https://doi.org/10.35845/kmuj.2023.21151 CASESERIES
Munchausen syndrome- a case series at Camp Jail Lahore, Pakistan
Khawar Saeed 1 
, Miqdad Haider 1, Faryal
Siddique 1
|
1: Social Security Hospital, Lahore, Pakistan Email Date Submitted: December 21, 2020 Date Last Revised: September 24, 2023 Date Accepted: September 26, 2023 |
|
THIS ARTICLE MAY BE CITED AS: Saeed K, Haider M, Siddique F. Munchausen syndrome- a case series at Camp Jail Lahore, Pakistan. Khyber Med Univ J 2023;15(3):187-9. https://doi.org/10.35845/kmuj.2023.21151 |
ABSTRACT
INTRODUCTION: Munchausen syndrome is a rare condition where individuals intentionally simulate illness despite the absence of actual symptoms. The objective of our case series was to underscore the importance of recognizing this mental disorder, frequently overlooked in routine clinical practice.
CASE PRESENTATION: This case series presents eight inmates in a central jail in Lahore, Pakistan, diagnosed with Munchausen syndrome within a period of one year (February 2019 to March 2020). Cases include a death row inmate complaining of abdominal pain, investigations revealing no pathology, and subsequent self-harm; a drug user with recurrent rectal bleeding resorting to self-inflicted injuries; prisoners intentionally causing head injuries, resulting in a fatality; a chest pain complaint used as a diversion for escape; a prisoner with a recurring leg ulcer engaging in self-mutilation; ingestion of a shaving blade; simulated sexual activity for admission; and inmates faking severe chest pain for medical attention.
CONCLUSION: The study highlights diverse manifestations of Munchausen syndrome in a jail setting, emphasizing the need for psychological evaluation and management. In constructing a differential diagnosis for diverse pathologies, it's important to consider Munchausen syndrome, especially when confronted with a cluster of signs and symptoms that prove difficult to elucidate.
KEYWORDS: Munchausen Syndrome (MeSH); Factitious disorder (Non-MeSH); Prisoners (MeSH).
INTRODUCTION
Munchausen syndrome, also sometimes referred as factitious disorder imposed on self, is a mental health condition characterized by the fabrication, amplification, or induction of physical, emotional, or cognitive ailments. 1
Individuals with factitious disorders exhibit these behaviours not for tangible gains like obtaining medication or financial benefits but rather to create a perception of illness or injury, stemming from an inner need for such recognition. It is essential to distinguish this from malingering, where individuals feign illness, often to evade responsibilities such as work.2 With regards to its prevalence, completing an accurate estimation of the prevalence of Munchausen syndrome is challenging, as clinicians may face difficulties in confirming the diagnosis. Many suspected Munchausen patients deny the diagnosis when confronted and can display hostility. However, certain risk factors have been identified, including being female, unmarried, working in healthcare, having borderline or histrionic personality traits or disorders, and a history of sexual abuse.3
Patients with Munchausen syndrome can often be deemed difficult to manage as their investigations findings contradict their clinical features, similarly, the response to the treatment would be inadequate.
Even though we don’t have enough literature regarding epidemiology, management and prognosis of this condition, it does result in substantial healthcare costs and unnecessary procedures, often due to a lack of healthcare professionals' awareness.4 This issue not only affects patients with Munchausen syndrome but also others exposed to significant morbidity and mortality due to fabricated symptoms, whether self-imposed or imposed on others.5
As compared to the general prevalence, it is quite common in prisons and it is frequently managed by jail general and medical staff. Prisoners at time can play the sick role to get medical attention, and to get bail. In this case series, we present similar cases who were eventually diagnosed with Munchausen syndrome.
CASE REPORTS
We present this case series of 8 inmates in a central Jail in Lahore, Pakistan, who were diagnosed with Munchausen syndrome after carrying out all the essential and relevant history, examination, and investigations. The period of study was one year (February 2019 to March 2020).
CASE 1: A 33 years ole male, who was in jail with death sentence in murder case 302. He complained of abdominal pain, severe in intensity, generalized without any rigidity or guarding no specific aggravating or relieving factors. He was admitted in jail hospital due to severity of symptom. His ultrasound, blood tests, Typhidot test, stool examination, were normal, he was shifted to services hospital as he was not improving, where, CT abdomen with and without contrast, urine toxicology were done which turned out normal.
Diagnostic laparoscopy was done with multiple omental biopsy which was normal. He was sent back to jail without any diagnosis. Constant vigilance was kept on the prisoner. He was diagnosed with the Munchausen Syndrome. He was put in punishment cell under constant vigilance of psychologist, jail doctor and jail staff. He is well without any symptom in last six month.
