Psychosomatics 45:350-353, August 2004
© 2004 The Academy of Psychosomatic Medicine
Factitious Physical Disorders, Litigation, and Mortality
Stuart J. Eisendrath, M.D., and
Dale E. McNiel, Ph.D.
Received Oct. 7, 2003; revision received Feb. 10, 2004; accepted March 10, 2004. From the Langley Porter Psychiatric Hospital and Clinics, University of California, San Francisco. Address reprint requests to Dr. Eisendrath, Langley Porter Psychiatric Hospital and Clinics, University of California, 401 Parnassus Ave., San Francisco, CA 94143-0984; stuarte{at}lppi.ucsf.edu (e-mail).
Key Words: other forensic issues • symptoms/dimensions
This case report describes four patients who died of factors directly related to factitious physical disorder and whose cases involved civil litigation. The causes of death varied among the patients and included massive aspiration pneumonia, cardiac arrest, opioid overdose, and septic shock. We discuss how individuals with factitious disorder may enter the legal system through the process of civil litigation. This entry into the legal system, in which monetary gain plays a significant role, illustrates that the boundary between malingering and factitious disorder can be permeable. Nonetheless, individuals with factitious physical disorder have a strong tendency toward self-injurious behavior that may eventually result in death. In the case series of 20 patients from which these four patients were drawn, four (20%) patients died as a direct result of factitious disease. This mortality rate should serve as a warning sign to physicians who provide care for these patients that they are dealing with a potentially fatal disease.
Factitious physical disorders are those in which an individual consciously creates signs or symptoms of disease. The individual may create the signs or symptoms using a fictitious history, a simulation of disease, or by the actual production of disease states.1 These cases can be quite vexing for physicians and caregivers because they violate the basic patient-doctor contract. In this contract, patients are allowed to remain in the sick role with the expectation that they want to get out of that role as soon as possible. The patient with factitious disorder violates the contract by seeking to remain in the sick role as a primary goal. DSM-IV2 established the following criteria for a diagnosis of factitious disorder:
- Intentional production or feigning of physical or psychological signs or symptoms
- The motivation for the behavior is to assume the sick role
- External incentives for the behavior are absent
Factitious disorder can be with predominantly physical or psychological signs and symptoms or both. In contrast to patients with factitious disorder, individuals with malingering have clear secondary gains motivating their behavior. However, in cases in which litigation is present, the boundary between factitious disorders and malingering can become blurred. Litigation creates an external or secondary gain in the form of a potential monetary award and validation by the authority of the court. We will discuss four cases that demonstrate this configuration.
The cases represent a subset of 20 cases that have been described previously and featured both factitious disorders and civil litigation.3 One or both of the authors served as expert consultants to attorneys involved in the litigation but were not involved in the clinical care of any of the patients. This role as an expert gave the authors data and a longitudinal perspective on the patients that facilitated confirming the factitious diagnosis. The four cases were selected because they were known to have ended in death and were only described within aggregate summary statistical data in the previous publication. We will describe the cases and discuss the implications regarding mortality risk among individuals who litigate factitious physical disorders.
Case Report
Ms. A was a 35-year-old Asian woman who claimed to have sustained a head injury in an altercation with a geriatric patient in the health care setting where she worked as a nurse's aide. After going to a hospital emergency room, she passed out and appeared to be comatose for 3 days. When she awoke, she remembered the incident and where she was injured but failed to remember her family, including her husband and children. She slowly recovered her memory over a period of months but remained unable to work and claimed to have a variety of chronic pain problems, for which she received opioid management and consultation from a psychiatric pain specialist who never diagnosed factitious disorder. Despite a lack of objective evidence for any organic injury (including a normal EEG, computerized tomography scan, and magnetic resonance imaging), her workers' compensation carrier awarded her $500,000 in settlement because of her alleged disability. She and her husband sued the facility in which the alleged injury had taken place and settled out of court for approximately $1.5 million. The settlement was driven by the fact that the defendant facility had insurance up to this amount and did not wish to face any potential risk for liability beyond this level. Within 1 year of receiving her civil litigation award, Ms. A died of an opioid-related respiratory arrest at home. She had remained in a wheelchair until she died.
Mr. B was a 38-year-old married physical therapist who claimed to have a latex allergy producing a work-related disability. In addition to a workers' compensation claim, he initiated litigation against latex glove manufacturers, alleging that their faulty manufacturing process produced excess antigens and that this was the etiology of his illness. While pursuing a medical evaluation for presumed latex-related pulmonary symptoms, Mr. B was hospitalized repeatedly. A psychiatric consultant raised the possibility of factitious disorder as a diagnosis on several admissions. On several of these hospitalizations, Mr. B complained of chest pain and had ECG evidence of ischemia. He received two cardiac catheterizations, which both showed completely patent coronary arteries. On a subsequent hospitalization, he suffered another episode of chest pain, and an ECG demonstrated ventricular tachycardia. In this episode, he suffered massive cardiac ischemia and went on to have brain death as a result of cardiac failure. Before Mr. B had been transferred to the coronary care unit, where he died, a psychiatric consultant suggested a room search, which revealed several syringes filled with epinephrine taped to the underside of his bed. The injection of epinephrine appeared to cause coronary artery spasm in clean coronary arteries and was concluded as being the etiology of his arrhythmia and ischemia. His case was settled by his estate for an undisclosed amount.
