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Munchausen’s Syndrome or Sickle Cell Disease?

Tanveer Padder MD, Aparna Udyawar MD, Mohammad Azhar MD, Kamil Jaghab MD
From the Department of Consultation and Liaison Psychiatry, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow NY 11554

Keywords: Munchausen’s Syndrome, Factitious disorder

Abstract:

We are reporting an unusual case of Munchausen’s Syndrome in a 15-year-old patient with Sickle Cell Disease with both physical and psychological symptoms highlighting diagnostic difficulties. The patient has approximately 60 hospitalizations during a three and a half year period. Munchausen’s syndrome is one of the most intriguing of factitious disorders as these patients can present with diverse complaints that physicians should be aware of this entity. (1) Patients who present with overt demonstrable symptoms but prove to have a factitious disease, such as Munchausen’s syndrome, are particularly challenging and fascinating. This case emphasizes the need to consider Munchausen’s Syndrome even in patients with recognizable medical illness

Introduction:

Munchausen’s Syndrome was named after Karl Frederick Hieronymus, Frieherr Von Munchausen, a German Cavalry officer who was fighting with Russians against Turks and was well known for exaggerating his adventures. Over time his stories became more and more expansive and finally quite outlandish. Munchausen became somewhat famous after a collection of his tales was published. (2) The first probable cases of Munchausen’s syndrome were reported in n 1843 by Gavin (cited in Bhugra 1988) (3) however we consider that Asher’s article in 1951. (4) in which he introduced the term Munchausen’s Syndrome is the origin of ongoing medical interest in specific pathology. It entered the DSM classification for the first time in 1980. (5) Therefore, it is likely that this condition is under diagnosed. (6) Munchausen’s syndrome is a type of factitious disorder, a mental illness in which a person repeatedly acts as if he or she has a physical or mental illness when there truly is none. People with factitious disorders act this way because of an inner need to be seen as ill or injured, not to achieve a clear benefit, such as financial gain.

They are even willing to undergo painful or risky tests and operations in order to get the sympathy and special attention given to people who are truly ill. Munchausen’s syndrome is considered a mental illness because it is associated with severe emotional difficulties. The cases of Munchausen’s syndrome involving every organ system have been responsible for expensive and unnecessary medical workup. As medical technology advances, so too will the means by which persons attempt to act out their psychopathology
We report a patient who exhibited the classical features of Munchausen’s Syndrome viz (i) documented history of multiple hospitalizations (ii) convincing evidence that these hospitalizations involved the voluntary production of symptoms and (iii) acts of malingering excluded. To the best of our knowledge this is the first case of Munchausen’s Syndrome involving a child with sickle cell disease.

Case Report:

Mr. A then a 12 year old African American male with history of asthma and sickle cell disease ? thalessemia was admitted to the pediatric unit in January of 2001 with thigh pain. Mr. A was stabilized in the hospital with pain killers and IV fluids and was discharged after a week. Apparently Mr. A had a very difficult childhood as he had never seen his father and his mother was in and out of jail and he was under the care of his grandmother. Mr. A received a good care in the hospital, which was something he had missed in his life. This started a cycle of repeated admissions to the same hospital. He was admitted 9 times during 2001 with complaints including chest pain, shoulder pain, thigh pain, back pain, bloody sputum and vomiting. All the workup was negative except for mildly low hemoglobin and hematocrit. Mr. A continued to come to our pediatric emergency room in 2002 with the additional complaints of abdominal pain. All GI workup was negative .His admissions totaled 13 in 2002 and spent a total of 6 months in the hospital. Psychiatric consult was sought when treating physicians did not find any cause of Mr. A’s presenting complaints and suspected that he might be intentionally producing/ feigning the symptoms.

Mr. A was very uncooperative with the psychiatrist and refused to talk. During the initial mental status examination Mr. A appeared alert and oriented to time, place and person. He was angry, irritable and uncooperative and full mental status could not be done as he refused to answer questions. Mr. A was started on low dose antipsychotic and an antidepressant for his impulsive behavior and underlying depression. Mr. A continued to seek frequent admission to the hospital in 2003. The frequency of admissions increased from the previous year and in all he was admitted 19 times in 2003 spending more than 6 months in the hospital. This time apart from pain presentations Mr. A presented with dizziness, chest pain, abdominal pain, blood in the stool and other constitutional symptoms. He was seen by GI, Surgery and Hematology consult service and complete work up was done which did not reveal anything significant.

