Recurrent symptomatic bradycardia due to secret ingestion of beta ...

Steinwender et al., Recurrent symptomatic bradycardia due to secret ingestion of beta-blockers

Case Report

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WIENER KLINISCHE WOCHENSCHRIFT The Middle European Journal of Medicine

Wien Klin Wochenschr (2005) 117/18: 647–650 DOI 10.1007/s00508-005-0419-7

Printed in Austria

Recurrent symptomatic bradycardia due to secret ingestion of beta-blockers – a rare manifestation of cardiac Münchhausen syndrome Clemens Steinwender, Robert Hofmann, Alexander Kypta, and Franz Leisch Cardiovascular Division, City Hospital Linz, Linz, Austria Received February 21, 2005, accepted after revision April 5, 2005 © Springer-Verlag 2005

Rezidivierende symptomatische Bradykardien durch heimliche Beta-Blocker-Einnahme – eine seltene Form des kardialen Münchhausen-Syndroms Zusammenfassung. Der Begriff „MünchhausenSyndrom“ wurde 1951 von Asher in die klinische Praxis eingeführt, um eine schwere psychiatrische Störung zu beschreiben, bei der Patienten Symptome und Krankheiten simulieren. Wir berichten über den Fall einer praktischen Ärztin, die wiederholt heimlich hohe Dosen von Beta-Blockern einnahm, um ein symptomatisches Sick-Sinus-Syndrom zu imitieren. Sie wurde an mehreren Notfallaufnahmen vorstellig und auf insgesamt drei Intensivstationen verschiedener Krankenhäuser überwacht. Die Diagnose eines Münchhausen-Syndroms mit kardiovaskulärer Präsentation konnte erst durch das Auffinden und Identifizieren der Tabletten in einem Geheimfach ihrer Toilettetasche gestellt werden. Nach erfolgter psychiatrischer Evaluierung und kurzer Psychotherapie ordiniert sie nun seit einem Jahr wieder rückfallsfrei in ihrer Praxis. Dies ist der erste Bericht über die klinische Präsentation einer Patientin mit kardiovaskulärer Präsentation eines Münchhausen-Syndroms, die wiederholt Beta-Blocker einnahm, um eine synkopale Bradykardie zu provozieren. Der weitere Krankheitsverlauf sowie ein 1-Jahres-Follow-up geben einen Hinweis darauf, dass häufige und intensive Episoden dieser bemerkenswerten psychiatrischen Erkrankung von langen asymptomatischen Intervallen unterbrochen sein können.

Summary. The term Münchhausen syndrome was established in 1951 by Asher to describe a severe psychiatric illness in which patients simulate false symptoms and signs. We report on a female general practitioner who repeatedly ingested high doses of beta-blockers in order to simulate symptomatic sick-sinus syndrome. She had been admitted to intermediate care units in several hospitals before the correct diagnosis was made by finding the tablets in her toilet bag. Following psychiatric exploration

and psychotherapy, she has been working in her community again for about a year. This is the first report on the clinical presentation and course of disease in a patient with cardiac Münchhausen syndrome who secretly ingested beta-blockers to provoke a menacing bradycardia. The follow-up indicates that frequent and intense symptomatic episodes of this remarkable psychiatric disease can be interrupted by long normal intervals. Key words: Münchhausen syndrome, cardiopathia fantastica, factitious disorders, bradycardia, beta-blockers.

Introduction Named after Baron von Münchhausen, an 18th-century cavalry officer who became famous through the exaggerated narration of his military adventures, the term Münchhausen syndrome was established in 1951 by Richard Asher to describe a severe psychiatric illness in which adult patients simulate false symptoms and signs. In Asher’s original article he described three varieties of the syndrome: “laparotomia migrans” for reported recurrent abdominal pain, „hemorrhagica histrionica“ for various factitious bleedings and “neurologica diabolica” for several simulated neurological or psychiatric symptoms [1]. The first case of cardiovascular presentation of Münchhausen syndrome, a man pretending numerous episodes of angina pectoris, was reported by Davidson in 1953 [2]. First described in the 1970s, Münchhausen syndrome by proxy, a controversial variant of the disorder, concerns patients fabricating symptoms in persons they take care of, usually in children. Frequent presentations are vomiting, diarrhea, apnea and cyanosis including sudden infant deaths [3, 4]. According to recent psychiatric classifications, Münchhausen syndrome is an extreme variant of factitious disorder and is characterized by the triad of simulated illness, pathological lying and wandering from place to place [4]. Persons with factitious disorder simulate or fabricate physical or psychiatric symptoms and signs with

