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A Case Report of Munchausen Syndrome With Mixed Psychological Features
Case Reports
A Case Report of Munchausen Syndrome With Mixed Psychological Features PAMELA
E.
PARKER,
M
unchausen syndrome has been reported and studied extensively during the past 40 years. However, its diagnosis and management continue to be a challenge to psychiatrists as well as to other physicians. The following case report is significant because of its unique features of manipulation by the patient and final outcome. which were I) self-submitted commitment papers, 2) a complex array of psychological symptoms. and 3) successful case management.
Case Report Rose. a 51-year-old white woman. was admitted to the inpatient psychiatric service during the night. The medical student presented the patient as "one of the most tragic he had ever seen": One month prior to admission, the patient reponed that she had been robbed. beaten. and raped by an unknown assailant in her home. She had reponed the incident. but no charges were filed. Subsequently. she became overwhelmed with anxiety, fear, and sleeplessness. She was seen in an emergency room, diagnosed as having adjustment disorder with a depressed and anxious mood. but the emergency room psychiatrist had difficulty arranging for her follow-up because she lacked medical insurance. When attempts to refer her failed, he arranged time in his overloaded schedule to see her personally. For I month, he saw her twice weekly in Received October 4. 1991; revised December 12. 1991; accepted March 5. 1992. From the Depanment of Psychiatry. University of Alabama School of Medicine. Tuscaloosa Program. The University of Alabama. Address reprint requests to Dr. Parker. Dep!. of Psychiatry. Box l!70326. University of Alabama. Tuscaloosa. AL 35487-0326. Copyrighl © 1993 The Academy of Psychosomatic Medicine.
360
M.D.
allempts to provide supponive psychotherapy and pharmacotherapy for her depression. yet she became increasingly suicidal. A friend of the patient, Ms. Levy. urgently called one day from her car telephone to say that Rose had been walking along the freeway, confused and depressed. The evening before, she had been found bathing in a city park fountain. She had begun making references to a gun that she had hidden with plans to kill herself. and Ms. Levy agreed to file commitment papers and to assist in gelling the patient into the hospital. On admission. the patient was delirious, confused, minimally responsive to questions. and tossing in bed. She was poorly groomed. and there were diny shons and a shin lying on the chair at her bedside. She was slightly obese and had traces of wellworn makeup on her face. Her appearance was striking because of a total body tan that the patient said she got from "being in Barbados:' She also had anificially dyed platinum blonde hair that was striking against her dark tan. Her toenails were painted bright chanreuse green. She explained that an abdominal scar was from surgery for removal of"a tumor:' It was difficult to obtain her past medical history, current history. or any coherent details. She stated repeatedly during the interview phrases such as "those awful men.""1 feel so diny," "my bottom huns," "I don't know," and "\ don't remember." Occasionally, however, she answered more appropriately. She revealed that she had no brothers and sisters and that her parents had been killed in an automobile accident the prior year. She described her parents as overly protective, not allowing her to date or see friends. Her only living relative was her mother's elderly sister who lived in "Fleckenhaus," Germany, "a few meters from Munich." Her German accent waxed and waned during the interview. When asked to name some simple objects. she identified a pen as "mascara," a bottle of nail polish as "perfume," a watch as a "bracelet," and a tube of lipstick as a "pen." PSYCHOSOMATICS
Case Reports
During her first day in the hospital, housekeeping personnel reported that Rose had been twisting a sheet around her neck and had the pillowcase over her head. She continued to mumble about "those awful men" and "wanting to die." There was concern as to her motives regarding suicide, and she was transferred to a unit with higher security that lacked many of the amenities of her former ward. Following transfer to the closed psychiatric unit, the patient continued to be delirious and remained in bed. Her roommate was diagnosed with bipolar affective disorder and was delusional, paranoid, and hallucinatory. Because our patient's depiction of delirious behavior was extremely convincing, she was allowed to sleep during rounds while the patient in the adjacent bed was interviewed. The following day, Rose was noted to have new hallucinatory symptoms, remarkably similar to those her roommate exhibited the day before. Aggressive efforts to locate anyone with information about Rose were begun. Attempts to contact Ms. Levy, Rose's close friend who had signed the commitment papers (in accordance with state law), were markedly unsuccessful, even when we obtained information from the probate court regarding the petition's filing. We received a copy of the petition that was so sparse in data as to be marginal for commitment purposes. We learned that the commitment forms filed at probate court had been picked up by a taxicab driver and had been returned, signed, by a different taxicab