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Factitious disorder and coexisting depression: A report of successful psychiatric consultation and case management
Factitious Disorder and Coexisting Depression: A Report of Successful Psychiatric Consultation and Case Management Julius R. Earle, Jr., M.D. Child Psychiafvy Fellow, Depurfment of Psyckinfvy, University of New Mexico New Mexico
Sckoat of Medicine,
Albuquerque,
David G. Folks, M.D. Assistant Professor of PsychiOy, Birmingham, Alabama
Departmerlt
of Psychiatry,
Abstract: The aufkors
presezzt a case illustratirzg factitious illness with a coexistizzg depressive disorder. Tke factitial presentation involved self-mutilatzorz that served to procure and prolong ptient stafus, while obscarirzg the recognztiotr of a major depressive episode. T!ze rmportazzce of accurate assessmerzt and prompt recognition of factitiozzs illness is discussed, zuitlz emphasis upon the ide?zfification of contributirzg psyckodynamics, underlying psychopathology and ongoirzg psyckosocial stressors. Psychiatric consultation efforts were successful, but in the context ofconsiderubie morkidity. Psyckotkernpeutic gains occzured only after uigorous antidepressant drug tlzerapy and substantial psychotherapeutic efforts that empathically addressed the patient’s rnasoclzism and dependency.
Introduction Clinical presentations of cases involving artificially produced signs and symptoms often go unrecognized; if the factitious illness is identified, the physician’s negative emotional response can contribute to a therapeutic failure 11). The clinician who attempts to manage a factitious case must carefully evaluate developmental and personal history, together with current life stresses, and appreciate the possible enactment of past or present psychologic disturbances in the context of a medical setting [2]. We report a case that illustrates a factitious presentation and emphasizes two of the principal responsibilities of the physician-to identify any coexis448
ISSN 0163~8343/86/$3.50
University
of Alabama
School
of Medicine,
tent disorders, and, if possible, accept further treatment,
help the patient
Case Data Ms. B., a 27-year-old divorced white female with a T-9 paraplegia, was referred by the rehabilitation medicine service for psychiatric consultation regarding a factitial right inguinal decubitus ulcer, Conservative treatment had always resulted in initial improvement, but each time discharge planning was implemented her wound had resulted in deterioration, characterized by a traumatic-appearing, hemorrhagic midline band, Following a second episode of wound detethe patient was confronted with the rioration, implication of personal responsibility. Although the patient denied any responsibility for her wound, psychiatric consultation was requested. Past medical history was remarkable for a self-inflicted gunshot wound which had resulted in the paraplegia, transected the abdominal aorta requiring graft replacement, and an injured left lobe of the liver requiring surgical resection. After being lost to followup for 16 months, she initiated outpatient contact with our rehabilitation medicine facility (8 months prior to rehospitalization). The outpatient physician observed recurring bruises on her thighs and apparent cigarette burns on her legs. A family member reported witnessing Ms. B. “pounding her thighs” and corroborated that the burns were indeed self-inflicted. The patient offered vague and inconsistent reasons for these General Hosphd Psychiatry, 8, 448-450, 1986 0 1986 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Avenue, New York, NY 10017
Factitious
wounds. Also of interest, her outpatient record revealed that thioridazine 150 mg daily had been prescribed because she was “having difficulty distinguishing reality.” Psychosocial history included divorce after a 7-year marriage to an abusive alcoholic. Furthermore, marital discord had led to the traumatic episode where she impulsively shot and disabled herself. Prior to her irrevocable injury the patient had become increasingly unhappy with the marriage, exhibiting depressive demeanor and continuous comments referring to disappointments with her “failure” to attain the high social and monetary gains she had set for herself. In addition to her marital strife, we learned that the unexpected death of a close relative had precipitated another previous depressive episode requiring treatment by her primary physician. Occupational history showed frequent job changes due to “dissatisfaction.” She was the oldest of three children, the only girl. Her father, an alcoholic, had died in a motor vehicle accident when she was 11. Her oldest brother abused drugs “adjustment problems” and “deand experienced pression” requiring treatment as a young adult. The patient’s mother labeled her children as “great manipulators,” while admitting to her own feelings of chronic depression and frequent bouts of suicidal ideation. The psychiatric consultant learned that the hospital staff had observed the patient’s progressive withdrawal into fantasy with accompanying suspicious demeanor and flat affect, but without signs of a thought disorder or psychosis. An admitting diagnosis of “borderline, schizoidal” personality had been assigned. In the initial interview, the patient denied depressive feelings or suicidal ideation. She emphatically denied personal involvement with her nonhealing wound. Interestingly, she was agreeable to continuing psychiatric involvement in her care. Hospital course included another episode of wound deterioration