A Woman With Recurrent Back Pain and Fever February 7, 2007

A Woman With A Woman With Recurrent Back Recurrent Back Pain and FeverPain and Fever

February 7, 2007February 7, 2007

Case Information: Case Information: History & PhysicalHistory & Physical

PMHx: HTN, dyslipidemia, congenital PMHx: HTN, dyslipidemia, congenital neurogenic bladder, (requiring self-neurogenic bladder, (requiring self-cath), CKD, recurrent UTI, solitary cath), CKD, recurrent UTI, solitary right functioning kidney, (left atrophic right functioning kidney, (left atrophic kidney), vesicoureteral reflux, kidney), vesicoureteral reflux, (diagnosed in her teens), mitral valve (diagnosed in her teens), mitral valve prolapse, schizoaffective disorder, prolapse, schizoaffective disorder, eczemaeczema

PSHx: appy, lap chole, exploratory lapPSHx: appy, lap chole, exploratory lap

History & Physical History & Physical

Meds: Meds: Triamterene/HCTZ 37.5/25Triamterene/HCTZ 37.5/25

Lipitor 10 mgLipitor 10 mgASA 81mgASA 81mgOlanzapine 7.5mgOlanzapine 7.5mgMirtazapine 30mgMirtazapine 30mgLorazepam 1mg QIDLorazepam 1mg QIDClobetasol .05% cream prnClobetasol .05% cream prn

Allergies: PCN (dyspnea)Allergies: PCN (dyspnea)

Social HxSocial Hx

Moved to Madison to pursue degree Moved to Madison to pursue degree in counseling psychology, former in counseling psychology, former phlebotomist, single, never married, phlebotomist, single, never married, no children, lives with roommate, no children, lives with roommate, smokes 1ppd x 30 years, rare ETOH, smokes 1ppd x 30 years, rare ETOH, no exerciseno exercise

Family HxFamily Hx

Parents deceased. Mother died in Parents deceased. Mother died in 60s with MI/HTN. Father died of 60s with MI/HTN. Father died of lung CA/DM. Nine siblings, (second lung CA/DM. Nine siblings, (second youngest of ten). Sis with Breast CA youngest of ten). Sis with Breast CA in 40s, Bro with heart dz NOSin 40s, Bro with heart dz NOS

ROS (pertinent positives)ROS (pertinent positives)

Irregular menses x 2 yrs, recurrent Irregular menses x 2 yrs, recurrent UTIs, (several a year/none UTIs, (several a year/none currently), self-caths q 3-4 hrscurrently), self-caths q 3-4 hrs

Physical Physical

PE: Well-appearing, middle-aged PE: Well-appearing, middle-aged woman, pleasant, timid, flat affectwoman, pleasant, timid, flat affect

VS: afebrile, BP 130/84, HR 80, RR VS: afebrile, BP 130/84, HR 80, RR 16 ; 5’1, 140#16 ; 5’1, 140#Benign examBenign exam

RECURRENT BACK PAIN RECURRENT BACK PAIN AND FEVERAND FEVER

Initial Illness: One week progressive Initial Illness: One week progressive fever, (T Max 101.0), nausea, right low fever, (T Max 101.0), nausea, right low back pain, poor appetite, malaise. Denied back pain, poor appetite, malaise. Denied dysuria, urgency, frequencydysuria, urgency, frequency

PE: T 100.5, BP 160/100, HR 100, RR 16, PE: T 100.5, BP 160/100, HR 100, RR 16, Right CVA tendernessRight CVA tenderness

Pt felt she had a UTI.Pt felt she had a UTI. Urine Cx: pan-sensitive E. ColiUrine Cx: pan-sensitive E. Coli Tx with cipro x 14 days.Tx with cipro x 14 days. Sx resolved.Sx resolved.

TWO WEEKS LATER…TWO WEEKS LATER…

Same sx, UA not clean catch, Urine Same sx, UA not clean catch, Urine cx negative, CT abd without stone.cx negative, CT abd without stone.

Tx empirically with TMP/SulfaTx empirically with TMP/Sulfa Sx resolved.Sx resolved.


Sx of back pain and malaiseSx of back pain and malaise Tx empirically with levaquinTx empirically with levaquin Urine cx pan-sensitive E. ColiUrine cx pan-sensitive E. Coli Sx resolved.Sx resolved.