Ms. C was a 52-year-old female factory worker. She was in a single car accident in which her pelvis was fractured. After orthopedic surgery to reduce the fractures, she had a long series of wounds that did not heal. She refused psychiatric consultations when they were attempted. Her wounds were complicated by infections that eventuated in polymicrobial (fecal flora) cellulitis that was only poorly responsive to antibiotic treatments. She usually required indwelling central venous access for delivery of antibiotic treatment. During one episode, she was admitted to the hospital for septicemia, and a Hickman catheter was placed for antibiotic treatment. While recovering from the anesthesia, she aspirated a large volume of gastric contents and died. She supposedly had not had anything to eat or drink for more than 12 hours at the time of the aspiration. Her husband continued litigation that had begun before her death against the original surgeons who had repaired her pelvic fractures. In addition, he added the hospital that was last involved with her treatment to the list of defendants. Eventually, the case was settled for an amount below the National Practitioner Data Bank threshold.
Ms. D was a 42-year-old single white woman who had worked as a pharmacy technician. She had a 17-year history of cellulitis in different extremities of her body. For 12 years she had a wound in her left anterior thigh that failed to heal, despite numerous debridements and antibiotic trials. After this, she developed a similar lesion in her right thigh. Although she was able to work intermittently, her time spent in the hospital progressively increased as the years went on. She refused psychiatric treatment, saying that she did not trust psychiatrists because of negative experiences in the past.
During her last hospitalization, she was admitted with new evidence of infection with polymicrobial organisms, including a gram-negative organism, in her right thigh wound. Shortly after admission, she went into septic shock and died despite rigorous treatment. Her family continued a lawsuit that they had encouraged her to initiate before her death, claiming that several of her doctors had treated her inadequately and caused her problems. After her death, a settlement was reached based in part on the argument that her septicemia had been inadequately treated.
Discussion
In factitious disorder, the patient seeks the sick role for many potential reasons. The role may gratify dependency needs, act out patterns derived from childhood, or fulfill other psychological motivations. One common feature of factitious physical disorder is that it allows the individual to obtain socially sanctioned approval. Indeed as Parsons first described the sick role,4 individuals are relieved of the normal social demands of society because of their illness as long as they try to recover as soon as they can. In factitious physical disorder, individuals seek the sick role. In fact, when litigation is present, they may be attempting not only to obtain socially sanctioned approval but, in addition, judicially certified approval. The judge or jury may be seen as bestowing a judicial shield from any potential accusation of fabrication. Litigation may also result in additional rewards of obtaining a financial benefit as well as venting various emotions aimed at the defendants.
When factitious physical disorder is mixed with litigation, the process may fit with the individual's psychodynamic motivations that drive the factitious behavior in the first place. For example, when Mr. B sued his employer for his latex allergy, it may have allowed him to vent angry feelings toward authority figures that he might similarly have acted out by deceiving his doctors. This acting out may well have been related to childhood abuse at the hands of his father that had been noted in his history. In other cases, litigation itself, with the promise of a large lifetime annuity award, may parallel the dependency strivings found in factitious physical disorder.
In addition to psychodynamic considerations, the psychological impact of litigation on factitious behavior may be conceptualized from a learning theory model. If individuals learn that the sick role produces benefits, such as increased care or attention that would not otherwise be forthcoming, they may replicate the behavior to obtain the potential rewards. From this perspective, litigation may again serve as a potentially strong reinforcer for sick-role behavior.
Regardless of the theoretical perspective from which one views factitious physical disorders mixed with litigation, it appears that just as winning litigation may procure a judicial seal of approval, it may also yield a lifetime sentence. For example, Ms. A remained in the sick role and in her wheelchair despite no organic basis for the limitation, even after obtaining substantial monetary awards. Winning such an award may also make it even more difficult for the individual to relinquish the sick role without a marked loss of face. Outright malingerers are more prone to relinquish the sick role once the external reward has been obtained. Indeed, this ready relinquishment of the sick role may differentiate patients with factitious disorder from malingerers. Unfortunately, this type of judgment can often be made only in retrospective analysis. Furthermore, even some malingerers may be locked into the sick role lest they suffer a loss of face with a rapid recovery.
