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Munchausen Syndrome, Factitious Disorder and MalingeringGail H. Mallett
Much has been written regarding Munchausen Syndrome, Factitious Disorders and Malingering, focusing upon defining these disorders, as well as diagnosing them. This author suggests the need for further research regarding the etiology of such disorders. Is there a particular background or demographic history, that may result in a predisposition to such disorders? In particular, this author seeks information that may explore the notion that many people suffering from these disorders may be the offspring of medical personnel (such as doctors), and may be seeking attention that they feel had been directed elsewhere (toward the sick) during their childhood or lifetime. This paper will explore these disorders, as well as any information that may point toward this theory.
has been written that defines Munchausen Syndrome, factitious disorder
malingering. In fact, there is some conflicting information in the
in terms of the distinction among these disorders. There are several
authors/sources that regard Munchausen Syndrome and factitious disorder
Generally, Munchausen Syndrome is a condition in which a person intentionally fakes, simulates, worsens or self-induces an injury or illness for the main purpose of being treated like a medical patient (eMedicine, 2003). It is a psychiatric disorder in which the physical or psychological symptoms are under the voluntary control of the patient (HealthAtoZ, 2006). It is named after a German military man, Baron von Munchausen, who was reported to travel around telling fantastic tales about his imaginary exploits (eMedicine, 2003). The name was applied in 1951 to persons who traveled around from hospital to hospital, fabricating various illnesses, by Richard Asher (eMedicine, 2003). It is often used interchangeably with factitious disorder, although factitious disorder often refers to any illness that is intentionally produced for the main purpose of assuming the sick role, with that purpose often unknown to the sick person (eMedicine, 2003). It is not a new, modern disorder; the philosopher Galen, in the second century, reported observations of factitious disorder (Feldman & Ford, 1994). Karl Menninger, in 1934, reported on persons with a “doctor addiction”, marked by intense aggression against oneself and the physician, whom Menninger believed symbolized the “perceived sadistic parent” (Feldman & Ford, 1994, p.25).
Munchausen Syndrome may then be characterized as a chronic variant of a factitious disorder, with mostly physical signs and symptoms (eMedicine, 2003). There is much literature denoting the psychological or psychiatric Munchausen Syndrome (where persons feign psychiatric symptoms), but this paper will focus upon medical Munchausen and factitious disorder, as well as malingering.
Persons suffering from Munchausen Syndrome will intentionally cause signs and symptoms of an illness or injury by inflicting medical harm to their body, often to the point of having to be hospitalized; these people are often eager to undergo serious and invasive medical interventions (eMedicine, 2003). They are also known to move from doctor to doctor, hospital to hospital, or even town to town, in an effort to find new audiences for their medical claims; once they have exhausted the options available to them regarding treatment and medical workups in one medical setting, they will try others (eMedicine, 2003). It seems to be motivated by a need to be a patient (HealthAtoZ, 2006). Interestingly, persons with Munchausen Syndrome may also make false claims as to their accomplishments, credentials, relations to famous persons, etc. (eMedicine, 2003). A related condition, named Munchausen by Proxy, refers to a caregiver who fakes symptoms in a child or other person under their care, by deliberately causing injury to that person; they then will often want to be with that person in a hospital or similar medical setting (eMedicine, 2003). They may only exaggerate or fabricate their child’s symptoms, or they may deliberately induce symptoms through such methods as poisoning, starvation, suffocation or actually infecting a child’s bloodstream (HealthAtoZ, 2006).
Persons with Munchausen Syndrome will knowingly fake symptoms, but usually do so for psychological reasons, and not for monetary or other discrete objectives, as in the case of malingering (PsychNet-UK, 2003). Their series of successive hospitalizations tends to become a lifelong pattern, accompanied by internal, psychological motivation, as opposed to external rewards (PsychNet-UK, 2003). They will follow through with medical procedures and are often at risk for drug addiction and for the many complications that might accompany multiple surgeries (PsychNet-UK, 2003). People with factitious disorder are such expert liars that they appear to share characteristics with persons who have an antisocial personality disorder (Healthinmind, 2003). They appear, to an outsider, to share characteristics of a masochist, as they will arrange to cause pain to themselves through surgeries and other treatments (Healthinmind, 2003).
