Trastorno facticio en adultos: a propósito de un caso y revisión de literatura / Factitious disorder in adults: a case report and literature review

RESUMEN: El trastorno facticio consiste en falsificar, inducir o agravar las enfermedades para recibir atención médica, independientemente si están enfermas o no. El impacto que tiene esta patología va desde altos costos en salud asociado a la policonsulta, hospitalizaciones y tratamientos innecesarios; la funcionalidad y calidad de vida de estos pacientes, hasta el costo de vidas humanas. Este trastorno sigue siendo un desafío para los clínicos, puesto que no hay evidencia suficiente sobre la epidemiología, etiología, clínica y manejo dada su complejidad. En este artículo se presentará un caso clínico enfatizando en la evolución de la enfermedad, manejo inicial y posterior durante su hospitalización, junto con una actualización basada en la literatura, en torno al tratamiento de esta patología, con el fin de proponer intervenciones preventivas o protocolos que permitan evitar hospitalizaciones y tratamientos innecesarios. Luego se finalizará con la resolución del caso, pronóstico de esta enfermedad y una conclusión.

ABSTRACT Factitious disorder consists of falsifying, inducing or aggravating illnesses in order to receive medical attention, regardless of whether they are ill or not. The impact of this pathology ranges from high health costs associated with polyconsultation, hospitalizations and unnecessary treatments, the functionality and quality of life of these patients, up to the cost of human lives. This disorder continues to be a challenge for clinicians, since there is insufficient evidence on the epidemiology, etiology, clinic and management given its complexity. In this article, a clinical case will be presented, emphasizing the evolution of the disease, initial and subsequent management during hospitalization, together with an update based on the literature, on the treatment of this pathology, in order to propose preventive interventions or protocols that allow avoiding hospitalizations and unnecessary treatments. Then it ends with the resolution of the case, prognosis of this disease and a conclusion.

Factitious Disorder - Patient Pretending To Long Stay At Hospital

Factitious disorder (FD) is a psychiatric disorder where patients intentionally create false physical or psychological symptoms or exaggerate the already existing ones consciously in the absence of clear external motive. Patients feigned for the sole purpose of assuming the patient's role and to stay lifelong at hospital. Here we present a case of 61 years old Saudi patient presenting with so many various complaints and wasting valuable time and resources of doctors and wants potentially long hospital stays, which affects both the patient and the healthcare system.

Insights into the clinical profile and comorbidities of factitious disorder in a multispeciality setting in southwest Nigeria: A cases series and review

Background: Factitious disorder (FD) is an under-recognized and under-diagnosed mental condition. Healthcare professionals often have challenges to diagnose and treating the disorder. As a result, needless and endless medical resources are recommended to assess and evaluate those affected. FD may present as a physical condition, a psychological disorder, or maybe both depending on the prominent symptoms. However, there is a strong correlation between having FD and psychiatric symptoms. Main Text: FD occurs in early adulthood, with a mean age of onset of 25 years in both genders, although with differing demographic features. The lifetime prevalence of FD imposed on oneself in clinical settings is 1.0%, 0.1% in the overall population (ranging between 0.007% and 8.0%) and occurs more in female health care professionals. FD may make up 0.6%­3.0% of psychiatric referrals, and it accounts for 3-5% of doctor-patient contacts. In actuality, 1-2% of hospital admissions and an average of 6-8% of all psychiatric admissions have been underreported. The study aimed to highlight the signs and symptoms of FD identified in a psychiatry department of a multispecialty center and to increase the awareness of health practitioners. A critical review of the literature was done with an emphasis on psychological symptoms. PubMed, Mendeley, and Google Scholar were thoroughly searched and full-text publications of journals from 2010-2021 were included. Conclusion: FD is a diagnostic puzzle that necessitates adequate, prompt medical attention as well as social support because of the potentially fatal consequence. A stronger patient-therapist relationship can strengthen the patient's conscious self-control to minimize the symptoms; therefore the healthcare provider has to be openminded. For the diagnostic enigma to be removed and for ease of treatment, additional research, increasing awareness among medical professionals and the general public, accurate evaluation, diagnosis, and psychotherapy should be encouraged. These case studies will contribute to the knowledge base of FD and improve the quality of care.

