Munchausen Syndrome


Article Author:
Brennan Weber


Article Editor:
Michael Doyle


Editors In Chief:
Steven Anderson


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
2/28/2019 8:18:48 PM

Introduction

Munchausen syndrome, also called factitious disorder imposed on self, is a psychiatric disorder in which a person assumes the role of a sick patient without the intention of external gain (time off from work, medications). Physical symptoms are intentionally produced with the purpose of gaining the appearance of a "sick patient." These patients are often a medical mystery to healthcare workers as their laboratory, and radiographic results can be inconsistent with the history and physical exam. Furthermore, standard therapeutic interventions may not be effective in persons with Munchausen syndrome, causing increased confusion for the care team.[1][2][3][4][5]

Etiology

Though the etiology of the disorder is unknown, certain psychosocial factors do seem apparent in those with the diagnosis, including a traumatic childhood, experiencing death of a loved one at a young age and abandonment. Through the fabrication of a medical illness, these patients are able to receive the attention and, sometimes, affection within the healthcare community that they might not have had at home. Of the relatively few patients who have accepted the truth of their condition, almost all report that their intention was to create a sense of importance and find a place of "belonging."

Epidemiology

It is difficult to determine the precise number of persons with Munchausen as it can be difficult for a clinician to confirm the diagnosis. Most patients with suspected Munchausen will deny the diagnosis when confronted, and many can become hostile. It is not uncommon for a patient to sign out against medical advice and continue their performance at another hospital. However, certain risk factors have been identified. These include female gender, being unmarried and working within the healthcare community. Many patients have also exhibited borderline or histrionic personality traits or disorders, and a history of sexual abuse is common. It is estimated that 1% of patients in the clinical setting will have Munchausen disorder.

Pathophysiology

The pathophysiology of Munchausen disorder is primarily unknown as no large-scale studies have been conducted on the condition. Psychosocial factors are largely agreed upon to have the most influence in developing Munchausen syndrome.

History and Physical

In the large majority of cases, patients will present with somatic complaints that they present as correlated to a medical illness. Though the presentation of Munchausen disorder can vary widely, some of the most common presentations include chest pain, abdominal pain, vomiting and/or diarrhea, anemia, hypoglycemia, infections, seizures, skin wounds, and arthralgias. It is not uncommon for the patient to purposefully induce symptoms, such as intentionally eating spoiled food, injecting insulin, picking at skin causing wounds, overdosing on medications, and not taking medications as prescribed. In addition, patients have been known to forge medical records and tamper with laboratory results. It is not uncommon for a Munchausen patient with a benign known medical anomaly (such as a chronically abnormal ECG) to present with factitious symptoms that correlate with the finding.

Evaluation

Much of the time, the presenting symptoms are difficult to confirm with laboratory and radiographic tests, and the patient may take pride in being a "medical mystery" and confounding physicians. It can be useful to pay attention to any inconsistencies present, such as objective laboratory and physical exam findings that do not match the alleged symptoms. Additional hints that point toward the diagnosis include a history of many hospitalizations, eagerness to undergo medical procedures (even if they carry significant risk), history of frequent surgical intervention, few visitors, variability in the history, refusal of access to previous medical records, hostility toward psychiatric evaluation, extensive clinical workup without any positive results, poor response to standard therapies for disease (for example, anemia does not resolve with blood transfusions), unusual disease course that the patient can predict, and the new onset or exacerbation of symptoms when discharge is imminent.[6][7][8][9]

It can be greatly beneficial to obtain medical records from other hospitals, as divergences from a current presentation may be present, along with the possibility of a prior diagnosis of Munchausen disorder.

Treatment / Management

The diagnosis of Munchausen disorder falls within the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and requires certain criteria. This criterion includes evidence that the patient is taking steps to intentionally and falsely represent a psychiatric or general medical condition without evidence of malingering, and the behavior is independent of other medical or psychiatric conditions, such as schizophrenia and delusional disorder. Direct confrontation of the patient with suspected Munchausen disorder rarely results in acknowledgement of the illness and instead generally ends in denial and even hostility. Patients have been known to become upset, instigate lawsuits, leave against medical advice, and seek another care facility within a different hospital system. Instead, it can be more constructive for the physician to take an empathetic approach in which the patient is approached in a supportive manner. It is crucial to involve psychiatry (even if the patient opposes) to fully assess for any other psychiatric illnesses that may be present. 

The standard therapy for all patients with suspected Munchausen is psychotherapy, though most patients refuse. It is not necessary for the patient to admit to their factitious disorder and, in fact, most patients rarely do. In certain cases, it may be helpful to target cognitive behavioral therapy toward childhood trauma that could be the instigator for the disorder. It has also been concluded that various medical interventions such as anti-depressants and/or anti-psychotics showed no benefit in the disorder. 

There have been reported instances of patients confronted with their diagnosis initiating litigation; this can stem from a feeling of bitterness and resentment as well as retaliation against the clinicians. It is also a way to continue their ruse in the courtroom after discharge from a care facility.

Differential Diagnosis

It is important to distinguish Munchausen from malingering in which an external gain is a primary motivation. Additionally, it is different from conversion disorder in that patients with Munchausen are intentionally falsifying their condition for attention or feelings of importance. When differentiating Munchausen from other psychiatric disorders, it must be remembered that Munchausen patients have insight into their disorder and are aware that they are fabricating their illness.