driver. Ultimately, it was determined that Rose had filed her own commitment papers. Rose ate sparsely from her food trays though the nurses made attempts to get between-meal snacks that might appeal to her. It was quietly suggested to the housestaff on rounds at the patient's bedside that a nasogastric tube might be necessary; within 24 hours Rose's food intake significantly improved. She had no clear evidence of a factitious disorder, but the nursing staff fully understood the possibility and offered nurturance cautiously. Close observation was considered the primary diagnostic tool. Gradually, the patient began to provide more information about herself and to appear less delirious. She revealed that she was enrolled in the premed curriculum at a prestigious local college. She implied that her recent trauma from a rape and burglary had completely disrupted her ability to work. She provided the name of the college and her faculty adviser's name and phone number. Concerned that Rose was suicidally depressed, we contacted her
VOLUME 34· NUMBER 4· JULY - AUGUST 1993
adviser. Although the adviser was at the telephone number provided, her location was not at the esteemed college that the patient had mentioned. Rather, the adviser was at a small, little-known trade school where Rose was actually enrolled in a medical technician's program. While Rose had performed well there in the past, she had recently been in a highly emotional state, telling the teacher about her personal difficulties. This presentation had been in striking contrast to the patient's behavior during the previous 8 months, during which time the patient always appeared for class neatly dressed, carefully groomed, and behaved appropriately, according to the adviser. The only unusual feature, previously noted by classmates, was a designer tag hanging from a dress that Rose claimed to have made herself. The trade school's application records were used in efforts to find the patient's next of kin. None were listed. Of the five people listed as references, three turned out to be totally fictitious individuals or at least were not located at the address or telephone numbers that Rose had given. Two were found to be "real" people who had earlier known the patient 15 to 20 years ago. They knew nothing of her current life circumstances and had never known any of her relatives. One man recalled that Rose occasionally brought her small son to his house. Rose had managed to obtain a complete government scholarship for her studies without the required financial report for verification. Evidence surfaced that she had grown up in a neighboring town, not Germany. A review of police records by the officer who visited Rose's home strongly suggested that there had been no crime as she had reported I month prior to hospitalization. However, Rose had been hospitalized at our institution at about the same time for pseudoseizures. Medical records were unavailable because the patient had changed one letter of her name and altered her birth date by 10 years. Initially, Rose had no visitors or phone calls. At no time did we find any evidence that the patient's friend, Ms. Levy, existed. The patient had a black male visitor named Joe on two occasions. The first visit occurred during the evening hours of a weekend, when the nurses on duty knew little of her history and did not realize the staffs need to contact any of Rose's visitors. The second visit occurred during a busy afternoon. By the time the nursing staff had notified our team of the visitor's presence, he had left the unit. The patient identified this visitor as a part of a husband-wife team who "kept up" her parents' place. He brought the patient some items of clothing, including a white, frilly negligee that was
361
Case Reports
somewhat dingy and ragged in spots. We subsequently learned that the patient indeed had been married and had a son who lived with his father. Rose had a lengthy criminal record for writing bad checks and petty theft. and she had served a prison sentence. An informant from the jail where Rose had served time commented on the relative frequency of her "visits" for reasons that were often alcohol-related. An informant from Joe's community said that Rose always got "sick" when she and Joe were having a fight. and Rose had been known in the neighborhood as an uncontrollable liar and a prostitute. Hometown records revealed that Rose had three older brothers and an alcoholic father. There was strong evidence that Rose had endured sexual abuse by her father and her three older brothers. At least one brother was also a habitual liar. and another had been hospitalized in the state mental facility. Her parents had died 10 years apart of natural causes. Her illness was managed as a conversion symptom. She was told that although she had been through a very difficult experience. there was every reason to believe that she would get beller and that her symptoms would resolve. Psychotropic medications were avoided and one-to-one supervision was discontinued as soon as Rose's delirious and suicidal symptoms abated. She became beller oriented and her responses became more appropriate, but she continued to say that she had been through a severe trauma that was too painful to discuss. Although she wanted to return to the more open unit, it was discouraged. Her first EEG was un interpretable secondary to excessive motor activity (apparently a pseudoseizure). Her