A patient's tragic tale didn't add up

Special to The Times

The patient, in her early 20s, had red hair, pretty features and a disarming sincerity. When I first met her in the cardiac care unit, she told me that she had been on a flight from Helsinki, Finland, to Detroit, where her grandmother lived, when she developed palpitations and dizziness. Finding her pale and sweaty, a flight attendant had taken her to the back of the plane to lie down. The plane's automatic external defibrillator, she said, had revealed a potentially life-threatening arrhythmia.

When the plane landed at LaGuardia Airport for a short layover, the patient said, she hailed a taxi and asked the driver to take her to the nearest hospital. The airline had arranged for an ambulance, she said, but she had refused it. "They wanted three paramedics in the ambulance instead of two," she explained. "I don't have that kind of money." I told her that given the nature of the emergency, she would not have been responsible for the charges. "See, I didn't know that," she replied matter-of-factly.

She went to Flushing Hospital Medical Center because that is where the taxi driver took his own family when they were sick. Doctors there, after hearing her history, inserted a central intravenous line below her collarbone. They gave her some heart-stabilizing medications, monitored her for several hours and then transferred her to my hospital for further evaluation.

I asked about her medical history. She told me that her family suffered from an unknown blood disorder that caused premature heart attacks. Her mother had died at age 33. Three maternal uncles had died in their 30s and 40s. Her cousins were all dead. The first, Sarah, died at age 18. Sarah's brother died at age 22. John, Josh and Matthew all died in their 20s. Apart from her grandmother, my patient was the last one in her immediate family who was still alive.

I inquired about the medical work-up in Finland. She told me she had had a heart attack in her early 20s, necessitating angioplasty of a major coronary artery. She couldn't recall whether she had ever undergone an electrophysiology study. When I asked for permission to obtain medical records from hospitals in Helsinki, she refused. "There are confidentiality issues," she explained.

I performed a physical exam. Her blood pressure was 120/80: normal. Her lungs sounded clear, and her heartbeat was regular and normal. I noticed a long scar along the right side of her back, where, she told me, she had previously had lung surgery. "A blood clot was choking off part of my lung," she explained, another consequence of the blood disorder.

An EKG and an echocardiogram were performed: both normal. Continuous EKG monitoring was normal. Routine blood tests revealed nothing unusual. Though she said she had been taking digitalis, the drug was undetectable in her blood.

I asked if there were family members I could talk to. There were some distant relations in Finland, but she didn't want me to contact them. The same went for her fiance in Washington, D.C., who had weathered "enough stress" due to her many hospitalizations. There was a phone number for her grandmother in the front of the chart, but she insisted that no one from the cardiac care unit team call her. "She buried nine children!" the young woman cried. "She has suffered enough."

Because of the central line in her chest, my patient had been requesting painkillers, mostly morphine, around the clock. She had also been complaining of nausea but had refused to take Zofran, the usual anti-emetic, requesting promethazine instead, which accentuates the effect of morphine. "It's classic drug-seeking behavior," a nurse in the cardiac care unit told me.

The young woman remained in the care unit while the medical team tried to figure out what to do. That evening, her grandmother phoned the on-call resident, who had left a voice mail for her earlier in the day. "Oh, the old clotting disorder story again," the grandmother said. She explained that her granddaughter had used this story many times before to get hospitalized.

I felt sorry for my patient -- but also angry at the lie. When I told her that we would no longer give her narcotics, she demanded to be discharged immediately. The team tried to get her to stay so that they could piece together the whole story, but she left about an hour later, after the central line had been removed from her chest. "People don't know what it's like to lose your whole family, your mother, your cousins, and then be the last one and have to keep on living," she said on her way out.

Deception by patients assumes many different guises. One is what the diagnostic bible of psychiatry calls malingering: "the intentional production of false or grossly exaggerated physical or psychiatric symptoms" motivated by the desire to avoid work, evade prosecution, obtain drugs and so on. I believe my patient was suffering from a different disorder, called Munchausen syndrome. In this syndrome, patients will often intentionally produce or distort symptoms because of a need to be seen as ill or injured. They will undergo painful tests or diagnostic procedures if necessary to maintain the lie.

Named after Baron Munchausen, a German military officer in the 18th century who was known for telling tall tales, Munchausen syndrome most often affects young adults and usually involves physical symptoms, such as chest pain, stomach problems or fever. Diagnostic clues include dramatic but inconsistent medical history; eagerness to undergo medical tests, operations or other procedures; history of seeking treatment at numerous hospitals; and reluctance by the patient to allow doctors to meet with or talk to family, friends or prior healthcare providers.

Although a person with Munchausen syndrome actively seeks treatment for the various disorders he or she invents, the person often is unwilling to admit to and seek treatment for the syndrome itself. The outlook for recovery is usually poor.

"There's nothing you can really do in these situations," Dr. Alberto Goldwaser, a forensic psychiatrist at NYU Medical Center, told me. "We need acknowledgment from a patient that something is wrong to make them better. Patients with Munchausen don't have that insight."

He added that despite the proliferation of psychiatric medications, drug therapy is usually ineffective. "There are many diseases in psychiatry motivated by unconscious conflicts that are not amenable to treatment," he said. "This unfortunately is one of them. She'll end up going somewhere else, finding someone to give her what she needs. These patients are bound to repeat their mistakes."

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Dr. Sandeep Jauhar, director of the Heart Failure Program at Long Island Jewish Medical Center, is author of the new memoir "Intern: A Doctor's Initiation."

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