Patient privacy versus protecting the patient and the health system from harm: a case study.

A 71-year-old man who presented to hospital with chest pain and a history of cardiovascular disease was repeatedly hospitalised over the course of a month for care that included multiple investigations, intensive care, transfer to and from a metropolitan hospital, discharge, and readmissions for collapse, hemiparesis, and vision change. The medical team excluded underlying disease related to his initial chest pain and subsequent neurological symptoms. A search for (undisclosed) prior hospitalisations revealed multiple previous admissions and invasive investigations at hospitals across Australia, resulting in a diagnosis of Munchausen syndrome. Assuming that, despite interventions, patients with Munchausen syndrome or somatoform disorders often continue to seek care at other hospitals, we discuss the implications of this patient's behaviour for the health care system, society, and the risk to his own health. In our view, this case highlights conflicts between privacy legislation and doctors' mandates to protect the patient from harm, as well as their duty to attend to the financial viability of health services by communicating with other potential health care providers. The health care system and similar patients may benefit from efforts to educate doctors about this spectrum of disorders and from considering the implementation of a highly confidential, structured notification system.

"Through a glass, darkly": the clinical and ethical implications of Munchausen syndrome.

Patients who present repeatedly for care with medically unexplained symptoms raise challenges for the health system. One proposed strategy for dealing with such patients is the introduction of electronic medical records (EMRs) to identify these patients and thus limit the demands on resources their management involves. This measure may ultimately be appropriate but fails to consider equally critical core issues in psychiatric ethics. Identifying patients as "somatisers" invites a problematic relaxation of clinical vigilance, increasing the likelihood that an actual life-threatening medical problem will not be identified. Management of such patients requires regular, structured therapeutic contact with a skilled mental health clinician, that is independent of the patient's distress level. Psychiatric problems and medical problems are frequently seen as two distinct, unrelated categories. This is a false dichotomy, as mental health and physical health are interdependent. Given patient privacy considerations, EMRs would be unlikely to reveal the kind of sensitive mental health information needed for the identification and management of somatising patients in busy health systems. Cost-effective interventions for somatising patients' problematic behaviour, such as structured clinical intervention, antidepressant medication and cognitive behaviour therapy, are available at a fraction of the cost of EMR systems. Citing cost savings as a justification for violating the privacy of mental health patients compounds the manifest injustice these patients already face in the health system.

Cardiopathia fantastica: the cardiac variant of Munchausen syndrome.

Munchausen syndrome is a rare condition in which the patient repeatedly seeks medical care for factitious illnesses. Cardiac Munchausen syndrome was first reported in 1953 and later referred to as cardiopathia fantastica. It is characterized by clinical manifestations of acute cardiac disease that are feigned and recurrent. Cardiopathia fantastica can have a variety of presentations similar to true cardiac disease. Most cases have presented with chest pain simulating acute coronary artery disease, but arrhythmias, hypertensive crises, abnormal biochemistry, and electrocardiographic findings have also been noted. These patients are willing to undergo expensive, invasive, and risky procedures to evaluate their simulated illness. This condition is likely to be significantly underreported. In some patients, the presence of abnormal findings that are clinically insignificant may complicate the investigative approach. Patients with this disorder consume a disproportionate amount of health care dollars and sometimes are left with residual deficits as complications of invasive procedures. In this review, we discuss the recognition, manifestations, and treatment of cardiopathia fantastica.

Envenomations as a novel drug-seeking method.

Drug seekers have often sought narcotics and benzodiazepines through subjective reports of severe pain. We report 2 patients who claimed repeated envenomation to receive narcotic administration; 1 claimed black widow bite on 8 occasions at 7 separate healthcare facilities, the other claimed to have been bitten by a copperhead snake on 7 occasions at 4 separate healthcare facilities. A 3rd patient complained of lionfish envenomation with no tissue reaction and was refused analgesia. Inconsistent clinical presentations of envenomations may signal drug-seeking behaviors.

Munchausen syndrome in obstetrics and gynecology.

Munchausen syndrome (MS) is a well-defined clinical psychiatric entity. Furthermore, it is a complicated and intriguing problem in medicine in general and in obstetrics and gynecology in particular. The proportion of MS cases in obstetrics and gynecology is rising. This review covers relevant reports from the last four decades. Emphasis is put on the clinical expression of MS cases in obstetrics and gynecology. A discussion about their validity as such is included. Awareness of attending physicians to this type of illness in the era of patient rights, on the one hand, and the existence of defensive medicine on the other, is crucial.

The Munchausen syndrome in civil forensic psychiatry.

The diagnosis of Munchausen syndrome requires that a patient intentionally produce or feign physical symptoms with a psychological need to assume the sick role. To differentiate the disorder from malingering one must document the absence of an external incentive for the patient's behavior. Although malingering is a major topic of interest in forensic psychiatry, there has been no literature that looks at the Munchausen syndrome presenting in the civil forensic setting. This paper reports on two cases of the Munchausen syndrome that occurred in the areas of medical malpractice and workers' compensation. The cases highlight how the psychiatrist should approach these cases in the civil forensic setting. The malpractice case also illustrates how the disorder is viewed by an appellate court.

The million dollar man. Resource implications for chronic Munchausen's syndrome.

Munchausen's syndrome in a man of subnormal intelligence is described. The case is unique for the extent of detailed, corroborated history. This man has been a voracious consumer of NHS and other services, and an estimate has been made of his cost to the health and prison services. The case raises various ethical, forensic, and resource issues.

Munchausen's syndrome. A study of the casualty "Black books" of Melbourne.

Unofficial registers or casualty "Black books" have evolved to assist busy casualty department staff in the identification of patients who are suffering from Munchausen's syndrome, are drug abusers or have other "problem" disorders. Fourteen of Melbourne's 17 general public hospitals have such books which contain information on 835 patients. Amalgamation of information from all of these books reduced this to 713 individual patients, of whom 21 were regarded as cases of Munchausen's syndrome, 20 were probable cases, 652 were classified as drug abusers and 20 were classified as dangerous patients. All four groups shared a similar mean age, between 32 and 37 years. Munchausen's syndrome patients showed greater tendency to use aliases. Men predominated in all four groups, especially among dangerous patients. Conventional records rely upon obtaining an honest and accurate name and information from the patient and are quite inadequate for the identification and treatment of patients with Munchausen's syndrome and drug abusers. When these conditions are suspected, a detailed standard identification form, suitable for computerization, should be used at all hospitals.