Munchausen's Syndrome

Synonyms: Factitious disorder, Hospital addiction syndrome

The term Munchausen syndrome was first used by Richard Asher in a paper in 1951, taking the name of the legendary Baron von Munchausen who was renowned for his wide travels and dramatic and untruthful stories.¹

Munchausen syndrome can be characterised by three features:²

• Simulated illness: either physical or psychiatric.
• Pathological lying (pseudologia fantastica).
• Wandering from place to place (peregrination): the patient typically presents to numerous different hospitals using different names.

In Munchausen syndrome:

• Symptoms can be simulated, e.g. contamination of specimens to look like haematuria, haemoptysis, haematemesis.
• A pre-existing illness can be aggravated.
• Disease may even be self-induced, e.g. eating contaminated food to cause food poisoning.

People with Munchausen syndrome may go through unnecessary tests, operations, or uncomfortable investigations and procedures. They can cause themselves considerable injury. Costs incurred to health services for these repeated admissions and procedures can be huge.

There is a related condition known as Munchausen syndrome by proxy in which a parent or carer produces factitious illness in a child or adult in their care. There is a separate article on Munchausen Syndrome by Proxy.

Munchausen syndrome is not included as a discrete mental disorder in the World Health Organisation'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). The official diagnosis in these classifications is Factitious Disorder.³

However, many psychiatrists identify a subset of patients with factitious disorder and sub-classify them as having Munchausen syndrome. One way of looking at Munchausen syndrome is as an extreme variant of factitious disorder.

The DSM-IV-TR diagnostic criteria for Factitious Disorder are:³

• The patient intentionally produces or feigns physical or psychological signs or symptoms.
• Motivation for the behaviour is to assume the sick role.
• External incentives for the behaviour are absent.

Munchausen syndrome:

• The exact incidence is not known but it is rare.
• It probably accounts for less than 10% of all factitious disorders seen in hospital.⁴
• Patients are more commonly male.²

Factitious disorder:

• There is a predominantly female subset with a milder form of factitious disorder who exhibit a single set of symptoms instead of a myriad of different symptoms over time.
• They show less evidence of personality dysfunction, have a strong tendency to form personal bonds with a single doctor or group of clinicians, often work in medical settings, and are usually polite and deferential to medical staff, making them much more difficult to identify.

• There is little hard evidence of aetiology because it is a rare condition and it is difficult to engage people with Munchausen syndrome in analytic therapy.
• There is suggestion that Munchausen syndrome and Munchausen syndrome by proxy may have much in common and they have been reported in the same individual.
• Personality disorder, depression or substance abuse may feature.
• Some theories suggest that the patient or carer may:
  • Have suffered abuse or neglect as a child. The hospital is seen as a safe environment or a way to escape from everyday life.
  • Be trying to understand or cope with earlier serious illness by reliving the experience.
  • Be identifying with someone close who had a serious illness.
  • Have a very low self-image. They hope to strengthen their own identity or get sympathy for themselves or the person that they care for. The patient is also given a role in a social network by being admitted to hospital.³
  • Have an inability to trust authority figures, such as doctors. They may feel the need to test them, to try to catch them out.
  • Are subjecting themselves to painful medical procedures as a form of self-punishment.³

The patient can present in a multitude of different ways. Common presentations include:

• Feigning surgical illness and hoping for a laparotomy (historically known as laparotimophilia migrans)
• Bleeding alarmingly (historically known as haemorrhagica histrionica)
• Presenting with curious fits (historically known as neurologica diabolica)
• Presenting with false heart attacks (historically known as cardiopathia fantastica).⁵
• Taking drugs to induce side effects e.g. beta blockers to produce bradycardia, desmopressin to induce hyponatraemia, insulin to induce hypoglycaemia
• Wounds may not heal properly due to contamination or interference
• Gastrointestinal disorders such as vomiting and diarrhoea
• Respiratory problems often with breathlessness and hyperventilation
• Self-mutilation causing extensive scarring or loss of body parts, such as fingers
• Malnutrition and anaemia

Other features include:

• A long history of unexplained illness, often with many changes of doctor, practice and hospital should alert the doctor.
• They may be rather vague about the details of their illness or they may show an unexpectedly profound knowledge of the disease as if having read a medical textbook.
• There may be inconsistencies in the history.
• They are happy to accept invasive and unpleasant investigations and even surgery.
• They may be hostile, antagonistic or very dramatic.
• They may exaggerate or lie about other aspects of their lives.
• On examination there may be multiple operative scarring.
• There may be a failure to demonstrate physical signs that would be expected. For example, abdominal examination may fail to show guarding and neurological examination may fail to reveal the expected signs.

• If the diagnosis is suspected then investigation should be kept to a minimum. However, basic procedures for responding to the patient's symptoms and signs generally need to be followed.
• Patients may interfere with samples, for example putting blood in urine. They may also interfere with charts.
• They may ingest or inject themselves with toxic substances to produce abnormality.
• Be alert to inconsistencies in the history and symptoms and signs that do not seem to fit.
• Also remember that even people with Munchausen's disease can suffer from genuine organic disease.

• Malingering disorders: illness is feigned to achieve an obvious gain such as compensation or avoidance of a particular event such as a court appearance.
• Somatisation disorders: people have symptoms that cannot be medically explained but their symptoms are not deliberately produced.
• Hypochondriasis: the patient presents with anxiety as the main symptom and either no physical signs or medically insignificant physical signs.³ When test results are negative, this gives the patient temporary relief.

• When the diagnosis is suspected it is important to strike a balance between exclusion of serious disease and feeding the pathological needs.
• There is very little in the literature on the treatment of the disorder.⁶
• When the diagnosis seems sure, the patient should be confronted in a sympathetic way. However, they may also become hostile and aggressive if confronted.
• Confrontation often leads to the patient immediately discharging themselves from hospital. They may change to a different GP surgery.
• However, one paper suggested that many patients show improvement after diagnosis and confrontation with a reduction in their factitious behaviour.⁴
• A psychiatric referral may be helpful.
• The danger is that the patient may be denied a true need when they have organic illness.
• When a patient with Munchausen syndrome is identified, hospitals may keep a record of this in a 'Munchausen File'. However, one study showed that keeping such files up-to-date may not always occur.⁷
• Local hospitals may even share information about that person. Sharing such information would be easier with shared electronic care records. However, there are confidentiality issues surrounding this shared information.

• This is very difficult to predict due to the difficulty in tracking patients with Munchausen syndrome and therefore the lack of follow-up studies.
• There are also no scientifically tested treatments.