Bioética e sociedade: transtorno factício autoimposto e imposto a outro / Bioethics and society: factitious disorder imposed on oneself and imposed on another / Bioética y sociedad: trastorno facticio impuesto a uno mismo e impuesto a otro

Resumo: Objetiva-se compreender a síndrome de Münchhausen a partir da descrição das suas causas, dos critérios de identificação, dos sinais clínicos, do diagnóstico e do tratamento, bem como das assistências realizadas pela Enfermagem e pela equipe interdisciplinar com interface da Bioética. Trata-se de uma revisão narrativa de literatura de caráter exploratório reflexivo, com abordagem qualitativa. Realizaram-se buscas de estudos em periódicos publicados entre 2009 e 2019; a amostra final constituiu-se por 30 artigos, além de livros, manuais e normativas. Os resultados apresentados evidenciam o conhecimento da quinta edição do Manual Diagnóstico e Estatístico de Transtornos Mentais, no qual a expressão "síndrome de Münchhausen imposto a si próprio" foi substituída por "transtorno factício autoimposto", e a "síndrome de Münchhausen por procuração" foi alterada para "transtorno factício imposto a outro", quanto à bioética. Indivíduos com o distúrbio factício tendem a buscar tratamento para si mesmo ou para outro. O comportamento desses pacientes aumenta a probabilidade de terem realmente uma doença física e até mesmo ir a óbito, causado pelo excesso de uso de medicações e pelos diversos procedimentos invasivos. Portanto, conclui-se que identificar o quadro clínico pode ser uma das primeiras iniciativas para a detecção e a prevenção. O tratamento deve se concentrar no manejo, com a possibilidade do uso da psicoterapia e de antidepressivos, antipsicóticos e ansiolíticos. A equipe de enfermagem e a multiprofissional devem estar atentas a sinais e sintomas para uma intervenção precisa e precoce, pois desempenham importante papel na identificação adequada do diagnóstico.

Summary: The objective is to understand Münchhausen syndrome, with the description of its causes, identification criteria, clinical signs, diagnosis and treatment, as well as the assistance provided in nursing and the interdisciplinary team regarding bioethics. This paper is a narrative review of literature with a reflective exploratory nature, and a qualitative approach. We searched for studies in journals published between 2009 and 2019, and a final sample consisting of 30 articles, in addition to books, manuals and regulations. The results presented corroborate the claims in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, in which the term "Münchhausen syndrome imposed on self" was replaced by "factitious disorder imposed on self", and the "Münchhausen syndrome by proxy" was changed to "factitious disorder imposed on another", in Bioethics. People with factitious disorder tend to seek treatment for themselves or for others. The behavior of these patients increases the likelihood of physical illness and even death, caused by overuse of medications and as a result of various invasive procedures. Therefore, it is concluded that identifying the clinical picture may be one of the first initiatives for detection and prevention. Treatment should focus on management, being able to use psychotherapy, antidepressants, antipsychotics, and anxiolytics. The nursing team and the multidisciplinary team must be alert to the signs and symptoms for accurate and early intervention since they play an important role in the proper identification of the diagnosis.

Resumen: El objetivo es comprender el síndrome de Münchhausen, con la descripción de sus causas, criterios de identificación, signos clínicos, diagnóstico y tratamiento, así como la asistencia brindada en enfermería y el equipo interdisciplinario en cuanto a la bioética. Es una revisión narrativa de la literatura con un carácter exploratorio reflexivo, con un enfoque cualitativo. Se realizaron búsquedas de estudios en revistas publicadas entre 2009 y 2019, y una muestra final que consta de 30 artículos, además de libros, manuales y reglamentos. Los resultados presentados corroboran el conocimiento de la quinta edición del Manual Diagnóstico y Estadístico de los Trastornos Mentales, en el que el término "síndrome de Münchhausen impuesto a uno mismo" fue reemplazado por "trastorno facticio autoimpuesto", y el "síndrome de Münchhausen por proxy" se alteró a "trastorno facticio impuesto a otro", ante la Bioética. Las personas con trastorno facticio tienden a buscar tratamiento para sí mismas o para otros. El comportamiento de estos pacientes aumenta la probabilidad de tener una enfermedad física e incluso la muerte, causada por el uso excesivo de medicamentos y como resultado de varios procedimientos invasivos. Por lo tanto, se concluye que identificar el cuadro clínico puede ser una de las primeras iniciativas para la detección y la prevención. El tratamiento debe centrarse en el manejo, poder usar psicoterapia, antidepresivos, antipsicóticos y ansiolíticos. El equipo de enfermería y el equipo multidisciplinario deben estar atentos a los signos y síntomas para una intervención precisa y temprana, pues desempeñan un papel importante en la identificación adecuada del diagnóstico.