Another interesting manifestation of Munchausen Syndrome is Munchausen by Internet, where persons will utilize the internet to perpetuate their claims of serious illnesses and symptomology (Feldman, 2001). The internet can be a very helpful source of information and support for persons who are suffering from chronic illnesses, particularly those who may be confined to their homes as a result of their illnesses; however, persons who engage in Munchausen by Internet take advantage of this opportunity by going from site to site, support group to support group, telling tales of their grievous afflictions (Feldman, 2001).They can simplify the real-life process of going from hospital to hospital by joining multiple internet groups simultaneously; they can pretend to have several illnesses at once, and can gain a great deal of sympathy as a result (Feldman, 2001). Or, they can even pretend to be the loved one or parent of a person with a serious illness, again gaining sympathy from many others (Feldman, 2001).
There have also been cases of children themselves faking illnesses; there have been cases of children (as young as eight years old) that have convinced their caregivers that they are suffering from chronic illnesses (DeNoon, 2000). One case documents a girl who was thought to have suffered from a mysterious fever from the age of twelve until seventeen; however, it was discovered that she had been faking thermometer readings (DeNoon, 2000).There have also been cases where children had inflicted serious harm upon themselves or fooled doctors into admitting them for prolonged hospital stays or repeated operations (DeNoon, 2000). These children, if left untreated, will go on to become adults who repeatedly fake illness (DeNoon, 2000).
The main or central theme to all definitions of malingering is that the term applies to persons who deliberately pretend to have an illness or disability in order to receive financial or other gain, or to avoid punishment or responsibility (Booth, 2006). Personal gain is always the motivation behind malingering; persons who malinger will feign an illness in order to seek an external reward (Booth, 2006). Examples would be a criminal who wants to avoid punishment, someone who wishes to be paid for a nonexistent disability, or someone who is simply avoiding responsibility (Booth, 2006).
Malingering is the purposeful exaggeration of real symptoms, physical or psychological. in order to receive some kind of reward. Malaingering can take many forms; persons can feign either mental or physical illnesses. In the case of mental illness, with very little coaching, a person can easily simulate the symptoms of major depressive disorder, post-traumatic stress disorder or panic disorder with agoraphobia (Booth, 2006). Regarding more physical disorders, general symptoms such as headaches, dizziness, low back pain and stomach pain are easily manufactured; x-rays, magnetic resonance imaging (MRI), or CAT scans are often unable to determine a physical cause (Booth, 2006).
Interestingly, fakers will use less severe symptoms to escape detection; it is theorized that the feigning of more severe mental and physical disorders is more difficult to maintain. On measures designed to detect malingering, persons who successfully fake symptoms endorse fewer actual symptoms, staying away from unduly strange or bizarre symptoms (Booth, 2006).
Due to the difficulty of detecting malingering, its actual incidence is unknown (Booth, 2006). If a disorder is determined as having no basis in fact, then the diagnostician must consider the possibilities of either malingering or factitious disorder. Factitious disorder is a legitimate malady, where malingering is not; both involve feigned illnesses (Booth, 2006). In the case of factitious disorder, the person produces fake symptoms to fulfill the need to maintain the sick role-they may seek an emotional gain (Booth, 2006).Being sick gives the person with factitious disorder attention from physicians and sympathy from loved ones; this goal is not the same as the malingerer’s, whose motivation is always external (Booth, 2006). The malingerer is usually seeking to accomplish one of three things: evade hard or dangerous situations, punishment or responsibility; gain rewards such as free income, source of drugs, sanctuary from police or free hospital care; or avenge a monetary loss, legal ruling or job termination (Booth, 2006). It is usually suspected when a person is referred for evaluation by an attorney, or when there is a noticeable and distinct difference between the level of reported distress or disability and the actual functioning level of the person (observed at work, at leisure or at home) (Booth, 2006).
The person who is malingering frequently is uncooperative for an evaluation. In addition, persons who malinger are also often diagnosed with an antisocial personality disorder (Booth, 2006). In malingering, the person’s medical condition, while once existing, or greatly exaggerated (as in the case of low back pain, for which months of chiropractic care or physical therapy results in no improvement) (PsychNet-UK, 2003). Or, an accident is staged so that an injury is either caused, or can be claimed; the malingerer (as opposed to the Munchausen patient) is often unwilling to undergo extensive or painful diagnostic testing, treatment or surgery (PsychNet-UK, 2003). Malingering is often suspected if the patient’s symptoms are presented in a medicolegal context, or if there is a marked discrepancy between the person’s claimed disability and the objective findings (Wikipedia, 2006).
