Catch them if you can
Diagnosing and treating factitious disorder
By Stacey Butterfield
When Catherine Rockwood, MD, first read the chart of the patient being admitted from the emergency department, he seemed very sick.
“He presented with anaphylaxis and joint pain. He reported previous history of asthma, sickle cell disease, HIV, afib, transverse myelitis, cystic fibrosis and hyperthyroidism,” said Dr. Rockwood, a second-year resident at the University of Chicago. The patient's medication list appeared to confirm his history: He was taking 15 prescription medications, including warfarin, methylprednisolone and hydroxyurea.
Photo by Joseph M. Kane, Mayo Clinic Editorial Photography.
But as Dr. Rockwood and her colleagues got to know the patient, they became suspicious. “His story got to be a little bit too unbelievable,” she said. For example, the patient claimed he had several siblings currently hospitalized for one of the diseases he claimed to have. Testing confirmed the physicians' doubts. “We put him on telemetry for his afib, which he was never found to have, did a chest X-ray, which found no evidence of cystic fibrosis, and ran tests for HIV and sickle cell, which were negative,” she said.
Rather than any of the medical illnesses he reported, the patient suffered from factitious disorder, a mental health condition that can be difficult for hospitalists to identify and frustrating for them to treat. The problem was first described in 1951 as Munchausen syndrome, but physicians still struggle with the proper response to patients who seek medical care for fabricated symptoms.
Incidence estimates suggest that more than 1% of medical admissions could be factitious, and that's not counting the patients no one catches. “By the very nature of the disorder, it will be underreported,” said Christopher Kenedi, MD, ACP Member, a psychiatrist and hospitalist in Auckland, New Zealand. “It's a psychiatric disorder that's only ever seen by non-psychiatrists and so it's not going to be detected. We miss the ones who are successful.”
Spotting the disorder
The good news is that many factitious patients fit a pattern, exhibiting common traits that can make them easier to spot.
“Inconsistency is the byword, in terms of describing symptoms, and in terms of their affect,” said Ronald B. Goodspeed, MD, FACP, an instructor in health care management at the Harvard School of Public Health in Boston. “For example, they are telling you about back pain that's really been killing them for months, but they are talking about it as though they were describing the grocery list, in this nonchalant way.”
Dr. Rockwood observed such inappropriate affect in her patient: “I kept saying, ‘Isn't it great you don't have HIV?’ He would shrug and say politely, ‘OK.’”
Factitious patients can also have reactions that are excessive in the opposite direction. “Certain of these patients can be very dramatic in their descriptions…telling their tale and all the travails they've been through to get their problem taken care of,” said Dr. Goodspeed.
Faith Fitzgerald, MD, MACP, described her encounter with a patient like this in the March 6 Annals of Internal Medicine. “…[B]etween short periodic bouts of weeping and writhing, she told me that she had had ‘over 40 operations' on the currently affected knee alone, as well as at least 20 surgeries on other joints and various other parts of her body,” wrote Dr. Fitzgerald, a professor of medicine at the University of California, Davis.
A physical exam failed to confirm the patient's stated and documented diagnosis of Ehlers–Danlos syndrome, and led Dr. Fitzgerald to suspect factitious disorder. “She had this sort of joy in her disease, plus no evidence on physical exam of any elastic tissue dysfunction,” she said.
Strange behavior and physical and lab findings incongruent with symptoms are the most common route to a diagnosis of factitious disorder, experts said. “A small percentage of patients will be caught in-hospital red-handed—such as injecting egg whites into their bladder to simulate proteinuria or making a cut in their mouth to produce hemoptysis,” said Dr. Kenedi. Other traditional strategies of factitious patients include injecting insulin to induce hypoglycemia, making a small cut to put blood in a urine sample, or taking warfarin to cause bruising.
Advances in medical technology have made some of these tactics easier to spot. Electronic thermometers are harder to trick, a lab test can detect artificial insulin, and a CT scan will reveal the absence of kidney stones, for example. In the Sept. 9, 2011 New Zealand Medical Journal, Dr. Kenedi and colleagues published a systematic review of laboratory tests that may be useful in identifying factitious patients.
However, modern technology, specifically the Internet, has provided new tactics for these patients, as well. “There are websites all over the place that instruct people in what symptoms to have,” said Dr. Fitzgerald, noting Lyme disease and lupus as examples with significant Web presence.
Knowledge and terminology acquired from the Internet can make faking patients seem more credible. “They're really quite sophisticated and they will actually throw out medical terminology, which makes it very tempting for the physician to make a presumption that this person is intelligent and they know what they are talking about,” said Dr. Goodspeed.
Electronic health records (EHRs) can serve as either a help or a hindrance, the experts said. Dr. Kenedi described a patient who had presented herself to an oncology service, apparently carrying printouts of her EHR. “Because it was in the form of their health record printouts, it generated enormous credibility,” he said. The record turned out to be fabricated.
Dr. Fitzgerald suspects that delayed recognition of her patient's factitious disorder may have been the fault of the hospital's EHR. The patient had multiple previous admissions, with physical exams described in identical terminology. “You simply copy what somebody else has seen or done and said, and then copy copiously all of the laboratory studies and paste it, without critical review or even the necessary entry of your own thoughts,” she said.
The consistency of the prior records was also an obstacle to changing the patient's diagnosis in response to contrary findings, she added. “The medical student said, ‘Other people saw it. They said it was there. Who am I [to say it's not]?’”
Dr. Rockwood also found an apparent shortage of critical analysis in her patient's records. “He had echos and EEGs and other tests, and all the tests were negative. I don't know exactly why [his previous physicians] weren't paying attention to all these results being negative,” she said.
