Transcript Munchausen Syndrome What the future Medical Needs to Know

Munchausen Syndrome
Identification and Treatment
Brooke Adkins
UK Physician Assistant
February 28, 2008
Factitious Disorder
The DSM IV-TR for Dx:
 Criterion A: intentional production of
physical or physchological signs or
symptoms
 Criterion B: the motivation for the
behavior is to assume the sick role
 Criterion C: the external incentives for the
behavior are absent
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Factitious Disorder Patient
Presents their medical history with,
“dramatic flair,” however, are very vague if
questioned for more details regarding past
conditions, past hospitalizations/
practitioners, and medical interventions.
 They engage in pathological lying, in a
manner that is intriguing to the listener.
 They often have extensive knowledge of
medical terminology and hospital routines
– present with textbook definition of
diseases.
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Factitious Disorder Patient
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Pt will develop new complaints, physical or psychological,
after the admitting chief complaint is proven negative from
extensive testing.
The patient usually has few visitors
Complaints of pain and analgesics are very common
Multiple Scars
Reported symptoms only occur when pt is alone or
unobserved
Once staff suspects a Factitious Disorder and confronts the
patient with the evidence, the patient usually becomes
angry, denies any accusations, and leaves the hospital
against medical advice (AMA).
Munchausen Syndrome Background
First described in 1951 by Dr. Richard
Asher
 Described patients with imagined or
manipulation symptoms, inventions of
clinical entities including false names,
biographies, and inclination towards
deception (pseudologia fantastica or
pathological lying).
 The condition was associated with
wandering from hospital to hospital and
antisocial behavior.
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Munchausen?
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Named after Baron Von Munchausen who
traveled extensively and fabricated wild
tails of travel and life experiences.
Asher’s Classical Presentation
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laparotomophilia migrans, or abdominal pain, a
patient will present with many GI complaints and
a history of multiple abdominal surgeries and
physical findings of washboard-like abdomen.
neurologica diabolica – the neurologic type –
patients feign a variety of seizures or traumatic
brain injuries
hemorrhagica histrionica (bleeding) can be seen
in patients who use anticoagulant therapy
inappropriately.
A fourth variety cardiopathia fantastica (of
cardiovascular presentation) has been added
recently
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Initially any person presenting with a factious
disorder was diagnosed with MS
Munchausen Syndrome is the most severe and
chronic form of Factitious Disorder.
Consist of the core elements:
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recurrent hospitalizations
traveling
pseudologia fantastica.
All organ systems are potential targets, and the
symptoms presented are limited only by the
individual’s medical knowledge, sophistication,
and imagination
Etiology
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Rare – however difficult to get accurate count
Inflated number:
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High incidence of traveling, using different names
Low number:
Incorrect discharge diagnosis for fear that other medical
providers will not take future medical complaints
seriously
 Physicians/PAs do not know the psychiatric
nomenclature to describe this syndrome
No genetic link has been found
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What the Patient Looks Like
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Factitious Disorders are
more common in females
Men are more likely to
proceed onto MS
Normal to high intelligence
Work in a health care field
Lower than average
socioeconomic status
Socially isolated
Have a Co-morbid
psychiatric illness –
Borderline, mood d/o
Risk Factors
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Childhood trauma, such as emotional, physical or
sexual abuse
A serious illness during childhood that allowed
them to be cared for an nurtured
A relative with a serious illness
A poor sense of identity or self-esteem
Loss of a loved one through death, illness or
abandonment early in life
Unfulfilled desire to be a doctor or other health
professional
Work in the health care field
Personality disorder
Poor coping skills
Why important to Dx
Severe cases of undiagnosed MS patients
frequenting medical facilities between 42700 visits
 costing more than $410,000 – 725,000
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Comparison of psychiatric syndromes
with multiple physical complaints
Conditions
Production of
Symptoms
Gain
Painful or
Risky
Behavior
Somatization
D/O
Unconscious
Attention,
“pt role”
Accepted
Factitious D/O
Conscious
Attention, “Pt
role”
Accepted
Malingering
Conscious
External Gain
Avoided
Diagnosis
Very difficult because most of the patients
will have some self-inflicted, real, even
life-threatening medical conditions, which
become the primary concern for the
treating physicians and cover underlying
mental illness initially.
