Munchausen syndrome

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For cases of feigned illness not driven by a psychiatric disorder, see Malingering.
Factitious disorders
Classification and external resources
Specialty Psychiatry
ICD-10 F68.1
ICD-9-CM 301.51
DiseasesDB 8459 33167
eMedicine med/3543 emerg/322 emerg/830
MeSH D009110

Münchausen syndrome is a psychiatric factitious disorder wherein those affected feign disease, illness, or psychological trauma to draw attention, sympathy, or reassurance to themselves. Munchausen syndrome fits within the subclass of factitious disorder with predominantly physical signs and symptoms, but patients also have a history of recurrent hospitalization, travelling, and dramatic, extremely improbable tales of their past experiences.[1] The condition derives its name from the fictional character Baron Munchausen.

There is discussion to reclassify them as somatoform disorders in the DSM-5 as it is unclear whether or not people are conscious of drawing attention to themselves.[2] In the current iteration, the term "somatoform disorder" (as used in the DSM-IV-TR and other literature) is no longer in use; that particular section of the DSM-5 has been renamed "Somatic Symptom and Related Disorders". Officially, Munchausen syndrome has been renamed "Factitious Disorder", with specificity either as "Imposed on Self" or "Imposed on Another" (formerly "by Proxy").

Munchausen syndrome is related to Munchausen syndrome by proxy (MSbP/MSP), which refers to the abuse of another person, typically a child, in order to seek attention or sympathy for the abuser. This drive to create symptoms for the victim can result in unnecessary and costly diagnostic or corrective procedures. [3]

Description[edit]

In Munchausen syndrome, the affected person exaggerates or creates symptoms of illnesses in themselves to gain examination, treatment, attention, sympathy, and/or comfort from medical personnel. In some extreme cases, people suffering from Munchausen syndrome are highly knowledgeable about the practice of medicine and are able to produce symptoms that result in lengthy and costly medical analysis, prolonged hospital stays, and unnecessary operations. The role of "patient" is a familiar and comforting one, and it fills a psychological need in people with this syndrome. This disorder is distinct from hypochondriasis and other somatoform disorders in that those with the latter do not intentionally produce their somatic symptoms.[4] Munchausen syndrome is distinct from other psychiatric disorders such as malingering in that Munchausen does not fabricate symptoms for material gain such as financial compensation, absence from work, or access to drugs.

Risk factors for developing Munchausen syndrome include childhood traumas, growing up with parents/caretakers who were emotionally unavailable due to illness or emotional problems, a serious illness as a child, failed aspirations to work in the medical field, personality disorders, and low self-esteem. Munchausen syndrome is more common in men and is seen in young or middle-aged adults. Those with a history of working in healthcare are also at greater risk of developing it.[5]

Arrhythmogenic Munchausen syndrome describes individuals who simulate or stimulate cardiac arrhythmias to gain medical attention.[6]

A similar behavior called Munchausen syndrome by proxy has been documented in the parent or guardian of a child. The adult ensures that his or her child will experience some medical affliction, therefore compelling the child to suffer through treatments and spend a significant portion of their youth in hospitals. Furthermore, a disease may actually be initiated in the child by the parent or guardian. This condition is considered distinct from Munchausen syndrome. There is growing consensus in the pediatric community that this disorder should be renamed "medical abuse" to highlight the harm caused by the deception and to make it less likely that a perpetrator can use a psychiatric defense when harm is done.[7]

Diagnosis[edit]

Diagnosing Munchausen syndrome requires a clinical assessment.[8] Clinicians should be aware that patients (or persons reporting for patients) may malinger, and caution should be taken to ensure there is evidence for a diagnosis.[8] Lab tests may be required, including complete blood count (CBC), urine toxicology, drug levels from blood, cultures, coagulation tests, assays for thyroid function, or DNA typing. In some cases CT scan, magnetic resonance imaging, psychological testing, electroencephalography, or electrocardiography may also be employed.[8]

Common signs and symptoms [8]
Recurrent life-threatening events Seizures Bleeding Poisoning
Hypoglycemia or hyperglycemia Apnea CNS Depression Repeated infections
Diarrhea and vomiting Rashes Fevers

Treatment and prognosis[edit]

