Case Reports
these patients all too often may lead to a missed diagnosis of organic etiology. Psychiatric symptoms are not illness specific; carcinomatosis
should be added to the extensive list of specific medical disorders that may be misdiagnosed as a psychiatric disorder.
References I. Herridge CF: Physical disorders in psychialric illness: a sludy of 209 conseculive admissions. Lancet 2:949-951. 1960 2. Hall RCW. Gardner ER. Slickney SK. el al: Physical illness manifesling as psychialric disease. Arch Gen Psychiatry 37:989-995. 1980 3. Maguire GP. Grannville-Grossman KL: Physical illness in psychialric palienls. Br J Psychiatry 115: 1165-1169. 1988 4. Koryani EK: Physical heallh and illness in a psychialric oUlpalienl depanmenl populalion. Canadian Psychiatric AssociationJourna/l7(suppl):I09-116.1972 5. Koryani EK: Morbidily and rale of undiagnosed physical
illnesses in a psychialric clinic populalion. Arch Gen Psychiatry 36:414-419. 1979 6. Theodore WHo Gendelman S: Meningeal carcinomalosis. Arch Neuro/38:696--699. 1981 7. Yap HY. Yap CK: Meningeal carcinomalosis in breasl cancer. Cancer 42:283-286. 1978 8. Gonzalez-Vilale JC. Garcia-Bunuel R: Meningeal carcinomalosis. Cancer 37:2906--2911.1976 9. Lillie JR. Dale AJD. Okazaki H: Meningeal carcinomalosis. Arch Neuro/30: 138-143. 1974 10. Bluslein J. Seeman MV: Brain lumors presenling as funclional psychialric dislUrbances. Canadian Psychiatric Association Journal 17:59--63. 1972
Factitious Disorder With Respiratory Symptoms KAREN
B.
J. ROSENBERG, PH.D. MICHAEL G. MORAN, M.D.
SCHMALlNG, PH.D., SAMUEL
JOHN OPPENHEIMER, M.D.,
A
bdominal pain. bleeding. or neurological complaints are most frequently associated with factitious illness.' In contrast, a factitious illness consisting of pulmonary manifestations is rare. The few reports of respiratory cases that were diagnosed ultimately with factitious disorder or Munchausen's syndrome presented initially with the following symptoms: I) hemoptysis treated ineffectively by antibiotics and two thoracotomies 2; 2) sudden, severe dyspnea and periods of apnea, prompting intubation3-6; 3) symptoms described by proxy by the mother of a child who apparently had cystic fibrosis?; and 4) paradoxical vocal cord dysfunction. 8 described as "factitious asthma. 09 (although the characteristic laryngeal stridor is not consciously produced or feigned. and thus not. by definition. factitious). VOLUME 32· NUMBER 4· FALL 1991
Episodic laryngeal dyskinesia lO is a vocal cord dysfunction equivalent. Both have significant psychological overlay. Bronchorrhea. the excessive production of sputum. is associated with several pulmonary diseases. including asthma. tuberculosis. and alveolar cell carcinoma. I I The symptom can be maintained by a functional inability to clear seReceived May II. 1990; revised July 12.199O;accepled Seplember 14. 1990. From Ihe Nalionallewish Cenler for Immunology and Respiralory Medicine. Denver, and Ihe Universily of Colorado Heallh Sciences Cenler. Denver. Address reprinl requesls 10 Dr. Schmaling. Nalional Jewish Cenler for Immunology and Respiratory Medicine. 1400 Jackson Slreel. Denver. CO 80206. Copyrighl © 199 I The Academy of Psychosomalic Medicine.
457
Case Reports
cretions. We describe a patient with the presenting symptom of bronchorrhea. diagnosed ultimately with factitious disorder.