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Fig. 1. ECG at admission: sinus bradycardia with a heart rate of 31 beats per minute

the aim of experiencing the role and psychosocial advantages of a sick and pitiable person. Though widely published in literature, patients with Münchhausen syndrome are estimated to represent only about 10% of all factitious disorders treated in hospitals [4, 5] and are usually male, presenting with partly dramatic histories and symptoms in various medical institutions, and provoking numerous investigations and invasive diagnostic and therapeutic procedures. Irrespective of the clinical course or of suspicions aroused in the medical staff, patients with Münchhausen syndrome often suddenly disappear from in-hospital care without any prior notice. In contrast, the majority of factitious disorders occur in young women who are very often healthcare employees such as doctors, nurses or laboratory technicians. Compared with patients with Münchhausen syndrome, who have a long lasting history of sociopathic behavior, these persons are generally fully integrated into their social environment and usually experience only one or few episodes of the disorder as a reaction to stressful life-events [4, 5]. Though the psychodynamic underpinnings are little understood, patients with Münchhausen syndrome seem to suffer from much more extensive neurotic and sociopathic alterations than the vast majority of persons with factitious disorders, a factor that influences the therapeutic approach and the prognosis with regard to the time course and possibility of complete cure [4, 6]. Münchhausen syndrome patients with cardiovascular presentation, also named cardiopathia fantastica, represent a small subgroup of the disorder. In total, fewer than 60 cases could be found in a comprehensive literature research in 2002 [7]. These patients mostly reported recurrent episodes of angina pectoris, frequently giving rise to extensive and partly invasive diagnostic procedures. Only

very few of these cases could be identified as „wanderers“ with numerous hospital admissions in different medical institutions, thus fulfilling the defined criteria for Münchhausen syndrome. The other cases were lost to follow-up after one contact with the reporting institution and probably represent patients with only a single episode of factitious disorder [6–9]. We report on the clinical presentation and follow-up of a female general practitioner who repeatedly secretly ingested high doses of beta-blockers in order to simulate symptomatic sick-sinus syndrome requiring pacemaker implantation.

Case report A 39-year-old female general practitioner was transferred from a smaller municipal hospital to our intermediate care unit (ICU) for evaluation of recurrent episodes of unconsciousness, collapses and documented sinus bradycardia. She had been admitted to the municipal hospital twice during the last six weeks. After the first event she had been sent to another hospital for pacemaker implantation under the assumption of symptomatic sick-sinus syndrome, but left inpatient care the following day at her own request. At the time of admission to our hospital the patient complained of dizziness and fatigue. The ECG revealed no pathologic findings except sinus bradycardia with a heart rate of 31 beats per minute (Fig. 1). Re-evaluating the anamnesis, she reported a six-month period of recurrent bradycardia with weakness, vertigo and multiple collapses. She attributed the inappropriate heart rate and clinical symptoms to myocarditis involving the atria including the sinus node. Any kind of regular medication or co-morbidity was denied. During the following three days the heart rate, continuously monitored with adhesive ECG electrode cables, ranged from 30 to 45 beats per minute. Routine laboratory investigation including cardiac enzymes, infection parameters and thyroid


Fig. 2. Generic tablets containing metoprolol (100 mg) under the lining of the patient’s toilet bag hormones was normal. Nevertheless, on the third day the patient collapsed twice in the bathroom and the corridor of the ICU. Noticeably, the falls only occurred when she was not monitored. Neither episode of syncope was accompanied by the typical signs of circulatory arrest but both involved prolonged unconsciousness. As a result of these observations, underlying Münchhausen syndrome was suspected. Assuming the bradycardia to be drug induced, we inspected the patient’s toilet bag when she was in the echocardiography ward and found forty identical tablets in a secret compartment under the lining. The tablets were identified as a generic drug containing 100 milligrams of metoprolol (Fig. 2). The patient was not immediately confronted with the finding of the tablets because psychiatric evaluation was planned. Nevertheless she developed a severe episode of depression with suicidal tendencies during the following hours. She was offered psychiatric therapy in a specialized department, which she surprisingly accepted right away. After a two-week period of exploration and psychotherapy without any cardiologic symptoms, the patient was discharged from the psychiatric department with the diagnosis of a reactive depression due to familial conflicts. No medication was prescribed nor was ambulatory psychotherapy arranged. During the eleven months since discharge, the patient has been working as a general practitioner in her community and has not been treated in any of the previous hospitals.

