AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

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

INTRODUCTION

Section 2 of 11  

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

Background

The medical case literature provides compelling documentation of patients who have intentionally exaggerated, feigned, simulated, aggravated, or self-induced an illness or injury for the primary purpose of assuming the sick role. These occurrences were documented in the modern medical literature as early as the mid-19th century, and were identified as a distinct psychiatric disorder in 1951 by Asher, who coined the term Munchausen syndrome.

Although many health professionals use the term to describe all persons who intentionally feign or produce illness in order to assume the sick role, Munchausen syndrome is not included as a discrete mental disorder in the World Health Organization's International Statistical Classification of Diseases, 10th Revision (ICD-10) or in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). In both systems, the official diagnosis in these cases is factitious disorder (FD) (F68.1 in the ICD-10; 300.16 or 300.19 in the DSM-IV-TR). Nevertheless, numerous experts have identified a distinct subset of patients with FD for whom they reserve the term Munchausen syndrome.

The DSM-IV-TR diagnostic criteria for FD are as follows:

1. The patient intentionally produces or feigns physical or psychological signs or symptoms.
2. Motivation for the behavior is to assume the sick role.
3. External incentives for the behavior are absent.

The following subtypes are specified in the DSM-IV-TR.

1. Patients with primarily physical signs and symptoms (300.16)
2. Patients with primarily psychological signs and symptoms (300.19)
3. Combined subtype (300.19)

The subtype referred to as Munchausen syndrome lacks its own code but can be distinguished by the following characteristics:

• The factitious illness behavior is particularly chronic and severe and may be practiced to the exclusion of most other activities. The signs and symptoms of illness or injury are intentionally produced through medically dangerous manipulations of the patient's body (eg, self-inflicted infection, superwarfarin ingestion), thereby virtually guaranteeing hospitalization. These patients willingly, if not eagerly, submit to invasive interventions such as surgery.
• Peregrination, also commonly called itinerancy in the professional literature, is observed. The patient may move from hospital to hospital, town to town, and even country to country to find a new audience once his or her ruse is uncovered.
• Pseudologia fantastica is present in classic cases. The patient makes false claims about distinguished accomplishments, educational credentials, relations to famous persons, etc.

Some authors invoke additional diagnostic elements in addition to the triad described above. For instance, in relation to peregrination and pseudologia fantastica, the patient may use aliases or adopt false identities. Patients with Munchausen syndrome have little or no significant social contact with anyone other than health care professionals.

The published literature on FD is almost entirely limited to case reports and clinical guidelines based on unsystematic clinical observations (the subjectivist approach). Apparently, only 2 empirical studies of persons with Munchausen syndrome exist. The lack of systematic research is attributable to the reluctance of these patients to admit to their deceit or to cooperate with psychiatric investigations.

The literature on FD and Munchausen syndrome is not based on scientifically established facts so much as anecdotal and single case reports. In either scenario, the terms may have been misapplied. A peculiarity of the case literature on FD is that it reflects a bias toward the more extreme cases and those that pose the greatest medical danger, ie, cases that almost always involve induction of actual severe illness by the patient (eg, suppression of bone marrow through surreptitious use of chemotherapy medications).

Pathophysiology

No brain defect or dysfunction has been established to cause the behavior patterns that characterize Munchausen syndrome or FD more generally. A study of 5 cases of Munchausen syndrome suggested neurocognitive deficits. One case study reporting on the results of single-photon emission computed tomography (SPECT) analysis found hyperperfusion of the right hemithalamus in a patient with FD. It remains to be seen whether these results are replicable in larger samples, and if so, how these brain dysfunctions are linked to factitious illness behavior.

Frequency

United States

Epidemiological data on FD are scarce. Patients with FD are generally not open and honest about their medical deceptions. Because epidemiological studies of the general population rely on respondents' self-reports, estimating the prevalence of FD in the general population is impossible. Patients with Munchausen syndrome, who may not have a fixed address or a telephone number, are unlikely even to be recruited for such studies.

Studies of medical patients suggest that the prevalence of FD is probably in the range of 0.2-1% of hospital inpatients. Although patients with Munchausen syndrome have appeared with almost every medical condition, the prevalence is particularly high in a few select settings. These include patients who present with persistent rashes and nonhealing wounds, unexplained anemia, neurological problems, endocrine-related problems, hematuria, and joint and connective-tissue symptoms.

As might be expected, the prevalence is even higher among patients with unexplained or intractable medical complaints. For example, 9.3% of a sample of persons with fever of unknown origin were determined to have simulated or produced fevers. Another study found that an astounding 40% of brittle diabetics altered their medication compliance or diet to intentionally produce diabetic instability.

International

No epidemiological studies address the rate of FD or Munchausen syndrome in countries and cultures outside the United States and western Europe. Case reports indicate that the diagnosis of FD has been made in eastern Europe, Mediterranean countries, Asia, Africa, and South America.

Mortality/Morbidity

Four features of FD that are particularly prominent in Munchausen syndrome significantly increase morbidity and mortality risk.

