Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder

A central tenet of Western medicine (which we like to call a science) is that logic and reason and the application of the “scientific method”—replete with its hypotheses, logic, and mathematical analyses—are our best tools for cracking the mysteries of disease and treating those who suffer.

Often, the first challenge to this tidy philosophy is when a fledgling clinician encounters his or her first Munchausen patient, or someone else with otherwise “unexplainable medical complaints.” What physician doesn’t remember the frustration, shame, and anger after realizing he has been “duped”?

For me, it was 40 years ago, when I was an Army medical officer, providing primary care for 2,000 soldiers, including one who kept popping up repeatedly as an emergency admission to more than 15 military and civilian hospitals throughout Europe. During that two year period, his complaints were always the same: unbearable abdominal pain and hematuria. This patient confounded medical personnel, clogged administrative systems, and challenged the Army’s best legal talent. Relentless sleuthing eventually revealed that his hematuria was self-induced: he was surreptitiously using a hat pin to traumatize his proximal urethra.

The unveiling of these horrifically self-destructive acts, beyond the imagination of all his physicians, posed a dilemma: was this psychiatric illness (psychosis or sociopathy), or was this criminal behavior?.

I wish I’d had access then to Dr. Feldman’s Playing Sick? It would have helped to clarify these issues. But I doubt it would have taken the sting out of my feelings of therapeutic impotence, shame, and rage. That after 40 years I remember this patient so well speaks to the strong affective impact these “syndromes of simulation” have on freshly minted physicians, tutored in medical science and filled with idealism and therapeutic zeal. It’s hard to imagine that any physician would want to make such patients his or her predominant professional interest.

Yet this is exactly what Marc Feldman has done, and over the last 15 years he has churned out a large literature dealing with these confounding conditions. Only toward the book’s end does Dr. Feldman hint at what drives his interest, but he provides only that hint. I want to know more.

Unfortunately, this is the way things are throughout the book. Each of the many cases is noted briefly, without much depth of character development (if you take it as biography), or formulation (if you take it as clinical case presentation), or flow (if you take it as expository nonfiction).

Although the book is neither a text nor an academic “state of the art” treatise, it does have clinical utility for physicians and other health workers. I’m not convinced, however, that it works well for psychiatrists, who might have more inquiring minds about developmental symptoms and dual diagnoses (especially borderline and antisocial disorders, for example).

The lack of a focused readership would be more troublesome were it not for Dr. Feldman’s consistent role of mentor (he consoles those who have been “taken in”), and teacher (he lists the “10 signs” of medical deception, the “25 red flags” for patients with deceitful behaviors, etc.). All this information, interspersed with 65 clinical vignettes, is a bit overwhelming and becomes repetitive.

Dr. Feldman’s extensive background in psychiatric consultation and forensic medicine gives much weight to his words. He makes clear distinctions among people who play sick: he considers Munchausen syndrome and factitious illness to be illnesses, and the individuals so afflicted to be patients with legitimate diagnoses. However, he thinks of Munchausen by proxy and malingering as categories of behavior that do not justify medical (even psychiatric) diagnoses. Thus, he considers these behaviors to be criminal in nature.

For all that is fascinating about the subjects of this book, there are severe distractions. The ubiquitous use of the first person singular in most clinical vignettes, the complete absence of quotation marks (even in the vignettes), and the author’s intermittently chatty style add up to a confusing mélange of material. The book deserves better editing. At times it seems as if one is reading the transcript of a “Nancy Grace” or a “Geraldo at Large” show, without the visuals to help define who is who.

All this notwithstanding, the book is an eye-opener regarding these disturbed and disturbing people, who so easily “pass” into and through our health care systems, as well as in and out of our personal lives. A concern, however, is that the book might serve as a blueprint for those would-be medical deceivers whose classrooms are the television talk shows—for then there would be visuals!

Dr. Feldman’s klieg-light sweep through this cut of humanity does not have the style or depth of a modern-day Chaucer. But like Chaucer, Feldman causes the reader to take stock of those sometime peculiar people in our practices—as well as in our midst.

Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org.