But in this case, the EHR also helped her confirm the diagnosis of factitious disorder. The patient had been admitted to a children's hospital many years earlier and behaved suspiciously. “The nursing staff witnessed him manipulating the equipment,” she said.
Some physicians have dug even deeper in EHRs to catch a factitious patient. In a 2009 letter to the American Journal of Medicine, Thomas G. Van Dinter Jr., MD, and Brian J. Welch, MD, described running a date-of-birth search on a factitious patient to find previous admissions under other names. “Overall, during a 9-month period, the patient had at least 16 hospital encounters with similar symptoms at 6 different Baylor hospitals, and used at least 11 different aliases,” they reported.
Talk to everyone
Since most patients won't be caught easily, it can be difficult to definitively determine if a complaint is factitious.
“I live in fear of diagnosing it where it is not,” said Dr. Kenedi. “But if things don't start to add up, if the history's inconsistent, if there's lack of collateral, if there are a number of presentations all with vague symptoms or complaints, and if the laboratory values aren't consistent, I don't say that the person's factitious, but I put it on the differential—about the same time that I start hunting for zebras.”
Confirmation of suspicions requires conversation—with the patient, family and other clinicians, if possible. With the patient, the best course is honesty, the experts advised. “Just say to them, ‘Your findings don't make sense compared to your symptoms.’ It's a signal to them, if they're experienced at this. They realize that you're suspicious,” said Dr. Goodspeed.
Family members can provide history, but talking to the family may not always be helpful, noted Dr. Rockwood. “I spoke with our patient's girlfriend for a long time. She was very angry about our not treating him [for his alleged diagnoses]. She wanted to sue,” she said.
A primary care physician may offer more perspective to confirm or alleviate suspicions. “I'll talk to the patient's regular doctor and get a sense of ‘Who is this person? How do they deal with stress?’” said Dr. Kenedi.
A consulting psychiatrist may be helpful in conducting these conversations, as well as to provide the confirmation of an expert perspective. “These diagnoses take a lot of time. These patients take a lot of time,” Dr. Kenedi said. On the other hand, the patients' hospital stays should not extend longer than medical necessity dictates, to avoid potential harm to both their physical and mental health, experts said.
Once a diagnosis of factitious disorder is made, or strongly suspected, “We do prefer that they be followed up as an outpatient,” said Dr. Kenedi. However, that outpatient care may not be specifically psychiatric.
“They're not going to see a psychiatrist for any number of reasons: They don't believe something's wrong with them, they won't admit it,” said Dr. Kenedi. Instead, he enlists the patient's outpatient internist or family physician. “We'll say, ‘We don't know what's going on, but we think it may be factitious disorder. We'd like you to see this patient regularly.’”
For severe cases, Dr. Kenedi recommends two to three visits a week for the first few weeks after discharge, “need it or not,” followed by gradual weaning. Patients with less severe problems can start with weekly outpatient visits.
Explaining this treatment plan to patients requires honesty but also some tact. Dr. Kenedi offered an example: “We think that there is something wrong, that you are in distress, but we don't think that we can identify the causes. We're not giving up on you, but it's not appropriate for the care to be in the hospital.”
While the patient is still in the hospital, the best course is to provide the least aggressive care that still meets the standard of care. “Avoid invasive procedures that aren't absolutely necessary. We discuss with colleagues and we do a lot more watchful waiting,” said Dr. Kenedi.
Unnecessary testing and procedures are some of the most problematic consequences of factitious disorder. They are not only costly to the health care system but can hurt other patients.
Dr. Kenedi recently completed a review of factious decompression syndrome. “Those patients are being moved by ambulance or by pressurized aircraft, or a hovercraft in one case, to get them to a decompression chamber. Tremendous resources are being put into caring for them,” he said. “When that patient's in the chamber, no one else can use the chamber, so if another diver does develop the bends, or it needs to be used for wound healing or after radiation therapy, they can't use it.”
Factitious cases can also have a negative effect on the involved clinicians. “When I'm called in, a lot of what I have to deal with is the anger and frustration of the team. Their time is being wasted, their trust is being betrayed,” Dr. Kenedi said.
Finally, there's the potential iatrogenic harm to the patient. Dr. Kenedi related the story he had been told (during his combined internal medicine/psychiatry residency at Duke University Medical Center) of a patient who presented with symptoms of aortic dissection. In addition to a sternotomy scar, he claimed to have a contrast allergy, metal in his body preventing an MRI and a congenital heart defect. The patient stated he had recently come from Europe where he had received all his medical care, and his chest X-ray confirmed sternotomy wires.
“There was a team prepping an OR, when one of the other docs said, ‘This doesn't make sense. There are too many unusual factors in one person,’” Dr. Kenedi said. The team halted the surgery preparations, did an echocardiogram on the patient, and determined that he was factitious.
When a patient is so definitively exposed, or even in cases where there's a high suspicion but not certainty, documentation is important. “We document very carefully,” said Dr. Kenedi. “We document it in a very matter-of-fact, non-pejorative way. We document the behaviors of concern….The goal is to let future treatment teams and clinicians know that we don't know what's going on but we are concerned that this might be factitious disorder.”
The effectiveness of this documentation is limited by the tendency of some patients to travel far and wide in search of care, said Dr. Fitzgerald, who saw a patient once who had flown to hospitals around the country and even in Europe. “They used to publish letters to the editor, even in the Journal of the American Medical Association, the New England Journal of Medicine, Annals of Internal Medicine—notifications across the country of Munchausen patients,” she said.
Today, such notifications are the exception rather than the rule, a boon to patient privacy but perhaps not always to the successful care of factitious patients. The Duke team caught the patient faking aortic dissection before they operated, but they still weren't able to save him from himself.
“This patient reportedly ended up dying on the table in another hospital,” said Dr. Kenedi.
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