Severe right lower back pain, vomiting, Severe right lower back pain, vomiting, fever 102.0, tachycardiafever 102.0, tachycardia

Admitted directly to hospital for Admitted directly to hospital for presumptive pyelonephritispresumptive pyelonephritis Urine cx pan-sensitive E. Coli; Blood cx Urine cx pan-sensitive E. Coli; Blood cx

negativenegative CT Abd: left atrophic kidney, (5 cm), right CT Abd: left atrophic kidney, (5 cm), right

kidney with two renal cysts, (largest 17mm), kidney with two renal cysts, (largest 17mm), no evidence of urinary tract obstruction, two no evidence of urinary tract obstruction, two small right-sided renal parenchymal calculi, no small right-sided renal parenchymal calculi, no perinephric abscessperinephric abscess

Nephrology Consult:Nephrology Consult:

Chronic pyelonephritis secondary to Chronic pyelonephritis secondary to longstanding reflux, (resulting in longstanding reflux, (resulting in CKD). CKD).

Theorized that left atrophic kidney Theorized that left atrophic kidney was source of infection and was was source of infection and was seeding the right kidney via her seeding the right kidney via her reflux.reflux.

Infectious Disease Infectious Disease Consult:Consult:

Source was possibly renal cysts or Source was possibly renal cysts or calculi. Recommended CT-guided calculi. Recommended CT-guided aspiration of cyst. (Cystic fluid aspiration of cyst. (Cystic fluid negative for infection)negative for infection)

Urology Consult:Urology Consult:

Thought above theories all very Thought above theories all very unlikely. unlikely.

Convinced her recurrent infections Convinced her recurrent infections were due to poor self-catheter were due to poor self-catheter technique. (She was able to technique. (She was able to demonstrate meticulous technique; demonstrate meticulous technique; they were satisfied. Nothing to add)they were satisfied. Nothing to add)

Disposition:Disposition:

Pt gets better. Pt gets better. Discharged on prophylactic bactrim Discharged on prophylactic bactrim

DS one at bedtime. DS one at bedtime. Follow up urine cx was negative.Follow up urine cx was negative.

ILLNESS ESCALATIONILLNESS ESCALATION

Over the next few months, sx Over the next few months, sx become more frequent and severe, become more frequent and severe, despite antibiotic prophylaxis.despite antibiotic prophylaxis.

Numerous out-pt appointments, Numerous out-pt appointments, urgent care visits, and hospital urgent care visits, and hospital admissions. (7 admits in 6 months).admissions. (7 admits in 6 months).


Each admission pt sicker, requiring Each admission pt sicker, requiring longer stays, numerous tests, longer stays, numerous tests, consults.consults.

Final consensus was to proceed with Final consensus was to proceed with left nephrectomy. (Atrophic kidney left nephrectomy. (Atrophic kidney as source)as source)

Pt extremely relieved that definitive Pt extremely relieved that definitive plan and treatment was in place.plan and treatment was in place.


Urologist remained skeptical—Urologist remained skeptical—ordered VCUG to prove presence of ordered VCUG to prove presence of reflux before scheduling pt for reflux before scheduling pt for surgery. (Pt had been dx as teen)surgery. (Pt had been dx as teen)

VCUG cancelled—pt too sick and VCUG cancelled—pt too sick and again admitted with fever and back again admitted with fever and back pain.pain.

ILLNESS ESCALATION ILLNESS ESCALATION

Hospital Course: pt became Hospital Course: pt became hemodynamically unstable, hemodynamically unstable, transferred to ICU for tx of septic transferred to ICU for tx of septic shock, was intubated and required shock, was intubated and required multiple pressors.multiple pressors.

Urine cx: citrobacter, enterococcus, Urine cx: citrobacter, enterococcus, candida, klebsiellacandida, klebsiella

Blood cx: candida glabratta, (two Blood cx: candida glabratta, (two sets)sets)

HISTORY GATHERINGHISTORY GATHERING

ICU nurse informs emergency ICU nurse informs emergency contact of pt’s change in medical contact of pt’s change in medical status.status.

Sister visits and raises suspicion of Sister visits and raises suspicion of factitious disorderfactitious disorder

Hx of secretly making herself sick, Hx of secretly making herself sick, (beginning in childhood. Never self-(beginning in childhood. Never self-cathed as child/adolescent!)cathed as child/adolescent!)

TRUTHTRUTH

Pt weaned from vent. Medically Pt weaned from vent. Medically recovers.recovers.

