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Factitious Disorder: a Case Report and Literature Review of Treatment

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Factitious Disorder: a Case Report and Literature Review of Treatment Case notes I Fictitious disorder Factitious disorder: a case report and literature review of treatment Georgios Mousailidis MD, MSc, PhD, Carlo Lazzari MD, Shafalica Bhan-Kotwal MD, MSc, Basavaraja Papanna MD, MSc, Ahmed Shoka MD Diagnosis of factitious disorder motivation for the behaviour factitious disorder, treatment. Our (FD) is frequently difficult and c. absence of external gain, such as main aim is to provide information on patients may present with avoiding legal responsibility or treatment of this disorder whose man- physical symptoms only, improving physical wellbeing, as in agement may be very challenging. psychiatric symptoms only or malingering. Case presentation with a combination of both. As The following subtypes are specified: A 22-year-old female single patient was long as the nature of the a. patients with primarily physical signs admitted in our adult psychiatric ward disease is so secretive and and symptoms, after an unsuccessful serious suicidal large-scale studies are almost b. patients with primarily psychologi- attempt, by taking a significant over- impossible, every case report is cal signs and symptoms, and dose of diazepam. The patient was important. Here, the authors c. mixed subtype. already diagnosed with Emotionally present a case of severe FD and Unstable Personality Disorder the therapeutic approach taken. Patients with FD deceive clinicians in (EUPD) and mild depression. There order to assume the sick role and be was history of emotional dysregulation he term ‘Munchausen syndrome’ treated as patients. They may just since adolescence and occasionally Twas introduced in 1951 by Asher1 exaggerate or false report symptoms self-harming behavior by cutting. for people who purposefully create of a genuine physical illness or they There were no previous admissions in signs and symptoms of disease and may completely fabricate subjective psychiatric hospitals documented and who desire hospital or medical care. symptoms, physical examination and/ there was no history of previous over- The term ‘Munchausen’ is linked to or laboratory results. Fundamentally doses or suicide attempts. She was feel- Baron Munchhausen (1720–1797), these patients do not look for any kind ing low in mood for more than a year to whom factitious and unbelievable of gain such as monetary gain, days off due to stressors, including her physical stories about his life and encounters work, etc. They want to be cared for health and history of sexual abuse. were credited.2 and the factitious behavior is probably She was intermittently experiencing At present, regardless of the spread a maladaptive coping strategy in order auditory pseudo-hallucinations (the use of the term ‘Munchausen syn- for them to manage their inner emo- voice of the abuser). The patient drome’ this term is not included in the tional distress. This behavior results in described the voice as coming from International Classification of Dis- needless medical or surgical therapies her inner subjective space and lacked eases tenth version (ICD-10). that pose risks for their health or even the objectivity and sensory realness of Munchausen syndrome was incorpo- their life.5 a true hallucination. rated into the tenth version of the In the following paragraphs we will The patient under investigation- International Classification of Dis- present an interesting case of severe was physically unwell since childhood eases3 as Factitious Disorder (FD), FD in a young female patient, as well (asthma and epilepsy), which resulted which is intentional production or as our therapeutic approach. Our in several hospital admissions during feigning of symptoms or disabilities study also reviews the literature about childhood and excessive school absen- either physical or psychological – FD treatment. This is a narrative, teeism. She had started studying nurs- F68.1. The DSM-54 diagnostic criteria non-systematic review regarding ing science but was dropped out of for the FD imposed on self are: treatment of FD, which includes university. The relationship with fam- a. intentional production or feign- selected case reports, series of case ily members was poor after several ing of psychological or physical signs reports and reviews indexed in incidents of aggression/agitation or symptoms PubMed. We used the following towards them. During the last year b. assumption of the sick role as keywords: Munchausen syndrome; prior to admission in our psychiatric 14 I Progress in Neurology and Psychiatry I Vol. 23 Iss. 2 2019 www.progressnp.com Factitious disorder I Case notes ward she had several admissions in the disease, irritable bowel syndrome, her pretending to be ill. She used to local hospitals, in various wards with a spinal epidural lipomatosis and oste- become very aggressive and hostile variety of physical symptoms (chest oporosis. On admission, she was on towards the consultant in charge of pain, seizures, etc). Staff noticed 33 different medications from vari- treatment