Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Factitious disorder

Patient will present as → a 35-year-old female with c/o palpitations and chest pain for 2 days. She reports that she had been sweating with nausea and vomiting. She reports that she “checked her pulse which was about 156.” She denies any personal or family history of heart disease or anxiety disorders. She rated her chest pain as 10/10 “which radiates down my left arm and up my jaw.” ECG reads normal sinus rhythm. Troponin, CKMB and other labs were normal. When she was told that her labs were normal, she flopped onto the bed and started “seizing.” She stated, “I am seizing. Why won’t you help me?” When the ER PA calls her out, she got angry and left against medical advice.

Key Points:

Factitious disorder imposed on self (Munchausen syndrome)

  • The patient falsifies physical or psychological symptoms or induces injury or disease to themselves
  • The patient's deceptive behavior occurs in the absence of external rewards

Factitious Disorder Imposed on Another (Munchausen syndrome by proxy)

  • When in another person (e.g., a child) it is termed factitious disorder imposed on another (Munchausen syndrome by proxy)

DSM-5 Diagnostic Criteria

Factitious Disorder Imposed on Self

  • Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
  • The individual presents himself or herself to others as ill, impaired, or injured.
  • The deceptive behavior is evident even in the absence of obvious external rewards.
  • The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Specify: Single episode Recurrent episodes (two or more events of falsification of illness and/or induction of injury)

Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy)

  • Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.
  • The individual presents another individual (victim) to others as ill, impaired, or injured.
  • The deceptive behavior is evident even in the absence of obvious external rewards.
  • The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Note: The perpetrator, not the victim, receives this diagnosis.

Conjoint confrontation by the PCP and the psychiatrist.

  • Overt disclosure using therapies such as biofeedback, self-hypnosis and double-blind therapy (where a patient is told that there are possible diagnoses of their illness: one organic and the other factitious disorder).
  • In factitious disorder imposed on another (e.g., in a child)
    • Children must be removed by child protective services
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Question 1
A 9-year-old boy is brought to the emergency room with shortness of breath. His mother reports that his symptoms began two days ago and that this is the first time that her son has ever been sick. On exam, he is pale, diaphoretic, and lethargic, and his glucose is found to be 20 mg/dL. When looking up the patient's chart, the physician finds that the patient has been brought into the emergency room four times in the past year with the same symptoms, and his C-peptide levels at all visits have been low. After administration of glucose, what is the most appropriate next step?
A
Discharge to home with follow-up at with an endocrinologist
Hint:
The patient's C-peptide levels are low, and therefore this presentation is unlikely to be due to overproduction of endogenous insulin.
B
Refer the patient's mother to a psychiatrist
Hint:
Although the patient's mother may benefit from therapy, the providers must first protect the patient from further harm.
C
Contact the patient's outpatient pediatrician for follow-up diabetes testing
Hint:
This patient has low, not high glucose. Although the outpatient pediatrician should be involved in the case, the patient does not need follow-up testing for diabetes.
D
Contact the hospital ethics board
Hint:
Since this is a case of very likely child abuse, the hospital ethics board does not need to be involved.
E
Contact child protective services
Question 1 Explanation: 
This clinical presentation is most consistent with Factitious disorder imposed on another (Munchausen syndrome by proxy). This is considered a form of child abuse, and providers should contact child protective services in suspected cases. Factitious disorder imposed on another is a psychiatric condition in which a patient consciously reports false symptoms, or induces symptoms, with the goal of playing the "sick role." Patients may inflict significant self-harm in the process of creating symptoms, such as injecting insulin or swallowing food that is known to be contaminated
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Psychiatry EOR: Somatic Symptom and Related Disorders; Nonadherence to Medical Treatment (Pearls) (Prev Lesson)
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