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.     

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.     

Munchausen's syndrome: a syndrome of drug dependence

The syndrome of chronic factitious illness is likely more common than has been reported in the literature, and quite probably it is both missed and denied frequently by physicians and surgeons. An attempt has been made to emphasize the drug-dependent nature of this illness with a view toward adopting a more realistic approach to treatment.     

Conversion syndromes in neurology. A psychopathological and psychodynamic differentiation of conversion disorder, somatization disorder and factitious disorder

Conversion syndromes are frequent among medically unexplained somatic symptoms in neurology. A careful differential diagnosis must be carried out in a psychiatric consultation service. In a prospective study lasting for over four years 169 patients with pseudoneurological signs of conversion were included. From a clinical point of view the following conversion syndromes were presented: astasia/abasia: 27.2%, paresis/plegia: 24.3%, aphonia: 1.8%, hyp-/anaesthesia: 21.9%, blindness: 5.3%, non-epileptic seizures: 19.5%. According to the diagnostic criteria of DSM-III-R three subgroups were differentiated: conversion disorder (n = 132), somatisation disorder (n = 28), factitious disorder (n = 9). Intermittent courses of illness were prevailing in conversion disorder, whereas chronic courses predominated in the other two subgroups. High rates of psychiatric comorbidity were typical signs of somatisation disorder. Frequent autodestructive motives (suicidality, deliberate and covert self-harm, chronic pain, high rate of operations) in illness behaviour had to be registered in somatisation and factitious disorder. Both subgroups were characterised by frequent traumatic events during early development. Important socio-economic aspects of illness behaviour above all in somatisation and factitious disorder were underlined. The results are discussed in terms of psychiatric differential diagnosis and psychiatric comorbidity, psychodynamic evaluation, illness behaviour and therapeutic options in a C/L-service.     

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.     

Cerebral mitochondrial respiration in diabetic and chronically hypoglycemic rats

The respiratory function of cerebral mitochondria harvested from genetically diabetic (BB/W) and streptozotocin-diabetic rats deprived of insulin for 3-4 weeks was found to be unchanged from control values. Furthermore, insulin-deprived BB/W rats subjected to 30 min of insulin-induced hypoglycemic coma demonstrated a normal mitochondrial respiration following a 60 min period of glucose restitution, a finding consistent with earlier results in non-diabetic rats. However, in rats exposed to 1 week of moderate hypoglycemia (plasma glucose = 3.0 mumol.ml-1), both state 3 respiration and the respiratory control ratio (RCR) were reduced from control. In fact, when the chronic hypoglycemia was imposed following a 3-4 week period of diabetic hyperglycemia, the state 3 rate and RCR were found to be reduced to a greater degree than in chronically hypoglycemic, non-diabetic, previously normoglycemic rats. Finally, when 1 week of moderate hypoglycemia preceded a 30 min period of insulin-induced hypoglycemic coma, a disturbed pattern of mitochondrial respiration (i.e. increased state 4, decreased RCR) was found at 60 min of recovery following coma. These results indicate that chronic increases in glucose (and insulin deprivation) have no effect on cerebral mitochondrial respiratory function, whereas prolonged, albeit moderate, reductions in cerebral glucose supply result in perturbations in mitochondrial respiration. These results demonstrate the importance of an adequate glucose supply for normal mitochondrial activity.     

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.     

Factitious hemiplegia and Munchausen's syndrome.

We report a case of a thirty-year-old woman suffering from chronic factitious disorder with hemiplegia. Such a pathomimia is very uncommon in Munchausen's syndrome. Indeed, most often, the clinical picture is characterised by acute abdominal pain, fainting, haemoptysis, precordialgia, hematemesis or dermatological lesions.     

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.     

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.     

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.     

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.     

Pathomimies endocrinométaboliques : à propos de deux cas

Despite being recognised as a psychiatric disease, pathomimia is often encountered in the professional life of physicians. It is a factitious disorder with important diagnostic stakes: first, it needs to be diagnosed quickly because physical damage can be horrendous; furthermore, this concept is a mix of many entities (mythomania, self-mutilation, hypochondria, conversion, simulation, psychosis…) which complicate differential diagnosis. Through two clinical cases, we will go through the different clinical aspects of pathomimia, then we will cover the diagnostical approach and finally we will conclude on psychopathological thoughts about these observations.     

