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A Doherty,JD Sheehan
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AM Doherty, JD Sheehan
Department of Adult Psychiatry, UCD/ Mater Misericordiae University Hospital, 63 Eccles St, Dublin 7
Abstract
Munchausen’s syndrome is a condition whereby a patient deliberately simulates symptoms of an illness in order to gain admission to hospital and gain the sick role. It is an uncommon condition and is possibly underdiagnosed. This case-series examines the cases of three patients with Munchausen’s syndrome who presented to a Dublin hospital within a four-month period. Two of the presentations involved the feigning of psychiatric symptoms. It is important that clinicians not only in psychiatry, but in all medical specialities have an awareness of this disorder, so that unnecessary procedures and treatments may be avoided.
Introduction
In Munchausen syndrome or factitious disorder, the affected person exaggerates or creates symptoms of illnesses in themselves in order to gain investigation, treatment, attention, sympathy, and comfort from medical personnel. The term was coined by Asher in 19511, with reference to Baron von Munchausen, a legendary teller of tall tales. Typically, such patients have a history of repeated feigned or simulated illness, pseudologia fantastica (pathological lying) and peregrination (travelling or wandering from hospital to hospital). Patients with Munchausen’s syndrome may have other features, including an unusual or dramatic presentation, equanimity for diagnostic procedures, treatments or operations, evidence of self-induced physical signs, multiple scars and multiple hospitalisations2. They may simulate various illnesses in various systems, including fever, skin infections, anaemia, asthma, Cushing’s disease, phaeochromocytoma and even cancer3-9. They are often admitted through an Emergency Department, sometimes under an alias.10 Psychiatry, with the dependence of the clinician on the patient’s history, is a particularly difficult specialty in which to detect factitious disorders11-13. In this case series we describe three cases of Munchausen’s syndrome which presented to the Liaison Psychiatry service of a Dublin hospital, two of which involved feigned psychiatric symptoms.
Case 1
In April 2003, a patient with global amnesia was admitted to the Psychiatric unit from the Emergency Department. In trying to identify the patient, the media had publicised his story and printed his picture. Interpol were involved. Two weeks later, another patient, “P.B.” presented to the Emergency Department via a local police station. He complained of global amnesia. He did not know his name, address or occupation. Mental state examination showed a casually dressed man with poor hygiene. His speech was normal and his mood euthymic. There were no symptoms of psychosis elicited and no evidence of cognitive impairment. He was admitted to the psychiatric unit. After three days a telephone number was found on his person, this transpired to be his father’s number. He said “P.B.” was “in the habit of going from hospital to hospital” and that he was currently on the waiting list for admission to his local psychiatric hospital because of “paranoid schizophrenia”. He was discharged with a diagnosis of Munchausen’s Syndrome.
Case 1a
“M.C.” was admitted to the orthopaedic ward with multiple fractures having fallen from scaffolding in late 2007. Two weeks later, his treating orthopaedic team sought a psychiatric consultation querying paranoid ideation. On interview, he described well-circumscribed delusions of persecution and passivity. He denied hallucinations in any modality. His affect was congruent and his mood euthymic. He gave a past psychiatric history of post-traumatic stress disorder and depression, asserting that he had a two-day psychiatric admission twenty years previously. Furthermore, he gave a family history of “elation”. He said he had been living with his mother prior to admission, but that he could not return to this house. A CT brain requested was normal. He was commenced on 10mg of Olanzapine, and his psychotic symptoms resolved within 3 days. A referral was sent for follow-up to his local mental health service, which contacted the Liaison Psychiatry service having discovered that he had given a false address. The named general practitioner did not know the patient and the next of kin given was uncontactable. The patient made unconvincing excuses for these. He was referred to the homeless services on discharge.
After discharge, it was realised that “MC” was in fact an alias for “PB” as described in Case 1. It was then discovered that “MC/PB” had eight aliases in the hospital, giving slightly different personal details & histories on each admission. He was being treated by his local psychiatric service for “paranoid schizophrenia” for the preceding 12 years. Several weeks later, he presented at the outpatients department without an appointment, saying he was homeless and seeking accommodation. On mental state examination there was no evidence of any psychopathology. The following day he was admitted to his local psychiatric hospital, describing symptoms of acute psychosis, having been caught breaking into a house.