The four cases described in this series of patient deaths provide the opportunity for a final retrospective analysis. The outcome of death suggests that the factitious disorder appeared to be aimed at achieving a primary psychological gain. Even though litigation raised the question of secondary gain playing some role, the fact that the patients died because of conditions related to their factitious behavior highlights the persistent pursuit of the sick role. Even the approximately $2 million that Ms. A received was not enough to shift her behavior from the sick role. Indeed, one way of conceptualizing the difference between factitious disorders and malingering is that in factitious disorder, the primary gain of the psychological benefit accruing with the sick role is more important than any secondary gain. In malingering, however, the secondary gain is greater than the primary gain, and once the secondary gain has been achieved in the form of an external reward, the fabricated illness behavior diminishes.
The family of the patient with factitious disorder can play an important role in the pursuit of litigation. For example, family members may encourage a patient to pursue litigation when they do not believe that their relative actually has a self-induced disorder. In some instances, the family member encourages litigation in order to obtain monetary redress for the suffering that their relative has undergone without realizing it was self-induced. In all of our cases, family members were co-plaintiffs alleging complaints such as loss of consortium and loss of earnings from the plaintiff. Family members may inadvertently reinforce factitious behavior when they encourage litigation or become a party to it. In addition, family members may find the defendants readily available targets upon which to focus their anger.
This ability to externalize may allow the family to avoid closer inspection of the possible factitious etiology of their relative's health problems. This psychological process may help relieve the family from any sense of responsibility for the disorder, which could be heightened if they were aware of its factitious etiology. Thus, litigation may diminish the guilt or shame that can arise with the diagnosis of a psychological disorder. This family reaction seemed evident with patient D. Despite the fact that Ms. D had suffered for many years with episodes of cellulitis that had been identified by multiple physicians as being factitious, the family ignored this possibility and instead focused on the doctors and the hospital as being at fault. As Appelbaum and Gutheil5 have described, a bad outcome coupled with bad feelings may make a family more likely to pursue litigation.
These cases raise another issue regarding factitious disorders once litigation is present. Factitious physical disorder should be regarded as a serious condition that can be life threatening. When factors are present that lead to litigation, such as the increased need to obtain judicial endorsement of the presence of an illness, there may be an increased mortality rate associated with the condition. Moreover, it is possible that the litigation process, with its attendant stressors, may accelerate a worsening in patients with factitious physical disorder. The four cases described in this article involved litigation before the deaths occurred. This combination of factitious disorder and litigation had a mortality rate of four of 20 cases, or 20%. Our follow-up was limited to a 2-year period. Because of the difficulty in correctly ascribing medical illness to a factitious etiology and the loss of patients in the follow-up process, it is possible that the actual mortality rate is even higher. Although our group size was small and thus limits generalizability, the mortality rate in our case series appears higher than in one other study related to patients with factitious disorder who were not identified as being involved in litigation. In that study, Krahn et al.6 reported a mortality rate of 2% in their case series that had follow-up over a mean period of 64 months.
Consulting psychiatrists and psychologists can serve an important role in educating physicians to recognize factitious disorders. Once recognized, clinicians treating patients with factitious disorder should be alert to the possible presence of litigation. Given the mortality rate in our series, once litigation is present, it may be a marker for an elevated risk of death and should prompt clinicians to take all possible preventive steps. The mortality rate observed in our case series should alert clinicians to consider that in patients who are identified as having factitious physical disorders and reveal that they are in litigation, there is significant risk of a life-threatening condition.
ACKNOWLEDGMENTS
This research was approved by the Committee on Human Research (H5270-18621-01).
The authors thank Ellen Haller, M.D., for reviewing the article.
REFERENCES
- Eisendrath SJ: Factitious illness: a clarification. Psychosomatics 1984; 25:110–117[Abstract/Free Full Text]
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, APA, 1994
- Eisendrath SJ, McNiel DE: Factitious disorders in civil litigation:20 cases illustrating the spectrum of abnormal illness behavior. J Amer Acad Psychiatry Law 2002, 30:391–399
- Parsons T: The Social System. New York, Free Press, 1951
- Appelbaum PS, Gutheil TG: Clinical Handbook of Psychiatry and the Law, 2nd ed. Baltimore, Williams & Wilkins, 1991
- Krahn LE, Li H, O'Connor MK: Patients who strive to be ill: patients with factitious physical disorder. Am J Psychiatry 2003, 160:1163–1168
This article has been cited by other articles:
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H. Fliege, A. Grimm, A. Eckhardt-Henn, U. Gieler, K. Martin, and B. F. Klapp
Frequency of ICD-10 Factitious Disorder: Survey of Senior Hospital Consultants and Physicians in Private Practice
Psychosomatics,
February 1, 2007;
48(1):
60 - 64.
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[Full Text]
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