second was completely normal as was a CT scan of her head. Minnesota Multiphasic Personality Inventory and Millon testing batteries revealed depression. hysteria. and antisocial features. Two attempts at an interview with amobarbital (Amytal) were unsuccessful because the patient continued to give false information up to the point of total sedation. Halsted-Reitan batteries revealed only malingering. Records of Rose' s enrollment in a substance abuse treatment center affiliated with the local courts were located. They suggested previous barbiturate abuse. A pelvic examination showed that she had no uterus. though she claimed to be taking birth control pills. After a 2-week hospitalization. Rose denied suicidal thoughts and was discharged. She kept her first follow-up appointment at which time she complained billerly about insomnia and was clearly 362
seeking drugs. She did not appear for her second follow-up. but several weeks later the secretarial staff received a call from Rose' s housekeeper (probably Rose herself) stating how terribly Rose was doing. The patient follow-up was lost for an 8-month period until Rose called one day asking for an appointment. After that time, she was seen weekly without fail. Approximately the first two sessions were spent in setting limits. especially regarding being on time for the appointment. Within four sessions, it became apparent that a 30-minute session was optimal for her abilities to interact with the therapist. It was brought to her attention that she had a large. outstanding bill from her previous hospitalization and that in order for her to continue in outpatient therapy, she would need to regularly provide a small amount (unstated) of compensation for services. Afterward. she began to bring a small amount of cash to pay for each appointment. During her earliest sessions. her behavior was highly attention-seeking. It included wearing unusual apparel. striking colors. childish hairpieces. and heavy makeup. She made allusions to life-threatening behaviors and continued to give out information that had already been confirmed as false. She frequently became extremely bizarre in her behavior just as the session was ending, and on one occasion pulled a pair of bloody underwear from a paper bag. When these presumed efforts at extending the session were ignored, they ceased. Gradually, the sessions contained less sensational behavior, and there was a modest increase in Rose's expression of her feelings.
Discussion
This patient meets the criteria for Munchausen syndrome. She has repeatedly used feigned medical illness to gain entry into the medical system. Her name and age have varied, and pseudologia fantastica is evident. During this admission, her symptoms were psychological, and one of the more unique aspects of this case was that she filed her own commitment papers under a false name. This patient also meets the diagnostic criteria for Ganser syndrome. The classical finding of approximate answers led to the diagnostic consideration of Ganser syndrome, and she fit Ganser's own description of the syndrome in PSYCHOSOMATICS
Case Reports
light of her previous incarceration. The similarity of dynamics in Ganser syndrome and Munchausen syndrome has been discussed in a case reviewed by Bustamente and Ford.' The diagnosis of posttraumatic stress disorder was considered when Rose's purported story of the rape event unfolded. This diagnosis was never discarded, as the author suspected the presence of an unreported, but equally threatening, psychological trauma. The fact that she was accepting of the highly structured and intrusive observation of the closed unit suggested that she was in severe need of treatment. The possibility of multiple personality disorder is arguable. Similar to the patient in a recently reported case of multiple personality and Munchausen syndrome,2 Rose probably came from a background ofsexual abuse. Although the patient has never clearly identified different personalities, she claimed to have no memory for some events and has been described in a variety of social circumstances that are in striking contrast to her presentation in the medical setting. The presence of true dissociation can be neither supported nor refuted. The role of malingering is equally questionable. While admission to mental institutions is often found in malingering patients who want to escape prison sentences, this effort toward commitment had no identifiable secondary gain. A review of state police records revealed that Rose had no criminal charges from which she might be seeking to escape. A nonconfrontational approach, as previously suggested by Eisendrath,J is the cornerstone of what may be considered success in managing this episode of Munchausen syndrome. This approach is in contrast to a convincing argument for confrontation by Nadelson. 4 Psychiatric care was provided with the implication that the actual details of her intrapsychic trauma had become irrelevant. Like the patient described by Feldman,s nurturance appeared to be an unconsciously motivated goal. She clearly experienced isolation, loneliness, fearfulness, and anxiety, and case management was planned accordingly. Ford 6 noted an association between separation and Munchausen syndrome, a findVOLUME 34· NUMBER 4· JULY -AUGUST 1993