just prior to a planned discharge, but the patient was discharged as recommended by the psychiatric consultant. Outpatient follow-up was arranged at the rehabilitation hospital and individual psychotherapy was begun twice weekly. Also, treatment with thioridazine was continued. Only 2 months after discharge the patient was readmitted to another hospital. The inguinal wound was remarkably worse with considerable necrotic tissue and exposure of the femur. The patient was transferred to our facility, where she was observed “picking at her wound“ and was noted to be refusing hydrotherapy. The patient became septic, experiencing a prolonged course in the intensive care unit. During her stay in the intensive care unit, the patient encouraged procedures and expressed an interest in knowing if her death would be “soon.” Ultimately she did require disarticulation of the right hip and further wound debridement.
Disorder and Coexisting
Depression
The case was presented to a visiting professor of psychiatry who suggested vigorous treatment of the “coexisting depressive feature,” e.g., a positive family history, prior depressive episodes, including suicidal behavior, and continued symptoms of social withdrawal, self-mutilation, and hopelessness. The consultation team carried out a more extensive diagnostic review of the case and was surprised that DSM-III criteria for both major depression and melancholia were present. Furthermore, a review of the circumstances surrounding the death of the father suggested that he too had suffered from an affective disorder and may have committed suicide. Consultation efforts were then focused on daily cognitive/supportive psychotherapy, which resulted in improvement of her mood and affect; maprotiline 50 mg twice daily was also begun and thioridazine stopped. The staff noted progressive diminution in her depressive symptoms and simultaneous improvement in compliance. Four weeks later she appeared “bright,” more alert, and significantly less depressed. Throughout the remainder of her hospital course psychotherapy was continued twice weekly; efforts were also focused on mobilizing her psychosocial support system, redefining her factitious illness (as depression) and encouraging more personal involvement in her hospital care. The patient showed steady improvement in wound healing. A muscle flap graft showed 90% success with the remainder of the wound undergoing granulation healing. Five months postadmission the patient was discharged to a nursing home. After 1 year of follow-up including weekly psychiatric sessions and maintenance with antidepressant drug treatment, the patient’s wound remains healed. The patient was chosen to edit a biweekly nursing home newsletter. She has also expressed future plans to attend college and secure a semi-independent apartment designed for the physically handicapped.
Discussion This case meets DSM-III diagnostic criteria for chronic factitious illness with physical symptoms; the symptoms were voluntarily produced for no apparent goal other than to assume the patient role and resulted in multiple and prolonged hospitalizations. The patient’s presenting symptoms were initially viewed as a manifestation of her borderline personality, a personality type often diagnosed in factitiously disordered cases [1,2]. However, Ms. B’s complex physical and psychiatric symptoms, especially her personality problems, resulted in an initial clinical assessment that fell short of diagnosing a coexistent “somatizing” depression. The patient’s favorable outcome, despite significant mor-
449
J. R. Earle and D. G. Folks
bidity resulting from her factitious behavior, illustrates that a better prognosis may be expected for patients with depressive symptoms than for those merely possessing a personality disorder ]3,41. The nonpunitive confrontation by the primary physician with subsequent involvement of the psychiatric consultant proved to be a valuable strategy; the patient’s acknowledgment of factitia1 behavior was initially denied, but perhaps implied by her willingness to accept further psychiatric treatment. Hollender and Hersh [5] have fully discussed the implications for the physician who requests psychiatric consultation for factitious illness, i.e., to confront the patient prior to the consultant’s first patient contact. The psychiatric consultant is especially skillful in considering carefulIy possible psychodynamics with respect to developmental disturbances, or in identifying existing psychopathology in the context of the current psychosocial stressors [6]. The psychotherapeutic gains in this case illustrate that attention to the historical, psychosocial, and behavioral components of the illness are imperative in achieving a successful treatment outcome [7]. In summary, Ms. B was actively prolonging her hospitalization through the use of illness behavior. Clinical improvement was possible only after recognition of the factitious disorder and supportive confrontation by the treating physician(s). Establishment of a therapeutic alliance with the psychiatric consultant, as well as further diagnostic assessment and initiation of treatment for a depressive illness,
450
were the keys to successful treatment. Furthermore, those psychosocial issues that might have perpetuated the factitious illness were addressed, a major factor in the successful outcome that we experienced. The authors would like to express their appreciation to the patient and to her primary care physicians, Shirlq McCluer, M.D., and ]. Scott Richards, Ph.D., for allowing this communicafion.
