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Factitious disorder imposed on self

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(Redirected from Münchausen's syndrome)
For cases of feigned illness not driven by a psychiatric disorder, see Malingering.

Factitious disorder imposed on self
Other namesMunchausen syndrome[1]
SpecialtyPsychology, psychiatry

Factitious disorder imposed on self (FDIS), sometimes referred to as Munchausen syndrome, is a complex mental disorder where individuals play the role of a sick patient to receive some form of psychological validation, such as attention, sympathy, or physical care.[2] Patients with FDIS intentionally falsify or induce signs and symptoms of illness, trauma, or abuse to assume this role.[3] These actions are performed consciously, though the patient may be unaware of the motiviations driving their behaviors. There are several risk factors and signs assocaited with this illness and treatment is usually in the form of psychotherapy.

Factitious disorder imposed on self is related to factitious disorder imposed on another, which refers to the abuse of another person in order to seek attention or sympathy for the abuser. This is considered "Munchausen by proxy", and the drive to create symptoms for the victim can result in unnecessary and costly diagnostic or corrective procedures.[3]

Terminology

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Tales from the fictional German character Frieherr Von Munchausen.

The name "Munchausen syndrome" derives from Baron Munchausen, a literary character loosely based on the German nobleman Hieronymus Karl Friedrich Freiherr von Münchhausen (1720–1797).[4] 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.[5][6]

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.[6] 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; 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 with the disorder.[7] Some healthcare providers avoid this term because it downplays the complexity of the illness and devalues the patient experience. The term "factitious disorder imposed on self" provides a more accurate and encompassing description of this mental disorder; however, both terms may still be used interchangeably in practice.[8]

Risk factors

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The exact cause of this illness is unknown due to limited research but is likely the result from multiple psychosocial factors. Specific risk factors have been assocaited with developing FDIS, specifically a history of childhood trauma, abandonment, having a serious childhood illness, and certain personality disorders.[9][10] Patients are more likely to be female, middle aged, and work in the healthcare industry.[11] Individuals with this disorder may also have a history of recurrent hospitalizations and frequent visits to multiple different physicians (i.e. doctor shopping). They are also more likely to have underlying depression, though it is unclear if it is a cause or symptom of this illness.[12]

Signs and symptoms

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In factitious disorder imposed on self, the affected person exaggerates or creates physical or psychological symptoms of illnesses in themselves to gain examination, treatment, attention, sympathy or comfort from medical personnel. Because these symptoms can vary depending on how patients induce these symptoms, there is no consistent symptom specific for this illness. However, there are several common themes that may raise suspicion for FDIS. Some of these common themes include:

  • Prolonged, repeated hospital stays[13]
  • Frequent visits to multiple different physicians[14]
  • Opting for unnecessary operations or procedures where the results are generally normal or inconclusive[3]
  • Inconsistencies in past medical history, where illness/procedural history stated by patient is different than their documented history[15]
  • Vague, nonspecific pain unresponsive to normal treatment options[15]

Common examples of commonly induced physical symptoms include intentionally infecting a wound with debris or unsanitary material, taking laxatives to induce diarrhea, and ingesting thyroid hormone replacement medication to simulate a hyperactive thyroid or hyperthyroidism.[14]

Diagnosis

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Due to the behaviors involved, diagnosing factitious disorder is very difficult. Because induced symptoms may mimic those of a real disease or disorder, physicians must first rule out genuine disease. Therefore, FDIS is usually a diagnosis of exclusion.[16] To rule out genuine illness, lab tests may be required, including complete blood count (CBC), urine toxicology, drug tests, blood cultures to rule out infection, coagulation tests, assays for thyroid function, or DNA typing, depending on the mimicked disease. In some cases CT scan, magnetic resonance imaging, psychological testing, electroencephalography, or electrocardiography may be required. A more extensive list of how organic illness is differentiated from FDIS is provided below.[17]

If the healthcare provider finds no physical reason for the symptoms, they may refer the person to a psychiatrist or psychologist (mental health professionals who are specially trained to diagnose and treat mental illnesses). Psychiatrists and psychologists use thorough history, physical examinations, laboratory tests, imagery, and psychological testing to evaluate a person for physical and mental conditions and to distinguish between feinged versus real illness. Once the person's history has been thoroughly evaluated, diagnosing factitious disorder imposed on self requires a clinical assessment, typically performed by a psychiatrist.[18]

For a person to be diagnosed with factitious disorder imposed on self, they must meet the following criteria[19][20]:

  1. The patient presents as sick or injured motivated by a primary gain, or internal reward of validation/attention as opposed to a secondary gain, which usually involves external benefits.
  2. There is evidence that the patient is inducing or falsifying their symptoms
  3. There is no alternative explanation, mental disorder, or illness to explain the patient's symptoms

