Factitious disorders in a general hospital setting: clinical features and a review of the literature

[Factitious disorder imposed on self and Munchausen syndrome: An update]

Factitious disorder imposed on self (FDIS) is a mental disorder characterized by conscious manipulative behavior from patients with no clearly identifiable external objective. It affects subjects with a wide range of characteristics, only some of whom fit the stereotypical profile of the young female working in the health sector. It can take the form of a variety of symptoms or clinical signs, and is likely to involve all specialties. Munchausen syndrome is a particular form of FDIS, more prevalent in men and marked by its severity. Psychiatric comorbidities are common in patients with FDIS. Death is rare but possible, either as a result of the disease itself, complications of examinations or treatments, or suicide. The diagnostic approach must seek to identify positive arguments in favor of the disorder. Diagnosis by elimination remains possible when no other hypothesis can explain a clinical picture suggestive of FDIS. The prognosis is often poor, at least in the short and medium term. Avoiding unnecessary prescriptions is essential to prevent iatrogenesis. The management of FDIS is poorly codified. In all cases, the practitioner must adopt a non-aggressive, empathetic attitude.

A descriptive, retrospective case series of patients with factitious disorder imposed on self

BACKGROUND

Despite cases of factitious disorder imposed on self being documented in the literature for decades, it appears to remain an under-identified and under-diagnosed problem. The present study aimed to explore factitious disorder imposed on self in a series of French patients.

METHODS

Patients 18 years old and over with factitious disorder imposed on self were retrospectively included by two independent reviewers according to DSM-5 criteria in Rennes University Hospital for the period 1995 to 2019. Patients were identified from a clinical data warehouse.

RESULTS

49 patients with factitious disorder imposed on self were included. Among them, 36 (73.5%) were female. The average age at diagnosis was 38.4 years. The 16 patients with a health-related profession were all female. Direct evidence of falsification was found in 20.4% of cases. Falsification was mainly diagnosed on the basis of indirect arguments: history of factitious disorder diagnosed in another hospital (12.2%), extensive use of healthcare services (22.4%), investigations that were normal or inconclusive (69.4%), inconsistent or incomplete anamnesis and/or patient refusal to allow access to outside information sources (20.4%), atypical presentation (59.2%), evocative patient behaviour or comments (32.7%), and/or treatment failure (28.6%). Dermatology and neurology were the most frequently involved specialities (24.5%). Nine patients were hospitalized in intensive care. Some of them received invasive treatments, such as intubations, because of problems that were only reported or feigned. The diagnosis of factitious disorder imposed on self was discussed with the patient in 28 cases (57.1%). None of them admitted to making up the disorder intentionally. Two suicide attempts occurred within 3 months after the discussion of the diagnosis. No deaths were recorded. 44.9% of the patients returned to the same hospital at least once in relation to factitious disorder imposed on self.

CONCLUSIONS

The present study reinforces data in favour of a predominance of females among patients with factitious disorder imposed on self. This diagnosis is difficult and is based on a range of arguments. While induced cases can be of low severity, cases that are only feigned can lead to extreme medical interventions, such as intubation.

The girl who cried wolf: A literature review and case report of pediatric factitious disorder

Pediatric presentations of factitious disorder (Munchausen syndrome) remain underdiagnosed and poorly understood compared to adult cases. The purpose of this study is to review the current literature on child and adolescent factitious disorder in order to better understand the differences between pediatric and adult presentations of this disorder. We also present the case of an adolescent girl with factitious disorder; her hospital course draws attention to the excessive healthcare expenditures and risk of iatrogenic complications associated with this diagnosis. We utilized MEDLINE and Google Scholar databases to conduct our review. Despite the limited number of high-quality studies analyzing pediatric presentations of factitious disorder, our review yielded several important findings. Studies suggest that the general acceptance of somatization as a common way for young people to manifest emotional stress may explain the under-diagnosis of this disorder in pediatric populations. Studies also highlighted differences in the clinical characteristics of factitious disorder when patients are stratified by age; most notably, younger patients are more willing to admit intentional falsifications when confronted and more likely to accept treatment, making them a potentially more effective target for intervention.

Striving to Die: Medical, Legal, and Ethical Dilemmas Behind Factitious Disorder

Factitious disorder (FD) imposed on self is one of the most challenging and controversial problems in medicine. It is characterized by falsified medical or psychiatric symptoms where patients misrepresent, simulate, or cause symptoms of an illness in the absence of obvious tangible gains. Munchausen syndrome accounts for approximately 10% of all factitious illnesses and represents its most malignant form. An unknown number of deaths have likely occurred when considering that most cases go unrecognized and unreported. Here we describe a case in which the patient’s condition remained unrecognized, only being diagnosed months before her death from complications of FD.