Chinese mainland′s first case report of Munchausen syndrome by proxy in children / 中华实用儿科临床杂志

Clinical data of a case of Munchausen syndrome by proxy (MSBP) admitted to the Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology in November 2020 were retrospectively analyzed.The 4 years and 4 months old female patient presented with retrosternal and abdominal pain for 1 month, and aggravated with multi-organ pain for 20 days.She complained about the retrosternal pain with acid reflux, pain in the teeth, esophagus, and abdomen, etc.During the hospitalization, she frequently complained of multi-organ pain.Her mother repeatedly declared her painful hip joint and she often cried for pain at night, and even could not walk.However, the clinical examination showed no obvious abnormalities.Combining characteristics of the patient and her caregiver, the patient was confirmed as MSBP.It is suggested that MSBP in children should be concerned in cases with complicated severe chief complaints, frequent medical visits, and a strong willing to see a doctor or be hospitalized by their caregivers, but normal physical and auxiliary examination findings.

Bioética e sociedade: transtorno factício autoimposto e imposto a outro / Bioethics and society: factitious disorder imposed on oneself and imposed on another / Bioética y sociedad: trastorno facticio impuesto a uno mismo e impuesto a otro

Resumo: Objetiva-se compreender a síndrome de Münchhausen a partir da descrição das suas causas, dos critérios de identificação, dos sinais clínicos, do diagnóstico e do tratamento, bem como das assistências realizadas pela Enfermagem e pela equipe interdisciplinar com interface da Bioética. Trata-se de uma revisão narrativa de literatura de caráter exploratório reflexivo, com abordagem qualitativa. Realizaram-se buscas de estudos em periódicos publicados entre 2009 e 2019; a amostra final constituiu-se por 30 artigos, além de livros, manuais e normativas. Os resultados apresentados evidenciam o conhecimento da quinta edição do Manual Diagnóstico e Estatístico de Transtornos Mentais, no qual a expressão "síndrome de Münchhausen imposto a si próprio" foi substituída por "transtorno factício autoimposto", e a "síndrome de Münchhausen por procuração" foi alterada para "transtorno factício imposto a outro", quanto à bioética. Indivíduos com o distúrbio factício tendem a buscar tratamento para si mesmo ou para outro. O comportamento desses pacientes aumenta a probabilidade de terem realmente uma doença física e até mesmo ir a óbito, causado pelo excesso de uso de medicações e pelos diversos procedimentos invasivos. Portanto, conclui-se que identificar o quadro clínico pode ser uma das primeiras iniciativas para a detecção e a prevenção. O tratamento deve se concentrar no manejo, com a possibilidade do uso da psicoterapia e de antidepressivos, antipsicóticos e ansiolíticos. A equipe de enfermagem e a multiprofissional devem estar atentas a sinais e sintomas para uma intervenção precisa e precoce, pois desempenham importante papel na identificação adequada do diagnóstico.

Summary: The objective is to understand Münchhausen syndrome, with the description of its causes, identification criteria, clinical signs, diagnosis and treatment, as well as the assistance provided in nursing and the interdisciplinary team regarding bioethics. This paper is a narrative review of literature with a reflective exploratory nature, and a qualitative approach. We searched for studies in journals published between 2009 and 2019, and a final sample consisting of 30 articles, in addition to books, manuals and regulations. The results presented corroborate the claims in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, in which the term "Münchhausen syndrome imposed on self" was replaced by "factitious disorder imposed on self", and the "Münchhausen syndrome by proxy" was changed to "factitious disorder imposed on another", in Bioethics. People with factitious disorder tend to seek treatment for themselves or for others. The behavior of these patients increases the likelihood of physical illness and even death, caused by overuse of medications and as a result of various invasive procedures. Therefore, it is concluded that identifying the clinical picture may be one of the first initiatives for detection and prevention. Treatment should focus on management, being able to use psychotherapy, antidepressants, antipsychotics, and anxiolytics. The nursing team and the multidisciplinary team must be alert to the signs and symptoms for accurate and early intervention since they play an important role in the proper identification of the diagnosis.

