Bloody Tears: A Rare Presentation of Munchausen Syndrome

Abstract

Background: Haemolacria, or bloody tears, is a rare and alarming clinical presentation with a broad differential diagnosis encompassing ocular, systemic, and psychological causes. Factitious disorder imposed on self (previously known as Munchausen syndrome) is characterized by the deliberate fabrication of symptoms to assume the sick role and is particularly challenging to identify in adolescents. Awareness of this association is limited, often leading to extensive and unnecessary investigations.

Case Presentation: A 17-year-old female presented with a six-month history of intermittent, painless bleeding from both eyes. Episodes were sudden, not associated with trauma, menstruation, or systemic illness, and caused significant distress to her family, while the patient remained relatively unconcerned. Comprehensive ophthalmic, hematological, and radiological evaluations, including CT and MR angiography, revealed no abnormalities. Mental state examination revealed anxiety related to familial stressors, particularly concerns about her father’s health and financial insecurity.

Diagnosis: Following detailed psychiatric assessment and psychotherapy, the patient disclosed deliberate fabrication of symptoms using red watercolour paint to simulate bleeding episodes during periods of emotional stress, primarily to gain attention and care. A diagnosis of factitious disorder imposed on self presenting as haemolacria was established.

Management and Outcome: An eclectic psychotherapeutic approach focusing on insight development, addressing maladaptive coping mechanisms, and enhancing stress management skills was initiated. Regular follow-up sessions resulted in significant symptomatic improvement and cessation of fabricated bleeding episodes.

Conclusion: This case highlights haemolacria as a rare but striking manifestation of factitious disorder in adolescents. It underscores the importance of considering psychiatric etiologies after exclusion of organic causes, particularly in unexplained and recurrent presentations. Early recognition can prevent unnecessary investigations, reduce iatrogenic harm, and facilitate timely psychological intervention.