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Ask Dr. Stern about factitious illness. Webcast May 2, 2007, at 1:30 PM EDT. For details, see page 58.

Factitious illness: A 3-step consultation-liaison approach

Make the diagnosis when it is present, and rule it out when it is not ® Dowden Health Media s. J, age 33, arrives at the emergency department CopyrightFor personal use(ED) only complaining of chest pain and shortness Mof breath—symptoms she says are similar to those she had during episodes of pulmonary embolism (PE). Routine laboratory workup, including chest CT and ultrasound of the lower extremities, indicate a very low likelihood of PE, but she insists that she be admitted. On the medical fl oor, nursing staff note that Ms. J appears short of breath only when directly observed. Medical records reveal multiple visits to other hospitals with repeated requests for admission. When gently confronted, she maintains she will die if she is not treated. BENNETT PETER Has your hospital’s medical staff ever been puzzled by a 2007

© patient’s inconsistent presentation or unsettled by a con- cern that he or she was not being straightforward with Lucy A. Epstein, MD Clinical Fellow, Department of Psychiatry them? Have they suspected that a patient such as Ms. J Massachusetts General Hospital may be voluntarily producing his or her symptoms? This article suggests a 3-step approach by which the Theodore A. Stern, MD Chief, Psychiatric Consultation Service consultation-liaison psychiatrist can help medical staff Massachusetts General Hospital identify and manage patients with factitious illness. Professor of Psychiatry

Harvard Medical School Boston, MA Cardinal features In factitious illness, the patient’s symptoms are: • under voluntary control and consciously produced • not a direct result of a medical or psychiatric Current Psychiatry 54 April 2007 condition