Case 2
“I.D.”, a 40-year-old male presented to the Emergency Department with police and the presenting complaint: “I have no memory”. He claimed to have travelled by boat from Holyhead, Wales to Dublin Port, and then presented himself to a nearby police station complaining of amnesia. As in Case 1, one week previously a patient with global amnesia had presented to the same Emergency Department, with global amnesia. Her case had been widely reported in the media as police attempted to ascertain her identity. On interview, “I.D.” initially claimed to be amnesic, but after a short while as the inconsistencies in his story became more apparent, he admitted that he had fabricated his story: “I have been lying. I’ve not got amnesia”. He admitted to being an inpatient for the past year in a psychiatric hospital in the UK with a diagnosis of “treatment resistant schizophrenia”. He described what he termed “delusions”, saying: “I have delusions about Andrea Corr”, but did not seem convincing. He also claimed: “I was coming here to become God”. When asked if he fabricated this ‘delusion’, he said: “That’s for the doctors to decide”. On mental state examination his speech was normal, his affect congruent and his mood euthymic. He described “delusions”, as above but there was no evidence of any other psychotic symptoms. He was cognitively intact.
He described a fifteen-year history of schizophrenia, currently treated with clozapine. He was due to be imminently discharged from the secure psychiatric unit where had been an inpatient for one year. Collateral obtained from patient’s treating hospital confirmed his “diagnosis”, medications, that he was currently an inpatient and had absconded the previous day. They reported that he had travelled to Ireland in a similar fashion previously. A diagnosis of Munchausen’s syndrome was made, and “I. D.” was repatriated.
Case 3
“POR”, a 49-year-old woman was referred from the breast clinic for a psychiatric opinion; she had requested a prophylactic bilateral mastectomy. She stated her 4 sisters had died before age sixty, all from breast cancer. One aunt had died aged 67 from breast cancer. She met the criteria for capacity to consent to treatment. There was no evidence of any affective or psychotic illness. She denied any personal or family history of any psychiatric illness. She had a hysterectomy aged twenty-seven for “uterine cancer”. She was currently being prescribed tamoxifen prophylactically. She gave a history of having been brought up by her grandmother in Kildare, away from the rest of her siblings and her parents in Dublin. She said she had three adult children from a twenty-year relationship, which had ended twelve years previously. She was a trained nurse, who quit employment 6 years earlier to care for her grandson. She had changed religion 3 years previously, but had returned to her original Church a few months earlier. A letter was found in her medical file from the bishop attached to the Church she had recently left, who had written to the surgeon inquiring if “POR” had cancer. He stated she had solicited money and other favours from members of the congregation claiming to have breast cancer, to have lost her hair due to chemotherapy, and that she was awaiting a mastectomy.
Collateral obtained from her general practitioner indicated she had not attended him for more than one year. Although he had been told by the patient that three of her sisters had died from breast cancer, he had never known any of them. The patient withheld consent to contact being made with her next of kin. Her old microfilmed hospital notes, from twenty years previously, indicated that the patient had just one sister not three. The one sister supposedly had died from Hodgkin's lymphoma, not breast cancer. The hysterectomy had been performed for menorrhagia not uterine cancer, and had been carried out largely at the patient’s request. When “POR” was confronted with the above facts, she became upset and irritable. She claimed that her sister who died of Hodgkin's was a stepsister. She was told that she had a diagnosis of Munchausen’s syndrome. She again refused to consent to her next of kin being contacted. She did not attend any further appointments.
Discussion
Factitious disorder is defined as “the wilful production of physical and/or psychological signs and symptoms for no apparent goal other than to assume the role of being a patient”. The disorder may be divided into three subtypes: those with predominantly physical signs and symptoms (most common), those with predominantly psychological signs and symptoms, and those with a combination. The majority of patients with Munchausen’s syndrome present with somatic complaints, are reluctant to see a psychiatrist and may abscond before being interviewed. In one series, only 16 of 38 cases had a psychiatric consultation14. This makes those patients who deliberately simulate mental illness and seek out psychiatric services a paradoxical subtype. The subtype of predominantly psychological signs and symptoms, also known as Psychiatric Munchausen’s, is uncommonly reported, likely due to the subjective nature of the symptoms reported11-13. It has been suggested that this disorder may be more common than generally recognised15. One Spanish study found an 8% rate of factitious symptoms in an inpatient psychiatric population16. Making a diagnosis of factitious disorder requires an appropriate index of suspicion, clinical perseverance and recognition of the common features.
In Cases 1 and 2, there are a number of marked similarities. Each patient had simulated amnesia after media reports of global amnesia. They both also simulated symptoms of schizophrenia convincingly. In Case 1, the patient had been treated for schizophrenia by his local psychiatric service for several years, but in his second presentation described in Case 1a above, he denied any such history. In Case 2, the patient had been treated for schizophrenia for several years. As his “symptoms” did not improve on medications he was considered to be treatment-resistant. Case 1 also gives an example of how psychiatry may be abused in order to seek exemption from the normal rigours of the law. In the incident described, where the patient described dramatic psychotic symptoms having been caught in the act of burglary, he took the step from Munchausen’s into frank malingering, in changing his objective from secondary gain to primary gain. Munchausen’s syndrome has been associated with elective mastectomies, and it is the practise in many countries for a patient to have a psychiatric assessment as part of the pre-operative work-up17,18. Case 3 is typical in her history of a deprived childhood and her background in the healthcare profession.
