Diagnosis Of Factitious Disorder Research Articles

Clinical impact and misdiagnosis of functional ophthalmological symptoms: a case report

BackgroundThere is a high prevalence of somatoform disorders and medically unexplained symptoms. When it comes to deciding whether a patient is able to work, it is essential to differentiate a somatoform disorder from a factitious disorder. The case presented demonstrates the impact on disability benefits and the subsequent psychosocial repercussions of misdiagnosing between a factitious disorder and a somatoform disorder.Case presentationA 42-year-old Caucasian woman worked as a 100% fiduciary accountant until the age of 32 when she was placed on medical leave due to persistent trigeminal neuralgia. Afterward, she developed total blindness, not explained by a physiological process, accompanied by distress in a crucial emotional context. We evaluated the patient for a revision of a disability income after a diagnosis of factitious disorder with severe consequences such as disability income suspension and family conflict. Our psychiatric examination concluded the diagnoses of pain disorders related to psychological factors and a dissociative neurological symptom disorder with visual disturbance.ConclusionsBlindness not explained by a physiological process may accompany trauma and psychological distress. Differentiating this pathology from factitious disorder or simulation is essential from an insurance medicine point of view, but also for its treatment.

Feigning Capgras Syndrome and Developmental Prosopagnosia: A Rare Case of Pediatric Factitious Disorder

Background: Factitious Disorder is a condition included among psychiatric disorders, where symptoms are intentionally produced to seek medical attention. Its epidemiology, treatment, and outcome are largely unknown. Objective: To increase knowledge of the condition, we discuss a pediatric case where the patient feigned neuropsychiatric symptoms. Methods: A 15-year-old female adolescent presented with neuropsychiatric symptoms suggestive of rare conditions such as Delusional Misidentification Syndrome (i.e., Capgras and Fregoli syndromes) and Developmental Prosopagnosia as well as epileptic seizures. Results: When Delusional Misidentification Syndrome was suspected, she was treated with Risperidone. Due to suboptimal response, Alprazolam and Sertraline were added and then Risperidone was cross-titrated to Haloperidol. The condition severity led to her admission to an inpatient Child and Adolescent Neuropsychiatry Unit. MRI scan and electroencephalographic recording were normal. The self- and parent-reported psychological assessment indicated several psychiatric symptoms. Instead, the clinician-administered Minnesota Multiphasic Personality Inventory-Adolescent and Structured Inventory of Malingered Symptomatology suggested a fake-bad profile and neuropsychiatric symptom simulation. Along with evidence of incongruent symptoms between the patient’s interviews, such investigations led to the diagnosis of Factitious Disorder. Psychopharmacological treatment was discontinued, and psychological support was offered to the patient and her parents. Conclusion: Increasing knowledge about Factitious Disorder is needed.

Clinical impact and misdiagnosis of functional ophthalmological symptoms: a case report

Introduction The disease burden due to non-specific, functional, and somatoform disorders is high. An unknown part of these medically unexplained symptoms belongs to factitious disorders. When it comes to deciding whether a patient is able to work, it is essential to differentiate a somatoform disorder from a factitious disorder.ObjectivesThe aim is to highlight, on the one hand, the differences between somatoform disorder and factitious disorder and, on the other hand, the potential impact of misdiagnosis in medical expertise regarding eligibility for a disability income.MethodsA case report of Ms A. a 42-year-old Caucasian woman. She worked as a 100% fiduciary accountant until the age of 32 when she was placed on medical leave due to persistent trigeminal neuralgia. Subsequently, she developed total blindness, accompanied by distress in a crucial emotional context. A diagnosis of factitious disorder was retained by an expert psychiatrist, with severe consequences for her, such as disability income suspension and family conflict. We evaluated Ms. A. in our multidisciplinary medical expertise service for a disability income review.ResultsThe patient reported a total absence of light perception in both eyes (subjective), not confirmed by objective ocular examination and spécific neuro-ophthalmological examination.Psychiatric examination revealed that Ms. A. had been sexually assaulted at age of 7 and sexually abused for a year by her teacher at age of 14. Regarding the identity of the first abuser, she describes that she “can’t see his face” and that the multiple sexual assaults during her teenage years took place in the classroom after school, with the teacher “pulling down the window shades so it was totally dark.” She explains that, defensively, to avoid thoughts related to the traumatic experience, she was heavily invested in her studies. But, at the age of 30, after separation with her first boyfriend, diffuse pain and progressively total blindness appeared.We concluded the diagnoses of pain disorders related to psychological factors and a dissociative neurological symptom disorder with visual disturbance.Conclusions Blindness not explained by a physiologic process may accompany trauma and psychological distress, with the search for the link between the onset of symptoms and significant unconscious psychic conflicts being crucial in the psychiatric investigation. A new diagnosis of dissociative neurological symptom disorder with visual disturbance (6B60.0) is included in the ICD-11. It is characterized by visual symptoms such as blindness, tunnel vision, diplopia, visual distortions, or hallucinations that are not consistent with a recognized disease of the nervous system, other mental, behavioral, or neurodevelopmental disorders. Differentiating this pathology from factitious disorder or simulation is essential from an insurance medicine point of view, but also for its treatment.Disclosure of InterestNone Declared