• The first is dangerous manipulations of the patient's own body, including the ingestion of chemical toxins, self-infection, aggravation of wounds, and so on. Although patients with Munchausen syndrome are generally medically knowledgeable and sophisticated, their manipulations sometimes result in unintended serious injury, permanent disability, or death.
• Second, the patients place themselves at risk for iatrogenic illness and injury by repeatedly engaging in deceptions that cause medical care providers to perform risky diagnostic and treatment procedures. In some cases, the resultant damage is part of the patient's plan. For example, a patient who pretends to have a malignancy may desire the adverse effects of chemotherapy, or a patient may simulate adrenal gland dysfunctions with the intention of having an adrenal grand removed. In other cases, the iatrogenic damage results from unintended medical accidents such as adverse medication effects, allergic reactions, or surgical complications. Because patients with Munchausen syndrome subject themselves to so many medical procedures, their lifetime risk of experiencing an unintended adverse medical event is many times greater than that of the average person.
• Third, patients with Munchausen syndrome frequently provide incomplete or false medical history information that intentionally or accidentally causes increased morbidity or mortality risk. For example, they may experience dangerous adverse medication effects because they withhold information about known drug allergies, or they may suffer surgical complications because they fail to inform the medical staff that they have taken anticoagulant medications.
• Finally, although patients with FD or Munchausen syndrome are more likely than typical patients to claim illness or injury, they are no less likely than anyone else to actually become ill or injured. However, for genuinely ill patients with a known history of factitious medical complaints, medical staff may delay or withhold necessary tests and treatments to minimize unnecessary iatrogenic risks and to avoid reinforcing patients' inappropriate behavior. As with the boy who cried wolf in Aesop's famous tale, patients with Munchausen syndrome may be unable to mobilize the serious attention of medical staff when they truly need it.

Race

The case literature clearly shows that most patients with Munchausen syndrome are white. In the absence of demographic data describing the racial/ethnic composition of the patient populations in which these cases were identified, it is currently impossible to know whether race represents a significant risk factor.

Sex

Among Munchausen syndrome cases described in published reports, there are many more cases of male patients than female. This observation is particularly noteworthy in light of the fact that the literature on FD and the somatoform disorders suggests a much higher prevalence among women than men.

Age

The published cases of Munchausen syndrome generally describe patients aged 30-50 years. Infants and toddlers whose medical problems reflect intentionally produced signs of illness or injury are typically abused by a parent or other custodial adult (see Munchausen Syndrome by Proxy). The diagnostic picture is much less clear in cases of older children and young adults, who may be feigning illness on their own but who also may be encouraged to adopt the sick role by a parent or other custodian.

CLINICAL

Section 3 of 11  

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

History

• Medical history
• • The self-reported medical history of patients with Munchausen syndrome might be extensive. In these cases, the lack of medical documentation to substantiate the self-reported medical history is notable, and the patient might claim that the previous injuries or illnesses occurred in a foreign country or that the records of the treating physician were destroyed in a fire. They often decline to sign releases of information and give odd excuses in denying access to relatives and friends.
  • Alternatively, the patient may lie and deny an extensive medical history. Such reports are sometimes contradicted by surgical scars, other evidence from the physical examination, or the laboratory, radiologic, or other test findings that suggest a significant medical/surgical history (eg, the presence of benign surgical clips). The patient's description of his or her current problem and medical history may be overly dramatic or inconsistent. The literature is replete with tales of patients who diverted all attention to themselves in the ED by appearing to be spewing blood or having sustained seizures. At the same time, the patients might be surprisingly vague or guarded about the details of their medical history, especially regarding details of prior treatments.
  • The case literature describes cases in which the patients repeatedly simulated or self-induced a single medical problem (eg, nonhealing wounds) and a roughly equal number of cases in which individual patients presented over time with a wide diversity of medical problems. Although a history involving diverse symptoms and organ systems has been regarded by a few authors as an important indicator of FD and Munchausen syndrome, this feature is not a sensitive indicator.
• Psychiatric history
• • Patients with Munchausen syndrome are seldom willing to admit that they have feigned or caused their own medical or emotional problems. When confronted by medical and nursing staff or with policies they find offensive (eg, no leaving the unit at will), they often become angry and discontinue their care at that particular facility. Against-medical-advice (AMA) discharges are common, as are threats of retribution through lawsuits or physical attacks.
  • Few patients agree to accept psychiatric consultation or psychological assessment. Among those who do, many report a history of physical, emotional, or sexual abuse or physical or emotional neglect. Many describe having been separated from the family for extended periods or note that, at a young age, a spontaneous illness (eg, appendicitis) introduced them to the care and concern elicited by the sick role.
  • Unlike the latter, a pattern of claims of childhood abuse and neglect is also observed among the wider population of patients who present with chronic unexplained medical complaints. Abuse and neglect have been linked to the development of personality disorders, particularly the more florid and dramatic ones (cluster B), especially borderline personality disorder. These personality disorders are frequently comorbid with Munchausen syndrome. Whether a unique link exists between abuse and factitious illness behavior that is independent of their mutual relation to these personality disorders is unknown.
  • Note that patients who truly have Munchausen syndrome engage in chronic lying. Their reports of childhood abuse might be spurious, even if detailed and elaborate. This potential indicator is supported by case studies of persons who presented with various sorts of factitious victimization complaints such as false reports of rape, stalking, battery, or sexual harassment. Given the extent of the lies and deceptions that are a central component of Munchausen syndrome, it is not surprising that a particularly strong connection apparently exists between Munchausen syndrome and antisocial personality disorder.

Physical

The physical examination of the patient with Munchausen syndrome frequently suggests an extensive history of illnesses and injuries. Older patients might show evidence of multiple surgical scars on the abdomen, indicating numerous exploratory surgeries. As in conversion disorder, the neurological examination may reveal inconsistent findings.