"Impossible" patients in oncology: Two unusual cases.

OBJECTIVE: Cancer patients can present with impossible behavior, which can jeopardize their treatment and challenge healthcare professionals' teamwork. METHOD: Report of two unusual psychiatric cases, including Munchausen and Peter Pan syndromes, which occurred in a comprehensive cancer center.ResultGuidelines in medical and surgical wards are suggested to address such situations regarding oncologic compliance.Significance of resultsMultidisciplinary collaboration between medical and surgical teams and the psycho-oncologic department is highly recommended.

Protocolo de atención en salud integral de niñas y niños en situación de maltrato infantil / Comprehensive health care protocol for girls and boys in situations of child abuse

A partir de la premisa, que el maltrato infantil se está convirtiendo en un problema cada vez más serio a nivel nacional, situación que es avalada por la Organización Panamericana de la Salud (OPS) que considera que la violencia y sus diferentes manifestaciones son un problema que afectan a la salud y al desarrollo social y económico de amplios sectores de la población. Este protocolo considera que es importante que los proveedores de salud desarrollen habilidades y competencias que ayuden a detectar los casos de niños maltratados, así como conocer las mejores estrategias de intervención. El objetivo de este protocolo es proponer una herramienta que proporcione los elementos básicos a proveedores y proveedoras de salud para brindar atención de calidad en salud integral y realizar la notificación oportuna de los casos de maltrato infantil. Para ello han seleccionado un modelo basado en el triage del AIEPI (Atención Integral a las Enfermedades Prevalentes de la Infancia). Es una estrategia elaborada por la Organización Mundial de la Salud (OMS) y el Fondo de las Naciones Unidas para la Infancia (Unicef) presentada en 1996 como principal método para mejorar la salud en la niñez. La metodología del modelo se lleva a cabo por medio de tres componentes. El primero está dirigido a mejorar el desempeño del personal de salud para la prevención de enfermedades en la niñez y su tratamiento. El segundo se dirige a mejorar la organización y funcionamiento de los servicios de salud para que brinden atención de calidad apropiada; y el tercer componente está dirigido a mejorar las prácticas familiares y comunitarias de cuidado y atención de la niñez. Contiene un marco teórico, marco legal, así como una serie de anexos dirigidos a apoyar tanto el diagnóstico, como el seguimiento dado a las víctimas.

Munchausen syndrome revealed by subcutaneous limb emphysema: a case report.

INTRODUCTION: Limb subcutaneous emphysema secondary to a Munchausen syndrome represents a rare and severe entity because it involves the functional prognosis of the limb and vital prognosis of the patient. CASE PRESENTATION: We report the case of an 18-year-old Moroccan woman patient who presented to our hospital with a subcutaneous emphysema of the shoulder girdle and the right arm, caused by our patient. Treatment was aggressive, with a wide surgical debridement, parenteral antibiotic therapy and hyperbaric oxygen therapy. The results have been favorable. CONCLUSIONS: The correlation of anamnestic data and clinical and para-clinical exams were essential for the diagnosis of Munchausen syndrome in this case. In this regard, we report a rare case of subcutaneous limb emphysema secondary to Munchausen syndrome.

Two unusual cases of intractable hyperthyroidism responsive to octreotide: Munchausen syndrome or not?

BACKGROUND: The effective treatment for patients with resistant hyperthyroidism is difficult. METHODS: In this case report with 4-year follow-up data, we present 2 unusual cases of hyperthyroidism that were unresponsive to almost all antithyroid treatments including total thyroidectomy, but both were controlled with octreotide. RESULTS: Cases 1 and 2 were both middle-aged women. They presented thyrotoxicosis with a low serum concentration of TSH and thyroidal radioactive iodine uptake (RAIU). The underlying causes, such as thyroiditis, metastatic thyroid cancer and struma ovarii were explored. Iodine-induced hyperthyroidism, particularly factitious hyperthyroidism was highly suspected, but there was no direct evidence to establish these diagnoses. In spite of good compliance, their thyrotoxicosis could not be controlled with large doses of PTU or MMI. ß-blocker, methylprednisolone, radio-iodine therapy and even thyroidectomy were all attempted and failed. Short-acting octreotide was first administered to case 1 and then to case 2. Thyroid function improved greatly within 3 days in both cases. The doses of octreotide were tapered down to twice a week with consistent efficacy. During the follow-up periods, case 1 required octreotide 0.1mg twice per week and case 2 is on thyroid replacement therapy due to hypothyroidism. The recurrences of hyperthyroidism in both cases were again rapidly controlled with the increased dose of octreotide in case 1 and re-started the usage of octreotide in case 2. CONCLUSIONS: The etiology of thyrotoxicosis in these 2 cases is not clear. In the absence of struma ovarii or wide-spread follicular thyroid cancer, factitious hyperthyroidism due to Munchausen syndrome should be considered first. The efficacy of the off-label use of octreotide in hyperthyroidism was highly effective (only) in these 2 cases.