CASE 2: A 22 year’s old male came in jail in July 2018 in illicit drug use 9-C. He presented in OPD with the history of bleeding per rectum and was returned to barrack. He remained well for 5 days. He again presented with bleeding per rectum. Proctoscopy was done which shows hyperemic ulcerated anal canal. He was given treatment after which he improved and initial symptoms were subsided. He again developed more severe bleeding. He was shifted to services hospital colonoscopy, and Endoscopy was normal. Abdominal ultrasound, hepatitis B, C serology was negative. Stool was negative for blood was normal he was discharged with nonspecific bleeding. He remained well for 2 weeks. He again presented with bleeding per rectum, this time his roommate caught him putting finger in his rectum and damaging his anal canal with finger nails (washroom in the jail cells are open washrooms). He was hand cuffed with the iron rod of the door. He remain well with hand cuff all the day except while going to washroom in direct vigilance. After one month, he again presented with bleeding per rectum this time he self-harm the anal canal with sharp corner of Panadol wrapper. This time one leg and hand was cuffed with iron rod of the door till he was released after two month.
CASE 3: Three prisoners came in the jail January 2019 in case 392 (Robbery). On Eid night they had made plan to spend night outside jail, as a result, all three strike there head forcibly on the wall multiple times, this resulted in severe injuries to the face and skull. All of three of them were shifted to the hospital urgently. One of them died due to skull fracture and intracranial bleed. Rest of two were released after 6 months.
CASE 4: A 45 years old male, in case 302, suddenly develop chest pain at mid of night 2 AM, very severe in intensity. ECG was normal, however due to severity of the pain, he was referred outside jail for necessary treatment. However, during the transfer, his gang members were present who helped him run away from the police custody after killing two police men.
CASE 5: A 41 years old male, came in case 302, he presented with non-healing leg ulcer on right side. He was admitted in the jail hospital. He was seen by surgeon dermatologist regularly, wound culture shows positive for skin flora. In 3 months ulcer shows alternating phases of healing phase then suddenly wound worsened within 24 hours. One day he was found to mutilating the wound with blade. He was put in punishment cell with hand cuff. Dressing was done and he was kept under direct observation 24/7. His wound healed within two weeks.
CASE 6: A 35 years old male in Case 302, ingested the shaving blade (Figure 1). He was transferred to tertiary care center, endoscopy was done, which was unsuccessful. Blade was passed in the stools on 4th post admission day.
CASE 7: A 27 year old male got admitted with severe abdominal pain in jail hospital, same day another prisoner from different barrack admitted in jail hospital with blood in stools. While in the hospital, both patients were found to be involved in sexual activity. Both were closed in punishment cells separately. Later on blood in stool was not proved on proctoscopy and stool examination. Both played the sick role to be together and admit in jail hospital. Both remained well without any symptom till after 3 months of release.
CASE 8: Sixteen cases who presented in emergency of jail hospital with severe chest pain, 8/10 in intensity, with ages 30-45 years, ECG were either normal or nonspecific ST-T changes. They were shifted to Punjab Institute of Cardiology. Where they were kept in observation for 72 hours, blood tests include serial troponin, blood tests, lipid profile. Was done. CT angiography was done in 10 prisoner and conventional angiography was done in 6 prisoners. Which was normal and referred back to jail with the advice not recommended for follow-up. Later on there were diagnosed as Munchausen Syndrome to get medical antension.
DISCUSSION
Munchausen syndrome is uncommon factious disorder which need recurrent hospitalization. This syndrome there is pathological presentation of sick role for medical treatment. This syndrome is diagnosed after excluding other diseases.6 Munchausen syndrome come under the title of factitious disorder to get medical interest. This disease was first described by Richard Asher in 1951. This name was given after Born Munchausen who was famous for fabricated travel stories.7 This disease is different from “hypochondriasis” or other somatoform disorder where symptoms are not produced intentionally.8 This syndrome is clearly to get external benefits. Detail history medical record evaluation, physical and psychological evaluation is required to get the diagnosis. In our case series all of them symptoms were produce to get hospital admission so truly termed as “hospital addiction syndrome”. In jail this syndrome is not uncommon disease, the prisoners pretend to be sick to gain different benefit. The sick role is to get bail from jail, get admission outside hospital, and get sympathy from public and media, to have comfortable life like mattress, heater, and room cooler. Munchausen Syndrome is mostly seen in death sentence prisoners and life time imprisoned person to avoid adversities of prisons. Heavy bribe is offered to get potential gains. Lot of prisoners have been bailed out on “sick role”. Diagnosis of disease, excluding organic pathology is the core crux of the disease management.9 These people either come with factious symptoms even underwent surgical intervention just to get medical care.10 Treatment of Munchausen Syndrome is treatment of self-mutilating behavior and psychiatric help. But most of them refuse to get psychiatric help and deny psychiatric illness even threaten the medical staff for serious consequences.11
CONCLUSION
This study illuminates varied manifestations of Munchausen syndrome in a prison context, emphasizing the imperative for psychological assessment and intervention. The literature review underscores the rarity of Munchausen Syndrome, a challenge frequently encountered by jail doctors. Communicating the nature of the disorder to prisoners, places doctors in a precarious position, including potential threats to personal safety, family, and legal repercussions. Timely diagnosis and effective management are crucial for resource optimization.