 Note: increased incidence of these pts in
specialized medicine
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Ways to Inflict Self harm
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Inject saline into their orbits resulting in eventual exenteration
Inject feces into the abdominal wall leading to bowel fistula
Paraffin into the rectum, causing extensive inguinal an lower bowel
granuloma initially regarded as rectal carcinoma
Lighter fluid or milk into the breast to mimic breast cancer
Re-inject their own blood to stimulate hemolytic anemia
Induce recurrent metabolic encephalopathy by means of self administered
gastric lavage
Hit their bodies with an iron bar to create the appearance of widespread
purpura
Simulate bronchospasm
Mimic dental sepsis
Self-inject human chorionic gonadotropin to stimulate a tubal ectopic
pregnancy
Epinephrine or hydrocortisone to mimic pheochromocytoma or Cushing’s
diease
Insulin to induce hypoglycemia
Apply phenol to simulate gangrene
Inject feces to induce sepsis
So How Do We Dx?
Made with the help of a psychiatric
examination
 Patients will refuse any type of
psychological intervention, and usually
leave AMA after presented
 Refusal should be documented in the
patient’s medical record, along with any
unusual demands, request, or behaviors
exhibited by the patient
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Questions We Should Ask Ourselves
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Do the patient’s reported symptoms make sense
in the context of all test results and
assessments?
Do we have collateral information (previous MD/
family) for other resources that confirm the
patient’s information? (If the patient does not
allow this, this is a helpful clue.)
Is the patient willing to take the risk for more
procedures and test than you would expect?
Are treatments working in a predictable way?
Treatment
No standard treatments for the condition.
 People with Munchausen often are
unwilling to seek treatment – flight once
thought “caught”
 Involve Psychiatry early, although pt not
receptive, helps medical team manage
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Four Principles to Tx
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Team should only perform those diagnostic
procedures that are indicated by objective signs
or data
Consistency in communication and treatment is
crucial – reduce splitting of staff and keep the
plan of care consistent
Setting of compassionate and firm limits will help
to reduce distress in both the staff and the
patient
The team’s attention can be refocused on the
“chase.”
Why Can’t They Be Committed?
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Usually do not meet criteria
for involuntary admission to
hospital.
They are neither homicidal
nor suicidal, and their mental
illness does not incapacitate
them sufficiently to impair
their ability to carry out their
activities of daily living
Most diagnosed patients with
MS not receiving treatment
for their illness on an
inpatient bases, and only
those who are willing to seek
treatment receiving
outpatient psychotherapy
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The first goal of treatment is to modify the
person’s behavior and reduce his or her
misuse or overuse of medical resources.
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Done by utilizing trusted medical gatekeeper
and psychotherapy if pt willing
Once this goal is met, treatment aims to
work out any underlying psychological
issues that might be causing the person’s
behavior
Drugs
There are no medications to treat
factitious disorders themselves.
 Medicine might be used, however, to treat
any related disorder – such as depression,
anxiety, or a personality disorder
 SSRIs only medications
mildly effective for
controlling the impulsive
behavior
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Prognosis
POOR
 Some of these patients only suffer one or
two brief episodes of symptoms
 Most cases are chronic and difficult to
treat because of the generally
unwillingness by the patient to undergo
treatment
 Best prognosis is have a co-morbid
psychological condition that can be treated
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TAKE HOME
Identify Early and Dx correctly
 Only tx the objective findings
 Consistent and united medical staff
 There is limited effectiveness in treatment
of these patients
 Poor Prognosis
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References
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