A case of factitious homicidal ideation

Homicidal ideation is often fabricated or embellished by psychiatric patients in both the emergency room and inpatient settings. Typically, this symptom is malingered to achieve short-term hospital admission and temporary relief from complications of substance abuse, homelessness, and illicit activities. Very rarely, a patient may feign homicidal intent for the primary purpose of remaining in the role of patient (factitious disorder). Although factitious disorder with psychological symptoms has been described in a variety of circumstances, the psychiatric literature lacks any reports of factitious homicidal ideation. This is a report on the case of a patient who was civilly committed on numerous occasions for protracted periods based solely on his self-professed homicidal ideation. The case raises both forensic and clinical questions and reinforces the authors' belief that further investigation is needed to develop more sophisticated methods of detection, evaluation, and treatment of factitious disorder with psychological symptoms.     

Munchausen's syndrome: a reconceptualization of the disorder

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) delineates three categories of factitious disorders: chronic with physical symptoms (Munchausen's syndrome); factitious disorder with psychological symptoms; and other factitious disorders with physical symptoms. Munchausen's syndrome served as the prototype for all factitious disorders at the time DSM-III was drafted, partly due to the disproportionate attention given to this variant of the disorder. Clinical experience suggests that existing categories do not adequately provide for commonly seen forms of factitious illness. It is now recognized that factitious disorder is the result of a complex interaction of personality factors and psychosocial stressors that often present with both medical and psychiatric symptomatology. Proposed changes in the revised edition of the diagnostic manual DSM-III-R include separate categories of factitious disorder with psychological, physical, and both psychological and physical symptoms. A case report of a patient for whom extensive records and thorough psychological assessment were available is exemplary of a more common course of the disorder (both psychological and physical symptoms) that by current classification would be considered "atypical." A reconceptualization of the disorder that gives emphasis to course and clinical features is suggested.     

Factitious disorder as repeated diabetic ketoacidosis: a case report

Factitious disorder is a challenging entity, both in diagnosis and treatment. The clinical presentation is variable in feigned symptoms and spans virtually all organ systems. The diagnostic criteria are simple, yet making the diagnosis is often complicated and can be delayed by focusing on the urgent or readily observable diagnosis. In this article, the authors present a case of factitious diabetic ketoacidosis resulting from the deliberate withholding of exogenous insulin. This particular case is dissected in order to portray the underlying psychopathology. In doing so, the authors illustrate how a patient with factitious disorder might fulfill unmet, presumably unrealized needs. The authors also discuss the diagnostic criteria and treatment strategies of factitious disorder, both of which are of considerable debate within the psychiatric community.     

A case of factitious disorder involving menstrual blood smeared on the face

This article presents a case of factitious disorder in which a female smeared menstrual blood on her face. The patient was admitted to our otolaryngology clinic complaining of bleeding from the mouth, nose, ears and eyes. This event reportedly occurred three to four times on a daily basis. She acknowledged nine prior admissions to different specialists over the last two years. Following psychiatric consultation, we diagnosed factitious disorder with predominantly physical signs and symptoms. She was started on Fluoxetine 20 mg/day and supportive interviews were organized. After diagnosis, we observed that her symptoms decreased over two months. The symptoms did not reoccur three to nine months after treatment. This case report outlines two important features. The first is that a case of this type has not been reported before, and the second feature is that this case demonstrates the effect of cultural factors greatly different from those seen in classical factitious disorder.     

Dual factitious disorder

The DSM-III classification of factitious disorders encourages artificial separation into disorders with physical and those with psychologic symptoms. Despite documented examples of similar patients who present with psychiatric complaints, Munchausen's syndrome is usually considered a form of chronic factitious physical disorder. Three patients with both factitious physical and psychologic symptoms are presented. These patients illustrate the importance of focusing on the fundamental behavior of assuming the patient role, rather than on the specific category of symptoms. We recommend that the category of symptoms be used as a modifying statement, rather than defining separate disorders.     

Factitious disorder in a manic patient: case report and treatment considerations

A case of factitious disorder with physical symptoms is described in a patient with manic-depressive illness. The coexistence of factitious disorder and bipolar disorder has not been previously reported. Clinicians should search for an underlying affective disorder in patients who fabricate signs and symptoms of physical illness, since mania may simulate or contribute to the production of factitious behavior.     

Insulin-induced factitious hypoglycemic coma

Hypoglycemia due to the ingestion of oral hypoglycemic agents or injection of insulin is a common way for chronic factitious disorder to present to physicians. Despite this fact, factitious hypoglycemic coma is rare. Because hypoglycemia is potentially fatal, with numerous sequelae, physicians need to be aware of its occurrence and method of detection. A case of chronic factitious disorder presenting as hypoglycemic coma is presented and its implications discussed.     

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.     

Identifying and Managing Malingering and Factitious Disorder in the Military

Malingering is the intentional fabrication of medical symptoms for the purpose of external gain. Along similar lines as malingering, factitious disorder is the intentional creation or exaggeration of symptoms, but without intent for a concrete benefit. The incidence of malingering and factitious disorder in the military is unclear, but likely under reported for a variety of reasons. One should be aware of potential red flags suggesting malingering or factitious disorder and consider further evaluation to look for these conditions. A deliberate and intentional management plan is ideal in these cases. Furthermore, a multi-disciplinary team approach, a non-judgmental environment, and the use of direct but dignity sparing techniques will likely be most “successful” when confronting the patient with malingering or factitious disorder.     

Pseudologia fantastica and factitious disorder: review of the literature and a case report

Pseudologia fantastica is sparsely defined in the psychiatric literature, and has not been reviewed in the English-language psychiatric literature since 1988. To redefine the role of pseudologia fantastica in factitious disorder, the case of a 56-year-old man with factitious disorder is discussed.     

