ABSTRACT
The patient was a 23-year-old female with typical symptoms of cluster headache
that began shortly after a cervical trigger point injection for radicular
pain.She underwent multiple hospitalizations, was frequently seen in outpatient
offices,and was given a number of cluster and migraine medications. She became
well versed in the textbook presentation of cluster headache.The patient
displayed a very dramatic presentation of pain, but could be easily distracted
from the pain.While it was suspected that she was using artificial tears
to simulate tearing, this was not definitely confirmed.In addition, despite
the patient claiming to have severe nausea and vomiting, actualvomiting was
never witnessed by medical personnel.Antiemetics were unsuccessful in relieving
her nausea.The patient craved attention, and was very persistent in attempting
to be hospitalized.Psychological testing revealed weak coping mechanisms,
depression, low frustration tolerance, and a low self esteem.
INTRODUCTION
Factitious disorders are displayed by patients who actively seek to assume
the sick role, without obvious secondary gains from feigning illness.If they
do display ulterior motives, the disorder would most likely be termed
malingering.The popular name for these factitious disorders with physical
symptoms has become Munchausen's syndrome, labeled as such by Richard Asher.He
based the name and syndrome on the German officer Karl Friedrich Hieronymus,
Frieherr von Munchausen (1720-1797), well known for exaggerating his own
adventures.With this disorder, there is a need to remain in the sick role,
and these patients often are hospitalized multiple times for the feigned
illness.In the following report, a young woman feigned cluster headache,
which began after an injection for cervical pain.
HISTORY
The patient was a 23 year old white female with a 1 year history of right
periorbital and temporal sharp pain, eye tearing, and nasal congestion. The
attacks occurred 1 to 5 times per day, lasting 1 to 2 hours. She had associated
nausea and vomiting. Neurological exam was always normal, with no pupillary
abnormalities, and no skin changes. The symptoms began shortly after a right
sided cervical trigger point injection for radicular pain. With the onset
of the cluster headaches, the patient was admitted multiple times for prolonged
hospitalizations, was seen in outpatient offices at least once per week,
and was given numerous medications. Virtually every known cluster, migraine, and pain preventive medication
was a failure. Within 2 months after the clusters began, she was very well
versed in the textbook presentation of cluster headache. Narcotics provided
the only benefit, and the patient did actively seek them out. Her presentation
of the pain was often dramatic, but she could be easily distracted from the
pain. She was caught several times manipulating and lying in order to obtain
narcotics. While it was suspected that the patient was using artificial tears
to simulate tearing, this was not able to be
confirmed. Despite her description of nausea and vomiting, actual
vomiting was never confirmed by medical personnel.Antiemetics were unsuccessful
in alleviating her nausea. The patient was exceedingly dependent,
but had little or no support from family or
friends. Her hospitalizations were marked by a notable absence
of visitors. Psychological testing revealed depression, denial of psychological
problems, poor impulse control, low frustration tolerance, low self esteem,
and a dependent personality. In addition, testing revealed weak coping mechanisms,
social isolation, little experience of pleasure, and agitation. There was
no evidence for distorted reality testing.
The patient craved attention, and was very persistent in her attempts to
be hospitalized.She felt very comfortable in the sick role and described
herself as an extremely severe chronic cluster patient. There was no obvious
secondary gain other than increased attention, and the obtaining of
narcotics.
The patient was followed in our headache clinic for two years.She cooperated
with regular visits to the psychotherapist, but very minimal progress was
made.After several years, the symptoms had not abated, and the patient was
still very forceful in attempting to obtain hospitalization.She was subsequently
lost to follow-up.
COMMENTS
DSM-IV lists the following Factitious Disorders:
Factitious Disorder with Predominantly Psychological Signs and
Symptoms
Factitious Disorder with Predominantly Physical Signs and Symptoms
(Munchausen's Syndrome)
Factitious Disorder with Combined Psychological and Physical Signs
and Symptoms
Factitious Disorder Not Otherwise Specified (NOS)
Factitious disorder must be distinguished from malingering.As with factitious
disorder, patients who are malingering feign illness and produce physical
or psychological symptoms.With malingering, there is a definite secondary
gain such as money, evading the law, avoiding responsibility, etc.Patients
with factitious disorder are assuming the sick role; malingerers have goals
outside of this.In the past, patients with factitious disorders often
became;hospital hoboes; however, as it is much more difficult to obtain
admissions to the hospital in the past few years, and those admissions are
for a short period of time, many of these patients bounce from outpatient
clinic to outpatient clinic.Factitious disorder does not have to be limited
to oneself; factitious disorder by proxy is the assumption of the sick role
by feigning illness in another person or a child.
Most of the Munchausen patients fake physical symptoms, but with some patients
it is primarily psychological symptoms that are feigned. The patients may
actively take in toxic substances, place blood or other substances in their
urine, overmedicate with drugs such as insulin, or produce home-grown
thermometers that are pre-set.Some patients are more active in their feigning
of illness than others.In the case presented here, the patient primarily
complained of typical cluster symptoms, but she did have eye tearing that
was felt to be feigned.No eye drops were ever found on her
person.
Munchausen's syndrome is relatively rare, even among chronic pain
patients.One study of 2,860 chronic pain patients identified 4 Munchausen
patients, for a frequency of 0.14%.
Munchausen syndrome often begins in early adulthood, and as in the current
case, it may begin after a hospitalization or a medical problem.While many
of the patients are medical personnel, or are well versed in medical terminology,
the young woman in this case did not have specific medical
training.
Various psychodynamic scenarios have been described in patients with factitious
disorder.Rejecting mothers, serious illness in a parent, and a history of
childhood deprivation have been described. If the patient has been raised
primarily by institutional personnel, this may make it more likely for the
person to seek that type of care as an adult.Psychological testing may reveal
a narcissistic personality, an inability to tolerate frustration, a poor
sense of identity, but no evidence for a true formal thought disorder.
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