The following have been cited as the main points of difference between the 2 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 influence of persuasion, which is usually effective in hysteria and not in the malingerer; and (3) the attitude of the patient. The patient with hysteria appears more genuinely ill and invites examination; the malingerer seems less ill and evades examination. Most of the more obvious cases of malingering seen by the present authors have been in sociopaths, for which reason discussions of the 2 conditions have been juxtaposed here.
A particular form of sociopathy or malingering, which consists essentially of systematically and specifically deceiving the medical profession, has been described as Munchausen’s syndrome—named (not altogether aptly) after a 17th-century German soldier, Baron von Munchausen, who invented incredible tales of adventure and daring. Ireland and colleagues, who analyzed 59 cases (45 men, 14 women), listed 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-mutilation; a history of many hospitalizations (sometimes more than 100); extensive travel or visits to innumerable physicians; and, finally, regular departure from the hospital against medical advice. Unlike the usual forms of compensation hysteria, an ulterior motive is not readily discernible and the psychopathology of this syndrome is obscure. It has been regarded by various experts as a form of sociopathy, malingering, or 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 uncertain to be useful.
Designated by this title is an uncommon disorder, the characteristic feature of which is the occurrence of repetitive, unpredictable outbursts of violent, aggressive behavior disproportionate to the provoking situation. This condition needs to be set apart from the uncontrollable outbursts that sometimes are associated with dementia, mental retardation, schizophrenia, drug addiction, or alcoholism, or those that follow serious head injuries or other brain diseases. Neurologic opinions have been solicited on our services for patients afflicted with this condition, the question usually being one of seizures as a cause of the aberrant behavior. Some persons with intermittent explosive disorder have, from early childhood, reacted to frustration with a loss of self-control, striking out in blind rage at anyone who crossed them (episodic dyscontrol syndrome); as adults, they may inflict serious injury or kill. Lesser degrees are recognized as expressions of “hot temper.” Sometimes such behavior appears to be a continuation of the temper tantrums of earlier childhood. What is surprising in some of our patients has been a discrepancy between this episodic behavior and a pleasant and concerned demeanor at other times. Such patients are aware of the inappropriate nature of their behavior and its impact on others; they express remorse and may seek medical assistance to mute the outbursts. Others, of course, have no such insight and their anger episodes are simply an extension of their sociopathy.