A descriptive, retrospective case series of patients with factitious disorder imposed on self

BackgroundDespite cases of factitious disorder imposed on self being documented in the literature for decades, it appears to remain an under-identified and under-diagnosed problem. The present study aimed to explore factitious disorder imposed on self in a series of French patients.MethodsPatients 18 years old and over with factitious disorder imposed on self were retrospectively included by two independent reviewers according to DSM-5 criteria in Rennes University Hospital for the period 1995 to 2019. Patients were identified from a clinical data warehouse.Results49 patients with factitious disorder imposed on self were included. Among them, 36 (73.5%) were female. The average age at diagnosis was 38.4 years. The 16 patients with a health-related profession were all female. Direct evidence of falsification was found in 20.4% of cases. Falsification was mainly diagnosed on the basis of indirect arguments: history of factitious disorder diagnosed in another hospital (12.2%), extensive use of healthcare services (22.4%), investigations that were normal or inconclusive (69.4%), inconsistent or incomplete anamnesis and/or patient refusal to allow access to outside information sources (20.4%), atypical presentation (59.2%), evocative patient behaviour or comments (32.7%), and/or treatment failure (28.6%). Dermatology and neurology were the most frequently involved specialities (24.5%). Nine patients were hospitalized in intensive care. Some of them received invasive treatments, such as intubations, because of problems that were only reported or feigned. The diagnosis of factitious disorder imposed on self was discussed with the patient in 28 cases (57.1%). None of them admitted to making up the disorder intentionally. Two suicide attempts occurred within 3 months after the discussion of the diagnosis. No deaths were recorded. 44.9% of the patients returned to the same hospital at least once in relation to factitious disorder imposed on self.ConclusionsThe present study reinforces data in favour of a predominance of females among patients with factitious disorder imposed on self. This diagnosis is difficult and is based on a range of arguments. While induced cases can be of low severity, cases that are only feigned can lead to extreme medical interventions, such as intubation.

A case of factitious disorder presenting as acute kidney injury

The unnecessary need for hemodialysis based on abnormal laboratory investigations is rare. We report a case of a 36-year-old male patient who complained of abdominal pain and passing red colored urine, with documentation of azotemia and hyperkalemia. He underwent unnecessary hemodialysis before a diagnosis of factitious disorder could be made.

Factitious Disorder in Seven Patients: A Saudi Experience.

BackgroundFactitious disorder (FD) is a psychiatric disease where signs and symptoms are produced, falsified, or exaggerated consciously in the absence of clear external motivations. Through needless medical visits, costly investigatory testing, and potentially long hospital stays, patients with FD waste valuable time and resources, which affects both the patient and the healthcare system. It can be very challenging for physicians who have never encountered patients with FD to recognize them promptly as symptoms of FD vary greatly.MethodologyThis was a retrospective study of patients diagnosed with FD attending King Abdulaziz Medical City in Riyadh, Saudi Arabia, a tertiary care military hospital and one of the most prominent academic and referral medical institutions in the country. Using the BESTCare health information system, we reviewed patients’ electronic health records from January 2015 to December 2020. The diagnosis of FD was based on the International Classification of Diseases and Related Health Problems 10th edition.ResultsA total of seven patients were included in the study, of whom five (71%) were males and two (29%) were females. Of the total seven patients, three were 21 years old and younger, one was 38 years old, and three were 56 years old and older. Three (43%) patients were married and four (57%) were single. In terms of occupation, three (43%) patients were retired, one (14%) worked in a private company, one (14%) was unemployed, and two (29%) were students. A total of four (57%) patients initially presented to the Emergency Department (ED), and only three (43%) presented to the outpatient clinics. Induced disease or injury was found in five (71%) patients. Induced skin injury was found in four (57%) patients. Counseling and psychotherapy were only offered to one (14%) patient.ConclusionsFD remains a rare psychiatric condition that is difficult to recognize. Despite a small sample size, FD in the present study showed a male predominance, affecting patients of all age groups. About half of the patients presented initially to the ED. Induced disease or injury was the most commonly reported pattern of clinical presentation. Induced skin injury was the most common clinical presentation found in around half of the patients. We believe that the number of FD patients in the present study is likely underreported and is expected to be higher. This highlights the need for better awareness of FD among physicians in different medical fields. We emphasize that there is a need for better professional training in the identification of FD.

