eMedicine Specialties > Psychiatry > Psychosomatic

Munchausen Syndrome: Follow-up

Author: James C Hamilton, PhD, Associate Professor, Coordinator of Clinical Health Psychology, Department of Psychology, Clinical Affiliate Associate Professor of Internal Medicine, University of Alabama
Coauthor(s): Marc D Feldman, MD, Clinical Professor of Psychiatry, Department of Psychiatry and Behavioral Medicine, and Adjunct Professor, Department of Psychology, University of Alabama, Tuscaloosa, AL
Contributor Information and Disclosures

Updated: Sep 16, 2009

Follow-up

Further Inpatient Care

• Inpatient medical care
  • By definition, patients with Munchausen syndrome present repeatedly for inpatient medical care. One prolific patient claimed 800 hospitalizations at 650 hospitals throughout Europe, though this claim may have been an example of pseudologia fantastica. A pattern of signs that remit during inpatient hospitalizations only to recur when the patient is not under observation may constitute a very important clue that the patient's medical problem is simulated or self-induced.
  • Thorough wrapping of affected areas (eg, a healing ulceration on the leg) to prevent access can forestall self-harm and rehospitalization in some cases; however, tampering with bandages is common in cases of Munchausen syndrome and often forces rehospitalization due to an unexpected infection, a surprising dehiscence of a skin graft, or a bizarre opening of stapled or sutured wound. In the hospital, voluntarily restraining or placing mittens on a patient's hands can reduce the likelihood of tampering. Painting the wound with scarlet red can provide an important clue if the dye subsequently appears on the fingers.
  • Although some patients are hospitalized many times at a particular hospital, especially if the primary physician is amenably unquestioning, doting, or naive, the patient with true Munchausen syndrome continually seeks new medical audiences each time the ruse is exposed or when they tire of the current hospital setting.
• Inpatient psychiatric care
  • Although patients with Munchausen syndrome pose a very real and imminent danger to themselves, they are rarely subject to civil commitment. Civil commitment is particularly unlikely in states in which "treatability" or the expectation of improvement is a criterion for petition or commitment. Outpatient commitment can prove difficult for the same reason, though at least one successful case has been reported. Even the successful use of house arrest was reported in one case.
  • For a patient with Munchausen syndrome to accept inpatient psychiatric care on a voluntary basis is probably very rare unless the patient is predominantly feigning psychological signs and symptoms or has the combined variant of the syndrome.
  • Medical guardianship, open access to a hospital bed so that admission is no longer contingent on illness, 12-step programs, and Internet chats among patients have been proposed or attempted at various times with mixed results. At the time of this writing, an Internet group for patients with factitious disorder is available at Cravin4Care.
  • To the authors' knowledge, no specialized inpatient (or outpatient) program for patients with Munchausen syndrome exists in the United States, just as no federal or foundation funds have ever been awarded for research into this perplexing and costly syndrome.

Further Outpatient Care

To the extent that patients with Munchausen syndrome harm themselves to garner the gratification of the sick role (eg, sympathy, nurturance, lenience, association with high-status professionals), several commentators have suggested that morbidity and mortality rates in these patients might be reduced by allowing them to assume the sick role on an outpatient basis without having to provide any evidence of illness or injury. Regular and frequent physician consultations that are contingent upon time, not demonstrable medical necessity, may reduce both the associated risks and costs.

Deterrence/Prevention

• Little can be done to prevent development of Munchausen syndrome. The best hypothesis holds that the disorder develops from a combination of factors related to personality development and early experiences with illness and medical care. A biological diathesis has not been demonstrated, though MRI study findings and neuropsychological testing results have sometimes emerged as nonspecifically abnormal. Factitious disorder can be multigenerational, however, and can precede, follow, or be comorbid with the form of maltreatment (abuse and/or neglect) called Munchausen by proxy.
• Because the patient does not regard Munchausen syndrome as undesirable, he or she has no incentive to engage in activities to reduce the morbidity and mortality associated with inauthentic illness behavior.
• In the United States, aside from the Veterans Administration system, no database exists to allow examiners to track the readmissions and diagnoses of patients and thus to identify patients who likely have Munchausen syndrome. In countries with socialized medicine, this capacity exists, but the extent of its use has not been reported. Certain countries, such as the United Kingdom and Australia, appear to distribute "black books" of patients who are known to overuse care, but the reasons may include substance addiction, malingering, or other causes as well as Munchausen syndrome. Some authorities have expressed concern that patients with legitimate illnesses superimposed on one of these diagnoses will be denied urgent medical or surgical care, and such cases have been reported, at least one resulting in death.
• Although surveillance of persons with factitious disorder is not possible in the United States at this time, there are steps that individual physicians can take to prevent excessive and unnecessary illness behavior.
  • First, it is unlikely that the onset of severe and continuous medical deceptions is sudden. It is more reasonable to suspect that Munchausen syndrome follows a progression that starts with more pedestrian forms of feigned or exaggerated illness. For this reason, primary care physicians should take decisive steps to assess and manage the psychological problems of any patient who presents with repeated unexplained medical complaints. The research literature on medically unexplained symptoms makes clear that medically unexplained symptoms are strongly and linearly associated with increasingly severe anxiety and depression. So, even if only a small fraction of persons with unexplained medical complaints are destined to develop severe factitious disorder, psychological intervention for all persons with medically unexplained symptoms is fully justified.
  • Anecdotal evidence that excessive sick role behavior can be trained at an early age suggests that pediatricians may play a particularly important role in preventing factitious illness behavior in their patients when they become adolescents and adults. Parents should be educated explicitly on the pernicious effects of encouraging unnecessary illness behavior in their children. Parents should be given clear expectations about the things that their ill or injured child can and cannot do, along with information about the time course of recovery for acute illness. This sort of information should be presented to all adult patients and their families.
• The prevention of factitious illness behavior can also be improved by several relatively minor changes in the way primary care physicians manage cases. For example, the practice of assigning official medical diagnoses in the absence of adequate evidence should be sharply curtailed. Often cases of Munchausen syndrome reveal that decisions to perform excessive diagnostic or treatment procedures are based on the existence of a definitive, but incorrect, diagnosis. Although for most patients, providing a definitive diagnosis may be reassuring to the patient and the provider, and may facilitate third-party reimbursement, for the patient at risk for factitious illness behavior, an official diagnosis can enable medical deception.

