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This problem arises frequently in connection with both hysteria and sociopathy and the physician should know how to deal with it It is not a medical diagnosis except under the rare circumstances in which a patient is caught in the act of producing a sign of disease or confesses to having done so The term malingering refers to the conscious and deliberate feigning of illness or disability in order to attain a desired goal It does not appear as an isolated phenomenon, and its occurrence must be interpreted as a sign of a serious personality disturbance, often one that prevents effective work or military service, as a means of obtaining recompense for an alleged injury, although noteworthy exceptions to this statement can be found In the malingerer one may observe pain, hyperesthesia, anesthesia, limping gait, tremor, contracture, paralysis, amaurosis, deafness, stuttering, mutism, amnesia, pseudoconvulsions and fugues, unexplained gastrointestinal bleeding, and unexplained skin lesions in short, the same array of symptoms and signs, singly or in combination, as in the patients with compensation hysteria Certainly there is a similarity between hysteria and malingering, but the nature of the relationship is nebulous, and there may be great dif culty in establishing a clinical differentiation As Jones and Llewellyn have observed: Nothing resembles malingering more than hysteria; nothing, hysteria more than malingering In both alike we are confronted with the same discrepancy between fact and statement, objective sign and subjective symptom the outward aspect of health seemingly giving the lie to all the alleged functional disabilities We may examine the hysterical person and the malingerer, using the same tests, and get precisely the same results in one case as the other Most authors cite the following as the main points of difference between the two conditions: (1) The conscious or unconscious quality of the motivation, which seems more unconscious in the hysteria patient and more conscious in the malingerer (2) The in uence of persuasion, which is usually effective in hysteria and not in the malingerer (3) The attitude of the patient The hysteria patient appears more genuinely ill and invites examination; the malingerer seems less ill and evades examination The tendency of the sociopath to malinger has already been mentioned Most of the more obvious cases of malingering seen by the present authors have been in sociopaths, for which reason discussions of the two conditions have been juxtaposed A particular form of sociopathy or malingering, which consists essentially of systematically and speci cally deceiving the medical profession, has been described as Munchausen s syndrome named (not altogether aptly) after a seventeenth-century German soldier, Baron von Munchausen, who invented incredible tales of adventure and daring Ireland and colleagues, who analyzed 59 well-documented cases (45 men, 14 women), list the following characteristic features, which will be recognized at once by all neurologists with extensive hospital experience: feigned severe illness of a dramatic and emergency nature; factitious evidence of disease, surreptitious interference with diagnostic procedures, or self-mu-
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tilation; a history of many hospitalizations (sometimes more than a hundred); extensive travel or visits to innumerable physicians; evidence of laparotomy scars and cranial burr holes; pathologic lying; aggressive, unruly, evasive behavior; and, nally, regular departure from the hospital against medical advice Unlike the usual forms of compensation hysteria, an ulterior motive is not readily discernible The psychopathology of this syndrome is obscure It has been regarded by various experts as a form of sociopathy, malingering, and compensation hysteria, but the distinctions between them are too ambiguous to be of clinical value Probably the medical profession has placed too great a reliance on degree of conscious awareness of deception In such unstable and immature individuals, the terms conscious, unconscious, and deception are too subjective to be useful in practical work
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