- Email: [email protected]
Hospital Management of a Patient With Intractable Factitious Disorder
Case Reports Hospital Management of a Patient With Intractable Factitious Disorder KATE SCHWARZ, M.D., ROBERT HARDING, M.D. DANIEL HARRINGTON, M.D., BARRY FARR, M.D., M.Sc.
M
anagement of patients with chronic factitious disorder presents many challenges. Helping the patient to accept psychiatric care, the role of confrontation, treatment of comorbid mental illness, and proper medical care are all in question. l -<> The excess use of diagnostic and therapeutic measures in these cases creates financial burdens on hospitals and third-party payers. At this time no comparative trials exist that examine the question of treatment. Case reports vary7-12 but have the advantage of highlighting basic principles, such as the need for a strong patient-therapist alliance. We describe one patient whose factitious disorder had become entrenched and who had been considered untreatable. A multidisciplinary team developed a unique approach that included paradoxical free access to a hospital bed at all times for I year. Subsequently, the patient became hospital independent. This approach may be useful in other cases where factitious disorder is enacted through strong dependency on a hospital.
Case Report The patient was hospitalized for factitious cellulitis of an ann 52 times between ages 35 and 45 years. Medical evaluation yielded no other explanation for the infections, and casting the extremity led to local healing. The patient did not have characteristics of a Munchausen's variant. The patient became very well known to the medical, surgical, and psychiatric services of a state university hospital. Attempts at confrontation led to passive denial and reports of suicidal ideation. She complained of depressed mood and insomnia that she attributed to conflict VOLUME 34 • NUMBER 3 • MAY - JUNE 1993
with care providers. Over the most recent 12-month period, the patient had been in the hospital for 235 days at an estimated cost of $115,000. Government third-party payers no longer reimbursed the hospital for these repeated admissions. A multidisciplinary team, including internists, surgeons, psychiatrists, nurses, social workers, and hospital administrators, agreed that conventional medical and psychiatric measures had failed. The patient demonstrated an overwhelming need to maintain a relationship with care providers in a hospital setting. An innovative approach was then adopted, which included the following: I. Paradoxical free access to hospital with a designated permanent bed on a medical ward for I year 2. Opponunity to come in or leave the hospital freely depending on the patient's own perceived need for treatment 3. An emphasis on independent wound care, assessment, and decision making regarding need for treatment 4. A focus on holistic health and rehabilitation, with literacy and vocational training, and physical therapy 5. Minimal consultation, radiologic, and laboratory testing 6. Ongoing weekly psychotherapy with a primary care provider: attempts at confrontation were abandoned and amitriptyline was used for depressed mood
Received November 7. 1990; revised September 6, 1991; accepted September 12, 1991. From the Departments of Psychiatry and Internal Medicine, University of Virginia, Health Sciences Center, Charlottesville, VA. Address reprint requests to Dr. Schwarz. 57 Exchange St., Suite 400, Portland, ME 04101-5009. Copyright IS> 1993 The Academy of Psychosomatic Medicine.
265
Case Reports
The plan was discussed with the patient, and she accepted it. She developed a predictable pattern of hospital use and need for antibiotics. This generally abated around weekends and holidays but intensified during absences of her primary care provider and therapist. She discovered methods of controlling the cellulitis with minor variations in wound care technique. She reported her first dissociative episode and thus provided an opportunity for interpretations around behavior that can occur unconsciously. Complaints of rejection at the hands of care providers ceased along with the improvement in patientstaff relationships in the hospital. At the same time, depressed mood and insomnia improved. At the end of the year, the number of actual days spent in the hospital added up to 130, drastically reduced from the previous year's 235 days (P < 0.001, chi-square). The decline in hospital days, laboratory tests, and intravenous antibiotics resulted in a significant reduction in hospital costs. Because the patient was charged for the room even when absent, the hospital charges were approximately 35% higher than in the previous year. These charges were assumed by the hospital as indigent care and were not believed to represent significant financial loss for the hospital during the experimental year because of low hospital census. Moreover, since discharge the patient has not been readmitted for 16 months. She now manages her cellulitis as an outpatient and professes never to need the hospital again.
