Factitious disorder imposed on self

Factitious disorder imposed on self, also known as Munchausen syndrome, is a factitious disorder wherein those affected feign disease, illness, or psychological trauma to draw attention, sympathy, or reassurance to themselves. Munchausen syndrome fits within the subclass of factitious disorder with predominantly physical signs and symptoms, but patients also have a history of recurrent hospitalization, travelling, and dramatic, extremely improbable tales of their past experiences.[2] The condition derives its name from fictional character Baron Munchausen.

For cases of feigned illness not driven by a psychiatric disorder, see Malingering.

Factitious disorder imposed on self
Other namesMunchausen syndrome[1]
SpecialtyPsychology, Psychiatry

Factitious disorder imposed on self is related to factitious disorder imposed on another, which refers to the abuse of another person, typically a child, in order to seek attention or sympathy for the abuser. This drive to create symptoms for the victim can result in unnecessary and costly diagnostic or corrective procedures.[3]

Signs and symptoms

In factitious disorder imposed on self, the affected person exaggerates or creates symptoms of illnesses in themselves to gain examination, treatment, attention, sympathy, and/or comfort from medical personnel. It often involves elements of victim playing and attention seeking. In some extreme cases, people suffering from Munchausen syndrome are highly knowledgeable about the practice of medicine and are able to produce symptoms that result in lengthy and costly medical analysis, prolonged hospital stays, and unnecessary operations. The role of "patient" is a familiar and comforting one, and it fills a psychological need in people with this syndrome. This disorder is distinct from hypochondriasis and other somatoform disorders in that those with the latter do not intentionally produce their somatic symptoms.[4] Factitious disorder is distinct from malingering in that people with factitious disorder imposed on self don't fabricate symptoms for material gain such as financial compensation, absence from work, or access to drugs.

The exact cause of factitious disorder is not known, but researchers believe both biological and psychological factors play a role in the development of this disorder. Risk factors for developing factitious disorder may include childhood traumas, growing up with parents/caretakers who were emotionally unavailable due to illness or emotional problems, a serious illness as a child, failed aspirations to work in the medical field, personality disorders, and low self-esteem. While there are no reliable statistics regarding the number of people in the United States who suffer from factitious disorder, FD is believed to be most common in mothers having the above risk factors. Those with a history of working in healthcare are also at greater risk of developing it.[5]

Arrhythmogenic Munchausen syndrome describes individuals who simulate or stimulate cardiac arrhythmias to gain medical attention.[6]

A similar behavior called factitious disorder imposed on another has been documented in the parent or guardian of a child. The adult ensures that his or her child will experience some medical affliction, therefore compelling the child to suffer through treatments and spend a significant portion during youth in hospitals. Furthermore, a disease may actually be initiated in the child by the parent or guardian. This condition is considered distinct from Munchausen syndrome. There is growing consensus in the pediatric community that this disorder should be renamed "medical abuse" to highlight the harm caused by the deception and to make it less likely that a perpetrator can use a psychiatric defense when harm is done.[7]

Diagnosis

Due to the behaviors involved, diagnosing factitious disorder is very difficult. If the healthcare provider finds no physical reason for the symptoms, he or she may refer the person to a psychiatrist or psychologist (mental health professionals who are specially trained to diagnose and treat mental illnesses). Psychiatrists and psychologists use thorough history, physical examinations, laboratory tests, imagery, and psychological testing to evaluate a person for physical and mental conditions. Once the person's history has been thoroughly evaluated, diagnosing factitious disorder imposed on self requires a clinical assessment.[8] Clinicians should be aware that those presenting with symptoms (or persons reporting for that person) may exaggerate, and caution should be taken to ensure there is evidence for a diagnosis.[8] Lab tests may be required, including complete blood count (CBC), urine toxicology, drug levels from blood, cultures, coagulation tests, assays for thyroid function, or DNA typing. In some cases CT scan, magnetic resonance imaging, psychological testing, electroencephalography, or electrocardiography may also be employed.[8] A summary of more common and reported cases of factitious disorder (Munchausen syndrome), and the laboratory tests used to differentiate these from physical disease is provided below:[9]

Disease Mimicked Method of Imitation Laboratory/Diagnostic Confirmation
Bartter syndrome
  • Surreptitious intake of diuretics
  • Self-induced vomiting
  • High performance liquid chromatography (HPLC) analysis of urine
  • Urine chloride analysis
Catecholamine-secreting tumorInjection of epinephrine into urine or blood streamAdjunct analysis of increased Chromogranin A
Cushing’s syndromeSurreptitious steroid administrationHPLC to differentiate endogenous and exogenous steroids
HyperthyroidSurreptitious thyroxine administrationBlood tests for free T4 and thyroid stimulating hormone
HypoglycaemiaExogenous insulin or insulin secretagoguesSimultaneous blood analysis of insulin, C-peptide, proinsulin, and insulin secretagogues
Sodium imbalanceIntake large quantities of saltMeasure fractional sodium excretion to differentiate intentional salt overload from dehydration.
Chronic diarrhea
  • Watered down stool samples
  • Laxative abuse
Induced vomitingAlthough many alternatives possible, ipecacuanha ingestionHPLC measurement of serum or urine for elevated creatine kinase, transaminases and ipecacuanha
ProteinuriaEgg protein injection into bladder, albumin (protein) addition to urine samplesUrine protein electrophoresis analysis
HaematuriaBlood introduction to urine samples, deliberate trauma to the urethraImaging to rule out insertion of a foreign body, monitor sample collection, analysis of red blood cell shape in samples

