by Meagher & Bell
DAVID J MEAGHER*. MB, DPM, MRCPsych.
Senior Registrar in Psychiatry
St Ita's Hospital,
Republic of Ireland.
PHILIP J BELL. MA, MB.
Registrar in Psychiatry,
Republic of Ireland.
A case of factitious bereavement is described. A review of the literature regarding factitious psychological disorders suggests that feigned grief is a relatively common feature of these increasingly described disorders. Possible aetiological factors, diagnostic indicators and management strategies are discussed. This case emphasizes the need to recognise that patients with factitious disorders may present with psychological symptoms alone.
Factitious disorder, Bereavement, Munchausen's syndrome.
The occurence of physical factitious disorders has been recognised in medical literature for over a century (1). These include the extreme variant known as Munchausen's syndrome, a term coined by Asher (2) to describe wandering patients with dramatic medical presentations and pseudologia fantastica. More recently attention has been drawn to factitious disorders with psychological symptoms (3) including psychiatric Munchausen's syndrome (4) and factitious bereavement (5). We report an unusual case which highlights the clinical problems associated with these disorders.
MH, a 28 year old male, presented to the psychiatric unit in a distressed and intoxicated state. He described a seven week history of increasing dysphoria associated with marked suicidal ideation which he related to two recent bereavements. Firstly the tragic death of his wife in a road traffic accident seven weeks previously, followed three weeks later by the death of his mother due to a "heart attack". He also indicated that his wife had been seven months pregnant at the time of the accident and went on to describe in graphic detail the traumatic experience of having to identify her body. Mental state examination revealed a depressed mood and a preoccupation with feelings of anger related to the loss of his wife. He described feelings of hopelessness and reported that he had on one occasion "walked in front of a bus" and on another had been restrained from "jumping into the river". He reported an alcohol intake in excess of forty units per day since the death of his wife but denied previous excessive alcohol consumption.
Past history revealed that M was the youngest of fourteen children. Three of these had died as the result of "a motorbike accident", "leukemia" and "cancer of the throat" respectively. He described a happy childhood without emotional difficulties in a stable and supportive family. A student of moderate academic ability, he was a good mixer and left school at fifteen having obtained the group certificate. He then worked as a mechanic in his home town but became increasingly estranged from his family because he was "a bit wild and hot headed". He emigrated to the United Kingdom where he worked as an electrician. Soon after this he met his wife and they married after a brief courtship. He reported having little contact with his family in Ireland apart from a brief period when he returned home after the sudden death of his father five years previously.
He denied any past psychiatric or medical history and stated that he had been in excellent psychological health until "suddenly everything was taken away". He was admitted with a diagnosis of a severe adjustment reaction secondary to the recent bereavements.
The initial hospital course was relatively uneventful. M's case was viewed sympathetically by staff members who were supportive and concerned. He refused permission for his family to be contacted stating that they wouldn't be interested. His suicidal ideas gradually abated over a four week period and he was discharged with a plan for active follow up including bereavement counselling. He re-presented two weeks later in a distressed and intoxicated state. He reported depressed mood associated with anergia, early morning wakening, anorexia and weight loss. He was commenced on antidepressant medication and made a rapid recovery and was discharged after a three week admission.
M re-presented one week later with a similar clinical picture and was re-admitted. Two days later the hospital was contacted by M's landlord who had "heard that M had been killed in a car accident". When questioned about this M offhandedly explained that his landlord had just got mixed up. He again refused permission for his family to be contacted. Liaison with his bereavement counsellor revealed that he had resisted anything other than the most superficial discussion of events and had especially objected to producing any photographs of his wife. Soonafter M, who had hitherto been an affable and co-operative patient became threatening and hostile with the staff and left hospital against medical advice. At this point the validity of M's story was questioned and, because of concern about the patient's threatening mental state, attempts were made to contact his family through the police in his stated home town.
His family were successfully contacted and indicated that M was in fact single and that his mother and eleven siblings were all alive and well. The three siblings previously reported as deceased were in fact non-existent. Further questioning revealed that he had no known previous psychiatric contact and had resided in his home town until four months previously when he had left after an argument at work over a forged cheque. He had no other forensic history.
M re-presented five days later reporting the same history as previously but with a number of minor omissions including the story of his three deceased siblings. He also changed the date of his marriage. He was confronted with these inconsistencies and with the details of the collateral history from his family. He adamantly maintained that his story was true but refused admission. One year later he has not re-presented.
According to ICD-10 (6) the intentional production or feigning of symptoms is termed factitious disorder and is classified under disorders of adult personality and behaviour. Factitious psychological diorder must be distinguished from conversion disorders (in which the patient is not conscious of producing the symptoms) and from malingering (in which patients have a recognisable 'goal' other than to assume the patient role). Our patient meets the criteria for factitious psychological disorder. The issue of the forged cheque could be considered an external incentive but was not the subject of any further proceedings and seems unlikely to have provoked such extreme behaviour.
