Patients Who Deceive: Assessment and Management of Risk in Providing Health Care and Financial Benefits

This book about patients with factitious disorders is fascinating to read. Dr. Pankratz draws on his wealth of personal experience and his extensive knowledge of the recent and historical literature. Although the book title suggests that malingering will also be addressed, malingering is discussed primarily in contradistinction to factitious disorders.

Dr. Pankratz explains concepts clearly. For instance, he points out that the malingerer wants to appear sick but that the patient with factitious disorder wants to be sick, or to appear sick, even when no one is watching. The sick role is a goal in itself and not merely a means to another goal. Patients with factitious disorder lie to stay in the sick role; patients with somatoform disorder believe they are doomed to live in it.

The author's style is very readable, and he uses vivid language. For example, he states that "distortions are those colorings of truth that result from observing the world through the tinted glasses that all of us wear. Deceptions, on the other hand, are the pictures carefully painted to lure others into believing a new reality."

Dr. Pankratz points out the similarities between drug-seeking behavior and engaging in confidence games. For example, "hooking" is a con man's ploy that confirms that a sucker has taken the bait. The drug seeker uses similar techniques. A narcotic-seeking patient may suggest that a physician make a phone call to learn more about the patient's accident on the theory that the physician will assume no one would suggest such a call if the story were a hoax.

The book contains many dramatic examples of creating illusions of illness. They include patients who give themselves blood enemas to fake a gastrointestinal bleed or take digitalis to create electrocardiogram abnormalities. Others add saliva to their urine sample so that an elevated amylase will give the illusion of pancreatitis.

One chapter describes how far some people go to injure themselves to receive sympathy or financial benefit. Some beggars actually remove their feet to increase their sympathetic appeal. In an 1880s insurance fraud, 37 persons elected to amputate one of their hands to receive insurance benefits. The book includes other fascinating historical tidbits. For example, the author explains the origin of the exhortation "to keep out of hot water." Death by poisoning was so feared by kings that in 1531 Henry VIII of England made murder by poison punishable by being boiled in water.

Although Patients Who Deceive will interest all physicians who treat deceptive patients, it will be of special interest to consultation-liaison psychiatrists, pain clinic doctors, forensic psychiatrists, managed care administrators, and disability insurers. The book presents an excellent overview of patients with factitious disorders, a trenchant analysis of the theories of why such patients behave the way they do, and a carefully reasoned approach to managing these challenging patients.

Dr. Resnick is professor of psychiatry at Case Western Reserve University School of Medicine in Cleveland.