Case Report A 19-year-old female came to our center for evaluation and treatment of intractable bronchorrhea. She described frequent episodes of bronchitis since 6 weeks of age. resulting in multiple emergency room visits and antibiotic therapy throughout childhood. At age 13. an allergist's workup revealed negative skin tests and a negative sweat chloride test. According to her account. since 17 years of age she had had nine hospital admissions for "status asthmaticus." required prednisone chronically. and suffered from cushingoid habitus. Previous evaluations included multiple x-rays. cr scans. and bronchoscopies without significant results. An outpatient evaluation at our center revealed normal pulmonary function tests. negative methacholine and histamine challenges. and negative exercise study; immunologic workup was normal. The patient was discharged home and encouraged to return should her symptoms exacerbate. She was hospitalized within 2 weeks of discharge. treated with steroids. and discharged a week later. only to be readmitted the next day. Ten days later she was transferred to our center via air ambulance. Upon arrival. the patient exhibited laryngeal stridor and diffuse. loud. wet rhonchi. Early in the evaluation a sputum culture grew Proteus mirabilis. an organism unusual for bronchial secretions. Throughout her hospitalization. she displayed coarse rhonchi, nonproductive cough, and the inability to clear secretions, even after saline induction. A mucociliary clearance scan was within normal Iimits. A sputum with high amylase suggested that the patient may have aspirated saliva. The presence of Proteus raised the concern that she intentionally may have aspirated material contaminated by genitourinary or gastrointestinal excretions. Psychosocial consultation was conducted throughout the patient's outpatient and inpatient stays. The patient lived with her parents and older sister but was otherwise socially reclusive. Her mother had required multiple psychiatric hospitalizations for suicide attempts and was maintained on lithium carbonate. Since age 7. the patient had engaged 458
repeatedly in psychotherapy. focusing primarily upon somatic complaints and her relationship with her mother. with little apparent success. Psychological testing was performed to assist with diagnostic and treatment formulation. The patient completed the Rorschach inkblot test. the Minnesota Multiphasic Personality Inventory. and several subscales of the Wechsler Adult Intelligence Scale-Revised. The test results were valid and suggested a passive. ineffectual. and immature person who experienced herself as unable to cope with the real or imagined stressors of everyday life. In response. she strove desperately to embrace powerful others in hopes of assistance. From this perspective. multiple somatic complaints allied the patient with omnipotent. idealized physicians. Despite the patient's low average level of intellectual functioning. another defense she attempted to employ was intellectualization. which she used to ward off distressed feelings. When these maneuvers failed. she narrowed her range of perception onto small. minor details. resulting in a distorted perception of reality. Thus. denial of painful affects predisposed this patient to somatization; her inadequate attempts at cognitive defenses caused her to scrutinize her body and to develop distorted and unrealistic ideas about her physical functioning. It was therefore imperative for the patient to preserve relationships with powerful others to maintain her self-experience. perception of reality. and affect modulation. We did not confront the patient with our concerns about intentional production of symptoms; such a stance likely would sever abruptly the patient's tenuous relationship with her idealized physicians. This loss. in tum. might have prompted exacerbation of somatic complaints. psychological regression. or increased self-destructive behavior. Thus. consistent with suggestions proposed recently 12 by Eisendrath. we employed inexact interpretations and face-saving techniques to address evaluation results. while preserving the patient's important relationship with her physicians. For example. we conveyed puzzlement that her sputum had grown Proteus because this organism was most always found in urine; our suspicions that she aspirated her urine were never stated overtly. As face-saving techniques. we suggested that her body needed help in clearing her secretions; speech pathology was consulted to coach the patient in productive coughing. and the nursing staff began postural drainage and clapping. The patient's referring physician revealed subsequently that she presented with a recurrence of her PSYCHOSOMATICS
Case Reports
symptoms several weeks after discharge. The physician saw the patient with her mother. stating that no intervention was indicated and that he would continue treating the patient only if she initiated psychotherapy. The patient's motherreponedly became enraged and stormed out of the physician's office; the patient followed thereafter. During the next 2 months. the physician received no calls from the patient; most likely she sought other treaters.
Discussion This patient afforded an opportunity to examine a rare case of factitious disorder with respiratory symptoms. As with many cases in which the patient is suspected of volitional production of the symptoms. we did not observe the behavior itself or related behaviors (i.e.• the aspiration of foreign material. such as urine). Had she indeed aspirated material containing Proteus. it need have occurred only shortly before the hospitalization to contaminate her oral cavity or tracheobronchial tree. The voluntary avoidance of coughing and secretion clearance explains the volume and maintenance of the bronchorrhea. The mother's psychiatric history raises the additional possibility of a factitious disorder by proxy. Support for such a systemic disorder is the family's fluctuation from sadistic treatment of the patient when she was not actively symptomatic (e.g.• smoking in her presence despite their firm beliefs that she had asthma and allergies). to
overinvolved protectiveness when she was symptomatic. Somatizing patients. especially those with factitious disorders. are widely known to be poor candidates for psychotherapy. Indeed. the recommendation for psychotherapy can enrage the patient and prompt an increase in somatic symptoms. communicating the need for traditional medical treatment. Instead. these patients may be best evaluated initially in an inpatient medical setting with active psychological consultation. Such consultation need not focus exclusively upon direct interaction with the patient. Rather. consultation with the hospital staff can be helpful I) in suggesting ways to interact with the patient to maximize the likelihood of acceptance of the information and rejection ofcontinued symptomproducing or symptom-maintaining behavior. and 2) in managing the staff's anger toward the patient. expressed concretely by unnecessary procedures or premature patient discharge. Once a somatizing diagnosis is made. psychotherapy can be recommended. The therapist then can empathize with the disruptive impact of the symptoms and thus avoid blaming the patient for medical complaints. Thereafter. communication between primary physician and psychotherapist is useful in helping the physician manage the often distressing reactions to the patient with factitious disorder.