For mass reproduction, content licensing and permissions contact Dowden Health Media. • produced to assume the sick role (not Table 1 to accrue secondary gain—a core fea- Medical clues to a patient with pSYCHIATRY ture of ). factitious illness Patients with factitious illness tend to currentpsychiatry.com present with realistic scenarios that sug- Vague symptom history that frays upon gest a physical or psychological disorder. examination Irritability and evasiveness with continued CASE questioning Self-infl icted injury Familiarity with hospital procedures and Ms. H, age 50, surprises even the most protocols (some patients have received seasoned clinicians when she presents to the medical training) ED with brain parenchyma herniating from an Multiple scars as evidence of past procedures open wound in her skull. She denies having and hospitalizations picked at her scalp and does not endorse a Acceptance of painful medical procedures history of obsessive-compulsive disorder or without complaint . Itinerant lives devoid of close personal Clinical Point On the medical fl oor, however, she is relationships seen picking at the wound, which leaves Minimize barriers Failure to accurately identify themselves blood on her protective mittens. Surgical to care by explaining Lack of a verifi able history repair is repeatedly attempted, and her case to medical staff that is complicated by chronic infections and a Source: Reference 1 nonhealing wound. the disorder is a while an inpatient—the ED physician is re- manifestation of luctant to dismiss his complaints and unsure psychiatric suff ering Clinical presentation about how to proceed. Factitious disorder presents 3 diagnostic and treatment challenges for a hospital’s 3-step diagnostic approach medical staff: Treating factitious illness is predicated upon • To recognize and treat (even self-in- making the correct diagnosis, which re- fl icted) serious medical conditions that can quires the medical team to investigate and be life-threatening. gather data from collateral sources, such as • To orchestrate appropriate diagnostic outside hospital medical records and other evaluation. (Remember that factitious ill- providers. The diagnostic process can be ness is a diagnosis of exclusion.) summarized in 3 steps: • To handle countertransference reac- Ñ Step 1. Determine whether the patient tions to patients that can be intense; phy- has an identifi able medical or psychiatric sicians may experience anger, frustration, problem that could explain the symptoms. resignation, and hatred. Ñ Step 2. Determine whether the symptoms You can help medical staff manage these are consciously or unconsciously produced. patients’ behaviors and minimize barri- Somatoform disorders—such as conversion ers to care by explaining the disorder as a disorder and , for ex- manifestation of psychiatric suffering. ample—are thought to result from processes outside the patient’s control. CASE Ñ Step 3. Distinguish if the motivation is ‘Suicidal’ but not depressed to obtain the sick role (consider factitious Mr. B, age 48, presents to the ED with thoughts illness) or if material benefi ts are the goal of suicide and profoundly depressed mood. (consider malingering). Both motivations On examination, however, he does not appear may be operative in a given patient. depressed. He repeatedly requests food, ciga- rettes, and assistance in fi nding shelter, which Medical evaluation. Certain aspects of lead to concern that his main goal is second- the patient’s medical presentation can ary gain. However, because Mr. B has a history steer the physician to making a diagnosis Current Psychiatry of serious suicide attempts—including some of factitious illness (Table 1).1 For patients Vol. 6, No. 4 55 with physical symptoms, staff should or- Box der standard evaluations based on clinical Factitious disorder: judgment (such as ECG and cardiac mark- Presentation severity ranges ers to evaluate chest discomfort). Some- times somatized symptoms are superim- up to Munchausen syndrome posed on an identifi able physical problem, unchausen syndrome—a and effective management includes treat- Mparticularly severe factitious Factitious ing both the medical illness and its created illness—is characterized by peregrination, disorder counterpart.2 recurrent presentations, and pseudologia fantastica (stories that seem outrageously 4 Psychiatric evaluation. Physicians should exaggerated). In 1951, Asher named this think of factitious psychiatric illness when: syndrome for Baron von Munchausen, an 18th century Prussian offi cer who • a patient’s behavior is notably differ- wandered from city to city creating tall tales ent when he believes he is being directly about his life.5 observed and when he believes he is alone3 Munchausen by proxy, in which a • psychiatric symptoms do not readily fi t Clinical Point parent is responsible for producing illness into diagnostic categories (such as a vague in a child, may lead to extensive medical The emergency mix of memory loss, suicidal thoughts, and evaluations and treatment. department