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 disorders with psychological symptoms.

BACKGROUND: Factitious disorders with psychological symptoms have been underdiagnosed and hence undertreated. Historically, the literature has focused on factitious disorder with physical symptoms, particularly Munchausen's syndrome. METHOD: The authors report three cases of factitious disorder with psychological symptoms that had diverse clinical presentations. RESULTS: Two of the patients had features of a psychiatric Munchausen's syndrome--being middle-aged, aggressive men who falsified their symptoms, treatments, and backgrounds. The third patient was a younger woman with comorbid substance abuse, dysthymia, and borderline personality disorder. CONCLUSION: The authors feel that there is a need for refinement of diagnostic criteria, greater awareness, and evaluation of treatment approaches for this condition.     

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.     

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.     

ECT in the Treatment of Organic Psychosis in Huntington's Disease

Huntington's disease (HD) is a progressive neurological disorder characterized by choreiform movements, dementia, and psychiatric symptoms. The psychiatric symptoms often lead to long-term psychiatric hospitalization. We report the case of a 49-year-old woman with HD of 1 year's duration who presented with an organic psychotic syndrome with voices telling her to kill herself or her children. The psychosis was refractory to neuroleptic treatment (up to 1,250 mg chlorpromazine equivalents per day). Depressive symptoms emerged but were neither of a magnitude nor of a duration to suggest a major affective disorder. Nonetheless, we treated the patient empirically with antidepressants, which had to be discontinued because of symptomatic orthostatic hypotension. Based on the persistent psychosis with suicidal and homicidal ideation and possible long-term state psychiatric hospitalization, we recommended electroconvulsive therapy (ECT). ECT was successful in treating the psychosis as well as the depressive symptoms. There was no worsening of the patient's dementia and only a slight progression in her choreiform movements. The authors question whether ECT may be of benefit in treating the psychosis of HD in the presence or absence of depressive symptoms and call for further research to determine if the use of ECT in HD patients with psychosis could prevent, or at least delay, placement in a long-term psychiatric hospital.     

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.     

Predictors of homicidal ideation and intent in schizophrenia: an empirical study

Correlations of age, gender, and psychosocial variables with ratings of current homicidal ideation and intent were investigated among psychiatric facility clients with schizophrenia. Multiple regression analyses revealed, irrespective of age or gender, significantly positive correlations of three psychosocial variables--manic symptoms, psychotic symptoms, and impaired global functioning--with homicidal ideation and intent. Implications for research are discussed.     

A bewitching case of factitious disorder in Zimbabwe

A rural Zimbabwean man attributed the appearance of needles in his leg to witchcraft, but medical practitioners suspected that the needles were self-introduced. Psychiatric evaluation revealed no major mental illness. The patient met criteria for the Euro-American diagnosis of factitious disorder, persisting in his claim that he had been the victim of witchcraft. The patient's claim cannot be considered delusional because belief in witchcraft is culturally sanctioned within Shona culture. The case appears to be one of factitious disorder with both physical and psychological symptoms. Differential diagnoses must be broadened to consider culturally specific phenomena such as witchcraft.     

Therapeutic approach to a case of simulated disorder with psychiatric symptoms]

The case of a 38-year-old female inpatient with the diagnosis of factitious disorder with psychological symptoms--a presentation rarely reported in the psychiatric literature--is presented with special respect to her personality traits. On the basis of her biographical history a therapeutic approach was possible which tried to understand the symbolic value of the histrionic patient's symptoms. We regarded the manifestation of psychological symptoms as an attempt to express conflicts verbally and as an offer of a more mature form of communication in comparison to the former, autodestructive physical syndromes.     

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.     

Successful management of a patient with pseudomalabsorption of levothyroxine

Pseudomalabsorption of levothyroxine is a factitious disorder. Despite the administration of large doses of levothyroxine, patients with this disorder show hypothyroidism due to noncompliance. These patients are different from the patients with simple noncompliance in that they have a psychiatric disorder. Because their psychological identities are rooted in their being a "patient," they go to great lengths to become and stay a patient. We report a case of pseudomalabsorption of levothyroxine. A 28-year-old woman was referred to us because she was believed to have unusual malabsorption of levothyroxine. We diagnosed the patient as having this factitious disorder, and as treatment, had her visit a hospital twice a week to take medicine under the observation of nurses so that she would not lose her status as a "patient." Her serum free T4 level normalized during three years with twice weekly dosing of thyroxine after hospital discharge. Our approach could be a therapeutic choice for this intractable disorder. To our knowledge, this is the first report of successful management of a patient with pseudomal-absorption of levothyroxine.     