Novel splice site mutations in the gamma glutamyl carboxylase gene in a child with congenital combined deficiency of the vitamin K-dependent coagulation factors (VKCFD).

Congenital combined deficiency of the vitamin K-dependent coagulation factors is a rare bleeding disorder caused by either a defect in the gamma-glutamyl carboxylase or the vitamin K epoxide reductase enzyme complex. The diagnosis should be considered when vitamin-K dependent factor activities are decreased and liver dysfunction, vitamin K deficiency, and factitious coumarin ingestion have been excluded. We report a case of VKCFD in a child resulting from compound heterozygosity for two novel splice site mutations of the gamma-glutamyl carboxylase gene. Oral vitamin K supplementation resulted in partial resolution of proteins and complete resolution of bleeding.

Playing patient, playing doctor: Munchausen syndrome, clinical S/M, and ruptures of medical power.

This article deploys sadomasochism as a framework for understanding medical practice on an institutional level. By examining the case of the factitious illness Munchausen syndrome, this article analyzes the operations of power in the doctor-patient relationship through the trope of role-playing. Because Munchausen syndrome causes a disruption to the dyadic relationship between physicians and patients, a lens of sadomasochism highlights dynamics of power in medical practice that are often obscured in everyday practice. Specifically, this article illustrates how classification and diagnosis are concrete manifestations of the mobilization of medical power.

Psychosomatic medicine: the divergent legacies of Freud and Janet.

A series of differing explanations of a puzzling case of psychosomatic illness introduces some reflections on a century's history of psychoanalytic interest in the mind-body problem. Freud and Janet explained the physical symptoms of hysteria using radically different models of the mind. Since then Janet's model, banished early on, has returned to haunt the castle of psychoanalysis. The enduring influence of Janet's model on subsequent thought in this field, especially that of Marty and de M'Uzan, Sifneos, LeDoux, and others, is traced, as is the influence of Freud's model on Groddeck, Alexander, McDougall, Fonagy, and others. It is argued that although these models are vastly different at one level of abstraction, at a higher level they share an important set of assumptions.

Síndrome de munchausen: un reto para el clínico / Munchausen's syndrome: a challenge for the clinician

Se afirmó que en las últimas décadas, y por la creciente medicalización de la sociedad, se ha descrito la aparición de pacientes con enfermedades ficticias ®complejas¼, que durante años son atendidos en diversas instituciones, demandan gran cantidad de recursos e increpan a los profesionales de la salud por no resolver sus quejas y enfermedades. No es posible demostrar las abigarradas entidades que se buscan afanosamente y que la mayoría de los médicos no se atreven a descartar totalmente por diversos motivos. No son histéricos ni simuladores en el sentido clásico, aunque conscientes de sus actos, tal parece como si los realizaran impelidos por razones que ni ellos mismos comprenden. Para ellos se ha introducido la denominación de síndrome de Munchausen. Se hizo un breve recuento sobre los criterios diagnósticos, grupos de riesgo, cuadro clínico, modus operandi, consecuencias adversas, tratamiento y pronóstico de este moderno desafío que pone a prueba la sagacidad clínica del médico contemporáneo (AU)

Síndrome de munchausen: un reto para el clínico / Munchausen's syndrome: a challenge for the clinician

Se afirmó que en las últimas décadas, y por la creciente medicalización de la sociedad, se ha descrito la aparición de pacientes con enfermedades ficticias ®complejas¼, que durante años son atendidos en diversas instituciones, demandan gran cantidad de recursos e increpan a los profesionales de la salud por no resolver sus quejas y enfermedades. No es posible demostrar las abigarradas entidades que se buscan afanosamente y que la mayoría de los médicos no se atreven a descartar totalmente por diversos motivos. No son histéricos ni simuladores en el sentido clásico, aunque conscientes de sus actos, tal parece como si los realizaran impelidos por razones que ni ellos mismos comprenden. Para ellos se ha introducido la denominación de síndrome de Munchausen. Se hizo un breve recuento sobre los criterios diagnósticos, grupos de riesgo, cuadro clínico, modus operandi, consecuencias adversas, tratamiento y pronóstico de este moderno desafío que pone a prueba la sagacidad clínica del médico contemporáneo

Superwarfarin poisoning.