References I. Asher R: Munchausen's syndrome. Lancet 1:339-341. 1951 2. Bush A.CollinsJV: Pulmonary Munchausen·ssyndrome. Postllrad Med} 58:564-565. 1982 3. Burkle FM. Calabro 11. Parks FB: Munchausen's syndrome presenting as respiralOry failure requiring intubation. Ann Emerll Med 16:203-208.1987 4. Mitchell DM. Doyle PM. Spiro SO: Munchausen's syndrome with mulliple pulmonary manifestations. } Royal Soc Med78:681--{)82. 1985 5. Ng LL: Munchausen's syndrome presenting as bronchospasm. Br} Clin Pract41 :714-715. 1987 6. Roethe RA. Fuller PB. Byrd RB. et al: Munchausen syndrome with pulmonary manifestations. Chest 79:487488.1981 7. Orenstein DM. Wasserman AL: Munchausen syndrome
VOLUME 32· NUMBER 4· FALL \99\
by proxy simulating cystic fibrosis. Pediatrics 78:621624. 1986 8. Freedman MR. Rosenberg SJ. Schmaling KB: Childhood sexual abuse in patients with paradoxical vocal cord dysfunction.} Nen' Mem Dis 179:295-298. 1991 9. Downing ET. Braman S5. Fox MJ. et al: Factitious asthma. }AMA 248:2878-2881. 1982 10. Ramirez-R J. Le6n I. Rivera LM: Episodic laryngeal dyskinesia: clinical and psychiatric characterization. Chest 90:7 16-721. 1986 II. Lopez-Vidriero M. Charman J. Keal E. et al: Bronchorrhoea. Thorax 30:624-630. 1975 12. Eisendrath SJ: Factitious physical disorders: treatment without confrontation. Psychosomatics 30:383-387. 1989
459
these patients all too often may lead to a missed diagnosis of organic etiology. Psychiatric symptoms are not illness specific; carcinomatosis
should be added to the extensive list of specific medical disorders that may be misdiagnosed as a psychiatric disorder.
References I. Herridge CF: Physical disorders in psychialric illness: a sludy of 209 conseculive admissions. Lancet 2:949-951. 1960 2. Hall RCW. Gardner ER. Slickney SK. el al: Physical illness manifesling as psychialric disease. Arch Gen Psychiatry 37:989-995. 1980 3. Maguire GP. Grannville-Grossman KL: Physical illness in psychialric palienls. Br J Psychiatry 115: 1165-1169. 1988 4. Koryani EK: Physical heallh and illness in a psychialric oUlpalienl depanmenl populalion. Canadian Psychiatric AssociationJourna/l7(suppl):I09-116.1972 5. Koryani EK: Morbidily and rale of undiagnosed physical
illnesses in a psychialric clinic populalion. Arch Gen Psychiatry 36:414-419. 1979 6. Theodore WHo Gendelman S: Meningeal carcinomalosis. Arch Neuro/38:696--699. 1981 7. Yap HY. Yap CK: Meningeal carcinomalosis in breasl cancer. Cancer 42:283-286. 1978 8. Gonzalez-Vilale JC. Garcia-Bunuel R: Meningeal carcinomalosis. Cancer 37:2906--2911.1976 9. Lillie JR. Dale AJD. Okazaki H: Meningeal carcinomalosis. Arch Neuro/30: 138-143. 1974 10. Bluslein J. Seeman MV: Brain lumors presenling as funclional psychialric dislUrbances. Canadian Psychiatric Association Journal 17:59--63. 1972
Factitious Disorder With Respiratory Symptoms KAREN
B.