Common Manifestations

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There are common methods for inducing certain symptoms and mimicking specfic diseases. As mentioned earlier, it is important ot first rule out true disease. Physicians usually must have a high suspicion for FDIS to pursue it as a likely diagnosis based on abnormal patient behaviors and medical history. Some examples of these are listed in the table below, along with how to differentiate them from real versus mimicked disease using medical laboratory tests or imaging.[21]

Disease Mimicked Method of Imitation Laboratory/diagnostic confirmation
Bartter syndrome
  • Taking diuretics to urinate excessivly or self-induced vomiting
  • Termed "pseudo-Bartter syndrome"
  • Creates an electrolyte imbalance in the body
  • Measure blood or urine diuretic levels to detect medication as the cause
  • Urinary chloride levels will be high in true Bartter syndrome vs. low in pseudo-Bartter syndrome[22]
Catecholamine-secreting tumor (i.e. Carcinoid tumor) Chromogranin A, a tumor marker for Carcinoid tumor, blood levels will be increased for a tumor and normal in those with FDIS.[24]
Cushing's syndrome
  • Secret steroid medication (e.g. prednisone) administration (note: patients admitting that they are prescribed steroids for another medical condition will experience this, but this would not be considered FDIS since the patient is not deceitful or withholding information or intending to have Cushing's syndrome)
  • Over time, patients will experience weight gain, easy brusing, rounding of the face, increae in blood pressure, and increase in infections[25]
 Urine test to detect use of steroids[26]
Hyperthyroidism
  • Secret thyroxine, a thyroid hormone, administration (note: patients may be prescribed this medication for low thyroid levels)
  • Produces symptoms of heart palpitations, weight loss, hot flashes, diarrhea, and abnormal menstrual cycles[27]
  • Low radioactive iodine thyroid uptake, which would be elevated in true hyperthyroidism
  • Low thyroglobulin levels, which should be elevated in true hyperthyroidism[28]
Hypoglycaemia
  • Secretly using more insulin than prescribed and acting as though they are not
  • Produces symptoms of low blood sugar, including shaking, sweating, dizziness, confusion, and an irregular heartbeat[29]
  • C-peptide, a byproduct of normal insulin production in the human body, will be low in patients with FDIS
  • C-peptide is not found in medical insulin but is found in the body, as it is produced at the same time as insulin[30]
Chronic diarrhea
  • Excessive intake of laxatives to produce diarrhea and acting like it's from an unknown cause
  • Produces electrolyte imbalances in the body and dehydration
  • Stool analysis to detect laxative use
  • Stool osmolality >600 mOsm/kg or <290 mOsm/kg may indicated FDIS
  • Colonoscopy may show brown discoloration of the colon, called melanosis coli, often seen in laxative abuse[31]
Haematuria (bloody urine)
  • Deliberately contaminating urine sample with blood
  • Intentionally causing trauma to the urethra
  • Imaging to rule out insertion of a foreign body
  • monitor sample collection
  • analysis of red blood cell shape in samples, which will show excessively destroyed red blood cells in FDIS[32]

Munchausen by Internet is a term describing the pattern of behavior in factitious disorder imposed on self, wherein those affected feign illnesses in online venues to gain sympathy from online supporters. It has been described in medical literature as a manifestation of factitious disorder imposed on self.[33] Reports of users who deceive internet forum participants by portraying themselves as gravely ill or as victims of violence first appeared in the 1990s due to the relative newness of Internet communications. The specific internet pattern was named "Münchausen by Internet" in 1998 by psychiatrist Marc Feldman.[33] New Zealand PC World Magazine called Munchausen by Internet "cybermunch", and those who posed online "cybermunchers".[34]

Treatment

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When confronted with this diagnosis, patients often refuse to accept it and will continue their behaviors seeking healthcare at different institutions or physicians.[35] Those who accept the diagnosis benefit most from psychotherapy delivered by a skilled therapist or psychiatrist. In doing so, patients can learn the underlying subconscious motivations that drive their conscious behaviors in order to develop a sense of awareness the prevents them from continuing these harmful behaviors.[36][37] If a person is considered to be at risk of harming themself or others, psychiatric hospitalization may be initiated.[38]

Specific forms of therapy may be tailored to underlying personality disorders contributing to their behaviors. For example, dialectical behavior therapy (DBT) can be used to treat borderline personality disorder.[39] Medications may be necessary to treat an underlying mood disorder or anxiety disorder, as many patients with this disorder may have underlying depression.[40] Patients with underlying depression and/or anxiety are typically responsive to antidepressants with or without cognitive behavioral therapy, a form of psychotherapy.[41][42][43]