ing also noted by Geracioti et al. 7 The possibility that Rose had a long-standing relationship with Joe that became "rocky" at the time of her reported rape could have easily precipitated Rose's hospitalization. Previously suggested treatment approaches for multiple personality disorderH may have relevance for this patient. The challenge is to integrate the various aspects of the patient's psychological life (especially reality and fantasy). This was attempted in a manner that supported the patient's strengths and avoided the rewards for her acting-out behavior. At present, the patient is not incarcerated, hospitalized, or engaged (with one exception, a minor infraction) in illegal activities. She has been seen weekly in psychotherapy for approximately 8 months and has been on time for every single appointment. It is the belief of this author that the patient revealed her intrapsychic conflicts in a manner that felt safest to her-by changing the facts. She has "learned such behavior in a culture receptive to this particular form of behavior as an effective option when all else fails.'''! Nevertheless, dynamics and feelings are interpretable and amenable to psychotherapy. Her descriptions of herself, including pseudologia fantastica, represented her fantasies and the antithesis of her actual childhood experiences. These fantasies have been most helpful in the psychotherapeutic approach. Exposing her factual inconsistencies would serve only to alienate the patient and perpetuate and strengthen her need for nurturance and nurturing behavior. Her pathological lying was not always used for deceptive purposes only but, rather, appeared to be a form to dramatically seek attention. Amidst total fabrication, she periodically provided elements of factual information that served to keep the attention of the treatment team. Her ability to mix fact with fiction in a truly dramatic style may actually have been (and still be) a very clever, conscious or unconscious, hysterical style of obtaining nurturance. The borderline personality structure is common in patients with both Munchausen syndrome and multiple personality disorder, but Rose demonstrated few traits of splitting and manipulation. 363
Case Reports
She did have unstable relationships, impulsivity, recurrent suicidal behavior, identity disturbance, chronic emptiness, and fears of abandonment. She also meets the criteria for antisocial personality disorder, to which her substance abuse contributes. Histrionic traits are the most prominent feature in her interactions. This case underscores the need to recognize that the Munchausen patient may present with psychological symptoms alone. Furthermore, the psychological symptoms may be so complex as to make distinctive diagnoses in other categories, such as personality disorders or Axis I disorders, impossible. Although the diagnostic category,
Factitious Disorder with Psychological Symptoms, has been pointedly questioned by Rogers et al.,9 this case would support the diagnostic category. It is this author's belief that the nonconfrontational approach was necessary in this case, but that case management must be individualized. Some patients, especially those capable of harming themselves physically, may require a confrontational intervention. We must continue to be innovative with the goal of managing factitious disorders in a cost-effective manner that will lead to an improved quality of life for the patient.
References I. Bustamente JP. Ford CV: Ganser's syndrome. Psychiatric Opinion 1977; 14:39-41 2. Toth EL. Baggaley A: Coexistence of Munchausen's syndrome and personality disordcr: detailed repon of a case and theorctical discussion. Psychiatry 1991; 54: 176183 3. Eisendrath SJ: Factitious physical disorders: treatment without confrontation. Psychosomatics 1989; 30:383387 4. Nadelson CT: The Munchausen spectrum-borderline character features. Gen Hosp Psychiatry 1979 I: 11-17 5. Feldman MD. Escalona R: The longing for nunurancea case of factitious cancer. Psychosomatics 1991;
32:226-228 6. Ford CV: The Munchausen syndrome: a repon of four new cases and a review of psychodynamic considerations. Psychiatry in Medicine 1973; 4:31-45 7. Geracioti TO. Van Dyke C. Mueller J. et al. The onset of Munchausen's syndrome. Gen Hosp Psychiatry 1987; 9:405-409 8. Nadelson T: False patients/real patients: a spectrum of disease presentation. Psychother Psychosom 1985; 44:175-184 9. Rogers R. Bagby RM. Rector N: Diagnostic legitimacy of factitious disorder with psychological symptoms. Am J Psychiatry 1989; 146:1312-1314
Late-Onset Depression With White Matter Lesions IRA M. LESSER, M.D., ELIZABETH HILL-GUTIERREZ, M.N., R.N., BRUCE
L.
MILLER, M.D., KYLE
Received July 19. 1991; revised October I. 1991; accepted December 12. 1991. From the Depanments of Psychiatry and Neurology. Harbor-UCLA Medical Center. Torrance. CA. Address reprint requests to Dr. Lesser. Depanment of Psychiatry, Box 498. Harbor-UCLA Medical Center. 1000 W. Carson Street. Torrance. CA 90509. Copyright © 1993 The Academy of Psychosomatic Medicine.
364
B.
C.S.
BOONE, PH.D.
R
ecent investigations have postulated a relationship between the lesions in brain white matter (WM) and depressive illness, particularly depression presenting for the first time in late life. 1- s These studies have consistently identified a subgroup of depressed patients who have a large area of WM lesions compared with agematched, elderly individuals in control groups. PSYCHOSOMATICS
A Case Report of Munchausen Syndrome With Mixed Psychological Features PAMELA
E.