J. ROSENBERG, PH.D. MICHAEL G. MORAN, M.D.
SCHMALlNG, PH.D., SAMUEL
JOHN OPPENHEIMER, M.D.,
A
bdominal pain. bleeding. or neurological complaints are most frequently associated with factitious illness.' In contrast, a factitious illness consisting of pulmonary manifestations is rare. The few reports of respiratory cases that were diagnosed ultimately with factitious disorder or Munchausen's syndrome presented initially with the following symptoms: I) hemoptysis treated ineffectively by antibiotics and two thoracotomies 2; 2) sudden, severe dyspnea and periods of apnea, prompting intubation3-6; 3) symptoms described by proxy by the mother of a child who apparently had cystic fibrosis?; and 4) paradoxical vocal cord dysfunction. 8 described as "factitious asthma. 09 (although the characteristic laryngeal stridor is not consciously produced or feigned. and thus not. by definition. factitious). VOLUME 32· NUMBER 4· FALL 1991
Episodic laryngeal dyskinesia lO is a vocal cord dysfunction equivalent. Both have significant psychological overlay. Bronchorrhea. the excessive production of sputum. is associated with several pulmonary diseases. including asthma. tuberculosis. and alveolar cell carcinoma. I I The symptom can be maintained by a functional inability to clear seReceived May II. 1990; revised July 12.199O;accepled Seplember 14. 1990. From Ihe Nalionallewish Cenler for Immunology and Respiralory Medicine. Denver, and Ihe Universily of Colorado Heallh Sciences Cenler. Denver. Address reprinl requesls 10 Dr. Schmaling. Nalional Jewish Cenler for Immunology and Respiratory Medicine. 1400 Jackson Slreel. Denver. CO 80206. Copyrighl © 199 I The Academy of Psychosomalic Medicine.
457
Case Reports
cretions. We describe a patient with the presenting symptom of bronchorrhea. diagnosed ultimately with factitious disorder.
Case Report A 19-year-old female came to our center for evaluation and treatment of intractable bronchorrhea. She described frequent episodes of bronchitis since 6 weeks of age. resulting in multiple emergency room visits and antibiotic therapy throughout childhood. At age 13. an allergist's workup revealed negative skin tests and a negative sweat chloride test. According to her account. since 17 years of age she had had nine hospital admissions for "status asthmaticus." required prednisone chronically. and suffered from cushingoid habitus. Previous evaluations included multiple x-rays. cr scans. and bronchoscopies without significant results. An outpatient evaluation at our center revealed normal pulmonary function tests. negative methacholine and histamine challenges. and negative exercise study; immunologic workup was normal. The patient was discharged home and encouraged to return should her symptoms exacerbate. She was hospitalized within 2 weeks of discharge. treated with steroids. and discharged a week later. only to be readmitted the next day. Ten days later she was transferred to our center via air ambulance. Upon arrival. the patient exhibited laryngeal stridor and diffuse. loud. wet rhonchi. Early in the evaluation a sputum culture grew Proteus mirabilis. an organism unusual for bronchial secretions. Throughout her hospitalization. she displayed coarse rhonchi, nonproductive cough, and the inability to clear secretions, even after saline induction. A mucociliary clearance scan was within normal Iimits. A sputum with high amylase suggested that the patient may have aspirated saliva. The presence of Proteus raised the concern that she intentionally may have aspirated material contaminated by genitourinary or gastrointestinal excretions. Psychosocial consultation was conducted throughout the patient's outpatient and inpatient stays. The patient lived with her parents and older sister but was otherwise socially reclusive. Her mother had required multiple psychiatric hospitalizations for suicide attempts and was maintained on lithium carbonate. Since age 7. the patient had engaged 458
repeatedly in psychotherapy. focusing primarily upon somatic complaints and her relationship with her mother. with little apparent success. Psychological testing was performed to assist with diagnostic and treatment formulation. The patient completed the Rorschach inkblot test. the Minnesota Multiphasic Personality Inventory. and several subscales of the Wechsler Adult Intelligence Scale-Revised. The test results were valid and suggested a passive. ineffectual. and immature person who experienced herself as unable to cope with the real or imagined stressors of everyday life. In response. she strove desperately to embrace powerful others in hopes of assistance. From this perspective. multiple somatic complaints allied the patient with omnipotent. idealized physicians. Despite the patient's low average level of intellectual functioning. another defense she attempted to employ was intellectualization. which she used to ward off distressed feelings. When these maneuvers failed. she narrowed her range of perception onto small. minor details. resulting in a distorted perception of reality. Thus. denial of painful affects predisposed this patient to somatization; her inadequate attempts at cognitive defenses caused her to scrutinize her body and to develop distorted and unrealistic ideas about her physical functioning. It was therefore imperative for the patient to preserve relationships with powerful others to maintain her self-experience. perception of reality. and affect modulation. We did not confront the patient with our concerns about intentional production of symptoms; such a stance likely would sever abruptly the patient's tenuous relationship with her idealized physicians. This loss. in tum. might have prompted exacerbation of somatic complaints. psychological regression. or increased self-destructive behavior. Thus. consistent with suggestions proposed recently 12 by Eisendrath. we employed inexact interpretations and face-saving techniques to address evaluation results. while preserving the patient's important relationship with her physicians. For example. we conveyed puzzlement that her sputum had grown Proteus because this organism was most always found in urine; our suspicions that she aspirated her urine were never stated overtly. As face-saving techniques. we suggested that her body needed help in clearing her secretions; speech pathology was consulted to coach the patient in productive coughing. and the nursing staff began postural drainage and clapping. The patient's referring physician revealed subsequently that she presented with a recurrence of her PSYCHOSOMATICS
Case Reports
symptoms several weeks after discharge. The physician saw the patient with her mother. stating that no intervention was indicated and that he would continue treating the patient only if she initiated psychotherapy. The patient's motherreponedly became enraged and stormed out of the physician's office; the patient followed thereafter. During the next 2 months. the physician received no calls from the patient; most likely she sought other treaters.
