Notes designed as an aid to professional education. Fatal hypoglycaemia from intentional insulin overdosage

Hypoglycemia: factitious and felonious

Factitious diseases are characterized by physical or psychologic symptoms that are voluntarily self-induced. These diseases are as old as mankind. Once called "malingerers," these patients must be distinguished from hysterics in whom symptoms are produced unconsciously. In factitious diseases, illness is produced by deliberate acts by the patient who when seeking medical help omits to mention them and may continue strenuously to deny them even when confronted with the evidence. Factitious diseases occur in patients who simulate or exaggerate symptoms or disability to obtain some kind of discernible personal gain or avoid an unpleasant situation; however, such actions may only produce disadvantages by exposing the patient to the risk of death or permanent injury. This has been described as Munchausen syndrome, which is probably a manifestation of severe psychiatric disease. The use of medicines or poisons to induce illness in others also produces a type of factitial disease and presents similar or greater difficulties in diagnosis. In both situations, the clinical history, ordinarily the most important clue to the correct diagnosis, is not only incomplete but often misleading. Sometimes referred to as Munchausen by proxy, this form of factitial disease may be impossible to distinguish from attempted murder or grievous bodily harm. The subtle differences between these disorders, if any, have not been discussed herein.