Psychiatry was consulted to see a 49-year-old Caucasian female regarding depression, poor oral intake, and her insistence on the placement of a feeding tube. The initial evaluation was negative for findings consistent with psychiatric illness. A review of records in our hospital was significant for one previous psychiatric inpatient stay eight months prior during which a diagnosis of FD imposed on self was made. Collateral information suggested a cycle of deception and simulation of illnesses with the patient’s daughter labeling her actions as “doctor shopping.” At our facility alone, she had accrued roughly 40 inpatient medical admissions and 70 ED visits in four years though only two encounters involving Psychiatry. A detailed chronological analysis of her records showed the only documented concern of deception to be that of an Internal Medicine resident two years prior. Psychiatry was not consulted despite this concern. During the present encounter, psychiatry recommended ethics consult, outpatient psychotherapy, and frequent follow-ups with primary care. A formal ethics consult was not completed before discharge. Within two months, the patient died at another facility. 

FD can lead to diagnostic and therapeutic procedures that result in irreversible morbidity and iatrogenic harm. Physicians in other medical specialties often suspect a patient of consciously deceiving others, though fail to assign psychiatric nomenclature due to lack of familiarity or comfort in making the diagnosis. This further substantiates the role of a multidisciplinary collaboration between medical, surgical, and psychiatry teams. Heightened awareness of, and suspicion for, Munchausen syndrome may improve rates of diagnosis and prognosis of these patients.

Incidence of the diagnosis of factitious disorders - Nationwide comparison study between Germany and Norway

Factitious disorders (FD) like Munchausen syndrome are well known to most physicians, yet the corresponding ICD-10 diagnosis F68.1 remains severely under-assigned and often misdiagnosed. To approach this problem, we conducted a nationwide inquiry for Germany and Norway as well as a comparison between these two countries regarding the incidence of diagnosis of FD. The assignment rates of F68.1 in somatic hospitals from 2008 to 2016 were analyzed based on the Diagnosis Related Groups statistic from the German Federal Statistical Office and the data provided from the Norwegian Patient Registry. The Norwegian data also included information on individual patients whereas the German data only contained the total number of F68.1 assignment due to strict medical confidentiality laws. The incidence of the diagnosis of FD in Germany and Norway showed similar assignment rates with 3.71 and 3.18 per 100,000, respectively. The mean age was 39.4 years for German patients and 35.6 years for Norwegian patients. The gender distribution was almost equal for the individual patients’ rate (49% female and 51% male). Furthermore, our results indicate that female patients with FD tend to demand healthcare services more frequently than male patients. Smaller studies focusing on the diagnosis of FD have significantly higher assignment rates compared to nationwide inquiries. Our results illustrate substantial differences between estimations of the incidence of FD and the need for further studies. Besides the many obstacles associated with diagnosis of FD, strict medical confidentiality laws prevent reliable and scientific investigations of this matter.

Differentiating factitious psychological presentations from malingering: Implications for forensic practice

Practitioners and researchers have long been challenged with identifying deceptive response styles in forensic contexts, particularly when differentiating malingering from factitious presentations. The origins and the development of factitious disorders as a diagnostic classification are discussed, as well as the many challenges and limitations present with the current diagnostic conceptualization. As an alternative to a formal diagnosis, forensic practitioners may choose to consider most factitious psychological presentations (FPPs) as a dimensional construct that are classified like malingering as a V code. Building on Rogers' central motivations for malingering, the current article provides four explanatory models for FPPs; three of these parallel malingering (pathogenic, criminological, and adaptational) but differ in their central features. In addition, the nurturance model stresses how patients with FPPs attempt to use their relationship with treating professionals to fulfill their unmet psychological needs. Relying on these models, practical guidelines are recommended for evaluating FPPs in a forensic context.

"Impossible" patients in oncology: Two unusual cases

OBJECTIVE

Cancer patients can present with impossible behavior, which can jeopardize their treatment and challenge healthcare professionals' teamwork.

METHOD

Report of two unusual psychiatric cases, including Munchausen and Peter Pan syndromes, which occurred in a comprehensive cancer center.ResultGuidelines in medical and surgical wards are suggested to address such situations regarding oncologic compliance.Significance of resultsMultidisciplinary collaboration between medical and surgical teams and the psycho-oncologic department is highly recommended.

