Cardiopathica fantastica

Cardiac Munchausen's syndrome

Ten years' experience of cardiac Munchausen's syndrome in the Cardiac Care Unit of an Inner London teaching hospital is reported. Thirty-six admissions in this category were identified and analysed, and 4 typical cases are described. The common presenting complaints, recurring features and the relationship with other forms of Munchausen's syndrome are discussed, as are posible strategies available to deal with this clinical entity.

Cardiac Munchausen syndrome

OBJECTIVE

To examine the reports on cardiac Munchausen syndrome for clinical characteristics.

METHODS

Cases, case series, and related articles on the subject in all languages were identified through a comprehensive literature search.

RESULTS

Fifty-eight cases of cardiac Munchausen syndrome were identified. Mean +/- SD patient age was 44 +/- 12 years (range, 23 to 71 years). Fifty-four patients (93%) were men. The most common presenting complaint was chest pain simulating acute coronary syndrome (86%). Syncope and dyspnea were also reported. Mostly, these patients were admitted directly from the emergency department to the coronary care unit. Acute myocardial infarction was the most common admitting diagnosis. The other admitting diagnoses were cardiac arrest and arrhythmia. The average number of hospital admissions for cardiac symptoms was 6 per patient (range, 1 to > 29 admissions). Numerous procedures including cardiac catheterization, coronary angiography, peripheral arteriography, permanent pacemaker placement, electrophysiological studies, intra-aortic balloon insertion, pulmonary artery catheter insertion, and electrical cardioversion have been performed in these patients. Twenty-four patients (41%) had history of undergoing prior multiple invasive procedures, but only 10 of these patients admitted having undergone these procedures. Ninety-five percent of patients altered their stories, with many leaving the hospital against medical advice when confronted with possibility of cardiac Munchausen syndrome as the correct unifying diagnosis. None of the patients reported for follow-up.

CONCLUSION

Cardiac Munchausen syndrome results in unnecessary investigations and organ damage from unneeded aggressive procedures. There is scarce information available on the prognosis of these patients, especially in the long term.

Cardiopathia fantastica exposed by rapid sequential serum creatine kinase analysis

Rapid, sequential serum creatine kinase measurements may be used to exclude acute myocardial infarction in patients presenting with acute chest pain. Two cases of cardiopathia fantastica (the cardiac variant of Munchausen's syndrome) are described. Both patients presented with symptoms of acute myocardial infarction and had electrocardiographic changes consistent with this diagnosis. Both patients also had a raised serum creatine kinase level at the time of presentation but were unable to mimic the rise in serum creatine kinase associated with acute myocardial infarction. Munchausen's syndrome was suspected when both patients responded poorly to news that their enzyme results excluded acute myocardial infarction.

Pseudologia fantastica

Pseudologia fantastica has not been reviewed in the English literature in over 50 years, but the term is still used, for example, among the diagnostic criteria for the Munchausen syndrome. Based upon a review of 72 cases of pseudologia fantastica collected from 26 reports since its initial description in 1891, pseudologia is distinguished from other types of lying. Pseudologia fantastica is typified by these characteristics: (1) the stories are not entirely improbable and are often built upon a matrix of truth; (2) the stories are enduring; (3) the stories are not told for personal profit per se and have a self-aggrandizing quality; and (4) they are distinct from delusions in that the person when confronted with facts can acknowledge these falsehoods. The authors compile phenomenological data about "the pseudolouge", who is represented equally males and females. Intelligence varies, but at least 40% have evidence of central nervous system dysfunction. The authors suggest that disease simulation, peregrination, and imposture are secondary behavioral manifestations of pseudologia, which is deserving of additional study.

[Factitious disease. Observations on 44 cases at a medical clinic and recommendation for a subclassification]

From 1971 to 1985, 44 cases of self-induced factitious disorders were observed in the Medical Department of a University Hospital. The diseases were often severe, one patient even died. The various symptoms and diseases presented by the patients, the methods of producing them, and the diagnostic and therapeutic aspects of these cases are described. Patients were analysed with regard to age, sex, profession, psychosocial adaptation, number and duration of hospitalisations, presentation of complaints, behaviour on the ward, relation to the doctor, self-destructive tendencies, readiness to suffer and possible motivations. According to the criteria of the DSM-III, seven patients were malingerers (DSM-III: V 65.20) and 37 had a "chronic factitious disorder with physical symptoms" (DSM-III: 301.51). However, the findings in the patients of the latter group strongly suggest that they form an extremely heterogeneous population. Therefore we propose a subclassification of the DSM-III category 301.51 as follows: Type A. Muenchausen syndrome in the proper sense; dramatic deception of mainly acute illness; pseudologia fantastica; social maladaptation, chaotic life situations; many, mostly short hospitalisations; many interventions; at first well adapted, later hostile; mostly men. Type B. Self-induced, mainly chronic illness; behaviour adequate, highly compliant; often little emotion, contrasting with the sometimes severe illness; socially adapted; history remarkably blank with regard to psychosocial stress; several often longlasting hospitalisations and many interventions; almost exclusively younger women from (para-)-medical professions. Type C. Willfull interference with the healing of wounds, cutaneous ulcers, abscesses or dermatological artefacts; history with marked personal losses or severe chronic medical problems; at first well adapted, later hostile, passive/aggressive; women prevail. A conversion syndrome (DSM-III: 300.11) was not observed. In contrast to malingering, the basis of the disorder in types A, B and C is unconscious in origin, thus similar to the conversion syndrome. Contrary to the latter, however, the production of physical symptoms is under voluntary control. The proposed subclassification represents a hypothesis for testing which might facilitate the analysis of the basic personality disorder, so far lacking. The investigation of the psychopathology of these patients and their treatment is difficult if not impossible because most refuse psychiatric exploration and therapy. Consequently follow-up studies and data on the prognosis are rare.