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Munchausen’s Syndrome: In favour of ‘Measured Scepticism’.
- Udemezue O Imo (3 October 2008)
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Udemezue O Imo, Locum Consultant Psychiatrist Mascalls Park, Brentwood
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udemezuei{at}yahoo.com Udemezue O Imo
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I am in
favour of a management approach for Munchausen's Syndrome which I have termed ‘Measured Scepticism’.
I will illustrate the broad concepts using two fictionalised case examples.
A young lady self-presented at a London A&E department saying she was depressed and suicidal. Following assessment she was detained under Section and placed on close observation on the ward. By the next day it became clear that all the information she had given, including her name was unverifiable. There was no objective evidence of depression or cognitive impairment observed by staff. By the third day her level of risk was considered low to medium. She was taken off Section and placed on intermittent observation. It was suggested to her that the police had to be involved as she was considered a missing and potentially vulnerable person. At this stage she quickly confessed that she had a factitious disorder and requested discharge. Another lady presented to another London A&E saying she had a history of schizophrenia and epilepsy and was known to a CMHT in North of England. She declared she was on a number of tablets including three mood stabilizers/anti-epileptics, an antidepressant, a benzodiazepine and an antipsychotic. The assessing doctor unfortunately prescribed all these medications on her chart, at significantly high doses, even in the absence of corroborating information. By the second day when seen by the consultant all her details had been shown to be false. She was not overtly psychotic. He discontinued all her medication and prescribed rectal diazepam on an as required basis as a precautionary measure. This was considered safer even though the lady described her seizures as “lasting for hours and not responsive to treatment”. It served to communicate to her the fact that the team was not going to act on unsubstantiated and potentially hazardous claims making it her responsibility to provide verifiable information. She stayed four days in hospital and did not have any seizures or manifest any psychotic features. Further inquiry revealed that she had a diagnosis of Munchausen’s syndrome with non-epileptic seizures. From these examples it is clear that the core principles of acting in a patient’s best interest and maintaining safe practice were not compromised. By applying a healthy dose of scepticism and reacting in a calculated manner in situations where a patient is not forthcoming harm is prevented or at least minimized. |
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