- Email: [email protected]
Dual factitious disorder
Dual Factitious Disorder Edward L. Merrin, M.D.,
Craig Van Dyke, M.D., Seth Cohen, M.D., and
Donald J. Tusel, M.D. Department of Psychiatry,
University
Service, Veterans Administration
of California
Medical Center,
School
Abstract: The DSM-III classification of factitious disorders encourages artificial separation into disorders with physical and those with psychologic symptoms. Despite documented examples of similar patients who present with psychiatric complaints, Munchausen’s syndrome is usually considered a form of chronic factitious physical disorder. Three patients with both factitious physical and psychologic symptoms are presented. These patients illustrate the importance of focusing on the fundamental behavior ofassuming the patient role, rather than on the specific category of symptoms. We recommend that the category of symptoms be used as a modifying statement, rather than defining separate disorders.
Asher [l] originally called attention to a perplexing group of patients who developed a life-style based on deceiving physicians by dramatically simulating illness. Because of their persistent wanderings from hospital to hospital (peregrination) and ability to spin tall tales (pseudologia fantastica), he coined Syndrome,” a reference the term, “Munchausen’s to eighteenth century German literature that portrayed the fictitious exploits of an actual individual. Subsequent reports [2-41 have emphasized additional features of these patients, such as imposture and medical sophistication as well as certain behaviors in the hospital-demandingness, willingness to undergo invasive procedures, absence of visitors, and frequent discharge against medical advice. Although several authors [5-lo] have pointed out the shortcomings of this label and have sugthe term remains in wide gested alternatives, clinical use. Munchausen’s syndrome, like the patients it refers to, has succeeded in capturing the attention of the medical community in a compelling fashion. 246 ISSN 0163~8343/86/$3.50
of Medicine,
Sun Francisco,
Sun Francisco,
Culiforniu und Psyclziutry
California
Along with most standard textbooks of psychiatry, the DSM-III manual [ll] explicitly defines Munchausen’s syndrome as a disorder with chronic factitious physical symptoms. It considers chronic factitious illness with psychologic symptoms as a separate and even more rare condition, citing the Ganser syndrome as the primary example. This nosology is misleading, since patients with Munchausen’s syndrome commonly have factitious psychoIogic as we11 as physical symptoms. In our view, many patients with Munchausen’s syndrome carry about multiple patient identities, switching emphasis from one set of symptoms to another depending on circumstances. In such cases the medical staff may obtain history and signs of a specific psychiatric disorder in a patient manifesting factitious physical symptoms, failing to appreciate the possibility that the psychologic symptoms may be just as factitious as the physical. To illustrate our point, we present three patients with chronic factitious physical symptoms who meet DSM-III criteria for Munchausen’s syndrome. In addition, they manifest chronic factitious psychologic symptoms quite distinct from Ganser’s syndrome. These patients demonstrate the limitations of our current classification of factitious disorders and suggest specific revisions of DSM-III.
Case 1 Ms. A, a 27-year-old white female with a self-reported history of renal calculi was admitted to our Urology Service complaining of right flank pain. Following an unremarkable urologic evaluation the medical staff informed her that there was no longer a basis for continued hospitalization or further narcotic anal-
GeneralHospital Psychiatry 8, 246-250, 1986 0 1986 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Avenue, New York, NY 10017
Dual Factitious Disorder
gesia. She responded to this by threatening to leave and commit suicide. This prompted an emergency psychiatric consultation, during which she refused an offer of psychiatric treatment. She was eventually discharged several days later against medical advice. Ms. A returned 10 days later and was admitted to our psychiatric inpatient unit complaining of suicidal ideation, nightmares, and “flashbacks” of having been raped 2 months previously by her assistant pastor. She believed that the rape had been instigated by her estranged husband, whom she had met while they were both medical students in Central America. She alleged his motive was anger over her threat to have his visa cancelled, after she discovered that he had married her solely to enter this country. She found herself confused, angry, and unable to prepare for upcoming medical school examinations. She also reported anorexia, with 4-pound weight loss, profound sleep difficulty, and nightmares of the rape. She contemplated suicide by driving off an embankment. The patient also cIaimed to be a masters-level psychiatric nurse. She was on a leave of absence from her summer job as the head nurse on a psychiatric unit. During the past 2 years of medical school