In the case of medical malingering, it is difficult for doctors who are presented with patients who claim a confusing variety of symptomology, consisting of a confusing collection of musculoskeletal complaints (Kiester & Duke, 1999). Oftentimes, their evaluation does not suggest a definitive diagnosis, but physicians are reluctant to merely pass it off as being “all in their heads”, in case they may be missing a genuine injury or disability. For this reason, many doctors are utilizing the eight Waddell signs that are very useful in identifying nonorganic back pain (Kiester & Duke, 1999). It is a systematic approach that appears to be an effective way to help patients receive the best treatment for their true condition, and may avoid long and expensive periods of testing and treatment.
Nonorganic pain can be a deliberate deception or a process that is unknown to the patient (Kiester & Duke, 1999). It includes malingering motivated by secondary gain, Munchausen’s Syndrome and psychosomatic disorders.
Through a thorough knowledge of neuroanatomy, as well as the effects of organic pain syndromes upon various nerves, muscles and bodily functions, the physician conducting the examination for Waddell signs can distinguish real from imagined or feigned pain (Kiester & Duke, 1999). An examination for these eight signs include: superficial tenderness; nonanatomic tenderness; axial loading; simulated rotation; distracted straight-leg raise; regional sensory change; regional weakness; and overreaction (Kiester & Duke, 1999). The predictive value of this process is greatly improved when three or more positive signs are present.
The idea behind these signs is that a person who is presenting with back pain will react with pain when many different manipulations are conducted; the average person does not have a sophisticated knowledge of many of the specific neuropathways that certain musculoskeletal pain takes. Therefore, their statement of pain may not always be consistent with the injury they are claiming, and the Waddell Signs are very specific to certain types of back pain. It is a very useful tool to a differential diagnosis of back injury versus nonorganic pain.
The assessment of malingering can be very difficult; for that reason, most clinicians find it helpful and necessary to employ standardized assessments to help them in this most difficult process. Several standardized assessments have been reviewed that might be utilized in the assessment of malingering (Pope, 2005). Those that are cited here might be used to detect medical malingering.
It appears that there are many instruments designed to detect malingering among brain injured claimants and those who may be feigning mental illness. However, there are not as many instruments that assess maligning of other disorders, suggesting that is, indeed, a difficult disorder to diagnose. Assessment instruments that are useful in this respect are often designed to focus upon the person’s claims and presentation of symptoms; they appear to be designed to assess consistency in patient response, as well as patterns of exaggeration.
Interestingly, a review in the American Journal of Forensic Psychology in 2002 concluded that the DSM-IV is far too limited in its definition to be considered a reliable method of detecting malingering, and by its language, may frequently lead to false positives (Gerson, 2002). Another review suggests, using data from the TOMM, that malingering tests themselves, though very accurate, can be imperfect, because the test results of honest responders overlap with those of test takers who are feigning or exaggerating (Mossman, 2003).
In order to assess reports of pain, the McGill Pain Questionnaire (MPQ) and the Modified Somatic Perception Questionnaire (MSPQ) were compared (Larrabee, 2003). The study found that the MPQ was better than the MSPQ at detecting exaggerated pain symptoms; however, the author cautions that elevations in scores should not be used independently to detect malingering (Larrabee, 2003). A study of the Lees-Haley Fake Bad Scale and its ability to measure somatic malingering was utilized on 408 persons in a chronic pain group (among other groups) (Butcher, Arbisib, Atlisa & McNulty, 2003). The study found that the FBS is more likely to measure general maladjustment and somatic complaints, rather than malingering. When malingering takes on a legal context, evidence is often gathered by a private investigator (e.g., videotaping a “paralyzed” person dancing at a party, or even walking around their home) (Wikipedia, 2006).
