Gaslighting in alleged assault ascertained as Munchausen syndrome transcending to malingering in highly counterintuitive self inflicted acid burns

A factitious disorder leading to the self-infliction of highly counter-intuitive burns was diagnosed in a middle-aged female. The injuries were otherwise alleged to have been sustained by assault inflicted upon her by an unknown person. The case was diagnosed by medico-legal interpretation of injuries, in spite of a highly deceptive and concocted history by the patient and her husband. The entity was unique in being associated with magnificent primary, secondary and tertiary gains. The exploitation of the morbid sequel to malinger by the patient, and the involvement of the husband for the prolongation of the illness of his wife for financial gains as gaslighting was highly unusual. The self-infliction of injuries over hands is seen in factitious disorder. However, a combination of a guarded self-immersion of the hands and feet in a corrosive by an illiterate female, followed by malingering to earn livelihood is unprecedented in factitious disorders. The delayed presentation which required amputation of all the limbs to save the life of the patient is a glaring highlight of this case.

Factitious Disorder (Munchausen Syndrome) in Plastic Surgery: A Systematic Review of 42 Cases

INTRODUCTION

Patients with factitious disorder (FD) or "Munchausen syndrome" intentionally fabricate or induce medical problems for psychological gratification. They may deceive plastic surgeons into performing multiple unnecessary procedures. We undertook the first systematic review of FD case reports in plastic surgery. Our aims were 2-fold: (1) describe the adverse outcomes associated with these cases and (2) identify strategies for their prevention by surgeons.

METHODS

MEDLINE, EMBASE, and SCOPUS databases were searched. We included cases in which an adult with FD presented to a plastic surgeon. Our search returned a total of 42 eligible cases reported from North America (43%), Europe (37%), and Asia (20%).

RESULTS

Seventy-six percent of patients were women, and 62% worked in health care. Sixty percent had a comorbid psychiatric disorder, the most common (50%) being depression. Ninety-three percent of our sample presented with self-induced lesions. The average delay in diagnosis of FD was 54 months, with 46% of patients receiving multiple surgical procedures in this time, including debridement (36%) and skin grafts (39%). Surgical wounds were frequently exploited by patients to remain in, or return to, hospital: 50% contaminated or manipulated their wounds to prevent healing. Thirty-six percent of cases resulted in significant long-term disability (24%) or disfigurement (12%). Ten percent of patients received an amputation. Outcomes were improved when patients were confronted by surgeons, however, and 62% were willing to see a psychiatrist. Surgeons were able to support recovery in 33% of cases-for example, by using occlusive wound dressings.

CONCLUSIONS

Patients with FD who present to plastic surgeons are high risk: the majority require surgical intervention for severe self-injury, and many engage in harmful behaviors, such as "doctor-shopping." Early recognition of FD in plastic surgery is, therefore, crucial and may be achieved via careful examination of lesions for unusual morphology. Medical records may reveal extensive health care service use and negative investigations. Finally, plastic surgeons may play an important role in managing such patients. Management strategies include direct observation by nursing staff in the postoperative period and use of strict occlusive dressings to prevent access to surgical wounds.

Munchausen syndrome: report of a case and implications for dentists

Munchausen syndrome (MunS), or factitious disorder imposed on self, is an exceedingly rare and immensely difficult syndrome to identify and manage and is considered a diagnosis of exclusion. Few reports exist in the dental literature to date, so the objective of this article is to describe a case of MunS in a 60-year-old woman who sought treatment for bilateral jaw pain and uncontrolled jaw movements. The patient's symptoms started 19 months previously, following placement of a 6-unit metal-ceramic bridge. Her pain started as a mild, intermittent ache that lasted for 30 minutes. However, gradually her symptoms became severe and constant. In addition, she started to experience episodes of uncontrolled jaw contractions that were associated with bilateral episodes of stabbing and shooting pain. Results from her comprehensive clinical assessment and investigations suggested that the patient had masticatory myalgia pain disorder and oromandibular dystonia. She experienced significant relief of symptoms with pharmacologic intervention. However, after an intermittent period of relief, she returned to the clinic with an inconsistent history, irregular clinical examination, and history of erratic behavior. The patient was referred to a psychiatrist, who eventually rendered a diagnosis of MunS. This article will also address considerations for the dental team, including how to identify cases of MunS, relevant courses of action, including appropriate referral, and the consequences of overdiagnosis of MunS.

