Bangabandhu Sheikh Mujib Medical University Journal

Volume 17, Issue 1, March 2024

 

CASE REPORT

Unexplained bleeding as a presentation of Munchausen syndrome: A case reportOpen access - Wikipedia

 

Fatima Zohra, Maheen Rahman A green circle with white letters

Description automatically generated, Rasheda Nasrin Lopa, Shawkat Ara Jahan

 

Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.

 

DOI: https://doi.org/10.3329/bsmmuj.v17i1.70450

Received: 19 Dec 2023; Revised version received: 1 Feb 2024; Accepted: 1 Feb 2024

Published online: 7 Feb 2024

Responsible Editor: M Mostafa ZamanA green circle with white letters

Description automatically generated; Reviewer A: Anonymous; Reviewer B: Syed Emdadul Haque A green circle with white letters

Description automatically generated

INTRODUCTION

Factitious disorder imposed on oneself, also called Munchausen syndrome, encompasses the intentional creation of physical or psychological manifestations. This may encompass fabricating a state of illness, deliberately causing self-harm, or even simulating a medical condition to mislead others into perceiving the individual as genuinely unwell, impaired, or damaged. This deceitful conduct yields no extrinsic benefits, such as financial gain or evading legal obligations. Munchausen syndrome is considered to be the most severe and chronic manifestation of the condition.1 This disease is sometimes referred to as hospital addiction, poly-surgical, and professional patient syndrome.2 The precise frequency of this disease in Bangladesh is unknown. There is evidence from a few studies suggesting that individuals with factitious disorder may constitute roughly 8 to 10 per 1000 patients seeking psychiatric consultations.3 Diagnosing Munchausen syndrome is challenging due to its deceptive features. Reporting such occurrences could draw attention to clinical features, warning signs, and diagnostic criteria. For medical professionals dealing with similar cases, sharing the difficulties and solutions in identifying and treating Munchausen syndrome can be helpful. It may potentially aid in the formulation of protocols and guidelines about the management of factitious disorder cases. We describe this academic case of a young Bangladeshi woman who had a history of bleeding from multiple sites and was diagnosed and treated for Munchausen syndrome.

 

LEARNING POINTS

1.   Frequent hospital admissions or emergency visits for recurrent bleeding without a clear medical explanation should trigger further investigation into the possibility of Munchausen syndrome.

2.   Diagnosing and managing Munchausen syndrome with a history of recurrent bleeding necessitates a multidisciplinary approach, involving a psychiatrist, as the case warrants.

3.   Building trust and providing proper psychotherapy and pharmacological intervention may aid in management.

 

CASE DESCRIPTION

A young, educated woman aged 22 years of age was admitted on the Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University, with complaints of bleeding from her mouth, nose, eye, ear, and umbilicus. She had been suffering from bleeding through her mouth since 2006 and continued up to 2010. She has been suffering from such bleeding about 8 - 9 times per month, mostly at night, not mixed with food material or vomitus. None of her family members had ever witnessed such bleeding episodes. She had consulted with several physicians on numerous occasions and had undergone several investigations.

However, all the investigations revealed no abnormality, and no definitive diagnosis was made. In childhood, she lost her parents and was adopted, where she always felt neglected and unwanted. Since her menarche, she has had normal menstruation with a history of no bleeding from any other sites. None of her family members were suffering from any bleeding disorders. She was utterly symptom-free for about 8 - 10 years. Recently, she experienced a worsening of symptoms, including new symptoms as stated: bleeding from the nose, eye, ear, and umbilicus. The exacerbation was mainly experienced following a dispute between the husband and mother-in-law after getting married for three years. She was evaluated for possible causes after taking a proper history, a physical examination, and investigations, including an endoscopy and a colonoscopy. However, no abnormality in laboratory tests was detected, and she was referred to the Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University. Following no sign of a physical abnormality that may cause such bleeding, the patientís mental health was evaluated. Then, she was diagnosed with Munchausen syndrome. The diagnosis was based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).1

 

CASE MANAGEMENT

With the available investigations and circumstantial evidence, the patient was approached in a non-confrontational manner and explained her diagnosis. Initially, she disagreed with her diagnosis. However, a therapeutic relationship was sought with the patient, and she was offered psychological interventions. She eventually accepted her diagnosis and admitted to her deliberate symptomsí productions. During those sessions, she expressed that her worsening symptoms were linked to her subconscious need for love and attention from her loved ones, which she thought was neglected by her adoptive parents after the birth of their biological child and by her husband for his involvement with her in-laws. She was prescribed sertraline to combat her depressive mood and impulsivity. Her symptoms stopped abruptly after acceptance of her condition, pharmacotherapy, and psychotherapy. After the completion of six psychotherapy sessions, she was discharged.  Follow-up was done outdoors, and she was taught relaxation, exercise, and stress coping to manage her stress better.

