AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Patients who present with overt symptoms who subsequently prove to have factitious disease are particularly challenging to physicians.

Munchausen syndrome is distinguished from other factitious diseases by the lack of secondary gain. The patient's reason for engaging in deception is not to escape some consequence in life. Instead, the patient suffers from an apparent deep-seated need to be sick; a need which can impel the sufferer to injure or poison themselves in an effort to sustain the illusion of organic illness. 

Richard Asher coined the eponym in 1951. Asher named the syndrome after Karl Friedrich Hieronymus, Baron Munchausen (1720-1797), a man who traveled widely and was renowned in his time for telling fantastic and exaggerated stories about his life.¹

Pathophysiology

The pathophysiology of this disorder is unknown. Patients with Munchausen syndrome often are noted to have associated personality disorders (eg, poor impulse control, self-destructive behavior, borderline or passive-aggressive personality trait or disorder). However, the relationship of these constellations of personality disorders to the primary syndrome is unclear. Patients with Munchausen syndrome are adept at concealing the fact that their diseases are factitious and are markedly resistant to psychiatric evaluation. Information is often difficult to obtain.

Frequency

United States

Rare

International

Rare

Mortality/Morbidity

The potential for significant morbidity and mortality exists, as patients with Munchausen syndrome go to extreme measures to simulate true organic diseases and may cause real disease in the process. For example, injection of exogenous material to produce febrile symptoms may result in local or systemic infection. One case report discusses beta-blocker ingestion in a patient who wished to maintain the diagnosis of sick sinus syndrome.² Morbidity and mortality may also arise from unnecessary medications and procedures when physicians are taken in by the patient's factitious symptoms.

Sex

• The majority of patients suffering from Munchausen syndrome are male.
• The typical presentation of Munchausen syndrome is characterized by a restless journey from physician to physician and hospital to hospital, an ever-changing list of complaints and symptoms, and an alarming variety of self-intoxications and self-injuries designed to better portray the illness that the patient asserts he or she has.
• There is a subset of women patients who vary from the classic presentation in that they reproduce a single set of symptoms, repeatedly. Patients in this subset exhibit less evidence of comorbid personality dysfunction than the average patient with Munchausen syndrome, and they have a strong tendency to form personal bonds with a single physician or group of physicians.

Age

• Incidence of Munchausen syndrome peaks in young–to–middle-aged adults, but it has been reported in patients of all ages (ie, childhood through advanced age).
• Pediatric Munchausen syndrome is a different disease from Munchausen syndrome by proxy (MSBP). MSBP is a syndrome in which an adult simulates or creates symptoms in a child to receive an ill-defined secondary gain from the child's hospitalization.
• MSBP is child abuse and must be dealt with when it is suspected. Because of the dangerous nature of the varied means used to create factitious symptoms, the mortality rate is significant; estimates range from 5-50%. MBSP is currently a topic of intense interest and research, given its potentially dire prognosis for the children who are its victims.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• Dramatic presentations of apparently severe illnesses
• Reported symptom patterns that fit diagnoses too perfectly and are too much like a textbook presentation
• A history of extensive surgical procedures and inpatient workups for a variety of diseases, particularly when the workup spans multiple hospitals and cities
• Notable vagueness or inconsistency in the details of the medical problems
• Evidence of pathological lying in areas other than the presenting symptoms

Physical

• Patients with Munchausen syndrome may display any combination of signs and symptoms.
• In an effort to obtain hospitalization, an invasive workup, and extensive interventions, patients with Munchausen syndrome may mimic any severe disease that generates physical findings and symptoms.
• Cardiac presentations of Munchausen syndrome are common enough to have allowed cardiologists to identify cardiac Munchausen syndrome—sometimes referred to as cardiopathia fantastica³—as a distinct subset of the Munchausen spectrum.

Causes

• Once it has been determined that a disease presentation is factitious, the absence of a clear source of primary or secondary gain is the hallmark that distinguishes Munchausen syndrome from other factitious illnesses. No convincing explanation of secondary gain has yet been described in patients with Munchausen syndrome.
• In contrast to Munchausen syndrome, malingering patients have a clear primary gain in their efforts to escape some task or obligation.
• Conversion and somatoform disorders also are driven by a secondary gain. Treating the underlying stressor often can alleviate the presenting symptoms.
• In contrast, a patient with Munchausen syndrome actively seeks hospitalization and invasive painful procedures as a primary goal.
• Munchausen syndrome afflicts the patient who presents with the complaint. Munchausen syndrome by proxy involves inflicting injury on a child or other dependent person in order to simulate symptoms. There is no obvious or plausible secondary gain to the caretaker who performs these actions. Munchausen syndrome by proxy is a form of abuse and must promptly be acted upon when suspected.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Malingering

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• Depending upon the presenting complaint, any laboratory test used in the ED may be indicated in the initial evaluation of patients with underlying Munchausen syndrome.
• Laboratory results that are atypical in pattern (eg, dramatically positive results, paradoxically normal results) may be an early indication of the presence of a factitious illness. Efforts may then be made to refine the diagnosis.

