Diagnosis of Munchausen's Syndrome by an Electronic Health Record Search

Abstract

A 29-year-old man presented to the hospital complaining of seizures, galactorrhea, and acromegaly. He reported a family history of multiple endocrine neoplasia type 2 in both parents, and “genetically proven” multiple endocrine neoplasia type 2 in 2 of 17 siblings. His stated occupation was fraud investigator for a telephone company. He reported a recent hospitalization for the same symptoms at a different medical center, and consented to release of information from other hospitals and family members. Multiple attempts to contact family members were unsuccessful, and there was no record of admissions to other hospitals. An extensive endocrine evaluation was negative for multiple endocrine neoplasia. This, when combined with his dramatic style, implausible genetic history, and unusual name (Arkandy McAnders), caused us to suspect Munchausen syndrome. However, we had no evidence of recurrent hospitalizations, an essential feature of Munchausen syndrome.1American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders.4th edn. American Psychiatric Association, Washington, DC2000Google Scholar We conducted an electronic health record search within the Baylor hospital system in an attempt to identify other hospitalizations by our patient using different aliases. Using only the first 2 letters of his last stated name and date of birth, 7 matches were revealed among 1.9 million patients within the Baylor hospital electronic health record system since 2001. Records of the 7 matches were reviewed, and 5 had presentations nearly identical to that of our patient. In a second search, using date-of-birth matches only, an additional 95 patient encounters were returned, and 5 additional aliases for our patient were uncovered. Overall, during a 9-month period, the patient had at least 16 hospital encounters with similar symptoms at 6 different Baylor hospitals, and used at least 11 different aliases, several of which resembled classic Roman, Greek, and Biblical names (Table). The discovery of multiple aliases was possible only because the patient used the same date of birth on multiple occasions. Prior records did not reveal evidence that Munchausen syndrome was ever considered before.TableEleven Aliases Discovered Using Two Different EHR Search Criteria“Mc” and DOB SearchDOB Search OnlyArkandy McAnders (4)Orphacious White (2)‡Orpheus: a poet and musician who charmed Hades in Greek mythology.Ananious McAnders⁎Ananias: name of 3 persons in the New Testament.Ananious Geter⁎Ananias: name of 3 persons in the New Testament.Octavious McAnderson†Octavius or Gaius Julius Caesar Octavianus (Augustus) was the first Roman emperor.Adrian GeterAaron McKnightAdrian MichaelsAustralia McTurner (2)Lamont AdrianAustralia McFearNote: The true name of the patient is not mentioned in the report or the Table.Numbers in parentheses indicate the number of times the alias was used.DOB=date of birth. Ananias: name of 3 persons in the New Testament.† Octavius or Gaius Julius Caesar Octavianus (Augustus) was the first Roman emperor.‡ Orpheus: a poet and musician who charmed Hades in Greek mythology. Open table in a new tab Note: The true name of the patient is not mentioned in the report or the Table. Numbers in parentheses indicate the number of times the alias was used. DOB=date of birth. This case illustrates several features of Munchausen syndrome, most notably pathologic lying (pseudologia fantastica), peregrination (traveling), and use of aliases.2Asher R. Munchausen's syndrome.Lancet. 1951; 1: 339-341Abstract PubMed Scopus (752) Google Scholar, 3Pallis C.A. Bamji A.N. McIlroy was here Or was he?.Br Med J. 1979; 1: 973-975Crossref PubMed Scopus (19) Google Scholar To our knowledge, Munchausen syndrome diagnosed by an electronic health record search has not been reported. Legal and ethical questions may arise from such searches, but at this time there is no case law or precedent to establish guidelines.4Eisendrath S.J. Rand D.C. Feldman M.D. Factitious disorders and litigation.in: Feldman M.D. Eisendrath S.J. The Spectrum of Factitious Disorders. American Psychiatric Publishing, Washington, DC1996: 65-81Google Scholar, 5Kass F.C. Identification of persons with Munchausen's syndrome: ethical problems.Gen Hosp Psychiatry. 1985; 7: 195-200Abstract Full Text PDF PubMed Scopus (26) Google Scholar We conclude that an electronic health record search may be warranted to establish the diagnosis of Munchausen when done under the ethical guideline of beneficience (ie, to prevent iatrogenic disease), preferably in conjunction with a Health Insurance Portability and Accountability Act compliance officer.