Recurrent Renal Colic in a Patient with Munchausen Syndrome

Background: In most of the cases regarding children, factitious disorders (FDs) are intentionally produced by parents. Less attention is paid to FDs in which a child or adolescent intentionally induces or falsifies the disease to attain a patient’s role. Case presentation: A 13-year-old immigrated and adopted boy previously underwent an operation for renal joint syndrome and was affected by recurrent episodes of renal colic. The boy was admitted reporting acute left flank pain with scars on the mucous face of his prepuce and had a recent previous hospitalization for the same reason. Laboratory tests and radiological findings did not reveal any morphological or functional alterations. Self-induced FD was suspected, and a psychiatric consultation was performed. After psychiatric consultation and remission of the symptoms with a placebo, a diagnosis of Munchausen syndrome was suspected. The patient’s uncle was not initially convinced of the diagnosis. Some videos clearly showed that the boy was handling his prepuce to excrete stones, explaining the scars. A therapeutic plan with psychiatrist support was later accepted with a positive outcome. No further signs and symptoms of renal colic were reported. Conclusions: It is recommended that paediatricians include FD in the differential diagnosis of a persistent and unexplained medical condition. If suspicion arises, confirmation and long-term therapy by a group of qualified specialists, including psychiatrists, should be planned.

Can factitious disorder reach delusional level? A case study

The paper describes a patient, who has been consulted and hospitalized multiple times, due to dermatological lesions on his face. We will present his medical history and describe circumstances leading to the final diagnosis of factitious disorder. In the theoretical part we will try to answer the question, whether the extreme severity of the factitious disorders can, at some point, reach the level of delusions.

The Peregrinating Psychiatric Patient in the Emergency Department

Many emergency department (ED) psychiatric patients present after traveling. Although such travel, or peregrination, has long been associated with factitious disorder, other diagnoses are more common among travelers, including psychotic disorders, personality disorders, and substance abuse. Travelers’ intense psychopathology, disrupted social networks, lack of collateral informants, and unawareness of local resources complicate treatment. These patients can consume disproportionate time and resources from emergency providers. We review the literature on the emergency psychiatric treatment of peregrinating patients and use case examples to illustrate common presentations and treatment strategies. Difficulties in studying this population and suggestions for future research are discussed.

Factitious disorder: a systematic review of 455 cases in the professional literature

OBJECTIVE

Patients with factitious disorder (FD) fabricate illness, injury or impairment for psychological reasons and, as a result, misapply medical resources. The demographic and clinical profile of these patients has yet to be described in a sufficiently large sample, which has prevented clinicians from adopting an evidence-based approach to FD. The present study aimed to address this issue through a systematic review of cases reported in the professional literature.

METHOD

A systematic search for case studies in the MEDLINE, Web of Science and EMBASE databases was conducted. A total of 4092 records were screened and 684 remaining papers were reviewed. A supplementary search was conducted via GoogleScholar, reference lists of eligible articles and key review papers. In total, 372 eligible studies yielded a sample of 455 cases. Information extracted included age, gender, reported occupation, comorbid psychopathology, presenting signs and symptoms, severity and factors leading to the diagnosis of FD.

RESULTS

A total of 66.2% of patients in our sample were female. Mean age at presentation was 34.2 years. A healthcare or laboratory profession was reported most frequently (N=122). A current or past diagnosis of depression was described more frequently than personality disorder in cases reporting psychiatric comorbidity (41.8% versus 16.5%) and more patients elected to self-induce illness or injury (58.7%) than simulate or falsely report it. Patients were most likely to present with endocrinological, cardiological and dermatological problems. Differences among specialties were observed on demographic factors, severity and factors leading to diagnosis of FD.

CONCLUSIONS

Based on the largest sample of patients with FD analyzed to date, our findings offer an important first step toward an evidence-based approach to the disorder. Future guidelines must be sensitive to differing methods used by specialists when diagnosing FD.

The Interplay of Factitious Disorder and Palliative Care Encounters: A Case Series

BACKGROUND

Individuals with factitious disorders often suffer emotional pain, which motivates them to assume a "sick role" rather than experience the intensity of emotional distress. Such individuals may experience iatrogenic harm as a consequence of their psychological disorder. Their clinicians may develop strong negative emotions such as disgust and the health care system can accrue increased medical costs from diagnostic dilemmas. If the disorder remains unrecognized, the resulting tension can cause interdisciplinary team (IDT) conflicts and impact the effectiveness of care.