It is very difficult to measure or detect malingering, and there are few standardized instruments available to help in the cases of persons who continually present to doctors with chronic complaints. Therefore, assessment is complex, and must address many facets of the person, including a thorough examination of psychological factors, such as overall maladjustment or personality disorders. Malingering is often thought of as intentional deceptive behavior, and not a medical or psychiatric disorder (Med League Support Services, 2006).
difficult to diagnose or identify persons with Munchausen or factitious
disorder because they often move from one doctor or hospital to
particularly when they feel that they are in danger of being discovered
(eMedicine, 2003). One method to track persons who present with chronic
appearances at hospitals or clinics has been implemented by the state
These patients make the simulation of disease the center of their lives; their constant illnesses result in joblessness and drifting behavior (Feldman & Ford, 1994). Their self-destructive, itinerant behavior often puts them at odds with the law, and can push them over the line that separates Munchausen from malingering; they may use their symptoms to gain room and board, or other types of ill-gotten gain (such as social security payments that allow them to continue to be sick) (Feldman & Ford, 1994).
Munchausen by internet can be suspected if the person’s claims mimic the writing of previously published accounts of the disease from journals, books or other health-related websites (Feldman, 2001). If the person feigning the illness emerges as a caricature, or they alternate between near-fatal bouts of illness and miraculous recoveries, or there are continual dramatic events in the person’s life, Munchausen by internet can be suspected (Feldman, 2001).
Little is known regarding the etiology or psychopathology of factitious disorders with physical or psychological symptoms (Szoke, 1999).Some possible predisposing factors may include: the presence of other mental disorders or general medical conditions during childhood or adolescence that may have led to extensive medical treatment and hospitalization; family disruption or emotional and/or physical abuse in childhood; a grudge against the medical profession; employment in a medically-related position; and the presence of a severe personality disorder (Feldman, 2004).
Besides the aforementioned difficulties with diagnosis, the reluctance of these patients to undergo psychological testing or treatment make it all the more difficult to associate certain personality characteristics with these disorders (Healthinmind, 2003). Demographically, one study showed that 65% of the persons identified with Munchausen Syndrome and/or factitious disorders (they are used interchangeably in this study) were male (Szoke, 1999). Age of onset for these disorders was 25.8 years, and 83% were single (Szoke, 1999). Of the persons involved in the study, 60% were presenting with factitious physical disorders (Szoke, 1999). Some researchers have suggested that patients with factitious disorder often present in childhood with traumatic events, such as abuse and deprivation, as well as numerous hospitalizations; as adults, they lack support from relatives and friends (Szoke, 1999). Because they lack such support, it has been theorized that hospitalization is unconsciously used to recreate the desired parent-child bond that they lacked in reality (Kaplan, Sadock & Grebb, 1994).
It has also been theorized that a factitious disorder allows the patient to feel in control in a way that they never did in childhood; it is a coping mechanism, learned and reinforced in childhood (Szoke, 1999). These patients often resemble persons with borderline personality in that they manifest identity disturbance, unstable interpersonal relationships and recurrent suicidal or self-mutilating behaviors; in addition, their deceitfulness, lack of remorse, reckless disregard for their own safety and repeated failure to sustain consistent work behavior resemble antisocial personality disorder (Szoke, 1999). It has also been theorized that Munchausen patients are motivated by a desire to be cared for, a need for attention, dependency, an ambivalence toward doctors or an existing personality disorder (HealthAtoZ, 2002). They may delight in outwitting the medical profession, whom they regard as highly trained (Feldman, 2004).
Some persons suggest that Munchausen syndrome is a defense mechanism against sexual and aggressive impulses; others believe that it is a form of self-punishment (eMedicine, 2003). They may hold a positive regard for their own self-inflicted pain as proof of their boundaries and selfhood; it may be the result of a psychic conflict turned outward, or may be a way of expressing abuse and taking control over it (Feldman, 2004). The determination of an exact cause is made more difficult by the fact that those who are afflicted are generally not open and honest (eMedicine, 2003). Often, these persons have an early history of emotional and physical abuse; they have problems with their identity, have intense feelings, inadequate impulse control, a deficient sense of reality, brief psychotic episodes and unstable interpersonal relationships (Merck Manual, 2006). They may have been trained by parents or caregivers to be deceptive or dishonest (Feldman & Eisendrath, 1996). They appear to have a desperate need to find the caring they often had not received elsewhere in their lives; they often learn that whatever nurturance they might receive in life would have to come from doctors and nurses (Feldman & Ford, 1994). Their need to be taken care of may conflict with their inability to trust authority figures, and they continually manipulate and provoke such figures; they may exhibit feelings of guilt and an associated need for punishment (Merck Manual, 2006). Pain may remind them that they are real, and pain may actually organize them; pain results in their becoming patients, giving them a definitive role in life (Feldman, 2004). They may view pain as having spiritually redeeming qualities, and they seek pain as a form of punishment (Feldman, 2004).