For example, patients with paralysis may have normal muscle tone in the affected limb, or anesthesias might not follow the anatomical distribution of peripheral nerves. Other physical inconsistencies include an absence of signs of dehydration in patients complaining of persistent diarrhea and vomiting. Clinicians should look to case reports in their medical specialties to acquaint themselves with the types of factitious complaints that have been observed by their colleagues and the means by which these deceptions were carried out and eventually uncovered.

• Patients with FD with psychological signs and symptoms, or those simulating neuropsychological problems, often present with patterns of symptoms that do not match known syndromes or diagnostic categories. For example, they may portray the euphoric mood and pressured speech characteristic of a manic episode but show no disruptions in sleep.
• Specific symptoms might be presented in an atypical manner. For example, a patient feigning dementia might perform poorly on both recent and remote memory tests, or a patient feigning a closed head injury might show more errors than would be expected by chance on a visual discrimination test.
• Psychological and neurocognitive symptoms might appear worse when the patient is undergoing active examination then when the patient is casually interacting with staff members or other patients. The patient with dementia who could not remember any of 3 items after 5 minutes might later complain that the cafeteria served the same entrée 2 nights in a row.

Causes

The causes of Munchausen syndrome are unknown. These patients are so elusive that it is nearly impossible to conduct systematic empirical research on them. Psychoanalytic hypotheses have been put forth to explain Munchausen syndrome, but the volume of this work is quite small compared to the pertinent literature on the psychodynamics of the somatoform disorders.

False illness experiences in the somatoform disorders are regarded as unconsciously produced and are therefore amenable to traditional psychoanalytic explanations involving the notion of defense against unacceptable wishes or unspeakable fears. Because the false illness behavior in FD is conscious and intentional, explanations involving unconscious processes are less compelling when applied to FD. Nevertheless, some psychoanalytic writers have argued that whereas the illness behavior of FD patients is conscious, the reasons for the behavior are not.

Several authors have regarded factitious illness behavior as a primitive defense mechanism against sexual and aggressive impulses. Others have hypothesized that patients with FD subject themselves to painful medical procedures as a form of self-punishment. It has also been hypothesized that the cruel and embarrassing deception of physicians is an expression of oedipally based hostility toward authority figures.

More contemporary theorizing has focused on gratuitous sick-role behavior as a reflection of problems with object relations. These authors have focused on the high degree of comorbidity with the cluster B personality disorders and have suggested that the sick-role behavior of patients with FD might serve as a means of establishing or stabilizing the patient's sense of self and their relations to others. Enactment of the sick role confers unconditional acceptance and concern, and admission to a hospital gives patients a clearly defined role in a social network. This automatic sense of importance and belonging might be difficult for patients with Munchausen syndrome to secure in more routine social contexts.

Case studies support the role of social learning mechanisms in factitious illness behavior. Many patients with FD have either personally experienced a severe illness in childhood or as a child had a family member who experienced a severe illness. Through these experiences, the child is introduced to the various benefits and dispensations attached to the sick role, and these experiences may predispose persons with other psychological vulnerabilities to engage in factitious illness behavior.

DIFFERENTIALS

Section 4 of 11  

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• Differentials
• Workup
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Other Problems to be Considered

Differential medical diagnoses

The initial presentation of patients with FD or Munchausen syndrome always suggests a medical or psychiatric problem, with features compatible with the ailment being feigned or produced. The ruses are limited only by the patient's creativity, knowledge, and motivation and can include esoteric diagnoses about which most doctors would be largely unaware.

FD should be excluded when routine examination and testing fail to confirm any of the most obvious diagnostic possibilities. At this juncture, clinicians should consider among their differential diagnoses idiopathic medical illnesses that have a fluctuating course or that manifest across several different organ systems (eg, multiple sclerosis, systemic lupus erythematosus). The case literature suggests that the most frequent medical diagnoses among patients who are falsely believed to have FD or conversion disorder are central nervous system diseases (eg, encephalopathy), metabolic diseases, and structural diseases of the muscles and connective tissue.

When creating a working list of hypotheses for the diagnosis of a puzzling medical case, it is important to follow base-rate information about the frequency of each diagnostic possibility. If this procedure were followed, FD or Munchausen syndrome would probably emerge as the third-to-fifth most likely diagnosis in such cases. Even if FD occurs only once per 10,000 patients (probably an underestimate), it would still be more prevalent than some of the exceptionally rare disorders that a physician might consider before entertaining the possibility that the patient is feigning illness. Cases abound in which doctors have bypassed consideration of FD as they repeatedly performed yet more tests, medication trials, and/or surgeries or applied literally novel diagnoses.

Differential psychiatric diagnoses

FD and Munchausen syndrome must be distinguished from two related types of clinical problems.

The first of these is simple malingering. When a discernible primary external motive for the deceptive illness behavior exists, the label of malingering is applied. Examples of external goals are acquiring narcotics, evading criminal prosecution, gaining disability payments, and avoiding military service. Unlike the others, malingering is not an official mental disorder, though it can sometimes be a focus of clinical attention.

In practice, this determination almost always requires a weighing of internal and external incentives because the sick role itself almost always includes rewards and dispensations of various kinds (eg, financial assistance that a church insists the patient accept). The external goal in malingering is usually obtained by first securing a physician's official confirmation of an authentic illness or injury. The malingering patient will abide only as much testing and treatment as necessary to achieve this aim. In contrast, persons with Munchausen syndrome actively attempt to maintain the sick role and willingly undergo as much testing and treatment as possible.