often ) After more than 50 years, factitious is these patients’ • the patient is suggestible or provides a illness continues to draw scientifi c and diffusely positive review of systems (for ex- clinical attention. A search of PubMed over gateway; they arrive ample, he may report additional symptoms the last 10 years found nearly 500 citations. in the evening or on after having observed other patients). Presentations included: weekends when less When evaluating a patient with sus- • symptomatic bradycardia caused by beta-blocker ingestion6 pected factitious psychiatric symptoms, experienced staff • refractory hypoglycemia caused by perform a comprehensive psychiatric eval- are on call surreptitious insulin injections7 uation to identify an Axis I or II disorder. • false reports of aortic dissection8 Rule out possibilities such as as- • recurrent episodes of self-harm including sociated with complaints of memory loss, bilateral blindness from ocular trauma9 psychosis associated with reports of hal- • fabricated sweat chloride test results in a lucinations, or affective symptoms or Axis patient claiming to have cystic fi brosis.10 II pathology associated with thoughts of suicide. Patients with factitious disorder often have an underlying psychiatric ill- Because the patients’ somatic complaints ness such as a , but the predominate, the ED physician must com- Axis II disorder does not fully explain the plete a full evaluation, even if aspects of presenting complaint. the history are inconsistent. Patients tend The psychiatric presentations of Mun- to appeal to physicians’ nurturing quali- chausen syndrome can be especially ties in an attempt to have them provide complicated, as they are usually associ- care and attention.12 ated with less objective evidence than are medical presentations (Box).4-10 Clarity of Escalating demands. During the hos- the history and diagnosis may be in the eye pital stay, patients with factitious illness of the beholder. may make repeated requests for care, which may escalate into demands if their needs are not met.13 At this point, staff Admission characteristics often start to experience negative coun- Somatic complaints. Chaos often sur- tertransference reactions. As medical rounds the hospitalized patient with fac- tests reveal little to no evidence of an titious illness. The ED commonly is their organic basis for their symptoms and no gateway, and they tend to arrive in the cohesive psychiatric diagnosis is reached, evening or on weekends when less experi- patients may complain of misdiagnosis Current Psychiatry 56 April 2007 enced staff are on call.11 and mistreatment.13 Patients usually leave before psychiat- Table 2 ric consultation can be obtained, and the Recommended care for pSYCHIATRY underlying suffering that led to their fac- a patient with factitious illness titious complaints remains unaddressed. currentpsychiatry.com Typically, patients are lost to follow-up un- Fully investigate all medical and psychiatric complaints, especially if physical safety is til the next presentation at another hospi- threatened tal, where the process begins again. Maintain a healthy skepticism about unusual or illogical presentations while attempting to preserve an empathic connection with the What motivates patients? patient The motivation behind factitious presen- Be aware of countertransference reactions, tations can be bewildering. Asher’s pa- as they may provide valuable insight about the per on Munchausen syndrome described underlying cause of the patient’s symptoms several possible reasons for patients’ be- Realize that psychiatric symptoms and havior, such as desire to be the center of medical presentations fall on a continuum from attention, holding a grudge against the conscious to unconscious; at times there may medical profession, drug seeking, look- be a mix of motivations ing for shelter, and running from police.5 Bottom Report all fi ndings nonjudgmentally, both to This list, however, includes correlates of the patient and in medical documentation secondary gain, which with today’s psy- Line chiatric nomenclature would lead to a di- Factitious illness is a agnosis of malingering. ment is well-supported in the literature. diagnosis of exclusion. Approaches that have been reported in- Avoid premature Psychological factors. Some clinicians clude preventing patients from being have tried to address underlying psychi- re-admitted to medical facilities, admit- and unsubstantiated atric factors, but data on evaluation and ting patients for psychiatric treatment, interventions or management are limited because these and providing outpatient therapies such painful procedures. patients usually eschew psychiatric exami- as individual psychodynamic psycho- A 3-step approach can nation. Although the patient is voluntarily therapy, behavioral modifi cation, and help staff conduct an producing the symptoms, unconscious group psychotherapy.18 psychological factors are at play and are Other management strategies suggested appropriate diagnostic an essential part of the picture.14 