Munchausen syndrome: Playing sick or sick player.

Munchausen syndrome is rare factitious disorder which entails frequent hospitalization, pathological lying and intentional production of symptoms for sick role. Management requires collateral history taking, sound clinical approach, exclusion of organicity and addressing psychological issues. A case which presented with unusual symptoms of similar dimension is discussed here. The case brings out finer nuances in evaluation and management of this entity.

Munchausen syndrome is a rare psychiatric illness which comes under the broad rubric of factitious disorder. In this disorder affected people feign physical or psychological symptoms to gain sympathy, attention or sick role. It has also been named as hospital addiction syndrome, thick chart syndrome or hospital hopper syndrome. Munchausen syndrome is a subclass within the factitious disorder which additionally entails repeated hospitalization, travelling and untrue but improbable tales of their illness.[1] Illness was described by Richard Asher in 1951; who named it after Baron Munchausen who was known for his wild fabricated tales of his travels.[2] This disorder is different from hypochondriasis or other somatoform disorders in that symptoms are not produced intentionally.[3] It is also different from pretending illness for clear external benefits like financial compensation, excuse from work etc.[4] Munchausen syndrome patients requires proper evaluation which includes detailed history taking, perusal of available medical records, ascertaining of mental illness, assessment of risk of self harm and requirement of hospitalization.[5] This patient reported with unusual symptoms which was expressed with a dramatic flair and persisted despite repeated intervention and exclusion of any evidence to organicity. The case is reported here for its unusual presentation, rarity and issues in management approach.

CASE REPORT

A 19-year-old housewife who got married at the age of 17 years from a nuclear to a joint family was referred by the medical specialist with history of multiple hospital admissions following complaints of episodes of pink colored vomitus, pink tears and sweat of 2 years duration for which no organicity could be detected so far. History from the individual and her family members revealed that the Individual was apparently well and functional till 2 months into her marriage in Jan 12 when one day while working alone in the kitchen she started retching loudly. Her husband who was in the next room watching television rushed in and saw her standing over a small pool of pink colored liquid. The patient claimed that she had vomited this pink liquid which was staining her teeth, lips, lower face, neck and cloths. They tried rinsing the stain but it proved tenacious and took 7–10 days to remove completely. She was asked to rest and was fine till the next afternoon when again alone in the kitchen her family members heard her retching. On reaching the kitchen they found her holding a pail with 200–250 ml of pink colored liquid. They rushed to a private hospital where she was admitted and investigated on lines of hematemesis. All relevant investigations such as hemogram, stool for occult blood, ultrasound abdomen were within normal limit. She was managed with antiemetic and intravenous fluids; subsequently discharged after 5 days. During the hospital stay she did not have any complaints or similar manifestation. After discharge from the hospital, she was sent to her parents to rest. She stayed there for 10 days and was taken care by her parents and siblings. Four days after returning to her in law's house while washing clothes alone in the bathroom she again had pink colored liquid. She was now admitted to another hospital where in addition to blood, stool and urine examination she underwent an endoscopy. All her investigations were again normal. During her 6 days of hospital stay she did not have recurrence of her symptoms. After discharge from the hospital she stayed with her parents and remained asymptomatic. Back again at her in-law's place she continued to complain of copious pink colored vomitus. Keeping in mind her “ill health” she was provided a separate room with her husband by the in-law. The episodes continued to occur at regular interval. There has never been an eyewitness account of the vomiting as she would manifest with the complaint, after returning from the kitchen/bathroom where she would be alone. In Mar-Apr 12; one day after dismounting from the scooter in which she was ridding pillion her husband noticed that her both eyes were red and swollen. She also had dark pink vertical stains on the cheek. Individual claimed that it was pink tears rolling down her eyes and staining her face. She was immediately taken to a dispensary where she was prescribed some eye drops with which her swelling subsided in 3–4 days. No pink tears were noted then on ophthalmological examination. After a period of 7–10 days she returned from the bathroom complaining of pink colored sweat staining her forearms and palms. Since the doctors were not able to “cure” her she was taken by her parents and in laws to multiple places of worship all over Maharashtra with the hope of a “cure”. Individual delivered a healthy male child in Dec 12. She continued to have the earlier complaints. Now whenever she had the episode she was given rest from childcare duty as the color would stain the child as well.