Prognosis

Though evidence for the most helpful intervention is lacking, the prognosis for Munchausen disorder is generally poor as few patients are willing to admit to their maladaptive behaviors. Those with co-morbid substance abuse, anxiety, and depressive disorders seem to do better long-term versus those with diagnosed co-morbid personality disorders.

Consultations

It is paramount to consult psychiatry if a patient has suspected Munchausen disorder.

Enhancing Healthcare Team Outcomes

The diagnosis and management of Munchausen syndrome is complex. It is best managed by a multidisciplinary team that includes a psychiatrist, mental health nurse, sociologist, psychotherapist, and the primary care provider. In many cases, the diagnosis is delayed. 

The standard therapy for all patients with suspected Munchausen is psychotherapy, though most patients refuse. It is not necessary for the patient to admit to their factitious disorder and, in fact, most patients rarely do. In certain cases, it may be helpful to target cognitive behavioral therapy toward childhood trauma that could be the instigator for the disorder. It has also been concluded that various medical interventions such as anti-depressants and/or anti-psychotics showed no benefit in the disorder. 

There have been reported instances of patients confronted with their diagnosis initiating litigation; this can stem from a feeling of bitterness and resentment as well as retaliation against the clinicians. It is also a way to continue their ruse in the courtroom after discharge from a care facility. The overall prognosis is very poor because many of these patients also have other comorbid disorders like substance abuse, depression, anxiety and personality disorders. [10][11](Level V)


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Munchausen Syndrome - Questions

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Unnecessary multiple invasive procedures with negative findings are common in which diagnosis?



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A person with Munchausen syndrome would have what finding at surgery?



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A 2-year-old boy has been hospitalized numerous times for unexplained drops in his blood sugar. The mother, a nurse, is very astute and is highly involved in her child's care. All tests done cannot explain these episodes. The mother is not hesitant to allow any tests even those that are very invasive. Which of the following is a true concerning the suspected syndrome in this case?



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A patient presents to the emergency department with intractable abdominal pain and reports of nausea, vomiting, and diarrhea. A full workup including CBC, comprehensive metabolic panel, and CT scan yield no pertinent positives. While in the department, the patient has no episodes of vomiting or diarrhea. Upon chart review, the patient has been to this hospital many times before with the same complaint and has even had an exploratory laparotomy without result. Munchausen syndrome is suspected. Which of the following is not suggestive of this diagnosis?



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Which of the following patients is most likely to be diagnosed with Munchausen syndrome?



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Which of the following psychiatric illnesses is most frequently correlated with Munchausen syndrome?



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A 43-year-old woman presents to the emergency department with the chief complaint of chest pain. Upon chart review, you find that she has had a thorough workup including lab testing, stress testing, cardiac catheterization, and psychiatry consult within the last two months. When asked about the previous testing, the patient becomes defensive and attempts to explain that her previous care providers were "incompetent." When faced with discharge, she quickly states that her pain has changed in nature and is different than before, demanding a "full workup." Which one of the following is the most likely diagnosis?



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Munchausen Syndrome - References

References

Cardona L,Asnes AG, Disclosure of caregiver-fabricated illness to a child: A team-based approach to communicating with pediatric patients. Clinical child psychology and psychiatry. 2019 Jan 9;     [PubMed]
Kuhne ACA,Pitta AC,Galassi SC,Gonçalves AMF,Cardoso ACA,Paz JA,Campos LMA,Silva CA, Munchausen by proxy syndrome mimicking childhood-onset systemic lupus erythematosus. Lupus. 2019 Jan 7;     [PubMed]
Al Ghadeer H,Al Othaimeen S,Al Amry M, Ocular Munchausen's Syndrome induced by introduction of ant's particles into the conjunctival fornices. Saudi journal of ophthalmology : official journal of the Saudi Ophthalmological Society. 2018 Oct-Dec;     [PubMed]
Patel A,Daniels G, Hypoglycemia secondary to factitious hyperinsulinism in a foster care adolescent - a case report of munchausen syndrome in a community hospital emergency department setting. BMC emergency medicine. 2018 Dec 11;     [PubMed]
Sirka CS,Pradhan S,Mohapatra D,Mishra BR, Cutaneous Munchausen Syndrome by Proxy: A Diagnostic Challenge for Dermatologist. Indian dermatology online journal. 2018 Nov-Dec;     [PubMed]
Noeker M,Franke I, [Structured interviewing of children in suspected child endangerment cases: The German version of the revised NICHD Investigative Interview Protocol]. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2018 Dec;     [PubMed]
Noeker M,Franke I, [Interviewing children in cases of suspected child endangerment: pitfalls and quality assurance]. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2018 Dec;     [PubMed]
Abeln B,Love R, An Overview of Munchausen Syndrome and Munchausen Syndrome by Proxy. The Nursing clinics of North America. 2018 Sep;     [PubMed]
Moon LM,Childress KJ,Isaac R,Adeyemi-Fowode O, Medical Child Abuse: A Case Presenting as Anogenital Bleeding of Unknown Origin in an Older Child. Journal of pediatric and adolescent gynecology. 2018 Dec;     [PubMed]
Yates G,Bass C, The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) - A systematic review of 796 cases. Child abuse     [PubMed]
Kannai R, Munchausen by mommy. Families, systems     [PubMed]

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