Factitious disorder in adults: a case report and literature review.

ABSTRACT

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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.
Key  words:  factitious  disorder;  Munchausen  syndrome;  unexplained  symptoms;
adult; psychiatry.

CLINICAL CASE

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A  37-year-old  female  patient  with  a  history of mental health treatment and early institutionalization at the Dr. José Horwitz Barak Psychiatric  Institute  since  2002.  She  presents a clinical picture with depressive and chronic psychotic symptoms difficult to management and multiple   pharmacological   schemes   associated with multiple attempts at self-harm. She has found herself  homeless  for  much  of  her  life,  without a  support  network  and  living  in  foster  homes. She has been diagnosed throughout her life with schizophrenia,   borderline   personality   disorder with histrionic traits, and minimal intellectual disability, polyconsumption (tobacco, alcohol, marijuana, cocaine base paste, neoprene, and inhalants) since the age of 12.

From what has been investigate, this patient has had at least 8 hospitalizations only in the Complejo Asistencial Dr. Sótero del Rio Hospital between
2006  and  2020,  of  which  her  diagnoses  range from induced abortions to status epileptic, hospital administrative discharges for misconduct with health professionals.

The patient is referred from the emergency department  of  the  Padre  Hurtado  Hospital  on
10/21/2020 to the Complejo Asistencial Dr. Sótero del Rio Hospital for a lucid psychotic episode under study. She refers as a medical history schizophrenia  diagnosed  at  age  20,  currently in treatment at Padre Hurtado Hospital, arterial hypertension, non-insulin requiring type 2 diabetes mellitus, lupus, thrombophilia, Crohn’s disease, non-Hodgkin   lymphoma,   treated   liver   tumor, early menopause, and hypothyroidism. About medications, she consumes: Azathioprine (does not remember dose), Mesalazine 500 mg (1 tablet a day), Methotrexate 2.5 mg (1 tablet every 12 hours), Prednisone 20 mg (1 tablet every 8 hours), Oral anticoagulant (does not remember name) and Modecate 1 ampoule monthly. She denies drug allergy, drug use and psychiatric pathology.

It is described in the medical record at the Padre Hurtado  Hospital  that  the  patient  consults  on 08/20/17 for sudden onset of consciousness compromise at the bus stop where she was after running away from the house where she lived. She was taken by ambulance suffering during the journey a generalized clonic tonic seizure with computed tomography scan and electroencephalogram study without pathological findings and interpreted as a pseudoseizures. During her hospitalization, the patient presented significant somatization with normal tests; for example, chest pain with normal electrocardiogram, factitious fever, “intestinal obstruction”, but she had 3 stools a day. In addition, multiple episodes of psychomotor agitation with escape attempts,  so  it  is  decided  to  sedate  her with propofol while she is taken to a care unit of increased complexity.

In the care unit of Padre Hurtado Hospital, the patient  persists  with  psychomotor  agitation  and 4 escape attempts, so it is decided to sedate her again with good response. On 09/27/2017 presents septic shock which Citrobacter freundii is isolated in a central venous catheter and later in 2 blood cultures, which requires the initiation of vasoactive drugs that can be suspended at approximately 20 hrs along with sedation. She completes antibiotic treatment with Amikacin and Imipenem for 1 week with good response. From the psychiatric point of view,  she  maintains  daily  visual  hallucinations, with frequent escape attempts and self-aggression that have not been possible to control with therapy indicated by liaison psychiatry. There are no clinical protocols, specialized units, or trained personnel to manage decompensated psychiatric patients of high complexity, so patients are referred to Complejo Asistencial Dr. Sótero del Rio Hospital.

At the admission of the unit, given the suspicion of FD, all the medical records of the patient are requested in the Complejo Asistencial Dr. Sótero del Rio Hospital, in which it is observed the diagnosis of FD on 09/27/2012, in the context of  evaluation  by  the  Internal  Medicine  team, who ruled out their basic pathologies: insulin- requiring type 2 diabetes mellitus, lupus, old stroke, acute myocardial infarction and epilepsy.