Factitious Disorder (Munchausen Syndrome) in Plastic Surgery: A Systematic Review of 42 Cases.

Patients with factitious disorder (FD) or "Munchausen syndrome" intentionally fabricate or induce medical problems for psychological gratification. They may deceive plastic surgeons into performing multiple unnecessary procedures. We undertook the first systematic review of FD case reports in plastic surgery. Our aims were 2-fold: (1) describe the adverse outcomes associated with these cases and (2) identify strategies for their prevention by surgeons. MEDLINE, EMBASE, and SCOPUS databases were searched. We included cases in which an adult with FD presented to a plastic surgeon. Our search returned a total of 42 eligible cases reported from North America (43%), Europe (37%), and Asia (20%). Seventy-six percent of patients were women, and 62% worked in health care. Sixty percent had a comorbid psychiatric disorder, the most common (50%) being depression. Ninety-three percent of our sample presented with self-induced lesions. The average delay in diagnosis of FD was 54 months, with 46% of patients receiving multiple surgical procedures in this time, including debridement (36%) and skin grafts (39%). Surgical wounds were frequently exploited by patients to remain in, or return to, hospital: 50% contaminated or manipulated their wounds to prevent healing. Thirty-six percent of cases resulted in significant long-term disability (24%) or disfigurement (12%). Ten percent of patients received an amputation. Outcomes were improved when patients were confronted by surgeons, however, and 62% were willing to see a psychiatrist. Surgeons were able to support recovery in 33% of cases-for example, by using occlusive wound dressings. Patients with FD who present to plastic surgeons are high risk: the majority require surgical intervention for severe self-injury, and many engage in harmful behaviors, such as "doctor-shopping." Early recognition of FD in plastic surgery is, therefore, crucial and may be achieved via careful examination of lesions for unusual morphology. Medical records may reveal extensive health care service use and negative investigations. Finally, plastic surgeons may play an important role in managing such patients. Management strategies include direct observation by nursing staff in the postoperative period and use of strict occlusive dressings to prevent access to surgical wounds.

Identification of chloramphenicol in human hair leading to a diagnosis of factitious disorder

Introduction: Chloramphenicol (2,2-dichloro-N-[1,3-dihydroxy-1-(4-nitrophenyl)porpan-2-yl]acetamide) is a bacteriostatic antibiotic of the phenicolated family, used in the past to treat meningitis, plague, cholera, or typhoid fever. Treatment with chloramphenicol can have life threatening side effects, the most serious of which is aplastic anemia, which may be fatal. For this reason, the antibiotic was removed from the French market in 2008.Case report: In this paper, the authors report the case of a woman consuming chloramphenicol possibly in the context of factitious disorder. After a capsule containing chloramphenicol was discovered in her hospital bed, a hair specimen (about 16 cm, brown, not oriented) was collected and sent to the toxicological laboratory in order to document exposure to chloramphenicol.Results: The drug was identified in the hair specimen of the subject at 13.7 ng/mg.Discussion: Identification of chloramphenicol in hair has not been reported in the literature. As consequence, the interpretation of the concentration, the dosage and the frequency of abuse are difficult to establish.Conclusion: Given the context, physicians considered the case as a possible factitious disorder, thus being a unique observation of using chloramphenicol in such a context.