The second vital differential is hypochondriasis. In a typical case of hypochondriasis, the patient presents with anxiety, and either no physical signs are present and objective test findings are within normal limits, or a medically insignificant sign is noted (eg, discoloration of the skin). The patient may insist with true conviction that he or she is gravely ill and demand various tests. When the results of the tests are negative, the patient is typically relieved, at least for a short time.

This presentation is not easily confused with FD or Munchausen syndrome; however, in rare instances, the patient's conviction that he or she is gravely ill may be so strong that the patient resorts to simulation or self-injury as a means of soliciting further diagnostic testing. The differential diagnosis may thus depend on subtle signs such as the presence or absence of relief when the patient is informed of negative test results and the patient's willingness to permit caregivers to communicate with each other and with family members.

According to the DSM-IV-TR, FD and Munchausen syndrome must also be distinguished from the other somatoform disorders, particularly somatization disorder, conversion disorder, and pain disorder. The DSM-IV-TR assumes these disorders represent a completely distinct category of psychiatric disorders and are distinguished from FD by the belief that patients with somatoform disorders do not intentionally exaggerate or feign illness: Complaints in somatoform disorder are presumed to be generated through unconscious processes. In practice, it may be impossible to distinguish between somatoform disorders and FD in patients who do not carry out physical simulations or self-injury that might provide concrete evidence of intentional deception.

WORKUP

Section 5 of 11  

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Lab Studies

• The medical assessment of patients with chronic FD is analogous to the task of piloting an airplane through dense clouds. Under those flying conditions, it is important for pilots to follow the basic rules of flying and to trust their navigational instruments. Pilots who depart from these procedures and rely instead on their own inner sense of direction and orientation are at risk for a bad—if not disastrous—outcome. Similarly, physicians who encounter patients they cannot diagnose and who do not respond to the usual treatments can experience a similar feeling of panic and disorientation.
• • When this occurs, the physician should (1) follow the basic procedures for responding to the patient's signs and symptoms, (2) trust the reliability and validity of the medical tests that he or she performs, and (3) respect base-rate information about the prevalence of various diseases that must be excluded. Cases abound in which tests have been needlessly repeated, invasive procedures performed without adequate justification, or medications prescribed with such apparent zeal that iatrogenic problems actually come to dominate the clinical picture.
  • Patients with Munchausen syndrome use several techniques to disrupt the physician's usual practices. Typically, they exploit the clinician's fear of overlooking a rare, life-threatening disease. Simultaneously, they play to the clinician's fascination with rare and inscrutable medical problems. The patient with Munchausen syndrome understands the appeal of a medical mystery and the personal satisfaction, notoriety, and esteem that the physician experiences when he or she solves one. These factors combine to cause the physician to depart from standard procedures and to overlook more benign explanations for the patient's signs and symptoms.
  • Paradoxically, patients with Munchausen syndrome can also disrupt the physician's usual practices by persuading the physician to forego basic diagnostic procedures. Striking evidence of this phenomenon is noted in reports of patients who have successfully feigned diseases such as AIDS with Kaposi sarcoma and malignancies such as breast cancer. In both of these real-life examples, definitive tests were available to establish the presence of these diseases, but they were not performed because the patients' persuasive but false medical history, perhaps combined with their physical appearance, led to the mistaken assumption that the tests were unnecessary. Doctors may also erroneously believe that the ailment under consideration could not possibly be feigned or self-induced.
• Laboratory tests may be particularly helpful in identifying patients with Munchausen syndrome. Because many of these patients have a medical background, they often know the routine tests performed for a particular symptom presentation.
• • For example, a patient with anemia would anticipate that routine blood work would not include screens for the anticoagulants he or she has ingested, thus prolonging the medical or surgical investigation as the professionals search for the elusive etiology, such as unexplained hematuria or hematochezia.
  • The number of other ways in which patients have used tests and test results to mislead doctors is staggering. Several examples illustrate the range. Patients commonly self-inject insulin to create a baffling, tenacious, and dangerous hypoglycemic state. Before a diagnosis of insulinoma is made, doctors can expose the ruse by assessing whether or not the C-peptide level is compatible with the insulin level. High insulin levels combined with low C-peptide levels indicate factitious hypoglycemia.
  • Patients can create alarming laboratory evidence of proteinuria simply by adding a drop of egg white (a pure protein) to their urine specimens. A small amount of blood, perhaps added to a stool specimen or swallowed prior to endoscopy, appears as conclusive evidence for gastrointestinal pathology. The presence of unexplained puncture sites, especially in odd areas (eg, base of the tongue) can provide very compelling evidence of such dissimulation.
  • Conversely, laboratory test results may be inconsistent with the claimed illness, such as a lack of an elevated WBC count or left shift in an apparent case of sepsis or necrotizing fasciitis. Bacterial cultures may grow an overly wide variety of enteric flora when taken from infected sites distant from the pelvic or groin area because the patient has contaminated the wound with feces. Intractable diarrhea or vomiting may be missed unless the physician specifically asks laboratory personnel to assess for agents such as phenolphthalein or ipecac.
  • Some patients enter the nurses' station or access the vital-sign clipboards outside their doors and directly change laboratory values from normal to abnormal. They may present the doctor with letters from colleagues purporting to verify laboratory pathology, but a follow-up call reveals that the letterhead paper was stolen and a worrisome report was typed by the patient. Of course, self-induced but real illnesses (eg, extreme lead poisoning created by drinking water in which lead-based items were boiled) show corresponding authentic laboratory analyses that compel emergency treatment.