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.     

Artificial diseases (self-induced diseases)--a review]

Factitious disorders have gained greater significance in all medical specialties during recent years, and continue to pose difficult problems. At present factitious disorders can be divided into four sub-types, the pretence and/or production of somatic and/or psychic medical symptoms being central to all. Apart from disturbance of ego structure the self and the body image (self) a specific disturbance of the doctor-patient relationship is of pathognomonic value. An integrated therapeutic approach (combination of palliative measures, somatic therapy and psychotherapy) seems to be most successful. In the differential diagnosis, factitious diseases have to be delineated from many other diseases in which self-destructive behaviour may occur.     

Psychiatric and behavioral correlates of factitious blindness

In factitious disorder, an individual feigns, exaggerates, or actually self-induces physical or psychiatric illness to achieve ends such as mobilizing care and concern, ventilating aggression, diminishing guilty feelings, or gratifying dependency wishes. We present 2 new cases of factitious binocular blindness, which has rarely been reported but readily illustrates the dramatic range of factitious illness behaviors. Psychiatric and behavioral correlates culled from these cases include extravagant claims about the impairment and ludicrous claims for nonvisual sensory abilities. These patients typically refuse psychiatric care, but earlier detection can help abort the illness deceptions and forestall iatrogenic complications.     

Factitious stroke presenting for acute treatment.

Four patients who were ultimately determined to have factitious neurological deficits were initially assessed as meeting eligibility criteria for treatment with intravenous recombinant tissue plasminogen activator (IV rt-PA), or enrollment in an acute stroke study. Two patients presented within the 3-hour IV rt-PA window; two presented between 4 and 6 hours after symptom onset. Evaluation by the Stroke Team responsible for IV rt-PA treatment or clinical study enrollment determined that three patients met all eligibility criteria, except for a fluctuating or rapidly improving deficit; these patients did not receive rt-PA or study enrollment. One patient whose deficit did not fluctuate or improve on Stroke Team evaluation was enrolled in an acute stroke study. Compared with 36 nonfactitious patients who received IV rt-PA or study enrollment, factitious patients were less likely to have facial weakness, aphasia, neglect, or visual field deficit. Because criteria for IV rt-PA and many stroke studies do not currently require imaging of a vascular occlusion or ischemic brain tissue, patients with factitious stroke may appear to meet these eligibility criteria. Physicians experienced in acute stroke evaluation and management are most likely to identify patients with factitious stroke and exclude them from consideration for thrombolysis or stroke study enrollment.     

The Munchausen patient in a forensic facility

The many reports in the literature of chronic factitious illness (Munchausen's Syndrome) have emphasized the difficulty of treating these patients because of their propensity to leave medical facilities as soon as the factitious nature of their symptoms is discovered, and because of their disinclination to accept psychiatric help. The authors report on their treatment of such a patient who was incarcerated for over ten years under a criminal commitment, and discuss methods for overcoming resistances to treatment in Munchausen's patients.     

Factitious disorder and factitious disorder by proxy

Similar to the adult patient, a child or adolescent may actively feign or produce artificial symptoms (synonymous: Munchausen syndrome). The more frequent case is that the child suffers from being an object of symptom fabrication induced by a close person caring for the child, regularly the mother (Munchausen syndrome by proxy). This review focuses on psychopathological aspects of the clinically more relevant factitious disorder by proxy. Typical behaviour and personality characteristics are presented that can be taken as clinical warning signs. Doctor-mother-interaction is affectively challenging due to conflicting tasks imposed on the physician. Complementary to pediatric exclusion of genuine disease, psychopathological assessment is required to exclude other sources of deviant illness behaviour. Factious disorder shares particular features (active violation of the child, false report of history, aggravated symptom presentation and increased doctor-hopping, difficulties in conforming maternal report in biomedical data) with other psychopathological entities (child abuse, simulation, dissociative disorders, somatoform disorders including hypochondria, variants of maternal overprotection and infantilization, psychosis or delusion in the mother). Criteria for differentiation are presented. Three concepts on the psychopathological etiology of factitious disorder by proxy are relevant: In some cases, it may be conceived as secondary manifestation of a primary psychopathological entity or personality disorder. Learning theory emphasises operant rewards received from vicarious sick role. Attachment theory provides possible explanations concerning the traumatic impact on the child, early sources of psychopathology in the fabricating mother and risks for intergenerational transmission of factitious disorders.     

A case report of comorbid eating disorder and factitious disorder

A review of the literature on comorbid eating disorder and factitious disorder reveals that they are very rare. In this report the authors present the case of a 26-year-old Japanese female, who, in the midst of treatment for eating disorder, was found to be fabricating her physical symptoms, by injecting unclean water into her intravenous bottle. As a result she was diagnosed with factitious disorder.     

A pediatric case of factitious disorder with unexplained bleeding symptoms

Factitious disorder is characterized by deliberate production or imitation of physical or psychological symptoms in order to adopt the sick role. The disorder can be seen as factitious bleeding. Factitious bleeding is a rare disorder in pediatric population. The concomitant appearance of hemoptysis and hematuria in the same patient has not been previously reported. In this case report, we present a pediatric case of factitious disorder with both hemoptysis and hematuria.     

Pseudoadolescent Munchausen syndrome

Munchausen syndrome has not been reported in adolescents. We report two cases in young adults who, because they feigned adolescence, were first seen by pediatricians and then treated on a locked adolescent psychiatric ward. Their presentations resembled Munchausen syndrome, but included prominent factitious psychological symptoms as well as factitious physical symptoms. These cases are discussed in relation to the syndrome's classification, natural history, and associated character pathology.