Complications

Munchausen syndrome is itself a complication. As described in the preceding sections, a combination of the patients' self-harming behavior, physician 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 rates.

Prognosis

• Based upon current case-based reports and anecdotes shared among interested professionals, the prognosis for factitious disorder is fair, but the prognosis for the more chronic and severe Munchausen variant is poor even though selected individuals have recovered.
• A positive prognostic sign is the presence of a treatable concurrent mental disorder such as major depression. Some investigators believe that both disorders attenuate with age and maturity, as with personality disorders. Still, patients with Munchausen syndrome are reluctant to accept that they have a psychological disorder and are generally unwilling to undergo psychiatric treatment. Even if they are amenable to treatment, there are no scientifically based models of the etiological factors responsible for the development and maintenance of factitious illness behavior and no scientifically tested treatments.
• The Internet shows promise for collecting standardized but anonymous data about such patients, and patients and those affected by them have used it to share stories of both triumph and defeat. Thus, newer technologies could be mobilized to increase general information about treatment, outcome, and prognosis.

Patient Education

• Educational efforts targeted toward the general public are not likely to decrease the incidence of Munchausen syndrome. Whether these efforts might help friends, family members, teachers, or co-workers to identify persons with Munchausen syndrome and to urge them to seek mental health care is debatable. Such efforts could also lead to cruel and unwarranted skepticism toward persons with genuine chronic illnesses.
• Educational efforts are most effective when they are targeted toward medical staff, nursing professionals, and other allied health care professionals. In the absence of scientific evidence related to identification and management of patients with Munchausen syndrome, exposure to case reports is the best available method for communicating the types of medical deceptions that have been used and the clues that led to the eventual discovery of the deception.
• In almost every medical specialty, published case studies describe the specific techniques that have been used to simulate or induce conditions that fall within the purview of that specialty. These cases are invaluable sources of hypotheses that might explain unusual patterns of signs and symptoms that cannot be explained by routine diagnostic procedures. However, using published cases as teaching tools is inherently dangerous because the published reports are almost certainly biased toward the most extreme, chronic, and dramatic cases. Educational efforts that do not attempt to correct for this fact may increase the detection rate of Munchausen syndrome but cause staff to overlook less dramatic cases of factitious disorder. Published case reports should be supplemented with less spectacular cases seen by experienced staff nurses and physicians
• To the extent that Munchausen syndrome is associated with borderline and antisocial personality disorder, the presence of a patient with Munchausen syndrome frequently produces rifts among the staff. The patients are generally well practiced at identifying staff members whom they can win over as allies and advocates. The patients are often able to play these staff members against those who actively question the authenticity of the patient's complaints.
  • This splitting often results in acrimony and self-doubt among the staff and always delays the eventual detection of the deception. Regardless of whether the case is eventually diagnosed as an occult medical condition or as factitious disorder, the treatment team as a whole is hurt. Advocates for the Munchausen patient feel embarrassed and emotionally abused; accusers of a truly ill patient are left feeling embarrassed and unsure of their medical competence.
  • The best way to avert these undesired outcomes is to prepare staff ahead of time for dealing with difficult cases. Educating staff about the strong emotions and interpersonal tensions elicited in these cases may be the simplest and most effective way of ensuring effective teamwork. One element of this education might emphasize the fact that the diagnostic question is not whether or not the patient is ill; the question instead concerns the type of illness the patient has. Emphasizing that the accurate and timely diagnosis of Munchausen syndrome is a medically important service to the patient may help reduce polarization and factional strife.
• Other potentially useful strategies include training staff to raise concerns about medical deception as soon as they arise, adding medical deception to the working diagnostic hypotheses, and making careful plans for evaluating that hypothesis along with all other viable hypotheses. The earlier the issue is raised and incorporated into the case conceptualization, the less likely it is that decisions will be based on irrelevant emotional factors such as anger, frustration, or sympathy.
• Effective implementation of this strategy requires that the treatment team members have a realistic idea about the prevalence of Munchausen syndrome and factitious disorder, and that they foster a climate in which a member can raise concerns about medical deception without fear of reproach from other team members.
• Because Munchausen patients tend to alienate others, including family members, any social supports should be mobilized and encouraged as the patient relinquishes the factitious illness behaviors.
• For excellent patient and family education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient/family education article Munchausen Syndrome.