REFERENCES
1. Gajda R, Drygas W, Gajda J, Kiper P, Knechtle B, Kwaśniewska M, at al. Exercise-Induced Arrhythmia or Munchausen Syndrome in a Marathon Runner?. Diagnostics 2023;13(18):2917. https://doi.org/10.3390/diagnostics13182917
2. Alkhattabi F, Bamogaddam I, Alsagheir A,Al-Ashwal A, Alhuthil R. Munchausen syndrome by proxy: a case report. J Med Case Rep 2023;17(1):148. https://doi.org/10.1186/s13256-023-03848-7
3. Singh S. Munchausen Syndrome Presenting with Hematemesis And school refusal: A Rare Case Report. Eur Psychiatry 2023;66(S1):S971-2. https://doi.org/10.1192%2Fj.eurpsy.2023.2066
4. Aboishava L, Eremkina A, Ioutsi V, Bibik E, Mirnaya S, Mokrysheva N. Rare case of Munchausen Syndrome in endocrinology: artificial hypokalemia. Endocr Abstracts 2023;90:EP49. https://doi.org/10.1530/endoabs.90.EP49
5. Persani L, dell’Acqua M, Ioakim S, Campi I. Factitious thyrotoxicosis and thyroid hormone misuse or abuse. Ann Endocrinol 2023;48(3):367-9. https://doi.org/10.1016/j.ando.2023.03.008
6. Yates G, Bass C. The perpetrators of medical child abuse (Munchausen Syndrome by Proxy)–A systematic review of 796 cases. Child Abuse Negl 2017;72:45-53. https://doi.org/10.1016/j.chiabu.2017.07.008
7. Abeln B, Love R. An overview of Munchausen syndrome and Munchausen syndrome by proxy. Nurs Clin 2018;53(3):375-84. https://doi.org/10.1016/j.cnur.2018.04.005
8. Gomila I, López-Corominas V, Pellegrini M, Quesada L, Miravet E, Pichini S, et al. Alimemazine poisoning as evidence of Munchausen syndrome by proxy: A pediatric case report. Forensic Sci Int 2016;266:e18-22. https://doi.org/10.1016/j.forsciint.2016.08.010
9. Abdurrachid N, Marques JG. Munchausen syndrome by proxy (MSBP): a review regarding perpetrators of factitious disorder imposed on another (FDIA). CNS Spectr 2020;27(1):16-26. https://doi.org/10.1017/s1092852920001741
10. Schrader H, Bøhmer T, Aasly J. The incidence of diagnosis of Munchausen syndrome, other factitious disorders, and malingering. Behav Neurol 2019;2019:3891809. https://doi.org/10.1155/2019/3891809
11. Sousa Filho DD, Kanomata EY, Feldman RJ, Maluf Neto A. Munchausen syndrome and Munchausen syndrome by proxy: a narrative review. Einstein 2017;15(4):516-21. https://doi.org/10.1590/s1679-45082017md3746
12. Di Lorenzo R, Lannocca L, Burattini M, Vasta A, Galletti M, Minarini A, et al. Early death in Munchausen syndrome: A case report. Clin Case Rep 2019;7(8):1473-7. https://doi.org/10.1002%2Fccr3.2254
13. Weber B, Gokarakonda SB, Doyle MQ. Munchausen Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Accessed on: September 20, 2023. Available from URL: https://www.ncbi.nlm.nih.gov/books/NBK518999/
|
Following authors have made substantial contributions to the manuscript as under: KS, MH & FS: Identification, diagnosis and management of case, drafting the manuscript, critical review, approval of the final version to be published. Authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
|
CONFLICT OF INTEREST Authors declared no conflict of interest GRANT SUPPORT AND FINANCIAL DISCLOSURE Authors declared no specific grant for this research from any funding agency in the public, commercial or non-profit sectors |
|
DATA SHARING STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request |
|
|
|
KMUJ web address: www.kmuj.kmu.edu.pk Email address: kmuj@kmu.edu.pk |