RESUMO A síndrome de Munchausen e a síndrome de Munchausen por procuração são condições caracterizadas pela invenção ou pela. La Sindrome di Munchausen per procura. Malerba: storia di una infanzia lacerata: Malerba: storia di una infanzia lacerata (Italian Edition) eBook: . Las metrorragias en el tercer trimestre de la gestación que parecen un cuadro de placenta previa pueden corresponder a una llamada de atención del paciente.

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Keywords: Munchausen syndrome; Munchausen syndrome by proxy;. Child abuse; Factitious disorders. RESUMO. A síndrome de Munchausen e a síndrome de. Language: English | Portuguese. Munchausen syndrome and Munchausen syndrome by proxy: a narrative review. Síndrome de Munchausen e síndrome de . La sindrome di Munchausen per procura. Front Cover. Alex V. Levin, Mary S. Il minore autore e vittima di reato. Competenze professionali, principi di.

These included but were not limited to the following: Deliberately dehydrating himself to get sick Scratching his IV sites to get infected Rubbing dirty chalk into his IV line Putting dirt on his IV site Cheeking his pain medications Taking out his medication port Mixing blood in his urine. Many times, Patient A's room was searched and staff found syringes and pieces of chalk.

Patient A was regularly followed by the psychiatric and became very hostile when confronted with his behavior of feigning symptoms. He craved attention and was very persistent in attempting to be hospitalized. Psychological testing revealed weak coping mechanisms, depression, low frustration tolerance, and a low self esteem.

Patient A was tried on antipsychotics, antidepressants, and individual psychotherapy, but nothing seemed to change his behavior of assuming a sick role. Finally, after being confronted for the last time in July of , Patient A never returned to our hospital and reportedly sought admission at another children's hospital that transferred him to an out-of-state facility for patients needing both medical and psychiatric care. Although Patient A presented with some of the traits of borderline disorder like impulsivity, low frustration tolerance, self mutilation, low self esteem, and frantic efforts to avoid abandonment, it is difficult to say whether he will develop borderline personality disorder as adult.

Patient A was willing to undergo painful or risky tests and operations in order to get sympathy and special attention, with no evidence of any secondary gain. His apparent sole aim was assuming a sick role, which supports the presence of a FD as opposed to malingering. Another important feature of this unique case was that Patient A was a male patient with sickle cell disease, while most cases of FDs reported in literature are in female patients with no known medical illness.

This case demonstrates that these disorders can occur in either gender, even in patients with known medical illnesses. There was no evidence of Munchausen syndrome by proxy in this case as Patient A had no contact with his mother, and the intentional production and feigning of his symptoms occurred while he was hospitalized.

Further, while hospitalized, Patient A had no real contact with his grandmother, and he spent the majority of his time in the hospital during these three years. Other reported cases in literature. Other reported cases of Munchausen syndrome in children include the following: Peebles, et al. Ballas, et al. Christopher, et al. Sneed and Bell 22 reported the case of a year-old-boy who inserted small stones into his urethra to simulate passage of renal stones.

Schade, et al. White, et al. Yates 26 described the case of an year-old girl with apurpura rash on her chin and lips and six-month history of sucking on pieces of glass. Lovejoy, et al. Brouhard 28 described cases of a year-old girl and an year-old boy with factitious hypoglycemia and histories of insulin manipulation. Libow 29 described the case of an year-old boy with oral bleeding with a four-month history of stabbing himself in the mouth with a ruler. Sheehy 30 described a case of a year-old boy with factitious hypoglycemia with a two-year history of insulin manipulation.

Abe, et al.

Aduan, et al. Herzberg and Wolff 33 described a case of an year-old girl with factitious fever and a history of thermometer manipulation.

Orr, et al.

Munchausen's Syndrome and Other Factitious Disorders in Children

Gilarski and Graham 35 described case of a year-old girl with factitious toenail infections and a three-year history of hydrofluoric acid use. Kazak, et al. Witt and Ginsberg-Fellner 37 described a case of a year-old girl with factitious Cushing's syndrome and six-month history of prednisone ingestion.

Rodriguez-Morenoet, et al. Tojo, et al. AUT: ok as edited? Fonseca and Rubio 40 described a case of a year-old girl with factitious systemic lupus and a history of coloring her face with paint.

Joseph-Di Caprio and Remafedi 41 described a case of a year-old boy with factitious HIV disease and a two-week history of false symptom-reporting.

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Reich, et al. Edwards and Butler 43 described a case of a year-old girl with factitious fevers who admitted to using a heating pad to heat her skin. Ackerman, et al. Reich and Gottfried 45 described cases of a year-old girl with self-induced bruises; a year-old girl with fever of unknown origin and three-year history of thermometer manipulation; and a year-old girl with chronic wound infections and a four-month history of wound interference.