she had spent weekends doing medical missionary work, returning each summer to live with her parents and work as a nurse. She was troubled by the recent suicide of three of her patients. Ms. A was a neatly groomed young woman with a tattoo of a flower on her left forearm. This allegedly resulted from an episode in Army nursing school when she was put into a drugged state as a prank. There was no evidence of psychosis or of an affective disturbance. Hospital course was marked by complaints of headaches, vomiting with hematemesis (never verified), nightmares, and insomnia. She demanded sedatives and narcotics and at one point arranged an appointment with an outside gynecologist. She repeated the history of sexual assault to this physician, complaining of pain and concerns over possible pregnancy. Ultrasound examination of the abdomen and pelvis and a pregnancy test revealed a normal, nonpregnant uterus. Subsequently, the gynecologist telephoned a IocaI rape crisis center and was informed that the patient had been complaining of recent sexual assault for a number of years. Records obtained from other hospitals revealed several previous hospitalizations for renal colic. Multiple abdominal x-rays, renal ultrasounds, and retrograde and intravenous pyelograms had failed to uncover evidence of renal calculi. During one hospitalization the patient presented the medical staff with a gravel-like substance, stating that she had just passed it in her urine. Laboratory analysis determined this substance to be an artifact. Although the patient denied to us either previous rape or psychiatric treatment, we were able to document four previous psychiatric hospitalizations. Dur-
ing each of these the patient had reported a recent rape and feelings of worthlessness, helplessness, and wanting to kill herself. She was described during those hospitalizations as uncooperative and complaining of multiple physical symptoms. Army documents contained no record of her being a nurse.
Case 2 Mr. B. was a 36year-old white male admitted to our psychiatric unit for evaluation and treatment of “depression.” Complaining of symptoms consistent with a major depressive episode, he recounted a lengthy list of unsuccessful antidepressant medication trials, specifying dosages and durations of treatment. This, he insisted, necessitated the immediate use of electroconvulsive treatment (ECT). He was uncooperative with attempts to obtain a more detailed history and would not allow relatives or acquaintances to be contacted. Rather than appearing depressed, he was irritable and demanding, with a somewhat constricted and aloof affect. The staff was unable to document his complaints of psychomotor retardation, sleep disorder, or diminished appetite. Perceiving that further evaluation rather than ECT was forthcoming, he left the unit without notice and did not return. Shortly afterward he was admitted to a psychiatric clinical research unit at a nearby medical center. When he was informed after evaluation that he was not a candidate for a research project on the treatment of depression, he angrily signed out of the hospital. Review of past medical records revealed hospitalization in a state mental hospital at the age of 23 after an arrest for writing bad checks. Symptoms included paranoid delusions but not depression. He eventually escaped by jumping out of a window. The patient’s claim that he had 11 ECTs during that hospitalization was not substantiated. He was hospitalized briefly on several other occasions over the ensuing 5 years but details were extremely sparse. Over a number of years, repeated attempts at outpatient treatment had resulted in missed appointments and numerous telephone calls, often consisting of angry tirades or suicidal threats. Although in one clinic he was treated with antipsychotic medication for presumed schizophrenia, there was little symptomatology consistent with this diagnosis. At one point, he was discovered to have fraudulently obtained travel compensation from the VA by claiming a nonexistent address in a distant city. This patient was also well known in local hospitals for medical complaints. For nearly 10 years he had been appearing at emergency rooms with complaints of chest pain, offering a history of multiple pulmonary emboli and thrombophlebitis since a traumatic leg injury in 1969. In 1975 he received an inferior vena cava plication and was treated with anticoagulants on a sporadic basis. Indications for this surgery were un247
E. L. Men-in et al
clear from available records. Subsequently, he frequented numerous emergency rooms over a wide
area. During these visits he was demanding of attention and on several occasions attempted to remove or destroy parts of his medical record. Often he disappeared before definitive tests could be completed. Once an emergency room physician advised him that admission was not indicated since he was not coughing blood. Within several days he returned and saw a different physician, adding this symptom to his complaints. On the one occasion when he was admitted to our hospital an extensive evaluation for pulmonary emboli was negative.
