FACTITIOUS DISORDER/MUNCHHAUSEN SYNDROME

FACTITIOUS DISORDER/MUNCHHAUSEN SYNDROME - Irere C. Coletsos, MD; Harold J. Bursztasn, MD
BASICS
DESCRIPTION
• Factitious disorders are challenging to diagnose and, once suspected, it is difficult to deliver compassionate care.
• These patients are aware they are not ill, but will try to mimic illnesses because of an unresolved need to be taken care of (1).
• Patients may make themselves ill to produce symptoms. Thus, the symptoms may be real.
• If questioned, patients will deny the illness was self-inflicted, although they are aware that this is the case (2).
• Their goal is to maintain a sick role (vs. malingering, in which the goal may be more concrete, such as avoiding work). They are aware that they are not physically ill and/or they have caused their own illnesses (vs. somatoform disorders, including conversion disorder, in which patients feel the symptoms they are reporting and believe they are physically ill. They are not consciously responsible for the illnesses' etiology).
• Types of factitious disorders include
- Factitious disorder with predominantly physical signs and symptoms
 Often occurs after a major stress
 Typically simulates 1 physical disease (3). Munchhausen syndrome (an extreme form) is named after an 18th-century German nobleman who served in the Russian military and told tall tales of his adventures upon return. These patients spend a majority of their lives seeking medical care from different providers and hospitals (changing when treatment is refused) and are willing to undergo painful procedures and surgeries to maintain their sick role.
- Factitious disorder with predominantly psychological signs and symptoms
 Patients with this disorder mimic the behavior of people with mental illnesses, claiming they are hearing voices or having visual hallucinations; give wrong answers to simple questions to mimic psychosis; act confused or bizarre. This is also known as Ganser syndrome, for the 20th-century German psychiatrist Sigbert Joseph Maria Ganser, who described this behavior in some prisoners. This is a rare disorder, and care must be taken to differentiate it from physical causes of psychotic-like symptoms, such as stroke, head injury, or chronic alcoholism.
- Factitious disorder with combined psychological and physical signs and symptoms
 Patients claim to have both symptomsneither the physical nor the psychological predominate.
EPIDEMIOLOGY
Incidence
Unknown
Prevalence
• Factitious disorder with predominantly physical signs and symptoms: ~1-5% of people presenting with medical illness, according to some studies, but hard to estimate due to the secretive nature of the disorder.
• Factitious disorder with predominantly psychological signs and symptoms or the combined disorder: Thought to be much more rare.
RISK FACTORS
• Abuse/deprivation in childhood.
• Childhood traumas, including hospitalizations or the experience of growing up with ill or emotionally unavailable caretakers.
Genetics
None known at this time.
ETIOLOGY
The theoretical psychological basis of factitious disorder is thought to be an unresolved sense of deprivation from childhood that, in a time of stress in adulthood, leads a patient to falsely claim (or even self-inflict) medical illness in order to get medical care. In Munchhausen, this behavior is chronic.
ASSOCIATED CONDITIONS
• History of many medical procedures
• Substance abuse
• Suicide attempts
• Psychiatric comorbidities, including adjustment disorder, borderline personality disorder, depression, somatoform disorder


DIAGNOSIS
SIGNS AND SYMPTOMS
A patient will relate a history of disease symptoms, often with "classic" textbook details, but has no signs of disease on examination. Or, if signs are noted, there may be evidence they were self-inflicted or are not medically caused (2)[C].
History
Careful elicitation of the patient's developmental history may reveal the patient's earlier abuse or deprivations (1)[B], (4)[C].
Physical Exam
• Normal, or evidence of self-inflicted wounds, such as scars
• Abscesses
• Rashes
• Old wound with fresh bleeding (4)[C]
• Tenderness on palpation (and no tenderness noted by patient when the same areas are auscultated with pressure applied)
TESTS
High fevers, abnormal urine studies not reproducible if the patient is directly observed. (Patients may surreptitiously heat their thermometers or contaminate urine specimens.)
Lab
• Skin infection (abscesses, IV sites, Foley sites): Culture shows infection via E. coli, presumably a patient's own fecal material (4)[B].
• Lab results fail to show the expected markers of the disease suggested by the patient's reported symptoms.
• Lab results may reveal the ingestion of agents that could mimic disease states (insulin, to produce hypoglycemia; thyroxine or cytomel to produce hyperthyroidism; laxative and diuretic abuse, to produce hypokalemia; self-injection of epinephrine or isoproterenol hydrochloride, to mimic Cushing disease; warfarin, to produce bleeding; quinidine, to produce purpura; alkylating agents, to produce pancytopenia) (5)[B].
Diagnostic Procedures/Surgery
Invasive diagnostic procedures and surgeries are often welcomed by the patient. Clinicians should avoid these, if possible, in patients with factitious disorders. However, reports that patients have often undergone several such procedures before the psychological nature of their illness was discovered.
DIFFERENTIAL DIAGNOSIS
• For factitious disorder with predominantly physical signs and symptoms, also consider
- Somatization disorders: A chronic psychiatric disease in which a patient's unconscious need to be cared for leads him to experience recurrent physical symptoms, such as GI, sexual, pain, and neurologic symptoms (see "Conversion Disorder," below), and these symptoms cannot be explained fully by any evident physical disorder.
- Conversion disorder: A psychological conflict is unconsciously transformed into physical symptoms that resemble a neurologic disorder.
