Munchausen Syndrome Clinical Presentation

• Medical history

  • The self-reported medical history of patients with Munchausen syndrome might be extensive. In these cases, the lack of medical documentation to substantiate the self-reported medical history is notable, and the patient might claim that the previous injuries or illnesses occurred in a foreign country or that the records of the treating physician 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, the patient may lie and deny an extensive medical history. Such reports are sometimes contradicted by surgical scars, other evidence from the physical examination, or the laboratory, radiologic, or other test findings that suggest a significant medical/surgical history (eg, the presence of benign surgical clips). The patient's description of his or her 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 ED by appearing to be spewing blood or having sustained seizures. At the same time, the patients might be surprisingly vague or guarded about the details of their medical history, especially regarding details of prior treatments.
  • The case literature describes cases in which the 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 diversity of medical problems. Although a history involving diverse symptoms and organ systems has been regarded by a few authors as an important indicator of factitious disorder and Munchausen syndrome, this feature is not a sensitive indicator.
• Psychiatric history

  • Patients with Munchausen syndrome 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 with 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 (AMA) discharges are common, as are threats of retribution through lawsuits or physical attacks.
  • Few patients 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 note that, at a young age, a spontaneous illness (eg, appendicitis) introduced them to the care and concern elicited by the sick role.
  • Unlike the latter, a pattern of claims of childhood abuse and neglect is also observed among the wider population of patients who present with chronic unexplained medical complaints. Abuse and neglect have been linked to the development of personality disorders, particularly the more florid and dramatic ones (cluster B), especially borderline personality disorder. These personality disorders are frequently comorbid with Munchausen syndrome. Whether a unique link exists between abuse and factitious illness behavior that is independent of their mutual relation to these personality disorders is unknown.
  • Note that patients who truly have Munchausen syndrome engage in chronic lying. Their reports of childhood abuse might 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 that are a central component of Munchausen syndrome, it is not surprising that a particularly strong connection apparently exists between Munchausen syndrome and antisocial personality disorder.
  • 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. But like patients with conversion disorder, patients with Munchausen syndrome may be quite unaware of the reasons and motivations behind their pursuit of the sick role.

The physical examination of the patient with Munchausen syndrome frequently suggests an extensive history of illnesses and injuries. Older patients might show evidence of multiple surgical scars on the abdomen, indicating numerous exploratory surgeries. As in conversion disorder, the neurological examination may reveal inconsistent findings.

For example, patients with paralysis may have normal muscle tone in the affected limb, or anesthesias might not follow the anatomical distribution of peripheral nerves. Other physical inconsistencies include an absence of signs of dehydration in patients complaining of persistent diarrhea and vomiting. Clinicians should look to case reports in their medical specialties to acquaint themselves with the types of factitious complaints that have been observed by their colleagues and the means by which these deceptions were carried out and eventually uncovered.

• Patients with factitious disorder with psychological signs and symptoms, or those simulating neuropsychological problems, often present with patterns of symptoms 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 might be presented in an atypical manner. For example, a patient feigning dementia might perform poorly on both recent and remote memory tests, or a patient feigning a closed head injury might show more errors than would be expected by chance on a visual discrimination test.
• Psychological and neurocognitive symptoms might appear worse when the patient is undergoing active examination than when the patient is casually interacting with staff members or other patients. The patient with dementia who could not remember any of 3 items after 5 minutes might later complain that the cafeteria served the same entrée 2 nights in a row.

A representative Mental Status Examination follows for a patient feigning signs and symptoms of reflex sympathetic dystrophy of the left leg.

The patient ambulated slowly and gingerly using a Canadian crutch to support his left side. He demonstrated severe pain behaviors, including grimacing and cursing with each step, and he sat in the chair with a considerable sigh. Superficial wrist scars were evident. The patient demonstrated his reflex sympathetic dystrophy to the examiner by lifting his left pant leg and exposing the leg from his knee downward. When the examiner moved to lift the pant leg further, the patient complained of extreme hypersensitivity, though no pain was evidenced moments earlier when he had lifted his own pant leg. With more of the leg exposed, a circumferential indentation suggestive of a ligature was evident above the knee.

His speech was generally of appropriate rate and volume, but latency was increased in response to challenges as he appeared to be carefully formulating his answers. Mood was aggrieved and sorrowful as he recounted the fall that ostensibly resulted in the reflex sympathetic dystrophy. Affect was often irritated, especially when he realized that the interview was going to be relatively lengthy. Although processes were negativistic and absolutistic, the patient insisted he would never be more functional.

Thought content centered about the fall and doubts about eventual recovery. The patient denied suicidal ideation and refused to answer a question about the wrist scars. Homicidal ideation or first-rank symptoms of psychosis were not evident. The Mini Mental Status Examination score was 29/30 (forgot 1 of 3 items after 5 minutes). Cognitive function was otherwise grossly intact based on his responses. Insight and judgment were poor, as the patient refused to acknowledge to the examiner his own role in the expression of his pain and reddened, edematous left leg.

The causes of Munchausen syndrome are unknown. These patients are so elusive that it is nearly impossible to conduct systematic empirical research on them. Psychoanalytic hypotheses have been put forth to explain Munchausen syndrome, but the volume of this work is quite small compared to the pertinent literature on the psychodynamics of the somatoform disorders.

False illness experiences in the somatoform disorders are regarded as unconsciously produced and are therefore amenable to traditional psychoanalytic explanations involving the notion of defense against unacceptable wishes or unspeakable fears. Because the false illness behavior in factitious disorder is conscious and intentional, explanations involving unconscious processes are less compelling when applied to factitious disorder. Nevertheless, some psychoanalytic writers have argued that whereas the illness behavior of patients with factitious disorder is conscious, the reasons for the behavior are not.

Several authors have regarded factitious illness behavior as a primitive defense mechanism against sexual and aggressive impulses. Others have hypothesized that patients with factitious disorder subject themselves to painful medical procedures as a form of self-punishment. It has also been hypothesized that the cruel and embarrassing deception of physicians is an expression of oedipally based hostility toward authority figures.

More contemporary theorizing has focused on gratuitous sick-role behavior as a reflection of problems with object relations. These authors have focused on the high degree of comorbidity with the cluster B personality disorders and have suggested that the sick-role behavior of patients with factitious disorder might serve as a means of establishing or stabilizing the patient's sense of self and their relations to others. Enactment of the sick role confers unconditional acceptance and concern, and admission to a hospital gives patients a clearly defined role in a social network. This automatic sense of importance and belonging might be difficult for patients with Munchausen syndrome to secure in more routine social contexts.

Case studies support the role of social learning mechanisms in factitious illness behavior. Many patients with factitious disorder have either personally experienced a severe illness in childhood or as a child had a family member who experienced a severe illness. Through these experiences, the child is introduced to the various benefits and dispensations attached to the sick role, and these experiences may predispose persons with other psychological vulnerabilities to engage in factitious illness behavior.