Ethical and management considerations in factitious illness: one and the same

Paternalism and factitious disorder: medical treatment in illness deception

The primary aims are to consider whether a range of paternalistic medical interventions can be justified in the treatment of factitious disorder (FD) and to show that the particularities of FD and its management make it an ideal phenomenon to highlight the difficulties of balancing respect for self-determination, responsibility and duty of care in psychiatry. FD is usually classified as a mental disorder involving deliberate and hidden feigning or inducement of illness, in order to achieve patient status. Both the nature of the disorder and the approach to treatment are controversial and under-researched. It is argued that FD should be classified as a mental disorder; may well expose the patient to extreme risk; can warrant paternalistic interventions, in order to fulfil duty of care. Moreover, treatment of FD is inherently paternalistic and therefore raises interesting questions about justifications and type of paternalistic interventions in psychiatry both for FD and in general. A brief account of key questions concerning psychiatry and paternalism is followed by some case histories of FD, the clinical dilemmas posed and the question of how this disorder might warrant paternalistic interventions. In order to answer this question, two things are considered: the legitimacy and character of FD as a mental disorder; possible frameworks for and types of paternalistic interventions. To conclude, it is argued that there are no compelling reasons for rejecting the use of paternalistic interventions for FD, but that further investigation of FD and type and frameworks for psychiatric paternalism, in relation to FD and other mental disorders, are urgently needed.

Fatal Factitious Cushing’s Syndrome and Invasive Aspergillosis: Case Report and Review of Literature

OBJECTIVE

To present the first reported fatality from invasive aspergillosis related to factitious Cushing's syndrome.

METHODS

We summarize the history, clinical findings, and outcome in a patient ultimately found to have factitious Cushing's syndrome. In addition, the dangers of fulminant infections in untreated Cushing's syndrome are analyzed relative to molecular and immunologic aspects, and the pertinent literature is reviewed.

RESULTS

A 33-year-old female medical transcriptionist was admitted with rapidly fatal septic shock and diffuse pulmonary infiltrates. Autopsy revealed invasive pulmonary aspergillosis and atrophied adrenal cortices. On subsequent investigation, hidden bottles of prednisone were found throughout the patient's home. Factitious Cushing's syndrome has rarely been described and can be a difficult diagnosis to establish, but it is important to recognize this condition because of its potentially drastic consequences. Our understanding of the mechanism of immunosuppression from glucocorticoids related to the increased risk of invasive fungal infections is evolving. Factitious illness can manifest in numerous ways; therefore, health-care providers in all specialties should be familiar with epidemiologic, diagnostic, and treatment considerations for this illness.

CONCLUSION

Endocrinologists should be aware of the possibility of factitious Cushing's syndrome because it can be an elusive and ultimately fatal condition.

Deception and detection in psychiatric diagnosis

Deception is ubiquitous in all communication and relationships. It can be conscious, unconscious, or both. It is present in all psychiatric diagnoses as alterations of history, symptom fabrication, symptom enhancement or minimization, and noncompliance with treatment recommendations. We are born better deceivers than we are detectors and untrained intuition may result in very unreliable discrimination. In order to improve our ability to distinguish fact from fiction, the diagnostician must attend to clues in the patient's history and physical and mental status examinations. Laboratory examination, psychological testing, and polygraphy also can be useful adjuncts in detection; however, the first step is always suspicion.

Factitious triplegia: case report

A 37-year-old woman was admitted for rehabilitation of triplegia with diagnoses of conversion disorder and possible multiple sclerosis. Attempts to manage the patient with techniques often effective with conversion disorders were unsuccessful, and the patient was discharged to a nursing home. After the development of further symptoms and a second extensive medical work-up, the factitious nature of her symptoms became evident. Awareness of the characteristics of factitious disorders, early background investigation, and psychiatric consultation can facilitate the appropriate management and referral of these patients, and spare rehabilitation providers the frustrations and possible medicolegal complications of patients with this disorder.

Munchausen syndrome by proxy: a study of psychopathology

Munchausen Syndrome by Proxy (the fabrication of illness by a mother in her child) is often a serious form of child abuse that has been recognized increasingly over recent years. Approximately one-half of the mothers in this study had either smothered or poisoned their child as part of their fabrications. Lifetime psychiatric histories are reported for 47 of the mothers. Thirty-four had a history of a Factitious or Somatoform disorder, 26 a history of self harm, and 10 of alcohol or drug misuse. Nine mothers had a forensic history independent of convictions related to child abuse. Nineteen of these mothers were interviewed from 1-15 years after the original fabrications. The most notable psychopathology was the presence of a personality disorder in 17 of the mothers, which were predominantly Histrionic and Borderline types. Most subjects, however, met the criteria for more than one category of personality disorder.

Factitious hemoptysis. Adding to the differential diagnosis

BACKGROUND

We report a dramatic case of factitious hemoptysis in a 36-year-old black man who presented with hemoptysis and chest pain.

METHODS

After an exhaustive evaluation, including many invasive procedures, we discovered that the patient's complaints were fabricated, although the method used to simulate hemoptysis was not determined. Documentation was obtained of at least 23 other hospital admissions with similar complaints. During these hospitalizations, numerous diagnostic procedures were performed, including 16 fiberoptic bronchoscopies and 3 cardiac catheterizations, with negative results.

RESULTS

Review of 11 other reported cases of factitious hemoptysis reveals that these patients are generally young (mean age, 32 years; range, 21 to 47 years) and often health-care workers (4 of 12 cases) and that the method of simulating hemoptysis, if discovered, usually involves a self-inflicted wound (5 cases).

CONCLUSION

A factitious cause should be considered in the differential diagnosis of hemoptysis of unclear etiology, especially when the medical history or the patient's behavior is unusual.

Case of a 29-year-old nurse with factitious disorder. The utility of psychiatric intervention on a general medical floor

A 29-year-old nurse was treated for septic arthritis of the knee. She was suspected of producing this infection and others. The consultation-liaison team intervened early, and the patient was treated in individual outpatient psychotherapy for 1 year. Her course was complicated by criminal behavior and a suicide attempt, prompting relocation to her home town. The patient demonstrated a strong need to be nurtured, as noted in other cases of factitious disorders. An overview of factitious disorders is presented, and guidelines for managing these difficult patients in the hospital are provided.

The million dollar man. Resource implications for chronic Munchausen's syndrome

Munchausen's syndrome in a man of subnormal intelligence is described. The case is unique for the extent of detailed, corroborated history. This man has been a voracious consumer of NHS and other services, and an estimate has been made of his cost to the health and prison services. The case raises various ethical, forensic, and resource issues.

Update on factitious disorders

OBJECTIVE

Since factitious disorders entered the official psychiatric nomenclature in DSM-III and DSM-III-R, there has been a proliferation of reports and commentary about this unusual disorder. We present an update of the recent literature.

METHOD

The psychiatric and medical literature was searched. Clinical reports and critical/theoretical papers were reviewed; eighty-five are summarized here.

RESULTS

Available data is descriptive and anecdotal. Reports focus on the following four topics, which are discussed here: 1) diagnostic issues, 2) the newly proposed DSM-IV category of factitious disorder by proxy, 3) epidemiology and course, 4) new developments in treatment and management.

CONCLUSIONS

Factitious disorders are uncommon but serious illnesses that present diagnostic and management dilemmas. Deriving systematic information about these illnesses is a major challenge.