Continuing Education Activity

Factitious disorder imposed on self, formerly known as Munchausen syndrome, is a psychiatric disorder in which a person assumes the role of a sick patient without the intention of external gain. Physical symptoms are intentionally produced with the purpose of appearing to be sick. These patients are often a medical mystery to healthcare workers as their laboratory, and radiographic results may be inconsistent with the history and physical exam. This article reviews the pathophysiology of factitious disorder imposed on self and highlights the role of the interprofessional team in its management.

Objectives:

• Review the presentation of a patient with factitious disorder imposed on self.
• Explain the etiology of factitious disorder imposed on self.
• Summarize the treatment options for factitious disorder imposed on self.
• Outline the need to optimize communication among interprofessional teams to improve outcomes for patients with factitious disorder imposed on self.

Introduction

Munchausen syndrome, also called factitious disorder imposed on self, is a psychiatric disorder in which a person assumes the role of a sick patient without the intention of external gain (time off from work, medications). Physical symptoms are intentionally produced with the purpose of gaining the appearance of a "sick patient." These patients are often a medical mystery to healthcare workers as their laboratory, and radiographic results can be inconsistent with the history and physical exam. Furthermore, standard therapeutic interventions may not be effective in persons with Munchausen syndrome, causing increased confusion for the care team.[1][2][3][4][5]

Etiology

Though the etiology of the disorder is unknown, certain psychosocial factors do seem apparent in those with the diagnosis, including a traumatic childhood, experiencing the death of a loved one at a young age, and abandonment. Through the fabrication of a medical illness, these patients are able to receive the attention and, sometimes, care within the healthcare community that they might not have had at home. Of the relatively few patients who have accepted their diagnosis, almost always report that their intention was to create a sense of importance and find a place of "belonging."

Epidemiology

It is difficult to determine the precise number of persons with Munchausen as it can be difficult for a clinician to confirm the diagnosis. Most patients with suspected Munchausen will deny the diagnosis when confronted, and many can become hostile. It is not uncommon for a patient to leave against medical advice and seek care at another hospital. However, certain risk factors have been identified. These include the female gender, being unmarried, and working within the healthcare community. It is common in patients with borderline or histrionic personality traits or disorders, and a history of sexual abuse. It is estimated that less than 1% of patients in the clinical setting will have Munchausen disorder[6]. In a National Hospital Discharge Survey, there is an incidence of 6.8 cases of factitious disorder per 100000 patients[7].

Pathophysiology

The pathophysiology of Munchausen disorder is primarily unknown as no large-scale studies have been conducted on the condition. Psychosocial factors are largely agreed upon to have the most influence in developing Munchausen syndrome.

History and Physical

In the large majority of cases, patients will present with somatic complaints that they present as correlated to a medical illness. Though the presentation of Munchausen disorder can vary widely, some of the most common presentations include chest pain, abdominal pain, vomiting and/or diarrhea, anemia, hypoglycemia, infections, seizures, weakness, headaches, vision loss, skin wounds, and arthralgias. It is not uncommon for the patient to purposefully induce symptoms, such as intentionally eating spoiled food, injecting insulin, picking at skin causing wounds, overdosing on medications, and not taking medications as prescribed. In addition, patients have been known to forge medical records and tamper with laboratory results. It is not uncommon for a Munchausen patient with a benign known medical anomaly (such as a chronically abnormal ECG) to present with factitious symptoms that correlate with the finding.

Evaluation

In the majority of the patients, the presenting symptoms are difficult to confirm with laboratory or radiographic tests. The patient may take pride in being a "medical mystery" and confounding physicians. It may be useful to pay attention to any inconsistencies present, such as objective laboratory and physical exam findings that do not match the alleged symptoms. Additional hints that point toward the diagnosis include a history of many hospitalizations, eagerness to undergo medical procedures (even if they carry significant risk), history of frequent surgical intervention, few visitors, variability in the history, refusal of access to previous medical records, hostility toward psychiatric evaluation, extensive clinical workup, poor response to standard therapies for disease (for example, anemia does not resolve with blood transfusions), unusual disease course that the patient can predict, and the new onset or exacerbation of symptoms when discharge is imminent.[8][9][10][11]. It is highly essential to obtain medical records from other hospitals, as divergences from a current presentation may be present, along with the possibility of a prior diagnosis of Munchausen disorder.

Treatment / Management

The diagnosis of Munchausen disorder falls within the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and requires certain criteria. This criterion includes evidence that the patient is taking steps to intentionally and falsely represent a psychiatric or general medical condition without evidence of malingering, and the behavior is independent of other medical or psychiatric conditions, such as schizophrenia and delusional disorder. Direct confrontation of the patient with suspected Munchausen disorder rarely results in acknowledgment of the illness and instead generally ends in denial and even hostility. Patients have been known to become upset, instigate lawsuits, leave against medical advice, and seek another care facility within a different hospital system. Instead, it can be more constructive for the physician to take an empathetic approach in which the patient is approached in a supportive manner. It is crucial to involve psychiatry (even if the patient opposes) to fully assess for any other psychiatric illnesses that may be present. 

The standard therapy for all patients with suspected Munchausen is psychotherapy, though most patients refuse. It is not necessary for the patient to admit to their factitious disorder and, in fact, most patients rarely do. In certain cases, it may be helpful to target cognitive-behavioral therapy toward childhood trauma that could be the instigator for the disorder. It has also been concluded that various medical interventions such as anti-depressants and/or anti-psychotics showed no benefit in the disorder. 

There have been reported instances of patients confronted with their diagnosis initiating litigation; this can stem from a feeling of bitterness and resentment as well as retaliation against the clinicians. It is also a way to continue their ruse in the courtroom after discharge from a care facility.

Differential Diagnosis

It is important to distinguish Munchausen from malingering in which an external gain is a primary motivation. Additionally, it is different from conversion disorder in that patients with Munchausen are intentionally falsifying their condition for attention or feelings of importance. When differentiating Munchausen from other psychiatric disorders, it must be remembered that Munchausen patients have insight into their disorder and are aware that they are fabricating their illness.

Prognosis

Though evidence for the most helpful intervention is lacking, the prognosis for Munchausen disorder is generally poor as few patients are willing to admit to their maladaptive behaviors. Those with co-morbid substance use disorders, anxiety, and depressive disorders seem to do better long-term versus those with diagnosed co-morbid personality disorders.

Consultations

It is paramount to consult psychiatry if a patient has suspected Munchausen disorder.

Enhancing Healthcare Team Outcomes

The diagnosis and management of Munchausen syndrome are complex. It is best managed by an interprofessional team that includes a psychiatrist, psychologist, primary care provider, social work, and nursing staff. In many cases, the diagnosis is delayed. 

The standard therapy for all patients with suspected Munchausen is psychotherapy, though most patients refuse. It is not necessary for the patient to admit to their factitious disorder and, in fact, most patients rarely do. In certain cases, it may be helpful to target cognitive-behavioral therapy toward childhood trauma that could be the precipitating and perpetuating factor for the disorder. It has also been concluded that various medical interventions such as anti-depressants and/or anti-psychotics showed no benefit in the disorder. 

There have been reported instances of patients confronted with their diagnosis initiating litigation; this can stem from a feeling of bitterness and resentment as well as retaliation against the clinicians. It is also a way to continue their ruse in the courtroom after discharge from a care facility. The overall prognosis is very poor because many of these patients also have other comorbid disorders like substance abuse, depression, anxiety, and personality disorders. [12][13](Level V)