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Mastectomy Resulting From Factitious Disorder

TO THE EDITOR: Mastectomy as a direct result of factitious disorder (termed "Munchausen syndrome" in its most severe form) is distinctly rare, with only one report in English.¹ In that case, reported in Psychosomatics, a woman misled surgeons into believing she had a profound family history of breast and ovarian cancer, a claim they did not attempt to corroborate, and they proceeded with a prophylactic bilateral radical mastectomy. The patient declined psychiatric care and was lost to follow-up. As a cautionary tale, we present another woman whose false claims of a history of familial breast and ovarian cancer led to an unwarranted bilateral mastectomy.

Case Report
"Ms. A," a 28-year-old single nurse with a history of unexplained illness and manufactured crises, presented to surgeons with a factitious report of breast and ovarian cancer in numerous relatives, including her twin sister. She insisted on a prophylactic bilateral mastectomy; it was performed, in part, because there was the suggestion of a lump in one breast, although a mammogram had been negative. The patient failed to appear for a scheduled biopsy, but the surgery proceeded nevertheless. Immediately after the procedure, the doctor spoke with Ms. A’s parents and learned that the twin had always been in good health. It was also determined that the report of a family history of malignancy was spurious, and that the patient had a history of pathological lying about her background and about illness. Three weeks post-surgery, the patient suddenly developed a wound infection, one of several suspicious infections she had developed over the years. She has moved back with her parents and, unlike most factitious-disorder patients, is receiving psychiatric care. She has indicated that she had always believed that her twin got more attention from their parents and that her lies were intended as a diversion and a form of retaliation.

Discussion
Several lapses led to the unwarranted surgery. These included a failure to obtain any outside records, to insist upon a biopsy, consult with family members, and pursue genetic testing. However, it is the ability of the factitious-disorder patient to convince the practitioner to depart from standard clinical practices that is a root cause of the morbidity and mortality risks associated with the disorder. Factors that might raise suspicion in such gynecological cases, for instance, are the patient’s not knowing about the cancer treatments received by close relatives, claiming primary cancers in both breasts, showing an unusual disease pattern, offering other medical complaints determined to be false, giving a history that cannot be corroborated through family reports or outside records, and overeagerly pursuing surgery. This case highlights the fact that the consequences of factitious disorder can be irreversible and iatrogenic. Although it may seem counterintuitive, in at least one case, physicians were sued because they administered treatment based upon a fallacious history. (The case was settled for a dollar amount in six figures.)²

REFERENCES

1. Feldman MD: Prophylactic bilateral radical mastectomy resulting from factitious disorder. Psychosomatics 2001; 42:519–521[Free Full Text]
2. Lipsitt DR: The factitious patient who sues (letter). Am J Psychiatry 1986; 143:1482[Medline]

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