Imaging Studies

• As with laboratory testing, almost any imaging technique used in the ED may be indicated in the initial workup.

Procedures

• If the initially credible impression suggests severe enough disease or the attempts the patient has made to mimic organic illness have themselves produced sufficient illness and/or injury, appropriate procedures for workup and/or treatment must be undertaken.
• Clinicians often become frustrated at the thought of performing invasive procedures on healthy people.
• Persons with Munchausen syndrome often develop remarkable skill in inducing or duplicating symptoms. Further, the ED physician has a duty not to ignore organic disease where it is plausibly believed to exist. These factors, in concert, often make the performance of such procedures unavoidable.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Prehospital Care

Emergency medical services (EMS) care will be directed at the initial presenting symptoms. It is unlikely that prehospital teams will be able to effectively establish a diagnosis of Munchausen syndrome, they should not attempt to do so.

Emergency Department Care

Initial care and stabilization of patients with Munchausen syndrome is driven by the presenting symptoms.

The fact that symptoms may well be the result of sophisticated lying or of self-injury or self-intoxication by the patient does not make the workup and treatment of those symptoms any less necessary.

Consultations

• If in doubt, consult the appropriate specialist for the purported illness and arrange for admission to the hospital.
• If the diagnosis of Munchausen syndrome is clear, psychiatric consultation and referral should be offered to the patient even if admission for the patient's medical problems is declined.
• • The patient nearly always declines such referrals, and a refusal should be documented in the patient's record.
  • Although not intuitively obvious, persons with Munchausen syndrome generally do not meet criteria for involuntary admission to hospital. They are neither homicidal nor suicidal, and their mental illness does not incapacitate them (in most cases) sufficiently to impair their ability to carry out their activities of daily living. They thus fail statutory criteria for involuntary commitment as it is set forth in many states' laws. Psychiatric consultation should be sought if the issue is unclear in the state or province of the physician.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Drugs that may be proposed for a patient with Munchausen syndrome fall into 2 categories, (1) drugs used to treat the presenting symptoms, and (2) antipsychotic medications, which are used to treat the underlying condition.

The first category is necessarily broad because patients with Munchausen syndrome have portrayed nearly every disease known to medicine.

No good evidence exists that antipsychotic drugs have any effect on the course or prognosis of Munchausen syndrome.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Inpatient admission will be indicated by the presenting symptoms.
• As mentioned in Procedures, there will come a time in the care of a patient with Munchausen syndrome when the suspicion of factitious illness has arisen, but evidence is insufficient to be certain of that diagnosis.
• Physicians have a duty not to miss authentic pathology in the patient with a factitious illness. The observation of such patients actually taking steps to feign a symptom in a controlled environment is often the final step in securing the diagnosis of Munchausen syndrome.

Further Outpatient Care

• At least one report exists of a patient being placed under legal restraint, house arrest, and mandatory outpatient psychiatric therapy in an attempt to deal with the patient's persistent disease.⁴
• Given the current poor success rate of psychiatric interventions in Munchausen syndrome such an approach seems appropriate only as a last resort, especially as recent case reports suggest that those with Munchausen syndrome can have long periods of apparent normalcy before symptoms recur.

Transfer

• Even if Munchausen syndrome is suspected, ordinary care must be provided until the patient is fully diagnosed. As with any other patient, if (1) a constellation of symptoms has placed, or appears to have placed, the patient in need of certain therapies, and (2) the initial hospital lacks the resources or staffing to deal with the symptoms in question, then transfer to a secondary or tertiary referral center should be arranged, in accordance with federal law and established clinical practice.

Complications

• Manifold complications may occur from the simulation of symptoms, depending upon the technique that the patient used to induce such symptoms. The severity of complications may range from trivial to lethal.

Prognosis

• The prognosis for patients with Munchausen syndrome generally is poor.
• There is no substantial understanding of the psychopathology of this disorder.
• Patients generally are unwilling to undergo therapy. Even if they are willing, no good therapeutic strategy exists.