Factitious disorder: a case report and literature review of treatment

Diagnosis of factitious disorder (FD) is frequently difficult and patients may present with physical symptoms only, psychiatric symptoms only or with a combination of both. As long as the nature of the disease is so secretive and large‐scale studies are almost impossible, every case report is important. Here, the authors present a case of severe FD and the therapeutic approach taken.

Factitious disorder: a systematic review of 455 cases in the professional literature.

Patients with factitious disorder (FD) fabricate illness, injury or impairment for psychological reasons and, as a result, misapply medical resources. The demographic and clinical profile of these patients has yet to be described in a sufficiently large sample, which has prevented clinicians from adopting an evidence-based approach to FD. The present study aimed to address this issue through a systematic review of cases reported in the professional literature. A systematic search for case studies in the MEDLINE, Web of Science and EMBASE databases was conducted. A total of 4092 records were screened and 684 remaining papers were reviewed. A supplementary search was conducted via GoogleScholar, reference lists of eligible articles and key review papers. In total, 372 eligible studies yielded a sample of 455 cases. Information extracted included age, gender, reported occupation, comorbid psychopathology, presenting signs and symptoms, severity and factors leading to the diagnosis of FD. A total of 66.2% of patients in our sample were female. Mean age at presentation was 34.2 years. A healthcare or laboratory profession was reported most frequently (N=122). A current or past diagnosis of depression was described more frequently than personality disorder in cases reporting psychiatric comorbidity (41.8% versus 16.5%) and more patients elected to self-induce illness or injury (58.7%) than simulate or falsely report it. Patients were most likely to present with endocrinological, cardiological and dermatological problems. Differences among specialties were observed on demographic factors, severity and factors leading to diagnosis of FD. Based on the largest sample of patients with FD analyzed to date, our findings offer an important first step toward an evidence-based approach to the disorder. Future guidelines must be sensitive to differing methods used by specialists when diagnosing FD.

Factitious Disorder Manifesting as Hematemesis and Hematochezia.

To the Editor: According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,1 factitious disorder is characterized by (1) falsification of physical or psychological signs or symptoms by an individual, with the deception subsequently identified by others; (2) presentation of oneself as ill, impaired, or injured; and (3) absence of an obvious external or tangible reward for the behavior. A number of factitious physical symptoms and syndromes have been described in the extant literature, including but not limited to aortic dissection, cancer, chronic pain, deafness or blindness, hemiplegia, hemoptysis, human immunodeficiency infection, hypoglycemic coma, mydriasis, various neurologic syndromes, osteomyelitis, and quadriplegia.2 However, we were unable to locate a reported factitious case of combined hematemesis and hematochezia. In addition, the creation of signs and symptoms in this case were somewhat unique. Case report. Ms A was a 37-year-old woman with a past medical history of bipolar disorder, chronic anxiety, polysubstance abuse, chronic hepatitis with cirrhosis, esophageal varices, coagulopathy, and Crohn disease who presented with an acute episode of hematochezia. Hemoglobin level at admission was 11.5 g/dL. An initial esophagogastroduodenoscopy indicated no acute source of bleeding in the oral cavity, esophagus, stomach, or duodenum, yet fresh blood was found in the oropharynx after an episode of vomiting. A subsequent colonoscopy demonstrated shallow linear nonbleeding lesions and edema of the ascending colon that were inconsistent with inflammatory bowel disease. When the rectal bleeding ceased and hemoglobin level stabilized, the patient was discharged. Five days later, Ms A returned with recurrent rectal bleeding with a hemoglobin level of 11.1 g/dL. Flexible sigmoidoscopy indicated an increased number of linear ulcers in the same region as before, 2 of which were found to be bleeding immediately proximal to the anal verge. Overnight, the patient continued with persistent hematochezia accompanied by a 0.5 g/dL decrease in hemoglobin. A second flexible sigmoidoscopy was ordered. Prior to the procedure, as the patient was being positioned, a small serrated jackknife was found in the bedding just behind the patient. When confronted, the patient initially adamantly denied but then affirmed that the rectal lesions were self-inflicted. The patient explained that she inserted her finger into her rectum with the blade of the knife closely pressed against it, and then carefully made abrasions as deep as possible in her colon. She also confessed that the hematemesis was created through the ingestion of fresh blood from her intravenous line. A meaningful challenge in the diagnosis of factitious disorder is the extent to which the individual’s reported symptoms are due to choice or psychopathology.3 When factitious disorder is detected, intervention may be compromised by the patient’s unwillingness to cooperate as well as the lack of evidence-based treatment for this disorder. In terms of treatment, psychotherapy is recommended,4 although there is no evidence of efficacy for one treatment over another.5 Dialectical behavior therapy has been proposed.6 Overall, with the development of the Internet, factitious disorders will quite likely become more complex and primary care providers will very likely continue to be challenged. This case report illustrates the fortitude entailed in generating elusive symptoms.

