Jeffrey S. Dubin and Mark Smith
Factitious disorder, malingering, and conversion disorder constitute a spectrum of medical conditions in which the patient’s symptoms are false, pretended, or grossly exaggerated. The patient’s symptoms may be voluntary (malingering and factitious disorder) or may be an involuntary expression of an underlying psychological conflict (conversion disorder) (1). Distinguishing the physiologic conditions from the functional while addressing the patient’s psychologic issues is a test of the emergency physician’s diagnostic acumen and therapeutic skill.
FACTITIOUS DISORDER
CLINICAL PRESENTATION
The syndrome of factitious disorder with physical symptoms is better known as Munchausen syndrome, named by Asher (2) after novelist Rudolph Raspe’s character, Baron Munchausen, who enjoyed a series of fabricated adventures. Munchausen patients are impostors who invent bizarre and often fantastic stories and accept painful and potentially dangerous procedures (e.g., cardiac catheterization, exploratory laparotomy) to reach their presumed goal: to become a patient and assume the “sick role” (1). There is no other secondary gain, thus distinguishing the Munchausen patient from the malingerer.
Munchausen patients typically present to the emergency department in a dramatic fashion, with a constellation of physical symptoms, plausibly suggesting the presence of substantial pathologic illness that is not present. Examples of Munchausen practices:
• Applying mydriatics to stimulate anisocoria (3)
• Misusing an insulin pump to induce hypoglycemia (4)
• Creating skin lesions or placing foreign bodies in skin (5)
• Overdosing with caffeine to induce tachyarrythmia (6)
• Feigning respiratory distress that results in intubation (7)
Munchausen patients are typically young or middle-aged men (although the age range spans the pediatric to the geriatric) and often report a medical history of previous hospitalizations and operations, in many cases performed in other cities. They are knowledgeable about hospital routines and may have worked in the medical field but are often vague or inconsistent about their own medical details. Munchausen patients are clever, realistic, and facile in their simulation of clinical reality, but the extent and severity of symptoms are often out of proportion to physical findings and demeanor, and may seem almost too classic. The Internet has not only made it easy for Munchausen patients to find descriptions of disease symptoms to mimic, but has enabled a new outlet for the medical imposter. Munchausen by Internet has been described when persons without disease join Internet support groups and pose as having true illness and disrupt these online communities (8).
Munchausen patients have been characterized as hostile, dependent persons with poor impulse control and a history of self-destructive behavior. They tend to be socially isolated, rarely are accompanied to the emergency department by friends or family and, once admitted to the hospital, usually have no visitors. When confronted, they usually become hostile and querulous, deny the allegation of factitious disorder, and sign out of the hospital against medical advice.
When parents falsify illness in their children, the disorder is termed factitious disorder by proxy (FDBP). FDBP describes abuse in which the perpetrator (most often the mother) is motivated by the desire to assume the sick role by proxy or to seek attention from the hospital staff (1). Whenever this diagnosis is considered, it is important to define the specific abuse to the child. FDBP refers to the context of the abuse and the disorder of the parent. FDBP is child abuse and should be treated as such (9). Examples of FDBP are as follows:
• Infant apnea, cyanosis, seizures from smothering (9)
• Severe diarrhea and hypernatremia in infant (10)
• Factitious hypoglycemia in children (11) and elders (12)
• Self-induced premature labor and resultant neonatal injury (13)
DIFFERENTIAL DIAGNOSIS
Munchausen syndrome must be distinguished both from organic disease and malingering and from three conditions in which the production of nonorganically based symptoms is not voluntary: conversion disorder, somatization disorder, and hypochondriasis.
