Munchausen's??

[VivaLasViejas, ASN, RN]

I've heard of this disorder, of course, and I've certainly seen plenty of TV shows depicting it more or less accurately........but until last week, I'd never met a real person who exhibited symptoms of it. This 30-year-old woman is well known at my workplace for drug-seeking, and she does indeed have some undiagnosed psychiatric issues as well as a history of depression. Now that I've taken care of this pt. for several days, however, I've become highly suspicious that Munchausen's is what we're really dealing with.

Here's why: Pt. is a non-compliant diabetic, has had multiple episodes of DKA, the most recent of which landed her in the ICU on an insulin drip. She wasn't admitted for DKA, however; she had presented to the ER on three consecutive days with complaints of sharp, shooting pains in the epigastric region that radiated to her right flank which mysteriously disappeared as soon as she was assessed. Finally, they decided to admit her on the third visit, because she was complaining of nonstop vomiting (although no one had actually seen her vomit) and her electrolytes were off. She came up to the general med/surg floor, but within hours of admission she was found on the floor, having some kind of seizure. Fingerstick was 450, so she was sent to ICU and insulin drip started. She was moved out to the floor again after her electrolytes were brought back in line and the insulin gtts were discontinued.

Now, here's where it gets complicated. Just about every available test has been run, and almost every possible cause for all this has been ruled out. CT was negative for both renal calculi and gallstones, MRI negative for tumors. EGD was done, along with gastric emptying and a colonoscopy---all negative. They've even done EKGs, cardiac enzymes, and an echocardiogram---all normal. In the meantime, she continues with frequent episodes of sharp, tearing pain, nausea, and vomiting, the latter of which no member of the staff has ever witnessed. She requires almost constant attention, likes to 'cluster' her pain and nausea meds so she can sleep for blocks of time, and then complains bitterly that no one is listening to her.

So why does my intuition say this patient is more than the average drama queen? Well, for one thing, there is some pathology here; obviously, she's diabetic, but she chooses not to take her meds......she's on public assistance, so it's not a matter of whether or not she can afford them, she just doesn't take them. Most of her symptoms arise when she is left alone for any length of time; when I had her in intensive care, she was on the call light at least four or five times an hour, and I was in there every hour anyway to check her blood sugars and titrate the insulin drip.

What was interesting was that I had given her a dose of pain medication and told her it would be a couple of hours before she could have more; she promptly developed chest pain that was accompanied by some actual changes in her EKG tracing. However, it lasted only as about as long as it took to get the doctor in there and some additional tests ordered. I heard it happened again over the weekend after she was moved out to the floor on telemetry, and yet no cause was ever found, nor did the resulting EKG changes continue for long.

Today, she reported vomiting several times, yet not once did I ever see any evidence of it. She makes sure everyone measures her urine and takes a look at her stools before she flushes the toilet---"I know you guys have to keep track of my I&O"---but she won't let anyone see that emesis basin. She knows more about her medical issues than most MDs, and can tell you what's wrong with her in perfect medical-ese. She knows every test, what the labs mean, even the generic AND brand names of the medications she's receiving. Then that tearing, ripping, searing pain in the epigastric and flank area shows up every 2 1/2 hours, right on schedule---you could set your watch by it---and she is in obvious distress, pale, diaphoretic, trembling violently. She gets her meds, and two minutes later she's snoring.

Something very definitely isn't right here. I don't know for sure if it IS Munchausen's, but this is more than your average case of hypochondria.

What I'd like to know is, have any of you ever dealt with this at work? Despite the media's fascination with the subject, I know this is very uncommon, and since I work in a small city hospital, my experience with the more exotic forms of mental illness is quite limited. So before I take my little theory to the patient's doctor, I need to know if I might be on to something, or if I'm barking up the wrong tree entirely. Any suggestions would be sincerely appreciated........even if it's not Munchausen's, I think this girl needs a psych consult and some serious therapy at the very least.

Thanks!

[canoehead, BSN, RN]

My first thought is- can you smell vomit out of the barf bucket? Even if she washed it there should be an odor.

If you promise (and give) the pain meds on schedule instead of prn does she still get the same pain?

[Still Riding]

i thought Munchausen's was when a care taker makes a child or dependant sick. but i could be wrong as i don't know the syndrom other than what is on TV. and TV is not very often accurate

[UM Review RN, ASN, RN]

i thought Munchausen's was when a care taker makes a child or dependant sick.

That would be Munchausen's Syndrome by Proxy. The proxy being the child or the dependent that the caretaker gets plenty of attention "treating."

There was a case of this (MSBP) years ago, which interested me so I followed it. They finally caught the mother by taking the child away and noting the child's immediate and dramatic health gains.

But in your case, in which you suspect the patient herself, there might be some privacy issues in installing cameras.

(Funny how you can sit and watch a patient 24/7 but if you let a camera do it, it's suddenly a privacy issue....)

[TracyB,RN, RN]

Still Riding: Munchausen's by proxy is when the caretaker projects s/s onto another.

MJLRN, sounds like a psych eval & a visit by social services is LOOOOONG overdue.