The aetiology of factitious disorder is not wholly understood, but unconscious motives, developmental or family factors, life stressors, psychodynamic mechanisms such as mastery, masochism and dependency are thought to play a role. Its management involves recognising the diagnosis and addressing the issue with the patient in an objective and non-punitive manner, allowing them to find an honourable way out. Although previously confrontation was thought to be unhelpful, new evidence suggests that it may be helpful in offering the patient an interpretation of his/her behaviour19. It is also important to protect the patient from iatrogenic risk20. Psychotherapy may have a role in treatment, which may mean involving the family to set limits. In some areas, support groups have been found helpful. The prognosis is generally poor, especially if there is severe co-morbid personality disorder (antisocial or borderline)21, or if there has been co-morbid malingering, but is better if associated with a treatable mental disorder (e.g. mood) or if the personality is compulsive, depressive or histrionic11. Having a stable support system with an ability to form and maintain relationships is predictive of better prognosis. It is important that clinicians in all medical specialities have an awareness of this disorder, so that unnecessary procedures and treatments may be avoided.
Correspondence: AM Doherty
Department of Adult Psychiatry, UCD/ Mater Misericordiae University Hospital, 63 Eccles St, Dublin 7
Email: annedohertyemail@gmail.com
References
1. Asher R. Munchausen’s Syndrome. Lancet. 1951; 1, 339-341.
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994, 471–475.
3. Aduan RP, Fauci AS, Dale DC, Herzberg JH, Wolff SM. Factitious fever and self-induced infection: a report of 32 cases and review of the literature. Ann Intern Med. 1979; 90, 230-242.
4. Rumans LW, Vosti KL. Factitious and fraudulent fever. American Journal of Medicine. 1978; 65, 745-755.
5. Downing ET, Braman SS, Fox MJ, Corrao WM. Factitious asthma: physical approach to diagnosis. JAMA 1982; 248, 2878-2881.
6. Daily WJ, Coles JM, Creger WP. Factitious anaemia. Annals of Internal Medicine. 1963; 58, 533-538.
7. Bruns AD, Fishkin PA, Johnson EA, Lee YT. Munchausen's syndrome and cancer. J Surg Oncol. 1994; 56: 136-8.
8. Cizza G, Nieman LK, Doppman JL, Passaro MD, Czerwiec FS, Chrousos GP, Cutler GB. Factitious Cushing syndrome. Journal of Clinical Endocrinology & Metabolism, 1996: 81; 3573-3577.
9. Stern TA, Cremens MC. Factitious pheochromocytoma - one patient history and literature review. Psychosomatics 1998; 39:283-287.
10. Guthrie E, Creed F. Seminars in liaison psychiatry. The Royal College of Psychiatrists, London. 1996,144-151.
11. Limosin F, Adès J. Maladie de Behçet et psychose maniaco-dépressive factices: un cas de syndrome de Münchhausen. [Behçet's disease and factitious manic-depressive psychosis: a case of Münchausen syndrome.] Presse Med. 1999; 18; 28:1460-2.
12. Popli AP, Masand PS, Dewan MJ. Factitious disorders with psychological symptoms. J Clin Psychiatry. 1992; 53: 315-8.
13. HG Pope Jr, JM Jonas, B Jones. Factitious psychosis: phenomenology, family history, and long-term outcome of nine patients. Am J Psychiatry 1982; 139:1480-1483.
14. Gelenberg AJ. Munchausen's syndrome with a psychiatric presentation. Dis Nerv Syst. 1977 ;38 :378-80.
15. Gregory RJ, Jindal S. Factitious disorder on an inpatient psychiatry ward Am J Orthopsychiatry. 2006; 761: 31-6.
16. Catalina M, Gómez V, de Cos A. Prevalence of factitious disorder with psychological symptoms in hospitalized patients. Actas Esp Psiquiatr. 2008.
17. Grenga TE, Dowden RV. Munchausen's syndrome and prophylactic mastectomy. Plast Reconstr Surg. 1987; 80: 119-20.
18. Edlich RF, Winters KL, Faulkner BC, Lin KY. Risk-reducing mastectomy. J Long Term Eff Med Implants. 2006 ;16:301-14.
19. Catalina M, de Ugarte L, Moreno C. A case report. Factitious disorder with psychological symptoms. Is confrontation useful? Actas Esp Psiquiatr. 2008.
20. Huffman JC, Stern TA. The diagnosis and treatment of Munchausen's syndrome. Gen Hosp Psychiatry. 2003; 25: 358-63.
21. Folks DG. Munchausen's syndrome and other factitious disorders. Neurol Clin. 1995; 13: 267-81.
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Author's Correspondence
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No Author Comments
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Acknowledgement
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No Acknowledgement
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Other References
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No Other References
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