August 25, 2005

"How easy is it to fool the medical establishment into thinking that you are mentally ill, if you are not?"

We've debated this topic here before — a propos of the Piano Man — with me saying it would be hard to fool them and a commenter insisting Piano Man was a big phony. Consider this, by someone who works with homeless people with mental problems:
The theorist Talcot Parsons, in the 1950s, described what he called the "sick role". He argued that illness is a temporary, medically sanctioned form of deviant behaviour. He went on to suggest that there was a conflict for people labelled "ill" to, on one hand, get better, and on the other, to continue to enjoy the "secondary gains" of attention and exemption from normal duties.

Doctors act as the gatekeepers to the sick role, in that they are the ones who decide whether or not a person enters this role. While society must show compassion to those deemed unwell, it must also make sure that the gains are not so great that everyone wants to join in.

The difficulty for doctors is to identify those that are faking, and those that are genuinely unwell. It's a surprisingly common difficulty, and with mental illness, it's especially tricky because psychiatrists aren't mind readers - diagnosing exactly what is going on inside someone's head relies on them exhibiting certain symptoms.

Mutism, for example, is a symptom in a number of serious mental illnesses, but is also fairly easy for sane people to mimic. However, living a lie isn't easy and the impressive thing is maintaining the charade, because there is something inherent in us that seems to make us want to come clean. It occurs to me that you'd have to be pretty mad to want to stay in a psychiatric hospital in the first place, but perhaps this shows how desperate the Piano Man was. Then again, being ill means you get attention, and when in hospital, shelter and food. If you are actually well, in some ways it's like a trip to Butlins, but with white coats instead of red ones.

There's a fine line between what's classed as malingering and what is accepted as genuine illness. When someone has a breakdown, for example, what they're saying is that they've had enough, that they can't cope any more and that things have got to change in their lives. They enter the sick role, which facilitates the attention and change that is needed. But when does this become manipulative?

What surprises me is that more people don't do it.

Have you ever played sick to take a break from the pressures of life — not just called in sick to a job, but tried to fool people whom you took advantage of for care and support? Have you ever wondered whether you were really sick — physically or mentally — or whether you were indulging yourself and exploiting other people?

Has anyone ever done it to you, or have you ever suspected anyone of doing this? How much would it upset or outrage you if someone who wasn't really that sick, let himself droop into a sickly way of being and let you take care of him? How long would it take you to feel suspicious and stop providing your services?

Or are you the sort of person who suspects people who actually are sick are just faking it to get attention?


Eddie said...

I honestly think that there are two types of people:

- The first are almost always healthy and when they get sick, they don't wish to admit it.

- There are the perpetually healthy who always claim to be sick, and fake it all the time. Maybe they think they are sick, but their definition is far different than mine.

Mom Underground said...

I've called in sick to work, but have never created anything elaborate to gain sympathy, etc. An acquaintance of ours, however, once told everyone he had cancer. It went on for about a year and has pretty much been disregarded as phony for a number of reasons too elaborate to detail here. He doesn't mention his "bout with cancer" and neither do we. It's kind of odd and I question his mental health because of it all, as it seems indicative of some sort of problem that he'd manipulate people this way. Needless to say, I don't believe much of what he says anymore.

Joan said...

I think just about any parent has had to deal with "I have a tummy ache" or "I don't feel good" from a child who doesn't want to eat dinner/go to school/do something else he doesn't want to do.

And yes, I'm torn. I don't want to ignore potentially serious symptoms -- a friend in college nearly lost his little sister when his parents ignored her complaints about a stomach ache; her appendix had burst! On the other hand, it's pretty easy to tell if a kid really is sick, just by their affect. So I check for symptoms and act sympathetic, but in the absence of hard evidence I'll accuse them of malingering, no problem.

With adults, especially in cases of mental illness, it's a lot more difficult and I'm glad I don't have to make those calls.

Another dimension to this discusion: for people like me who are struggling with chronic illnesses, the whole sick/well dichotomy is a joke. I deal with symptoms every day that I could've legitimately used as excuses to get out of school when I was younger. But I'm still an active parent and rarely, very rarely, crawl to the couch for a nap in the afternoon.

It's never "Are you well?" It should be, rather, "Are you well enough?" I'm fortunate that so far, for me, the answer to that question is "usually."

iocaste said...

I don't know if this was covered when you debated the topic before, but there was a famous experiment in the 1970s run by a professor named David Rosenhan. Research assistants checked themselves into mental hospitals with one complaint: I hear voices. Nothing else.

Not one doctor discovered that they were faking it -- all were given serious diagnoses. In fact, many researchers found they had trouble getting out.

But oddly, the patients suspected that the researchers did not belong there.

Tonya said...

The stand up comic David Cross had a guest starring role on the sitcom "Just Shoot Me." He played the character Elliot's younger brother Donnie. As the younger brother, he was scamming his family into believing that he was "slow." It was absolutely hilarious. He'd act all simple and innocent like a small child. Meanwhile, he lived at home for free, did not have to hold a job, and everyone took care of him. The only one who knew he was pretending was Maya, the character played by Laura San Giacomo. Whenever they were alone, Donnie would make a pass at Maya. But when Maya told Eliot that his brother was a fake, Eliot didn't believe her.

Ron said...

It's odd but I've experienced people who do not get sick and think that sickness in others is some form of moral failing. They don't get sick, so you must have been too much of something or not enough of something's a repugnant attitude, and, in their cases, makes me root for some form of Atomic Crotch Glemmies...