Munchausen's Syndrome—Masquerading as Necrotizing Fasciitis

We would like to present a novel form of Munchausen's syndrome which presented us with a difficult problem in the midst of the recent media hysteria regarding flesh eating bacteria. This condition, first described by Richard Asher in 19511, is often very difficult to diagnose and it is not, therefore, surprising that the victims have been through several epsiodes of treatment before the suspicions of staff are raised. It owes its name to a fictitious character, Baron Karl Friedrich Hieronymus Freihess von Munchausen, who recounted extraordinary and wildly exaggerated exploits of adventure and daring, not unlike patients who present with this condition.

Our enquiries revealed that the laid down procedure when faced with a patient with this condition is that the regional medical officer (RMO) should be contacted. It is then his responsibility to contact other RMOs, who in turn pass the information on to accident and emergency consultants in their area.

Cardiac Munchausen's syndrome

Ten years' experience of cardiac Munchausen's syndrome in the Cardiac Care Unit of an Inner London teaching hospital is reported. Thirty-six admissions in this category were identified and analysed, and 4 typical cases are described. The common presenting complaints, recurring features and the relationship with other forms of Munchausen's syndrome are discussed, as are posible strategies available to deal with this clinical entity.

[Pseudohypoacusis associated with Munchausen's syndrome]

The authors describe a rare clinical case of psychogenic hearing loss in a female patient presenting Munchausen's syndrome with special reference to the objective and subjective methods designed to evaluate the hearing ability and used for diagnostics of this condition.

Munchausen Syndrome and the Wide Spectrum of Factitious Disorders

Since its initial description in 1851, Munchausen syndrome has been widely used interchangeably with factitious disorder. Nevertheless, this syndrome is only one form of factitious disorder that is both severe and chronic. The syndrome was named after Karl Friedrich Hieronymus, Baron von Münchhausen (1720-1797), a German nobleman who became famous as a narrator of false and exaggerated exploits. His name was progressively corrupted to Munchausen. Factitious disorders and Munchausen syndrome remain a great diagnosis challenge for physicians. All medical specialities are concerned by these disorders. The diagnosis process involves a first step to exclude an unusual presentation of a common medical condition. The second step consists of excluding somatoform disorders and malingering. Unfortunately, the boundaries between factitious disorder, somatization, and malingering are often unclear. In 1977, the term "Munchausen's syndrome by proxy" was coined to define a situation where a person produces false symptoms in another one, especially a child. This term was extended to similar interactions between human and pets. Because varied conditions have been included in the definition of this syndrome, there is ongoing debate about alternative names.

[Non usual cases of hypoglycaemia--hypoglycaemia factitia]

Hypoglycaemia factitia means also in recent time serious diagnostic and therapeutic problem in medical clinical practice, whereby often repeating episodes of serious hypoglycaemia in patients with diabetes mellitus, but also in patients without diabetes mellitus could be very difficult do resolve. First unsuccessful diagnosis implicit from wrong chose of examination algorithm, can lead to unidentified surgical interventions as are laparotomy and pancreatectomy, respectively. Hypoglycaemia factitia is considered to be one of many manifestations of so called Münchhausen's syndrome for that is typical acting of diabetic patient with goal to intentionally making hypoglycaemia or within suicidal attempt of patient on the basis psychological disease with intention to attract attention of surrounding community to himself due to application of insulin or sulfonylurea drugs. Diagnostic and therapeutic process could be in the case of hypoglycaemia factitia extremely difficult as from time side, than from health and also from economical side and that why necessary to approach with maximum responsibility.

[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.

Bilateral suborbital rash: a dermatologic manifestation of neuropsychiatric disease in a pediatric patient

A 10-year-old girl presented with a new onset bilateral suborbital rash. Dermatologic examination revealed violaceous, non-tender, well-demarcated patches with an atypical distribution and pigmentation. After further investigation, a diagnosis of Munchausen syndrome was made and the patient was referred to her primary care provider for further management.

