IPT Book Reviews

Title: Patient or Pretender: Inside the Strange World of Factitious Disorders  Positive Review
Authors: Marc D. Feldman and Charles V. Ford
Publisher: John Wiley and Sons, Inc. 1994

John Wiley and Sons, Inc.
605 Third Avenue
New York, NY 10158-0012


This 227-page book by two psychiatrists is divided into 15 chapters and describes factitious disorders.  The book provides many examples of patients with these disorders and one chapter is entitled "Victims of the Great Pretenders."

According to the DSM-III-R, the factitious disorders are characterized by physical or psychological symptoms that are intentionally produced or feigned.  This disorder is distinguished from malingering in which there are external incentives for the fabrication.  In the factitious disorders, there is a psychological need to assume the sick role.  The judgment that the symptom is produced intentionally can only be inferred by the physician and this diagnosis can only be given by ruling out all other possible causes of the behavior.

Patients with a factitious disorder are able to produce or simulate illnesses so that their deception is not immediately discovered.  Many such patients manifest the "brave victim persona" (p. 3), fooling physicians, nurses, and members of support groups.  The best known form of this disorder is Munchausen syndrome.  Often, the disorder looks much like malingering.

The book ends with an index, but there is no reference list.


The book contains many fascinating facts and case examples.  Most hoaxers are young females, with good knowledge of the disease being faked, and with heavy denial on discovery.  One woman conned a social work class into letting her speak before the class and then collected $125 from them so she could fly in a balloon before she died.  In another case, a patient obtained 50 blood transfusions before the hospital discovered the fabrication.  Most hoaxers find lying to counselors "easy" and even a well-known law school fell for the Brawley hoax and invited her to speak to their classes.
 Hoaxes have been discovered that involved starch injection, blood-letting, self-injection of bacteria, and disorders such as transsexualism, cancer, AIDS, seizures, and multiple personality disorder.  Diagnoses of these disorders is further complicated by "Munchausen syndrome by proxy" in which the illness is induced into a child by the parent or other caretaker.  The authors urge physicians to become detectives as well as diagnosticians in order to identify cases of factitious disorder.

One New York Psychiatric hospital reported that 1% of all admissions were for factitious disorders, and a Toronto hospital reported .08% of the total hospital population were for these disorders.  Using 1992 inflation rates, it was estimated that an individual with factitious illness for 12 years costs the taxpayer some $1,466,601.  Neither the courts nor the medical community knows what to do about these hoaxers, and no precedent-setting civil suit has yet been filed.

This is an interesting and informative book but its major shortcoming is in its neglect of false charges, especially those of Munchausen syndrome by proxy.

Reviewed by LeRoy G. Schultz, Professor Emeritus of Social Work, West Virginia University, Morganstown, West Virginia.

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