Striving to Die: Medical, Legal, and Ethical Dilemmas Behind Factitious Disorder.

Factitious disorder (FD) imposed on self is one of the most challenging and controversial problems in medicine. It is characterized by falsified medical or psychiatric symptoms where patients misrepresent, simulate, or cause symptoms of an illness in the absence of obvious tangible gains. Munchausen syndrome accounts for approximately 10% of all factitious illnesses and represents its most malignant form. An unknown number of deaths have likely occurred when considering that most cases go unrecognized and unreported. Here we describe a case in which the patient's condition remained unrecognized, only being diagnosed months before her death from complications of FD. Psychiatry was consulted to see a 49-year-old Caucasian female regarding depression, poor oral intake, and her insistence on the placement of a feeding tube. The initial evaluation was negative for findings consistent with psychiatric illness. A review of records in our hospital was significant for one previous psychiatric inpatient stay eight months prior during which a diagnosis of FD imposed on self was made. Collateral information suggested a cycle of deception and simulation of illnesses with the patient's daughter labeling her actions as "doctor shopping." At our facility alone, she had accrued roughly 40 inpatient medical admissions and 70 ED visits in four years though only two encounters involving Psychiatry. A detailed chronological analysis of her records showed the only documented concern of deception to be that of an Internal Medicine resident two years prior. Psychiatry was not consulted despite this concern. During the present encounter, psychiatry recommended ethics consult, outpatient psychotherapy, and frequent follow-ups with primary care. A formal ethics consult was not completed before discharge. Within two months, the patient died at another facility.  FD can lead to diagnostic and therapeutic procedures that result in irreversible morbidity and iatrogenic harm. Physicians in other medical specialties often suspect a patient of consciously deceiving others, though fail to assign psychiatric nomenclature due to lack of familiarity or comfort in making the diagnosis. This further substantiates the role of a multidisciplinary collaboration between medical, surgical, and psychiatry teams. Heightened awareness of, and suspicion for, Munchausen syndrome may improve rates of diagnosis and prognosis of these patients.