Resumen: El objetivo es comprender el síndrome de Münchhausen, con la descripción de sus causas, criterios de identificación, signos clínicos, diagnóstico y tratamiento, así como la asistencia brindada en enfermería y el equipo interdisciplinario en cuanto a la bioética. Es una revisión narrativa de la literatura con un carácter exploratorio reflexivo, con un enfoque cualitativo. Se realizaron búsquedas de estudios en revistas publicadas entre 2009 y 2019, y una muestra final que consta de 30 artículos, además de libros, manuales y reglamentos. Los resultados presentados corroboran el conocimiento de la quinta edición del Manual Diagnóstico y Estadístico de los Trastornos Mentales, en el que el término "síndrome de Münchhausen impuesto a uno mismo" fue reemplazado por "trastorno facticio autoimpuesto", y el "síndrome de Münchhausen por proxy" se alteró a "trastorno facticio impuesto a otro", ante la Bioética. Las personas con trastorno facticio tienden a buscar tratamiento para sí mismas o para otros. El comportamiento de estos pacientes aumenta la probabilidad de tener una enfermedad física e incluso la muerte, causada por el uso excesivo de medicamentos y como resultado de varios procedimientos invasivos. Por lo tanto, se concluye que identificar el cuadro clínico puede ser una de las primeras iniciativas para la detección y la prevención. El tratamiento debe centrarse en el manejo, poder usar psicoterapia, antidepresivos, antipsicóticos y ansiolíticos. El equipo de enfermería y el equipo multidisciplinario deben estar atentos a los signos y síntomas para una intervención precisa y temprana, pues desempeñan un papel importante en la identificación adecuada del diagnóstico.

Síndrome de Münchhausen / Münchhausen síndrome

Resumen Introducción: síndrome de Münchhausen es un subtipo de trastorno facticio grave y crónico, que se caracteriza por la producción de mentiras patológicas ("pseudología fantástica") y una conducta errante, de médico en médico, fingiendo una enfermedad física. Objetivo: presentar el caso de un paciente con hipoglicemia refractaria secundaria al uso de insulina exógena en el contexto de un síndrome de Münchhausen. Discusión: el paciente presentó una sumisión inusual a las hospitalizaciones y a las pruebas diagnósticas, las cuales confirmaron la administración exógena de insulina para desencadenar los síntomas. Los rasgos paranoides y la mitomanía observada se asocian a un estado larvado, crónico y delirante, propio de síndrome de Münchhausen. Conclusión: el síndrome de Münchhausen es una condición psiquiátrica difícil de diagnosticar y que constituye un importante reto para el clínico, es poco reconocido, afecta la relación médico-paciente y presenta un alto costo para el sistema de salud debido al uso de innecesaria de baterías diagnósticas y procedimientos terapéuticos. (Acta Med Colomb 2019; 44:43-46).

Abstract Introduction: Münchhausen syndrome is a subtype of serious and chronic factitious disorder, characterized by the production of pathological lies ("fantastic pseudology") and wandering behavior from doctor to doctor, pretending a physical illness. Objective: to present the case of a patient with refractory hypoglycemia secondary to the use of exogenous insulin in the context of a Münchhausen syndrome. Discussion: the patient presented an unusual submission to the hospitalizations and to the diagnostic tests, which confirmed the exogenous administration of insulin to trigger the symptoms. The paranoid features and the mythomania observed are associated with a latent, chronic and delirious state, typical of Münchhausen syndrome. Conclusion: Münchhausen syndrome is a psychiatric condition that is difficult to diagnose and that constitutes an important challenge for the clinician; it is little recognized, affects the doctor-patient relationship and presents a high cost for the health system due to the use of unnecessary diagnostic and therapeutic procedures. (Acta Med Colomb 2019; 44: 43-46).

