Factitious Disorder Imposed on Self (Munchausen's Syndrome) Clinical Presentation

Updated: Dec 01, 2016
  • Author: Todd S Elwyn, MD; Chief Editor: Glen L Xiong, MD  more...
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Presentation

History

Individuals with factitious disorder imposed on self (including Munchausen syndrome) may feign illness by means any of the following:

  • A factitious history alone (eg, falsely claiming to have had a syncopal episode)
  • A factitious history plus the manipulation of assessment instruments (eg, claiming illness and manipulating a thermometer to show fever)
  • A factitious history plus the use of external agents that mimic disease (eg, adding exogenous blood to urine and claiming hematuria)
  • A factitious history plus the induction of an actual medical condition (eg, injecting bacteria to produce infection or ingesting central nervous system [CNS]-active medications to induce psychiatric symptoms); individuals with an actual medical condition may provide a fictitious history consistent with their condition (eg, pseudoseizures in a patient with epilepsy)

Detection of the disorder is typically slowed by the natural tendency among physicians to believe what patients say. Indeed, this tendency may even be enhanced in such cases because many patients with factitious disorder work in the healthcare field and are colleagues. Detection of factitious disorder among those who have an actual medical condition can be even more difficult.

Patients with this disorder may present in self-help groups; cases have been reported in which such patients use Internet-based patient support groups to fulfill their need to “be sick.” Physicians who assist these groups may run across cases of this type, or their colleagues may ask about such cases, having become frustrated when dealing with these behaviors.

Medical history

The self-reported medical history of patients with factitious disorder imposed on self may be extensive. In these cases, the lack of medical documentation to substantiate the self-reported medical history is notable, and patients might claim that the previous injuries or illnesses occurred in a foreign country or that the medical records 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, patients may lie and deny having an extensive medical history. Such denials are sometimes contradicted by surgical scars, by other evidence from the physical examination, or by laboratory, radiologic, or other test findings that suggest a significant medical or surgical history (eg, the presence of benign surgical clips).

Patients’ descriptions of their 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 emergency department (ED) by seemingly spewing blood or undergoing sustained seizures. At the same time, patients may be surprisingly vague or guarded about the details of their medical history, especially regarding details of previous treatments.

The case literature describes cases in which 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 range of medical problems. Although a history involving diverse symptoms and organ systems is sometimes regarded as an important indicator of factitious disorder, this feature is not a sensitive indicator.

Psychiatric history

Patients with factitious disorder imposed on self 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 subjected to 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 discharges are common, as are threats of retribution through lawsuits or physical attacks.

Few patients with this disorder 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 state that when they were young, a spontaneous illness (eg, appendicitis) introduced them to the care and concern elicited by the sick role.

A pattern of claimed childhood abuse and neglect is also observed among the wider population of patients who present with chronic unexplained medical complaints. Abuse and neglect are linked to the development of personality disorders, particularly the more florid and dramatic ones, such as borderline personality disorder. Such disorders are frequently comorbid with factitious disorder. Whether a unique link exists between abuse and factitious illness behavior that is independent of their mutual relation to these personality disorders is unknown.

It should be noted that that patients who truly have Munchausen syndrome engage in chronic lying. Their reports of childhood abuse may 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 characteristic of this syndrome, the apparent strong connection between it and antisocial personality disorder is not surprising.

Unlike patients with conversion disorder (eg, conversion blindness after witnessing a war atrocity), whose illness behavior is neither planned nor willful, patients with Munchausen syndrome consciously fabricate, exaggerate, or induce signs and symptoms. Like patients with conversion disorder, however, patients with Munchausen syndrome may be quite unaware of the reasons and motivations behind their pursuit of the sick role.

