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Article Abstract

Medically Self-Sabotaging Behavior and Multiple Symptoms on the Review of Systems

To the Editor: A minority of primary care patients report multiple symptoms during routine reviews of systems. We explored any correlation between intentionally sabotaging one’s own medical care (ie, an overall psychological need to maintain numerous physical symptoms, authentic or not) and multiple somatic symptoms as reported on a review of symptoms.

Method. Participants were men and women, aged 18 years or older, in an outpatient internal medicine clinic staffed predominantly by residents. We excluded individuals with medical, intellectual, cognitive, or psychiatric symptoms that would preclude the ability to complete a survey.

One of the authors (C.L.) remained in the lobby, approached incoming patients, and informally assessed exclusion criteria. With potential candidates, she reviewed the project and invited each to complete a survey.

The survey consisted of 3 sections: (1) a demographic query; (2) the Self-Harm Inventory,1 from which we selected 3 items related to medical sabotage: “Have you ever intentionally, or on purpose, prevented wounds from healing,” “made medical situations worse on purpose,” or “abused prescription medication?”; and (3) a symptom checklist of 35 items, adapted from a preappointment questionnaire by Sinsky,2 which were preceded by the question, “Have you experienced any of the following symptoms in the past week?” with yes/no response options.

Results. At the outset, 417 of 471 individuals approached agreed to participate, for a participation rate of 88.5%. Of these, 367 completed all study measures—124 men and 243 women, aged 19-97 years (mean = 50.13, SD = 15.46). Most (88.0%) were white (African American, 7.9%; other, 2.2%; Hispanic, 1.1%; Asian, 0.8%). All but 6.6% reported having attained at least a high school diploma, with 28.7% of the sample reporting a bachelor’s degree or higher.

Nineteen (5.2%) indicated ever having prevented wounds from healing, 25 (6.8%) indicated ever having made a medical situation worse on purpose, and 36 (9.8%) indicated ever having abused prescription medication. The number of endorsed symptoms in the review of systems ranged from 0 to 32 (mean = 6.87, SD = 5.95), with 89.9% endorsing at least 1 symptom. The mean number of such symptoms was greater for respondents who indicated a history of preventing wounds from healing (mean = 12.68, SD = 6.01) than for those who denied such a history (mean = 6.56, SD = 5.79; F1,365 = 20.07, P < .001). Similarly, the mean number of such symptoms was greater for respondents who indicated a history of having made medical situations worse (mean = 11.12, SD = 7.65) than for those who denied such a history (mean = 6.56, SD = 5.70; F1,365 = 14.13, P < .001). However, the mean number of endorsed symptoms was not greater for those who indicated a history of abusing prescription medication (mean = 8.43, SD = 6.25) than for those who denied such a history (mean = 6.71, SD = 5.91; F1,365 = 2.69, P < .12).

These findings suggest that 2 forms of volitional medical self-sabotage—preventing wounds from healing and making medical situations worse on purpose—may be associated with and contribute to numerous physical symptoms on a review of systems. They also broach the deeper question of whether, in some patients, medical self-sabotaging symptoms and multiple self-reported symptoms in the review of systems purposefully function to engage health care professionals, maintain an illness identity, and/or self-sabotage a healthy lifestyle by promoting a sense of disability. Only further research will tease out the underlying psychological functions of these patient behaviors.


1. Sansone RA, Wiederman MW, Sansone LA. The Self-Harm Inventory (SHI): development of a scale for identifying self-destructive behaviors and borderline personality disorder. J Clin Psychol. 1998;54(7):973-983. PubMed doi:10.1002/(SICI)1097-4679(199811)54:7<973::AID-JCLP11>3.0.CO;2-H

2. Sinsky CA. Improving office practice: working smarter, not harder. Fam Pract Manag. 2006;13(10):28-34. PubMed

Randy A. Sansone, MD

Charlene Lam, MD, MPH

Michael W. Wiederman, PhD

Author affiliations: Departments of Psychiatry and Internal Medicine, Wright State University School of Medicine, Dayton (Dr Sansone); Kettering Medical Center, Kettering (Drs Sansone and Lam), Ohio; and Department of Human Relations, Columbia College, Columbia, South Carolina (Dr Wiederman).

Potential conflicts of interest: None reported.

Funding/support: None reported.

Published online: July 7, 2011 (doi:10.4088/PCC.10l01128).