Case 3 Mr. C., a white male, described himself as a 30-yearold psychologist. He presented himself to our emergency room with complaints of headaches and “flashbacks” of an incident in Vietnam when he shot a group of children. The flashbacks had bothered him intermittenly for 8 years and consisted of hallucinations of automatic weapons fire and the smell of burning flesh. The previous night he had had a 7-hour “attack’ severe enough that two girlfriends stayed with him through the night. He appeared agitated, sobbed frequently, and intermittently screamed for someone to stop the pain. He was unsure of a precipitant for this attack but wondered whether skydiving the previous week had brought it on. He was concerned that he would “get into trouble” if not placed in a protective setting, since he had destroyed property and hurt people during previous episodes. In addition, he reportedly suffered from “cluster headaches” and a seizure disorder, both since removal of a right temporal lobe astrocytoma 7 years previously. At times he could not be sure whether he was experiencing “flashbacks” or a pre-ictal aura, since the symptoms were similar. Because his symptoms were consistent with both posttraumatic stress disorder (PTSD) and complex partial seizures, he was admitted to our psychiatric unit for further evaluation. Shortly after admission his symptoms disappeared, but he continued to be preoccupied with Vietnam experiences. He briefly attended “rap” sessions at a local Veterans’ Center, expressing concerns that one of his girlfriends might be pregnant and that his exposure to Agent Orange created a high risk for birth defects in the fetus. When the authenticity of his Vietnam experiences was challenged by other veterans, he returned to the ward with severe stuttering that required 5 days to resolve. Thereafter, he avoided veterans’ meetings. The medical staff also became skeptical of his story. A CT scan with contrast and a sleep-deprived EEG failed to reveal evidence of brain surgery or seizure disorder. Investigation of his military file revealed that
248
he had served only 2 months and was never in Vietnam. There was an &year difference in age between what he claimed on the current admission and on a visit to the emergency room 4 years earlier, when he gave a totally different history. Records obtained from other VA hospitals documented a long series of hospital stays for complaints of depression, cluster headaches, and seizure disorder. Often the details of the story would change-on separate occasions he attributed a concussion either to being struck by a rifle butt or to falling from a tree. During his hospitalization he was manipulative, tested limits, and provoked confrontations between the staff and other patients. He was finally discharged after smoking in his room, a repeated offense that he knew would result in discharge. After his discharge a telex arrived from another VA hospital. It described this patient’s frequent falsification of neurologic illness and the 21 negative medical evaluations that had been performed at various VA medical centers. The telex also stated that he had been discharged early from the Army for falsifying data. Despite this warning, he was evaluated for neurologic complaints at yet another VA facility and suffered an embolic infarction during a cerebral angiogram. A telephone conversation with the neurologist evaluating him revealed that the patient had succeeded in convincing the staff that he was a Vietnam veteran.
Discussion These three cases present a clinical picture consistent with both DSM-III criteria for chronic factitious physical disorder and Asher’s original description of Munchausen’s syndrome [l,ll]. Our patients had histories of multiple hospitalizations for evaluation and treatment of simulated medical diseases. They distorted and falsified their histories, spinning detailed and dramatic tales. All three were medically knowledgeable and two were imposters [i.e., nurse (patient 1); Vietnam veteran (patient 3)]. Their behavior in the hospital was also consistent with that described for patients with Munchausen’s syndrome. Initially they elicited concern and empathy from the staff, only to provoke skepticism later as they had more difficulty maintaining the charade. In response to the medical staff’s skepticism, they became more angry and demanding. One left the hospital against medical advice and another was discharged for repeatedly violating hospital safety rules. In addition, all three patients meet DSM-III criteria for factitious disorder with psychologic symptoms. Patients 1 and 3 had factitious PTSD while Patient 2 had a factitious depression. However, the
Dual Factitious Disorder