BACKGROUND: Superwarfarin sodium exposure or poisoning is a growing public health problem. There were 5133 reported cases of superwarfarin exposure and poisoning in 1988 and 13 423 cases in 1995. Cases may be associated with accidental exposure, suicide attempts, or Munchausen syndrome, and may be difficult to diagnose. PATIENTS AND METHODS: Patients from northern Wisconsin with superwarfarin exposure or poisoning were examined at a tertiary referral center in rural Wisconsin to determine what led to their exposure and to review the clinical manifestations, diagnosis, treatment, and prevention of superwarfarin poisoning. RESULTS: Eleven cases satisfied the criteria for superwarfarin exposure or poisoning. All 7 children included in the study had accidentally ingested superwarfarin, 2 adults had Munchausen syndrome, and 1 teenager and 1 adult had attempted suicide using superwarfarin. Nine of the 11 cases had taken brodifacoum. The patients who had accidentally ingested superwarfarin or attempted suicide using it were easily diagnosed, while diagnosis was markedly delayed for the 2 patients with Munchausen syndrome. Full reversal of anticoagulation was quickly achieved in the cases of accidental ingestion and attempted suicide. We examined and treated the patients with Munchausen syndrome for months before establishing a diagnosis and fully reversing the anticoagulation. None of the patients in our study died of superwarfarin poisoning. CONCLUSIONS: Superwarfarin exposure or poisoning is a growing public health problem that should be part of the differential diagnosis of patients who present with a coagulopathy consistent with vitamin K deficiency in the absence of coumadin therapy, liver disease, or the use of an inhibitor, and whose conditions do not resolve with large doses of parenteral vitamin K1 therapy.

Tc-99m HMPAO brain SPECT scanning in Munchausen syndrome.

Regional cerebral blood flow was studied in a patient with Munchausen syndrome using high resolution Tc-99m HMPAO SPECT. The scan demonstrated marked hyperperfusion of the right hemithalamus. The cranial CT scan was normal. The abnormal right hemithalamic blood flow is discussed in relation to the hypothesized neuropathy of this disorder.

Hemorrhagic colitis and pseudomelanosis coli in ipecac ingestion by proxy.

This report describes a toddler with chronic diarrhea, vomiting, and hypotonia due to surreptitious administration of syrup of ipecac by his mother (Munchausen's syndrome by proxy). Several features of this case distinguish it from previous reports of chronic ipecac ingestion in childhood: the development of grossly bloody stools; radiologic, endoscopic, and biopsy evidence of a chronic moderate colitis resembling ulcerative colitis; and the histologic finding of pseudomelanosis coli, providing an important clue to toxic ingestion. The significance and possible mechanism for genesis of pseudomelanosis coli is discussed. This case emphasizes the variability in presentation and difficulty in diagnosing long-term ipecac ingestion by proxy. Ipecac toxicity should be considered in children with unexplained colitis and vomiting.

A treatment program for functional paraplegia/Munchausen syndrome.

Two patients, referred following lengthy, extensive and frequent medical evaluations, were diagnosed as suffering from chronic factitious disorder with physical symptoms (DSM III). A treatment plan to eliminate the positive reinforcements apparently operating in the hospital and home environment, while preventing "loss of face" of the patient, was formulated and successfully carried out. Two detailed case histories to provide evidence for the diagnosis, the "faradic massage" treatment, patient response, and follow-up are documented.

Paleodigms and paleodigmatics: a new theoretical construct applicable to Munchausen's syndrome by proxy, child-abuse dwarfism, paraphilias, anorexia nervosa, and other syndromes.

A paleodigm is a formulation of ancient folk wisdom that encodes a causal explanation in a saying or story that penetrates the idiom of everyday language and influences behavior. Although paleodigms are not, per se, causative, they have diagnostic, prognostic, and therapeutic significance in syndromes like Munchausen's syndrome by proxy.