Munchhausen patients in general hospitals--Clinical features and treatment approaches in C-L psychiatry settings

Factitious disorders have been reported in 0.5 - 1 % of general hospital patients. It often takes several years until the disorder is detected. During this period, enormous health care cost can arise not least out of iatrogenic self-induced mutilations and related secondary somatic complications. Apart from surgeons and physicians, consultation-liaison (C-L) psychiatrists are particularly called on to diagnose factitious disorders at an early stage in order to avoid unnecessary diagnostic and therapeutic procedures, treatment dropout and doctor shopping. This article gives an overview of clinical features and treatment approaches in C-L psychiatry settings.     

Neglected phenomena in factitious illness: A case study and review of literature

Illustrated by casuistics, a review of factitious disorders is given. In the present report, problems concerning definition, incidence, diagnosis, and treatment are discussed. Emphasis is put on patients suffering from a factitious disorder superimposed on an already existing somatic disease. It is stated that the conscious refrain from adequate actions as a result may lead to factitious symptoms.     

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.     

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.     

Extracellular pH in the rat brain during hypoglycemic coma and recovery

It has previously been shown that hypoglycemic coma is accompanied by marked energy failure and by loss of cellular ionic homeostasis. The general proposal is that shortage of carbohydrate substrate prevents lactic acid formation and thereby acidosis during hypoglycemic coma. The objective of the present study was to explore whether rapid downhill ion fluxes, known to occur during coma, are accompanied by changes in extra- and/or intracellular pH (pHe and/or pHi), and how these relate to the de- and repolarization of cellular membranes. Cortical pHe was recorded by microelectrodes in insulin-injected rats subjected to 30 min of hypoglycemic coma, with cellular membrane depolarization. Some rats were allowed up to 180 min of recovery after glucose infusion and membrane repolarization. Arterial blood gases and physiological parameters were monitored to maintain normotension, normoxia, normocapnia, and normal plasma pH. Following depolarization during hypoglycemia, a prompt, rapidly reversible alkaline pHe shift of about 0.1 units was observed in 37/43 rats. Immediately thereafter, all rats showed an acid pH shift of about 0.2 units. This shift developed during the first minute, and pHe remained at that level until repolarization was induced. Following repolarization, there was an additional, rapid, further lowering of pHe by about 0.05 units, followed by a more prolonged decrease in pHe that was maximal at 90 min of recovery (delta pHe of approximately -0.4 units). The pHe then slowly normalized but was still decreased (-0.18 pH units) after 180 min when the experiment was terminated. The calculated pHi showed no major alterations during hypoglycemic coma or after membrane repolarization following glucose administration.(ABSTRACT TRUNCATED AT 250 WORDS)     

Factitious torsion dystonia in rehabilitation: a singular new case and literature review

We report a case of a 29-year-old woman suffering from chronic factitious disorder (FD) with torsion dystonia. For nearly five years, she traveled widely over the country, going from one hospital to another, taking serious medical risk in order to prolong her illness. After several admissions to Rehabilitation Units and multiple explorations, we find convincing evidence for factitious origin and the diagnosis of Munchausen syndrome was evoked. Such a clinical presentation is infrequent in Munchausen's syndrome. Indeed, most often the clinical picture is characterized by acute abdominal pain, fainting, hemoptysis, precordialgia, hematemesis or dermatological lesions. Physicians should be aware of this rare and potentially critical form of FD. Awareness in identifying these patients may lead to prevent unnecessary medical and/or surgical interventions.     

Effect of insulin-induced hypoglycemia on blood-brain barrier permeability

The effects of hypoglycemia on cerebrovascular permeability to the Evans blue-albumin complex were studied in rats injected with 50 IU/kg, i.v. crystalline zinc insulin. One group of hypoglycemic animals was warmed to keep their body temperatures close to 37 degrees C, and the rats in the other group were allowed to become hypothermic by hypoglycemia. The arterial blood pressures of the hypoglycemic rats were continuously monitored during the coma and a significant rise in pressure was observed in most animals at the end of the coma. When glucose was administered i.v. to five animals of each group, this elevated pressure returned to normal values within 0.5 min and the animals slowly recovered normal behavior. At termination of the coma, most brains in the hypothermic hypoglycemic group showed an intensive and extensive staining by Evans blue; whereas only two brains in the normothermic hypoglycemic group showed any noticeable extravasation of Evans blue-albumin. Arterial PO2, PCO2, and pH were determined and no significant difference was found between values from animals in hypoglycemic coma and the controls. Four animals were surface-cooled and were used to examine the effects of hypothermia on blood-brain barrier permeability. These brains did not show any macroscopically evident Evans blue-albumin extravasation. The results indicated that prolonged, severe hypoglycemia with hypothermia caused a profound blood-brain barrier dysfunction whereas normothermic hypoglycemia resulted in few cases of any noticeable increase in blood-brain barrier permeability.