Psicosis instrumental: a propósito de dos probables casos / A propos of two probable cases of instrumental psychosis

El Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM-5) define a la simulación como larepresentación intencional de síntomas físicos o psicológicos falsos o muy exagerados, motivada por incentivosexternos diversos, aunque reconoce que, en muchos casos, la simulación puede tener cierto valor adaptativo.Estrictamente hablando, la simulación no es un trastorno mental sino un problema que puede ser objeto de atenciónclínica. Sin embargo, se presume erróneamente que la simulación podría darse solamente en contextos forenses,lo que dificulta su identificación en ámbitos clínicos. La “psicosis instrumental” es una variante de simulaciónconsistente en el fingimiento de síntomas por parte de un individuo con diagnóstico subyacente de una psicosisprimaria y que simula sus síntomas en momentos de estabilidad clínica. Se presentan dos casos de personas condiagnóstico primario de esquizofrenia que pueden ser considerados también como aparentes casos de psicosisinstrumental. No existen reportes previos de este trastorno en nuestro país, aunque presumiblemente su número nodebe ser exiguo. Se revisa también la literatura pertinente a este interesante fenómeno que, más alláde su naturaleza psicopatológica, parece reflejar conductas de una definida índole psicosocial..

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines malingering as the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives; under some circumstances, malingering may represent a sort of adaptive behavior. In fact, malingering is not a mental disorder but a problem that may be require clinical attention. Nevertheless, it is erroneously assumed that malingering could only occur in forensic contexts, therefore difficult to identify in clinical settings. “Instrumentalpsychosis” is a variant of malingering which consists in the intentional production of symptoms by an individualwith a diagnosis of primary psychosis, who feigns his/her symptoms during periods of clinical stability. Two cases of patients with a primary diagnosis of schizophrenia and who qualify as apparent cases of instrumentalpsychosis, are presented. There are no previous reports of this disorder in our country, although presumably itsnumber may not be small. Relevant literature on this interesting clinical phenomenon is reviewed as, beyond its mere psychopathological content, it seems to reflect behaviors of a definite psychosocial nature.

Simulación de síntomas psicóticos y su evaluación para ayudar a establecer inimputabilidad / Simulation of psychotic symptoms and evaluation to help establish criminal responsibility

El profesional en psicología debe conocer sobre la versatilidad que su rol puede tener en diversos contextos, sobre todo cuando se enfrente a una pregunta jurídica como ayudar a determinar dinámicas de simulación para ayudar a decidir sobre inimputabilidad en un sistema de justicia. Por ello se brinda una recopilación bibliográfica basada en el trabajo final de graduación para optar al grado de psicólogo clínico, titulado “Simulación de síntomas psicóticos y su evaluación psicológica: algunos elementos psicojurídicos y su relación con aspectos clínicos y forenses en el contexto costarricense”, en la cual se reflexiona sobre estos temas. En primera instancia se brindará una ubicación general del rol del psicólogo en estas circunstancias, pasando a describir diversas dinámicas de simulación de síntomas psicóticos que abarcan las concepciones de simulación y como se han registrado en síntomas positivos y negativos. Se brindan ejemplos de sintomatología atípica, extraña o exagerada y se concluye con un resumen de pruebas psicológicas que generan tanto indicadores indirectos como otras que tienen como fin específico detectar simulación de psicosis. Una reflexión final abarca la necesidad integrar estos datos con la revisión exhaustiva de información colateral, escogencia y aplicación adecuada de pruebas psicológica y los cuidados pertinentes al describir dinámicas de simulación en una persona, por las delicadas implicaciones que conllevan su diagnóstico.

A professional in psychology should know about the versatility that his or her role can have in various contexts, especially when faced with legal treatments as helping to determine dynamic simulation throughout the insanity justice system. Therefore, it provides a bibliography based on the final graduation to obtain the degree of clinical psychologist, entitled “Simulation of psychotic symptoms and psychological assessment: psycho-legal elements and their relationship to clinical and forensic on costarrican context “ in which we go on reflection on these kind of issues. First of all, we provide a general placement of the role as psychologists in these circumstances, reviewing and describing various dynamic simulations of psychotic symptoms that include the concepts of simulation and are reflected in positive and negative symptoms. Examples are given of atypical symptoms, strange or exaggerated and conclude with a summary of psychological tests that generate both indirect indicators and others that are designed to detect specific simulation of psychosis. One final thought concerns the need to integrate these data with an exhaustive review of collateral information, choice and proper application of psychological tests and appropriate care dynamics simulation to describe a person, by the delicate implications involving diagnosis.