METHODS

In this article, we describe three cases of factitious behaviors, as either a comorbid illness or an underlying condition, that potentiate untoward health effects among patients seen by a palliative care team. We use these examples to illustrate common features of factious disorders, identify clinical pitfalls when caring for such patients, and offer care strategies for palliative care providers who may encounter such patients with increasing prevalence considering the larger national push to involve palliative care teams earlier in disease trajectories.

Factitious disorders and malingering in relation to functional neurologic disorders

Interest in malingering has grown in recent years, and is reflected in the exponential increase in academic publications since 1990. Although malingering is more commonly detected in medicolegal practice, it is not an all-or-nothing presentation and moreover can vary in the extent of presentation. As a nonmedical disorder, the challenge for clinical practice remains that malingering by definition is intentional and deliberate. As such, clinical skills alone are often insufficient to detect it and we describe psychometric tests such as symptom validity tests and relevant nonmedical investigations. Finally, we describe those areas of neurologic practice where symptom exaggeration and deception are more likely to occur, e.g., postconcussional syndrome, psychogenic nonepileptic seizures, motor weakness and movement disorders, and chronic pain. Factitious disorders are rare in clinical practice and their detection depends largely on the level of clinical suspicion supported by the systematic collection of relevant information from a variety of sources. In this chapter we challenge the accepted DSM-5 definition of factitious disorder and suggest that the traditional glossaries have neglected the extent to which a person's reported symptoms can be considered a product of intentional choice or selective psychopathology largely beyond the subject's voluntary control, or more likely, both. We present evidence to suggest that neurologists preferentially diagnose factitious presentations in healthcare workers as "hysterical," possibly to avoid the stigma of simulated illness.

[Factitious diseases in oncology]

Factitious diseases and pathomimias and particularly Munchausen's syndrome, due to their rarity, are poorly diagnosed by medical teams working in oncology. Consequences can be serious and result in unadapted surgery or non justified implementation of chemotherapy and radiotherapy regimens. These patients simulate diseases in order to attract medical attention. They might become belligerent and are likely to promptly discharge themselves from hospital if they do not get the desired attention or are unmasked. With two following case reports and literature review, we would like to alert clinicians about difficulties encountered in diagnosis and management of factitious disorders. When faced with this diagnosis, the patient will tend to deny reality and break contact with the medical team who exposed him. Medical peregrinating behavior surrounded by conflicts with medical team, past psychiatric illness, history of working in the medical and paramedical field and social isolation can guide the diagnosis. Somaticians and especially surgeons working in the oncologic field must remain vigilant about this diagnosis and collaborate with either the psycho-oncologic team or the consultation-liaison psychiatric team. Some recommendations for medical professionals how to cope with these patients will be suggested.

Factitious Disorder in Crohn's Disease: Recurrent Pancytopenia Caused by Surreptitious Ingestion of 6-Mercaptopurine

Factitious disorder is a rare psychiatric illness characterized by the willful and deceptive induction of illness for the purpose of assuming the sick role. It presents a substantial diagnostic challenge, as patients often go to great lengths to conceal their deception. Accordingly, its presence in the full spectrum of gastrointestinal diseases is likely underappreciated. While factitious gastrointestinal bleeding, abdominal pain and diarrhea are relatively common, factitious non-gastrointestinal symptoms in the setting of gastrointestinal illness have been infrequently reported. We present the case of a patient with Crohn's disease with recurrent pancytopenia attributed to the surreptitious ingestion of 6-mercaptopurine. In patients with possible access to immunomodulatory drugs, a high suspicion for and early identification of factitious disorder may improve patient outcomes and avoid invasive and costly diagnostic evaluations.

Factitious disorder-experience at a neuropsychiatric center in southern India

OBJECTIVE

Factitious disorder is amongst the more intriguing but less-studied psychological disorders. Studies from different parts of the world have reported of varying prevalence rates. Here, we try to study the prevalence of factitious disorder in a specific sample of patients attending a neuropsychiatric center in India.

MATERIALS AND METHODS

We did a retrospective review of our institute's database for cases with a diagnosis of factitious disorder in the 10-year duration from 2001 to 2010. We reviewed the available clinical and socio-demographic data.

RESULTS

Of the 81,176 patients seen in the 10-year duration, only 8 patients had been assigned the diagnosis of factitious disorder, leading to a prevalence rate of 0.985 per 10,000 patients in this sample. Most of the patients were lost to follow-up; hence.

CONCLUSION

Factitious disorder remains highly underdiagnosed in developing countries like India. Mental health professionals need to be more aware and inquisitive about this particular disorder, so that they do not miss the diagnosis.

