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A 61-year-old woman with an unknown psychiatric history presented with mutism, stupor, negativism, and withdrawn behavior. She was admitted to the psychiatric unit for what appeared to be catatonia. Medical records were not readily available. A comprehensive evaluation did not uncover any medical etiology. Lorazepam was ineffective at consistently reversing her catatonic symptoms. During week three of hospitalization, she was given olanzapine with subsequent improvement in her negativism. Several physicians believed her catatonic symptoms were feigned given multiple episodes of spontaneous purposeful movement when she was not under the direct supervision of staff. There is minimal literature on distinguishing catatonia and factitious disorder. This distinction is crucial because these diagnoses require very different treatments, and the iatrogenic complications related to the treatment of catatonia with high-dose benzodiazepines and electroconvulsive therapy are significant. Rapid access to electronic health records can facilitate treatment for patients who cannot provide a medical history, especially when factitious disorder is included in the differential diagnosis.
Catatonia is etiologically related to numerous psychiatric, neurologic, and medical conditions. Catatonia was thought to be under-recognized in the Diagnostic and Statistical Manual, 4th Edition (DSM-4),1 so its diagnostic criteria was updated in the Diagnostic and Statistical Manual, 5th Edition (DSM-5) in order to improve recognition and enhance clinical utility. This update has increased the importance of catatonia given its associated morbidity and mortality and the need for urgent and specific treatments. If left untreated, malignant catatonia has a mortality rate of almost 100%.2,3 We present a case of a homeless psychiatric inpatient who appeared to be feigning her catatonic symptoms, which led to greater consideration of the diagnosis of factitious disorder and how this significantly changed her treatment and disposition.
Patients with factitious disorder can present with numerous types of physical and behavioral symptoms. The core definition of factitious disorder is a condition in which a person intentionally feigns illness in the absence of obvious external rewards in order to assume the “sick role.”4 To date, there is very little literature on factitious disorder presenting as catatonia. While DSM-5 will likely bring increased recognition and diagnosis of catatonia, factitious disorder should also be considered since the treatment for these two diagnoses are very different. The mainstay treatments of catatonia include high-dose benzodiazepines and electroconvulsive therapy, both of which may have unintended complications. Treatment of factitious disorder is usually psychotherapy. According to DSM-5, factitious disorder in hospital settings is estimated to be present in 1% of individuals.4 In psychiatric inpatient units, there is a greater percentage of homeless and transient patients who do not provide a psychiatric history. Consequently, identifying inpatient psychiatric patients with factitious disorder poses a unique challenge. Moreover, patients with factitious disorder can endure serious iatrogenic harm related to the treatment of their feigned signs or symptoms, so accurate diagnosis is essential.5
Homelessness in Hawai‘i has gained a tremendous amount of attention over the past few years. The state's rapidly growing homeless population has reached a five-year high of 7,620 which is the highest per capita in the country.6 Approximately 70% of Hawai‘i's homeless population are immigrants, and this steady influx of homeless has placed an insurmountable strain on the state's resources, forcing the government to declare a state of emergency.6 Obtaining a psychiatric history from these patients can sometimes be difficult, impeding an accurate diagnosis. This in turn can substantially increase the length of stay and the overall cost of healthcare.
A 61-year-old woman with an unknown history was brought to a Hawai‘i emergency department by the police for disruptive behavior and psychotic symptoms. Soon after arriving to the hospital, she became immobile, mute, and would not eat or drink. A history could not be obtained secondary to mutism. On hospital day 20, collateral information was obtained from a friend, and medical records were received from the continental United States (US). Apparently, three days prior to admission, she had traveled by herself from the East Coast of the United States to Hawai‘i. Twenty years ago, she had lived in Hawai‘i with her ex-husband, who was a registered nurse and taught her about medicine. Following their divorce many years ago, she had moved to the East Coast. Her medical records revealed numerous psychiatric hospitalizations, multiple episodes of muteness, a mood disorder, and conversion disorder.
Upon admission, she was mute, immobile, and minimally responsive to painful stimuli. Physical exam was negative for rigidity, waxy flexibility, and echopraxia. Laboratory values including thyroid stimulating hormone level, toxicology, and computerized tomography of the brain were all unremarkable.