Factors suggestive of factitious disorder

In summary, the presence of the following factors may raise the possibility that the illness is factitious:

  • Dramatic or atypical presentation
  • Inconsistencies between history and objective findings
  • Details that are vague and inconsistent, though possibly plausible on the surface
  • Long medical record with multiple admissions at various hospitals in different cities
  • Knowledge of textbook descriptions of illness; a presentation that hews too closely to the textbook example
  • Admission circumstances that do not conform to an identifiable medical or mental disorder
  • An unusual grasp of medical terminology
  • Employment or education in a medically related field
  • Pseudologia fantastica (ie, uncontrollable lying characterized by the fantastic description of false events) [10]
  • Presentation in the ED during times when old medical records are difficult to access or when experienced staff are less likely to be present (eg, holidays and late Friday afternoons)

Other clues that may arise during the course of treatment include the following:

  • A patient who has few visitors despite giving a history of holding an important or prestigious job or a history that casts the patient in a heroic role
  • Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
  • Acceptance, with equanimity, of the discomfort and risk of surgery
  • Substance abuse, especially of prescribed analgesics and sedatives
  • Symptoms or behaviors that are only present when the patient is aware of being observed
  • Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
  • Evidence of pathologic lying in areas other than the presenting symptoms
  • Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
  • Giving approximate answers to questions (eg, a horse has 3 legs, or 7 x 6 = 41); this usually occurs in factitious disorder with predominantly psychological signs and symptoms
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Physical Examination

The physical examination of the patient with factitious disorder frequently suggests an extensive history of illnesses and injuries. Suspicion is raised when the patient has multiple surgical scars (reflecting numerous exploratory surgical procedures) or a gridiron abdomen, indicating the chronic form of factitious disorder (Munchausen syndrome), or shows evidence of self-induced physical signs (see the image below).

Classic multiple scarred abdomen of woman with Mun Classic multiple scarred abdomen of woman with Munchausen syndrome. Photograph on left shows abdomen as it appeared on presentation, after patient had undergone 42 unwarranted operations. Photograph on right shows abdomen after additional surgery revealed authentic colon cancer. Courtesy of Marc D Feldman, MD, University of Alabama School of Medicine.

As in conversion disorder, the neurologic examination may reveal inconsistent findings. For example, patients with paralysis may have normal muscle tone in the affected limb, or anesthesia may not follow the anatomic distribution of peripheral nerves.

Other physical inconsistencies include an absence of signs of dehydration in patients complaining of persistent diarrhea and vomiting. Cardiac presentations of Munchausen syndrome are common enough to have allowed cardiologists to identify cardiac Munchausen syndrome—sometimes referred to as cardiopathia fantastica—as a distinct subset of the Munchausen spectrum. [11, 12]

Clinicians should look to case reports in their medical specialties to acquaint themselves with the types of factitious medical complaints that have been observed by their colleagues and the means by which these deceptions were carried out and eventually uncovered.

Patients who have factitious disorder with psychological signs and symptoms, as well as those who are simulating neuropsychological problems, often present with symptom patterns 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 may be presented in an atypical manner. For example, a patient feigning dementia may perform poorly on both recent and remote memory tests, or a patient feigning a closed head injury may show more errors on a visual discrimination test than would be expected on the basis of chance alone.

Psychological and neurocognitive symptoms may appear worse when the patient is undergoing active examination than when he or she is casually interacting with staff members or other patients. A patient with feigned dementia who could not remember any of 3 items after 5 minutes may later complain that the cafeteria served the same entrée 2 nights in a row.

Mental status examination

Patients with factitious disorder may vary in their presentation, and no findings have been shown to be pathognomonic. The following findings are possible:

  • Appearance may include the physical findings described above
  • Attitude may range from cooperative with assessment and treatment to evasive and vague regarding details
  • Mood and affect may be brighter than would be expected on the basis of the patient’s medical condition
  • Perceptual abnormalities (eg, hallucinations and disturbances of thought process or thought content), suicidality, or homicidality may be present with factitious disorder with predominantly psychological signs and symptoms; suicidal or homicidal ideation should always be taken seriously, regardless of whether it is suspected of being factitious
  • Patients who have factitious disorder with predominantly physical signs and symptoms usually do not confess to thoughts of harming themselves or others, even when they have actually harmed themselves by deliberately inducing physical illness
  • Orientation and recall may be aberrant if the patient is feigning mental illness
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Complications

Manifold complications may occur in factitious disorder imposed on self, potentially ranging from trivial to lethal. Such complications may arise either from the induction of factitious illness or from the workup or treatment for the condition. High health care costs typically result.

From one point of view, factitious disorder is itself a complication. The combination of patients’ self-harming behavior, physicians’ 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.

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