PARKER,
M
unchausen syndrome has been reported and studied extensively during the past 40 years. However, its diagnosis and management continue to be a challenge to psychiatrists as well as to other physicians. The following case report is significant because of its unique features of manipulation by the patient and final outcome. which were I) self-submitted commitment papers, 2) a complex array of psychological symptoms. and 3) successful case management.
Case Report Rose. a 51-year-old white woman. was admitted to the inpatient psychiatric service during the night. The medical student presented the patient as "one of the most tragic he had ever seen": One month prior to admission, the patient reponed that she had been robbed. beaten. and raped by an unknown assailant in her home. She had reponed the incident. but no charges were filed. Subsequently. she became overwhelmed with anxiety, fear, and sleeplessness. She was seen in an emergency room, diagnosed as having adjustment disorder with a depressed and anxious mood. but the emergency room psychiatrist had difficulty arranging for her follow-up because she lacked medical insurance. When attempts to refer her failed, he arranged time in his overloaded schedule to see her personally. For I month, he saw her twice weekly in Received October 4. 1991; revised December 12. 1991; accepted March 5. 1992. From the Depanment of Psychiatry. University of Alabama School of Medicine. Tuscaloosa Program. The University of Alabama. Address reprint requests to Dr. Parker. Dep!. of Psychiatry. Box l!70326. University of Alabama. Tuscaloosa. AL 35487-0326. Copyrighl © 1993 The Academy of Psychosomatic Medicine.
360
M.D.
allempts to provide supponive psychotherapy and pharmacotherapy for her depression. yet she became increasingly suicidal. A friend of the patient, Ms. Levy. urgently called one day from her car telephone to say that Rose had been walking along the freeway, confused and depressed. The evening before, she had been found bathing in a city park fountain. She had begun making references to a gun that she had hidden with plans to kill herself. and Ms. Levy agreed to file commitment papers and to assist in gelling the patient into the hospital. On admission. the patient was delirious, confused, minimally responsive to questions. and tossing in bed. She was poorly groomed. and there were diny shons and a shin lying on the chair at her bedside. She was slightly obese and had traces of wellworn makeup on her face. Her appearance was striking because of a total body tan that the patient said she got from "being in Barbados:' She also had anificially dyed platinum blonde hair that was striking against her dark tan. Her toenails were painted bright chanreuse green. She explained that an abdominal scar was from surgery for removal of"a tumor:' It was difficult to obtain her past medical history, current history. or any coherent details. She stated repeatedly during the interview phrases such as "those awful men.""1 feel so diny," "my bottom huns," "I don't know," and "\ don't remember." Occasionally, however, she answered more appropriately. She revealed that she had no brothers and sisters and that her parents had been killed in an automobile accident the prior year. She described her parents as overly protective, not allowing her to date or see friends. Her only living relative was her mother's elderly sister who lived in "Fleckenhaus," Germany, "a few meters from Munich." Her German accent waxed and waned during the interview. When asked to name some simple objects. she identified a pen as "mascara," a bottle of nail polish as "perfume," a watch as a "bracelet," and a tube of lipstick as a "pen." PSYCHOSOMATICS
Case Reports
During her first day in the hospital, housekeeping personnel reported that Rose had been twisting a sheet around her neck and had the pillowcase over her head. She continued to mumble about "those awful men" and "wanting to die." There was concern as to her motives regarding suicide, and she was transferred to a unit with higher security that lacked many of the amenities of her former ward. Following transfer to the closed psychiatric unit, the patient continued to be delirious and remained in bed. Her roommate was diagnosed with bipolar affective disorder and was delusional, paranoid, and hallucinatory. Because our patient's depiction of delirious behavior was extremely convincing, she was allowed to sleep during rounds while the patient in the adjacent bed was interviewed. The following day, Rose was noted to have new hallucinatory symptoms, remarkably similar to those her roommate exhibited the day before. Aggressive efforts to locate anyone with information about Rose were begun. Attempts to contact Ms. Levy, Rose's close friend who had signed the commitment papers (in accordance with state law), were markedly unsuccessful, even when we obtained information from the probate court regarding the petition's filing. We received a copy of the petition that was so sparse in data as to be marginal for commitment purposes. We learned that the commitment forms filed at probate court had been picked up by a taxicab driver and had been returned, signed, by a different taxicab driver. Ultimately, it was determined that Rose had filed her own commitment papers. Rose ate sparsely from her food trays though the nurses made attempts to get