Psychosomatics 48:71-73, January-February 2007
doi: 10.1176/appi.psy.48.1.71
© 2007 Academy of Psychosomatic Medicine
Factitious Ovarian Cancer: Feigning via Resources on the Internet
James L. Levenson, M.D.,
Weldon Chafe, M.D., and
Phelicia Flanagan, M.D.
Received January 7, 2006; revised February 11, 2006; accepted February 17, 2006. From the Depts. of Psychiatry and Obstetrics and Gynecology, VA Commonwealth University, Richmond, VA. Send correspondence and reprint requests to James L. Levenson, M.D., Dept. of Psychiatry, VA Commonwealth University, Box 980268, Richmond, VA 23298-0268. e-mail: jllevens{at}vcu.edu
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INTRODUCTION
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The growing use of Internet resources has been dramatically influencing medical practice. Patients and their families turn to the Internet on their own to research their illnesses, often before presenting to physicians’ offices. Others, with the assistance of their healthcare providers, are guided in their search for medical knowledge about their conditions. Some websites offer expert second-opinion consultation for patients and their physicians. Recognized cancer specialists on certain websites render second oncology opinions, where patients are encouraged to submit summaries of their care and copies of pertinent test results. In order to encourage utilization of these programs, sample consultations are provided on these websites to document the quality of the second-opinion program offered.
Persons who have factitious disorders intentionally feign or self-induce symptoms or disease. Their deceptive behavior is conscious but surreptitious.1 Such patients present requesting medical care and may undergo surgery or other interventions that carry substantial risk. In this case report, we describe a woman with factitious disorder who utilized Internet healthcare information in a novel manner: to support the deception of her physicians, in which she feigned ovarian cancer.
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Case Report
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A 23-year-old single woman, "G3 P1," presented to our gynecology clinic with a history of having recently been diagnosed with ovarian cancer elsewhere. After a 6-month history of abdominal pain, bloating, change in bowel habits, and a 30-pound weight loss, she had had a diagnostic laparoscopic procedure done at a hospital in another state. Family history was significant for ovarian cancer in her maternal grandmother. After this procedure, as a single parent, she had relocated to her parents’ home to seek further medical care.
When seen in our clinic, she was in pain, with a tender, swollen abdomen. She had brought a typed consultation report from the other hospital, documenting the history, surgical findings, pathology review, and recommendations for future management, including the recommendation that she have additional staging surgery. On pelvic exam, a palpable 8-cm soft mass in the posterior cul-de-sac was found, which was nonmobile on recto-vaginal exam. Pre-operatively, she had a bowel prep, and then, at the time of surgery, an exam under anesthesia revealed that the mass previously palpated was now gone. It was suspected that what had been previously palpated most likely represented low-colonic stool during the previous exam in the clinic. A mini-laparotomy was carried out, and all internal organs and peritoneal surfaces were determined to be normal, with the only positive finding being that of the sigmoid colon adherent in the posterior cul-de-sac.
Given the inconsistency between the operative findings and the out-of-state laparotomy report, we suspected that the content of the latter might have been copied. Immediately post-operatively, a paragraph from the report was entered in an Internet search engine, which identified a website that provided consultative second opinions for oncology patients. A sample consultation report was found on that site that was essentially identical to the report that the patient had provided at the time of her initial visit. Previous records from the out-of-state hospital had been requested but did not arrive until after her mini-laparotomy, indicating an admission only for a laparoscopic cholecystectomy, with no mention of ovarian malignancy. A call to the referring consultant’s office indicated she was not a registered patient at that practice.
Psychiatric consultation was requested. She gave a history of two elective abortions and a previous pregnancy carried to term within the past 5 years, and of becoming depressed after the abortions. She reported chronic pelvic pain and attributed her current illness to the fear that her boyfriend (father of her child) might leave her. She indicated she had been receiving treatment for depression, for which she was prescribed citalopram. She denied physical or sexual abuse but said that her father had physically abused her brother. After appropriate social work and psychiatry consultations, the patient’s attending gynecologist, in a nonconfrontational manner, presented her with the inconsistencies and the finding of deception, stressing his understanding that a person would have to be very unhappy to do something like this, and offering referral for psychiatric treatment. She admitted to the deception, acknowledging that she had downloaded a copy of the online consultant’s report, creating her own document by inserting her name and other identifying information, and printing it on photocopied, modified records from her laparoscopic cholecystectomy.