I gently confront pt.I gently confront pt. Pt reveals medical supplies, (urine-Pt reveals medical supplies, (urine-

filled syringe, IV tubing, etc…)filled syringe, IV tubing, etc…) Dr. Grant strangely relieved.Dr. Grant strangely relieved.

PLANPLAN

Assure pt medical care would Assure pt medical care would continue, (prolonged tx for continue, (prolonged tx for fungemia).fungemia).

I would not abandon her.I would not abandon her. Protect pt from self-harm and from Protect pt from self-harm and from

harmful medical procedures. (24 harmful medical procedures. (24 hour sitter).hour sitter).

PLANPLAN

Engage psychiatric care, (Tx both Engage psychiatric care, (Tx both factitious disorder and factitious disorder and schizoaffective disorder)schizoaffective disorder)

Resume antipsychotics and Resume antipsychotics and psychotherapy while on medical psychotherapy while on medical floorfloor

Transfer to psychiatric unit when Transfer to psychiatric unit when medically stablemedically stable

PLANPLAN

Enlist family support.Enlist family support. Pt accepts plan.Pt accepts plan.

FACTITIOUS DISORDERFACTITIOUS DISORDER

Form of feigned illness, Form of feigned illness, distinguished from malingering and distinguished from malingering and somatoform disorders. somatoform disorders.

The distinction is based on The distinction is based on intentionality and objective.intentionality and objective.


Malingering—feigning illness has Malingering—feigning illness has external incentive, (avoiding work).external incentive, (avoiding work).

Factitious D/O—No other incentive Factitious D/O—No other incentive than to be a patient and experience than to be a patient and experience the sick role.the sick role.

Somatoform D/O-- symptoms are Somatoform D/O-- symptoms are NOT voluntarily produced.NOT voluntarily produced.


Factitious illnesses have broad Factitious illnesses have broad spectrum of presentations.spectrum of presentations. Mild form—physical symptoms simply Mild form—physical symptoms simply

exaggerated.exaggerated. Extreme form—Munchausen’s Extreme form—Munchausen’s

SyndromeSyndrome The seeking of multiple invasive procedures The seeking of multiple invasive procedures

and operations, sometimes with serious risk and operations, sometimes with serious risk to life.to life.

HISTORYHISTORY

““Munchausen’s Syndrome” coined by Sir Munchausen’s Syndrome” coined by Sir Richard Asher in a famous paper in the Richard Asher in a famous paper in the Lancet in 1951.Lancet in 1951.

Re Baron Karl Friedrich von Munchausen, Re Baron Karl Friedrich von Munchausen, (1720-1797), a retired German cavalryman (1720-1797), a retired German cavalryman who traveled around entertaining people who traveled around entertaining people with his preposterous stories. Feats with his preposterous stories. Feats included riding cannonballs, traveling to included riding cannonballs, traveling to the moon, and escaping from a swamp by the moon, and escaping from a swamp by pulling himself up by his own hair.pulling himself up by his own hair.

HISTORYHISTORY

Asher identified and classified the Asher identified and classified the major presenting profiles of most major presenting profiles of most factitious pts:factitious pts: Abdominal: “laparotomophilia migrans”Abdominal: “laparotomophilia migrans” Hemorrhagic: “hemorrhagica histrionica”Hemorrhagic: “hemorrhagica histrionica” Neurologic: “neurologica diabolica”Neurologic: “neurologica diabolica” Dermatologic: “dermatitis autogenica”Dermatologic: “dermatitis autogenica” Febrile: “hyperpyrexia figmentastica”Febrile: “hyperpyrexia figmentastica” Hospital hoboes, polysurgery addicts, Hospital hoboes, polysurgery addicts,

professional patientsprofessional patients

Psychiatric Diagnosis:Psychiatric Diagnosis:

Factitious illness as a formal psychiatric Factitious illness as a formal psychiatric disorder was first added to the DSM in 1952 disorder was first added to the DSM in 1952 when it described malingering. “factitious when it described malingering. “factitious disorder” itself wasn’t added until 1980, with disorder” itself wasn’t added until 1980, with Munchausen’s syndrome being absorbed Munchausen’s syndrome being absorbed under the term “fictitious disorder NOS”under the term “fictitious disorder NOS”

Factitious Disorder—Defining characteristics:Factitious Disorder—Defining characteristics: Intentional production of symptomsIntentional production of symptoms Illness behavior reflects a wish to assume the sick Illness behavior reflects a wish to assume the sick

rolerole Absence of external incentives for the behaviorAbsence of external incentives for the behavior

PATHOGENESIS: PATHOGENESIS:

Conjectural. Conjectural. Research is lacking. Research is lacking. Possible explanations found largely Possible explanations found largely

in psychiatric and psychoanalytic in psychiatric and psychoanalytic literature.literature.