problematic behaviors manifested by these patients centered on their assuming the role of patient, not in the selection of symptoms as either physical or psychologic. They were able to shift focus from one set of symptoms to the other with great facility. Frequently both types of symptoms were intertwined so tightly that dealing with them as separate entities was impossible. A dual presentation of factitious physical and psychologic symptoms differs from the usual concept of Munchausen’s syndrome or Ganser’s syndrome. In fact, others have reported cases similar to ours, but have either minimized the dual nature of the symptoms [12-151 or, as in DSM-III, attributed them to separate diagnoses [16]. Other authors [17,18] have pointed out that Munchausen’s patients may present with primarily psychiatric symptoms. These reports imply that patients with dual factitious symptoms are rare and neglect the possibility that mixed complaints are common in patients with factitious disorders. They overlook the unifying feature of posing as patient by simulating medical and/or psychiatric conditions. A further difficulty with the classification in DSM-III is that factitious disorder with psychologic symptoms is equated with Ganser’s syndrome. This is at odds with Ganser’s original description [19]. In 1898 he described a relatively brief “hysterical twilight state” in prison inmates in which the chief symptom was vorbeireden (paralogia), namely giving approximate answers or talking past the point. Despite having obviously understood the nature of the question, his patients offered an answer that was clearly wrong (e.g., 2 + 2 = 3). AI1 of his original patients manifested multiple “hysterical” motor and sensory symptoms as well as transient excitements, anxiety, visual and auditory hallucinations, and clouding of sensorium with disorientation. The patients also had a recent history of head injury, typhus or severe emotional stress and were amnestic for the period of their symptoms. Subsequent cases have been described in nonprisoners [ 16,20-231. Most reported cases of factitious psychologic symptoms do not fit either the original description of Ganser’s syndrome or the examples of pseudodementia or pseudopsychosis cited in DSM-III. Factitious bereavement and PTSD represent more common examples [13-151. By using a nosology separating factitious disorders into physical and psychologic symptoms, DSM-III implies that these are two separate conditions resulting from different processes and that
mixed cases must be exceedingly rare. Since most descriptions of Munchausen’s syndrome focus on physical symptoms, clinicians may be led to overlook the factitious basis of the psychologic symptoms in patients who otherwise manifest all the classic Munchausen’s behaviors. Even when factitious physical symptoms are recognized, an accompanying history of psychiatric symptoms and treatment may not be considered with the appropriate level of skepticism. Such patients should not be subjected to the risks of inappropriate psychiatric treatment. Instead, efforts should be directed towards treating the underlying factitious disorder. Because of its widespread influence on psychiatric teaching and clinical practice, we recommend that the DSM-III classification of factitious disorders be modified. Separation of factitious psychologic disorders from the main body of chronic factitious disorders as exemplified by the Munchausen’s syndrome should be eliminated. Instead, a single entity of factitious disorder should be defined with the nature of the symptoms (i.e., physical, psychologic, or mixed) serving as modifying statements, much as the presence of psychotic symptoms or melancholia are used as modifying statements in the classification of affective disorders (see Appendix).
Appendix Factitious
Disorder
1. The production
of symptoms is apparently under the individual’s control. 2. The symptoms produced are not completely explained by any other mental disorder (although they may be superimposed on one). 3. The individual’s goal is apparently to assume the “patient role” and is not otherwise understandable in light of the individual’s environmental circumstances (as in the case of malingering) .
Cfpes a) Physical symptoms, b) Psychologic symptoms, c) Mixed physical and psychologic
References 1. Asher R:
Munchausen’s
syndrome.
symptoms.
Lancet
1:339-
341, 1959
249
L. Merrin et al.
2. Bursten B: On Munchausen’s syndrome. Arch Gen Psychiatry 13:261-268, 1965 3. Ireland I’, Sapira JD, Templeton B: Munchausen’s syndrome: Review and report of an additional case. Am J Med 43:579-592, 1967 4. Hyler SE, Sussman N: Chronic factitious disorder with physical symptoms (The Munchausen syndrome). I’sychiatr Clin North Am 4:365-377, 1981 5. Wingate I’: (letter) Lancet 1:1412-1413, 1951 6. Chapman JS: Peregrinating problem patients: Munchausen’s syndrome. JAMA 165:927-933, 1957 7. Barker JC: The syndrome of hospital addiction (Munchausen syndrome): A report of the investigation of seven cases. J Ment Sci 108:167-182, 1962 8. Clarke E, Melnick, SC: The Munchausen syndrome or the problem of hospital hoboes. Am J Med 25:6-12, 1958 9. Spiro HR: Chronic factitious illness. Arch Gen Psychiatry 18:569-579, 1978 10. Sheckter DC: Self-induced diseases and disabilities. Lawyers Med J 1:281, 1973 11. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, D.C., American Psychiatric Association, 1980 12. Ford CV: The Munchausen syndrome: A report of four new cases and a review of psychodynamic considerations. Int J Psychiatry Med 4:31-45, 1973 13. Phillips MR, Ward NG, Ries RK: Factitious mourning: painless patienthood. Am J Psychiatry 140:420425, 1983 14. Sparr L, Pankratz LD: Factitious posttraumatic stress disorder. Am J Psychiatry 140:1016-1019, 1983