References 1. Lipsitt DR: The enigma of factitious illness. In Medical
2. 3. 4. 5. 6. 7.
and Health Annual. Chicago: Encyclopedia Brittanica, 1982, pp 114-127 Carney MWP, Brown JP: Clinical features and motives among 42 artifactual illness patients. Br J Med Psycho1 56:57-66, 1983 Folks DG, Freeman AM: Munchausen syndrome and other factitious illness. Psychiatr Clin North Am 8:263-278, 1985 Ford CF: The Somatizing Disorders: Illness as a Way of Life. New York: Elsevier, 1983, pp 149-152 Hollender MH, Hersh SP: Impossible consultation made possible. Arch Gen Psychiatry 23:343-345, 1970 Stern TA: Munchausen’s syndrome revisited. Psychosomatics 21:329-336, 1980 Lipsitt DR: Factitious vesicocutaneous fistula: An enigma in diagnosis and treatment (Discussion). Plast Reconstruct Surg 72:88-89, 1983
Direct
reprint requests to: David G. Folks, M.D. Assistant Professor of Psychiatry Department of Psychiatry University of Alabama School of Medicine Birmingham, AL 35294
Sckoat of Medicine,
Albuquerque,
David G. Folks, M.D. Assistant Professor of PsychiOy, Birmingham, Alabama
Departmerlt
of Psychiatry,
Abstract: The aufkors
presezzt a case illustratirzg factitious illness with a coexistizzg depressive disorder. Tke factitial presentation involved self-mutilatzorz that served to procure and prolong ptient stafus, while obscarirzg the recognztiotr of a major depressive episode. T!ze rmportazzce of accurate assessmerzt and prompt recognition of factitiozzs illness is discussed, zuitlz emphasis upon the ide?zfification of contributirzg psyckodynamics, underlying psychopathology and ongoirzg psyckosocial stressors. Psychiatric consultation efforts were successful, but in the context ofconsiderubie morkidity. Psyckotkernpeutic gains occzured only after uigorous antidepressant drug tlzerapy and substantial psychotherapeutic efforts that empathically addressed the patient’s rnasoclzism and dependency.