CLINICAL CLINICAL PRESENTATION:PRESENTATION:

Feigned illness usually very clever & Feigned illness usually very clever & convincing. Pts often have familiarity convincing. Pts often have familiarity with med terminology, usually from with med terminology, usually from extensive contact with the health extensive contact with the health profession, either as pts or profession, either as pts or employees. Suspicion usually not employees. Suspicion usually not raised for long periods of time.raised for long periods of time.

CLINICAL CLINICAL PRESENTATIONPRESENTATION

Illness is feigned through variety of Illness is feigned through variety of ways—confabulated history, ways—confabulated history, (neurogenic bladder), faking (neurogenic bladder), faking symptoms, (back pain), creating real symptoms, (back pain), creating real illness by artificial means, illness by artificial means, (ingestion/injection of (ingestion/injection of contaminants), tampering with contaminants), tampering with instruments, (IVs, thermometers, lab instruments, (IVs, thermometers, lab specimens).specimens).

CLINICAL CLINICAL PRESENTATIONPRESENTATION

Transparent forms of self-mutilation are Transparent forms of self-mutilation are generally avoided.generally avoided.

Pts usually appear more comfortable than their Pts usually appear more comfortable than their “condition” would warrant.“condition” would warrant.

Pts generally cooperative/receptive to all Pts generally cooperative/receptive to all recommendations for evaluation—no matter recommendations for evaluation—no matter how complicated or risky, (nephrectomy).how complicated or risky, (nephrectomy).

Requests for consent to contact family Requests for consent to contact family members or other hospitals are usually denied.members or other hospitals are usually denied.

Nursing staff commonly observes lack of Nursing staff commonly observes lack of visitors, lack of phone calls, (suggesting asocial, visitors, lack of phone calls, (suggesting asocial, isolated, or secretive behavior).isolated, or secretive behavior).

DIAGNOSIS:DIAGNOSIS: No specific tests.No specific tests. Dx relies on astuteness of clinicianDx relies on astuteness of clinician First clue usually from checking other First clue usually from checking other

sources, (family, hospitals).sources, (family, hospitals). Source of illness should be questioned Source of illness should be questioned

when routine tx of illness does not result when routine tx of illness does not result in improvement.in improvement.

Pt’s readiness to acquiesce to Pt’s readiness to acquiesce to procedures/surgeries that would normally procedures/surgeries that would normally provoke anxiety in other pts raises provoke anxiety in other pts raises suspicion.suspicion.

EPIDEMIOLOGY:EPIDEMIOLOGY: Prevalence data is lacking. Pts who simulate Prevalence data is lacking. Pts who simulate

dz are elusive/secretive by nature. dz are elusive/secretive by nature. Severe cases adopt aliases and modify their Severe cases adopt aliases and modify their

stories. stories. Histories fabricated/unreliable and defy Histories fabricated/unreliable and defy

checking against factual accounts. When on checking against factual accounts. When on the verge of detection, pts often leave AMA. the verge of detection, pts often leave AMA.

Serious personality disorders often Serious personality disorders often compromise the development of compromise the development of relationships needed to help them. relationships needed to help them.

EPIDEMIOLOGY:EPIDEMIOLOGY:

Extremely difficult to distinguish Extremely difficult to distinguish between naturally occurring dz and between naturally occurring dz and dz secondary to fictitious behavior. dz secondary to fictitious behavior.

Laws regulating medical privacy and Laws regulating medical privacy and confidentiality also create barriers to confidentiality also create barriers to data gathering. data gathering.

All of above result in few All of above result in few opportunities to work with and try to opportunities to work with and try to understand these pts.understand these pts.

EPIDEMIOLOGY: EPIDEMIOLOGY:

These roadblocks to accumulating These roadblocks to accumulating data suggest that the problem, data suggest that the problem, although likely rare, is seriously although likely rare, is seriously under recognized and under recognized and underreported.underreported.

PREVALENCE DATA: PREVALENCE DATA:

Study at University of Toronto, Study at University of Toronto, Published 1990 in Psychosomatics.Published 1990 in Psychosomatics.