Factitious AIDS in a psychiatric inpatient

This article reports the case of a 28 year-old female presenting to a psychiatric inpatient unit with depression and a history of acquired immune deficiency syndrome (AIDS). Although medical assessment was negative for AIDS, psychiatric evaluation and psychological testing were consistent with a presentation of factitious disorder. This case illustrates the need to be on the alert for individuals admitted to psychiatric units who report they have AIDS or its related conditions.     

Psychiatric Symptoms in Temporal Lobe Epilepsy with Left Mesial Hippocampal Sclerosis

A 16-year-old woman was referred to us for depression and persistent suicidal and homicidal ideation. From 2010, the patient visited a neurologist due to recurrent grand mal epilepsy, auditory and visual hallucinations, episodic memory loss, and persistent depression. Upon admission, it was revealed through clinical history taking that she had suffered from chronic bullying from same-sex peers and sexual abuse, twice, from an adult male in the neighborhood when she was 10 years old. A brain magnetic resonance imaging study showed left mesial hippocampal sclerosis. The patient exhibited improvement of her psychiatric symptoms after treatment with a combination of fluoxetine (30 mg) and aripiprazole (10 mg). Children and adolescents with epilepsy experience conflicts in the family, challenges at school, stigma, and psychosocial limitations or deprivations due to their comorbid psychiatric symptoms and hence, psychiatric evaluation and early intervention is important when treating these patients.     

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.     

Diagnostic legitimacy of factitious disorder with psychological symptoms

The authors question the clinical status of factitious disorder with psychological symptoms as a mental disorder. In particular, they argue that unresolved issues regarding the motivational basis of this disorder and the lack of clearly delineated inclusion, exclusion, and outcome criteria seriously compromise its diagnostic legitimacy. Two case reports are presented to illustrate these difficulties. Future studies should consider these empirical and conceptual difficulties in refining the diagnosis of factitious disorder with psychological symptoms for DSM-IV.     

False allegations of child physical abuse: a case of Münchausen by proxy-like syndrome?

The diagnosis of factitious disorder by proxy is still under investigation. Few studies have researched the psychological status and potential underlying psychopathology of the perpetrator, as well as the impact on the child's development and the pathological reactions of rearing a child within the context of a distorted reality. In this article, we present the case of a 12-year-old boy where this diagnosis was suspected. Both he and his parents brought forth false allegations of repeated physical abuse induced by his schoolteacher. The parents presented with shared psychosis and the child presented with conduct disorder, factitious disorder, and emotional problems. We suggest that this case represents a Münchausen by proxy-like syndrome involving both the legal and medical systems. Hypotheses regarding the pathogenesis of symptoms in the child are noted, underscoring the differences between Münchausen by proxy syndrome appearing in infancy with that appearing in older children.     

Quantitative electroencephalographic measures in homicidal men with antisocial personality disorder

Many symptoms of antisocial personality disorder have been proposed to be related to decreased daytime vigilance. To explore this hypothesis, quantitative analyses were conducted of the electroencephalographic (EEG) activity of drug-free and detoxified homicidal male offenders with antisocial personality disorder as the primary diagnosis. Subjects comprised 16 men recruited from a forensic psychiatric examination in a special ward of a university psychiatric hospital. Fifteen healthy age- and gender-matched controls with no criminal record or history of physical violence consisted of hospital staff and students. An overall reduction of alpha power was observed in the waking EEG of offenders. A bilateral increase in occipital delta and theta power was also found in these individuals. This study provides further support to the growing evidence of brain dysfunction in severe aggressive behavior. Homicidal offenders with antisocial personality disorder seem to have difficulties in maintaining normal daytime arousal. Decreased vigilance, together with social and psychological variables, may explain their aberrant behavior in everyday life. New studies are, however, needed to specify the vigilance problems of this patient group.     

Anticoagulant abuse: a psychotic syndrome?

A case of surreptitious ingestion of oral anticoagulants is presented. The patient, a 31-year-old nurse, was followed for more than 3 years and underwent thorough psychological and psychiatric evaluation. Anticoagulant malingerers are by no means rare; however, little is known about the psychiatric disturbances in these patients. The tendency has been to regard these patients as having neurotic or personality disturbances. The data in the present case suggest that factitious hemorrhagic disease is caused by a psychotic disturbance. The results of psychiatric therapy are discussed.