between-meal snacks that might appeal to her. It was quietly suggested to the housestaff on rounds at the patient's bedside that a nasogastric tube might be necessary; within 24 hours Rose's food intake significantly improved. She had no clear evidence of a factitious disorder, but the nursing staff fully understood the possibility and offered nurturance cautiously. Close observation was considered the primary diagnostic tool. Gradually, the patient began to provide more information about herself and to appear less delirious. She revealed that she was enrolled in the premed curriculum at a prestigious local college. She implied that her recent trauma from a rape and burglary had completely disrupted her ability to work. She provided the name of the college and her faculty adviser's name and phone number. Concerned that Rose was suicidally depressed, we contacted her
VOLUME 34· NUMBER 4· JULY - AUGUST 1993
adviser. Although the adviser was at the telephone number provided, her location was not at the esteemed college that the patient had mentioned. Rather, the adviser was at a small, little-known trade school where Rose was actually enrolled in a medical technician's program. While Rose had performed well there in the past, she had recently been in a highly emotional state, telling the teacher about her personal difficulties. This presentation had been in striking contrast to the patient's behavior during the previous 8 months, during which time the patient always appeared for class neatly dressed, carefully groomed, and behaved appropriately, according to the adviser. The only unusual feature, previously noted by classmates, was a designer tag hanging from a dress that Rose claimed to have made herself. The trade school's application records were used in efforts to find the patient's next of kin. None were listed. Of the five people listed as references, three turned out to be totally fictitious individuals or at least were not located at the address or telephone numbers that Rose had given. Two were found to be "real" people who had earlier known the patient 15 to 20 years ago. They knew nothing of her current life circumstances and had never known any of her relatives. One man recalled that Rose occasionally brought her small son to his house. Rose had managed to obtain a complete government scholarship for her studies without the required financial report for verification. Evidence surfaced that she had grown up in a neighboring town, not Germany. A review of police records by the officer who visited Rose's home strongly suggested that there had been no crime as she had reported I month prior to hospitalization. However, Rose had been hospitalized at our institution at about the same time for pseudoseizures. Medical records were unavailable because the patient had changed one letter of her name and altered her birth date by 10 years. Initially, Rose had no visitors or phone calls. At no time did we find any evidence that the patient's friend, Ms. Levy, existed. The patient had a black male visitor named Joe on two occasions. The first visit occurred during the evening hours of a weekend, when the nurses on duty knew little of her history and did not realize the staffs need to contact any of Rose's visitors. The second visit occurred during a busy afternoon. By the time the nursing staff had notified our team of the visitor's presence, he had left the unit. The patient identified this visitor as a part of a husband-wife team who "kept up" her parents' place. He brought the patient some items of clothing, including a white, frilly negligee that was
361
Case Reports
somewhat dingy and ragged in spots. We subsequently learned that the patient indeed had been married and had a son who lived with his father. Rose had a lengthy criminal record for writing bad checks and petty theft. and she had served a prison sentence. An informant from the jail where Rose had served time commented on the relative frequency of her "visits" for reasons that were often alcohol-related. An informant from Joe's community said that Rose always got "sick" when she and Joe were having a fight. and Rose had been known in the neighborhood as an uncontrollable liar and a prostitute. Hometown records revealed that Rose had three older brothers and an alcoholic father. There was strong evidence that Rose had endured sexual abuse by her father and her three older brothers. At least one brother was also a habitual liar. and another had been hospitalized in the state mental facility. Her parents had died 10 years apart of natural causes. Her illness was managed as a conversion symptom. She was told that although she had been through a very difficult experience. there was every reason to believe that she would get beller and that her symptoms would resolve. Psychotropic medications were avoided and one-to-one supervision was discontinued as soon as Rose's delirious and suicidal symptoms abated. She became beller oriented and her responses became more appropriate, but she continued to say that she had been through a severe trauma that was too painful to discuss. Although she wanted to return to the more open unit, it was discouraged. Her first EEG was un interpretable secondary to excessive motor activity (apparently a pseudoseizure). Her second was completely normal as was a CT scan of her head. Minnesota Multiphasic Personality Inventory and Millon testing batteries revealed depression. hysteria. and antisocial features. Two attempts at an interview with amobarbital (Amytal) were unsuccessful because the patient continued to give false information up to the point of total sedation. Halsted-Reitan batteries revealed only malingering. Records of Rose' s enrollment in a substance abuse treatment center affiliated with the local courts were located. They suggested previous barbiturate abuse. A pelvic examination showed that she had no uterus. though she claimed to be taking birth control pills. After a 2-week hospitalization. Rose denied suicidal thoughts and was discharged. She kept her first follow-up appointment at which time she complained billerly about insomnia and was clearly 362