Imaging Studies

• Imaging studies may be useful in diagnosing Munchausen syndrome. They may be particularly useful in cases in which the patient presents with a well-established medical problem of the type that can be easily imaged (eg, inoperable malignancies, cardiovascular accidents). In these cases, errors are made by eschewing these tests to spare the patient the expense or inconvenience of "repeating" tests that have already returned positive indications of disease. For many patients with Munchausen syndrome, the use of imaging studies becomes part of the search for an explanation for their puzzling signs and symptoms.

Procedures

• Medical personnel should base testing on a well-considered and prioritized differential diagnosis. The performance of any procedures should be approached very conservatively if suspicions arise (eg, the patient has the "road-map" abdomen caused by scars from prior exploratory operations). Tests should not be needlessly repeated in the misguided hope that diagnostic pathology will suddenly emerge.
• Strongly subjective tests, such as electromyelography and nerve conduction velocity tests, should be understood as almost never definitive in isolation. An occasional positive finding, likely whenever anyone is subjected to extremely extensive and repeated testing, should not be misinterpreted. Clinicians should remember that each intervention poses a risk of iatrogenic complications that only complicate the picture. Indeed, such complications have frequently led to malpractice actions against physicians.

TREATMENT

Section 6 of 11  

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• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

In essence, the medical care of persons thought to have Munchausen syndrome should proceed in the same manner as the medical care of any other patient, despite the dramatic or compelling nature of the patient's problem or his or her demands for additional invasive and noninvasive intervention. As noted in the previous section, remember that these patients attempt to fool the treating physician into conducting more tests and trying more treatments than are necessary. When they succeed in doing so, it is often because of a failure to include FD and Munchausen syndrome in the differential. On the other hand, medical professionals are taught that the most important clue to a patient's diagnosis is the information they provide, and doctors should not abandon their belief in and advocacy for patients unless risk factors are present or suggestive signs arise.

Surgical Care

For patients with known or suspected Munchausen syndrome, use great caution in deciding to proceed with surgical treatment, particularly when the surgery involves an irreversible result such as amputation, radical mastectomy, or organ removal. Do not assume that a patient with FD would not play out the ruse to the point of acquiring a permanent disability or disfigurement—the case literature is replete with reports of patients who have done so. Remember that performing surgery on a patient gives him or her a legitimate sick role status, at least during the recovery period, perhaps longer in cases in which the surgery appears to result in complications or otherwise creates unexpected and unwanted physical consequences.

Consultations

The general practitioner who encounters a patient with Munchausen syndrome often makes specialty referrals in response to the puzzling or intractable symptoms that the patient presents. The specialist consultations should be carefully coordinated by the primary care provider. In some cases involving patients with Munchausen syndrome who have filed malpractice suits, the staggering number of concurrent treating and prescribing physicians can incriminate the doctor if he or she failed to ask about outside care. Referrals should be kept to a minimum; the primary care physician should serve as much more than a conduit for consultations. Referral issues, including any indication of Munchausen syndrome, should be clearly spelled out.

The patient's refusal to sign release of information forms should be thoroughly questioned and is a warning sign. The primary care physician should firmly resist attempts by the patient to exert inappropriate control over the consultation (eg, choosing the specialist, insisting on personally communicating the results to the primary care provider). Termination from the doctor's practice may have to be considered, although this measure does nothing to attenuate the root problem.

When the physician strongly believes that the patient is feigning illness or injury, it is natural to request a psychiatry consultation. Before doing so, the primary care physician should consider several issues.

First, no definitive affirmative psychiatric criteria exist for the diagnosis of FD. Second, the patient is unlikely to cooperate with a psychiatry consultation, so no new information will be elicited. Not only will the patient usually not agree to the consultation, he or she may leave the physician's care, angered by the implication that the physician believes that the patient is faking. Similarly, psychological testing is nondiagnostic, though it can be telling if a patient feigning mental illness receives discrepant scores on objective, well-validated tests. For these reasons, a typical psychiatric or psychological evaluation is not often effective in these cases. Additionally, as a group, psychiatrists and psychologists have no greater ability than average lay persons in discerning lying during interviews.

Still, it may be helpful for the physician to discuss the case with an experienced psychiatric consultant who can advise the physician, and sometimes the entire treatment team, on how to proceed with the evaluation and management of a patient with Munchausen syndrome.

After a diagnosis of FD has been established, it may prove more useful to conduct consultations with mental health professionals who practice behavioral medicine, reserving psychopharmacologic management for patients with clearcut mental disorders such as major depression. These professionals might include psychiatrists, psychologists, or social workers. Consultations may be acceptable to the patient if they are portrayed as aimed at helping the patient to cope with their medical problems and to understand more about the influence of the brain on the body. This approach can succeed because it places the patient in contact with mental health professionals in a way that does not challenge the patient's assertion that the problem is an authentic medical one. Ongoing psychotherapy can provide the patient with a time and place in which they are guaranteed the exclusive attention of a health care professional without resorting to "disease forgery."

Activity

If the patient is hospitalized, it may be important to limit his or her activities to the unit and to minimize the time he or she spends alone. Freedom to come and go (as on some psychiatric units) or infrequent checks offer increased opportunities for patients with Munchausen syndrome to self-induce renewed bouts of illness. Room searches (eg, for syringes or hidden medications) may be necessary, and permission to do so is commonly part of the consent forms patients sign before admission.

MEDICATION

Section 7 of 11  

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

No drug treatment trials specifically relate to pharmacological interventions for chronic FD.

Patients with comorbid depression or anxiety may benefit from pharmacotherapy with nonabusable medications such as serotonin reuptake inhibitors, though these medicines are very unlikely to reverse the patient's illness behavior problems.