Factitious disorders and Munchausen syndrome: the tip of the iceberg

This population-based study evaluates the prevalence of factitious disorders, Münchausen syndrome, and Münchausen syndrome by proxy in a clinical setting. All children referred to the Pediatric Unit of the Department of Pediatrics of the Catholic University Medical School (Agostino Gemelli Hospital) in Rome were recruited between November 2007 and March 2010. An experienced interdisciplinary team of medical professionals analyzed all suspected cases. A total of 751 patients were hospitalized. Factitious disorders were diagnosed in 14/751 patients, resulting in a prevalence of 1.8%. Three of 14 (21.4%) patients fulfilled the criteria for Münchausen syndrome. Münchausen syndrome by proxy was identified in four of 751 patients, resulting in a prevalence of 0.53%. The perpetrator was the mother in three of four of these cases. The epidemiological data obtained in this population-based study indicate that the prevalence of factitious disorders, Münchausen syndrome, and Münchausen syndrome by proxy is higher than previously observed. Moreover, early detection was possible thanks to the awareness of an expert interdisciplinary team. We suggest that physicians must consider the possibility of these diagnoses whenever there are discrepancies in a child's illness presentation.

Factitious Disorder in Intensive Care Unit — Are We Doing Enough?

A 23-year-old woman presented with clinical signs and symptoms suggestive of acute severe asthma requiring intensive care admission. She was later diagnosed to have factitious disorder. This case report highlights the importance of diagnosing factitious disorder in the intensive care unit and the teamwork required in dealing with such cases to prevent recurrence, mortality and litigation.

Wires in the body: a case of factitious disorder

Factitious disorder can present with a wide variety of symptomatology. We present a case of a young girl presenting with spontaneous extrusion of wires from her limbs. These metallic wires were present in both her upper and lower limbs in the muscle bulk and were visible on X-ray. She sought repeated surgical removal of these wires, but the wires would invariably reappear. The patient could not be engaged in a therapeutic relationship and the family took premature discharge against medical advice, as they believed in supernatural causation for the phenomenon and were afraid that medical intervention might bring further ill fortune. The case highlights the importance of belief systems of family members as a barrier in managing such cases.

The relationship between borderline personality symptomatology and somatic preoccupation among internal medicine outpatients

OBJECTIVE

In this study, we examined the relationship between borderline personality symptomatology and somatic preoccupation among a sample of internal medicine outpatients.

METHOD

Using a cross-sectional approach and a sample of convenience, we surveyed 116 patients who presented for nonemergent medical care in an outpatient resident clinic between September 2005 and August 2007. Survey measures for borderline personality disorder (BPD) were the Personality Diagnostic Questionnaire-4 (PDQ-4) (DSM-IV criteria) and the Self-Harm Inventory (SHI), both self-report measures. The study measure for somatic preoccupation was the Bradford Somatic Inventory, also self-report in format.

RESULTS

In this study sample, both measures of BPD demonstrated significant correlations with the measure of somatic preoccupation (PDQ-4, r = 0.58, p < .001; SHI, r = 0.53, p < .001).

CONCLUSION

In primary care settings, patients with high levels of somatic preoccupation should be evaluated for borderline personality symptomatology.

Factitious disorder comorbid with bipolar I disorder. A case report

We describe a case of factitious disorder with physical and psychological symptoms comorbid with bipolar I disorder in a 37-year-old woman. Since the onset of bipolar disorder, which occurred at the age of 31, she increasingly complained of physical symptoms, compulsively seeking medical and surgical interventions. She has been hospitalised several times and her Munchausen-type factitious disorder recently appeared to be developing into Munchausen by proxy, involving her 11-year-old daughter. The patient adhered poorly to stabilising and antipsychotic drug treatment and did not improve through the years. We here analyse her mood phases, which were always associated with changes in the quality of factitious symptoms, according to whether the disorder was in its depressive phase (somatic complaints and suicidal ideation prevail), or in its manic or mixed phase (medical intervention-seeking and manipulation of clinicians to obtain surgical interventions). We also briefly discuss some important forensic issues to consider in similar cases, mainly stemming from the psychotic aspects of these two co-occurring disorders. Clinicians should be aware of some patients' ability to produce signs and symptoms of physical and/or psychological illness and consult psychiatrists before giving consent to invasive diagnostic procedures or surgery.