As management, the treatment with olanzapine 20 mg per day was initiated, then carbamazepine 400 mg was added every 8 hours, observing adequate response. In the neuropsychiatric evaluation, borderline personality traits are observed. We work on  containment,  recognition  and  management of  anguish  progressively  achieving  recognition of lies in relation to medical pathologies. In the 3rd week of hospitalization presents behavioral imbalances, difficulty complying with the rules of the nursing team, insults to staff, episodes of significant distress, aggressive attitudes to the official when trying to be contained by him. In the context of multiple behavioral imbalances and in accordance with hospitalization regulations, it is decided to discharge administratively.

During hospitalization in the Complejo Asistencial Dr. Sótero del Rio Hospital, the patient initially reports intense, egodystonic, visual and auditory hallucinations associated with active suicidal ideation with planning. Subsequently, a patient was confronted in the context of a history of FD diagnosed in 2012 and a morbid history mentioned; to which she becomes initially surprised, reacts anxiously and then hostile attitude, so that confrontation continues in a more subtle and constructive way with partial response.

INTRODUCTION

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Factitious disorder corresponds to a psychiatric pathology    characterized    by    a    behavior, in which, the individual seeks medical attention by consciously executing multiple clinical and non- clinical behaviors ranging from the exaggeration of symptoms to the deliberate falsification of these.(1)

The prevalence of this picture, although unknown, is estimated that globally it would be between 0.5 - 2% and up to 1.4% in hospitalized patients. On the prevalence according to sex, recent studies indicate that it is more frequent in women than in men. In addition, about 40% and in some case reviews 58- 70%, the comorbidity with mental and behavioral disorders is high: factual behavior is mainly seen in personality, addiction, eating and stress-related disorders. According to a systematic review of 455 cases, a high proportion of cases are described in psychiatry (19%), accident and emergency departments (12%), neurology/neurosurgery (10%), infectology and dermatology (9% each), endocrinology (13%), as well as cardiology and dermatology (10% each).” (1,2,3,4)

On the etiology of this pathology, it is unknown, only some theories have been proposed, such as abuse in childhood, parenting styles in which a pattern of seeking care is generated and physical illness during early stages. In addition, the study with functional neuroimaging has shown some inconclusive patterns, such as the activation of executive brain regions with an increase in the prefrontal white matter, in the case of patients who present fantastic pseudology.(5)

Like other disorders of the somatoform spectrum, factitious disorder generates a great impact on health, specifically on the functionality and quality of life of those who suffer from it, given that they are usually polyconsultant users, and consequently, a significant cost to health. In Chile, adult polyconsultants consume approximately one third of health expenditures, 30% of all adult patients consume 80% of health center consultations.(6,7)

Therefore, it is that in this literature review and case report, it is intended on the one hand, to update the guidelines regarding the treatment of factitious disorder based on literature, and on the other hand, to expose a clinical case, in order to have an updated knowledge of this disease to propose preventive interventions or protocols that allow avoiding hospitalizations  and  /  or  unnecessary  treatments, and thus be able to reduce the impact it currently has.

GENERAL

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Factitious disorder has gone through multiple conceptions, since Richard Asher’s first clinical description  in  1951  of  Munchausen  syndrome, in which patients adorned their symptoms and invented medical records to get them admitted to the hospital, moving from one place to another in search of medical attention; to the diagnostic criteria that are known today in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in its fifth edition.(8,9)

The diagnosis of this disease is clinical, in which there may be a pattern of falsification of physical and/or psychological symptoms; or induce or worsen an injury or disease, associated with an identified damage that can be applied to oneself or to a third party. Usually, medical teams manage to make the diagnosis through investigative work, unless the patient reveals the elaboration of the symptoms. With regard to differential diagnosis, it is necessary to keep in mind both organic / mental pathologies and simulation. The latter is not considered a disease since the symptoms feigned or provoked can aim at a social or economic gain or avoid responsibilities.”(7)