Just b/c the pt is on medical assistance doesn't mean her meds are paid for. In IL, there is a list of meds that public aid will pay for & the doctors that accept aid are dwindling down b/c of the low reimbursement by the state. Definitely sounds like some major psych issues & drug dependency issues are at play here, but part of me has to wonder, if she is even seeing a primary care doctor for her uncontrolled diabetes. I am almost willing to bet that if her meds are covered by the state, she is selling them for cash to get narcotics. All these tests done & not one mention of a tox screen... I find that absolutely fascinating. Is her pain being treated with Demerol? Just curious...

[PMHNP10]

i thought Munchausen's was when a care taker makes a child or dependant sick. but i could be wrong as i don't know the syndrom other than what is on TV. and TV is not very often accurate

You are absolutely correct, Munchausen syndrome by proxy (MSBP) is characterized when a parent physically causes their own child to be ill in order to gain attention to themselves, whereas Munchausen is when pt does it to self which could be the case presented.

From the case presented I get a bit of a personality d/o; somatoform disorder for sure, hypochondriasis, maybe, maybe not; most likely fictitious, but possibly psychosomatic.

Or it could be you old run of the mill psychosis.

[veteranRN]

Don't discount the fact that she may in fact have some underlying medical disorder that is causing these "strange" symptoms. I mean, she does in fact have abnormal labs and EKGs. These are kinda hard to fake. I would just caution you to not let your bias or belief that this is all psychological prevent her from getting good care. Much of what was said in the OP sounded judgemental to me.

[Haunted]

I've seen this before and we discovered that the patient was having snickers bars, etc. brought in. It raised her blood sugars and the junk she was eating caused her GI distress.

[VivaLasViejas, ASN, RN]

You have all made good points, and I thank you for your responses. I apologize if my post sounded judgmental; I don't mean to be, but when you live in a small city with a disproportionately large population of females in their 30s and 40s with ongoing complaints of abdominal pain---for which every test possible is done and no cause is ever found---you tend to become a little jaded.

Don't get me wrong: My personal feelings don't change the way I care for patients. I take good care of everyone, and these ladies are treated just as courteously as anyone else.....in fact, I go out of my way to make sure their pain is controlled as well as it possibly can be. I've never had a complaint about my care, so I must be doing something right.......but these patients are difficult to deal with, not to mention utterly impossible to like, and it is frustrating when you cannot even come close to meeting their needs.

This particular patient fascinates me, however, because she does have some obvious medical problems, e.g. her diabetes, and because her attention-seeking is so extreme. We've all had pts. who demand a lot of our time; but this girl seems to literally thrive on crisis........and if there isn't one happening, she'll create one.

About the tox screen.........that was the first thing I thought of, but her initial one was normal except for opiates and benzos, which was expected because she is on narcotics for her pain issues and Ativan for anxiety. They haven't drawn another one, and it might be interesting to suggest it in order to find out if she's been ingesting something that could cause the transient EKG changes and high blood sugars (I've never seen any sweets in her room, and she receives controlled carbohydrate meals, but that doesn't mean anything).

The thing is, I really want to help this girl. She can be absolutely delightful at times, and she seems so lost and so frail.......having been through my share of misfortune when I was younger, I'm a sucker for people like this. But unless we can get to the bottom of what's really wrong with her, nothing we do for her medically will matter.......it's like putting a Band-aid on cancer.

Thanks again.

[CHATSDALE]

You can be a hypochronic and have unlying physical problems at the same time she can be depressed and seeking attention and playing her physical sx for all thely are worth...she does need a psyche and a physical eval...

[Still Riding]

Thanx for the clearing it up.

[viviannurse]

You have all made good points, and I thank you for your responses. I apologize if my post sounded judgmental; I don't mean to be, but when you live in a small city with a disproportionately large population of females in their 30s and 40s with ongoing complaints of abdominal pain---for which every test possible is done and no cause is ever found---you tend to become a little jaded.

Don't get me wrong: My personal feelings don't change the way I care for patients. I take good care of everyone, and these ladies are treated just as courteously as anyone else.....in fact, I go out of my way to make sure their pain is controlled as well as it possibly can be. I've never had a complaint about my care, so I must be doing something right.......but these patients are difficult to deal with, not to mention utterly impossible to like, and it is frustrating when you cannot even come close to meeting their needs.

This particular patient fascinates me, however, because she does have some obvious medical problems, e.g. her diabetes, and because her attention-seeking is so extreme. We've all had pts. who demand a lot of our time; but this girl seems to literally thrive on crisis........and if there isn't one happening, she'll create one.

About the tox screen.........that was the first thing I thought of, but her initial one was normal except for opiates and benzos, which was expected because she is on narcotics for her pain issues and Ativan for anxiety. They haven't drawn another one, and it might be interesting to suggest it in order to find out if she's been ingesting something that could cause the transient EKG changes and high blood sugars (I've never seen any sweets in her room, and she receives controlled carbohydrate meals, but that doesn't mean anything).

The thing is, I really want to help this girl. She can be absolutely delightful at times, and she seems so lost and so frail.......having been through my share of misfortune when I was younger, I'm a sucker for people like this. But unless we can get to the bottom of what's really wrong with her, nothing we do for her medically will matter.......it's like putting a Band-aid on cancer.

Thanks again.

I have cared for a pt like this before and not only did she have munchausens, she had a boderline personality disorder......if you research you will find that boderline's know alot about medicine, medical terminology and disease processes, they make caring for them very difficult and often ER and doc hop.........Good luck p.s. my pt eventually signed herself out ama and was in another facility in 2 days ...