Munchausen syndrome: an endless search for self, managed by house arrest and mandated treatment

Factitious Disorder in Seven Patients: A Saudi Experience

Background

Factitious disorder (FD) is a psychiatric disease where signs and symptoms are produced, falsified, or exaggerated consciously in the absence of clear external motivations. Through needless medical visits, costly investigatory testing, and potentially long hospital stays, patients with FD waste valuable time and resources, which affects both the patient and the healthcare system. It can be very challenging for physicians who have never encountered patients with FD to recognize them promptly as symptoms of FD vary greatly.

Methodology

This was a retrospective study of patients diagnosed with FD attending King Abdulaziz Medical City in Riyadh, Saudi Arabia, a tertiary care military hospital and one of the most prominent academic and referral medical institutions in the country. Using the BESTCare health information system, we reviewed patients’ electronic health records from January 2015 to December 2020. The diagnosis of FD was based on the International Classification of Diseases and Related Health Problems 10th edition.

Results

A total of seven patients were included in the study, of whom five (71%) were males and two (29%) were females. Of the total seven patients, three were 21 years old and younger, one was 38 years old, and three were 56 years old and older. Three (43%) patients were married and four (57%) were single. In terms of occupation, three (43%) patients were retired, one (14%) worked in a private company, one (14%) was unemployed, and two (29%) were students. A total of four (57%) patients initially presented to the Emergency Department (ED), and only three (43%) presented to the outpatient clinics. Induced disease or injury was found in five (71%) patients. Induced skin injury was found in four (57%) patients. Counseling and psychotherapy were only offered to one (14%) patient.

Conclusions

FD remains a rare psychiatric condition that is difficult to recognize. Despite a small sample size, FD in the present study showed a male predominance, affecting patients of all age groups. About half of the patients presented initially to the ED. Induced disease or injury was the most commonly reported pattern of clinical presentation. Induced skin injury was the most common clinical presentation found in around half of the patients. We believe that the number of FD patients in the present study is likely underreported and is expected to be higher. This highlights the need for better awareness of FD among physicians in different medical fields. We emphasize that there is a need for better professional training in the identification of FD.

Paternalism and factitious disorder: medical treatment in illness deception

The primary aims are to consider whether a range of paternalistic medical interventions can be justified in the treatment of factitious disorder (FD) and to show that the particularities of FD and its management make it an ideal phenomenon to highlight the difficulties of balancing respect for self-determination, responsibility and duty of care in psychiatry. FD is usually classified as a mental disorder involving deliberate and hidden feigning or inducement of illness, in order to achieve patient status. Both the nature of the disorder and the approach to treatment are controversial and under-researched. It is argued that FD should be classified as a mental disorder; may well expose the patient to extreme risk; can warrant paternalistic interventions, in order to fulfil duty of care. Moreover, treatment of FD is inherently paternalistic and therefore raises interesting questions about justifications and type of paternalistic interventions in psychiatry both for FD and in general. A brief account of key questions concerning psychiatry and paternalism is followed by some case histories of FD, the clinical dilemmas posed and the question of how this disorder might warrant paternalistic interventions. In order to answer this question, two things are considered: the legitimacy and character of FD as a mental disorder; possible frameworks for and types of paternalistic interventions. To conclude, it is argued that there are no compelling reasons for rejecting the use of paternalistic interventions for FD, but that further investigation of FD and type and frameworks for psychiatric paternalism, in relation to FD and other mental disorders, are urgently needed.

Factitious disorder (Munchausen's syndrome) in oncology: case report and literature review

BACKGROUND

Factitious disorder is where patients repeatedly seek medical care for feigned illnesses in the absence of obvious external rewards; 'Munchausen's syndrome' is the historical name for this disorder.

METHOD

We report on a case that was presented to a tertiary oncology center as a suspected rare bone cancer.

RESULTS AND CONCLUSIONS

Psychosocial clinicians working in oncology settings should be aware of the complexities of diagnosing factitious disorder in cancer settings where empathy is prominent and suspicion unusual. Moreover, comorbidity can cloud the diagnosis (in this case substance abuse), and, even when accurately diagnosed, there are no evidence-based management approaches to offer to the patient. What seems to linger most after the patient is discharged, usually in a huff, are strong counter-transference feelings and substantial medical bills. Copyright © 2015 John Wiley & Sons, Ltd.

Munchausen by internet: current research and future directions

BACKGROUND

The Internet has revolutionized the health world, enabling self-diagnosis and online support to take place irrespective of time or location. Alongside the positive aspects for an individual's health from making use of the Internet, debate has intensified on how the increasing use of Web technology might have a negative impact on patients, caregivers, and practitioners. One such negative health-related behavior is Munchausen by Internet.

OBJECTIVE

Munchausen by Internet occurs when medically well individuals fake recognized illnesses in virtual environments, such as online support groups. This paper focuses on the aspect of Munchausen by Internet in which individuals actively seek to disrupt groups for their own satisfaction, which has not yet been associated with the wider phenomena of Internet trolls (users who post with the intention of annoying someone or disrupting an online environment).

METHODS

A wide-ranging review was conducted to investigate the causes and impacts of online identity deception and Munchausen by Internet drawing on academic research and case studies reported online and in the media.

RESULTS

The limited research relating to motivation, opportunity, detection, effects, and consequences of Munchausen by Internet is highlighted and it is formally linked to aspects of trolling. Case studies are used to illustrate the phenomenon. What is particularly worrying is the ease with which the deception can be carried out online, the difficulty in detection, and the damaging impact and potential danger to isolated victims.

CONCLUSIONS

We suggest ways to deal with Munchausen by Internet and provide advice for health group facilitators. We also propose that Munchausen by Internet and Munchausen by Internet trolling should be formally acknowledged in a revised version of the Diagnostic and Statistical Manual DSM-5. This will assist in effectively identifying and minimizing the growth of this behavior as more people seek reassurance and support about their health in the online environment. We also suggest directions for future research.

Factitious disorder comorbid with bipolar I disorder. A case report

We describe a case of factitious disorder with physical and psychological symptoms comorbid with bipolar I disorder in a 37-year-old woman. Since the onset of bipolar disorder, which occurred at the age of 31, she increasingly complained of physical symptoms, compulsively seeking medical and surgical interventions. She has been hospitalised several times and her Munchausen-type factitious disorder recently appeared to be developing into Munchausen by proxy, involving her 11-year-old daughter. The patient adhered poorly to stabilising and antipsychotic drug treatment and did not improve through the years. We here analyse her mood phases, which were always associated with changes in the quality of factitious symptoms, according to whether the disorder was in its depressive phase (somatic complaints and suicidal ideation prevail), or in its manic or mixed phase (medical intervention-seeking and manipulation of clinicians to obtain surgical interventions). We also briefly discuss some important forensic issues to consider in similar cases, mainly stemming from the psychotic aspects of these two co-occurring disorders. Clinicians should be aware of some patients' ability to produce signs and symptoms of physical and/or psychological illness and consult psychiatrists before giving consent to invasive diagnostic procedures or surgery.