once she was confronted unusual behavior (simulating to be ill) ous medical specialties, including with the diagnosis of FD and she and she was referred for psychiatric inhalers, painkillers, etc. She had used to keep saying that it was a assessment six months prior to admis- been taking cimetidine, ranitidine false diagnosis and that she was only sion in our ward. The patient at that and omeprazole simultaneously. She physically unwell. point was uncooperative in disclosing had also been taking paracetamol, In terms of treatment she had any information and the psychiatric oxycodone, gabapentin, amitriptyline, weekly hourly appointments with the team concluded that there was insuffi- fentanyl patches and, when required, ward psychologist for stabilisation with cient evidence to make the diagnosis oramorph for neuropathic pain. The a view to starting psychotherapy in the of FD. only psychotropic medication was future. Initially she did not engage During the last 6 months prior to diazepam 5mg twice a day. We consid- well with the stabilisation therapy and psychiatric admission she used to ered that amount of medication as she missed lots of sessions. In our Trust attend A&E departments more fre- a significant substance misuse and when patients have a history of com- quently, especially during the nights we tried, with the assistance of the plex trauma, psychoeducation around and she got admitted on several wards. respiratory and medical team, to the diagnosis and stabilisation skills She used to present with chest pain, reduce her medication from 33 to are offered as a first phase of psycho- alleged seizures, dizziness, difficulty 19 drugs. Initially, she was very logical treatment. The intervention breathing, abdominal pain, urinary aggressive towards staff and was enables clients to understand their retention, etc. Her mother reported constantly asking for her initial diagnosis and develop skills to help that as the time progressed she was medication to be prescribed again. regulate their emotional intensity. leaving the house only to go to the During her admission she used to Stabilisation is a structured psycho- hospital or to the GP surgery. During simulate all kind of physical symptoms logical intervention. The number of her hospitalisation staff noticed again on a daily basis and several times dur- sessions provided depend on the unusual behaviour: she was saying she ing the day. She was very well informed patients level of understanding and couldn’t pass urine in order to have a about various medical conditions to ability to adopt new skills. All clients catheter put in. She was repeatedly the extent that all the on-call doctors with complex trauma have this inter- asking for intramuscular injections used to find the interaction with her vention prior to receiving either and more cannula insertions, even really challenging. She knew how to EMDR or psychotherapy.We started asking for central line insertion. She instigate an asthmatic crisis or how to her initially on quetiapine 200mg was putting herself on the floor and successfully pretend she was having a three times a day and sertraline 150mg saying she had a seizure (one incident seizure. Staff and doctors were trying in the morning, to help her with was recorded on one of the cameras). not to reinforce her attention seeking impulsive behavior and low mood, but She used to phone the respiratory behavior by not paying much atten- she experienced excessive drowsiness ward roughly twice a week saying she tion to her constant physical com- with quetiapine and we had to discon- was unwell and needed to be seen plaints, but they were very stressed tinue it. She was subsequently started urgently. When she went to the ward because this patient has already seri- on zuclopenthixol decanoate 200mg and doctors said her chest was fine, ous physical health problems and staff weekly injection. After less than a she would then wish to say a list of and doctors were afraid of being month of receiving the injection, she other problems unrelated to her res- accused of negligence. There is one showed significant improvement in piratory health, such as back pain, incident documented, when she terms of pretending less symptoms tooth ache, etc. A second referral to had a genuine asthmatic crisis and and engaging in far less impulsive the psychiatric services had been she was ignored by staff members. behaviors. made, but in the meantime the patient There were also a few incidents of At the end she became more took the overdose that resulted in her head banging, as well as some receptive towards the diagnosis of admission to our psychiatric ward. self-strangulation attempts. FD and she accepted to be trans- The patient had been suffering Interestingly, she accepted the ferred to a specialised unit for from asthma since childhood diagnosis of EUPD, but she was explic- patients with personality disor- (poorly controlled when young), itly denying the diagnosis of FD, ders for long-term rehabilitation. epilepsy, gastro-oesophageal reflux despite plenty of evidence showing Surprisingly, before her transfer, she www.progressnp.com Progress in Neurology and Psychiatry I Vol.
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