250
15. Snowden J, Solomons R, Druce H: Feigned bereavement: twelve cases. Br J Psychiatry 133:15-19, 1978 16. McEvoy J, Campbell T: Ganser-like signs in carbon monoxide encephalopathy, Am J Psych 134:14481449, 1977 17. Gelenberg AJ: Munchausen’s syndrome with a psychiatric presentation. Dis Nerv Sys 38:378-380, 1977 18. Cheng L, Hummel L: The Munchausen syndrome as a psychiatric condition, Br J Psychiatry 133:20-21, 1978 19. Ganser AJ: Uber einen eigenartigen hysterischen Dammerzustand. Arch Psychiatr Nervenkr 30:633640, 1898 20. Steinhart MJ: Ganser State: A case of hysteria1 pseudodementia. Gen Hosp Psychiatry 3:226-228, 1980 21. Whitlock FA: The Ganser syndrome. Br J Psychiatry 113:19-29, 1967 22. Latcham R, White A, Sims A: Ganser syndrome: The aetiological argument. J Neurol Neurosurg Psychiatry 41:851-854, 1978 23. Weiner H, Braiman A: The Ganser syndrome: A review and addition of some unusual cases. Am J Psychiatry 31767-773, 1955 Direcf reprinf requests to: Edward L. Merrin, M.D. Psychiatry Service (116N) VA Medical Center 4150 Clement St. San Francisco, CA 94121.
Craig Van Dyke, M.D., Seth Cohen, M.D., and
Donald J. Tusel, M.D. Department of Psychiatry,
University
Service, Veterans Administration
of California
Medical Center,
School
Abstract: The DSM-III classification of factitious disorders encourages artificial separation into disorders with physical and those with psychologic symptoms. Despite documented examples of similar patients who present with psychiatric complaints, Munchausen’s syndrome is usually considered a form of chronic factitious physical disorder. Three patients with both factitious physical and psychologic symptoms are presented. These patients illustrate the importance of focusing on the fundamental behavior ofassuming the patient role, rather than on the specific category of symptoms. We recommend that the category of symptoms be used as a modifying statement, rather than defining separate disorders.
Asher [l] originally called attention to a perplexing group of patients who developed a life-style based on deceiving physicians by dramatically simulating illness. Because of their persistent wanderings from hospital to hospital (peregrination) and ability to spin tall tales (pseudologia fantastica), he coined Syndrome,” a reference the term, “Munchausen’s to eighteenth century German literature that portrayed the fictitious exploits of an actual individual. Subsequent reports [2-41 have emphasized additional features of these patients, such as imposture and medical sophistication as well as certain behaviors in the hospital-demandingness, willingness to undergo invasive procedures, absence of visitors, and frequent discharge against medical advice. Although several authors [5-lo] have pointed out the shortcomings of this label and have sugthe term remains in wide gested alternatives, clinical use. Munchausen’s syndrome, like the patients it refers to, has succeeded in capturing the attention of the medical community in a compelling fashion. 246 ISSN 0163~8343/86/$3.50
of Medicine,
Sun Francisco,
Sun Francisco,
Culiforniu und Psyclziutry
California
Along with most standard textbooks of psychiatry, the DSM-III manual [ll] explicitly defines Munchausen’s syndrome as a disorder with chronic factitious physical symptoms. It considers chronic factitious illness with psychologic symptoms as a separate and even more rare condition, citing the Ganser syndrome as the primary example. This nosology is misleading, since patients with Munchausen’s syndrome commonly have factitious psychoIogic as we11 as physical symptoms. In our view, many patients with Munchausen’s syndrome carry about multiple patient identities, switching emphasis from one set of symptoms to another depending on circumstances. In such cases the medical staff may obtain history and signs of a specific psychiatric disorder in a patient manifesting factitious physical symptoms, failing to appreciate the possibility that the psychologic symptoms may be just as factitious as the physical. To illustrate our point, we present three patients with chronic factitious physical symptoms who meet DSM-III criteria for Munchausen’s syndrome. In addition, they manifest chronic factitious psychologic symptoms quite distinct from Ganser’s syndrome. These patients demonstrate the limitations of our current classification of factitious disorders and suggest specific revisions of DSM-III.
