According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV-TR) factitious disorders are characterised by intentional production of either physical, psychological or mixed symptoms that simulate various clinical syndromes with no apparent advantage for the individual concerned other than allowing him or her to assume the sick role in order to receive care and support.2
The definition applied by the International Statistical Classification of Diseases and Related Health Problems-10 is similar but adds absence of confirmed physical or other psychiatric pathology as an exclusion criterion.3
Despite the inexistence of this last criterion in DSM-IV-TR, diagnosis of factitious disorders should not be considered as definite and ongoing revision and further investigation should be conducted along its course. Munchausen syndrome is a specific subset of factitious disorders, usually with more extreme presentations, worse prognosis and a more refractory course than other forms of factitious disorders. Despite the fact that the secretive nature of Munchausen syndrome and of factitious disorders in general thwarts traditional epidemiological research, it is estimated that as much as 6–8% of all psychiatric admissions4 5
and 1.3% of general hospital admissions6
could be cases of factitious disorders.
Management of factitious disorders presents many challenges. Reports of success in treating factitious disorders are limited, but the varying case reports stress the need for a strong therapist–patient alliance.7
It is highlighted that the first step for management is a tolerant attitude8
and directing the efforts towards stopping self-discharge and the consequent peregrination throughout health services.9
Although the usual effects on staff exerted by these patients are initially those of concern and empathy they gradually change into scepticism as the deceptive nature of the disease becomes apparent.10
As a result, once a patient receives this diagnosis every new symptom presented tends to be regarded as feigned. This fact closely relates to the stereotype that considers a diagnosis of mental illness to be an everlasting entity. As a consequence, there is a tendency to interpret any abnormal behaviour or complaint in a psychiatric patient as a manifestation of the mental illness.
We described a case of Munchausen syndrome where psychiatric symptoms were the object of fabrication with an accompanying genuine acute pericarditis. The latter is a common disorder in several clinical settings. Although the exact incidence and prevalence are unknown, acute pericarditis is recorded in about 0.1% of patients admitted to hospital.11
Potential serious complications include cardiac tamponade, chronic pericarditis or constrictive pericarditis. Although a report of factitious disorders mimicking multiple personality disorder combined with real malignant hypertension could be found in the literature,12
this is, to the authors’ knowledge, the first report of simulated psychosis and mutism with concomitant genuine physical illness.
The patient in this case had a firm diagnosis of Munchausen syndrome, which could have made clinicians dismiss the new symptoms as feigned. Prompt evaluation in this case was cardinal for recognition and management of the intercurrence.
- A previous history of simulation does not exclude coexistence of genuine illness.
- Changes in clinical presentation in a patient diagnosed with factitious disorders/Munchausen syndrome should raise the possibility of concomitant genuine illness.
- FD is probably an under diagnosed condition, both in the psychiatric as well as in the general clinical setting.