Mr. A continued to come to the pediatric emergency room with same set of symptoms despite being on a good pain management regimen. Mr. A was admitted 14 times in year 2004.This presented a diagnostic dilemma to both the pediatric service as well as consultation and liason psychiatry. During the course of these hospitalizations Mr. A was found by the staff feigning and producing symptoms in many creative ways. These include but are not limited to:

-Deliberately dehydrating himself to get sick
-Scratching his IV sites to get infected
-Rubbing dirty chalk into his IV line
-Putting dirt at his IV site
-Cheeking his pain medications
-Self-injecting himself with contaminants
-Taking out his med port
-Mixing blood in his urine

Many times Mr. A’s room was searched and staff found syringes and chalks. Patient was regularly followed by psychiatry and was becoming very hostile when confronted with his behavior of feigning symptoms. Mr. A was tried on antipsychotics, antidepressants and individual psychotherapy but nothing seemed to change his behavior of assuming a sick role. Finally after being confronted last time in July 2004 patient, never came back to our hospital and reportedly sought admission at another children’s hospital who transferred him to an out of state facility for patients who need both medical and psychiatric care.

Discussion:

Malingering is a patient’s willful deliberate and fraudulent imitation and exaggeration of illness with conscious intent to deceive others for specific purpose. With Munchausen’s Syndrome, the sole objective is to assume a sick role without an acute emotional crisis or a recognizable motive and indeed without a need of treatment. Many of these patients make hospitalization as a prime objective and often a way of life. (7) Munchausen’s syndrome refers to a special type of factitious disorder meeting the DSM-IV criteria of chronic factitious illness with physical signs and symptoms.

Essential features:
• Pathologic lying (pseudo logia fantastica)
• Peregrination (traveling or wandering)
• Recurrent, feigned or simulated illness

Supporting features:
• Borderline and/or antisocial personality traits
• Deprivation in childhood
• Equanimity for diagnostic procedures
• Equanimity for treatments or operations
• Evidence of self-induced physical signs
• Knowledge of or experience in a medical field
• Most likely to be male
• Multiple hospitalizations
• Multiple scars (usually abdominal)
• Police record
• Unusual or dramatic presentation

Many of the patients show features of borderline personality disorder and often have histories of difficult childhood relationships with the parents. A history of milder degree of abnormal illness may present prior to the development of the syndrome. Subsequent illness behavior reinforced by professional over the years leads to the escalation of abnormal illness behavior. (8) Many patients report important childhood relationships with physicians or other parent figure that became selected objects against which love and anger can be directed. (9) Often, a true organic lesion from the past has left some genuine physical signs upon which the patient elaborates to convey a convincing story. (10) Munchausen’s Syndrome often begins in early adulthood and may begin after a hospitalization or medical illness, as is the case with our patient. Many of the patients are medical personnel and are well versed with medical terminology, as is the case with our patient.

The prognosis for Munchausen’s syndrome remains poor, treatment is extremely difficult as most of the patients disappear very early. Only one case has been reported as being successfully treated (11) and this patient was willing to stay in the hospital for three years. There are many different methods described for treatment of such patients, perhaps the best treatment for Munchausen’s syndrome is early recognition, as dangerous diagnostic or therapeutic interventions can be avoided and attempts to help the patient can begin without delay. (12) Factitious disorder is not a very uncommon or benign pathology. Our knowledge in this particular pathology is limited mainly because of diagnostic difficulties and lack of solid statistical data.

Once the diagnosis of Munchausen’s syndrome is suspected, failure to obtain a psychiatric consultation places some degree of responsibility upon the clinician for any serious damage the patient may inflict upon himself or herself.

References:

1. Baylin RIS. The deceivers. BMJ 1984; 288: 583-4
2. J. G Jones, H. L. Butler,B. Hamilton, J. D Perdue, H. P. Stern, and R. C. Woody, “Munchausen syndrome by proxy,” Child Abuse and Neglect, October 1986, 33-403. Bhugra D (1988) Psychiatric Munchausen’s Syndrome .Literature review with case reports. Acta Psychiatr. Scand. 77:497-503
4. Asher R. 1951: Munchausen’s Syndrome. Lancet i:339-341
5. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders, 3rd edition Washington D.C
6. Pope H G., Jones J.M, Jonas B. 1982 Factitious psychosis: Phenomenology, family history and long term outcome of patients. Am. J. of Psychiatry 139:1480-1483
7. Sussmen, N. and Hyler, S. E: Factitious disorder in: “Comprehensive textbook of Psychiatry.” Editors: H. I. Kaplan and B. J. Sadock, 4th edition Williams and Wilkins, Baltimore, 1985, 1985,pp. 1242-1247
8. Sale I, Kalvey R. An observation on the genesis of Munchausen’s syndrome. A case report.Aus, NZ J Psychiatry 1980; 14: 61-4
9. Cramer B, Gershberg MR, Stern MR. Munchausen syndrome: its relationship to malingering hysteria and the physician-patient relationship. Arch Gen Psychiatry 1971;24:573-8.
10. Myall, RWT, Collins FJU, Ross A, et al. Chronic factitious illness: recognition and management of deception. J Oral Maxillofac Surg 1984;42:97-100.
11. Yassa R. Munchausen syndrome: A successfully treated case. Psychosomatic 1978;19:242-3.
12. Folks DG, Freeman AM. Psychiatric Clinic of North America1985;2:263-78.

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