Factitious disorder in adolescence.

Factitious disorder in adolescence.

Factitious psychogenic nonepileptic paroxysmal episodes.

Mistaking psychogenic nonepileptic paroxysmal episodes (PNEPEs) for epileptic seizures (ES) is potentially dangerous, and certain features should alert physicians to a possible PNEPE diagnosis. Psychogenic nonepileptic paroxysmal episodes due to factitious seizures carry particularly high risks of morbidity or mortality from nonindicated emergency treatment and, often, high costs in wasted medical treatment expenditures. We report a case of a 28-year-old man with PNEPEs that were misdiagnosed as ES. The patient had been on four antiseizure medications (ASMs) with therapeutic serum levels and had had multiple intubations in the past for uncontrolled episodes. He had no episodes for two days of continuous video-EEG monitoring. He then disconnected his EEG cables and had an episode of generalized stiffening and cyanosis, followed by jerking and profuse bleeding from the mouth. The manifestations were unusually similar to those of ES, except that he was clearly startled by spraying water on his face, while he was stiff in all extremities and unresponsive. There were indications that he had sucked blood from his central venous catheter to expel through his mouth during his PNEPEs while consciously holding his breath. Normal video-EEG monitoring; the patient's volitional and deceptive acts to fabricate the appearance of illness, despite pain and personal endangerment; and the absence of reward other than remaining in a sick role were all consistent with a diagnosis of factitious disorder.

Proposing a Gastroenterologistʼs “Secondary Survey”: When to Consider Factitious Disorder in the Differential Diagnosis

Purpose: We are regularly consulted to evaluate GI bleeding. Occasionally, the clinical history and endoscopic findings do not correlate. This case report highlights the need to consider factitious disorder in the differential diagnosis of GI bleeding. Case Report: A 35-year-old man presented to the Emergency Department with 2 episodes of hematemesis on the day of admission, one witnessed by hospital staff. He reported a history of hepatitis C cirrhosis with multiple episodes of variceal bleeding, undergoing endoscopic banding on his last episode 3 weeks prior. Vital signs were stable. Laboratory data revealed Hemoglobin 9.8, PT 17.5, AST 107, ALT 81, & AKP 51. He refused NG tube placement. Esophagogastroduodenoscopy revealed normal mucosa. He was managed with octreotide, PPI, and antibiotics. On hospital day 2, he had witnessed gross hematochezia. A nuclear medicine bleeding scan revealed no active bleeding, and hemoglobin remained at 9.5. A colonoscopy revealed 2 linear ulcers in the rectum, explaining his hematochezia, and 2 sharp metallic objects in the cecum, found to be straight edge razor blades. The patient denied foreign body ingestion. The Psychiatry team was consulted, & a diagnosis of factitious disorder was made. Discussion: Factitious disorder is a psychiatric condition in which a patient intentionally feigns symptoms or produces physical harm to assume the role of the sick, without motivation for secondary gain. Presentation can vary, from reporting symptoms that do not exist to self-inflicting physical harm: 1) toxic ingestions (esophagitis/gastritis from corrosive agents); and 2) foreign body ingestions (presentation and symptoms depend on object ingested, from abdominal pain to GI bleeding to obstruction). Subacute presentations may have vague complaints that mimic other disorders. In the inpatient setting, careful evaluation of the patient's history, physical exam, and diagnostic results must be the first step. When the pieces of the puzzle do not fit - in this case acute upper followed by acute lower GI bleeding - we propose a Gastroenterologist's “Secondary Survey” be performed, as is done in Trauma Surgery to evaluate for initially missed injuries, expanding the differential diagnosis to include potentially inorganic causes, i.e., factitious disorder. Conclusion: Careful performance of the secondary survey combined with adherence to physician practice guidelines for procedural diagnosis of GI bleeding established a diagnostic and therapeutic outcome, minimizing further harm. A gastroenterologist's “Secondary Survey” should be performed in patients whom the clinical presentation does not fit, to include Factitious Disorder as part of an expanded differential diagnosis of gastrointestinal disorders.