Caregivers should routinely copy each other on every progress note and prescription written, with ongoing care contingent on the patient's signing the suitable consent forms. If abusable medications must be used (eg, because of a lack of response to nonabusable agents), firm written contracts should be signed by doctor, patient, and at least one witness. Examples are usually available from state medical licensure boards or pain-management colleagues. Contract provisions might include statements that no replacement pills will be provided if the patient claims to have lost their medication in some way and that the patient will submit to random urine or serum blood screens to exclude use of street drugs and to detect drug levels too high to be explained by use as the doctor instructed.

FOLLOW-UP

Section 8 of 11  

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• Introduction
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• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Inpatient Care

• Inpatient medical care
• • By definition, patients with Munchausen syndrome present repeatedly for inpatient medical care. One prolific patient claimed 800 hospitalizations at 650 hospitals throughout Europe, though this claim may have been an example of pseudologia fantastica. A pattern of signs that remit during inpatient hospitalizations only to recur when the patient is not under observation may constitute a very important clue that the patient's medical problem is simulated or self-induced.
  • Thorough wrapping of affected areas (eg, a healing ulceration on the leg) to prevent access can forestall self-harm and rehospitalization in some cases; however, tampering with bandages is common in cases of Munchausen syndrome and often forces rehospitalization due to an unexpected infection, a surprising dehiscence of a skin graft, or a bizarre opening of stapled or sutured wound. In the hospital, voluntarily restraining or placing mittens on a patient's hands can reduce the likelihood of tampering. Painting the wound with scarlet red can provide an important clue if the dye subsequently appears on the fingers.
  • Although some patients are hospitalized many times at a particular hospital, especially if the primary physician is amenably unquestioning, doting, or naive, the patient with true Munchausen syndrome continually seeks new medical audiences each time the ruse is exposed or when they tire of the current hospital setting.
• Inpatient psychiatric care
• • Although patients with Munchausen syndrome pose a very real and imminent danger to themselves, they are rarely subject to civil commitment. Civil commitment is particularly unlikely in states in which "treatability" or the expectation of improvement is a criterion for petition or commitment. Outpatient commitment can prove difficult for the same reason, though at least one successful case has been reported. Even the successful use of house arrest was reported in one case.
  • For a patient with Munchausen syndrome to accept inpatient psychiatric care on a voluntary basis is probably very rare unless the patient is predominantly feigning psychological signs and symptoms or has the combined variant of the syndrome.
  • Medical guardianship, open access to a hospital bed so that admission is no longer contingent on illness, 12-step programs, and Internet chats among patients have been proposed or attempted at various times with mixed results. At the time of this writing, an Internet group for patients with factitious disorder is available at Cravin4Care.
  • To the authors' knowledge, no specialized inpatient (or outpatient) program for patients with Munchausen syndrome exists in the United States, just as no federal or foundation funds have ever been awarded for research into this perplexing and costly syndrome.

Further Outpatient Care

• To the extent that patients with Munchausen syndrome harm themselves to garner the gratification of the sick role (eg, sympathy, nurturance, lenience, association with high-status professionals), several commentators have suggested that morbidity and mortality rates in these patients might be reduced by allowing them to assume the sick role on an outpatient basis without having to provide any evidence of illness or injury. Regular and frequent physician consultations that are contingent upon time, not demonstrable medical necessity, may reduce both the associated risks and costs.

Deterrence/Prevention

• Little can be done to prevent development of Munchausen syndrome. The best hypothesis holds that the disorder develops from a combination of factors related to personality development and early experiences with illness and medical care. A biological diathesis has not been demonstrated, though MRI study findings and neuropsychological testing results have sometimes emerged as nonspecifically abnormal. FD can be multigenerational, however, and can precede, follow, or be comorbid with the form of maltreatment (abuse and/or neglect) called Munchausen by proxy.
• Because the patient does not regard Munchausen syndrome as undesirable, he or she has no incentive to engage in activities to reduce the morbidity and mortality associated with inauthentic illness behavior.
• In the United States, aside from the Veterans Administration system, no database exists to allow examiners to track the readmissions and diagnoses of patients and thus to identify patients who likely have Munchausen syndrome. In countries with socialized medicine, this capacity exists, but the extent of its use has not been reported. Certain countries, such as the United Kingdom and Australia, appear to distribute "black books" of patients who are known to overuse care, but the reasons may include substance addiction, malingering, or other causes as well as Munchausen syndrome. Some authorities have expressed concern that patients with legitimate illnesses superimposed on one of these diagnoses will be denied urgent medical or surgical care, and such cases have been reported, at least one resulting in death.
• Although surveillance of persons with factitious disorder is not possible in the United States at this time, there are steps that individual physicians can take to prevent excessive and unnecessary illness behavior.
• • First, it is unlikely that the onset of severe and continuous medical deceptions is sudden. It is more reasonable to suspect that Munchausen syndrome follows a progression that starts with more pedestrian forms of feigned or exaggerated illness. For this reason, primary care physicians should take decisive steps to assess and manage the psychological problems of any patient who presents with repeated unexplained medical complaints. The research literature on medically unexplained symptoms makes clear that medically unexplained symptoms are strongly and linearly associated with increasingly severe anxiety and depression. So, even if only a small fraction of persons with unexplained medical complaints are destined to develop severe factitious disorder, psychological intervention for all persons with medically unexplained symptoms is fully justified.
  • Anecdotal evidence that excessive sick role behavior can be trained at an early age suggests that pediatricians may play a particularly important role in preventing factitious illness behavior in their patients when they become adolescents and adults. Parents should be educated explicitly on the pernicious effects of encouraging unnecessary illness behavior in their children. Parents should be given clear expectations about the things that their ill or injured child can and cannot do, along with information about the time course of recovery for acute illness. This sort of information should be presented to all adult patients and their families.
• The prevention of factitious illness behavior can also be improved by several relatively minor changes in the way primary care physicians manage cases. For example, the practice of assigning official medical diagnoses in the absence of adequate evidence should be sharply curtailed. Often cases of Munchausen syndrome reveal that decisions to perform excessive diagnostic or treatment procedures are based on the existence of a definitive, but incorrect, diagnosis. Although for most patients, providing a definitive diagnosis may be reassuring to the patient and the provider, and may facilitate third-party reimbursement, for the patient at risk for factitious illness behavior, an official diagnosis can enable medical deception.