Where a disorder involves pathological lying as a symptom it is virtually impossible to obtain an accurate estimate of its prevalence. Two case series published to date however, suggest that factitious mourning is uncommon but not rare and that a sensitized psychiatrist might recognise several cases per year (5) (7). Most of the cases reported involve males (25 of 32), were middle aged (mean age 33.0 years) and were single or separated (25 of 30 where marital status was ascertained.
The diagnosis of factitious bereavement is often missed or delayed due to the understandable reluctance of carers to accuse bereaved persons of falsehood. In our case the factitious nature of the symptoms was not recognised until ten weeks after the initial presentation. This issue has been emphasized by Philips and colleagues (7) who attributed the high case detection rate in their study to prior sensitization to the possibility of the diagnosis. One example in their series underwent two years of bereavement counselling before recognition.
The evaluation of patients who feign illness is hampered by many factors including the use of aliases, difficulty in tracing contacts, short hospital stays and the presence of concomitant disorders such as depression or substance abuse (8). Clinical indicators which should raise the index of suspicion include an unusual or inconsistent history, especially traumatic or detailed descriptions of events, inaccessability of informants and the denial of previous medical contact in those who seem well versed in hospital routines (5). In cases where doubt exists deaths can be confirmed with with the appropriate coroners office.
The presumed aetiology of factitious disorders has been discussed in detail elsewhere (7) (9). In essence this form of behaviour represents abnormal care eliciting behaviour which is frequently set against a background of a severely disturbed personality. Elements of re-living past traumas, aggressive feelings towards the medical care system and learning from abnormal parenting have all been repeatedly described as factors in various reports. In our case the actual symptom choice can be linked to the occurence of the five year anniversary of his fathers death in the days immediately preceding his initial presentation.
Once a firm diagnosis has been established it is important for staff members to address their own reactions towards such patients. The reluctance to accuse can be replaced by a desire to punish. It has been suggested that these responses by staff may be a significant factor in provoking the premature discharge which frequently occurs in these cases. Reed (10) has emphasized that the initial management should be aimed at preventing early self discharge and indeed compulsory detention has been advocated for study purposes (11) but remains contentious.
The most appropriate ongoing therapeutic strategy for these patients is also the subject of much debate. Improvement after direct confrontation has been reported (12), but more recently a non-confrontational approach has been persuasively advocated (13). This involves the use of inexact interpretations, therapeutic double binds and various face saving techniques aimed at allowing the patient to relinquish their symptoms without loss of face. In our case confrontation resulted in the patient ceasing to attend, perhaps migrating elsewhere to continue the cycle of deception with its accompanying risks of unnecessary or inappropriate treatments.
Factitious bereavement, whilst uncommon, is not rare. Case detection can be improved by being vigilant to a number of diagnostic indicators. The exact aetiology of these disorders remains unclear and requires further investigation to test the various hypotheses which currently prevail. Management should initially focus on preventing early self discharge and addressing staff reactions to the deception. The value of direct confrontation is contentious and may be avoided with a number of recently described techniques which facilitate the formation of a therapeutic relationship with these patients.
Dr Marc Feldman (US Psychiatrist)
"I am quite new to the Internet but was stunned to find a report of factitious bereavement. My writing and research has focused on factitious disorders and Munchausen syndrome by proxy and I am co-author with Charles Ford MD of Patient or Pretender: Inside the Strange World of Factitious Disorders published last year by John Wiley & Sons. in the book we devote a chapter to the phenomenon of facititious psychological disorders including factitious bereavement. My new book co-edited with Stu Eisendrath who is referred to in the report will also contain a chapter on factitious psychological disorders. This book is intended for a professional audience unlike the first. We had thought we had a complete listing of all the reports on the subject but hadn't thought to surf the Internet for more I am delighted to find this latest report while our book is still in pre-galley form."
Dr Doug Bey (US Psychiatrist)
"Karl Menninger in The Vital Balance (pp 208) said '...It is the compulsive deception represented by the feigning of disease. Curiously enough, the individual who does this, the malingerer, does not himself believe that he is ill, but tries to persuade others that he is, and they discover, they think, that he is not ill. But the sum of all this, in the opinion of myself and my perverse minded collegues, is precisely that he is ill, inspite of what others think. No healthy person, no healthy-minded person, would go to such extremes and take such devious and painful routes for minor gains that the invalid status brings to the malingerer.' I've run into a few "pseudologia fantastica" type patients over the years--one who came to Vietnam for his second tour having been wounded and received a silver star his first tour, brother killed in RVN, father an admiral killed in WWII--orders lost taken on as the driver for the head of JAG in the division--brought by the Col who told me to throw him in jail, evacuate him, administratively discharge him, but get rid of him. The general's birthday cake was missing and they found this fellow eating it in a storage container! Then they discovered he'd never been to Vietnam, no brother, father not an admiral and alive!! Since the head of the police for the division had been taken in and had gotten him as his driver he was mortified by the discovery! When confronted the meek appearing young man calmly stated that he had been pursued by an international drug cartel and it was necessary for him to assume a false identity!!"