In the absence of explicit evidence to the contrary, the clinician should presume that there is an organic basis for the patient’s complaints. When the patient fits the pattern of presentation for Munchausen syndrome, however, evidence should be sought to confirm or disprove that suspicion. In contrast to the Munchausen patient, the malingerer has a clearly understandable external incentive and goal other than wanting to be a patient. In the three somatoform disorders (conversion disorder, somatization disorder, and hypochondriasis), the patient’s symptoms are involuntary. Conversion disorder is discussed in subsequent paragraphs. The patient with somatization disorder has a chronic history of multiple symptoms involving different organ systems in a fluctuating and recurrent pattern that is not adequately explained by a physical disorder. The hypochondriac patient presents with fear and concern about the presence of disease and, despite reassurance, misinterprets normal bodily sensations and physical signs as pathologic conditions.
ED MANAGEMENT
Until a diagnosis of factitious disorder is confirmed, the patient should be treated as if an organically based disease is present. The usual diagnostic and therapeutic procedures should be followed. There are a myriad of symptoms and signs that patients with factitious disorder may feign. Kenedi et al. have compiled an extremely useful table of diagnostic tools clinicians should consider when evaluating suspected Munchausen patients (14).
If Munchausen syndrome is suspected but not confirmed, the physician may treat the patient in a modified manner (e.g., consider serial cardiac enzymes, no potentially harmful medications, and discharge home rather than admission for a suspected Munchausen patient with chest pain and normal ECG). When Munchausen syndrome is confirmed, the physician may elect to confront the patient in a supportive and nonthreatening manner, although the establishment of a therapeutic alliance between patient and physician is unlikely. There is no difference in outcomes of a confrontational versus nonconfrontational approach; most Munchausen patients will not participate in psychotherapy (15).
Patients who are labeled with Munchausen syndrome can still become organically ill. Procedures that have been performed because of their imposture may predispose them to real illness (e.g., a small-bowel obstruction may occur as a result of adhesions from a previous exploratory laparotomy for abdominal pain). Other patients may need medical treatment for self-induced physical ailments. The physician must not neglect to care for these patients because of their underlying psychopathologic condition.
An important caveat in the diagnosis of FDBP is that this is a very challenging diagnosis to make. If FDBP is suspected, consultation with a child abuse specialist is recommended prior to contacting child-protective services to help confirm these suspicions or avoid misdiagnosis in cases where no abuse exists (16).
DISPOSITION
If any doubt exists about the diagnosis of Munchausen syndrome and if the purported illness warrants hospitalization, the patient should be placed in observation for further evaluation. If the diagnosis of Munchausen syndrome is certain, however, the patient should be denied admission to the hospital for the presenting complaint. Psychiatric care is of little value and likely to be refused, if offered.
MALINGERING
CLINICAL PRESENTATION
Malingering is the voluntary and conscious presentation of false and exaggerated physical or psychological symptoms in pursuit of a recognizable goal. Such goals typically include avoiding work or other unpleasant obligations, obtaining shelter, obtaining controlled substances, or obtaining financial compensation through litigation. Malingerers may either exaggerate or invent symptoms.
In contrast to factitious disorder, in malingering the goal is clear and understandable, the behavior is conscious and situationally appropriate, and the symptoms abate once the goal is attained.
Malingerers present to the emergency department with a variety of demands or complaints. Some patients who complain of migraine headache or renal colic are seeking narcotic analgesics. Noncontrast helical computed tomography scan or sonography for nephrolithiasis is helpful, as the presence or absence of hydronephrosis is useful in distinguishing whether the possibly chronic stone is responsible for the degree of pain presented by the patient. Other individuals may present to the emergency department after missing several days or even weeks of work and request a retroactive “sick slip” because of a medical problem, the presence of which is difficult to document definitively. Patients who have been in minor motor vehicle accidents may present with exaggerated symptoms of cervical or lumbar strain in an effort to document damages and collect financial compensation.
Patients with underlying psychiatric disorders may feign exacerbations of mood and thought disorders so as to be hospitalized for secondary gain. These patients can be difficult to evaluate. Often they are admitted to the psychiatric service with a comorbid psychiatric diagnosis, with malingering strongly suspected.