Discussion Previous case reports of successfully managed patients with factitious disorder contain three common elements. 7- 11 First, the approach is multimodal, even comprehensive, in addressing several areas of functioning apart from the factitious illness. Second, a behavioral paradigm is adopted in which healthy behavior is encouraged while illness behavior is simply tolerated or ignored. Third, there is a primary patient-advocate or therapist who is somewhat removed from the scene and has a neutral role. In common with these cases, 7.9-11 our patient improved after a new and comprehensive approach was developed. Certainly the investment by hospital staff improves once the patient is seen as unique and worthy of an organized approach. Covert hostility is eliminated once a structured treatment plan is in effect, addressing the frustra266
tion of caring for such patients. The multimodal, open-door approach we employed conveyed to the patient that she was being cared for as a whole person, not just a case of cellulitis. We also shared with previous reports 7- 9 a behavioral approach in which positive behaviors (e.g., independence in wound care) are praised, whereas negative behaviors (e.g., worsening inflammation) are ignored. Our open door approach was paradoxical9 in that the patient was welcomed to be in the hospital, satisfying her dependency needs, in order to meet our goal for her of hospital independence. Like other reported cases,7·9-11 the role of the primary therapist was emphasized. This was held out as a consistent relationship that would continue regardless of the outcome of the infections or hospitalizations. Comorbid depression warranted vigorous treatment as well.' 1 The literature tends to be divided on the issue of confrontation of the patient with factitious disorder. Aduan 2 and Reich3 report that a majority of patients with factitious illnesses react to confrontation with rage or denial but then accept psychiatric referral. Others argue that confrontation is useless or even risky in patients with fragile ego structure,4-6 leading to depression, psychosis, or even suicide. In our case, we came to believe that confrontation had proven useless and if used repeatedly would have been cruel. We felt that this patient's denial of selfinjurious behavior was essential to maintaining her sense of dignity and that a gradual relinquishing of symptoms was to be more realistically expected. Eisendrath l2 successfully treated four cases of factitious disorder with confrontation. Inexact interpretation, the therapeutic double bind, and face-saving techniques were used to help patients relinquish their symptoms without experiencing humiliation. The interpretations used in regard to the patient's reports of dissociative experience could be viewed as inexact. Also, the team conveyed an expectation to the patient that her skills would largely determine the outcome of the infection. Worsening infection would then need to be viewed by her as inadequate self-care or poor decision making. Since independence and matuPSYCHOSOMATICS
Case Reports
rity were valued by the team and implicit in the free access paradigm, a desire to maintain these relationships placed the patient in a therapeutic double bind. To obtain our approval there had to be improvement in symptoms of cellulitis. Our experience as a hospital with this patient showed that medical and psychiatric teams can work together and alter the delivery of medical care in a way that is psychologically sophisticated. It is no small challenge to reverse the traditional view of the patient as a passive recipient. In this case we needed to convey to the
patient that the ultimate control of these infections lay in her hands. As a hospital, we learned that a case-oriented, flexible approach is best in treating patients with factitious disorder.Individualized variations on our management scheme might be used for other patients, especially those who repeatedly use inpatient services to gratify dependency needs. Day-treatment programs might, for example, serve in this fashion. Further studies using variations of residential and day care seem warranted.
