Asfandyar Sheikh ( 4th Year MBBS Students, Dow Medical College, DUHS, Karachi. )
Muhammad Muslim Noorani ( 4th Year MBBS Students, Dow Medical College, DUHS, Karachi. )
Muhammad Farhan Khaliq ( 4th Year MBBS Students, Dow Medical College, DUHS, Karachi. )
Madam, emergency departments (EDs) in Karachi are becoming more crowded than the quintessential fish markets. A large portion of this can be attributed to the cloud of brutality that seems to cover most of the city. However, an aspect that often goes neglected, relates to an array of psychiatric conditions, collectively known as "Factitious Disorders." These disorders are characterized by deliberate production or exaggeration of symptoms.1
Consider this scenario: a patient presented to the ED with refractory hypoglycaemia and dilated pupils. He was shifted to the intensive care unit, after which it was revealed that he had injected himself with insulin and instilled atropine in his eyes, in order to seek hospitalization.2
Patients with Munchausen\\\'s Syndrome, a factitious disorder,often have a history of childhood abuse, neglect or parents having psychiatric disorders. The motives include gaining of sympathy and attention by experiencing the sick role. Another variant of this condition, Munchausen by proxy, usually involves the parents fabricating their children\\\'s symptoms, in order to solicit attention and sympathy from healthcare practitioners or to subject their "proxies" to unnecessary medical tests.3 Both of these conditions not only put the subject\\\'s own life at stake (as his attempts at feigning symptoms may prove to be fatal), but are also a major concern for the healthcare system of a country, which is already battling with lack of finances in the health sector.
Other similar conditions, most of which are not included under the heading of factitious disorders, include malingering and hypochondriasis. Malingering is feigning of symptoms for a secondary motive. It is different from Munchhausen\\\'s in that there is always an external motive (obtaining compensation, avoiding work)involved.4 Hypochondriasis, a type of somatoform disorder (characterized by involuntary mimicking of symptoms), refers to an excessive sense of worry about having a serious illness.5 The easy availability of information regarding rare diseases on the internet has led to an overwhelming increase of such patients. A subset of this condition, Medical Student\\\'s Syndrome, leads a student into thinking that he has a disease which he recently read about. Such "patients" are frequent visitors to the EDs and may prove to be a source of delay and subsequent harm for those patients who require intensive emergency care.
The most important concern in our setting is the deficiency of proper diagnosis. Very often the condition is diagnosed at a later point of time, when expensive tests have already been ordered. This can be prevented by keeping records of such patients, and sharing them with other tertiary care centers. Moreover, introduction of the triage system, where emergency care is provided depending on need, can prove to be a blessing and may reduce the economic burden imposed by these patients on the healthcare system.
1. Leamon MH, Feldman MD, Scott CL: Factitious Disorder and Malingering. The American Psychiatric Publishing Board Review Guide for Psychiatry, 2009; 387.
2. Bretz SW, Richards JR: Munchausen syndrome presenting acutely in the emergency department. J Emerg Med 2000; 18: 417-20.
3. Shaw RJ, Dayal S, Hartman JK, DeMaso DR: Factitious disorder by proxy: pediatric condition falsification. Harvard Psychiatry 2008; 16: 215-24.
4. Duffy S. Malingering Psychological Symptoms: An Empirical Review. Illinois State University; 2011.
5. Borghuis MS, Lucassen PL, van de Laar FA, Speckens AE, van Weel C, olde Hartman TC. Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. J Psychosomatic Res 2009; 66: 363-77.