Case 1 Ms. A, a 27-year-old white female with a self-reported history of renal calculi was admitted to our Urology Service complaining of right flank pain. Following an unremarkable urologic evaluation the medical staff informed her that there was no longer a basis for continued hospitalization or further narcotic anal-
GeneralHospital Psychiatry 8, 246-250, 1986 0 1986 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Avenue, New York, NY 10017
Dual Factitious Disorder
gesia. She responded to this by threatening to leave and commit suicide. This prompted an emergency psychiatric consultation, during which she refused an offer of psychiatric treatment. She was eventually discharged several days later against medical advice. Ms. A returned 10 days later and was admitted to our psychiatric inpatient unit complaining of suicidal ideation, nightmares, and “flashbacks” of having been raped 2 months previously by her assistant pastor. She believed that the rape had been instigated by her estranged husband, whom she had met while they were both medical students in Central America. She alleged his motive was anger over her threat to have his visa cancelled, after she discovered that he had married her solely to enter this country. She found herself confused, angry, and unable to prepare for upcoming medical school examinations. She also reported anorexia, with 4-pound weight loss, profound sleep difficulty, and nightmares of the rape. She contemplated suicide by driving off an embankment. The patient also cIaimed to be a masters-level psychiatric nurse. She was on a leave of absence from her summer job as the head nurse on a psychiatric unit. During the past 2 years of medical school she had spent weekends doing medical missionary work, returning each summer to live with her parents and work as a nurse. She was troubled by the recent suicide of three of her patients. Ms. A was a neatly groomed young woman with a tattoo of a flower on her left forearm. This allegedly resulted from an episode in Army nursing school when she was put into a drugged state as a prank. There was no evidence of psychosis or of an affective disturbance. Hospital course was marked by complaints of headaches, vomiting with hematemesis (never verified), nightmares, and insomnia. She demanded sedatives and narcotics and at one point arranged an appointment with an outside gynecologist. She repeated the history of sexual assault to this physician, complaining of pain and concerns over possible pregnancy. Ultrasound examination of the abdomen and pelvis and a pregnancy test revealed a normal, nonpregnant uterus. Subsequently, the gynecologist telephoned a IocaI rape crisis center and was informed that the patient had been complaining of recent sexual assault for a number of years. Records obtained from other hospitals revealed several previous hospitalizations for renal colic. Multiple abdominal x-rays, renal ultrasounds, and retrograde and intravenous pyelograms had failed to uncover evidence of renal calculi. During one hospitalization the patient presented the medical staff with a gravel-like substance, stating that she had just passed it in her urine. Laboratory analysis determined this substance to be an artifact. Although the patient denied to us either previous rape or psychiatric treatment, we were able to document four previous psychiatric hospitalizations. Dur-
ing each of these the patient had reported a recent rape and feelings of worthlessness, helplessness, and wanting to kill herself. She was described during those hospitalizations as uncooperative and complaining of multiple physical symptoms. Army documents contained no record of her being a nurse.
