Munchausen Syndrome Treatment & Management

In essence, the medical care of persons thought to have Munchausen syndrome should proceed in the same manner as the medical care of any other patient, despite the dramatic or compelling nature of the patient's problem or his or her demands for additional invasive and noninvasive intervention. As noted in the previous section, remember that these patients attempt to fool the treating physician into conducting more tests and trying more treatments than are necessary. When they succeed in doing so, it is often because of a failure to include factitious disorder and Munchausen syndrome in the differential. On the other hand, medical professionals are taught that the most important clue to a patient's diagnosis is the information they provide, and doctors should not abandon their belief in and advocacy for patients unless risk factors are present or suggestive signs arise.

For patients with known or suspected Munchausen syndrome, use great caution in deciding to proceed with surgical treatment, particularly when the surgery involves an irreversible result such as amputation, radical mastectomy, or organ removal. Do not assume that a patient with factitious disorder would not play out the ruse to the point of acquiring a permanent disability or disfigurement—the case literature is replete with reports of patients who have done so. Remember that performing surgery on a patient gives him or her a legitimate sick role status, at least during the recovery period, perhaps longer in cases in which the surgery appears to result in complications or otherwise creates unexpected and unwanted physical consequences.

The general practitioner who encounters a patient with Munchausen syndrome often makes specialty referrals in response to the puzzling or intractable symptoms that the patient presents. The specialist consultations should be carefully coordinated by the primary care provider. In some cases involving patients with Munchausen syndrome who have filed malpractice suits, the staggering number of concurrent treating and prescribing physicians can incriminate the doctor if he or she failed to ask about outside care. Referrals should be kept to a minimum; the primary care physician should serve as much more than a conduit for consultations. Referral issues, including any indication of Munchausen syndrome, should be clearly spelled out.

The patient's refusal to sign release of information forms should be thoroughly questioned and is a warning sign. The primary care physician should firmly resist attempts by the patient to exert inappropriate control over the consultation (eg, choosing the specialist, insisting on personally communicating the results to the primary care provider). Termination from the doctor's practice may have to be considered, although this measure does nothing to attenuate the root problem.

When the physician strongly believes that the patient is feigning illness or injury, it is natural to request a psychiatry consultation. Before doing so, the primary care physician should consider several issues.

First, no definitive affirmative psychiatric criteria exist for the diagnosis of factitious disorder. Second, the patient is unlikely to cooperate with a psychiatry consultation, so no new information will be elicited. Not only will the patient usually not agree to the consultation, he or she may leave the physician's care, angered by the implication that the physician believes that the patient is faking. Similarly, psychological testing is nondiagnostic, though it can be telling if a patient feigning mental illness receives discrepant scores on objective, well-validated tests. For these reasons, a typical psychiatric or psychological evaluation is not often effective in these cases. Additionally, as a group, psychiatrists and psychologists have no greater ability than average lay persons in discerning lying during interviews.

Still, it may be helpful for the physician to discuss the case with an experienced psychiatric consultant who can advise the physician, and sometimes the entire treatment team, on how to proceed with the evaluation and management of a patient with Munchausen syndrome.

After a diagnosis of factitious disorder has been established, it may prove more useful to conduct consultations with mental health professionals who practice behavioral medicine, reserving psychopharmacologic management for patients with clearcut mental disorders such as major depression. These professionals might include psychiatrists, psychologists, or social workers. Consultations may be acceptable to the patient if they are portrayed as aimed at helping the patient to cope with their medical problems and to understand more about the influence of the brain on the body. This approach can succeed because it places the patient in contact with mental health professionals in a way that does not challenge the patient's assertion that the problem is an authentic medical one. Ongoing psychotherapy^[5] can provide the patient with a time and place in which they are guaranteed the exclusive attention of a health care professional without resorting to "disease forgery."

If the patient is hospitalized, it may be important to limit his or her activities to the unit and to minimize the time he or she spends alone. Freedom to come and go (as on some psychiatric units) or infrequent checks offer increased opportunities for patients with Munchausen syndrome to self-induce renewed bouts of illness. Room searches (eg, for syringes or hidden medications) may be necessary, and permission to do so is commonly part of the consent forms patients sign before admission.