Transtorno facticio en obstetricia reporte de caso / Factitious disorder in obstetrics: case report

Introducción: El síndrome de Münchausen es la condición más estudiada del trastorno facticio con síntomas físicos; sin embargo, su presentación clínica durante la gestación es poco frecuente y es escasa la literatura al respecto. Objetivo: Presentar un caso de trastorno facticio en obstetricia. Método: Revisión y análisis de caso clínico. Resultados:Se presenta el caso de una mujer de treinta años de edad con gestación de seis semanas, quien consulta en múltiples ocasiones por un cuadro de emesis y dolor abdominal. Fueron varios los diagnósticos con los que cursó la paciente y se llegaron a excluir patologías como porfiria intermitente aguda, colon narcótico, epilepsia abdominal y espasmo esofágico. La paciente expresó su deseo de interrumpir el embarazo en la semana 21 de gestación. Esta se llevó a cabo una vez su caso fue presentado a junta médica que concluyó que existen condiciones tanto orgánicas como mentales que representan un alto riesgo para la salud de la paciente. Conclusión: Por su alta complejidad, estos trastornos constituyen un reto para el clínico, particularmente en las fases iniciales de su presentación. Los trastornos facticios son rara vez sospechados y diagnosticados, incluso en el ámbito hospitalario; por ende, es de suma importancia educar a los profesionales de la salud en atención primaria y en el medio hospitalario para identificarlos y poder orientar un adecuado manejo y tratamiento…

Introduction: Munchhausen’s syndrome is the best-studied type of factitious disorder with predominantly physical signs and symptoms. However, its clinical presentation during pregnancy is rare and literature on the subject is scarce. Objective: To present a case of factitious disorder during pregnancy. Method: Review and analysis of a clinical case. Results: The case of a 30-year-old woman six weeks pregnant who consults on multiple occasions with emesis and abdominal pain is discussed. Various different diagnoses were considered and pathologiessuch as acute intermittent porphyria, narcotic bowel syndrome, abdominal epilepsy, and esophageal spasm were discarded. The patient expressed her desire to terminate the pregnancy at week 21. The pregnancy was terminated after a medical panel concluded that there were both organic and mental conditions that placed the patient’s health at risk. Conclusions: Factitious disorders are very complex and extremely challenging to the clinician especially during the initial phases. They are seldom suspected and rarely diagnosed even in hospital settings. Therefore it is of utmost importance to educate healthcare professionals in the detection of this disorder to ensure proper management and treatment…

Factitious disorder with abdominal pain and multiple surgical operations: A case report.

Factitious disorder is characterized by physical or psychological symptoms that a person intentionally produces or feigns to pretend to be sick although not for external benefits such as financial compensation. As a result of the difficulty in diagnosing the disorder, its prevalence is relatively rare. The definite diagnosis and its proper management is important, particularly in preventing unneeded medical procedures as well as reducing stress in these patients’ families and reducing cost of management. We report a 17-year-old woman who presented to the Department of Surgery with severe abdominal pain and underwent her 5th abdominal operation due to provisional diagnosis of gut obstruction. The surgeon found only some fibrosis which could not explain her severe abdominal pain. After the operation, she still had abdominal pain, distension and intermittent fever although no source of infection nor physical illness could be found to explain this. Psychiatric consultation was came out because of her disturbed behavior and because she was uncooperative. We found that she had been admitted to several hospitals more than 50 times and had undergone 4 major operations in the past 4 years because of her abdominal pain. Surprisingly she was not distressed at all despite these chronic physical illnesses. After close observation by ward nurses, her persistent fever finally disappeared. We transferred her to our psychiatric ward and gave one of serotonin-specific reuptake inhibitors (SSRIs) which is effective in treating compulsion as well as depression, together with family counseling and individual psychotherapy. Finally she confessed that she feigned the symptoms, so we could make the definite diagnosis of factitious disorder with predominantly physical signs and symptoms.

A Case of Factitious Herniated Lumbar Disc

The authors present a case of factitious disorder manifestating as a lumbar disc herniation. This 38-year-old woman has been operated on over ten times during a 20-year-period. Surgeons should be alert to avoid unnecessary operations for this uncommon but potentially serious disorder.