Introduction Clinical presentations of cases involving artificially produced signs and symptoms often go unrecognized; if the factitious illness is identified, the physician’s negative emotional response can contribute to a therapeutic failure 11). The clinician who attempts to manage a factitious case must carefully evaluate developmental and personal history, together with current life stresses, and appreciate the possible enactment of past or present psychologic disturbances in the context of a medical setting [2]. We report a case that illustrates a factitious presentation and emphasizes two of the principal responsibilities of the physician-to identify any coexis448
ISSN 0163~8343/86/$3.50
University
of Alabama
School
of Medicine,
tent disorders, and, if possible, accept further treatment,
help the patient
Case Data Ms. B., a 27-year-old divorced white female with a T-9 paraplegia, was referred by the rehabilitation medicine service for psychiatric consultation regarding a factitial right inguinal decubitus ulcer, Conservative treatment had always resulted in initial improvement, but each time discharge planning was implemented her wound had resulted in deterioration, characterized by a traumatic-appearing, hemorrhagic midline band, Following a second episode of wound detethe patient was confronted with the rioration, implication of personal responsibility. Although the patient denied any responsibility for her wound, psychiatric consultation was requested. Past medical history was remarkable for a self-inflicted gunshot wound which had resulted in the paraplegia, transected the abdominal aorta requiring graft replacement, and an injured left lobe of the liver requiring surgical resection. After being lost to followup for 16 months, she initiated outpatient contact with our rehabilitation medicine facility (8 months prior to rehospitalization). The outpatient physician observed recurring bruises on her thighs and apparent cigarette burns on her legs. A family member reported witnessing Ms. B. “pounding her thighs” and corroborated that the burns were indeed self-inflicted. The patient offered vague and inconsistent reasons for these General Hosphd Psychiatry, 8, 448-450, 1986 0 1986 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Avenue, New York, NY 10017
Factitious
wounds. Also of interest, her outpatient record revealed that thioridazine 150 mg daily had been prescribed because she was “having difficulty distinguishing reality.” Psychosocial history included divorce after a 7-year marriage to an abusive alcoholic. Furthermore, marital discord had led to the traumatic episode where she impulsively shot and disabled herself. Prior to her irrevocable injury the patient had become increasingly unhappy with the marriage, exhibiting depressive demeanor and continuous comments referring to disappointments with her “failure” to attain the high social and monetary gains she had set for herself. In addition to her marital strife, we learned that the unexpected death of a close relative had precipitated another previous depressive episode requiring treatment by her primary physician. Occupational history showed frequent job changes due to “dissatisfaction.” She was the oldest of three children, the only girl. Her father, an alcoholic, had died in a motor vehicle accident when she was 11. Her oldest brother abused drugs “adjustment problems” and “deand experienced pression” requiring treatment as a young adult. The patient’s mother labeled her children as “great manipulators,” while admitting to her own feelings of chronic depression and frequent bouts of suicidal ideation. The psychiatric consultant learned that the hospital staff had observed the patient’s progressive withdrawal into fantasy with accompanying suspicious demeanor and flat affect, but without signs of a thought disorder or psychosis. An admitting diagnosis of “borderline, schizoidal” personality had been assigned. In the initial interview, the patient denied depressive feelings or suicidal ideation. She emphatically denied personal involvement with her nonhealing wound. Interestingly, she was agreeable to continuing psychiatric involvement in her care. Hospital course included another episode of wound deterioration just prior to a planned discharge, but the patient was discharged as recommended by the psychiatric consultant. Outpatient follow-up was arranged at the rehabilitation hospital and individual psychotherapy was begun twice weekly. Also, treatment with thioridazine was continued. Only 2 months after discharge the patient was readmitted to another hospital. The inguinal wound was remarkably worse with considerable necrotic tissue and exposure of the femur. The patient was transferred to our facility, where she was observed “picking at her wound“ and was noted to be refusing hydrotherapy. The patient became septic, experiencing a prolonged course in the intensive care unit. During her stay in the intensive care unit, the patient encouraged procedures and expressed an interest in knowing if her death would be “soon.” Ultimately she did require disarticulation of the right hip and further wound debridement.
Disorder and Coexisting
Depression
The case was presented to a visiting professor of psychiatry who suggested vigorous treatment of the “coexisting depressive feature,” e.g., a positive family history, prior depressive episodes, including suicidal behavior, and continued symptoms of social withdrawal, self-mutilation, and hopelessness. The consultation team carried out a more extensive diagnostic review of the case and was surprised that DSM-III criteria for both major depression and melancholia were present. Furthermore, a review of the circumstances surrounding the death of the father suggested that he too had suffered from an affective disorder and may have committed suicide. Consultation efforts were then focused on daily cognitive/supportive psychotherapy, which resulted in improvement of her mood and affect; maprotiline 50 mg twice daily was also begun and thioridazine stopped. The staff noted progressive diminution in her depressive symptoms and simultaneous improvement in compliance. Four weeks later she appeared “bright,” more alert, and significantly less depressed. Throughout the remainder of her hospital course psychotherapy was continued twice weekly; efforts were also focused on mobilizing her psychosocial support system, redefining her factitious illness (as depression) and encouraging more personal involvement in her hospital care. The patient showed steady improvement in wound healing. A muscle flap graft showed 90% success with the remainder of the wound undergoing granulation healing. Five months postadmission the patient was discharged to a nursing home. After 1 year of follow-up including weekly psychiatric sessions and maintenance with antidepressant drug treatment, the patient’s wound remains healed. The patient was chosen to edit a biweekly nursing home newsletter. She has also expressed future plans to attend college and secure a semi-independent apartment designed for the physically handicapped.
