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Ocular factitious disorder presenting as endophthalmitis
LETTERS TO THE EDITOR Ocular factitious disorder presenting as endophthalmitis
I
thoroughly enjoyed the article "Ocular factitious disorder presenting as endophthalmitis," by Rashid Taber and colleagues, 1 and hope all ophthalmologists read it, as patients with factitious disorders can be very challenging to manage. However, I take issue with some of the authors' assertions. Taber and colleagues describe a woman who intentionally injected a mixture of saliva and tap water into her eye. They nicely discuss factitious disorders and distinguish them from malingering, somatoform disorders and hypochondriasis. They also discuss previously reported cases of ocular Munchausen's syndrome and leave the reader with the impression that their case is another example of ocular Munchausen's syndrome. As Taber and colleagues correctly point out, Munchausen's syndrome is "an extreme form of factitious disorder in which pathologic lying and the intent to deceive are prominent features." This was not the case with their patient. She readily admitted what she had done. In patients with true Munchausen's syndrome (Table 1) there is deliberate deception in which the patient attempts to manipulate physicians through factitious or misrepresented signs and symptoms. 2- 5 There are in fact several types of "deceiver" (those with Munchausen's syndrome being the best known and most publicized) that have been described. 5 Although Taber and colleagues' patient had several previous hospital admissions for other problems (a feature of Munchausen's syndrome), we do not know whether she volunteered what she had done on those
Table 1-Features of Munchausen's syndrome2 Feigned severe illness of a dramatic and emergency nature Factitious evidence of disease Evidence of many previous hospital procedures Pathologic lying Aggressive, unruly behaviour Departure from hospital against advice Numerous previous hospital admissions Absence of any readily discernable ulterior motive
occasions or whether she was trying to deceive the physicians. Nor do we know whether she had any history of aggressive, unruly behaviour or departure from hospital against advice. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders 6 states that factitious disorders are characterized by physical or psychologic symptoms that are produced or feigned intentionally in order to assume the sick role. Munchausen's syndrome is now incorporated into this broader category of disorders. 6 Patients with this syndrome without question have a factitious disorder, but not all factitious disorders are Munchausen's syndrome. It would have been more accurate for the authors to refer to their patient as having a factitious disorder. To suggest that she had Munchausen's syndrome would require documentation of pathologic lying, the intent to deceive and the other features listed in Table 1. I also take issue with the statement "feigned symptoms and secondary motives can be documented by the practitioner through painstaking history-taking and discreet but directed probing." Certainly, if the patient volunteers that he or she has done something to his- or herself, the diagnosis is easy. In cases in which the patient tries to "deceive" the doctor by lying and feigning illness through such means as manipulating test results, the diagnosis can be extremely difficult to discover. 2- 5 I agree with Ashe.-4 (who popularized the term Munchausen's syndrome) that "it is almost impossible to be certain of this diagnosis at first." Patients who feign illness often travel from one hospital to another, one service to another, and one doctor to another and undergo a variety of tests and interventions. Those trying to deceive do not volunteer all their past history, or, if they do, it is often inaccurate or untruthful. In my experience, they continue trying to deceive. 3 It is usually only after a careful search through old charts and progress notes that a pattern of numerous visits, hospital admissions and investigations of signs and symptoms without a definitive diagnosis is appreciated, arousing the suspicion of a factitious disorder. However, such a search is time consuming, has no reimbursement associated with it and is often left undone, allowing the diagnosis to go unappreciated for extensive periods, if not indefinitely. A search of the patient's personal belongings while she or he is in
CAN J OPHTHALMOL-VOL. 35, NO.5, 2000
247
Letters to the Editor
hospital may reveal the diagnosis? but possible medicolegal ramifications make this practice uncommon.
2.
3. 4. 5. 6.
REFERENCES
1. Taher RM, Singh AD, Hazariwala K. Ocular factitious
disorder presenting as endophthalrnitis. Can J Ophthalmol 2000;35:31-4. Ireland P, Sapira JD, Templeton B. Munchausen's syndrome: review and report of an additional case. Am J Med 1967;43:579-92. Jordan DR, Nerad J, Tse D. An unusual case of orbital cellulitis. Can J Ophthalmoll990;25:210-2. Asher R. Munchausen's syndrome. Lancet 1951;10: 339-41. Bayliss RI. The deceivers. BMJ 1984;288:583-4. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association; 1980.