Levin, et al. Karnik, et al. FD Management It is usually very difficult to treat people with FDs because they will go to great lengths to avoid being detected.

They may also become hostile and aggressive if confronted, or they may simply move on to another physician or hospital. In a younger child where FD is strongly suspected, nonthreatening but direct discussions with the patient can sometimes yield a confession. In cases of older children or adolescents, it is more likely that only tangible evidence e. A thorough psychosocial history and psychological assessment of the child and family system will help clarify the underlying motives.

The clinician should secure an enduring and stable patient-physician relationship by utilizing a nonconfrontational strategy. After that, the patient and physician can focus their efforts on resolving those real problems.

The clinician should also share with other members of the treatment team that the patient's deceitfulness and betrayal of trust is part of his or her illness pattern and is not to abuse the staff. This understanding may help team members avoid negative counter transference and aggressive and ineffective patient management during treatment of the patient with FD. Medications have not proven helpful in treating FD by itself, although they may be prescribed for symptoms of anxiety or depression if the individual also meets criteria for an anxiety or mood disorder.

Some case reports focus on the use of pharmacological agents in the treatment of FD. Prior and Gordon 49 reported good response to the antipsychotic drug pimozide. Both analytical and cognitive-behavioral approaches have been used to deal with FD, with some benefit, in patients who agreed to engage in such therapies.

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Approaches are limited by the fact that few people diagnosed with FD remain in long-term treatment. In many cases, however, the FD improves or resolves if the individual receives appropriate therapy for a comorbid psychiatric disorder. Supportive psychotherapy has proved beneficial in some cases. Patient education.

The clinician should convey empathy for the FD patient's distress that has led to the feigning or intentional production of illness. The clinician should inform the patient that his or her distress may improve with treatment. The clinician should point out that without treatment, the patient may again seek hospitalization.

The clinician should emphasize to the patient that each episode of producing or feigning illness can result in significant morbidity or even mortality for the patient through the production of illness or the undergoing of unnecessary tests or treatments.

Course and prognosis of FD with psychological signs and symptoms are not fully known because patients are generally lost at follow-up. In cases reported in literature, the course is usually chronic with numerous hospitalizations beginning in adolescence or early adulthood and extending to the late 40s. The rarity of cases older than 45 is an interesting and intriguing finding. Also, as the patient ages, it may be that the FD becomes milder, and fewer or no hospitalizations at all are needed like in the case of antisocial personality.

In their prospective study, Pope, et al. Discussion The risk factors for developing FD remain largely unclear. Based on the histories of patients with FD, the following can be projected as characteristics that may predispose an individual to develop a factitious illness: Presence of other mental disorders or medical conditions in childhood or adolescence that resulted in extensive medical attention; holding a grudge against the medical profession or having had an important relationship with a physician in the past; and the presence of a personality disorder, especially borderline, narcissistic, or antisocial personality disorder.

We know that the mean age of onset of adult FD is most commonly in the patient's early 20s 51 and up to perhaps half the cases may begin in adolescence. Reports of illness falsification cases that began in adolescence but were not identified until years later demonstrate that these deceptions can go undetected for years, resulting in serious and permanent damage.

A history of milder degree of abnormal illness may present prior to the development of the syndrome.

Subsequent illness behavior reinforced by professionals over the years leads to the escalation of abnormal illness behavior. Many of the patients are medical personnel and are well versed with medical terminology.

Once the diagnosis of Munchausen's syndrome or FD is suspected, failure to obtain a psychiatric consultation places some degree of responsibility upon the clinician for any serious damage the patient may inflict upon himself or herself.

Physicians should keep in mind that the patient with FD is entitled to the same rights to privacy and confidentiality of information as any other patient. Although patients with FD waste valuable resources, notifying other hospitals of patients with FD or circulating a blacklist of such patients probably violates the physician's ethical and legal duties; therefore, this practice should be discouraged. Keep in mind that patients with FD can and do litigate.

In a similar vein, searching a patient's belongings without permission for items used in perpetrating factitious illness violates the patient's privacy unless the search is conducted with the patient's consent. Consent can sometimes be gained by revealing the suspicions of FD to the patient while asking permission to search because patients may insist they have nothing to hide.

The use of video cameras to monitor patient behavior, if already in routine use to monitor patients' rooms, does not appear to violate privacy considerations.

Hospitals can usually satisfy legal concerns by posting signs stating that they use hidden video monitoring. Conclusion The prognosis of FD varies by subcategory.

Male patients diagnosed with the psychological subtype of FD are generally considered to have the worst prognosis.