seeking drugs. She did not appear for her second follow-up. but several weeks later the secretarial staff received a call from Rose' s housekeeper (probably Rose herself) stating how terribly Rose was doing. The patient follow-up was lost for an 8-month period until Rose called one day asking for an appointment. After that time, she was seen weekly without fail. Approximately the first two sessions were spent in setting limits. especially regarding being on time for the appointment. Within four sessions, it became apparent that a 30-minute session was optimal for her abilities to interact with the therapist. It was brought to her attention that she had a large. outstanding bill from her previous hospitalization and that in order for her to continue in outpatient therapy, she would need to regularly provide a small amount (unstated) of compensation for services. Afterward. she began to bring a small amount of cash to pay for each appointment. During her earliest sessions. her behavior was highly attention-seeking. It included wearing unusual apparel. striking colors. childish hairpieces. and heavy makeup. She made allusions to life-threatening behaviors and continued to give out information that had already been confirmed as false. She frequently became extremely bizarre in her behavior just as the session was ending, and on one occasion pulled a pair of bloody underwear from a paper bag. When these presumed efforts at extending the session were ignored, they ceased. Gradually, the sessions contained less sensational behavior, and there was a modest increase in Rose's expression of her feelings.
Discussion
This patient meets the criteria for Munchausen syndrome. She has repeatedly used feigned medical illness to gain entry into the medical system. Her name and age have varied, and pseudologia fantastica is evident. During this admission, her symptoms were psychological, and one of the more unique aspects of this case was that she filed her own commitment papers under a false name. This patient also meets the diagnostic criteria for Ganser syndrome. The classical finding of approximate answers led to the diagnostic consideration of Ganser syndrome, and she fit Ganser's own description of the syndrome in PSYCHOSOMATICS
Case Reports
light of her previous incarceration. The similarity of dynamics in Ganser syndrome and Munchausen syndrome has been discussed in a case reviewed by Bustamente and Ford.' The diagnosis of posttraumatic stress disorder was considered when Rose's purported story of the rape event unfolded. This diagnosis was never discarded, as the author suspected the presence of an unreported, but equally threatening, psychological trauma. The fact that she was accepting of the highly structured and intrusive observation of the closed unit suggested that she was in severe need of treatment. The possibility of multiple personality disorder is arguable. Similar to the patient in a recently reported case of multiple personality and Munchausen syndrome,2 Rose probably came from a background ofsexual abuse. Although the patient has never clearly identified different personalities, she claimed to have no memory for some events and has been described in a variety of social circumstances that are in striking contrast to her presentation in the medical setting. The presence of true dissociation can be neither supported nor refuted. The role of malingering is equally questionable. While admission to mental institutions is often found in malingering patients who want to escape prison sentences, this effort toward commitment had no identifiable secondary gain. A review of state police records revealed that Rose had no criminal charges from which she might be seeking to escape. A nonconfrontational approach, as previously suggested by Eisendrath,J is the cornerstone of what may be considered success in managing this episode of Munchausen syndrome. This approach is in contrast to a convincing argument for confrontation by Nadelson. 4 Psychiatric care was provided with the implication that the actual details of her intrapsychic trauma had become irrelevant. Like the patient described by Feldman,s nurturance appeared to be an unconsciously motivated goal. She clearly experienced isolation, loneliness, fearfulness, and anxiety, and case management was planned accordingly. Ford 6 noted an association between separation and Munchausen syndrome, a findVOLUME 34· NUMBER 4· JULY -AUGUST 1993
