Introduction
Usually, medical and surgical oncologic treatment requires the patient's full collaboration. Patients with behavioral disorders cannot fit in that idealistic method of management. “Impossible” patients can be particularly challenging for clinicians, nurses, and the institution (Peteet et al., Reference Peteet, Meyer and Miovic2011). We report two unusual clinical situations (Munchausen and Peter Pan syndromes) with specific recommendations to manage them.
Case 1: Munchausen syndrome
Poorly recognized in oncology, Munchausen syndrome belongs to factitious disorders. It represents a tremendous challenge for oncologists or surgeons who can feel betrayed by these patients, who express abnormal healthcare-seeking behavior (Bass & Halligan, Reference Bass and Halligan2014).
Characterized by a richly elaborate medical history, these patients simulate or create diseases or physical symptoms to influence treatment to attract medical attention (Baile et al., Reference Baile, Kuehn and Straker1992). They undergo unnecessary operations or even chemotherapy without having cancer, which can put them in danger (Baig et al., Reference Baig, Levin and Lichtenthal2016). It must be a differential diagnosis, especially if all the complementary examinations remain negative (Spiro, Reference Spiro1968).
They consume disproportionate medical time and resources with medical peregrinating behavior. Conflicts with a previous medical team, past psychiatric illness, history of working in the medical and paramedical fields, and social isolation can guide the diagnosis. Moreover, these patients can learn medical symptom behaviors from family, friends, or patients who have medical disorders and even falsify pathology reports and blood test results.
A 46-year-old man sought medical attention for a suspected right testicular tumor. He indicated that he worked in a hospital as a stretcher bearer and was undergoing follow-up for left testicular cancer discovered 5 years ago that was treated with surgery and adjuvant chemotherapy. To support his claims, he presented an anterior thoracic scar that could effectively correspond to a central venous access insertion.
Physical examination noted right testicular pain, no lymphadenopathy, hypotrophic peripheral testicles, and no orchiectomy scar. Standard laboratory tests and tumor markers were normal. Testicular ultrasound revealed no nodular lesion, a small right testicle, and an atrophic left testicle.
Bone scan and thoracic-abdominal-pelvic computed tomography scans were normal. Admitted to our institution to continue his cancer treatment, he claimed to have been diagnosed and operated on in another hospital where he did not want to continue the adjuvant treatment. Suspecting fallaciousness, the oncologist called the previous hospital and found no medical or pathology reports. Further tests were performed in our hospital, and no signs of testicular cancer were identified.
He has never recognized the absence of malignancy and always remained suspicious about the negativity of the complementary examinations he underwent. He probably had falsified his pathology reports.
Case report 2: Peter Pan syndrome
Described in the early 1980s by a psychologist as boys and more rarely girls who did not want to grow up and remain a child forever (Kiley, Reference Kiley1983), Peter Pan syndrome is a disorder in which a man or woman is unable to mature, even if he or she has grown physically into an adult. This syndrome is characterized by immaturity, avoidance of assuming responsibility as a mature individual, difficulty expressing emotions, blunt in affect, frustration that leads to self-pity and depression, and undependable and manipulative tendencies.
A 70-year-old, recently widowed woman was treated for a retroperitoneal leiomyosarcoma exclusively by primary surgery (curative left colectomy and nephrectomy and caudal spleen-pancreatectomy). Her postsurgical recovery was significantly delayed by pancreatic fistula with a need for reoperation and drainage and recovery impaired by psychological features with immaturity, regression, manipulative tendencies, and recurrence of anorexia disorders.
The patient would not react to intensive care healthcare professionals’ injunctions to mobilize her body, get to the armchair, or eat. She would always apologize for her behavior with a disarming smile. A psychiatrist's advice was requested based on these behavioral difficulties. The psychiatrist noticed fluctuations of mood without major depressive features, but a significant affective demand with regressive behavior.
The patient had lost her brother to pancreatic cancer and recently her husband to cancer of the prostate, used to be a school teacher, and had two sons that she brought up in a fusional way. Specific psychological features appeared through the patient's speech: immature, frail, soft-spoken and occasionally voiceless, and narcissistic (e.g., complaining nurses were not taking good care of her), with a history of anorexia during childhood.