References I. Sapira J: Munchausen's syndrome and the technologic imperative. South Med J 1981; 74:193-196 2. Aduan RP. Fauci AS. Dale DC, et al: Factitious fever and self-induced infection. Ann Intern Med 1979; 90:230-242 3. Reich P. Gottfried LA: Factitious disorders in a teaching hospital. Ann Intern Med 1983; 99:240-247 4. Camey MWP: Anefactual illness to attract medical attention. Br J Psychiatry 1980; 136:542-547 5. Justus PG. Kreutziger SS. Kitchens CS: Probing the dynamics of Munchausen's syndrome. Ann Intern Med 1980; 93: 120-127 6. Davis D. Weiss JMA: Malingering and associated syndromes, in American Handbook of Psychiatry. New York, Basic Books. 1974, pp 270-287 7. Yassa R: Munchausen's syndrome: a successfully treated case. Psychosomatics 1978; 19:242-243
8. Simmons DA. Daamen MJ. Harrison JW. et al: HospitaJ management of a patient with factitial dennatitis. Gen Hosp Psychiatry 1987; 9: 147-150 9. Klonoff EA. Youngner SJ, Moore DJ. et al: Chronic factitious illness: a behavioral approach. Int J Psychiatry Med 1983-1984; 13:173-183 10. Howe GL. Jordan HW. Locken EW. et aI: Munchausen's syndrome or chronic factitious illness: a review and case presentation. J Natl Med Assoc 1983; 75:175-182 II. Earle JR. Folks DG: Factitious disorder and coexisting depression: a repon of successful psychiatric consultation and case management. Gen Hosp Psychiatry 1986; 8:448450 12. Eisendrath SJ: Factitious physical disorders: treatment without confrontation. Psychosomatics 1989; 30:383387
Conversion Disorder Presenting as Primary Fibromyalgia STEPHEN
P
N.
MACCIOCCHI,
rimary fibromyalgia (PFM) is a syndrome that traditionally has had variable symptomatology but a generally consistent clinical presentation that includes generalized pain, local tenderness, weakness, fatigue, and stiffness as well as the less frequent occurrence of swelling, Raynaud's phenomena, and functional VOLUME 34 • NUMBER 3 • MAY - JUNE 1993
PH.D.
Received May 21. 1991; revised August 26. 1991; accepted September 5, 1991. From the University of Virginia Health Sciences Center-Medical Center. Department of Physical Medicine and Rehabilitation. Charlottesville. VA 22908. Address reprint requests to Dr. Macciocchi. Copyright @ 1993 The Academy of Psychosomatic Medicine.
11>7
M
anagement of patients with chronic factitious disorder presents many challenges. Helping the patient to accept psychiatric care, the role of confrontation, treatment of comorbid mental illness, and proper medical care are all in question. l -<> The excess use of diagnostic and therapeutic measures in these cases creates financial burdens on hospitals and third-party payers. At this time no comparative trials exist that examine the question of treatment. Case reports vary7-12 but have the advantage of highlighting basic principles, such as the need for a strong patient-therapist alliance. We describe one patient whose factitious disorder had become entrenched and who had been considered untreatable. A multidisciplinary team developed a unique approach that included paradoxical free access to a hospital bed at all times for I year. Subsequently, the patient became hospital independent. This approach may be useful in other cases where factitious disorder is enacted through strong dependency on a hospital.
Case Report The patient was hospitalized for factitious cellulitis of an ann 52 times between ages 35 and 45 years. Medical evaluation yielded no other explanation for the infections, and casting the extremity led to local healing. The patient did not have characteristics of a Munchausen's variant. The patient became very well known to the medical, surgical, and psychiatric services of a state university hospital. Attempts at confrontation led to passive denial and reports of suicidal ideation. She complained of depressed mood and insomnia that she attributed to conflict VOLUME 34 • NUMBER 3 • MAY - JUNE 1993
with care providers. Over the most recent 12-month period, the patient had been in the hospital for 235 days at an estimated cost of $115,000. Government third-party payers no longer reimbursed the hospital for these repeated admissions. A multidisciplinary team, including internists, surgeons, psychiatrists, nurses, social workers, and hospital administrators, agreed that conventional medical and psychiatric measures had failed. The patient demonstrated an overwhelming need to maintain a relationship with care providers in a hospital setting. An innovative approach was then adopted, which included the following: I. Paradoxical free access to hospital with a designated permanent bed on a medical ward for I year 2. Opponunity to come in or leave the hospital freely depending on the patient's own perceived need for treatment 3. An emphasis on independent wound care, assessment, and decision making regarding need for treatment 4. A focus on holistic health and rehabilitation, with literacy and vocational training, and physical therapy 5. Minimal consultation, radiologic, and laboratory testing 6. Ongoing weekly psychotherapy with a primary care provider: attempts at confrontation were abandoned and amitriptyline was used for depressed mood
Received November 7. 1990; revised September 6, 1991; accepted September 12, 1991. From the Departments of Psychiatry and Internal Medicine, University of Virginia, Health Sciences Center, Charlottesville, VA. Address reprint requests to Dr. Schwarz. 57 Exchange St., Suite 400, Portland, ME 04101-5009. Copyright IS> 1993 The Academy of Psychosomatic Medicine.