DIFFERENTIAL DIAGNOSIS
Malingering is suggested if the patient over-dramatizes complaints, symptoms, or physical signs; overreacts during the physical examination; is uncooperative during the diagnostic evaluation; declines to appear when scheduled for diagnostic testing; or is reluctant to accept a favorable prognosis. The history, physical examination, and laboratory data may not support the severity of the patient’s complaints, particularly those that lack objective correlates for diagnosis (e.g., migraine). During their evaluation, some patients may reveal their true objectives (e.g., a prescription for narcotic analgesics or a medical excuse from work).
Patients apparently suffering an acute neuromuscular syndrome may complain of symptoms that do not fit an anatomically consistent pattern or may exhibit weakness during testing that is belied by their ability to carry out other activities when they are not being examined. Patients complaining of low-back strain may demonstrate a disparity between the “straight leg-raise” test performed in a sitting versus supine position and, while in the supine position, the patient may not make an appropriate effort at raising the affected leg (detectable by placing a hand under the contralateral heel and feeling for the expected downward pressure associated with true effort).
If drug-seeking behavior is suspected, a review of past medical records or state narcotic database or other prescription database may be enlightening.
ED MANAGEMENT
Because the malingering patient may become defensive, angry, and hostile when confronted with the suspicion that the symptoms are false or exaggerated, the physician is often tempted to comply with the patient’s demands rather than risk a confrontation. Furthermore, the diagnosis of malingering can rarely be made with complete certainty. Because each patient reacts to illness or injury differently, the degree of volition or willfulness that underlies the patient’s exaggeration of symptoms is not always clear.
Perhaps a prudent way to deal with a suspected malingerer is to give the patient a minimal amount of gratification and to invoke general rules or established policies that prevent the physician from filling the patient’s demands completely. It is worthwhile to record on the patient’s chart suspicions or questions about the patient so that the next treating physician is aware of the concerns.
DISPOSITION
The usual criteria for admission to the hospital should apply, depending on the patient’s complaint. If the physician is convinced that the patient is malingering, a firm stand should be taken against admission.
CONVERSION DISORDER
CLINICAL PRESENTATION
Patients with conversion disorder present with physical symptoms that are not under voluntary control and cannot be explained as a manifestation of a physical disorder or on the basis of a pathophysiologic mechanism. The physical symptoms are unconscious expressions of underlying psychological conflict. These symptoms are often immediately preceded by an acute psychological stress, and that precipitant should be sought. Conversion disorder was previously called hysterical neurosis, conversion type. Conversion symptoms have long been theorized to result from an autohypnosis after a traumatic event. Furthermore, adult victims of severe childhood abuse appear to be more prone to developing conversion reactions as adults compared with their nonabused peers (17). Patients with conversion disorder often have other somatoform disorders (18).
The most typical conversion symptoms involve loss of neurologic function: blindness, aphonia, psychogenic seizures, paralysis, anesthesia, tunnel vision, gait abnormality, unresponsiveness, and amnesia (19). The conversion disorder symptom usually has a sudden onset. La belle indifférence, an attitude of relative unconcern despite the seriousness of the symptom, has historically been cited as a sign of conversion disorder. However, comprehensive review of the literature concluded that seeming unconcern on the part of the patient does not distinguish between conversion disorder and a stoic response to an organic disease (20). The diagnosis of conversion disorder depends on demonstrating that the patient’s symptoms are not due to organically based malfunction. With most neurologic presentations of conversion disorder, this is not difficult, because the patient’s deficits usually do not make neuroanatomic sense. The physician’s knowledge of neuroanatomy is usually better than the patient’s; moreover, the patient is not consciously trying to fool the physician. Nevertheless, these cases may sometimes mimic real disease patterns, including classic stroke presentations (21).