Patient Education

• Patients with Munchausen syndrome may present in self-help groups; reports are now surfacing of such patients using Internet-based patient support groups to fulfill their need to "be sick." Physicians who assist such groups may run across such cases, or their colleagues may ask about such things, having become frustrated when dealing with such people.
• For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education article Munchausen Syndrome.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Rushing to a diagnosis of a factitious disorder and, as a result, missing the presence of an authentic organic disease, may result in litigation.
• Other pitfalls that might delay or adversely affect the care of the patient, causing morbidity and mortality include the following:
• • Inadequate effort to distinguish Munchausen syndrome, malingering, and conversion disorders
  • Misdiagnosing patients as having any of the factitious illness syndromes because of unpleasant personality traits
  • Attributing symptoms to the Munchausen syndrome without proper investigation (Patients with documented Munchausen syndrome are as susceptible to develop true disease as any other patient.)

Special Concerns

As noted above, recent articles have reported a variation of Munchausen syndrome in which sufferers use Internet bulletin boards and patient self-help groups to further gratify their primary need to be sick. These deceptions, when challenged, often lead to extensive civil legal proceedings. Physicians may become involved as expert witnesses or as witnesses-of-fact to one of the Munchausen patient's multiple presentations to hospital.

Expert witnesses in such cases (or in cases where workers' compensation or tort are involved) must be prepared to make the distinction between primary and secondary gain clear to juries. They also need to be able to help juries distinguish between malingering, somatiform disorder, and Munchausen syndrome.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor, Craig Feied, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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2. Steinwender C, Hofmann R, Kypta A, Leisch F. Recurrent symptomatic bradycardia due to secret ingestion of beta-blockers--a rare manifestation of cardiac Münchhausen syndrome. Wien Klin Wochenschr. Sep 2005;117(18):647-50. [Medline].
3. Park TA, Borsch MA, Dyer AR, Peiris AN. Cardiopathia fantastica: the cardiac variant of Munchausen syndrome. South Med J. Jan 2004;97(1):48-52; quiz 53. [Medline].
4. Elmore JL. Munchausen syndrome: an endless search for self, managed by house arrest and mandated treatment. Ann Emerg Med. May 2005;45(5):561-3. [Medline].
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8. Eisendrath SJ. When Munchausen becomes malingering: factitious disorders that penetrate the legal system. Bull Am Acad Psychiatry Law. 1996;24(4):471-81. [Medline].
9. Falagas ME, Christopoulou M, Rosmarakis ES, et al. Munchausen's syndrome presenting as severe panniculitis. Int J Clin Pract. 2004;58(7):720-2. [Medline].
10. Feldman MD. Munchausen by Internet: detecting factitious illness and crisis on the Internet. South Med J. Jul 2000;93(7):669-72. [Medline].
11. Feldman MD, Peychers ME. Legal issues surrounding the exposure of "Munchausen by Internet". Psychosomatics. Sep-Oct 2007;48(5):451-2. [Medline].
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13. Hall DE, Eubanks L, Meyyazhagan LS. Evaluation of covert video surveillance in the diagnosis of munchausen syndrome by proxy: lessons from 41 cases. Pediatrics. Jun 2000;105(6):1305-12. [Medline].
14. Hopkins RA, Harrington CJ, Poppas A. Münchhausen Syndrome simulating acute aortic dissection. Ann Thorac Surg. Apr 2006;81(4):1497-9. [Medline].
15. Huffman JC, Stern TA, Huffman JC, Stern TA. The diagnosis and treatment of Munchausen's syndrome. Gen Hosp Psychiatry. 2003;25(5):358-63. [Medline].
16. Lad SP, Jobe KW, Polley J, et al. Munchausen's syndrome in neurosurgery: report of two cases and review of the literature. Neurosurgery. 2004;55(6):1436. [Medline].
17. Rabinerson D, Kaplan B, Orvieto R, et al. Munchausen syndrome in obstetrics and gynecology. J Psychosom Obstet Gynaecol. 2002;23(4):215-8. [Medline].
18. Smith MS. Factitious illness, malingering, and conversion disorder. In: Harwood-Nuss AL, Linden CH, Luten RC, et al, eds. The Clinical Practice of Emergency Medicine. 2^nd ed. Philadelphia, Pa: Lippincott-Raven; 1996:986.
19. Zuger A, O'Dowd MA. The baron has AIDS: a case of factitious human immunodeficiency virus infection and review. Clin Infect Dis. Jan 1992;14(1):211-6. [Medline].

Article Last Updated: Feb 14, 2008