For several days, she remained immobile and mute, except to make her needs known, such as requesting water. Quotations from four different physicians were as follows:
She was given 1 mg of intravenous lorazepam prior to meals, then would sometimes become alert and eat. On day 10, she was placed in a wheelchair for refusing to walk, in addition to concerns about an inability to walk. She was then removed from her private room for the first time and placed in the common area. In the common area, she refused all meals and broke her muteness and immobility to explain that her anorexia “was personal” before returning to her room without assistance. She was administered 2 mg of intramuscular lorazepam without subsequent improvement in her catatonic symptoms. This constituted a failed “lorazepam challenge test” and was repeated twice with the same results. On day 15, medical records were obtained and revealed prior diagnoses of bipolar disorder, unspecified and conversion disorder. Thus, the patient was empirically given 10 mg of intramuscular olanzapine. On day 31, her mood was “much better”, and she began talking to physicians. The following day, she was discharged to a shelter on 10 mg of oral olanzapine. Two weeks after discharge, she was admitted to a psychiatric unit in Georgia. Her diagnosis and length of stay in Georgia are unknown.
The patient presented with predominantly catatonic symptoms. She was evaluated by eight psychiatrists and one geriatrician. Her muteness and unavailable medical records contributed to a wide differential diagnosis which included factitious disorder, depressive disorder, personality disorder, conversion disorder, psychotic disorder and malingering. Depression was considered given her withdrawn behavior and a diagnosis of bipolar disorder during previous hospitalizations. Personality disorder was considered since it is frequently associated with factitious disorder. Conversion disorder was considered given her sudden inability to walk and a diagnosis of conversion disorder during previous hospitalizations. A psychotic disorder was considered given her very unusual behavior and psychotic symptoms which brought her to the hospital. Malingering was considered because the patient did not have a place to live in Hawai‘i, which may have motivated her to assume the “sick role.”
The patient's stupor, mutism, and negativism met the DSM-5 criteria for catatonia.4 However, her catatonic symptoms were found to be inconsistent when she was not under the direct supervision of staff. The patient was ultimately diagnosed with factitious disorder since her catatonic symptoms appeared feigned and given the lack of psychiatric hospitalizations prior to her divorce. Stressful events can trigger psychiatric hospitalizations in patients with factitious disorder due to abandonment issues.9,10 Feelings of abandonment in combination with the medical knowledge that she gained from her former marriage to a registered nurse in Hawai‘i could have directed her to present in Hawai‘i with catatonic symptoms. She also appeared to demand attention, and her history of psychiatric admissions in multiple US states was consistent with peregrination. She continued to assume the “sick role” soon after discharge by traveling to Georgia with admission to a psychiatric unit. Her medical records revealed previous diagnoses of bipolar disorder, unspecified, and conversion disorder. Bipolar disorder can present with catatonia, but not with deception as seen with this patient's inconsistent presentation.4 Conversion disorder was ruled against since “Factitious disorder with neurological symptoms is distinguished from conversion disorder by evidence of deceptive falsification of symptoms” per DSM-5.4
Catatonia is a psychiatric diagnosis that has gained more primacy in DSM-5. However, there remains minimal literature on distinguishing catatonia and factitious disorder.8 This distinction is crucial because these diagnoses require very different treatments, and the iatrogenic complications related to the treatment of catatonia with high-dose benzodiazepines and electroconvulsive therapy are significant.10,11 Rapid acquisition of medical records is extremely important because it influences the differential diagnosis and treatment decisions, especially for patients who cannot provide a medical history. There are often significant delays in obtaining medical records for the homeless and mentally ill who present with significant thought disorganization, cognitive deficits, or muteness. This is even more problematic for patients who have recently arrived from the continental US and have no family members or friends in Hawai‘i who can provide collateral information. Medical records are becoming more available through the widespread use of electronic medical records, which is especially helpful when considering the diagnosis of factitious disorder.12,13 The most salient clinical point of this case study is that if a patient demonstrates inconsistencies in symptoms of catatonia, the index of suspicion for factitious disorder should be increased.
Increased consideration for the diagnosis of factitious disorder should be given to patients who present with symptoms similar to this case study. This may significantly reduce the length of stay as an inpatient and therefore the cost of care. In light of Hawai‘i's rapidly growing migrant and homeless population, it is important to expedite acquisition of medical records for patients who are unable to provide a reliable medical history. Thus, efforts should be made to increase the availability of electronic health records.
In terms of a public health impact, the cost of care for immigrant homeless psychiatric inpatients has a substantial financial burden on the limited resources in Hawai‘i. A large majority of these patients do not have identifiable health insurance, which increases the financial strain for the state of Hawai‘i, which translates into less resources for all the people in Hawai‘i. A solution to this problem has yet to be found. In the meantime, healthcare providers in Hawai‘i will continue to provide the best quality of care to everyone, regardless of their psychiatric status and ability to pay.
The University of Hawai‘i Department of Psychiatry and the Queen's Medical Center in Honolulu, Hawai‘i.
None of the authors identify any conflict of interest.