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The Unique Challenge of Caring for an Obstetric Patient with Factitious Disorder: What Do You Do When You Don’t Believe Your Patient?
Abstract Number: SUN-58
Abstract Type: Case Report/Case Series
Introduction: Factitious disorder imposed on self (FDIS), formerly Munchausen Syndrome, presents unique challenges to healthcare providers, particularly in the parturient population. FDIS is characterized by misrepresentation of clinical symptoms as well as self-harming behaviors, frequently subjecting themselves to a battery of unnecessary tests, surgeries, and treatments in order to assume the sick role (1). FDIS is more likely to be found in women in the 4th decade of life who work in healthcare (2).
Case Presentation: A 36 y/o former RN G6P5 at 33w+6 s/p 3 previous CDs with extensive medical and surgical history presented in PTL. The patient reported a past medical history of MI x 2, COPD with oxygen dependence, pulmonary embolism, desquamating interstitial pneumonia s/p left lung wedge resection, recurrent urolithiasis and uro-sepsis s/p nephrostomy tubes, chronic pain syndrome with opioid dependence, tobacco abuse, anxiety and depression with multiple suicide attempts in her youth. The patient would not release her medical records due to perceived printing costs. Her vital signs were within normal limits (O2 sat 99% on RA). Physical exam was otherwise benign, with no scars to the chest wall to indicate previous thoracic surgery. Intrapartum work-up revealed an ECG without evidence of prior infarction, a TTE with normal left ventricular and valvular function, and PFTs with an isolated decreased diffusion capacity. A multidisciplinary approach was employed to facilitate her care consisting of MFM, cardiology, pulmonary, urology and anesthesiology services. Psychiatry consult was requested, but not performed prior to delivery. During labor, an epidural catheter was placed via CSE technique with intrathecal fentanyl given. The test dose of lidocaine with epinephrine was negative. The epidural was titrated with 0.125% bupivacaine + fentanyl 2mcg/mL to a T10 level. Due to labor progression, patient was taken for CD. Invasive monitoring was not utilized, but available if necessary and procedure was uncomplicated. She was discharged on POD #3 in stable condition.
Discussion: Given this patient’s complicated self-reported medical history and refusal to release her medical records from outside hospitals, she posed a unique challenge to her team of healthcare providers. Her history was inconsistent with her physical exam and intrapartum work-up; therefore, the decision was made to manage her labor based on her clinical findings alone with a low threshold to escalate if medically indicated. The ultimate goals of care for a patient with FDIS are to provide safe and cost-effective healthcare while maintaining physician-patient rapport despite any inconsistencies. Providers need to address patient concerns and demonstrate respect for their medical narrative while using clinical assessment to guide care.
1.) APA (2013). DSM (5th ed.). Arlington, VA: American Psychiatric Publishing.
2.) Krahn LE et al, Am J Psychiatry. 2003; 160(6): 1163