Pancytopenia Secondary to Cyclophosphamide in a Case of Factitious Breast Cancer

To the Editor: Reports of factitious symptoms have peppered the clinical literature since Dr Richard Asher’s initial identification and description of Munchausen’s syndrome in 1951.1 However, factitious symptoms may now be potentially groomed through the Internet, which not only offers endless information about medical symptoms but also enables access to non-supervised treatment. The following case demonstrates the ease with which patients can obtain and distort medical information as well as order potent medications online—and the harm that can ensue. Case report. Ms A, a 29-year-old white woman, was admitted to an acute-care hospital through the emergency department in 2010 for pancytopenia. She reported a history of stage 1, estrogen-positive breast cancer and was receiving cyclophosphamide therapy. The pancytopenia was initially discovered during routine blood work that was obtained prior to a dental procedure for an abscessed tooth. The patient was later directed to our emergency department for further evaluation. At the time of admission to hospital, the patient’s white blood cell count was 0.1 cells/mL, hemoglobin was 6.4 g/dL, hematocrit was 17.9%, and platelets were 2 × 109/L. Following laboratory confirmation, the patient was admitted to the intensive care unit (ICU) under neutropenic precautions. The cyclophosphamide was discontinued, and the patient was transfused with packed red blood cells and granulocyte colony-stimulating factor. In an attempt to gather additional information through medical records, we asked the patient about her current providers and received the names of several treating physicians as well as contradictory information regarding her treatment. Ultimately, all of the physicians whom the patient named as part of her treatment team denied seeing her as a patient. When confronted with this conflicting information, the patient admitted that she had diagnosed herself with breast cancer based upon a family history of breast cancer and assessment on an Internet breast-cancer risk-factor calculator. After personally concluding that she had breast cancer, the patient ordered cyclophosphamide online from a Web site based in India. At no time did she provide any reason or goal in attempting to deceive the treating medical team with regard to her alleged cancer. Further background investigation revealed that the patient had previous hospital admissions for intractable migraine headaches that included evaluation by magnetic resonance imaging, magnetic resonance angiography, magnetic resonance venography, and lumbar puncture—none of which revealed any abnormalities. Once the patient’s pancytopenia resolved, she was transferred from the ICU to a standard medical floor, where she developed unexplained hematomas on the left arm and right leg. Once the hematomas resolved, a psychiatry consultation was requested and the patient was transferred to the inpatient psychiatry unit with a DSM-IV diagnosis of factitious disorder with predominantly physical signs and symptoms. On the day of her transfer, the patient was sent to the emergency department for self-reported hematuria; urinalysis in the emergency department revealed no abnormalities. Although there is a previous case in which a patient feigned ovarian cancer by obtaining symptoms through online information2 and a second case in which a patient underwent bilateral mastectomies for self-reported breast cancer,3 there is no previously reported case in which a patient became cytopenic due to self-purchased chemotherapy for self-diagnosed breast cancer. Clearly, factitious medical disorders can take a number of dangerous forms when aided by the Internet.

Deceptive Examinees Who Committed Suicide: Report of Two Cases

Deceptive behavior by neuropsychological examinees does not preclude the presence of significant psychopathology. To illustrate this fact we present two cases. Case 1 had a diagnosis of factitious disorder and clear evidence on neurological and neuropsychological exams of exaggeration. Case 2 had a somatoform disorder and provided a deceptive social history. Long after the neuropsychological evaluations, both persons committed suicide. These cases provide anecdotal evidence that deceptive behavior does not preclude the presence of serious psychopathology, and that deceptive behavior and self-destructive behavior sometimes coincide.