Study attempted to document the Study attempted to document the incidence of factitious disorder in a incidence of factitious disorder in a general hospital setting, (Toronto general hospital setting, (Toronto General Hospital).General Hospital).

Method:Method:

Retrospective study conducted on Retrospective study conducted on 1361 referrals to the psychiatric 1361 referrals to the psychiatric consult service at the hospital.consult service at the hospital.

All referrals of medical and surgical All referrals of medical and surgical inpatients to the consult service inpatients to the consult service were examined over a three year were examined over a three year period ending in Feb 1988.period ending in Feb 1988.

Method:Method:

Pt information was obtained from Pt information was obtained from database forms that are routinely database forms that are routinely completed on all inpatients referred to the completed on all inpatients referred to the consult service.consult service.

The forms were completed by the The forms were completed by the residents rotating through the psychiatric residents rotating through the psychiatric consult service. Database forms contained consult service. Database forms contained info re demographics, reason for referral, info re demographics, reason for referral, DSM-III psychiatric diagnoses, and DSM-III psychiatric diagnoses, and treatment recommendations.treatment recommendations.

Method:Method:

The full hospital charts were The full hospital charts were reviewed in all the identified cases reviewed in all the identified cases of factitious disorder.of factitious disorder.

The dx of factitious disorder was The dx of factitious disorder was rejected when an examination of the rejected when an examination of the medical chart revealed that an medical chart revealed that an organic basis for disease was organic basis for disease was subsequently discovered.subsequently discovered.

Results:Results:

Of the 1361 consults reviewed, 73 patients Of the 1361 consults reviewed, 73 patients were seen more than once, thus 1288 were seen more than once, thus 1288 different patients were actually seen.different patients were actually seen.

Dx of factitious disorder was based on Dx of factitious disorder was based on DSM-III criteria.DSM-III criteria.

11 patients met criteria for dx.11 patients met criteria for dx. The dx of factitious d/o was subsequently rejected on The dx of factitious d/o was subsequently rejected on

one patient when organic basis for disease was later one patient when organic basis for disease was later discovered.discovered.

10 out of 1288 pts were diagnosed with factitious 10 out of 1288 pts were diagnosed with factitious disorder. (.8%) disorder. (.8%)

Results:Results: Age range: 19-64, median age 26Age range: 19-64, median age 26 7 of 10 pts female7 of 10 pts female Mean duration of sx prior presentation was Mean duration of sx prior presentation was

4 years, (range 0 to 11 years)4 years, (range 0 to 11 years) 2 pts worked in health care fields, 1 social 2 pts worked in health care fields, 1 social

worker, 2 factory workers, 2 students, 1 worker, 2 factory workers, 2 students, 1 housewife, 2 unemployed.housewife, 2 unemployed.

Personality D/O dx in 4 of 10, (3 borderline, Personality D/O dx in 4 of 10, (3 borderline, 1 atypical)1 atypical)

5 of 10 reported prior suicide attempts5 of 10 reported prior suicide attempts 2 of 10 had criminal histories2 of 10 had criminal histories

Results:Results:

Acknowledgment of the factitious Acknowledgment of the factitious behavior was unusual. (1 of 10 behavior was unusual. (1 of 10 admitted to her role in the illness)admitted to her role in the illness)

Acceptance of psychiatric treatment Acceptance of psychiatric treatment was unusual. (2 of 10).was unusual. (2 of 10).

Follow up available only on one Follow up available only on one patient who subsequently died of patient who subsequently died of self-induced illness.self-induced illness.

DISCUSSION:DISCUSSION:

The above study suggests that factitious The above study suggests that factitious disorders are not commonly identified in the disorders are not commonly identified in the general hospital setting, but that these cases general hospital setting, but that these cases are associated with considerable morbidity, are associated with considerable morbidity, mortality, and health care expenditure.mortality, and health care expenditure.

3 of 10 patients were involved professionally 3 of 10 patients were involved professionally in health care. Literature review suggests that in health care. Literature review suggests that pts with factitious disorder commonly have pts with factitious disorder commonly have backgrounds in medically related fields or backgrounds in medically related fields or caring professions. caring professions.


Factitious Disorder is a syndrome Factitious Disorder is a syndrome that encompasses a heterogeneous that encompasses a heterogeneous group of patients. The patients in group of patients. The patients in this study varied in their choice of this study varied in their choice of symptoms, methods of inducing symptoms, methods of inducing illness, chronicity of behavior, and illness, chronicity of behavior, and associated psychopathology.associated psychopathology.


