Munchausen Syndrome Identification and Treatment

1. Munchausen SyndromeIdentification and Treatment Brooke Adkins UK Physician Assistant February 28, 2008

2. 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

3. 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.

4. Factitious Disorder Patient • 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).

5. 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.

6. Munchausen? • Named after Baron Von Munchausen who traveled extensively and fabricated wild tails of travel and life experiences.

7. Asher’s Classical Presentation • 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

8. 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: • 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

9. Etiology • Rare – however difficult to get accurate count • Inflated number: • 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

10. What the Patient Looks Like • 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

11. Risk Factors • 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

12. Why important to Dx • Severe cases of undiagnosed MS patients frequenting medical facilities between 42-700 visits • costing more than $410,000 – 725,000

13. Comparison of psychiatric syndromes with multiple physical complaints

14. 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

15. Ways to Inflict Self harm • 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

16. 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

17. Questions We Should Ask Ourselves • 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?

18. 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

19. Four Principles to Tx • 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.”

20. Why Can’t They Be Committed? • 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

21. The first goal of treatment is to modify the person’s behavior and reduce his or her misuse or overuse of medical resources. • 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

22. 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

23. 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

24. 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

25. References • 1. Baker, P. Munchausens Syndrome: Still Alive and Well. Australian Family Physician 1999; 28(8): 805-807. • 2. Blyer, S, Casino, A, Reebye, U. Munchausen Syndrome: A Case Report of Suspected Self-induced Tempropmandibular Joint Subluxation. Journal of Oral and Maxillofacial Surfery 2007; 65(11): 2371-2374. • 3. Frances, A, Pincus, H, First, M. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition. American Psychiatric Association, 2000. • 4. Elmore, J. (2005). Munchausen Syndrome: An Endless Search For Self, Managed By House Arrest and Mandated Treatment. Annals of Emergency Medicine 2005; 45(5): 561-563. • 5. Emoehazy, W. “Munchausen Syndrome.” eMedicne. 26 February 2006. WebMD. 3 October 2007. <http://www.emedicine.com/emerg/topic322.htm> • 6. Feldmand, M. Breaking The Silence of Factitious Disorder. Southern Medical Journal 1998; 91(1): 41. • 7. Feldman, M. Recovery from munchausen syndrome. Southern Medical Journal 2006; 99(12): 1398-9. • 8. Huffman, J, Stern, T. The Diagnosis and Treatment of Munchausen’s Syndrome. General Hospital Psychiatry 2003; 25(5): 358-363. • 9. Lad, S, Jobe, K, Polley, J, Byrne, R (2004). Munchausen’s Syndrome in Neurosurgery: Report of Two Cases and Review of Literature. Neurosurgery 2004; 55(6): 1436. • 13. “Munchausen Syndrome.” MayoClinic. 18 May 2007. MayoClinic. 3 October 2007. <http://www.mayoclinic.com/health/munchausen-syndrome/DS00955/DSECTION=8> • 14. “Munchausen Syndrome.” The Cleveland Clinic Health Information Center. 7 October 2005. The Cleveland Clinic Foundation. 3 October 2007. <http://www.clevelandclinic.org/health/health-info/gocs/2800/2821.asp?index=9833> • 15. Pompili, M, Mancinelli, I, Girardi, P, Tatarelli, R. Countertransference in Factitious Disorder and Munchausen Syndrome. The International Journal of Psychiatric Nursing Research 2004; 9(2): 1041-1043. • 16. Saddock, B, Saddock, A. Kaplan & Saddock’s Concise Textbook of Clinical Psychiatry. 2nd Edition. Lippincott Williams & Wilkins, 2004. • 17. Stone, M. Factitious illness: psychological findings and treatment recommendations. Bulletin of the Menninger Clinic 1977; 41(3): 239-254.