P03-578 - Factitious disorder case series with predominant psychological signs and symptoms

IntroductionPatients with factitious disorder intentionally produce or feign signs of medical or mental disorders. The only apparent objective of this behavior is to assume the role of a patient without an external incentive. The high rate of comorbidity with other psychiatric disorders together with the knowledge that factitious disorder lies on a continuum between somatoform disorders and malingering renders the early detection and diagnosis of cases with feigned psychological signs and symptoms more demanding.Objective and methodPoor documentation of factitious disorder with predominant psychological signs and symptoms in the current literature reveals a blind spot in the diagnostic approach. With this in mind three cases were followed and reviewed to illustrate the elusive character of this clinical entity and demonstrate the importance of its early consideration in the differential diagnosis.ResultsThree patients presented to our acute psychiatric department with an extensive constellation of mood and psychotic symptoms. All patients underwent a thorough neuropsychological and medical evaluation. The diagnosis of factitious disorder was mainly based on their inconclusive mental status examination which could not definitively support the presence of another psychiatric or medical disorder, on the observation that their behavior on the psychiatric unit proved inconsistent with their chief complaints and on the past history from collateral sources which confirmed a pattern of multiple hospitalizations.ConclusionsFactitious disorder should be considered in patients with inconsistent psychiatric presentations and negative diagnostic results who are high utilizers of acute care facilities such as the emergency room and inpatient services.

Functional vision loss: A diagnosis of exclusion

Background Most cases of visual acuity or visual field loss can be attributed to ocular pathology or ocular manifestations of systemic pathology. They can also occasionally be attributed to nonpathologic processes or malingering. Functional vision loss is any decrease in vision the origin of which cannot be attributed to a pathologic or structural abnormality. Case reports Two cases of functional vision loss are described. In the first, a 58-year-old man presented for a baseline eye examination for enrollment in a vision rehabilitation program. He reported bilateral blindness since a motor vehicle accident with head trauma 4 years prior. Entering visual acuity was “no light perception” in each eye. Ocular health examination was normal and the patient made frequent eye contact with the examiners. He was referred for neuroimaging and electrophysiologic testing. The second case was a 49-year-old man who presented with a long history of intermittent monocular diplopia. His medical history was significant for psycho-medical evaluations and a diagnosis of factitious disorder. Entering uncorrected visual acuities were 20/20 in each eye, but visual field testing found constriction. No abnormalities were found that could account for the monocular diplopia or visual field deficit. A diagnosis of functional vision loss secondary to factitious disorder was made. Conclusions Functional vision loss is a diagnosis of exclusion. In the event of reduced vision in the context of a normal ocular health examination, all other pathology must be ruled out before making the diagnosis of functional vision loss. Evaluation must include auxiliary ophthalmologic testing, neuroimaging of the visual pathway, review of the medical history and lifestyle, and psychiatric evaluation. Comanagement with a psychiatrist is essential for patients with functional vision loss.

Factitious disorder with psychological symptoms: Learning to be ill

Invention, production or falsification of physical and psychological symptoms, are the core traits of Factitious Disorder. The aim is to assume a patient role.The etiology of Factitious Disorder is unknown, but cognitive-behavioural and psychoanalytic hypothesis have been formulated.Cognitive-Behavioural theories consider that the Factitious Disorder is related to the learning of illness behaviour with its positive and negative reinforcements. Therefore, past medical history in childhood or medical illness in relatives are risk factors for the development for Factitious Disorder.A Case-Control study was carried out to test this hypothesis. Patients with the diagnosis of Factitious Disorder with Psychological symptoms in a Psychiatric Inpatients Unit were included. We analyze medical history in childhood, age at the first admission in hospital, consequences derived of the patient role during this admission, and age and consequences of the first somatic and psychiatric severe episode in adult age.Data obtained in our study show that patients with Factitious Disorder with psychological symptoms have a higher proportion of illness in childhood and higher percentage of admissions. In addition, hospital admissions take place in the late childhood, when is possible to be conscious of the consequences of the illness.These results confirm that learning influences the pathogenesis of Factitious Disorder with psychological symptoms.

Pseudomalabsorção de levotiroxina: relato de um caso

A 49-year-old woman who had been treated with sodium levothyroxine because of hypothyroidism after diagnosis of Hashimoto thyroiditis and total thyroidectomy for multinodular atoxic goiter was evaluated for persistent hypothyroidism despite the use of large doses of levothyroxine (600 microg/day). The patient showed signs and symptoms of hypothyroidism and her laboratory tests were: TSH of 351 microUI/mL, free thyroxine of 0.20 ng/dL, and total triiodothyronine of 27 ng/dL. She was submitted, under medical supervision, to a levothyroxine overload test with no evidence of malabsorption of the thyroid hormone. Diagnosis of factitious disorder and Munchausen syndrome leading to the pseudomalabsorption of levothyroxine was considered.