IN THE NEXT ISSUE • DANS LE PROCHAIN NUMERO COS practice guidelines for refractive surgery Atypical features prompting neuroimaging in acute optic neuropathy
248
CAN J OPHTHALMOL-VOL. 35, NO. 5, 2000
I
thoroughly enjoyed the article "Ocular factitious disorder presenting as endophthalmitis," by Rashid Taber and colleagues, 1 and hope all ophthalmologists read it, as patients with factitious disorders can be very challenging to manage. However, I take issue with some of the authors' assertions. Taber and colleagues describe a woman who intentionally injected a mixture of saliva and tap water into her eye. They nicely discuss factitious disorders and distinguish them from malingering, somatoform disorders and hypochondriasis. They also discuss previously reported cases of ocular Munchausen's syndrome and leave the reader with the impression that their case is another example of ocular Munchausen's syndrome. As Taber and colleagues correctly point out, Munchausen's syndrome is "an extreme form of factitious disorder in which pathologic lying and the intent to deceive are prominent features." This was not the case with their patient. She readily admitted what she had done. In patients with true Munchausen's syndrome (Table 1) there is deliberate deception in which the patient attempts to manipulate physicians through factitious or misrepresented signs and symptoms. 2- 5 There are in fact several types of "deceiver" (those with Munchausen's syndrome being the best known and most publicized) that have been described. 5 Although Taber and colleagues' patient had several previous hospital admissions for other problems (a feature of Munchausen's syndrome), we do not know whether she volunteered what she had done on those
Table 1-Features of Munchausen's syndrome2 Feigned severe illness of a dramatic and emergency nature Factitious evidence of disease Evidence of many previous hospital procedures Pathologic lying Aggressive, unruly behaviour Departure from hospital against advice Numerous previous hospital admissions Absence of any readily discernable ulterior motive
occasions or whether she was trying to deceive the physicians. Nor do we know whether she had any history of aggressive, unruly behaviour or departure from hospital against advice. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders 6 states that factitious disorders are characterized by physical or psychologic symptoms that are produced or feigned intentionally in order to assume the sick role. Munchausen's syndrome is now incorporated into this broader category of disorders. 6 Patients with this syndrome without question have a factitious disorder, but not all factitious disorders are Munchausen's syndrome. It would have been more accurate for the authors to refer to their patient as having a factitious disorder. To suggest that she had Munchausen's syndrome would require documentation of pathologic lying, the intent to deceive and the other features listed in Table 1. I also take issue with the statement "feigned symptoms and secondary motives can be documented by the practitioner through painstaking history-taking and discreet but directed probing." Certainly, if the patient volunteers that he or she has done something to his- or herself, the diagnosis is easy. In cases in which the patient tries to "deceive" the doctor by lying and feigning illness through such means as manipulating test results, the diagnosis can be extremely difficult to discover. 2- 5 I agree with Ashe.-4 (who popularized the term Munchausen's syndrome) that "it is almost impossible to be certain of this diagnosis at first." Patients who feign illness often travel from one hospital to another, one service to another, and one doctor to another and undergo a variety of tests and interventions. Those trying to deceive do not volunteer all their past history, or, if they do, it is often inaccurate or untruthful. In my experience, they continue trying to deceive. 3 It is usually only after a careful search through old charts and progress notes that a pattern of numerous visits, hospital admissions and investigations of signs and symptoms without a definitive diagnosis is appreciated, arousing the suspicion of a factitious disorder. However, such a search is time consuming, has no reimbursement associated with it and is often left undone, allowing the diagnosis to go unappreciated for extensive periods, if not indefinitely. A search of the patient's personal belongings while she or he is in
CAN J OPHTHALMOL-VOL. 35, NO.5, 2000
247
Letters to the Editor
hospital may reveal the diagnosis? but possible medicolegal ramifications make this practice uncommon.
2.
3. 4. 5. 6.
REFERENCES
1. Taher RM, Singh AD, Hazariwala K. Ocular factitious
disorder presenting as endophthalrnitis. Can J Ophthalmol 2000;35:31-4. Ireland P, Sapira JD, Templeton B. Munchausen's syndrome: review and report of an additional case. Am J Med 1967;43:579-92. Jordan DR, Nerad J, Tse D. An unusual case of orbital cellulitis. Can J Ophthalmoll990;25:210-2. Asher R. Munchausen's syndrome. Lancet 1951;10: 339-41. Bayliss RI. The deceivers. BMJ 1984;288:583-4. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association; 1980.
IN THE NEXT ISSUE • DANS LE PROCHAIN NUMERO COS practice guidelines for refractive surgery Atypical features prompting neuroimaging in acute optic neuropathy
248
CAN J OPHTHALMOL-VOL. 35, NO. 5, 2000