There are several criteria that together may point to factitious disorder, including frequent hospitalizations, knowledge of several illnesses, frequently requesting medication such as pain killers, openness to extensive surgery, few or no visitors during hospitalizations, and exaggerated or fabricated stories about several medical problems. Factitious disorder should not be confused with hypochondria, as people with factitious disorder syndrome do not really believe they are sick; they only want to be sick, and thus fabricate the symptoms of an illness. It is also not the same as pretending to be sick for personal benefit such as being excused from work or school.[10]

People may fake their symptoms in multiple ways. Other than making up past medical histories and faking illnesses, people might inflict harm on themselves by consuming laxatives or other substances, self-inflicting injury to induce bleeding, and altering laboratory samples".[11] Many of these conditions do not have clearly observable or diagnostic symptoms and sometimes the syndrome will go undetected because patients will fabricate identities when visiting the hospital several times. Factitious disorder has several complications, as these people will go to great lengths to fake their illness. Severe health problems, serious injuries, loss of limbs or organs, and even death are possible complications.

Treatment

Because there is uncertainty in treating suspected factitious disorder imposed on self, some advocate that health care providers first explicitly rule out the possibility that the person has another early-stage disease.[12] Then they may take a careful history and seek medical records to look for early deprivation, childhood abuse, or mental illness.[8] If a person is at risk to themself, psychiatric hospitalization may be initiated.[13]

Healthcare providers may consider working with mental health specialists to help treat the underlying mood or disorder as well as to avoid countertransference.[14] Therapeutic and medical treatment may center on the underlying psychiatric disorder: a mood disorder, an anxiety disorder, or borderline personality disorder. The patient's prognosis depends upon the category under which the underlying disorder falls; depression and anxiety, for example, generally respond well to medication and/or cognitive behavioral therapy, whereas borderline personality disorder, like all personality disorders, is presumed to be pervasive and more stable over time,[15] and thus offers a worse prognosis.

People affected may have multiple scars on their abdomen due to repeated "emergency" operations.[16]

History

The name "Munchausen syndrome" derives from Baron Munchausen, a literary character loosely based on the German nobleman Hieronymus Karl Friedrich, Freiherr von Münchhausen (1720–1797). The historical baron became a well-known storyteller in the late 18th century for entertaining dinner guests with tales about his adventures during the Russo-Turkish War. In 1785 German-born writer and con artist Rudolf Erich Raspe anonymously published a book in which a heavily fictionalized version of "Baron Munchausen" tells many fantastic and impossible stories about himself. Raspe's Munchausen became a sensation, establishing a literary exemplar of a bombastic liar or exaggerator.[17][18]

In 1951, Richard Asher was the first to describe a pattern of self-harm, wherein individuals fabricated histories, signs, and symptoms of illness. Remembering Baron Munchausen, Asher named this condition Munchausen's Syndrome in his article in The Lancet in February 1951,[19] quoted in his obituary in the British Medical Journal:

"Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly the syndrome is respectfully dedicated to the Baron, and named after him."

— British Medical Journal, R.A.J. Asher, M.D., F.R.C.P.[20]

Asher's nomenclature sparked some controversy, with medical authorities debating the appropriateness of the name for about fifty years. While Asher was praised for bringing cases of factitious disorder to light, participants in the debate objected variously that a literary allusion was inappropriate given the seriousness of the disease; that its use of the anglicized spelling "Munchausen" showed poor form; that the name linked the disease with the real-life Münchhausen, who did not have it; and that the name's connection to works of humor and fantasy, and to the essentially ridiculous character of the fictional Baron Munchausen, was disrespectful to patients suffering from the disorder.[21]

Originally, this term was used for all factitious disorders. Now, however, in the DSM-5, "Munchausen syndrome" and "Munchausen by proxy" have been replaced with "factitious disorder" and "factitious disorder by proxy" respectively.