Discussion This case meets DSM-III diagnostic criteria for chronic factitious illness with physical symptoms; the symptoms were voluntarily produced for no apparent goal other than to assume the patient role and resulted in multiple and prolonged hospitalizations. The patient’s presenting symptoms were initially viewed as a manifestation of her borderline personality, a personality type often diagnosed in factitiously disordered cases [1,2]. However, Ms. B’s complex physical and psychiatric symptoms, especially her personality problems, resulted in an initial clinical assessment that fell short of diagnosing a coexistent “somatizing” depression. The patient’s favorable outcome, despite significant mor-
449
J. R. Earle and D. G. Folks
bidity resulting from her factitious behavior, illustrates that a better prognosis may be expected for patients with depressive symptoms than for those merely possessing a personality disorder ]3,41. The nonpunitive confrontation by the primary physician with subsequent involvement of the psychiatric consultant proved to be a valuable strategy; the patient’s acknowledgment of factitia1 behavior was initially denied, but perhaps implied by her willingness to accept further psychiatric treatment. Hollender and Hersh [5] have fully discussed the implications for the physician who requests psychiatric consultation for factitious illness, i.e., to confront the patient prior to the consultant’s first patient contact. The psychiatric consultant is especially skillful in considering carefulIy possible psychodynamics with respect to developmental disturbances, or in identifying existing psychopathology in the context of the current psychosocial stressors [6]. The psychotherapeutic gains in this case illustrate that attention to the historical, psychosocial, and behavioral components of the illness are imperative in achieving a successful treatment outcome [7]. In summary, Ms. B was actively prolonging her hospitalization through the use of illness behavior. Clinical improvement was possible only after recognition of the factitious disorder and supportive confrontation by the treating physician(s). Establishment of a therapeutic alliance with the psychiatric consultant, as well as further diagnostic assessment and initiation of treatment for a depressive illness,
450
were the keys to successful treatment. Furthermore, those psychosocial issues that might have perpetuated the factitious illness were addressed, a major factor in the successful outcome that we experienced. The authors would like to express their appreciation to the patient and to her primary care physicians, Shirlq McCluer, M.D., and ]. Scott Richards, Ph.D., for allowing this communicafion.
References 1. Lipsitt DR: The enigma of factitious illness. In Medical
2. 3. 4. 5. 6. 7.
and Health Annual. Chicago: Encyclopedia Brittanica, 1982, pp 114-127 Carney MWP, Brown JP: Clinical features and motives among 42 artifactual illness patients. Br J Med Psycho1 56:57-66, 1983 Folks DG, Freeman AM: Munchausen syndrome and other factitious illness. Psychiatr Clin North Am 8:263-278, 1985 Ford CF: The Somatizing Disorders: Illness as a Way of Life. New York: Elsevier, 1983, pp 149-152 Hollender MH, Hersh SP: Impossible consultation made possible. Arch Gen Psychiatry 23:343-345, 1970 Stern TA: Munchausen’s syndrome revisited. Psychosomatics 21:329-336, 1980 Lipsitt DR: Factitious vesicocutaneous fistula: An enigma in diagnosis and treatment (Discussion). Plast Reconstruct Surg 72:88-89, 1983
Direct
reprint requests to: David G. Folks, M.D. Assistant Professor of Psychiatry Department of Psychiatry University of Alabama School of Medicine Birmingham, AL 35294