- Gary is a patient described in the book “Head First” who continued to show up in ERs with seizures.
- It turned out he’d been inducing his symptoms with insulin pills and had “fictitious disorder.”
- The overlooked psychiatric condition leads patients to make themselves sick to remain in medical care.
Gary arrived in the emergency department light-headed, in abdominal pain, and unable to concentrate. Then, he had a seizure and fell into a coma.
Doctors discovered his blood sugar was low, and revived him through a glucose IV. They thought he had a rare tumor that releases dangerous levels of insulin, but all tests came up clear.
The next night, the scenario repeated: Gary at the ER, with a seizure that led to a coma that was successfully treated with glucose infusions.
The 24-year-old had turned up at at least a half dozen ERs in the UK in the months prior with the same unexplained symptoms. He never stuck around long enough to help doctors figure out why.
In his new book, “Head First,” British psychiatrist Dr. Alastair Santhouse describes how he and colleagues finally discovered the cause of Gary’s symptoms — insulin pills he was sneaking to induce them — and the strange and often overlooked mental illness that leads patients like him to make themselves sick.
A nurse discovered Gary’s insulin pills, but he denied taking them at first
A few days after his last episode, a nurse discovered insulin pills by Gary’s bedside. The meds can be critical for people with
who need them to lower blood sugar levels, but they’re dangerous for those with normal blood sugar — leading to, as Gary experienced, symptoms like dizziness, confusion, and fainting.
At first, Gary, identified only by his first name in the book, denied taking the pills but then admitted to snagging them from his grandfather’s cabinet. The medical team called in Santhouse, a consultant psychiatrist at two hospitals and past president of the psychiatry council at the Royal Society of Medicine, for help. They’d “resolved one problem but now had another: They didn’t know how they were going to be able to safely discharge him home,” Santhouse writes.
Fictitious disorder is likely underdiagnosed
Gary’s among about 1% of inpatient hospital cases of“fictitious disorder,” severe cases of which were called Munchausen’s syndrome, Santhouse explained, or when patients purposefully induce symptoms but hide that from clinicians.
Santhouse also saw someone who continued to fake a shoulder dislocation and another who underwent multiple abdominal surgeries despite any true medical problem. Others may prick their fingers to draw blood in order to dirty their urine samples.
The widely overlooked and dangerous condition is different than malingering, Santhouse said, in which people fake sickness for a clear gain, like getting sick benefits. “Patients with factitious disorder also deliberately fake their symptoms, yet the reasons they do so are less clear, not only to the doctor but also to the patients themselves,” he writes.
One theory is that a patient wants to embody “the sick role” so that a doctor can “legitimize his suffering by making a diagnosis and excuse the individual from his normal social responsibilities, such as going to work,” Santhouse says. Rather than following the doctor’s advice for getting well, the patient continues to make himself sick, remaining in medical care.
Gary’s unstable upbringing may have played a role in his behavior
For Gary, who saw Santhouse a handful of times, the problem began after he felt dismissed by his doctor for stomach pain. He realized the pills gave him symptoms doctors took seriously.
Santhouse also learned Gary had an abusive, unstable childhood and few hobbies or close relationships. He suggested Gary was seeking care from professionals given his “childhood of neglect,” but Gary just shrugged. Gary brushed off the danger of the situation too, and soon stopped going to therapy.
“The most likely outcome was that he would continue to take the tablets and would play out this same scenario in other hospitals where he was not known, with all the risks that entailed,” Santhouse writes. “I never saw him again.”