One of the most confusing and troubling situations that healthcare providers can face is being confronted with a patient who is mysteriously making themselves ill. The condition is known popularly as Munchausen syndrome, but falls under the diagnosis of “factitious disorder” in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). According to the DSM, the diagnostic criteria for factitious disorder are:
- The patient intentionally creates, worsens, exaggerates, or pretends physical or psychological symptoms. This distinguishes the disorder from somatic disorders, where the patient truly imagines or believes they are ill.
- There are no external incentives for the behavior, which distinguishes it from malingering, where the patient is hoping to escape work or receive some benefit from the feigned illness.
- Motivation for the behavior is simply to assume the sick role. Patients may be seeking attention, comfort, or sympathy from medical staff.
“Munchausen disease” is a complex and tricky syndrome, both to identify and to treat. The disorder is often comorbid with a history of childhood abuse or neglect, with mood disorders, and with personality disorders, especially borderline personality disorder. There have been very few studies on long-term prognosis or effective treatments. If you begin to suspect a patient may be showing signs of factitious disorder, how can you be sure? What can you do?
Munchausen syndrome symptoms and warning signs
- The patient may have a long and complex medical history with a lot of “doctor hopping.”
- There may be inconsistencies in the medical history.
- Their medical records may show an unusual amount of unexplained illnesses over the years. Fevers of unknown origin, vague respiratory symptoms, strange rashes, alarming bleeding, and many incidents of mysterious GI complaints are common. Wounds may take much longer than average to heal. All of these conditions may be indicative of tampering on the part of the patient, such as introducing infectious matter into a wound to worsen symptoms.
- The patient may have undergone many exploratory surgeries and extensive testing.
- They may express inappropriate eagerness to undergo even painful or invasive tests and treatments.
- The “hard evidence” of diagnostic testing such as MRIs or blood work may not match the presenting symptoms.
- The patient may exhibit an unusually in-depth level of knowledge about their claimed illness, as if they had been reading medical textbooks, and they may be very specific about the tests and procedures they are seeking. In this day of widespread medical information easily available online, this behavior may be seen in normal patients as well; however, a patient with factitious disorder may present with an unusual level of intensity and insistence.
What to do
- Approach the situation with caution. It’s imperative to rule out an early or subclinical case of a true medical issue so that nothing is missed before proceeding. It can be frustrating to feel as though you are feeding the pathological need through further (possibly unnecessary) testing, but you must be sure.
- If you decide to confront the patient, privacy and compassion are key. It’s natural to feel angry if you think you’ve been lied to, but an aggressive or emotional approach will simply lead the patient to shut down and “hop” to the next doctor.
- Make a note in their file to alert future medical personnel of your suspicions.
- Gently offer a psychiatric referral. While no specific treatment for factitious disorder has been identified, getting support and possibly medication for underlying and comorbid psychiatric conditions such as depression can help to lessen or resolve the behavior.
Patients with Munchausen syndrome can do themselves real harm by intentionally poisoning, injuring, or mutilating themselves in order to induce “realistic” symptoms before presenting themselves for medical care. There is also the very real danger that the patient could end up a victim of “The Boy Who Cried Wolf” effect and miss out on vital medical care when they actually need it. While the syndrome is rare, knowing how to identify and deal with these patients is extremely important.
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