- Malingering: Reporting symptoms that do not exist (or are the result of self-inflicted injury) as part of a conscious decision to attain a financial goal or to avoid a responsibility.
- Cultural differences in expressing pain and experiencing illness.
- Occult medical illness (early stages of disease when blood tests may still show negative results)
- Unusual presentations of disease
- False negative lab results
• For factitious disorder with predominantly psychological signs and symptoms, in addition to psychiatric illnesses that can have true psychotic symptoms, also consider medical etiologies, such as
- Drugs, ingested as prescribed or abused, such as benzodiazepines, cocaine, PCP, steroids
- Poisoning (alcohol, lead, manganese, mercury)
- Stroke
- Traumatic brain injury
- Cultural differences, especially in mourning ("seeing" the deceased as if he or she were alive) or in times of extreme stress (having the "devil" telling the patient to make certain choice)
• For the combined disorder, also consider
- Infection (especially sepsis)
- Postsurgical anesthesia/ metabolic/ psychological causes.
- Pneumonia (especially in older patients)
- Urinary tract infection (especially in older patients)
- Thiamine deficiency/Wernicke encephalopathy
ALERT
Munchhausen by proxy: This is a form of child abuse. A parent will injure his child, then bring the child to doctors with a false history, stating the child is a patient needing treatment for a disease. The parent in this case may appear very involved and comfortable in the hospital setting, and not saddened or surprised by the child's illnesses. A child in this situation may end up very ill, have frequent hospitalizations (and may get more ill after the parent visits), and may die from these injuries. Steps must be taken to protect these children and their siblings.
TREATMENT
STABILIZATION
• Form an alliance with the patient, identifying their suffering.
• Seek, attempt to elicit, a detailed history of childhood events. Asking about the health history of parents and siblings may help reveal early traumas to the patient (6)[B].
GENERAL MEASURES
• Clinicians should seek access to patient's medical and mental health records (a mental health history is a comorbidity often initially denied by these patients) (6)[B].
• Patients with factitious disorder may accept a frank but empathetic assessment that their actions themselves constitute the disorder.
• Patients with Munchhausen syndrome generally respond angrily over clinician refusal to authorize the medical treatment they seek. They will often seek treatment from another provider at another hospital. They may accept referrals. Management may be limited to clinician recognition the disorder and making sure these patients are not offered unnecessary drugs, risky procedures, or surgeries (3)[B].
• Clinicians must remain aware of their own responses and feelings toward these patients, to avoid countertransference, and the unconscious failure to offer appropriate treatment. A clinician should consider consulting with a psychiatrist or psychologist (1)[B].
• Clinicians must acknowledge the uncertainty involved in treating suspected factitious disorder or Munchhausen patients, to help prevent the undertreatment of true medical issues (7)[B].
SPECIAL THERAPY
• Refer the patient to a specialist (psychiatrist, psychologist, social worker) to treat the underlying mood or anxiety disorder.
• "Contract conferences" with a psychiatrist, in which the patient is guided toward talking about painful feelings, rather than medical illness (8)[C]
• Cognitive behavioral therapy to deal with the obsessive nature of these syndromes
MEDICATION (DRUGS)
Consider treating the underlying psychiatric disorder with appropriate drugs. Consult a psychiatrist for guidance.
SURGERY
Try to prevent unnecessary surgeries.
FOLLOW-UP
DISPOSITION
Admission Criteria
Factitious disorder or Munchhausen patients who appear resistant to treatment, and whose behavior threatens their own lives, may be considered for an emergency inpatient psychiatric commitment and evaluation (9)[C].
Issues for Referral
• Psychiatrist/psychologist/therapist: For underlying psychiatric disorders and treatment, or guidance on treatment
• Forensic psychiatrist: For the medico-legal issues surrounding treating such patients
• Neuropsychologist/neuropsychiatrist: For unexplained pain symptoms
PROGNOSIS
Fair to poor (especially if etiology underlying the disorder cannot be addressed)
COMPLICATIONS
Patient illness or death from self-harm and unnecessary medical interventions
REFERENCES
1. Ferenczi, S. Confusion of tongues between the adult and the child. Int J Psychoanal 1949;30: 225-230.
2. Turner MA. Factitious disorders: Reformulating the DSM-IV criteria. Psychosomatics 2006;47:23-32.
3. Beers MH, Berkow R, eds. Munchhausen syndrome. The Merck Manual of Diagnosis and Therapy, 17th ed. Merck and Company Inc. www.merck.com/mrkshared/CVMHighLight?file=/ mrkshared/mmanual/section15/chapter185/185d.jsp
4. Peebles R, Sabella C, Franco K, Goldfarb J. Factitious disorder and malingering in adolescent girls: Case series and literature review. Clin Pediatr 2005;44(3):237-243.
5. Wallach J. Laboratory diagnosis of factitious disorders. Arch Intern Med 1994;154(15):1690-1696.
6. Binder LM, Campbell KA. Medically unexplained symptoms and neuropsychological assessment. J Clin Experiment Neuropsychol 2004;26(3):369-392.
7. Bursztajn H, Feinbloom RI, Hamm RM, Brodsky A. Medical choices, medical chances: How patients, families and physicians can cope with uncertainty. New York: Delacorte/Lawrence, 1981.
8. Ritson B, Forrest A. The simulation of psychosis: A contemporary presentation. Br J Med Psychol 1970;43:31-37.
9. Johnson BR, Harrison JA. Suspected Munchhausen syndrome and civil commitment. J Am Acad Psychiatry Law 2000;28:74-76.