 

DISCUSSION

Munchausen syndrome primarily manifests through physical symptoms, often leading to hospitalization or the need for medical treatment.  The manifestations can exhibit considerable heterogeneity. 3  Patients with Munchausen syndrome may deliberately manifest various common clinical issues, such as abscess formation, pain, hypoglycaemia, anaemia, bleeding, rashes, seizures, disorientation, transient loss of consciousness, vomiting, diarrhoea, and fever.1 Bleeding is frequently reported by such individuals.4 Historical evidence also indicates that individuals afflicted with this condition have frequently encountered neglect as well as physical, mental, and emotional abuse throughout their childhoods.5 In Munchausen syndrome cases, confirming the causes with laboratory and radiographic tests is challenging, with inconsistent results. A significant history of hospitalizations, a solid willingness to undergo medical procedures despite the risks, inconsistencies in the patient's medical history, resistance to psychiatric evaluation, limited response to standard therapies (e.g., anemia persisting despite blood transfusions), a unique disease progression that the patient can anticipate, and the emergence or worsening of symptoms when discharge is approaching, may aid diagnosis.6

Early suspicion and identification of disease, rapid psychiatric referral, and the existence of a mood problem or personality disorder are considered to be the most significant prognostic variables for these patients.7 While there are currently no pharmaceutical interventions specifically designed to address factitious diseases, medications may be used to manage comorbid conditions such as depression, anxiety, or personality disorders. The typical approach to managing Munchausen syndrome entails engaging in psychiatric counselling to modify the cognitive processes and behavioural patterns that contribute to the development and maintenance of the disorder.1

In conclusion, physicians should be suspicious of Munchausen syndrome in case of factitious bleeding when the source of the bleeding is not clear, relevant history and investigations are negative, especially when the patient has a dramatic but inconsistent medical background and acts strangely. In such cases, physicians should seek a psychiatric history or the help of a psychiatrist. Early suspicion, prompt psychiatric referral, and diagnosis are necessary to improve outcomes in such patients. Supportive pharmacotherapy and psychotherapy have been the mainstream treatments for such patients.

Acknowledgments

We thank the respected faculty members of the Department of Psychiatry at Bangabandhu Sheikh Mujib Medical University.

 

Author contributions

Manuscript drafting and revising it critically: FZ, MR, RNL, SAJ. Approval of the final version of the manuscript: FZ, MR, RNL, SAJ. Guarantor of accuracy and integrity of the work: FZ, MR, RNL, SAJ.

 

Funding

This study did not receive any fund.

 

Conflicts of interest

We declare no conflict of interest.

 

Ethical approval

Ethical approval was not sought because this is a case report. However, consent was obtained from the patient to prepare this manuscript.

 

Data sharing

The data that support the findings of this study are available on request from the corresponding author.

 

 

References

1.       American Psychiatric Association, American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington: American Psychiatric Association; 2013, DOI: https://doi.org/10.1176/appi.books.9780890425596.

2.       Gomes RR. A Rare Case of Factitious Bleeding from Multiple Sites: Munchausenís Syndrome. Austin J Psychiatry Behav Sci. 2022; 8(1): 1085, DOI: https://doi.org/https://doi.org/10.26420/austinjpsychiatrybehavsci.2022.1085.

3.       Asher R. Munchausen's syndrome. Lancet. 1951 Feb 10;1(6650):339-341. DOI: https://doi.org/10.1016/S0140-6736(51)92313-6.

4.       Koufagued K, Chafry B, Benyass Y, Abissegue Y, Benchebba D, Bouabid S, Belkacem C. Munchausen syndrome revealed by subcutaneous limb emphysema: a case report. J Med Case Rep. 2015 Aug 18;9:172. DOI: https://doi.org/10.1186/s13256-015-0649-x.

5.       Hay GG. Feigned psychosis--a review of the simulation of mental illness. Br J Psychiatry. 1983 Jul;143:8-10. DOI: https://doi.org/10.1192/bjp.143.1.8.

6.       Weber B, Gokarakonda SB, Doyle MQ. Munchausen Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Dec 18]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK518999/.

7.     Doughty K, Rood C, Patel A, Thackeray JD, Brink FW. Neurological Manifestations of Medical Child Abuse. Pediatr Neurol. 2016 Jan;54:22-28. DOI: https://doi.org/10.1016/j.pediatrneurol.2015.09.010.

(c) 2024 The Authors. Published by BSMMU Journal