Case 2 Mr. B. was a 36year-old white male admitted to our psychiatric unit for evaluation and treatment of “depression.” Complaining of symptoms consistent with a major depressive episode, he recounted a lengthy list of unsuccessful antidepressant medication trials, specifying dosages and durations of treatment. This, he insisted, necessitated the immediate use of electroconvulsive treatment (ECT). He was uncooperative with attempts to obtain a more detailed history and would not allow relatives or acquaintances to be contacted. Rather than appearing depressed, he was irritable and demanding, with a somewhat constricted and aloof affect. The staff was unable to document his complaints of psychomotor retardation, sleep disorder, or diminished appetite. Perceiving that further evaluation rather than ECT was forthcoming, he left the unit without notice and did not return. Shortly afterward he was admitted to a psychiatric clinical research unit at a nearby medical center. When he was informed after evaluation that he was not a candidate for a research project on the treatment of depression, he angrily signed out of the hospital. Review of past medical records revealed hospitalization in a state mental hospital at the age of 23 after an arrest for writing bad checks. Symptoms included paranoid delusions but not depression. He eventually escaped by jumping out of a window. The patient’s claim that he had 11 ECTs during that hospitalization was not substantiated. He was hospitalized briefly on several other occasions over the ensuing 5 years but details were extremely sparse. Over a number of years, repeated attempts at outpatient treatment had resulted in missed appointments and numerous telephone calls, often consisting of angry tirades or suicidal threats. Although in one clinic he was treated with antipsychotic medication for presumed schizophrenia, there was little symptomatology consistent with this diagnosis. At one point, he was discovered to have fraudulently obtained travel compensation from the VA by claiming a nonexistent address in a distant city. This patient was also well known in local hospitals for medical complaints. For nearly 10 years he had been appearing at emergency rooms with complaints of chest pain, offering a history of multiple pulmonary emboli and thrombophlebitis since a traumatic leg injury in 1969. In 1975 he received an inferior vena cava plication and was treated with anticoagulants on a sporadic basis. Indications for this surgery were un247
E. L. Men-in et al
clear from available records. Subsequently, he frequented numerous emergency rooms over a wide
area. During these visits he was demanding of attention and on several occasions attempted to remove or destroy parts of his medical record. Often he disappeared before definitive tests could be completed. Once an emergency room physician advised him that admission was not indicated since he was not coughing blood. Within several days he returned and saw a different physician, adding this symptom to his complaints. On the one occasion when he was admitted to our hospital an extensive evaluation for pulmonary emboli was negative.
Case 3 Mr. C., a white male, described himself as a 30-yearold psychologist. He presented himself to our emergency room with complaints of headaches and “flashbacks” of an incident in Vietnam when he shot a group of children. The flashbacks had bothered him intermittenly for 8 years and consisted of hallucinations of automatic weapons fire and the smell of burning flesh. The previous night he had had a 7-hour “attack’ severe enough that two girlfriends stayed with him through the night. He appeared agitated, sobbed frequently, and intermittently screamed for someone to stop the pain. He was unsure of a precipitant for this attack but wondered whether skydiving the previous week had brought it on. He was concerned that he would “get into trouble” if not placed in a protective setting, since he had destroyed property and hurt people during previous episodes. In addition, he reportedly suffered from “cluster headaches” and a seizure disorder, both since removal of a right temporal lobe astrocytoma 7 years previously. At times he could not be sure whether he was experiencing “flashbacks” or a pre-ictal aura, since the symptoms were similar. Because his symptoms were consistent with both posttraumatic stress disorder (PTSD) and complex partial seizures, he was admitted to our psychiatric unit for further evaluation. Shortly after admission his symptoms disappeared, but he continued to be preoccupied with Vietnam experiences. He briefly attended “rap” sessions at a local Veterans’ Center, expressing concerns that one of his girlfriends might be pregnant and that his exposure to Agent Orange created a high risk for birth defects in the fetus. When the authenticity of his Vietnam experiences was challenged by other veterans, he returned to the ward with severe stuttering that required 5 days to resolve. Thereafter, he avoided veterans’ meetings. The medical staff also became skeptical of his story. A CT scan with contrast and a sleep-deprived EEG failed to reveal evidence of brain surgery or seizure disorder. Investigation of his military file revealed that
248
he had served only 2 months and was never in Vietnam. There was an &year difference in age between what he claimed on the current admission and on a visit to the emergency room 4 years earlier, when he gave a totally different history. Records obtained from other VA hospitals documented a long series of hospital stays for complaints of depression, cluster headaches, and seizure disorder. Often the details of the story would change-on separate occasions he attributed a concussion either to being struck by a rifle butt or to falling from a tree. During his hospitalization he was manipulative, tested limits, and provoked confrontations between the staff and other patients. He was finally discharged after smoking in his room, a repeated offense that he knew would result in discharge. After his discharge a telex arrived from another VA hospital. It described this patient’s frequent falsification of neurologic illness and the 21 negative medical evaluations that had been performed at various VA medical centers. The telex also stated that he had been discharged early from the Army for falsifying data. Despite this warning, he was evaluated for neurologic complaints at yet another VA facility and suffered an embolic infarction during a cerebral angiogram. A telephone conversation with the neurologist evaluating him revealed that the patient had succeeded in convincing the staff that he was a Vietnam veteran.