in the literature include: evaluation and handle When assessed, patients appear to have • reframing cognitive distortions countertransference lived rootless lives with few attachments, • drawing up a set of realistic hospital- reactions. which may have been the result of sadis- ization goals (with a written contract) tic and unsatisfying relationships with • maximizing the therapeutic alliance authority fi gures of their youth.15,16 Their • avoiding team splitting grandiosity and distortion of the truth sug- • minimizing iatrogenic harm.19 gest a narcissistic need to overcome feel- Whatever the treatment, educate the ings of incompetence or impotence.17 Their medical staff about this complex disorder ambivalent relationship to hospitals and (Table 2), including the hazards of prema- physicians may refl ect a need for caretak- ture and unsubstantiated interventions or ing, arising from early relationships and painful procedures. Also help them man- past caretakers. age countertransference reactions. Provide Lastly, there is a component of masoch- an outlet for the staff’s intense emotions, ism; this makes some individuals (errone- and help them place such emotions into a ously) believe that if you don’t infl ict pain therapeutic context. you don’t care about them.13 Confront patients? The effi cacy and style of confronting patients with factitious ill- Treatment challenges ness have been hotly debated. Although Because patients with factitious disorder no consensus has emerged, an empathic, Current Psychiatry are not easily studied, no particular treat- nonthreatening confrontation may help Vol. 6, No. 4 57 the patient accept much-needed psychi- atric care.13 Related Resources Nevertheless, prepare the physician • Barsky AJ, Stern TA, Greenberg DB, Cassem NH. Functional somatic symptoms and somatoform disorders. In: Stern for the patient to respond to confronta- TA, Fricchione GL, Cassem NH, et al, eds. The Massachusetts tion with denial and resistance because General Hospital handbook of general hospital psychiatry, 5th ed. Philadelphia: Mosby/Elsevier; 2004:269-91. he or she feels exposed and humiliated. If • Elwyn TS, Ahmed I. Factitious disorder. EMedicine from Web the physician makes it clear that ongoing Med. Last updated April 13, 2006. www.emedicine.com/med/ Factitious medical care will still be available—even if topic3125.htm. disorder the symptoms are fabricated—the patient may be more willing to accept psychiatric 13 treatment. 9. Salvo M, Pinna A, Milia P, Carta F. Ocular Munchausen syndrome resulting in bilateral blindness. Eur J Ophthalmol References 2006;16(4):654-56. 1. Stern T. Malingering, factitious illness, and somatization. In: 10. Highland K, Flume P. A “story” of a woman with cystic Hyman S, ed. Manual of psychiatric emergencies. Boston: Little, fi brosis. Chest 2002;121(5):1704-7. Brown, and Co; 1988:23;217-25. 11. Stretton J. Munchausen syndrome. Lancet 1951;1:474. 2. Turner J, Reid S. Munchausen’s syndrome. Lancet 2002; 12. Stern T. Munchausen’s syndrome revisited. Psychosomatics 359:346-9. 1980;21(4):329-36. 3. Popli A, Prakash S, Dewan M. Factitious disorders with 13. Stern T. Factitious disorders. In: Hyman S, Jenike M, eds. psychological symptoms. J Clin Psychiatry 1992;53:9. Manual of clinical problems in psychiatry. Boston: Little, Brown, and Co; 1990:21;190-4. 4. Huffman J, Stern T. The diagnosis and treatment of Munchausen’s syndrome. Gen Hosp Psychiatry 2003;25:358-63. 14. Greenacre P. The imposter. Psychoanal Q 1958;27:359-82. 5. Asher R. Munchausen’s syndrome. Lancet 1951;1:339-41. 15. Cramer B, Gershberg M, Stern M. Munchausen syndrome. Arch Gen Psychiatry 1971;24:573-8. 6. Steinwender C, Hofmann R, Kypta A, Leisch F. Recurrent symptomatic bradycardia due to secret ingestion of beta- 16. Ford C. The Munchausen syndrome: a report of four new cases blockers—a rare manifestation of cardiac Munchausen and a review of psychodynamic considerations. Psychiatry syndrome. Wien Klon Wochenschr 2005;117(18):647-50. Med 1973;4:31-45. 7. Bretz S, Richards J. Munchausen syndrome presenting 17. Bursten B. On Munchausen’s syndrome. Arch Gen Psychiatry acutely in the emergency department. J Emerg Med 2000; 1965;13:261-8. 18(4):417-20. 18. Yassa R. Munchausen’s syndrome: a successfully treated case. 8. Hopkins R, Harrington C, Poppas A. Munchausen syndrome Psychosomatics 1978;19:242. Current Psychiatry simulating acute aortic dissection. Ann Thorac Surg 19. Gregory RJ, Jindal S. Factitious disorder on an inpatient 58 April 2007 2006;81(4):1497-99. psychiatry ward. Am J Orthopsychiatry 2006;76(1):31-6.

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Dr. Theodore Stern Chief of Psychiatric Consultation When: Wednesday, May 2, 1:30 PM (EDT) Massachusetts General Hospital Where: www.CurrentPsychiatry.com

Dr. Stern explains how C/L psychiatrists help identify and manage factitious disorder. Interactive Q-and-A to follow Download the proceedings after May 2 Hosted by Dr. Henry Nasrallah Editor-in-Chief, CURRENT PSYCHIATRY

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