Job-hopping and factitious victimization.

To the Editor: As most readers are aware, factitious disorder (FD) involves a person's feigning or producing physical or psychological ailments that can range from infection and fever of unknown origin to bereavement and psychosis. The goal in FD has historically been viewed as the sick role, (1) with its attendant attention, nurturance, and lenience. However, a growing literature suggests that the primary goal of the role-playing in FD can be understood more generally as the pursuit of emotional satisfaction or security (in contrast, the goal in malingering is external and often tangible; examples include disability payments and opioids). Indeed, we believe that the sick role may simply be one of many roles that can be taken on illegitimately to serve psychological needs, a suggestion buttressed by Turner's (2) recent reformulation of the DSM-IV criteria for FD. This view is also supported by documented cases of FD, including at least one in the SMJ, (3) that involve the purloining of the role of "victim" (4) rather than "patient."

Interestingly, the experience of career consultants suggests that the role of unemployed person, a role that is widely understood and validated in our society, can be functionally similar to the sick or victim role. As subspecialists in FD and Munchausen syndrome, we have had several employment counselors report to us a subgroup of the unemployed who appear to pursue jobs but intentionally undermine placement, returning repeatedly for individual, time-intensive assistance. Their conclusion is that many of these individuals are seeking attention, concern, and social contact rather than job placement. In parallel to Parsons' (5) caveat that the sick person is to be indulged only to the extent that he or she earnestly tries to get well, the unemployed person generally has our sympathy only as long as he or she is sincerely pursuing work. Hoping to prompt further discussion, we suggest that both self-sabotaging employment behavior and the factitious illness scenario express the same underlying psychosocial mechanisms and that psychiatric or psychological services may be in order for "job-hoppers" who present themselves as victims of an employment system that cannot consistently accommodate them. Both factitious illness and self-defeating vocational activities serve as socially sanctioned refuges from the usual expectations made of fully functioning adults. Moreover, both roles shield their occupants from criticism or rejection. The personal vulnerabilities for this sort of refuge would include insecure attachment that makes these individuals particularly averse to the rejection that can occur with efforts at new jobs, and narcissistically high expectations that are virtually impossible to meet. Rather than coming down with a factitious fever or infection, they present themselves as down on their luck through no fault of their own (ie, as victims). We hope that this observation will prompt clinicians to focus their attention on the psychological and social processes that are manifested by those who fraudulently enact the victim role in its many diverse forms.

Marc D. Feldman, MD

Department of Psychiatry and Behavioral Medicine

University of Alabama 

Tuscaloosa, AL

James C. Hamilton, PhD

Department of Psychology

University of Alabama

Tuscaloosa, AL

References

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, pp 513-517.

2. Turner MA. Factitious disorders: reformulating the DSM-IV criteria. Psychosomatics 2006;47:23-32.

3. Feldman MD, Ford CV, Stone T. Deceiving others/deceiving oneself: four cases of factitious rape. South Med J 1994;87:736-738.

4. Feldman MD. Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York, Brunner-Routledge, 2004.

5. Parsons T. The Social System. Glencoe, The Free Press, 1951, pp 436-439.