Complications

• Munchausen syndrome is itself a complication. As described in the preceding sections, a combination of the patients' self-harming behavior, physician actions that are not based on accurate medical history information, and the simple additive iatrogenic risks entailed in multiple surgical procedures all greatly increase morbidity and mortality rates.

Prognosis

• Based upon current case-based reports and anecdotes shared among interested professionals, the prognosis for FD is fair, but the prognosis for the more chronic and severe Munchausen variant is poor.
• A positive prognostic sign is the presence of a treatable concurrent mental disorder such as major depression. Some investigators believe that both disorders attenuate with age and maturity, as with personality disorders. Still, patients with Munchausen syndrome are reluctant to accept that they have a psychological disorder and are generally unwilling to undergo psychiatric treatment. Even if they are amenable to treatment, there are no scientifically based models of the etiological factors responsible for the development and maintenance of factitious illness behavior and no scientifically tested treatments.
• The Internet shows promise for collecting standardized but anonymous data about such patients, and patients and those affected by them have used it to share stories of both triumph and defeat. Thus, newer technologies could be mobilized to increase general information about treatment, outcome, and prognosis.

Patient Education

• Educational efforts targeted toward the general public are not likely to decrease the incidence of Munchausen syndrome. Whether these efforts might help friends, family members, teachers, or co-workers to identify persons with Munchausen syndrome and to urge them to seek mental health care is debatable. Such efforts could also lead to cruel and unwarranted skepticism toward persons with genuine chronic illnesses.
• Educational efforts are most effective when they are targeted toward medical staff, nursing professionals, and other allied health care professionals. In the absence of scientific evidence related to identification and management of patients with Munchausen syndrome, exposure to case reports is the best available method for communicating the types of medical deceptions that have been used and the clues that led to the eventual discovery of the deception.
• In almost every medical specialty, published case studies describe the specific techniques that have been used to simulate or induce conditions that fall within the purview of that specialty. These cases are invaluable sources of hypotheses that might explain unusual patterns of signs and symptoms that cannot be explained by routine diagnostic procedures. However, using published cases as teaching tools is inherently dangerous because the published reports are almost certainly biased toward the most extreme, chronic, and dramatic cases. Educational efforts that do not attempt to correct for this fact may increase the detection rate of Munchausen syndrome but cause staff to overlook less dramatic cases of FD. Published case reports should be supplemented with less spectacular cases seen by experienced staff nurses and physicians
• To the extent that Munchausen syndrome is associated with borderline and antisocial personality disorder, the presence of a patient with Munchausen syndrome frequently produces rifts among the staff. The patients are generally well practiced at identifying staff members whom they can win over as allies and advocates. The patients are often able to play these staff members against those who actively question the authenticity of the patient's complaints.
• • This splitting often results in acrimony and self-doubt among the staff and always delays the eventual detection of the deception. Regardless of whether the case is eventually diagnosed as an occult medical condition or as FD, the treatment team as a whole is hurt. Advocates for the Munchausen patient feel embarrassed and emotionally abused; accusers of a truly ill patient are left feeling embarrassed and unsure of their medical competence.
  • The best way to avert these undesired outcomes is to prepare staff ahead of time for dealing with difficult cases. Educating staff about the strong emotions and interpersonal tensions elicited in these cases may be the simplest and most effective way of ensuring effective teamwork. One element of this education might emphasize the fact that the diagnostic question is not whether or not the patient is ill; the question instead concerns the type of illness the patient has. Emphasizing that the accurate and timely diagnosis of Munchausen syndrome is a medically important service to the patient may help reduce polarization and factional strife.
• Other potentially useful strategies include training staff to raise concerns about medical deception as soon as they arise, adding medical deception to the working diagnostic hypotheses, and making careful plans for evaluating that hypothesis along with all other viable hypotheses. The earlier the issue is raised and incorporated into the case conceptualization, the less likely it is that decisions will be based on irrelevant emotional factors such as anger, frustration, or sympathy.
• Effective implementation of this strategy requires that the treatment team members have a realistic idea about the prevalence of Munchausen syndrome and FD, and that they foster a climate in which a member can raise concerns about medical deception without fear of reproach from other team members.
• 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
• Multimedia
• References

Medical/Legal Pitfalls

• Some of the many legal and ethical issues arising in cases of medical deception have been the subject of considerable debate and several courtroom judgments. Despite this controversy, most of these issues remain unresolved and do not clearly direct the treating physician's response.
• The first question is whether these individuals are even patients, and therefore entitled to treatment, appropriate notice before termination, and so on. The American Medical Association, as with other organizations and esteemed experts, regards a patient in part as someone who seeks to get well. The patient with Munchausen syndrome may not be entitled to admission and care if "patienthood" and professional duty are conceptualized in this way.
• A second issue involves the doctor's responsibility following the discovery that a person has been feigning illness. Some patients explicitly refuse permission for the doctor to share this vital information with other doctors or even with family members who have unknowingly aborted their own careers to care for this deceptive person. A proposed solution tacitly encourages others to read between the lines by stating that "The patient has forbidden me to comment on whether they have a FD."

