Is your patient faking?

As physicians, we're trained to see sick people who want to be well. That makes it tough for us to recognize "well" people who want to be sick. Every once in a while, The New England Journal of Medicine publishes a letter reporting on a patient who's been duping doctors and gaining admission to one hospital after another with manufactured symptomatology. The writer almost invariably calls it "a classic case of Munchausen syndrome," as if it's a rarity.

But Munchausen isn't all that rare. Whenever I conclude a lecture for house officers or attendings about this illness, named for the 18th century German baron and tall-tale teller, I ask for a show of hands from doctors who've seen cases similar to those I've just described. Arms go up like smokestacks. I'm convinced that primary care physicians see a lot more patients who fake symptoms than the textbooks would have us believe-and not just those who do it for personal gain, like insurance malingerers.

How can you recognize these patients? Well, as I warn residents, you have to "think dirty," which isn't easy because doctors want to believe their patients. But unless you retain some skepticism, you'll miss the diagnosis. I've encountered or heard of factitious illnesses-meaning those produced by human rather than natural forces-involving every conceivable organ system.

In a typical primary care office practice, you're unlikely to encounter cases as extreme as those that show up at a tertiary care center. But the following examples will give you an idea of how far some patients will go to gain attention, to escape their humdrum lives, to fulfill obscure needs, to malinger, or simply to gain access to a pharmacological cornucopia. By recounting them, I hope to raise your index of suspicion a notch or two, and persuade you to include Munchausen syndrome in your differential diagnosis when a mysterious malady fails to respond to traditional therapy.

The angry man with the sausage arm A truck driver arrived at our emergency department with a massively swollen and reddened forearm. He indignantly reported that he'd checked himself out of another hospital where, despite his swollen limb, chills, and a temperature of 103, he hadn't been treated with pain medication. The immediate reaction of every doctor who saw him was "possible gas gangrene," and an X-ray revealing air pockets in his arm seemed to confirm that diagnosis.

With his life apparently in danger, the patient was rushed to the OR and his arm was filleted open. But when on-the-spot testing revealed no bacterial infection, he was sewn up. When puzzled caretakers took his temperature again, they found he'd become surprisingly afebrile.

Apparently, he had injected air into his arm and artificially raised his temperature to get the attention he craved. Had he hit an artery, the attention might well have come from a mortician. When confronted, he checked out quietly, doubtless to try his ruse elsewhere. In a way, that was unfortunate. Once doctors feel gulled in this manner, they rarely go out of their way to find out what the patient really needs: help with an emotional problem.

The return of the Thin Man As a resident, unwinding in the cafeteria with my midnight snack, I overheard a brand-new MD entertaining his fellow interns with the remarkable admission history he'd just taken from a tall, thin, 30-year-old heroin addict on methadone.