Munchausen syndrome: causes, symptoms, diagnosis, treatment

Munchausen syndrome, a severe and chronic form of illness malingering, consists of the repeated production of false physical symptoms in the absence of external benefit; the motivation for this behavior is to assume a sick role. Symptoms are usually acute, vivid, convincing, and accompanied by a shift from one physician or hospital to another. The exact cause is unknown, although stress and borderline personality disorder are commonly involved.

Symptoms of Munchausen syndrome

Patients with Munchausen syndrome may feign many physical symptoms and conditions (eg, myocardial infarction, hemoptysis, diarrhea, fever of unknown etiology). The patient's abdomen may be slashed with scars, or a finger or limb may have been amputated. Fever is often the result of self-injection of bacteria; Escherichia coli is often the infecting agent. Patients with Munchausen syndrome sometimes cause endless problems in medical or surgical clinics. However, the disorder is a psychiatric problem that is more complex than simply fraudulent feigning of symptoms and is associated with severe emotional problems. Patients may have features of histrionic or borderline personality disorder, but they are usually quick-witted and resourceful. They know how to feign illness and are knowledgeable about medical practice. They differ from malingerers because, although their deception and malingering are conscious and deliberate, their benefit beyond medical attention to their illness is unclear, and their motivation and attention-seeking are largely unconscious and hidden.

Patients may have suffered emotional or physical abuse at an early age. They may also have suffered a serious illness in childhood or have seriously ill relatives. The patient presents as having problems with their own identity, inadequate impulse control, a poor sense of reality, and unstable relationships. The false illness may be a way to enhance or protect self-esteem by blaming the failure of professionals to recognize their illness, which is often associated with seeing prestigious doctors and large medical centers, and by presenting themselves in a unique, heroic role as a knowledgeable, medically sophisticated person.

Diagnosis is based on history and examination, including tests to rule out medical disorders. Less severe and chronic forms of factitious disorder may also involve the production of physical symptoms. Other forms of factitious disorder may involve the faking of mental (rather than physical) signs and symptoms, such as depression, hallucinations, delusions, or symptoms of post-traumatic stress disorder. In these cases, the patient also assumes the sick role.

In other cases, patients may produce both mental and physical symptoms.

Munchausen syndrome by proxy

Munchausen syndrome by proxy is a variant in which adults (usually parents) intentionally induce or simulate symptoms in a person under their care (usually a child).

Adults falsify the medical history and may injure the child with drugs or other means or add blood and bacterial contamination to urine samples to simulate illness. The parent seeks medical attention for the child and appears deeply concerned and protective. The child has a history of frequent hospitalizations, usually for a variety of nonspecific symptoms but without a definitive diagnosis. Child victims may become seriously ill and sometimes die.

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Treatment of Munchausen syndrome

Treatment of Munchausen syndrome is rarely successful. Patients initially experience relief when their treatment demands are met, but their resentment tends to mount, eventually telling the physician what he or she must do. Confrontation or refusal to comply with treatment demands usually results in angry reactions, and the patient usually moves on to another physician or hospital. The patient usually refuses psychiatric treatment or tries to be cunning, but counseling and follow-up care may be accepted at least to help resolve the crisis. However, management is usually limited to early recognition of the disorder and prevention of risky procedures and excessive or inappropriate use of medications.

Patients with Munchausen syndrome or more limited factitious disorders should be confronted with their diagnosis in a non-aggressive and non-punitive manner, without inducing guilt or reproach, by defining the condition as a cry for help. Alternatively, some experts recommend a non-confrontational approach that offers patients a path to recovery from their illness without assuming their role as the cause of the illness. In both cases, it is helpful to promote the idea that the doctor and patient can work through the problem together.