Introduction
Background
Patients who present with overt symptoms who subsequently prove to have factitious disease are particularly challenging to physicians.
Munchausen syndrome is distinguished from other factitious diseases by the lack of secondary gain. The patient's reason for engaging in deception is not to escape some consequence in life. Instead, the patient suffers from an apparent deep-seated need to be sick; a need which can impel the sufferer to injure or poison themselves in an effort to sustain the illusion of organic illness.
Richard Asher coined the eponym in 1951. Asher named the syndrome after Karl Friedrich Hieronymus, Baron Munchausen (1720-1797), a man who traveled widely and was renowned in his time for telling fantastic and exaggerated stories about his life.1
Pathophysiology
The pathophysiology of this disorder is unknown. Patients with Munchausen syndrome often are noted to have associated personality disorders (eg, poor impulse control, self-destructive behavior, borderline or passive-aggressive personality trait or disorder). However, the relationship of these constellations of personality disorders to the primary syndrome is unclear. Patients with Munchausen syndrome are adept at concealing the fact that their diseases are factitious and are markedly resistant to psychiatric evaluation. Information is often difficult to obtain.
Frequency
United States
Rare
International
Rare
Mortality/Morbidity
The potential for significant morbidity and mortality exists, as patients with Munchausen syndrome go to extreme measures to simulate true organic diseases and may cause real disease in the process. For example, injection of exogenous material to produce febrile symptoms may result in local or systemic infection. One case report discusses beta-blocker ingestion in a patient who wished to maintain the diagnosis of sick sinus syndrome.2 Morbidity and mortality may also arise from unnecessary medications and procedures when physicians are taken in by the patient's factitious symptoms.
Sex
- The majority of patients suffering from Munchausen syndrome are male.
- The typical presentation of Munchausen syndrome is characterized by a restless journey from physician to physician and hospital to hospital, an ever-changing list of complaints and symptoms, and an alarming variety of self-intoxications and self-injuries designed to better portray the illness that the patient asserts he or she has.
- There is a subset of women patients who vary from the classic presentation in that they reproduce a single set of symptoms, repeatedly. Patients in this subset exhibit less evidence of comorbid personality dysfunction than the average patient with Munchausen syndrome, and they have a strong tendency to form personal bonds with a single physician or group of physicians.
Age
- Incidence of Munchausen syndrome peaks in young–to–middle-aged adults, but it has been reported in patients of all ages (ie, childhood through advanced age).
- Pediatric Munchausen syndrome is a different disease from Munchausen syndrome by proxy (MSBP). MSBP is a syndrome in which an adult simulates or creates symptoms in a child to receive an ill-defined secondary gain from the child's hospitalization.
- MSBP is child abuse and must be dealt with when it is suspected. Because of the dangerous nature of the varied means used to create factitious symptoms, the mortality rate is significant; estimates range from 5-50%. MBSP is currently a topic of intense interest and research, given its potentially dire prognosis for the children who are its victims.
Clinical
History
- Dramatic presentations of apparently severe illnesses
- Reported symptom patterns that fit diagnoses too perfectly and are too much like a textbook presentation
- A history of extensive surgical procedures and inpatient workups for a variety of diseases, particularly when the workup spans multiple hospitals and cities
- Notable vagueness or inconsistency in the details of the medical problems
- Evidence of pathological lying in areas other than the presenting symptoms
Physical
- Patients with Munchausen syndrome may display any combination of signs and symptoms.
- In an effort to obtain hospitalization, an invasive workup, and extensive interventions, patients with Munchausen syndrome may mimic any severe disease that generates physical findings and symptoms.
- Cardiac presentations of Munchausen syndrome are common enough to have allowed cardiologists to identify cardiac Munchausen syndrome—sometimes referred to as cardiopathia fantastica3 —as a distinct subset of the Munchausen spectrum.
Causes
- Once it has been determined that a disease presentation is factitious, the absence of a clear source of primary or secondary gain is the hallmark that distinguishes Munchausen syndrome from other factitious illnesses. No convincing explanation of secondary gain has yet been described in patients with Munchausen syndrome.
- In contrast to Munchausen syndrome, malingering patients have a clear primary gain in their efforts to escape some task or obligation.
- Conversion and somatoform disorders also are driven by a secondary gain. Treating the underlying stressor often can alleviate the presenting symptoms.
- In contrast, a patient with Munchausen syndrome actively seeks hospitalization and invasive painful procedures as a primary goal.
- Munchausen syndrome afflicts the patient who presents with the complaint. Munchausen syndrome by proxy involves inflicting injury on a child or other dependent person in order to simulate symptoms. There is no obvious or plausible secondary gain to the caretaker who performs these actions. Munchausen syndrome by proxy is a form of abuse and must promptly be acted upon when suspected.
More on Munchausen Syndrome |
 Overview: Munchausen Syndrome |
| Differential Diagnoses & Workup: Munchausen Syndrome |
| Treatment & Medication: Munchausen Syndrome |
| Follow-up: Munchausen Syndrome |
| References |
| Next Page » |
References
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Rabinerson D, Kaplan B, Orvieto R, et al. Munchausen syndrome in obstetrics and gynecology. J Psychosom Obstet Gynaecol. 2002;23(4):215-8. [Medline].
Smith MS. Factitious illness, malingering, and conversion disorder. In: Harwood-Nuss AL, Linden CH, Luten RC, et al, eds. The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1996:986.
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Further Reading
Keywords
Munchausen syndrome by proxy, MSBP, Munchausen syndrome, factitious illness, factitious disorder, cardiopathia fantastica, faking illness, factitious symptoms, self-injury, self-poisoning, unnecessary medical procedures, mental illness, malingering, psychiatric illness