Typical “mistakes” made by the conversion disorder patient with neurologic symptoms include the following:
• Acute onset of sensory loss in a sharp stocking-glove pattern (although this may be mimicked by the peripheral neuropathies of diabetes or alcoholism)
• Complete paralysis and sensory loss of one leg, with preservation of deep-tendon reflexes and antigravity muscle activity
• Hemianesthesia without contralateral pain-temperature loss or with nonanatomic midline splits in vibratory sensation
• Complete loss of motor function on one side of the body, with inability to turn the head to the side of paralysis (indicating contralateral sternocleidomastoid muscle dysfunction)
• Psychogenic seizures: Features include presence of fluttering eyelids or closed eyelids, thrashing of extremities, pelvic thrusts, and evidence of responsiveness to environmental stimuli during an apparent grand mal seizure. Typically absent are tongue biting, incontinence, physical injury, or postictal state (22)
• Inconsistencies in physical signs during unresponsiveness: Will not permit an upraised and suspended arm to strike the face when released but rather allows it to glide harmlessly over the face (note that substantial injury can occur to the nose and mouth if the arm does drop directly onto them). Vigorously resists manual eye opening by the physician (23)
• Inconsistencies in blindness: Ability to avoid injury and misstep when “blind” or with tunnel vision the visual field extending into space may be described as cylindrical rather than cone-shaped
DIFFERENTIAL DIAGNOSIS
Conversion disorder must be distinguished from organic illness, malingering, and Munchausen syndrome as well as from somatization disorder and hypochondriasis.
The tendency should be strongly resisted to diagnose conversion disorder in any patient with vague symptoms. Up to 30% of patients who have been given a diagnosis of conversion disorder at some time are eventually found to have organic disease that could explain these symptoms (24). Illnesses such as systemic lupus erythematosus, multiple sclerosis, and hyperthyroidism may present in the emergency department as subtle perturbations of physical functions; hypoglycemia can present in myriad different guises.
Patients with conversion disorder lack the characteristic features of the Munchausen patient: There is no tendency to submit to multiple procedures, and there is a lack of sophistication with respect to medical terminology. Unlike the malingering patient, there is no conscious fabrication of illness or disability.
ED MANAGEMENT
Patients with conversion disorder must be handled delicately, deftly, and with respect. These patients have usually experienced a recent or remote traumatic experience. It is unacceptable to confront the patient with an assertion or proof that the illness is faked or not real. The patient should be told that, although the symptoms are bothersome, they do not appear to be manifestations of a serious illness. Planting the suggestion that they will improve over the next several hours can sometimes relieve symptoms. Patients with aphonia can be told that they will be able to whisper; patients with paralysis can be told that they will begin to experience movement in their toes. Simultaneously, the physician can probe for underlying psychosocial conflicts that might have led to the appearance of the symptom.
CRITICAL INTERVENTIONS
• Treat patients with suspected but not confirmed Munchausen syndrome as if an organically based disease is present until the diagnosis is confirmed.
• Resist diagnosing conversion disorder in any patient with vague symptoms.
• Treat suspected malingering patients with a minimal amount of gratification and invoke general rules or established policies that prevent the provider from fulfilling the patient’s demands completely.
DISPOSITION
The neurologic consultant may assist the physician in differentiating organic from nonorganic illness. If the diagnosis of conversion disorder is secure and the patient’s symptoms persist and prevent the patient from carrying out the activities of ordinary living, a psychiatric consultant may assist in the process of symptom resolution in the emergency department.
Many patients with conversion disorder experience resolution of their physical symptoms during their emergency department stay, but some require admission to the hospital. If the diagnosis of conversion disorder is uncertain and if the presenting symptom could signify dangerous illness, hospital admission is warranted. Even when the diagnosis of conversion disorder is clear, patients whose manifestations persist and who cannot manage on their own (e.g., psychogenic unresponsiveness or paralysis) require inpatient care.
Common Pitfalls
• Failing to appreciate that the patient has an unusual presentation of an organic illness.
• Permitting unpleasant aspects of the patient’s personality to result in dismissal of the patient’s problem as “psychogenic.”
• Inadequately distinguishing among malingering, conversion disorder, and Munchausen syndrome.
• Classifying all patients with symptoms having no discernible anatomic cause as “crocks.”
• Losing interest in caring for the patient once it has been determined that the patient’s symptoms are not organically based.
REFERENCES
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