Discussion These three cases present a clinical picture consistent with both DSM-III criteria for chronic factitious physical disorder and Asher’s original description of Munchausen’s syndrome [l,ll]. Our patients had histories of multiple hospitalizations for evaluation and treatment of simulated medical diseases. They distorted and falsified their histories, spinning detailed and dramatic tales. All three were medically knowledgeable and two were imposters [i.e., nurse (patient 1); Vietnam veteran (patient 3)]. Their behavior in the hospital was also consistent with that described for patients with Munchausen’s syndrome. Initially they elicited concern and empathy from the staff, only to provoke skepticism later as they had more difficulty maintaining the charade. In response to the medical staff’s skepticism, they became more angry and demanding. One left the hospital against medical advice and another was discharged for repeatedly violating hospital safety rules. In addition, all three patients meet DSM-III criteria for factitious disorder with psychologic symptoms. Patients 1 and 3 had factitious PTSD while Patient 2 had a factitious depression. However, the
Dual Factitious Disorder
problematic behaviors manifested by these patients centered on their assuming the role of patient, not in the selection of symptoms as either physical or psychologic. They were able to shift focus from one set of symptoms to the other with great facility. Frequently both types of symptoms were intertwined so tightly that dealing with them as separate entities was impossible. A dual presentation of factitious physical and psychologic symptoms differs from the usual concept of Munchausen’s syndrome or Ganser’s syndrome. In fact, others have reported cases similar to ours, but have either minimized the dual nature of the symptoms [12-151 or, as in DSM-III, attributed them to separate diagnoses [16]. Other authors [17,18] have pointed out that Munchausen’s patients may present with primarily psychiatric symptoms. These reports imply that patients with dual factitious symptoms are rare and neglect the possibility that mixed complaints are common in patients with factitious disorders. They overlook the unifying feature of posing as patient by simulating medical and/or psychiatric conditions. A further difficulty with the classification in DSM-III is that factitious disorder with psychologic symptoms is equated with Ganser’s syndrome. This is at odds with Ganser’s original description [19]. In 1898 he described a relatively brief “hysterical twilight state” in prison inmates in which the chief symptom was vorbeireden (paralogia), namely giving approximate answers or talking past the point. Despite having obviously understood the nature of the question, his patients offered an answer that was clearly wrong (e.g., 2 + 2 = 3). AI1 of his original patients manifested multiple “hysterical” motor and sensory symptoms as well as transient excitements, anxiety, visual and auditory hallucinations, and clouding of sensorium with disorientation. The patients also had a recent history of head injury, typhus or severe emotional stress and were amnestic for the period of their symptoms. Subsequent cases have been described in nonprisoners [ 16,20-231. Most reported cases of factitious psychologic symptoms do not fit either the original description of Ganser’s syndrome or the examples of pseudodementia or pseudopsychosis cited in DSM-III. Factitious bereavement and PTSD represent more common examples [13-151. By using a nosology separating factitious disorders into physical and psychologic symptoms, DSM-III implies that these are two separate conditions resulting from different processes and that
mixed cases must be exceedingly rare. Since most descriptions of Munchausen’s syndrome focus on physical symptoms, clinicians may be led to overlook the factitious basis of the psychologic symptoms in patients who otherwise manifest all the classic Munchausen’s behaviors. Even when factitious physical symptoms are recognized, an accompanying history of psychiatric symptoms and treatment may not be considered with the appropriate level of skepticism. Such patients should not be subjected to the risks of inappropriate psychiatric treatment. Instead, efforts should be directed towards treating the underlying factitious disorder. Because of its widespread influence on psychiatric teaching and clinical practice, we recommend that the DSM-III classification of factitious disorders be modified. Separation of factitious psychologic disorders from the main body of chronic factitious disorders as exemplified by the Munchausen’s syndrome should be eliminated. Instead, a single entity of factitious disorder should be defined with the nature of the symptoms (i.e., physical, psychologic, or mixed) serving as modifying statements, much as the presence of psychotic symptoms or melancholia are used as modifying statements in the classification of affective disorders (see Appendix).
Appendix Factitious
Disorder
1. The production
of symptoms is apparently under the individual’s control. 2. The symptoms produced are not completely explained by any other mental disorder (although they may be superimposed on one). 3. The individual’s goal is apparently to assume the “patient role” and is not otherwise understandable in light of the individual’s environmental circumstances (as in the case of malingering) .
Cfpes a) Physical symptoms, b) Psychologic symptoms, c) Mixed physical and psychologic
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