265
Case Reports
The plan was discussed with the patient, and she accepted it. She developed a predictable pattern of hospital use and need for antibiotics. This generally abated around weekends and holidays but intensified during absences of her primary care provider and therapist. She discovered methods of controlling the cellulitis with minor variations in wound care technique. She reported her first dissociative episode and thus provided an opportunity for interpretations around behavior that can occur unconsciously. Complaints of rejection at the hands of care providers ceased along with the improvement in patientstaff relationships in the hospital. At the same time, depressed mood and insomnia improved. At the end of the year, the number of actual days spent in the hospital added up to 130, drastically reduced from the previous year's 235 days (P < 0.001, chi-square). The decline in hospital days, laboratory tests, and intravenous antibiotics resulted in a significant reduction in hospital costs. Because the patient was charged for the room even when absent, the hospital charges were approximately 35% higher than in the previous year. These charges were assumed by the hospital as indigent care and were not believed to represent significant financial loss for the hospital during the experimental year because of low hospital census. Moreover, since discharge the patient has not been readmitted for 16 months. She now manages her cellulitis as an outpatient and professes never to need the hospital again.
Discussion Previous case reports of successfully managed patients with factitious disorder contain three common elements. 7- 11 First, the approach is multimodal, even comprehensive, in addressing several areas of functioning apart from the factitious illness. Second, a behavioral paradigm is adopted in which healthy behavior is encouraged while illness behavior is simply tolerated or ignored. Third, there is a primary patient-advocate or therapist who is somewhat removed from the scene and has a neutral role. In common with these cases, 7.9-11 our patient improved after a new and comprehensive approach was developed. Certainly the investment by hospital staff improves once the patient is seen as unique and worthy of an organized approach. Covert hostility is eliminated once a structured treatment plan is in effect, addressing the frustra266
tion of caring for such patients. The multimodal, open-door approach we employed conveyed to the patient that she was being cared for as a whole person, not just a case of cellulitis. We also shared with previous reports 7- 9 a behavioral approach in which positive behaviors (e.g., independence in wound care) are praised, whereas negative behaviors (e.g., worsening inflammation) are ignored. Our open door approach was paradoxical9 in that the patient was welcomed to be in the hospital, satisfying her dependency needs, in order to meet our goal for her of hospital independence. Like other reported cases,7·9-11 the role of the primary therapist was emphasized. This was held out as a consistent relationship that would continue regardless of the outcome of the infections or hospitalizations. Comorbid depression warranted vigorous treatment as well.' 1 The literature tends to be divided on the issue of confrontation of the patient with factitious disorder. Aduan 2 and Reich3 report that a majority of patients with factitious illnesses react to confrontation with rage or denial but then accept psychiatric referral. Others argue that confrontation is useless or even risky in patients with fragile ego structure,4-6 leading to depression, psychosis, or even suicide. In our case, we came to believe that confrontation had proven useless and if used repeatedly would have been cruel. We felt that this patient's denial of selfinjurious behavior was essential to maintaining her sense of dignity and that a gradual relinquishing of symptoms was to be more realistically expected. Eisendrath l2 