Because there is uncertainty in treating suspected Munchausen patients, some advocate that medical professionals or doctors first explicitly rule out the possibility that the patient has an early-stage disease that is not yet clinically detectable in order to avoid under-treating real illness.[9] Then they may take a careful patient history and seek medical records to look for early deprivation, childhood abuse, or mental illness.[citation needed][8] If a patient is at risk to himself or herself, inpatient psychiatric hospitalization may be initiated.[10]

Medical providers or doctors may consider working with mental health specialists to help treat the underlying mood or disorder as well as to avoid countertransference.[11] Therapeutic and medical treatment may center on the underlying psychiatric disorder: a mood disorder, an anxiety disorder, or borderline personality disorder. The patient's prognosis depends upon the category under which the underlying disorder falls; depression and anxiety, for example, generally respond well to medication and/or cognitive behavioral therapy, whereas borderline personality disorder, like all personality disorders, is presumed to be pervasive and more stable over time,[12] and thus offers the worst or best prognosis.

Patients may have multiple scars on their abdomen due to repeated "emergency" operations.[13]

There are several symptoms that together point to Munchausen syndrome, including frequent hospitalizations, knowledge of several illnesses, frequently requesting medication such as pain killers, openness to extensive surgery, few or no visitors during hospitalizations, and exaggerated or fabricated stories about several medical problems. Munchausen syndrome should not be confused with hypochondria, as patients with Munchausen syndrome do not really believe they are sick; they only want to be sick, and thus fabricate the symptoms of an illness. It is also not the same as pretending to be sick for personal benefit such as being excused from work or school.[5]

There are several ways in which the patients fake their symptoms. Other than making up past medical histories and faking illnesses, patients might inflict harm on themselves such as taking laxatives or blood thinners, ingesting or injecting themselves with bacteria, cutting or burning themselves, and disrupting their healing process such as by reopening wounds.[citation needed] Many of these conditions do not have clearly observable or diagnostic symptoms and sometimes the syndrome will go undetected because patients will fabricate identities when visiting the hospital several times. Munchausen syndrome has several complications, as these patients will go to great lengths to fake their illness. Severe health problems, serious injuries, loss of limbs or organs, and even death are possible complications.[5]

History[edit]

The syndrome's name derives from Baron Munchausen, a literary character loosely based on the German nobleman Hieronymus Karl Friedrich, Freiherr von Münchhausen (1720–1797). The historical baron became a well-known storyteller in the late 18th century for entertaining dinner guests with tales about his adventures during the Russo-Turkish War. In 1785 German-born writer and con artist Rudolf Erich Raspe anonymously published a book in which a heavily fictionalized version of "Baron Munchausen" tells many fantastic and impossible stories about himself. Raspe's Munchausen became a sensation, establishing a literary exemplar of a bombastic liar or exaggerator.[14][15]

In 1951, Richard Asher was the first to describe a pattern of self-harm, wherein individuals fabricated histories, signs, and symptoms of illness. Remembering Baron Munchausen, Asher named this condition Munchausen's Syndrome in his article in The Lancet in February 1951,[16] quoted in his obituary in the British Medical Journal:

"Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly the syndrome is respectfully dedicated to the Baron, and named after him."

— British Medical Journal, R.A.J. Asher, M.D., F.R.C.P.[17]

Asher's nomenclature sparked some controversy, with medical authorities debating the appropriateness of the name for about fifty years. While Asher was praised for bringing cases of factitious disorder to light, participants in the debate objected variously that a literary allusion was inappropriate given the seriousness of the disease; that its use of the anglicized spelling "Munchausen" showed poor form; that the name linked the disease with the real-life Münchhausen, who did not have it; and that the name's connection to works of humor and fantasy, and to the essentially ridiculous character of the fictional Baron Munchausen, was disrespectful to patients suffering from the disorder.[18]

Originally, this term was used for all factitious disorders. Now, however, there is considered to be a wide range of factitious disorders, and the diagnosis of "Munchausen syndrome" is reserved for the most severe form, where the simulation of disease is the central activity of the affected person's life.