Discussion Münchhausen syndrome is a rare condition in which patients repeatedly seek medical care for factitious illnesses. Compared with patients presenting with neurological, dermatological or gastroenterological symptoms and signs, persons with cardiac manifestation of this syndrome are very rare [1–9, 11]. This is the first reported case of the presentation and course of disease, including follow-up, of a patient with Münchhausen syndrome who secretly ingested beta-blockers to simulate symptomatic sick-sinus syndrome. The underlying psychodynamic processes of Münchhausen syndrome are little understood. According to psychiatric classification, the syndrome seems to be an ex-

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treme variant of factitious disorder with the typical triad of simulated illness, pathological lying and wandering from place to place, resulting in frequent hospitalizations in different institutions [4, 7]. From the patients’ perspective, numerous diagnostic and therapeutic procedures are just as desirable as all forms of emergency treatment in the hospital setting [3–9]. When confronted with possible diagnosis of a psychiatric disease, patients with Münchhausen syndrome tend to change their behavior and mostly leave the hospital shortly afterwards. Psychiatric investigation is commonly refused and follow-up appointments not attended; instead other medical institutions are often frequented during the next months [3–6]. Our patient, an active female general practitioner, matched some but not all of the above characteristics. Though she did not present with angina pectoris, the most frequent symptom in cardiac Münchhausen syndrome, but with drug-induced bradycardia, she clearly wanted to provoke drastic reactions in the medical system. As two institutions did not provide the desired procedures, the same symptoms were described, provoked and simulated in a very subtle way in a third hospital. In our case the diagnosis could be made only by examining the patient’s property without her explicit consent, an otherwise unthinkable act. When she finally realized that her symptoms were not taken seriously, the patient first developed severe depression but then unexpectedly cooperated. During psychiatric exploration and psychotherapy no new symptoms of Münchhausen syndrome appeared – a hint that treatment touched the underlying psychodynamic mechanisms of this complex illness. With regard to differences between patients with factitious disorder and its most pronounced occurrence, Münchhausen syndrome, classification of our patient in one of these variants is difficult. Though her demographic data (female, healthcare profession) and objectively intact social life, as well as the good response to psychotherapy, favor a „normal“ factitious disorder, the diagnosis of Münchhausen syndrome is justified by the fact that three hospitals were visited and misled by repeated, planned and subtle deceptions over a longer period of time [4]. As a differential diagnosis, a suicide attempt in the course of underlying depression seems to be implausible in the face of the clinical circumstances. Furthermore, syncope resulting from other causes or from unexplained causes, as reported in high percentages in the literature [10], was denied by the patient herself during psychotherapy. Overall, this case presentation, which includes the first reported long-term clinical follow-up of a person with cardiac Münchhausen syndrome, may indicate that frequent and intense symptomatic episodes can be interrupted by long normal intervals. Whether complete cure of this remarkable disease can occur spontaneously or be obtained through psychotherapy or medical treatment is not yet known [11].

References 1. Asher R (1951) Munchausen’s syndrome. Lancet 1: 339–341 2. Davidson C (1953) Munchausen‘s syndrome [letter]. Lancet 3: 621

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3. Meadow R (1977) Munchausen syndrome by proxy: the hinterland of child abuse. Lancet 2: 343–345 4. Turner J, Reid S (2002) Munchausen’s syndrome. Lancet 359: 346–349 5. Reich P, Gottfried LA (1983) Factitious disorders in a teaching hospital. Ann Intern Med 99: 240–247 6. Kounis NG (1979) Munchausen syndrome with cardiac symptoms: cardiopathia fantastica. Br J Clin Sci 33: 67–72 7. Metha NJ, Khan IA (2002) Cardiac Munchausen syndrome. Chest 122: 1649–1653 8. Zahner J, Muehlenberg K (2001) Cardiopathia fantastica – Fallbericht und Literaturübersicht. Z Kardiol 90: 58–64

9. Ludwigs U, Ruiz H, Isaksson H, Matell G (1994) Fictitious disorder presenting with acute cardiovascular symptoms. J Intern Med 236: 685–690 10. Schillinger M, Domanovits H, Mullner M, Herkner H, Laggner AN (2000) Admission for syncope: evaluation, cost and prognosis. Wien Klin Wochenschr 112: 835–841 11. Zahner J, Schneider W (1994) Das Münchhausen Syndrom. Dtsch Med Wochenschr 119: 192–194 Correspondence: Dr. Clemens Steinwender, Cardiovascular Division, City Hospital Linz, Krankenhausstraße 9, 4020 Linz, Austria, E-mail: [email protected]