Stranger Than Fiction

Physicians are familiar with encountering patients who are unwell – which is in no way surprising. Many will have also treated (and potentially counseled) patients who are overly anxious about a minor issue – or prone to exaggeration. But only occasionally do ‘patients’ present themselves with a complaint that, upon further inspection, exhibits entirely fabricated – or even self-induced – symptoms. Such patients will lie, may cover up sources of information that contradict them, can become hostile if questioned, and sometimes go so far as to harm themselves to maintain the fantasy they have created.

The terms, “Factitious disorder” (FD) – and perhaps the more familiar and extreme, “Munchausen syndrome” – account for those patients who invent illnesses or injuries for psychological reasons and attempt to deceive the professionals involved in their care. Although these patients are most likely to report endocrinological, cardiological or dermatological problems (1), they can be observed faking conditions across the medical spectrum, including ophthalmic disorders. In some extreme examples, patients have even feigned binocular blindness (2). Patients who are malingering, or who have conversion syndrome, may also describe symptoms they are not experiencing – but with different aims. But how can these patients be spotted and what is the most appropriate way to proceed with their care? To find out the best ways of separating fact from fiction, we spoke with psychiatrist Marc Feldman – an expert on Munchausen syndrome and factitious disorder, and Valerie Purvin – a neuroophthalmologist with extensive experience in dealing with patients whose vision problems are only in their minds.

Tales of the Unexpected

Truth, Lies, and Ophthalmology