See also[edit]

References[edit]

  1. ^ Jerald Kay; Allan Tasman (2006). Essentials of psychiatry. John Wiley & Sons, Ltd. p. 680. ISBN 0-470-01854-2. 
  2. ^ Krahn, Lois E.; Bostwick, J. Michael; Stonnington, Cynthia M. (2008). "Looking Toward DSM–V: Should Factitious Disorder Become a Subtype of Somatoform Disorder?". Psychosomatics. 49 (4): 277–82. doi:10.1176/appi.psy.49.4.277. PMID 18621932. 
  3. ^ Huffman, J.C., Stern, T.A. (2003) The diagnosis and treatment of Munchausen's syndrome. General Hospital Psychiatry: 25:5, p. 358-363. doi: http://dx.doi.org/10.1016/S0163-8343(03)00061-6
  4. ^ Benjamin J. Sadock (Editor), Virginia A. Sadock (Editor) (January 15, 2000). Kaplan & Sadock's Comprehensive Textbook of Psychiatry (2 Volume Set) (7th ed.). Lippincott Williams & Wilkins Publishers. p. 3172. ISBN 0683301284. 
  5. ^ a b c Staff, Mayo Clinic. "Munchausen Syndrome." Mayo Clinic. Mayo Foundation for Medical Education and Research, 13 May 2011. Web. 11 Apr. 2013.[verification needed]
  6. ^ Vaglio JC, Schoenhard JA, Saavedra PJ, Williams SR, Raj SR (2010). "Arrhythmogenic Munchausen syndrome culminating in caffeine-induced ventricular tachycardia". J Electrocardiol. 44 (2): 229–31. doi:10.1016/j.jelectrocard.2010.08.006. PMID 20888004. 
  7. ^ Pediatrics 2007 May 05;119:1026-1030
  8. ^ a b c d e "Factitious Disorder Imposed on Another: Practice Essentials, Background, Pathophysiology". 
  9. ^ Bursztajn, H; Feinbloom, RI; Hamm, RM; Brodsky, A (1981). Medical Choices, medical chances: How patients, families and physicians can cope with uncertainty. New York: Delacourte/Lawrence. [page needed]
  10. ^ Johnson, B. R.; Harrison, J. A. (2000). "Suspected Munchausen's syndrome and civil commitment". The journal of the American Academy of Psychiatry and the Law. 28 (1): 74–6. PMID 10774844. 
  11. ^ Elder W, Coletsos IC, Bursztajn HJ. Factitious Disorder/Munchhausen Syndrome. The 5-Minute Clinical Consult. 18th Edition. 2010. Editor. Domino, F.J. Wolters Kluwer/Lippincott. Philadelphia.[page needed]
  12. ^ Davison, Gerald C.; Blankstein, Kirk R.; Flett, Gordon L.; Neale, John M. (2008). Abnormal Psychology (3rd Canadian ed.). Mississauga: John Wiley & Sons Canada. p. 412. ISBN 978-0-470-84072-6. 
  13. ^ Giannini, A. James; Black, Henry Richard; Goettsche, Roger L. (1978). Psychiatric, Psychogenic and Somatopsychic Disorders Handbook. New Hyde Park, NY: Medical Examination Publishing. pp. 194–5. ISBN 0-87488-596-5. 
  14. ^ McCoy, Monica L.; Keen, Stefanie M. (2013). Child Abuse and Neglect: Second Edition. Psychology Press. p. 210. ISBN 1136322876. Retrieved July 10, 2015. 
  15. ^ Olry, Regis (June 2002). "Baron Munchhausen and the Syndrome Which Bears His Name: History of an Endearing Personage and of a Strange Mental Disorder" (PDF). Vesalius. 8 (1): 53–7. Retrieved July 10, 2015. 
  16. ^ Asher, Richard (1951). "Munchausen's Syndrome". The Lancet. 257 (6650): 339–41. doi:10.1016/S0140-6736(51)92313-6. PMID 14805062. 
  17. ^ Atthili, Lombe (1873). "Reports of Societies". BMJ. 2 (665): 388. doi:10.1136/bmj.2.665.388. JSTOR 25235514. 
  18. ^ Fisher, Jill A. (2006). "Investigating the Barons: Narrative and nomenclature in Munchausen syndrome". Perspectives in Biology and Medicine. 49 (2): 250–62. doi:10.1353/pbm.2006.0024. PMID 16702708. 

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