Diagnosis and treatment of somatoform disorders

Many patients with somatoform disorders present to the neurology clinic, often after extensive evaluation that has left the patient and multiple other physicians frustrated. Knowledge of the typical characteristics of particular disorders enables the clinician to arrive at a positive diagnosis and facilitate referral to appropriate services. Using a series of representative cases, we review the DSM-IV-TR somatoform disorders most likely to present to the practicing neurologist, highlighting the epidemiologic features, typical presentations, and possible therapeutic approaches to each condition.

Bilateral corneal perforations and autoproptosis as self-induced manifestations of ocular Munchausen's syndrome

PURPOSE

To report a patient with bilateral corneal perforations and autoproptosis in a case of ocular Munchausen's syndrome.

DESIGN

Case report.

PARTICIPANT

A 26-year-old white male referred to the oculoplastics service with one month history of decreased vision bilaterally and painful right eye. Multiple eyelid scars and right corneal opacity were noted. The patient was previously seen at another institution for rapid loss of vision in both eyes.

INTERVENTIONS

An orbit decompression among many procedures failed to controlled extreme pain and proptosis.

MAIN OUTCOME MEASURES

Resolution of proptosis, stabilization of vision, pain resolution.

RESULTS

Three weeks after enucleation of the right eye was offered, patient presented with spontaneous left ruptured globe. After multiple episodes of self-mutilation and infections, both eyes were exenterated.

CONCLUSIONS

Munchausen syndrome can be seen with ophthalmic manifestations and should be considered in the differential diagnosis when ocular abnormalities cannot be explained after a thorough evaluation. Recognition of this psychiatric disease is not only important for correct medical diagnosis and treatment, but also essential in protecting the patients from unnecessary invasive and aggressive medical procedures.

Axis I comorbidity and psychopathologic correlates of autodestructive syndromes

OBJECTIVE

Nonsuicidal deliberate self-harm and factitious disorders have been proposed as subtypes within the autodestructive behavior spectrum, basically differing in the issue of concealment. Aims are to determine Axis I diagnoses and psychopathologic correlates of open self-harmers and patients diagnosed with factitious disorders.

METHODS

One hundred ninety-four psychosomatic medicine inpatients participated. Assessment included the structured World Health Organization Composite International Diagnostic Interview (computerized version) and self-report questionnaires for anxiety, depression, perceived stress, and personal coping resources.

RESULTS

Thirty-seven patients identified with self-destructive behavior were matched with 37 patients without such behavior. Overt self-harmers (n = 18) were more frequently diagnosed with anxiety, depressive, substance abuse/dependence, or eating disorders and reported more stress than factitious disorder patients (n = 19) or those without self-destructive behavior. Patients with factitious disorder exhibited lower Axis I comorbidity and less psychopathology than patients without self-harm behavior.

CONCLUSIONS

Regarding psychopathologic assessment, contrary to open self-harmers, factitious disorder patients appear strikingly inconspicuous.

Munchausen's syndrome presenting as rectal foreign body insertion: a case report

Background

This case report shows that Munchausen's syndrome can present as rectal foreign body insertion. Although the presentation of rectal foreign bodies has frequently been described in the medical literature, the insertion of foreign bodies into the rectum for reasons other than sexual gratification has rarely been considered.

Case presentation

A 30 year old, unmarried Caucasian male presented with a history of having been sexually assaulted five days earlier in a nearby city by a group of unknown males. He reported that during the assault a glass bottle was forcibly inserted into his rectum and the bottle neck broke. On examination, there was no evidence of external injury to the patient. Further assessment lead to a diagnosis of Munchausen's syndrome. The rationale for this is explained. A description and summary of current knowledge about the condition is also provided, including appropriate treatment approaches.

Conclusion

This case report is important because assumptions regarding the motivation for insertion of foreign bodies into the rectum may lead to the diagnosis of Munchausen's syndrome being missed. This would result in the appropriate course of action, with regard to treatment, not being followed. It is suggested that clinicians consider the specific motivation for the behaviour in all cases of rectal foreign body insertion, including the possibility of factitious disorder such as Munchausen's syndrome, and avoid any assumption that it has been carried out for the purpose of sexual gratification. Early involvement of psychiatrists is recommended. Cases of Munchausen's syndrome presenting as rectal foreign body insertion may be identified and addressed more effectively using the approach described.

Streamlined classification of psychopathological hand disorders: A literature review

In the surgical hand clinic, psychopathological hand disorders can be sorted into one of the following four categories: (1) factitious wound creation and manipulation; (2) factitious edema; (3) psychopathological dystonias, and (4) psychopathological sensory abnormalities and psychopathological Complex Regional Pain Syndrome. This article introduces these four categories. Pertinent literature that includes descriptions of each category's syndromes and diseases, demographic and psychological profiles, differential diagnoses, and appropriate treatment recommendations is reviewed.