[Munchausen's syndrome: a factitious disorder? A case report]

Munchausen's syndrome is classified as a chronic factitious disorder with predominant physical signs and symptoms. Several symptoms are specific to this disorder, such as travelling and pseudologia fantastica. Others symptoms, such as multiple physical complaints with no organic substrate, are shared with somatoform disorders. We report a case showing how difficult it is to diagnose a Munchausen syndrome. We discuss also the opportunity to classify such a syndrome as a factitious disorder. Indeed, several authors suggest classifying Munchausen syndrome as a subtype of somatoform disorders, as those two disorders share a lot of characteristics.

[Munchausen disease diagnosed ten years after debut]

Munchausen disease is difficult to diagnose especially because it is often an exclusion diagnosis. We present a case of skin ulcers in a young woman, who was eventually diagnosed with Munchausen disease.

[Munchausen syndrome in an extreme form of factitious disorder]

Patients suffering from this disorder mimic symptoms of diseases and seek medical procedures and operations. We present a case of a patient who underwent a thorough investigation for unexplained persistent hypoglycemia. According to the algorithm approach to the non-diabetic patient, we measured insulin and c-peptide plasma levels while glucose levels were low and looked for sulphonylurea, blood and urine traces. Following the above, an endoscopic ultrasound demonstrated a small pancreatic lesion and an explorative laparotomy was performed to detect an insulinoma. This procedure was complicated by partial colectomy due to colonic gangrene. Following the patient's recovery, hypoglycemia recurred and the laboratory tests were repeated, revealing trace amounts of glipizide in her serum and urine. Studies which examined the prevalence of the phenomenon among cases of unexplained hypoglycemia, including patients who were operated for presumed insulinoma, were reviewed. No specific therapy for factitious disorder has been established. Management is based upon psychotherapy which is often not very effective. We recommend that one has to keep in mind that negative tests for sulphonylurea traces in serum and urine, do not contradict the diagnosis of factitious disorder, and it is recommended to repeat these tests several times.

Laboratory diagnosis of factitious disorder: a systematic review of tools useful in the diagnosis of Munchausen's syndrome

AIMS

To assist clinicians in the diagnosis of factitious disorder.

METHODS

This is a systematic review of the role of laboratory, radiologic, procedural, and pathological modalities to assist in the diagnosis of factitious disorder (Munchausen's syndrome). The review evaluated 3104 article titles and abstracts that were identified from MEDLINE as of January 2010.

RESULTS

We found 190 articles that demonstrated techniques that will assist clinicians in recognizing fabricated manifestations of disease. The results are divided into 13 areas of clinical medicine for easy reference. They are further sub-divided by the diseases or conditions that patients have been reported to simulate and the diagnostic techniques suggested by the literature in each case.

CONCLUSIONS

Factitious disorder is difficult to diagnose and may present as a wide array of fabricated conditions, but there are a range of laboratory and technical means available to assist clinicians in the 21st Century.

[Munchausen syndrome, a factitious injury, presenting brain abscess and intraventricular hemorrhage: a case report]

Munchausen syndrome is a factitious disorder. Patients sometimes inflict injury on themselves in order to assume a sick role. The authors report a patient with Munchausen syndrome suffered from brain abscess, reopened wound and intraventricular hemorrhage. A 64-year-old male was admitted to our hospital after head injury. CT and MR imaging revealed a mass with surrounding edema in the right frontal lobe. The mass was surgically removed, and diagnosed as brain abscess. During the surgery, the authors noticed a small bone defect in the frontal bone above the brain abscess; therefore, we considered that head injury just concerned this lesion. There were no particular clues leading to other possible pathologies. After the first surgery, the patient presented atypical seizures several times. Once we discharged him from our hospital, we hospitalized him again because the wound had reopened. A subsequent operation was needed, and we removed the bone flap which we considered the origin of the infection. After the second surgery, he stabbed a nail into his head where the bone had been removed due to the previous surgery, and presented intraventricular hemorrhage. The hemorrhage decreased in size through non-surgical treatment and he was referred to the psychiatry department under a diagnosis of Munchausen syndrome. Diagnosis of this entity is difficult and often made at the later stage of hospitalization, because patients present a variety of complaints and clinical symptoms, which are hardly proved factitious. Early consideration of this syndrome will offer an early and accurate diagnosis, and is mandatory for a good prognosis.