  Paralleling the broader issue discussed above, several commentators have argued that the doctor-patient relationship, through which the right to confidentiality is established, requires that both the doctor and the patient carry out their roles in good faith. According to this view, the doctor-patient relationship ceases to exist when the patient engages in medical deception.

• A third issue involves fraud or other legal charges against patients. Those who are caught stealing even inexpensive merchandise from department stores are assuredly confronted and are likely to be criminally charged. Yet, though the patient with Munchausen syndrome steals the time of doctors and others and wastes medical resources and supplies, criminal indictments are rare. Still, one such case was heard in Arizona and resulted in a court finding of fraud and an order of reimbursement against the patient.
• A fourth issue concerns medical malpractice liability associated with the treatment of patients with FD or Munchausen syndrome. One of the authors (Feldman) has been an expert consultant or witness in numerous cases in which a patient with FD has sued some or all of the treating doctors and the facilities in which they worked. The standard claim is that the original ailment was real but mismanaged so that the patient is now permanently disabled or disfigured. These cases are notoriously difficult to defend, in terms of both time and money, even in those in which the patient has been observed to induce self-harm. Regardless of the evidence, judges and juries tend to find Munchausen syndrome scarcely believable and assume that such a patient would be obviously psychotic. The presence of a well-behaved, neatly groomed patient in the courtroom can clash with that erroneous assumption, leading to surprisingly large settlements or verdicts in favor of patients.
• A fifth issue appears to be the antithesis of the fourth. In these legal cases, a patient with FD or Munchausen syndrome eventually sues caregivers for their failure to detect that the illness was feigned. Therefore, they claim that any and all treatments were misapplied, that iatrogenic effects were completely unwarranted, and that the physician has breached the standard of care in diagnosis. One case resulted in a settlement to the patient of more than $300,000.
• A sixth issue involves room searches and covert surveillance of patients. As noted earlier, room searches for medical paraphernalia are permissible if, as is standard at many hospitals, the patient has consented to them as a condition of admission. The use of covert surveillance (eg, with cameras hidden in ceiling panels intended to catch FD behavior) is more controversial.
• • The arguments hinge on whether there is a reasonable expectation of privacy in a hospital room. Many legal precedents support the notion that such an expectation is unreasonable, but these have applied to cases of Munchausen by proxy abuse, in which, barring such an intervention, suspicions of abuse could not otherwise be confirmed (eg, the patient is often a nonverbal infant and cannot provide information).
  • Risk management and legal advisors should meet with team members and formulate a decision as a group before covert video surveillance is initiated. Hospitals are advised to develop relevant standards and policies even if no suspicious case has ever arisen. The authors are not aware of any cases in which search warrants of hospital rooms have been issued based exclusively on the possibility of self-damaging behavior.
• A seventh issue has been touched on earlier and concerns the legality of registries of patients with FD that are shared among treatment centers or that are available nationally or internationally. These registries can be used to determine whether a patient who is suspected of medical deception has indeed been previously identified as having FD.
• • Although the existence of such registries would undoubtedly hinder the ability of such patients to carry out their deceptions at one hospital after the next, the apparent consensus among legal authorities in the United States holds that such registries are a violation of patient confidentiality, particularly since the implementation of the HIPAA rules. However, these registries of troublesome patients are indeed maintained in some other countries.
  • Advocates of patients' rights caution that patients who are placed on such lists may be unable to receive quality medical services because of the presumption that their medical complaints are inauthentic, which may or may not be true. Patient advocates are also concerned about patients who might be listed simply because they were uncooperative or because the source of their medical complaints could not be definitively diagnosed. Individuals who support such measures view themselves as the real patient advocates for preventing unwarranted and potentially harmful treatment to people whose judgment is impaired.

MULTIMEDIA

Section 10 of 11  

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

Media file 1:  Baron Munchausen as he has been depicted in innumerable books. The real-life Baron Munchausen lived from 1720-1797 and never told tales about illness.
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Media type:  Image

Media file 2:  A playing card celebrating the literary Baron, who claimed to have ridden a cannonball into battle.
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Media type:  Image

Media file 3:  The classic, multiply scarred abdomen of a patient with Munchausen syndrome. The photograph on the left shows her abdomen as it appeared on presentation, after she had undergone 42 unwarranted operations. The photograph on the right shows her abdomen after additional surgery revealed an authentic colon cancer.
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Media type:  Photo

Media file 4:  An antique gyroscope showing Baron Munchausen riding a cannonball into battle as in the famous story attributed to him.
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Media type:  Photo

REFERENCES

Section 11 of 11

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

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• Hamilton JC, Feldman MD. Factitious disorders. In: Phillips KA, ed. Somatoform and Factitious Disorders. Washington, DC: American Psychiatric Publishing;2001:129-166.
• Rabinerson D, Kaplan B, Orvieto R. Munchausen syndrome in obstetrics and gynecology. J Psychosom Obstet Gynaecol. Dec 2002;23(4):215-8. [Medline].
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Article Last Updated: Apr 4, 2006