Self-mutilation and suicide attempts are common in these individuals. The prognosis for Munchausen's syndrome is also poor. The statistics for recurrent episodes and successful suicides range between 30 and 70 percent. These individuals do not usually respond to psychotherapy. The prognosis for nonchronic FD in women is variable; some of these patients accept treatment and do quite well. This subcategory of FD, however, often resolves itself after the patient turns Munchausen's syndrome by proxy involves considerable risks for the affected person often a child —9 to 10 percent of these cases end in the child's death.

A review of the literature on factitious illness in young people indicates that children and adolescents can intentionally falsify illness, although younger children tend to use more obvious, easily identified falsifications and more readily acknowledge their deceptions.

Although limited, follow-up data on children who admit to their deceptions suggest there may be less risk of repetition, particularly when the fabrications are confronted at an early stage.

Given the risk of these patients developing a chronic pattern of illness falsification and the potential for early intervention, it is proposed that there is value in differentiating this specific population of children from those with other forms of persistent, undiagnosed medical complaints.

It is recommended that pediatricians include illness falsification by the child patient in the differential diagnosis of a persistent and unexplained medical condition, along with somatization, malingering, and Munchausen's by proxy abuse. Conditions that always begin when the child is alone or unobserved e.

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A detailed examination of the child's early medical history indicating frequent, unexplained medical problems may provide clues to the possibility of the patient's earlier experiences of intentional illness exaggeration or falsification by a caregiver.

The parent's affect and degree of concern and cooperation should be carefully observed when presented with the physician's suspicions or evidence of deception, because this may yield clues to possible coaching or collusion.

Young children may even be willing to reveal specifics of parental coaching or collaboration if directly questioned. Contributor Information Kamil Jaghab, Dr. Kenneth B. Skodnek, Dr. Skodnek is the Chairman, Department of Psychiatry and Psychology. Tanveer A. Padder, Dr. References 1. Rosenberg D. Munchausen's syndrome by proxy: Currency in counterfeit illness. The Battered Child, Fifth Edition. Libow JA.

Munchausen syndrome. Munchausen syndrome by adult proxy: a review of the literature. J Hosp Med. Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management.

Factitious disorder imposed on self

Tran HA. A woman with malaise and hyponatremia. Hyponatremia factitia Munchausen syndrome secondary to desmopressin use. Arch Pathol Lab Med. Hypoglycemic seizure in Munchausen-by-proxy syndrome. Pediatr Emerg Care. Magen D, Skorecki K. Extreme hyperkalemia in Munchausen-by-proxy syndrome. N Engl J Med. Solomon S, Lipton RB. Headaches and face pains as a manifestation of Munchausen syndrome.

Pandey M, Sawhney A. Factitious bleeding disorder in a child: an unusual presentation of Munchausen Syndrome. Indian Pediatr. Munchausen syndrome by proxy with massive proteinuria and gastrointestinal hemorrhage. Pediatr Nephrol.

A case with unexplained bleeding from multiple sites: Munchausen syndrome by proxy. Pediatr Hematol Oncol. Munchausen syndrome in the act of creating and enacting macroscopic hematuria.

Urol Int. Infectious diseases presentations of Munchausen syndrome by proxy: case report and review of the literature. Clin Pediatr Phila ;37 3 — Munchausen syndrome in obstetrics and gynecology. J Psychosom Obstet Gynaecol.

Unexplained seizures in an infant. Factitious disorders in adults: two cases of unusual skin ulcers. Acta Dermatovenerol Alp Pannonica Adriat. Ashraf N, Thevasagayam MS. Munchausen syndrome by proxy presenting as hearing loss. J Laryngol Otol. Cervicofacial subcutaneous emphysema in a patient with Munchausen syndrome.

Ear Nose Throat J. Procedures, placement, and risks of further abuse after Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child. Eastwood S, Bisson JI. Management of factitious disorders: a systematic review. Psychother Psychosom. Countertransference in factitious disorders and Munchausen syndrome.Henderson S. FD not otherwise specified, which includes those disorders with factitious symptoms that do not meet the criteria for FD.

Magen D, Skorecki K. Solomon S, Lipton RB. All the workup was negative except for mildly low hemoglobin and hematocrit. This lack of trustworthy epidemiologic studies related to these disorders is attributed to the fact that patients, when diagnosed, often do not accept their diagnosis and refuse to adhere to any treatment, and they generally continue to seek other hospitals and health services.

Tec L. Ann Rheum Dis. Reich and Gottfried 45 described cases of a year-old girl with self-induced bruises; a year-old girl with fever of unknown origin and three-year history of thermometer manipulation; and a year-old girl with chronic wound infections and a four-month history of wound interference.