As Dr. House says on the TV series, “Everybody lies”. Doctors know their patients can’t always be trusted to provide a complete and accurate history. For one thing, doctors are taught to automatically double the patient’s own estimate of their alcohol intake. People want to look good, and they tend to minimize anything that might make them look bad. On the other hand, some people may wildly exaggerate so the doctor will take them more seriously. Sometimes people misremember. Sometimes they misunderstand what they are experiencing. Patients may lie on purpose or they may be unaware of lying.
Dr. Jonathan Howard recently wrote about malingering for SBM, but not all patients who lie are malingerers. Malingerers are just one part of an extensive spectrum of patients who deceive in different ways and for different reasons, and Loren Pankratz has met them all. His book Patients Who Deceive, now out in a much improved second edition, covers the entire continuum. As a clinical psychologist for the VA and a Professor at the Oregon Health and Science University (OHSU), he specialized in evaluating difficult and deceptive patients. As an expert witness, he has provided forensic evaluations for courts across the country and has become especially well-known for revealing false accusations of Munchausen by proxy.
The first chapter is about “The Actor,” a patient Pankratz was asked to see in the early 1980s. He kept seeking admission to the hospital after cardiac bypass surgery, and the cardiologist wanted to know if he was depressed. He was known as the Actor because he claimed to have recently been in several motion pictures, although he was no longer acting and was working on a master’s degree. Pankratz was able to track down 22 pounds of medical records covering 53 ER visits and 106 hospital admissions. He was not an actor but had only served as an extra in a local film. He was not working on a master’s degree; in fact, he had never graduated from high school. He was a professional patient with Munchausen’s syndrome, an unofficial label named for a teller of tall tales. The list of his presenting complaints was staggering, as was the extensive list of medications he had been prescribed. He had been dismissed as a malingerer, a sociopath, and a bum. He manipulated others to borrow money and he stole from petty cash on the ward. Drug-seeking might have explained much of his behavior, but drug addicts don’t ask for neuroleptic drugs. This patient insisted on Thorazine even after it caused tardive dyskinesia. As Pankratz says, “Psychiatrists joke that they will give Thorazine to anyone who asks because that patient must be crazy”.
Pankratz learned from this patient that the most important task in dealing with deceptive patients is gathering external information. These patients need services, but not usually the services they demand. Rather than speculate about their motives, he developed strategies to avoid conflict and enlist cooperation.
Malingering is deliberate deception for external gain. It has four components: an unexplained symptom, intentional actions, an understandable goal, and a cost-effective solution. Distinguishing it from other diagnoses like psychiatric, factitious, and somatization disorders can be tricky. Much of the book consists of fascinating case examples that read like detective stories. Some examples: Munchausen Syndrome Behind a Worker’s Accident, Factitious Disorder Masquerading as Depression, Somatic Disorder with Secondary Gain, Malingering vs. Somatic Pain Disorder.
Pankratz points out that patients with factitious disorders usually pay a higher price than malingerers. They have become enslaved to the sick role. He says that the diagnosis of factitious disorder need not consider volition; patients may act deliberately or they may be suffering from a compulsion they can’t control.
Munchausen’s syndrome is not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5); the correct term is factitious disorder. Pankratz covers the history and argues that the term still offers clarity when restricted to patients who travel to avoid follow-up or communication between providers and who are characterized by chronic lies, grandiosity, or convoluted fabrications. He asks if there is such a thing as a pathological liar and suggests that “pseudologia fantastica” be listed in future editions of the DSM as an impulse control disorder like pyromania and kleptomania.
In Munchausen’s by proxy, mothers fabricate symptoms in a child to get attention from doctors. Pankratz has been asked to consult on these cases and has found that false accusations are far more common than true ones. Children have been separated from their mothers because of false accusations, and when the child improves in foster care that has been falsely interpreted as evidence that the mother was harming the child. In one case, the child improved in foster care simply because the medication causing the symptoms had been discontinued. In another case, a mother was accused of starving her child when video surveillance showed her removing formula from the feeding tube; it turns out she was doing exactly what the doctor had instructed her to do for bloating or discomfort.
The book goes on to cover related subjects such as somatic symptom disorders, conversion disorders, coexisting personality disorders, assessment misadventures, theories about why patients deceive, fantasy-prone personalities, habitual wanderers, impostors and pretenders, addicts, drug seekers, con men, suicidal intent, requests for amputation, and more.
Perhaps the most valuable part of the book is Pankratz’s suggestions for managing deceptive patients in various settings. He believes confrontation is essential and shows how it can be achieved without conflict.
Conclusion: A very worthwhile book
The book is well written and illuminating. It’s worth reading whether for education or entertainment. It is scholarly and exhaustive, with many pages of endnotes, references, and even an annotated bibliography on malingering. If you deal with deceptive patients, if you want to better understand human behavior, or if you just like a good detective story, this book is for you. I wish everyone who encounters deceptive people in medical, legal, or social situations would read it.