Factitious disorders are a natural outgrowth of a relatively harmless, normal behavior, that of “playing sick”; however, persons with factitious disorders take this role to pathological extremes, that profoundly affect their own lives as well as the lives of those around them (Feldman & Ford, 1994). Although it is surmised that many of these persons come from turbulent childhood homes, recent research suggests that these patients may have underlying brain dysfunction that may predispose them to pathological lying and factitious illness behavior (Feldman & Ford, 1994). Or, they may find that the assumption of a sick role effectively permits them to avoid responsibilities and duties of life (Feldman, 2004).
Patients with Munchausen Syndrome are rarely treated successfully; acceding to their manipulations may merely relieve tension temporarily, but their provocations will escalate, and ultimately exceed what physicians are willing to do for them (Merck Manual, 2006). Doctors are advised not to merely dismiss patients who are presenting with nonorganic pain, as these patients are often very psychologically invested in their pain (Kiester & Duke, 1999). They should be confronted with their diagnosis without suggesting guilt or reproach (Merck Manual, 2006). They suggest giving patients a “ladder to climb out of their symptoms,” by explaining to them that they do not have a serious physical problem, and then directing them to therapies that can help them (Kiester & Duke, 1999). These therapies may include psychotherapy. Those found to be malingerers should be told outright that they cannot help them; this is useful in maintaining the integrity of the doctor, while not enabling the patient. It is suggested that examining doctors not assume that there are no physical problems co-occurring with a factitious disorder; they also suggest that the patient be kept in the hospital and placed in long-term treatment with a mental health professional, despite the small likelihood that the factitious disorder will be cured (Healthinmind, 2003). It has also been suggested that a child that is being victimized by a case of Munchausen by Proxy be hospitalized in an effort to protect them from the perpetrator (Healthinmind, 2003).
The prognosis for persons with factitious disorder and Munchausen syndrome is not easily known, as these people are often lost to follow-up, since they tend to move around from doctor to doctor; however, the course is often chronic, with numerous hospitalizations, beginning in adolescence or early adulthood, and lasting into the late 40’s (Szoke, 1999). Diagnoses of persons older than that are rare; perhaps because they have become so adept at faking symptomology (Szoke, 1999).
Overall, the results of therapy are disappointing; treatment is often focused upon management of symptoms, rather than a cure (Szoke, 1999). Persons afflicted are rarely treated successfully, and they often experience long-term medical complications from induced illnesses or the mechanisms and surgeries used to treat them (eMedicine, 2003). Early recognition of the disorder is important, and just as important is the establishment of an enduring and stable doctor-patient relationship (Szoke, 1999). This can lead to an approach known as a contract conference, whereby the physician or psychiatrist encourages the patient to express themselves in the language of difficult relationships, feelings and problems of living, rather than in the language of illness (Szoke, 1999). Therapy should focus upon the discovery of the underlying emotional problem that has caused such a need for sympathy in the patient (Feldman, 1998). Such strategies as hospitals sharing medical records may reduce the number of hospitalizations for Munchausen patients, but it does not address the underlying disorder; this may also endanger patients who have made themselves ill and may require treatment (HealthAtoZ, 2002).
Medications that have been used with some success have included drugs for depression (such as SSRI’s) and antipsychotic drugs (that address symptoms that are consistent with borderline personality disorder) (eMedicine, 2003).
Being knowledgeable about factitious disorder in general and the various motivations behind it is central to any hope of treating these individuals, because they are so good at what they do (Feldman, 2004). In addition, giving the patient information about their actual disorder (factitious disorder or Munchausen Syndrome) can be helpful and liberating for them; it sometimes helps them to know that they actually do have a disorder, and may reduce their need to feign a physical disorder (Feldman, 2004).