Additional social work and psychiatric consultations were obtained. She was discharged from the hospital on Postoperative Day 1 and did not return for postsurgical care. She declined the recommended psychiatric referral, instead initiating psychotherapy with a nonmedical therapist. She presented a largely false history to the therapist, including a fictitious account of a ‘mistaken’ diagnosis of cancer and unnecessary surgery at our medical center and extensive sexual abuse in childhood by her parents.
Her parents meanwhile made an appointment with the recommended psychiatrist (JLL), hoping to gain some understanding of what was wrong with their daughter and advice about what to do. They had initially been very worried when she told them she had ovarian cancer and then perplexed and upset when they learned she did not. She offered them the explanation that "I had so much pain I just wanted someone to open me up and take a look." They indicated that she had a long history of telling lies, starting around the age of 16, being both devious and purposeful (e.g., to cover her diversion of money from the family business) and transparent and purposeless (e.g., telling family acquaintances that a family member, who was actually quite healthy, had died after a serious illness). She was not living with her boyfriend, as she had reported to the inpatient psychiatric consultant, but was actually in a custody battle with him. She had also stolen money from her family and passed bad checks to neighbors. They denied that she had experienced any significant life traumas in childhood or adulthood, other than the ongoing custody battle. The only significant family history was of an aunt who frequently stole from family members and had been psychiatrically hospitalized several times, for unclear reasons. The psychiatrist explained factitious disorder to the parents, who were understandably upset and mystified. They were also provided with guidance regarding how to cope with their daughter’s stealing from family and friends.
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Discussion
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How this patient created her physical findings at presentation to the gynecology clinic is unclear, but constipation could account for both a tender, swollen abdomen and a pelvic mass. Physical examination is often insensitive in detecting ovarian cancer, and it was the records she brought in that were definitive in achieving the deception. This is the first presentation of factitious disorder that we could find where the patient took advantage of Internet medicine in constructing her presenting complaint, convincingly falsifying records, and deceiving physicians into intervention, although such patients have creatively utilized older sources of information, for example, the telephone, to help them feign illness.2
The diagnosis of factitious disorder may be suggested by discrepancies in the history, physical examination, laboratory, and imaging studies, but it is usually made via detective work by healthcare providers, based on a high index of suspicion. Krahn et al.3 stressed the essential value of reviewing past medical records from other institutions in order to establish the diagnosis.
It is thus especially ironic that this patient’s deception was accomplished via such records, convincingly fabricated by utilizing a sample evaluation and consultation found online on a website intended to benefit cancer patients. Surely other patients with factitious disorder are already (or soon will be) coaching themselves with disease information from the Internet, downloading sample referral letters, discharge summaries, imaging studies, and pathology reports. Thus, physicians and other healthcare providers must have a heightened index of suspicion for the possibility of factitious disorder, even when the patient has "written proof" of his or her disease, particularly when there are significant discrepancies in the patient’s presentation. Information on the Internet may be used for negative as well as positive ends. Just as some patients with factitious disorder have utilized new medical diagnostic tests to feign disease, this case illustrates that they are likely to use new information-technology in the service of deception, as well.
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REFERENCES
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- Ford CV: Deception Syndromes: Factitious Disorders and Malingering, in The American Psychiatric Publishing Textbook of Psychosomatic Medicine. Edited by Levenson JL. Washington, DC, American Psychiatric Publishing, 2005, pp297-310
- Reuber M, Zeidler M, Chataway J, et al: Munchausen syndrome by phone. Lancet 2000; 356:1358[CrossRef][Medline]
- Krahn LE, Li H, O’Connor MK: Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry 2003; 160:1163–1168[Abstract/Free Full Text]
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