ing also noted by Geracioti et al. 7 The possibility that Rose had a long-standing relationship with Joe that became "rocky" at the time of her reported rape could have easily precipitated Rose's hospitalization. Previously suggested treatment approaches for multiple personality disorderH may have relevance for this patient. The challenge is to integrate the various aspects of the patient's psychological life (especially reality and fantasy). This was attempted in a manner that supported the patient's strengths and avoided the rewards for her acting-out behavior. At present, the patient is not incarcerated, hospitalized, or engaged (with one exception, a minor infraction) in illegal activities. She has been seen weekly in psychotherapy for approximately 8 months and has been on time for every single appointment. It is the belief of this author that the patient revealed her intrapsychic conflicts in a manner that felt safest to her-by changing the facts. She has "learned such behavior in a culture receptive to this particular form of behavior as an effective option when all else fails.'''! Nevertheless, dynamics and feelings are interpretable and amenable to psychotherapy. Her descriptions of herself, including pseudologia fantastica, represented her fantasies and the antithesis of her actual childhood experiences. These fantasies have been most helpful in the psychotherapeutic approach. Exposing her factual inconsistencies would serve only to alienate the patient and perpetuate and strengthen her need for nurturance and nurturing behavior. Her pathological lying was not always used for deceptive purposes only but, rather, appeared to be a form to dramatically seek attention. Amidst total fabrication, she periodically provided elements of factual information that served to keep the attention of the treatment team. Her ability to mix fact with fiction in a truly dramatic style may actually have been (and still be) a very clever, conscious or unconscious, hysterical style of obtaining nurturance. The borderline personality structure is common in patients with both Munchausen syndrome and multiple personality disorder, but Rose demonstrated few traits of splitting and manipulation. 363
Case Reports
She did have unstable relationships, impulsivity, recurrent suicidal behavior, identity disturbance, chronic emptiness, and fears of abandonment. She also meets the criteria for antisocial personality disorder, to which her substance abuse contributes. Histrionic traits are the most prominent feature in her interactions. This case underscores the need to recognize that the Munchausen patient may present with psychological symptoms alone. Furthermore, the psychological symptoms may be so complex as to make distinctive diagnoses in other categories, such as personality disorders or Axis I disorders, impossible. Although the diagnostic category,
Factitious Disorder with Psychological Symptoms, has been pointedly questioned by Rogers et al.,9 this case would support the diagnostic category. It is this author's belief that the nonconfrontational approach was necessary in this case, but that case management must be individualized. Some patients, especially those capable of harming themselves physically, may require a confrontational intervention. We must continue to be innovative with the goal of managing factitious disorders in a cost-effective manner that will lead to an improved quality of life for the patient.
References I. Bustamente JP. Ford CV: Ganser's syndrome. Psychiatric Opinion 1977; 14:39-41 2. Toth EL. Baggaley A: Coexistence of Munchausen's syndrome and personality disordcr: detailed repon of a case and theorctical discussion. Psychiatry 1991; 54: 176183 3. Eisendrath SJ: Factitious physical disorders: treatment without confrontation. Psychosomatics 1989; 30:383387 4. Nadelson CT: The Munchausen spectrum-borderline character features. Gen Hosp Psychiatry 1979 I: 11-17 5. Feldman MD. Escalona R: The longing for nunurancea case of factitious cancer. Psychosomatics 1991;
32:226-228 6. Ford CV: The Munchausen syndrome: a repon of four new cases and a review of psychodynamic considerations. Psychiatry in Medicine 1973; 4:31-45 7. Geracioti TO. Van Dyke C. Mueller J. et al. The onset of Munchausen's syndrome. Gen Hosp Psychiatry 1987; 9:405-409 8. Nadelson T: False patients/real patients: a spectrum of disease presentation. Psychother Psychosom 1985; 44:175-184 9. Rogers R. Bagby RM. Rector N: Diagnostic legitimacy of factitious disorder with psychological symptoms. Am J Psychiatry 1989; 146:1312-1314
Late-Onset Depression With White Matter Lesions IRA M. LESSER, M.D., ELIZABETH HILL-GUTIERREZ, M.N., R.N., BRUCE
L.
MILLER, M.D., KYLE
Received July 19. 1991; revised October I. 1991; accepted December 12. 1991. From the Depanments of Psychiatry and Neurology. Harbor-UCLA Medical Center. Torrance. CA. Address reprint requests to Dr. Lesser. Depanment of Psychiatry, Box 498. Harbor-UCLA Medical Center. 1000 W. Carson Street. Torrance. CA 90509. Copyright © 1993 The Academy of Psychosomatic Medicine.
364
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C.S.
BOONE, PH.D.
R
ecent investigations have postulated a relationship between the lesions in brain white matter (WM) and depressive illness, particularly depression presenting for the first time in late life. 1- s These studies have consistently identified a subgroup of depressed patients who have a large area of WM lesions compared with agematched, elderly individuals in control groups. PSYCHOSOMATICS