Munchausen syndrome, a severe and chronic form of factitious disorder, consists of intentional production or feigning of physical symptoms or signs 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 a severe personality disorder, most often borderline personality disorder, are often implicated.

Patients with Munchausen syndrome may simulate many physical symptoms or conditions (eg, MI, hematemesis, hemoptysis, diarrhea, FUO). Their 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. These patients initially and sometimes chronically 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 and 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, their behavior is not motivated by external incentives, such as economic gain. It is unclear what they gain beyond medical attention for their suffering, and their motivations and quest for attention are largely unconscious and obscure.

Patients may have 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 as well as unstable relationships. Feigning illness may be a way to increase or protect self-esteem by blaming failures on their illness, by being associated with prestigious physicians and medical centers, and by appearing unique, heroic, or medically knowledgeable and sophisticated.

Diagnosis

Diagnosis is based on history and examination, along with any tests necessary to exclude physical disorders. Less severe forms of factitious disorder may also involve the feigning of physical or mental symptoms (eg, depression, hallucinations, delusions, or symptoms of posttraumatic stress disorder), with an apparent goal to assume the sick role. These forms are not considered Munchausen, which is more severe and chronic, with recurrent hospitalization, peregrination, and pseudologia fantastica (lying in a manner that is intriguing to the listener).

Treatment

• No clearly effective treatments

Treatment is usually challenging, and there are no clearly effective treatments. Patients may obtain initial relief by having their treatment demands met, but their symptoms 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 usually move from one physician or hospital to another (called peregrination). Recognizing the disorder and requesting psychiatric or psychologic consultation early is important, so that risky invasive testing, surgical procedures, and excessive or unwarranted use of drugs can be avoided.

A nonaggressive, nonpunitive, nonconfrontational approach should be used to present the diagnosis of Munchausen syndrome or other forms of factitious disorder to patients. To avoid suggesting guilt or reproach, a physician can present the diagnosis as a cry for help. Alternatively, some experts recommend providing mental health treatment without requiring patients to admit their role in causing their illness. In either case, conveying that the physician and patient can cooperatively resolve the problem is helpful.

Munchausen Syndrome by Proxy

Munchausen syndrome by proxy is a variant in which caregivers (usually a parent) intentionally produce or feign physical or mental symptoms or signs in a person in their care (usually a child).

The caregiver 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 caregiver 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 June 2008 by Katharine A. Phillips, MD