Phenomenology and outcome of factitious disorders in otolaryngology clinic in Oman

The phenomenology of factitious disorders from the Arab part of the world has been lacking in the medical literature and few reports have emerged from otolaryngology. Using an observational prospective case series study (n = 19) with long-term follow-up (two to six years), the present study reports the magnitude and mode of clinical profile of factitious disorders in a tertiary care hospital in Oman, an Arab-Islamic country. The outcome was operationalized as prognosis following culturally sensitive intervention akin to confrontation technique. The present observation suggests the prevalence of factitious disorders in the otolaryngology tertiary care setting was 0.2%. Approximately 42.1% (n = 8) had hemorrhagic factitious disorders, 15.8% (n = 3) were those who feigned for multiple surgical interventions. Approximately 15.8% (n = 3) presented neurological factitious disorders while the remaining 26.3% (n = 5) clinical profile suggested minor feigned illnesses. Objective "evidence factitia" was present in 68.4% (n = 13) of the cases. On subsequent follow-up, nine patients with chronic forms became asymptomatic, three patients had fewer episodes, four patients were unchanged, and three patients were lost to follow-up. The prognosis was good in patients who did not have associated psychiatric illnesses as compared to those with psychiatric disorders. Factitious disorders are often incorrectly diagnosed, with all consequences in terms of adverse sequels. The observed good prognostic outcomes are discussed in the context of socio-cultural patterning and the factors that may shape the presentation of factitious disorders in Oman.

Acute respiratory failure leading to emergency intubation: An unusual manifestation of Munchausen's syndrome

Munchausen's syndrome is a contrived psychiatric disorder, in which patients present with an intentionally produced or feigned illness with the aim to assume the sick role and to gain medical attention. Patients may even seek the application of invasive procedures, sometimes with serious risk to life. We describe the case of a 38-year-old woman, who repeatedly presented with apparent respiratory failure leading to tracheal intubation and mechanical ventilation. In addition, we present a systematic review of the literature over respiratory and pulmonary manifestations of Munchausen's syndrome. This case report may contribute to the awareness among emergency physicians of Munchausen's syndrome as a differential diagnosis of respiratory failure. Recognition of this psychiatric disease is not only important for correct medical diagnosis and treatment, but also essential in protecting the patients from unnecessary invasive and aggressive medical procedures.

Factitious aortic dissection leading to thoracotomy in a 20-year-old man

A 20-year-old man presented to an emergency department with dramatic, sudden-onset, tearing chest pain. He also claimed to have been previously diagnosed with Ehler-Danlos syndrome and a previous Type I aortic dissection (intimal tear of ascending aorta), rapidly increasing his treating physician's suspicion of an emergent aortic dissection. The patient was quickly transferred to a large university hospital, where he underwent a median sternotomy and thoracotomy, with no aortic pathology found on operation and biopsy. After the patient's postoperative recovery, he was treated at a mental health facility, where he remained ambivalent about his psychiatric condition and did not respond well to treatment. This case report describes a unique case of factitious disorder that led to a serious operative intervention and subsequent psychiatric care and assesses factors that might have contributed to his hospital course.

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.

Factitious disease: clinical lessons from case studies at Baylor University Medical Center

Factitious disease is defined as the intentional production (or feigning) of disease in oneself to relieve emotional distress by assuming the role of a sick person. Although the self-induction of disease is a conscious act, the underlying motivation is usually unconscious. It has been estimated that 3% to 5% of physician-patient encounters involve factitious disease. This article presents 6 case studies from Baylor University Medical Center that highlight various clinical aspects of factitious disease. Patients with factitious diseases are extremely difficult to recognize because they do not appear different from patients with authentic causes of similar symptoms, because their psychiatric abnormalities are not appreciated, and because doctors and nurses have alowindex of suspicion. Since patients with factitious disease present a false medicalhistory, their physicians prescribe unnecessary procedures and therapies that may result in iatrogenic disease. In many cases, damage to these patients from doctors' actions exceeds the harm resulting from the patients' self-induced illness. The clues that should suggest factitious disease, the diagnostic roles of the clinician and a consulting psychiatrist, and the ethical conflicts that confront doctors taking care of such patients are discussed. To help keep factitious disease in clinical perspective, one of the case studies involves the antithesis of factitious disease, where a patient was mistakenly diagnosed as having psychogenic pain when in fact the symptoms were caused by an overlooked physical disease. Better knowledge of the clinical features of factitious disease might have prevented the disastrous outcome.