Discussion This patient afforded an opportunity to examine a rare case of factitious disorder with respiratory symptoms. As with many cases in which the patient is suspected of volitional production of the symptoms. we did not observe the behavior itself or related behaviors (i.e.• the aspiration of foreign material. such as urine). Had she indeed aspirated material containing Proteus. it need have occurred only shortly before the hospitalization to contaminate her oral cavity or tracheobronchial tree. The voluntary avoidance of coughing and secretion clearance explains the volume and maintenance of the bronchorrhea. The mother's psychiatric history raises the additional possibility of a factitious disorder by proxy. Support for such a systemic disorder is the family's fluctuation from sadistic treatment of the patient when she was not actively symptomatic (e.g.• smoking in her presence despite their firm beliefs that she had asthma and allergies). to
overinvolved protectiveness when she was symptomatic. Somatizing patients. especially those with factitious disorders. are widely known to be poor candidates for psychotherapy. Indeed. the recommendation for psychotherapy can enrage the patient and prompt an increase in somatic symptoms. communicating the need for traditional medical treatment. Instead. these patients may be best evaluated initially in an inpatient medical setting with active psychological consultation. Such consultation need not focus exclusively upon direct interaction with the patient. Rather. consultation with the hospital staff can be helpful I) in suggesting ways to interact with the patient to maximize the likelihood of acceptance of the information and rejection ofcontinued symptomproducing or symptom-maintaining behavior. and 2) in managing the staff's anger toward the patient. expressed concretely by unnecessary procedures or premature patient discharge. Once a somatizing diagnosis is made. psychotherapy can be recommended. The therapist then can empathize with the disruptive impact of the symptoms and thus avoid blaming the patient for medical complaints. Thereafter. communication between primary physician and psychotherapist is useful in helping the physician manage the often distressing reactions to the patient with factitious disorder.
References I. Asher R: Munchausen's syndrome. Lancet 1:339-341. 1951 2. Bush A.CollinsJV: Pulmonary Munchausen·ssyndrome. Postllrad Med} 58:564-565. 1982 3. Burkle FM. Calabro 11. Parks FB: Munchausen's syndrome presenting as respiralOry failure requiring intubation. Ann Emerll Med 16:203-208.1987 4. Mitchell DM. Doyle PM. Spiro SO: Munchausen's syndrome with mulliple pulmonary manifestations. } Royal Soc Med78:681--{)82. 1985 5. Ng LL: Munchausen's syndrome presenting as bronchospasm. Br} Clin Pract41 :714-715. 1987 6. Roethe RA. Fuller PB. Byrd RB. et al: Munchausen syndrome with pulmonary manifestations. Chest 79:487488.1981 7. Orenstein DM. Wasserman AL: Munchausen syndrome
VOLUME 32· NUMBER 4· FALL \99\
by proxy simulating cystic fibrosis. Pediatrics 78:621624. 1986 8. Freedman MR. Rosenberg SJ. Schmaling KB: Childhood sexual abuse in patients with paradoxical vocal cord dysfunction.} Nen' Mem Dis 179:295-298. 1991 9. Downing ET. Braman S5. Fox MJ. et al: Factitious asthma. }AMA 248:2878-2881. 1982 10. Ramirez-R J. Le6n I. Rivera LM: Episodic laryngeal dyskinesia: clinical and psychiatric characterization. Chest 90:7 16-721. 1986 II. Lopez-Vidriero M. Charman J. Keal E. et al: Bronchorrhoea. Thorax 30:624-630. 1975 12. Eisendrath SJ: Factitious physical disorders: treatment without confrontation. Psychosomatics 30:383-387. 1989
459