Functional neuro-ophthalmology

Patients with physical signs and symptoms for which no adequate organic cause can be found may receive any one of a large range of diagnostic labels, including functional illness, functional overlay, hysteria, hysterical overlay, conversion reaction, psychophysiological reaction, somatization reaction, hypochondriasis, invalid reaction, neurasthenia, psychogenic reaction, psychosomatic illness, malingering, and Münchausen syndrome. In this chapter, we describe both common and uncommon "functional" ocular symptoms and signs, including visual loss in one or both eyes, constricted visual fields and other field defects, various types of ocular motor dysfunction, including disorders of ocular motility and alignment, disorders of pupillary size and reactivity, and abnormalities of eyelid position and function. We also discuss and illustrate the methods by which the nonorganic nature of these manifestations can be determined. In many cases simple techniques performed in the clinic are sufficient to establish a diagnosis of nonorganic ocular disease, whereas in other cases ancillary studies such as electrophysiological testing may be necessary. The chapter also describes the appropriate approach that the physician should take when dealing with a patient who has proven functional ocular signs and symptoms.

Munchausen's syndrome--more common than we realize?

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.

[Münchausen syndrome by proxy]

Münchausen syndrome by proxy (MSBP), is a psychiatric disorder, a particular form of child abuse. An impaired emotional relationship exists mainly between the mother and her child. According to the variety of victims' symptoms, all medicine doctors may deal with this syndrome in every day clinical practice. Still insufficient knowledge about the syndrome and its' rare consideration in the differential diagnosis result in only severe, potentially lethal cases recognition. For many years the rest remains a source of a long-term physical and mental injuries in victims. About 30 years from the first attempt to precisely point the signalling symptoms for a proper diagnosis, we present the current knowledge on epidemiology, aetiology, diagnostic criteria, advised management and psychological portrait of the mother with the syndrome and her child, the syndrome's victim.

[Münchhausen's syndrome--a diagnosis to remember]

We hereby report a case of self mutilation against the right upper extremity in a 26-year-old male. The condition started after a minor trauma. After a few days the diagnosis compartment syndrome was suspected and a fasciectomy of the forearm was performed. The patient subsequently claimed that he had experienced further symptoms. Despite countless investigations, it was not possible to identify the course of the patient's symptoms. It has become clear that the patient suffers from >>Münchhausen's syndrome<<.

[Pathomimesis and Münchhausen syndrome]

Factitious disorders, as pathomimesis and Münchhausen syndrome, have to be diagnosed early to avoid numerous exams and inadequate treatments, which intensify symptoms. Lesions are self-inflicted in a fully conscious manner. The patient does not search for direct benefits, hides his/her responsibility in the induction of lesions. Factitious disorders have to be differentiated from simulation and it is necessary to understand that they are the expression of an intense mental suffering, which is often unknown by the patient. Diagnosis is difficult, with various clinical manifestations, but it is not a diagnosis by a process of elimination: it is supported by the presence of personality disorders, usually borderline disorders. Management is complex and often disappointing. To keep a therapeutic relationship with the patient requires collaboration between all healthcare personals; psychotherapeutic treatment is possible only with the installation of a trusting relationship and with associated cares of physical symptoms.

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.

[Case of self mutilation of urethra in a Munchausen's syndrome patient]

A 33-year-old man presented with urethral bleeding and syncope. Urethroscopy revealed erosive lesion with bleeding at bulbar urethra. Magnetic resonance imaging, biopsy, and blood examination were performed, but the cause of urethral bleeding was not identified. By accident, chopsticks with blood ware detected in his ward. It was revealed that urethral bleeding was caused by self-mutilation with chopsticks. He consulted a psychiatrist, and was diagnosed with 'munchausen's syndrome'.

["I'd like to have a high-dose chemotherapy with stem cell transplantation!"]

Patients with factitious disorders can imitate complex diseases and cause multiple investigations and therapies. The presented patient showed the typical signs and behaviour of this psychiatric disorder. Confrontation may not be helpful in severe cases, whereas a supportive approach might help to avoid further useless and dangerous procedures.