She remembered being afraid of recurrent fights between her mother and father and always sought refuge in her bed. The psychiatrist hypothesized that based on her psychological construction, it was impossible for her to follow healthcare professionals’ injunctions for mobilization, although she was perfectly aware of the legitimacy of them. Her postsurgery condition and the medical “law” reactivated a Peter Pan syndrome and she was not willing to follow medical recommendations to recover and act as a normal adult would have done in such a situation.
Discussion
Munchausen syndrome
In reference to a German officer in the Russian cavalry (Hieronymus Karl Friedrich von Munchausen, known for his tall tales during campaigns against the Turks in 1740), British endocrinologist and hematologist Richard Asher (Reference Asher1951) proposed the term “Munchausen syndrome” to describe patients who fabricated stories, signs, and symptoms of illness; repeatedly demanding surgical and medical care; and traveled widely.
Such patients’ psychological characteristics and environments are unique: living within paramedical circles; and engaging in a despoiling ritual necessary for compulsive, repetitive, and perverse pleasure described as “auto vampirism” (Smith, Reference Smith1985). Other common features include gravity of the supposed symptoms, hostility at the slightest reproach, escape behavior when challenged by the doctor, and disruption and medical wandering to maintain control over the situation (Sutherland & Rodin, Reference Sutherland and Rodin1990). Munchausen syndrome could be considered a behavioral syndrome stemming from various personality disorders such as borderline and narcissistic personalities with neurotic, psychotic, masochist, and perverted features (Ehlers et al., Reference Ehlers and Plassmann1994; Nadelson, Reference Nadelson1979).
Regarding staff relationships, these patients are ambivalent, with a self-destructive behavior and willingness to make their accounts more credible by undergoing numerous unpleasant or dangerous explorations, which has been described as “medicine addiction” (Barker, Reference Barker1962). When faced with this diagnosis, patients tend to deny reality and promptly discharge themselves from the hospital to cut ties with the medical team that corrected them. In these cases, patients’ medico-legal responsibility remains to be determined, although these patients are in real distress and must not be turned away even if they are in search of secondary benefits.
Peter Pan syndrome
Peter Pan syndrome can be summarized by the description “a child into an adult body.” Invented by James Matthew Barrie in the early 20th century, Peter Pan is the story of a young boy who wants to live in a country called Neverland where people do not grow old, so he can remain a carefree child with no worries. In our case, the main concern was that the patient was not compliant with her treatment because of her regressive personality. We hypothesized that medical and nursing injunctions in the intensive care unit could be assimilated to the frightening world of adults that the patient has sought to escape and avoid for her entire life. Similar to how she reacted during her childhood when confronted with her parents’ quarrels, she sought refuge in her bed where she felt “untouchable.” Use of social support for these patients can be an effective strategy to help them accept responsibility (Patterson & McGrath, Reference Patterson and McGrath2000).
Summary
Regarding difficulties encountered by oncologic and surgical teams in the two situations presented here, general recommendations can be suggested to provide optimal care.
• Rapidly initiate collaboration with the psycho-oncologic unit before behavioral problems occur that alienate the medical or surgical team.
• Identify factitious symptoms and get corroborative information from other healthcare providers and/or family imperatively.
• Screen and implement pharmacological and/or psychotherapeutic treatment as soon as possible if behavioral disorders might interfere with oncologic treatment.
• Through regular staff meetings, provide a similar direction of how to react to impossible patient by educating healthcare members about psychiatric disorders in cancer patients, assessing team expectations, and facilitating appropriate attitudes.
• Place boundaries on the patient and implement preventive measures to avoid conflicts and acting out. Recall the institution law and avoid any threats, rudeness, or ambiguous comments. Use empathy and acknowledge difficulties of the situation can facilitate communication in a respectful manner.
• Focus the patient's problem behavior in a nonpunitive or guilt-free fashion with respect to each position or perspective.
• If possible, offer a psychiatric follow-up without any judgment.
Conclusion
“Impossible” patients can destabilize healthcare professionals who may react in a defensive manner by discriminating against them. To preserve the therapeutic “alliance,” it is paramount that medical and surgical oncologists collaborate with a psychiatric team. Education and practical guidelines should be delivered to the healthcare team to avoid negative behavior.
Conflicts of interest
None.
