The Factitious Career: Faking the Faces of Illness

Faking illness isn’t uncommon. Children do it all the time. Even adults find plenty of reasons to become ill.

Malingerers, for example, are people who fabricate illness or injury because of an obvious incentive: to avoid work or military duty or to obtain financial compensation, says psychologist Paul Lees-Haley.

Lees-Haley, a well-known researcher on malingering, tells of one young man committed to a mental institution for schizophrenia who refused to cooperate in his treatment. The man was receiving about $1,200 in Social Security, state and veterans benefits. And, he pointed out to Lees-Haley, he had an eighth-grade education, no job skills and poor prospects for the future.

“I’d be crazy not to be a schizophrenic,” he told Lees-Haley.

“How could I argue with that?” the Encino psychologist says.

But another, more serious, form of the behavior is factitious disorder or Munchhausen syndrome, named for a character in German fiction who told very tall battlefield tales.

In severe Munchhausen cases, individuals make a career of seeing doctors and checking into hospitals. Some will inflict damage on themselves, such as injecting bacteria under their skin, Lees-Haley says.

Another rare variation of the disorder, called Munchhausen syndrome by proxy, involves parents who take a child from doctor to doctor claiming the child is ill. In some reported cases, parents have poisoned or injured the child to solicit medical attention.

But no one really knows how common these maladies are. Sometimes, factitious disorder is confused with other types of behavior like hypochondria or malingering, in which individuals have some reason to act ill.

“My experience is that (cases of factitious disorder) are rare,” says psychologist Marc Schoen of Cedars-Sinai Medical Center. “I think people think they’re commonplace because they get blurred with other things.”

The trouble is, people with factitious disorder can be very convincing, says Dr. Marc Feldman, a Birmingham, Ala., psychiatrist who published the story of a woman who faked breast cancer in a recent issue of the medical journal Psychosomatics.

“My sense is it’s drastically unrecognized. My point in publishing this case was to alert clinicians to the fact that any symptom can be fabricated, and they need to be aware of the possibility,” Feldman says.

“There are probably loads of cases that come in to clinicians that they never identify. We may be good-naturedly treating people who have fabricated or exaggerated their illnesses.”

People with factitious disorder may set up such an elaborate ruse that medical professionals often fail to discover that the patient is, in fact, healthy.

“One of the common misconceptions is that they are easily identifiable,” Lees-Haley says. “Human beings are very intelligent, resourceful creatures. There are some who do things that are very obvious. But many are not at all obvious.”

It is rare for people with factitious disorder to readily admit they have fabricated the illness.

“These patients typically resist psychiatric treatment,” Feldman says. “We tend to see a poor response to treatment. People abruptly flee treatment. People move to another state, even another country, to engage another practitioner (in the ruse).”

Sometimes, family members or friends suspect the person is faking but keep their doubts to themselves.

Lees-Haley says he has seen a number of cases in which someone suspected fabrication but was reluctant to confront the individual:

“Family and friends will complain that they are faking it. But that’s a tricky thing because what if you had an illness that no one had heard of? People might think you are faking it when you really were not.”

Further, there is no strong profile of the type of person who is likely to develop factitious disorder. People with factitious disorder are more often males in their 30s or 40s, Feldman says. Many are knowledgeable about illnesses and symptoms.

“It seems to be largely people who have some medical background,” he says.

Often these people “have some background in medicine--nurses, lab technicians--and they’ve observed the nurturing sick people get in our society. They use their knowledge and sophistication to get medical help.

“It’s also often true that these people had real physical disorders in childhood or adolescence where they were exposed to medical treatment.”

And some research suggests that these people are more likely to have been abused as children.

But the reasons why people behave this way are not always clear, experts say.

Somewhat typical of people with factitious disorder is their need for nurturing, sympathy and companionship.

“I think for a lot of these people the only way they get nurturance is through being sick,” says Schoen of Cedars. This is an understandable, even common, emotion, he says.

In addition to seeking nurturance, some are motivated by the inability to deal with disappointment, Lees-Haley says:

“You’ll see a lot of people who devote a lot of years to their career and they realize they won’t make it to the top and (the fake illness) provides a way out, an escape with dignity. It preserves their self-esteem.”

This may be one reason men are more likely to succumb to a factitious disorder, Schoen suggests.

It may be easier for some men to say they are sick than to say they need attention or sympathy or need to slow down.

And the events that lead to such fabrication sometimes are truly sad.

“If you heard how they were treated, you would sympathize with this person,” Lees-Haley says.

“If we had some easy way for people to obtain apologies . . . but they are dealt with in an unjust manner, and they don’t see any way to get back at a person.”