Miscellaneous

Medicolegal Pitfalls

• Some of the many legal and ethical issues arising in cases of medical deception have been the subject of considerable debate and several courtroom judgments. Despite this controversy, most of these issues remain unresolved and do not clearly direct the treating physician's response.
• The first question is whether these individuals are even patients, and therefore entitled to treatment, appropriate notice before termination, and so on. The American Medical Association, as with other organizations and esteemed experts, regards a patient in part as someone who seeks to get well. The patient with Munchausen syndrome may not be entitled to admission and care if "patienthood" and professional duty are conceptualized in this way.
• A second issue involves the doctor's responsibility following the discovery that a person has been feigning illness. Some patients explicitly refuse permission for the doctor to share this vital information with other doctors or even with family members who have unknowingly aborted their own careers to care for this deceptive person. A proposed solution tacitly encourages others to read between the lines by stating that "The patient has forbidden me to comment on whether they have a FD." Paralleling the broader issue discussed above, several commentators have argued that the doctor-patient relationship, through which the right to confidentiality is established, requires that both the doctor and the patient carry out their roles in good faith. According to this view, the doctor-patient relationship ceases to exist when the patient engages in medical deception.
• A third issue involves fraud or other legal charges against patients. Those who are caught stealing even inexpensive merchandise from department stores are assuredly confronted and are likely to be criminally charged. Yet, though the patient with Munchausen syndrome steals the time of doctors and others and wastes medical resources and supplies, criminal indictments are rare. Still, one such case was heard in Arizona and resulted in a court finding of fraud and an order of reimbursement against the patient.
• A fourth issue concerns medical malpractice liability associated with the treatment of patients with FD or Munchausen syndrome. One of the authors (Feldman) has been an expert consultant or witness in numerous cases in which a patient with FD has sued some or all of the treating doctors and the facilities in which they worked. The standard claim is that the original ailment was real but mismanaged so that the patient is now permanently disabled or disfigured. These cases are notoriously difficult to defend, in terms of both time and money, even in those in which the patient has been observed to induce self-harm. Regardless of the evidence, judges and juries tend to find Munchausen syndrome scarcely believable and assume that such a patient would be obviously psychotic. The presence of a well-behaved, neatly groomed patient in the courtroom can clash with that erroneous assumption, leading to surprisingly large settlements or verdicts in favor of patients.
• A fifth issue appears to be the antithesis of the fourth. In these legal cases, a patient with FD or Munchausen syndrome eventually sues caregivers for their failure to detect that the illness was feigned. Therefore, they claim that any and all treatments were misapplied, that iatrogenic effects were completely unwarranted, and that the physician has breached the standard of care in diagnosis. One case resulted in a settlement to the patient of more than $300,000.
• A sixth issue involves room searches and covert surveillance of patients. As noted earlier, room searches for medical paraphernalia are permissible if, as is standard at many hospitals, the patient has consented to them as a condition of admission. The use of covert surveillance (eg, with cameras hidden in ceiling panels intended to catch FD behavior) is more controversial.
  • The arguments hinge on whether there is a reasonable expectation of privacy in a hospital room. Many legal precedents support the notion that such an expectation is unreasonable, but these have applied to cases of Munchausen by proxy abuse, in which, barring such an intervention, suspicions of abuse could not otherwise be confirmed (eg, the patient is often a nonverbal infant and cannot provide information).
  • Risk management and legal advisors should meet with team members and formulate a decision as a group before covert video surveillance is initiated. Hospitals are advised to develop relevant standards and policies even if no suspicious case has ever arisen. The authors are not aware of any cases in which search warrants of hospital rooms have been issued based exclusively on the possibility of self-damaging behavior.
• A seventh issue has been touched on earlier and concerns the legality of registries of patients with FD that are shared among treatment centers or that are available nationally or internationally. These registries can be used to determine whether a patient who is suspected of medical deception has indeed been previously identified as having FD.
  • Although the existence of such registries would undoubtedly hinder the ability of such patients to carry out their deceptions at one hospital after the next, the apparent consensus among legal authorities in the United States holds that such registries are a violation of patient confidentiality, particularly since the implementation of the HIPAA rules. However, these registries of troublesome patients are indeed maintained in some other countries.
  • Advocates of patients' rights caution that patients who are placed on such lists may be unable to receive quality medical services because of the presumption that their medical complaints are inauthentic, which may or may not be true. Patient advocates are also concerned about patients who might be listed simply because they were uncooperative or because the source of their medical complaints could not be definitively diagnosed. Individuals who support such measures view themselves as the real patient advocates for preventing unwarranted and potentially harmful treatment to people whose judgment is impaired.

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