Münchhausen Syndrome Simulating Acute Aortic Dissection

A young adult man presented to the emergency department reporting a convincing story for acute aortic dissection, a disorder in which diagnostic evaluations should occur in parallel with pharmacologic management. Transesophageal echocardiography demonstrated normal cardiac and aortic structures. Additional history was notable for extensive travel across numerous medical facilities with associated misrepresentation of his diagnosis and treatment. The patient was willing to undergo unpleasant and invasive procedures and succeeded at least once in the past to deceive clinicians to the point of performing a median sternotomy. The intentional presentation of false information leading to unnecessary treatments is consistent with Münchhausen Syndrome.

Factitious disorder on an inpatient psychiatry ward

The authors present 6 cases of factitious disorder seen on a general adult inpatient psychiatry unit of a university hospital. They review the clinical features of this disorder and suggest that factitious disorder is much more prevalent among psychiatric inpatients than is commonly recognized. Strategies to assist in the diagnosis and management this disorder are detailed.

Autodestructive syndromes

BACKGROUND

The phenomenon 'autodestructive behaviour' is becoming an increasingly serious disease and cost factor in a wide range of medical fields. The present paper presents a survey of the literature on autodestructive behaviour, excluding psychotic, substance-induced or organic brain disorders. Starting out with a conceptual overview, the paper goes on to look into the epidemiology of autodestructive behaviour and the forms in which it manifests itself.

METHOD

A literature search was conducted in Medline, Psycinfo and Psyndex using the search terms 'artifact', 'artificially induced', 'autodestructive', 'self-mutilation', 'factitious', 'self-harm', 'self-induced', 'self-inflicted', 'self-injuring' and 'self-mutilation' for the period from 1977 to 2003.

RESULTS

Five of a total of 18 empirical studies describe the simultaneous occurrence of direct and indirect forms of autodestructive behaviour. Reported prevalence rates range from 0.032% to 9.36%. The ratio of females to males was found to be 2:1 (average age: 31.5 years; SD: 9.3 years); in contrast, the gender ratio was reversed for Munchausen's syndrome. The case history data presented are patchy and differ in terms of their priorities. We found a large number of codiagnoses, which seems to indicate that personality and dependence disorders, or substance misuse, are characteristic of both direct and indirect forms of autodestructive behaviour.

CONCLUSIONS

The task at hand is to use a yet-to-be-developed nomenclature and adequately operational diagnostic criteria to work out standardised survey instruments that do justice to the heterogeneity of this disorder complex.

Somatization disorder: a practical review

OBJECTIVE

This paper reviews the present state of knowledge on the etiology, prevalence, diagnosis, and treatment of somatization disorder (SD).

METHOD

A comprehensive review of the literature on SD is described under the above headings.

RESULTS

SD is a common condition that is not well managed by many physicians. Patients with SD get caught between the cracks of the health care system, with expensive consequences. SD is a psychiatric disorder, but patients are reluctant to see and be treated by psychiatrists. They frequently are managed by nonpsychiatric physicians who have limited understanding of the condition. Cognitive-behavioural therapy (CBT) is the most efficacious treatment in SD, although antidepressants and supportive psychotherapy also have a role for some patients.

CONCLUSIONS

A cadre of clinicians with training in the theory and practice of CBT for SD is required. They need to be based both in the community and in tertiary health care centres, where most patients with this condition are located.

[Disturbed regulation of self-esteem in patients with overt versus covert self-destructive behaviour]

OBJECTIVES

According to psychoanalytic models self-harming patients are characterised by an unstable self-system and a disturbed regulation of self-esteem. This is presumed to be denied or dissociated to a greater degree by those who harm themselves secretly (factitious patients) as compared to those who show open self-harm. It is hypothesised and empirically tested that self-destructive patients have more profound disorders of narcissistic self-regulation than patients without self-destruction, and that this should be more evident in patients with overt self-destructive behaviour.

METHODS

The sample consists of 354 psychosomatic patients, 32 of whom demonstrated self-destructive behaviour (18 exclusively overt and 6 exclusively covert types of behaviour, according to Willenberg et al.). The narcissism inventory was applied.

RESULTS

Self-destructive patients showed higher levels on the "threatened self"-dimension than psychosomatic patients without self-harm. Overtly self-harming patients showed a higher degree of narcissistic self-regulation than covertly self-destructive patients.

CONCLUSIONS

This supports theoretical assumptions of a disturbed regulation of self-esteem in self-destructive patients, especially in overtly self-harming patients.