" This interesting case report reminded me of a patient who presented to the alcohol services in Liverpool a few months after the infamous Hillsborough stadium disaster in which many Liverpool football club supporters were killed in a crowd control disaster. This 40 year old gentleman presented with an alcohol problem and asked for detoxification. During this detoxification he told us that he was depressed and suicidal and he was transferred to an acute psychiatric ward, where he later went on to relate how his brother and nephew had been killed in the Hillsborough disaster, infront of his very eyes. The disclosure appeared to be very cathartic...at least the patient broke down into profound grief. He said that prior to a particular nurse's counselling he had b een unable to grieve. He appeared profoundly grateful, but maintained that he was still suicidal. Accordingly he stayed longer on the ward, until a night nurse became suspicious and asked him for specific details of the fateful match itself. The patient was unable to recall these details and further research proved his identity and address to be false. When confronted with these facts the patient went missing from the ward. Contact with other agencies established that this man had been admitted to several other hospitals with a similar story. He was lost to follow up."
"Interesting case I must say. What's the contribution of chronic alcohol abuse in this case? I have seen a few similar cases. One in Ireland was diagnosed by me as having Alcohol dependence with Korsakoff's, but unfortunately for me the diagnosis later turned out to be Munchausen's syndrome. Does confabulation play a part? T
Regarding management someone had suggested having a national register of such patients, but that's not really practical. Excellent article - keep going!
"Yes I see this in veterans. At times however it is closer to malingering as the patients are usually seeking admission to the hopsital. It's a confusing issue because if the patient is fabricating deaths etc. he may be hiding vital information that indicates why he is seeking admission. "
"Factitious disorders force us to examine the proper limits of confidentiality. We must assume from this case that the patient, having exhausted the good will of this treatment site, went on to another. We are tempted to advocate for some sort of national reporting system in which a list of such patients is made available to alert other such hospitals. Not only would such a system help to preserve precious resources but it would give the next treatment team a better chance at fundamentally helping this individual--who is obviously a very distressed person to have to communicate with the outside world in such an aberrant way. We must balance out confidentiality concerns against the need to better address this patient group. Incidentally at our hospital in Providence Rhode Island we've had a number of patients with factitious AIDS lately. As with M it's difficult for people to even consider that someone might make it up."
"I am intrigued by psychiatrists who see "illness" when patients lie to us. I note that no mention of a diagnosis of Personality Disorder is mentioned. They lie with seeming impunity, and make up all sorts of "symptoms", exaggerating or fabricating for who knows what reason. I think that seeking "etiology" for such behavior is naive. The smacks of the false memory syndrome or the liberal development of "multiple personality disorder" that is now rampant in our society. Virtually every patient is now conditioned to talk of being "abused" when they were 3 years old, and since we were not there to see it, it is impossible to disprove. But I see incredible acceptance of all patients report as absolutely true by many mental health professionals. The "false memory syndrome" has been dignified by professionals who think patients never lie to us. I think we do ourselves a disservice by continually finding new diagnostic terms for outright lying. Patients' "gain" is to mislead authority-to enjoy leading authority down the primrose path, in my clinical experience. And I doubt that any kind of therapy will work with a patient who is this dishonest with himself herself and others."
"Thank you for sharing this interesting case. I think this brings up two points. In psychiatry there are few truly objective signs so we must always remember, especially in court, how much we rely on the patient's history. In my own area of Post Traumatic Stress Disorder diagnosis and treatment we now have to grapple with the patients who perceived the trauma to be traumatic. As in common with this case there are those where the trauma does not appear to have happened. Usually the diagnosis is factitious rather than simple malingering. Secondly, the case illustrates the necessity of obtaining information from another person. I think this is needed in most cases. At least be in contact with the family physician who has known the patient for some time. The ethics of confidentiality in my mind preclude the giving of information not the obtaining of it."
Dr Charles Freed (US Psychoanalyst )
"It is conspicuous by it's absence that there was no attention given in the presentation of the case of M's substance abuse history.It is my suspicion that M has a substance abuse disorder and perhaps character pathology as well.His presentation as grieving may be a way to obtain relief from discovery by his family, employer, etc, while diverting attention from the real problem, allowing him to maintain denial about his substance abuse problems."
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