Systematic study of a larger number Systematic study of a larger number of cases is needed to determine of cases is needed to determine which characteristics are associated which characteristics are associated with the acceptance of with the acceptance of psychotherapeutic treatment and psychotherapeutic treatment and with favorable outcomes.with favorable outcomes.

TREATMENT TREATMENT CONCEPTS:CONCEPTS:

Confrontation is foundation of effective Confrontation is foundation of effective mgmt, when done in non-punitive manner mgmt, when done in non-punitive manner with assurance that care will not be with assurance that care will not be discontinued.discontinued.

Pts who also suffer from anxiety, Pts who also suffer from anxiety, depression, or psychotic disorders may also depression, or psychotic disorders may also respond to the usual kinds of tx for these respond to the usual kinds of tx for these disorders.disorders.

Focus on minimizing disruption to the Focus on minimizing disruption to the nursing unit, help to lessen the potential for nursing unit, help to lessen the potential for iatrogenic complications, and avoid iatrogenic complications, and avoid expensive/dangerous interventions. expensive/dangerous interventions.

TREATMENT TREATMENT CONCEPTS:CONCEPTS:

Protect the patient from self-harm.Protect the patient from self-harm. Limit pt care to one physician and Limit pt care to one physician and

one hospital.one hospital. If any approach is to be therapeutic, If any approach is to be therapeutic,

it is likely to occur in the context of a it is likely to occur in the context of a continuing pt-physician relationship, continuing pt-physician relationship, preferably with a primary care preferably with a primary care physician.physician.

BIBLIOGRAPHY:BIBLIOGRAPHY: Asher, R. Munchausen’s Syndrome. Lancet 1951; 1:339.Asher, R. Munchausen’s Syndrome. Lancet 1951; 1:339. American Psychiatric Association: Diagnostic and Statistical Manual of American Psychiatric Association: Diagnostic and Statistical Manual of

Mental Disorders, 3Mental Disorders, 3rdrd Edition, Revised. Washington, DC, American Edition, Revised. Washington, DC, American Psychiatric Association, 1987.Psychiatric Association, 1987.

Bean, W.B.: Munchausen’s Syndrome, Perspect Biol Med 2:347-353, 1959.Bean, W.B.: Munchausen’s Syndrome, Perspect Biol Med 2:347-353, 1959. Chapman, J. Peregrinating Problem Patients—Munchausen’s syndrome. Chapman, J. Peregrinating Problem Patients—Munchausen’s syndrome.

JAMA 1957; 166:927.JAMA 1957; 166:927. Kass, F.C. (1985). Identification of persons with Munchausen’s syndrome: Kass, F.C. (1985). Identification of persons with Munchausen’s syndrome:

ethical problems. General Hospital Psychiatry, 7, 195-200.ethical problems. General Hospital Psychiatry, 7, 195-200. Raspe, R.E., et al: Singular Travels, Campaigns, and Adventures of Baron Raspe, R.E., et al: Singular Travels, Campaigns, and Adventures of Baron

Munchausen, New York: Dover Publications, Inc, 1960.Munchausen, New York: Dover Publications, Inc, 1960. Raspe, R.E. (1785). Baron von Munchausen’s Narrative of his Marvelous Raspe, R.E. (1785). Baron von Munchausen’s Narrative of his Marvelous

Travels and Campaigns in Russia.Travels and Campaigns in Russia. Powell, R., Boast, N. The million dollar man. Resource implications for Powell, R., Boast, N. The million dollar man. Resource implications for

chronic Munchausen’s syndrome. British Journal of Psychiatry. 1993; chronic Munchausen’s syndrome. British Journal of Psychiatry. 1993; 162:253.162:253.

Spiro, HR. Chronic factitious illness. Munchausen’s syndrome. Archives of Spiro, HR. Chronic factitious illness. Munchausen’s syndrome. Archives of General Psychiatry 1968; 18:569.General Psychiatry 1968; 18:569.

Sutherland, AJ, Rodin, GM. Factitious disorders in a general hospital Sutherland, AJ, Rodin, GM. Factitious disorders in a general hospital setting: Clinical features and a review of the literature. Psychosomatics setting: Clinical features and a review of the literature. Psychosomatics 1990; 31:392.1990; 31:392.

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A Woman With Recurrent Back Pain and Fever February 7, 2007