[Abdominal wall necrosis as expression of Munchausen's syndrome: a case report]

Münchausen's syndrome is a psychiatric disease with behaviour disorders including self-injuries. Self mutilations interest all the body, and among others the abdominal wall, who can mimic complications of surgery. We report the history of a woman consulting for an abdominal wall panniculitis two years after a caesarean. Medical history, histological patterns and the psychological history of the patient excluded the diagnosis of a surgical complication and Münchausen's syndrome was strongly evocated. The treatment was surgical, with excision of the cutaneous necrosis. The healing was obtained by treatment with Vacuum Assisted Closure System (VAC).

[Somatic disorders, factitious disorders and simulation: the subtle art of differential diagnosis]

In every day practice, it is difficult, sometimes impossible, and always ethically delicate to determine the differential diagnosis between: disorders of a somatic nature, simulation and factitious disorders, as much for the psychiatrist as for the general practitioner in the front line. Our aim is to lead a reflection on this controversial theme on the basis of a clinical illustration.

Neonatal hyperinsulinism: clinicopathologic correlation

Neonatal hyperinsulinism is a life-threatening disease that, when treated by total pancreatectomy, leads to diabetes and pancreatic insufficiency. A more conservative approach is now possible since the separation of the disease into a nonrecurring focal form, which is cured by partial surgery, and a diffuse form, which necessitates total pancreas removal only in cases of medical treatment failure. The pathogenesis of the disease is now divided into K-channel disease (hyperinsulinemic hypoglycemia, familial [HHF] 1 and 2), which can mandate surgery, and other metabolic causes, HHF 3 to 6, which are treated medically in most patients. The diffuse form is inherited as a recessive gene on chromosome 11, whereas most cases of the focal form are caused by a sulfonylurea receptor 1 defect inherited from the father, which is associated with a loss of heterozygosity on the corresponding part of the mother's chromosome 11. The rare bifocal forms result from a maternal loss of heterozygosity specific to each focus. Paternal disomy of chromosome 11 is a rare cause of a condition similar to Beckwith-Wiedemann syndrome. A preoperative PET scan with fluorodihydroxyphenylalanine and perioperative frozen-section confirmation are the types of studies done before surgery when needed. Adult variants of the disease are less well defined at the present time.

Ocular Munchausen syndrome resulting in bilateral blindness

PURPOSE

Münchausen syndrome is a factitious disorder in which patients knowingly harm themselves for subconscious psychological reasons in order to be hospitalized. Recognition of this psychopathology is important, to prevent potentially severe eye damage. Ocular Münchausen syndrome is uncommon. The authors describe an elderly woman with recurrent, probably self-induced, ocular trauma leading to bilateral blindness. The authors are unaware of any previously reported cases of Münchausen syndrome resulting in bilateral blindness and occurring in old age.

CASE REPORT

A 73-year-old woman was first seen in 1991 with a closed-globe injury to the right eye, apparently following a household fall. Physical examination showed no sign of extraocular trauma. Right visual acuity was 20/30 after 2 months. She was readmitted in May 2003 with left globe rupture, allegedly following a domestic fall. No extraocular trauma was found. She developed ocular phthisis 6 months postoperatively. The patient was admitted again in February 2004 with right globe rupture, following another alleged domestic fall. Physical examination showed no sign of extraocular trauma. Right visual acuity was 20/400 2 months postoperatively. Psychiatric evaluation revealed Münchausen syndrome. Psychotherapy was prescribed, but refused by her family.

CONCLUSIONS

Diagnosis of Münchausen syndrome is difficult to make in the ophthalmic department. Münchausen patients have little or no ability to control their self-destructive behavior. A sympathetic and supportive approach is therefore required and these patients should be urgently referred to a psychiatrist with experience in factitious disorders. Even with psychotherapy, which is often refused, the prognosis remains poor.

Blood--but not bleeding--at a tracheotomy site: a case of Munchausen's syndrome

Munchausen's syndrome is a factitious illness in which patients fabricate medical problems in order to receive medical attention. Their "symptoms" are typical of actual medical conditions and their history is dramatic yet plausible, but no pathology can be found on imaging and other investigations. We report the case of a young woman whose Munchausen's syndrome manifested as purported bleeding from a tracheotomy site. In actuality, she had drawn the blood from an arm vein and spattered it on her neck.