed:

In the hospital dining-room, when, with a burst of laughter, one of the older residents exclaims: “Good heavens, you haven’t got Luella Priskins in again, surely? Why she’s been in here three times before and in Barts, Mary’s, and Guy’s [Hospitals] as well. She sometimes comes in with a different name, but always says she’s coughed up pints of blood and tells a stor...