However, merely confronting a patient with suspicions of factitious disorder can lead to dire consequences, namely, the threat of malpractice; although it seems unfair, many factitious disorder patients can and do bring malpractice suits against doctors and others (Feldman, 2004). They may sue when doctors refuse to continue treatment, or when they wish to find physicians responsible for the worsening of their symptoms (when they, the patients, are responsible). Occasionally, judgments have been rendered against physicians or other defendants who were involved in these cases (Feldman, 2004). Even more disturbing, a patient once sued 35 doctors (collectively, for 14 million dollars), after feigning cancer for several years, because they had failed to recognize and treat her for factitious disorder; the insurance companies settled out of court for more than a quarter of a million dollars (Feldman, 2004). This does emphasize the fact that early recognition of this disorder is important.A multimodal approach to treatment has proven to be effective in some cases; such treatment might involve devising a treatment plan that will: increase the patient’s self-esteem and sense of control; help to build better interpersonal relationships; and promote other interests that might occupy their time (Feldman, 2004). Recovery can sometimes take place as a result of a fortuitous life change (such as a positive, caring life partner or a job that the person really enjoys); relationships that exist outside of medical settings seem to be a positive influence (Feldman, 2004). However, as with other addictions, the impulse to continue the factitious behaviors still continues, even in the cases of recovery, resulting in ongoing battles against such impulses (Feldman, 2004). The prognosis for persons suffering from Munchausen and factitious disorder is guarded (Feldman, 2004).
Implications for Further Research
It is very difficult to make generalizations about persons with factitious disorders, and medical professionals should look at these individuals in the broadest of terms, overlooking nothing as a possible cause (Feldman, 2004). Very little research has been done regarding the background and family history of persons with factitious disorder, Munchausen Syndrome and malingering. There is a surprising lack of evidence regarding the families of origin of these patients; they come to hospitals, cause uproar and display drama, but disappear just as quickly once they are discovered (Feldman, 2004). This would be an interesting area to research, and many theories regarding the etiology of these disorders point to the possibility that the children of physicians may be prone to this disorder. However, this theory should be used with reservation and restriction; not all children of physicians have been neglected emotionally, but some may have been. If persons with Munchausen Syndrome and factitious disorder are seeking attention and comfort that they did not receive as children, then any person who was neglected emotionally might be at risk. It would appear that the children of physicians might be more prone to these disorders, rather than malingering, as they might be seeking emotional gain, rather than a definitive secondary gain, such as money.
If one wanted to determine how many factitious disorder sufferers are the children of physicians, then one could ask the “frequent flyers” in hospitals and clinics to fill out social history questionnaires. However, since many persons will flee once they are asked for too much information, they may simply avoid filling out the questionnaire, and may go elsewhere. Or, since it has been established that many of these sufferers tend to fabricate the details of their lives, they may not answer such questions truthfully. Only a small percentage of patients will allow medical personnel to contact their families, so not much is known about them (Feldman, 2004).
It appears that it is more accurate to suggest that persons who suffer from Munchausen and factitious disorder have a general history of emotional deprivation, whether it be by a physician parent or anyone else who did not view meeting the emotional needs of their children as a priority. Research ahs shown that rejecting a child may result in the development of a factitious disorder (Feldman & Eisendrath, 1996). However, research has also shown that ignoring a child is even more destructive emotionally than rejection; this occurs when a parent deprives the child of essential stimulation and responsiveness by virtue of parental incapacity or preoccupation (Feldman & Eisendrath, 1996). This, by itself, will not always result in a factitious disorder, however, as not all emotionally neglected persons present with false medical claims. Perhaps a concomitant personality disorder, such as antisocial personality or borderline personality, explains the manifestation of the disorder. But, it does present as an interesting theory to suggest that a person who is neglected emotionally by a doctor might go on to seek the attention of other doctors in order to compensate.
Another interesting area of study might focus upon the fate of persons who present for years with factitious disorders; as mentioned previously, patients who present for multiple surgeries, or who continually harm themselves in order to continue and worsen symptoms, will no doubt suffer dire physical consequences. In one case, a woman who had been feigning many illnesses expired from the use (as prescribed, not abused) of the 21 medications that had been prescribed for her by various doctors; the use and interaction of these medicines caused organ damage that was severe enough to culminate in her death (Feldman, 2004).
Research might also be undertaken
regarding the satisfaction of debts, and incidence of fraud prosecution
persons who seek medical treatment under fraudulent circumstances. Many
these patients rely upon private insurance carriers; or, in the case
have rendered themselves unemployable, they rely upon Medicare,
other payers to absorb their costs (Feldman, 2004). Or, they simply do
their medical bills. In some states, it is illegal to seek medical
fraudulently (such as
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