APF said...
This comment has been removed by a blog administrator.
APF said...

Interesting. It's often said that the "medical-industrial complex" has an interest in keeping people sick and/or medicated, yet this hypothesizes the polar opposite--that it's the "sickly-simpathy complex" that makes people want to be ill in the first place...

Ann Althouse said...

I must confess to being the sort of person who thinks people are if not faking then exaggerating to try to get attention. Sometimes I even feel an instinctive anger at the person who complains of medical symptoms, though I've also gotten angry at family members who wouldn't take symptoms seriously and get proper care.

In fact, three members of my immediate family died as a result of not seeking timely medical attention for severe physical symptoms. At the other end of the spectrum, one of my grandmothers was regarded as a hypochondriac by everyone in the family for years, until she eventually died of scleroderma, a very painful disease!

I don't know why I felt so sympathetic toward the Piano Man. It must be that he looked sweet in the photograph and I'm a bit of a sucker for art.

Steven said...

Having been confined in mental hospitals several times as a youth (for being suicidally depressed), I am quite of the opinion that anybody who wants to be committed is sufficiently insane that they should be committed.

SippicanCottage said...
This comment has been removed by the author.
amba said...

I love iocaste's story: the "crazy" patients had better bullshit (or authentic distress) detectors than the doctors!

If that isn't an argument for the shamanic "wounded healer," what is?

Freeman Hunt said...

I tend to be suspicious of illness. How many times has everyone seen this:

Person at work/school has been slagging off. Others start to notice the slagging off. Person suddenly comes down with vague sickness and misses work/school. Person returns and solemnly relates tales of their awful (but vague) illness.

I think people do this because subconciously they feel bad about being lazy and they feel sorry for themselves. They make themselves ill. Much better to be thought a sick person than a lazy person.

Incidentally, I also think that IBS is the new back pain. Some people actually have it, but it couldn't possibly be as many people as I have recently heard say that they have it.

george said...

Having viewed the mental health establishment from the outside for many years due to family involvement, I have no doubt that the patients are better able to tell if hospitalization is appropriate than the Doctors. The doctors see the patient only a few minutes a day if that. The patients interact with them all day. Unless one retreats from all contact with fellow patients the continual faking it is too hard to keep up. Similarly the family if minimaly understanding would recognize a severe case suitable for hospitalization. Physical ailments are another thing and Doctors probably are tremendously better in diagnosis.

ziemer said...

i once had a great aunt who had been in the hospital for MONTHS. one day, i got a call and went down there, and the social worker says she has to go to a nursing home. right away.

i finnagled two days more from her, and then told the aunt she has two options: either she can prove in two days that she's well enough to go home; or she's going to a nursing home.

within 24 hours, the social worker called me up talking about miracles. she also told me i was very insensitive when my response was "yeah, whatever."

i had been through this before, needless to say.

knoxgirl said...

Tonya: I saw that episode, it was hilarious! There's a movie coming out where Johnny Knoxville pretends to be slow in order to get into the Special Olympics. I'm not really a big fan of J.K. or the Farrelly Brothers, but I'm looking forward to this one...

Pogo said...

Doctors generally believe what their patients tell them about pain and medical symptoms. Unlike drug-seeking behavior, the benefits for pseudo-illness are opaque at best. (Imagine what an interview with a doc would be like if she always thought you were lying.)

Sure, it's easy to fool docs about illness, especially certain mental illness. Absent avoidance of prison, the upside to illness appears negative to most.

I would argue that it's a cultural expectation for MDs to believe what their patients tell them, unless proof otherwise is obtained. The police are expected to view the world in quite the opposite fashion.

Rockeye said...

I work at a hospital in Madison just a short walk from Land-Of-Althouse. On my unit we have three rooms used for prolonged epilepsy monitoring. What that means is that we hook patients who report epileptic symptoms to a brain wave monitor for as long as two weeks straight. A video camera which follows a transponder worn around their necks watches them with the added bonus of night vision.
The whole point is to have both a video and brain wave recording of their seizures. This was a long set-up but here's the payoff: at least half of the patients don't have epilepsy. Many have been using medications for decades, some have had brain stimulator implants (very major surgery,) most haven't worked or been able to have a drivers license for years.
My hospital serves a generally older and more male population. The other hospital in Madison that has an epilepsy monitoring program serves a more general crowd (i.e. younger and more females) and their rate of "pseudoseizures" is even higher than ours.
Why would anyone pretend to have seizures who doesn't really have them? Some do it to get a medical discharge from the military, others are hoping for medical disability payments. But based on my experience most of the pseudoseizure patients aren't faking it, per se. For whatever reason I see a constellation of other related complaints/diagnosis'/personal histories. 1. Severe chilhood sexual abuse, usually by a family member or trusted adult. 2. Diagnosed with depression AND anxiety disorders. 2. Severe physical abuse as a child and/or adult. 3. Migraine headaches. 4. Fibromyalgia. 5. Drug abuse. 6. And finally a long list of allergies.
Very strange and no doubt even with epilepsy removed from the equation these are generally some pretty messed up people. When informed by the neurologists that they don't really have epilepsy and instead would benefit more with psychiatric therapy the majority of the patients seem relieved.
My point is this; sometimes finding out if someone is really ill can be an awful lot of work. And when you find out that they don't have what you thought all it really means is that the patient has something else altogether (and not necessarily less severe.)