Patient or Pretender: Inside the Strange World of Factitious Disorders.

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Feldman, Marc D., and Ford, Charles V. (with Toni Reinhold). Patient or Pretender: Inside the Strange World of Factitious Disorders. New York: John Wiley & Sons, 1994. ix + 228 pp. $19.95.The primary intent of this book is to educate “health care professionals” about factitious disorders and about the legal implications of attempting to cope with patients who fake illness. With the aid of professional writer Toni Reinhold, Patient or Pretender is constructed in the form of a series of topical vignettes illustrating the lengths to which some persons will go to gain medical attention, and the consequences for those exposed to this strange duplicitous behavior. Readers with a taste for the bizarre will find it amply represented here: infections produced by self-injection of feces, kidney disease faked by inserting one's own blood in a urine sample, ingestion of rat poison, widespread misuse of insulin, imitation of the symptoms of schizophrenia, and so on. The authors point out that such pretenders are often well-informed about contemporary medicine, and that about one third of the reported cases were in fact employed somewhere in the health-care system themselves. Such patients are quick to pick up on the signs of “trendy” affictions such as AIDS, anorexia nervosa, and posttraumatic stress disorder.Given their medical expertise, it is often difficult to detect a factitious patient, and the conclusion that someone may be faking does not come easily in any event-hence, the educative role of the book, which illustrates the various ruses that have been used and the signs that have led to their detection. However, the authors point out that one should not rush to judgment in such matters, and illustrate the proposition with a lengthy account of a woman who was actually ill but suspected of dissimulating. A good deal of attention is also reserved for what is considered the most shocking instance of factitious behavior, so-called Munchausen by proxy-mothers who make their own children sick for the secondary gain it brings them. In this context, a passing shot is gotten in at therapists who see a history of child abuse in their patients, even when the latter do not remember it-an iatrogenic mirror image of a factitious disorder (p. 155).The examples in the book are useful, as are the conclusions which point to the legal and clinical implications of the problem. In the present climate of respect for individual rights, doctors cannot simply search a patient's room for syringes nor set up surreptitious video cameras on the grounds of mere suspicion, nor directly accuse a patient of factitious behavior without fear of libel action. One example is even given of a patient who at first feigned cancer and then, on discovery that her claims were phony, launched a malpractice suit against her doctors because they did not treat her for the real problem: a factitious disorder. In the light of all this, Feldman and Ford make a number of practical recommendations about what, given this potentially litigious context, can be done to expose factitious patients, get them the psychiatric treatment they need, and remove codependent victims from their grip.The authors want to be clear that factitious disorders are, in fact, real “disorders” that require treatment of their own, no matter that such patients are troublesome and expensive liars. Since factitious patients are aware that their behavior is contrived, these afflictions are not of the sort which could lead to an insanity plea. Yet they are disorders nonetheless.

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