In May 13, she came to our medical out-patient department (OPD) with a bottle of pink colored liquid claimed was vomitus. She was again evaluated on lines of Hematemesis. All her relevant Investigations that is hemogram, liver function test (LFT), renal function test (RFT), ultrasound (USG) Abdomen, Thyroid function test, USG thyroid, urine porphobilinogen, serum ceruloplasmin, stool for occult blood and ocular and dermatological examination were within normal limit. Individual continued to report to Medical OPD on a regular basis with persisting complaints. On 03 Jan 14 following a fresh complaint of pink colored vomitus; she was admitted and psychiatric consultation was sought.

There was no history of blood stained vomitus, malena, cramp abdomen, diarrhea, constipation, asthenia, pruritis, skin rash, skin allergy, foreign body sensation eye, visual disturbance, epiphora, pain eye, mood, thought or perceptual disturbance, head injuries, seizures, altered sensorium, fever etc., There is no history of psychiatric illness in the past. She is the youngest daughter and was particularly close to her father. She was a pampered child and was never involved in household chores as they were performed by her mother and elder sisters. DOB: 11 Dec 1994. History of nail biting and bed wetting till age of 9 years was present. Educated up to VI standard. Does not have any close friends. Spent most of the childhood at home in the company of her younger brother and father. Married her maternal cousin in an arranged ceremony. Her husband is a tempo driver and spends most of the time out of the house. Her in-law's have a joint family comprising of none members. Being the youngest she was expected to perform most of the physically demanding domestic chores like washing clothes and sweeping the house. She claimed cordial relationship with her spouse.

General physical and systemic examinations were within normal limit. Psychiatric evaluation and ward observation revealed him to be comfortable while in hospital. She remained cheerful and did not show any obvious concern for the disease which has not been found out so far. On deeper question she avoided the subject but discussed on length at other topics. During her entire hospital stay she had no vomiting and her sweat/tears were not pink. She stated in defense that it comes only once in a while, is unpredictable and never comes while at hospital or in OPD. Her father whole heartedly supported her daughter's statement but on detailed interview it was found out that he never had an eye witness account of an episode. Her husband denied any occurrence of any episode in front of people. He also denied her of suffering from any associated fatigue, pain abdomen, malaise which generally comes with vomiting.

Individual was diagnosed as a case of Factitious disorder (F68.1, Munchausen's syndrome). Psychometry revealed elevation on scales of anxiety, depression and hysteria. She was managed in an empathetic and non-confrontational manner. Psychotherapy aimed at enhancing positive coping skills and improving interpersonal relationship was imparted. Family members were educated about her sick role behavior and measures for the reduction. Individual was subsequently discharged after 2 weeks of inpatient management. She is under regular follow-up since then and has not reported with recurrence of the episode.

DISCUSSION

The patient presented with unusual symptoms which neither occurred in presence of others nor in the hospital situations. She underwent all investigations without any discomfort. She talked about her symptoms with full convictions and was found unusually at ease while at hospital considering her problems. Extensive relevant investigation and clinical evaluation on various occasions ruled out all possible organciity. She went around hospitals and religious institutions with these symptoms and landed this time to our hospital. The above profile aptly fits into the prototype of factitious disorder and in that; Munchausen syndrome.[6] Her family dynamics and initial upbringing suggests vulnerability and the expected role in the expanded family of in-laws a perceived stress. The pattern is not uncommon in such cases. Her symptoms increased in dimension with the increasing requirement of sick role behavior. Attention she gained due to the problem is evident and probably responsible for continuation of the problem. She had neurotic traits in the psychometry which was not of syndromal dimension and thus did not require medication. Psychotherapy aimed at reducing gains (sick role benefits) and promoting socially acceptable and positive behavior was imparted to the individual. Husband and family members were involved for better gains. An early recognition of illness, exclusion of organicity and empathetic approach to treatment is the crux of the management of Munchausen syndrome.[7]