A 38-year-old female nurse presents to the emergency department with an apparent seizure. This is her seventh ED visit in 4 months across three different hospitals. Chart review reveals she has injected herself with insulin to produce hypoglycemic episodes and added blood to her urine samples. When confronted with these findings, she becomes tearful but cannot articulate why she engages in these behaviors. There is no pending disability claim, no litigation, and no identifiable external incentive. Between hospitalizations, she actively seeks out new providers and has told friends she has a 'rare medical condition.'