Given that it is a pathology of intermittent course, characterized by having episodes of recurrence with or without treatment, therefore, uncertain prognosis and that, once the diagnosis is revealed, a small percentage accepts to be treated. In a retrospective study, 80 of 93 patients underwent psychiatric consultation, and 71 of them faced the suspicious diagnosis; only 16 admitted to having the disease and only 19 of 93 patients accepted psychiatric treatment, while 18 left the hospital against medical advice. In a review of 32 case reports, 17 patients faced suspected autolysis, 14 of them with a non-punitive approach, but without a discernible correlation with the outcome.(12,13)

Currently,    there    are    no    clear,    evidence- based pharmacological, psychological, or environmental  management  treatments;  only  a few recommendations are found based on expert opinions. However, patients who have comorbid psychiatric conditions such as depression, it is important to treat the symptoms appropriately, as this can indirectly improve factual behavior.”(5,10,11)

MANAGEMENT RECOMMENDATIONS

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In the event of suspected FD, according to the clinical guideline presented by Hausteiner-Wiehle& Hungerer (2020), patients should be informed of the differential diagnosis of autolysis and, where appropriate, confront the patient with the diagnostic suspicion of FD in a gradual, constructive, and supportive  approach  (indirect  confrontation). This approach includes maintaining a vigilant and considerate attitude, involving particularly careful team coordination and clear directions. In addition, communication with the patient should be as empathetic  as  possible.  Clear  reference  should be made to the medical duty of care in relation to dangerous developments and unnecessary measures.  Both  concrete  psychosocial  support and  the  transfer  of  responsibility  for  treatment to the patient are important steps on the path to developing autonomy and perspectives beyond the role of the patient.

Before confirming the diagnosis of FD, the doctor should not abruptly discharge the patient once this pathology is suspected and should avoid telling him his diagnostic suspicion. Once the diagnosis is confirmed, it is important to address the underlying emotional needs of the patient to determine the motivation of the FD; the patient may not fully understand the new diagnosis. The priority in the management of the disease is focused on allowing the person to recognize when they feel obliged to participate in the symptomatology of FD and prevent it from recurring.(10)

Early evaluation by a psychiatric, psychosomatic, or psychological consultant supports specialized diagnostic confirmation of FD and should include an assessment of the risk that patients pose to themselves or others and the initiation of new contacts.(4)

PROGNOSIS

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The limited prognostic data available indicate drastic differences in the degree of self-harm and the resulting degree of disability: approximately

10-30%  of  factual  acts  appear  to  be  isolated and harmless events; mild disease courses and complete remissions are seen. However, episodic or chronic courses with sometimes lasting disabilities seem to be more common. Mortality is likely to increase: causes of death may include complications from (provoked) interventions or suicide, while approximately 14% of patients have suicidal thoughts. The lack of recognition of the feigned and the manufacture of symptoms carries the risk of iatrogenic chronification and worsens the prognosis.(4)

CONCLUSION

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Despite  the  systematic  and  literature  reviews that have appeared over the years; we are still far from having an optimal knowledge of this disease. FD is inevitably a difficult pathology to  diagnose,  and  therefore  complex  to  study and  manage.  However,  if behaviors  can  be taken  to  increase  the  probability  of  success in the management of these patients, such as maintaining a igilant, empathetic attitude, giving clear indications, and referring to the specialist  making  clear  the  limits  in  relation to the type of management that will be taken to avoid hospitalizations and unnecessary treatments.

REFERENCES

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1. Bass C & Halligan P. (2014). Factitious disorders and malingering: challenges for clinical assessment and management. Lancet 383, 1422–32.
   
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3. Yates  GP  &  Feldman  MD  (2016).  Factitious disorder:  a  systematic  review  of  455  cases  in the professional literature. Gen Hosp Psychiatry
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4. Hausteiner-Wiehle   C   &   Hungerer   S.   (2020).
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8. Sadock B, Sadock V & Ruiz P. (2015). Kaplan & Sadock, Sinopsis de Psiquiatría 11º Ed. Barcelona: Editorial Wolters Kluwer.
   
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10. Galli S, Tatu L, Bogousslavsky J & Aybek, S (2018).
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11. Carnahan KT & Jha A (2020). Trastorno facticio.
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13. Eastwood  S  &  Bisson  JI  (2008).  Management of   factitious   disorders:   a   systematic   review. Psychother Psychosom 77:209-18