successfully treated four cases of factitious disorder with confrontation. Inexact interpretation, the therapeutic double bind, and face-saving techniques were used to help patients relinquish their symptoms without experiencing humiliation. The interpretations used in regard to the patient's reports of dissociative experience could be viewed as inexact. Also, the team conveyed an expectation to the patient that her skills would largely determine the outcome of the infection. Worsening infection would then need to be viewed by her as inadequate self-care or poor decision making. Since independence and matuPSYCHOSOMATICS
Case Reports
rity were valued by the team and implicit in the free access paradigm, a desire to maintain these relationships placed the patient in a therapeutic double bind. To obtain our approval there had to be improvement in symptoms of cellulitis. Our experience as a hospital with this patient showed that medical and psychiatric teams can work together and alter the delivery of medical care in a way that is psychologically sophisticated. It is no small challenge to reverse the traditional view of the patient as a passive recipient. In this case we needed to convey to the
patient that the ultimate control of these infections lay in her hands. As a hospital, we learned that a case-oriented, flexible approach is best in treating patients with factitious disorder.Individualized variations on our management scheme might be used for other patients, especially those who repeatedly use inpatient services to gratify dependency needs. Day-treatment programs might, for example, serve in this fashion. Further studies using variations of residential and day care seem warranted.
References I. Sapira J: Munchausen's syndrome and the technologic imperative. South Med J 1981; 74:193-196 2. Aduan RP. Fauci AS. Dale DC, et al: Factitious fever and self-induced infection. Ann Intern Med 1979; 90:230-242 3. Reich P. Gottfried LA: Factitious disorders in a teaching hospital. Ann Intern Med 1983; 99:240-247 4. Camey MWP: Anefactual illness to attract medical attention. Br J Psychiatry 1980; 136:542-547 5. Justus PG. Kreutziger SS. Kitchens CS: Probing the dynamics of Munchausen's syndrome. Ann Intern Med 1980; 93: 120-127 6. Davis D. Weiss JMA: Malingering and associated syndromes, in American Handbook of Psychiatry. New York, Basic Books. 1974, pp 270-287 7. Yassa R: Munchausen's syndrome: a successfully treated case. Psychosomatics 1978; 19:242-243
8. Simmons DA. Daamen MJ. Harrison JW. et al: HospitaJ management of a patient with factitial dennatitis. Gen Hosp Psychiatry 1987; 9: 147-150 9. Klonoff EA. Youngner SJ, Moore DJ. et al: Chronic factitious illness: a behavioral approach. Int J Psychiatry Med 1983-1984; 13:173-183 10. Howe GL. Jordan HW. Locken EW. et aI: Munchausen's syndrome or chronic factitious illness: a review and case presentation. J Natl Med Assoc 1983; 75:175-182 II. Earle JR. Folks DG: Factitious disorder and coexisting depression: a repon of successful psychiatric consultation and case management. Gen Hosp Psychiatry 1986; 8:448450 12. Eisendrath SJ: Factitious physical disorders: treatment without confrontation. Psychosomatics 1989; 30:383387
Conversion Disorder Presenting as Primary Fibromyalgia STEPHEN
P
N.
MACCIOCCHI,
rimary fibromyalgia (PFM) is a syndrome that traditionally has had variable symptomatology but a generally consistent clinical presentation that includes generalized pain, local tenderness, weakness, fatigue, and stiffness as well as the less frequent occurrence of swelling, Raynaud's phenomena, and functional VOLUME 34 • NUMBER 3 • MAY - JUNE 1993
PH.D.
Received May 21. 1991; revised August 26. 1991; accepted September 5, 1991. From the University of Virginia Health Sciences Center-Medical Center. Department of Physical Medicine and Rehabilitation. Charlottesville. VA 22908. Address reprint requests to Dr. Macciocchi. Copyright @ 1993 The Academy of Psychosomatic Medicine.
11>7