Munchausen syndrome, a severe and chronic form of factitious disorder, consists of repeated production of feigned physical symptoms without an external incentive; the motivation for this behavior is to assume the sick role. Symptoms are usually acute, dramatic, and convincing and are accompanied by a tendency to wander from one physician or hospital to another for treatment. The exact cause is unknown, although stress and borderline personality disorder are often implicated.

Munchausen patients may simulate many physical symptoms or conditions (eg, MI, hematemesis, hemoptysis, diarrhea, FUO). A patient's abdominal wall may be crisscrossed by scars, or a digit or a limb may have been amputated. Fevers are often due to self-inflicted injection with bacteria; Escherichia coli is often the infecting organism. Munchausen patients initially and sometimes interminably become the responsibility of medical or surgical clinics. Nevertheless, the disorder is a mental problem, is more complex than simple dishonest simulation of symptoms, and is associated with severe emotional difficulties. Patients may have prominent histrionic or borderline personality features but are usually intelligent and resourceful. They know how to simulate disease and are sophisticated regarding medical practices. They differ from malingerers because, although their deceits and simulations are conscious and volitional, it is unclear what they gain beyond medical attention for their suffering, and their motivations and quest for attention are largely unconscious and obscure.

There may be an early history of emotional and physical abuse. Patients may also have experienced a severe illness during childhood or had a seriously ill relative. Patients appear to have problems with their identity, inadequate impulse control, a deficient sense of reality, and unstable relationships. Feigning illness may be a way to increase or protect self-esteem by means of blaming failures on their illness, being associated with prestigious physicians and medical centers, and appearing unique, heroic, or medically knowledgeable and sophisticated.

Diagnosis is based on history and examination, including any tests necessary to exclude physical disorders. Less severe and chronic forms of factitious disorder may also involve the production of physical symptoms. Other forms of factitious disorder may involve feigning of mental (rather than physical) signs and symptoms, eg, depression, hallucinations, and delusions or symptoms of posttraumatic stress disorder. In these cases, too, the patient's apparent goal is to assume the sick role. In other cases, patients may produce both mental and physical symptoms.

Treatment

Treatment is rarely successful. Patients get initial relief by having their treatment demands met, but their provocations typically escalate, ultimately surpassing what physicians are willing or able to do. Confrontation or refusal to meet treatment demands often results in angry reactions, and patients generally move on to another physician or hospital. Psychiatric treatment is usually refused or circumvented, but consultation and follow-up care may be accepted, at least to help resolve a crisis. However, management is generally limited to recognizing the disorder early and avoiding risky procedures and excessive or unwarranted use of drugs.

Munchausen patients or those with a more limited factitious disorder can be nonaggressively and nonpunitively confronted with the diagnosis without suggesting guilt or reproach by redefining it as a cry for help. Alternatively, some experts recommend a nonconfrontational approach that offers patients a way to recover from their illness without admitting their role in its cause. In either case, it is helpful to convey that the physician and patient can cooperatively resolve the problem.

Munchausen Syndrome by Proxy

Munchausen syndrome by proxy is a variant in which adults (usually parents) intentionally produce or feign symptoms in a person who is under their care (usually a child).

The adult falsifies history and may injure the child with drugs or other agents or add blood or bacterial contaminants to urine specimens to simulate disease. The parent seeks medical care for the child and appears to be deeply concerned and protective. The child typically has a history of frequent hospitalizations, usually for a variety of nonspecific symptoms, but no firm diagnosis. Victimized children may be seriously ill and sometimes die.

Last full review/revision November 2005