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See also

References
  1. Ray, William J. (2016). Abnormal Psychology. SAGE Publications. p. PT794. ISBN 9781506333373.
  2. Kay, Jerald; Tasman, Allan (2006). Essentials of psychiatry. Hoboken, New Jersey: John Wiley & Sons, Ltd. p. 680. ISBN 978-0-470-01854-5.
  3. Huffman, Jeffrey C.; Stern, Theodore A. (2003). "The diagnosis and treatment of Munchausen's syndrome". General Hospital Psychiatry. Amsterdam, Netherlands: Elsevier. 25 (5): 358–63. doi:10.1016/S0163-8343(03)00061-6. PMID 12972228.
  4. Sadock, Benjamin J.; Sadock, Virginia A., eds. (15 January 2000). Kaplan & Sadock's Comprehensive Textbook of Psychiatry (2 Volume Set) (7th ed.). Philadelphia, Pennsylvania: Lippincott Williams & Wilkins. p. 3172. ISBN 978-0683301281.
  5. Repper, John (February 1995). "Münchausen syndrome by proxy in health care workers". Journal of Advanced Nursing. Hoboken, New Jersey: John Wiley and Sons. 21 (2): 299–304. doi:10.1111/j.1365-2648.1995.tb02526.x. ISSN 0309-2402. PMID 7714287.
  6. Vaglio, Jeffrey C.; Schoenhard, JA; Saavedra, PJ; Williams, SR; Raj, SR (2010). "Arrhythmogenic Munchausen syndrome culminating in caffeine-induced ventricular tachycardia". Journal of Electrocardiology. London, England: Churchill Livingstone. 44 (2): 229–31. doi:10.1016/j.jelectrocard.2010.08.006. PMID 20888004.
  7. Stirling J (2007). "Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting". Pediatrics. 119 (5): 1026–30. doi:10.1542/peds.2007-0563. PMID 17473106.
  8. Brannon, Guy E. (11 November 2015). "Factitious Disorder Imposed on Another: Practice Essentials, Background, Pathophysiology". Medscape.
  9. Kinns, H; Housley, D; Freedman, DB (May 2013). "Munchausen syndrome and factitious disorder: the role of the laboratory in its detection and diagnosis". Annals of Clinical Biochemistry. 50 (Pt 3): 194–203. doi:10.1177/0004563212473280. PMID 23592802.
  10. Worley, Courtney B.; Feldman, Marc D.; Hamilton, James C. (30 October 2009). "The Case of Factitious Disorder Versus Malingering". Psychiatric Times. Cranbury, New Jersey: MJH Associates.
  11. Kinns, H; Housley, D; Freedman, DB (May 2013). "Munchausen syndrome and factitious disorder: the role of the laboratory in its detection and diagnosis". Annals of Clinical Biochemistry. 50 (Pt 3): 194–203. doi:10.1177/0004563212473280. PMID 23592802.
  12. Bursztajn, H; Feinbloom, RI; Hamm, RM; Brodsky, A (1981). Medical Choices, medical chances: How patients, families and physicians can cope with uncertainty. New York: Delacourte/Lawrence.
  13. Johnson, BR; Harrison, JA (2000). "Suspected Munchausen's syndrome and civil commitment". The Journal of the American Academy of Psychiatry and the Law. 28 (1): 74–6. PMID 10774844.
  14. Elder W, Coletsos IC, Bursztajn HJ. Factitious Disorder/Munchhausen Syndrome. The 5-Minute Clinical Consult. 18th Edition. 2010. Editor. Domino, F.J. Wolters Kluwer/Lippincott. Philadelphia.
  15. Davison, Gerald C.; Blankstein, Kirk R.; Flett, Gordon L.; Neale, John M. (2008). Abnormal Psychology (3rd Canadian ed.). Mississauga: John Wiley & Sons Canada. p. 412. ISBN 978-0-470-84072-6.
  16. Giannini, A. James; Black, Henry Richard; Goettsche, Roger L. (1978). Psychiatric, Psychogenic and Somatopsychic Disorders Handbook. New Hyde Park, NY: Medical Examination Publishing. pp. 194–5. ISBN 978-0-87488-596-5.
  17. McCoy, Monica L.; Keen, Stefanie M. (2013). Child Abuse and Neglect: Second Edition. Psychology Press. p. 210. ISBN 978-1136322877.
  18. Olry, Regis (June 2002). "Baron Munchhausen and the Syndrome Which Bears His Name: History of an Endearing Personage and of a Strange Mental Disorder" (PDF). Vesalius. 8 (1): 53–7. PMID 12422889.
  19. Asher, Richard (1951). "Munchausen's Syndrome". The Lancet. 257 (6650): 339–41. doi:10.1016/S0140-6736(51)92313-6. PMID 14805062.
  20. Atthili, Lombe (1873). "Reports of Societies". BMJ. 2 (665): 388. doi:10.1136/bmj.2.665.388. JSTOR 25235514.
  21. Fisher, Jill A. (2006). "Investigating the Barons: Narrative and nomenclature in Munchausen syndrome". Perspectives in Biology and Medicine. 49 (2): 250–62. doi:10.1353/pbm.2006.0024. PMID 16702708.

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