See also

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References

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  1. ^ Ray WJ (2016). Abnormal Psychology. SAGE Publications. p. PT794. ISBN 978-1-5063-3337-3.
  2. ^ Kay J, Tasman A, eds. (2007). Essentials of psychiatry. West Sussex, England Hoboken, NJ: Wiley. ISBN 978-0-470-03099-8.
  3. ^ a b c Ray WJ (2021). Abnormal psychology (Third ed.). Los Angeles London New Delhi Singapore Washington DC Melbourne: SAGE. ISBN 978-1-5443-9920-1.
  4. ^ Tatu L, Aybek S, Bogousslavsky J (2018). "Munchausen Syndrome and the Wide Spectrum of Factitious Disorders". Frontiers of Neurology and Neuroscience. 42: 81–86. doi:10.1159/000475682. ISBN 978-3-318-06088-1. ISSN 1662-2804. PMID 29151093.
  5. ^ McCoy ML, Keen SM (2013). Child Abuse and Neglect: Second Edition. Psychology Press. p. 210. ISBN 978-1-136-32287-7.
  6. ^ a b Olry R (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. PMID 12422889.
  7. ^ Fisher JA (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. S2CID 12418075.
  8. ^ Yates GP, Feldman MD (1 July 2016). "Factitious disorder: a systematic review of 455 cases in the professional literature". General Hospital Psychiatry. 41: 20–28. doi:10.1016/j.genhosppsych.2016.05.002. ISSN 0163-8343. PMID 27302720.
  9. ^ Jafferany M, Khalid Z, McDonald KA, Shelley AJ (22 February 2018). "Psychological Aspects of Factitious Disorder". The Primary Care Companion for CNS Disorders. 20 (1): 17nr02229. doi:10.4088/PCC.17nr02229. ISSN 2155-7780. PMID 29489075.
  10. ^ Repper J (1995). "Munchausen Syndrome by Proxy in health care workers". Journal of Advanced Nursing. 21 (2): 299–304. doi:10.1111/j.1365-2648.1995.tb02526.x. ISSN 1365-2648. PMID 7714287.
  11. ^ Weber B, Gokarakonda SB, Doyle MQ (2025), "Munchausen Syndrome", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30085541, retrieved 14 January 2025
  12. ^ Yates GP, Feldman MD (1 July 2016). "Factitious disorder: a systematic review of 455 cases in the professional literature". General Hospital Psychiatry. 41: 20–28. doi:10.1016/j.genhosppsych.2016.05.002. ISSN 0163-8343. PMID 27302720.
  13. ^ Sousa Filho Dd, Kanomata EY, Feldman RJ, Maluf Neto A (2017). "Munchausen syndrome and Munchausen syndrome by proxy: a narrative review". Einstein (Sao Paulo, Brazil). 15 (4): 516–521. doi:10.1590/S1679-45082017MD3746. ISSN 2317-6385. PMC 5875173. PMID 29364370.
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  15. ^ a b Sousa Filho Dd, Kanomata EY, Feldman RJ, Maluf Neto A (December 2017). "Munchausen syndrome and Munchausen syndrome by proxy: a narrative review". Einstein (São Paulo). 15 (4): 516–521. doi:10.1590/S1679-45082017MD3746. ISSN 2317-6385. PMC 5875173. PMID 29364370.
  16. ^ Caselli I, Poloni N, Ielmini M, Diurni M, Callegari C (2017). "Epidemiology and evolution of the diagnostic classification of factitious disorders in DSM-5". Psychology Research and Behavior Management. 10: 387–394. doi:10.2147/PRBM.S153377. ISSN 1179-1578. PMC 5729833. PMID 29270035.
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  20. ^ DSM-IV-TR. 1000 Wilson Boulevard, Arlington, VA 22209: American Psychiatric Association. January 2000. doi:10.1176/appi.books.9780890420249.dsm-iv-tr. ISBN 0-89042-024-6.{{cite book}}: CS1 maint: location (link)
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  22. ^ Kinns H, Housley D, Freedman DB (1 May 2013). "Munchausen syndrome and factitious disorder: the role of the laboratory in its detection and diagnosis". Annals of Clinical Biochemistry. 50 (3): 194–203. doi:10.1177/0004563212473280. ISSN 0004-5632. PMID 23592802.
  23. ^ Mulders MC, de Herder WW, Hofland J (7 May 2024). "What Is Carcinoid Syndrome? A Critical Appraisal of Its Proposed Mediators". Endocrine Reviews. 45 (3): 351–360. doi:10.1210/endrev/bnad035. ISSN 1945-7189. PMC 11074795. PMID 38038364.
  24. ^ Ma ZY, Gong YF, Zhuang HK, Zhou ZX, Huang SZ, Zou YP, Huang BW, Sun ZH, Zhang CZ, Tang YQ, Hou BH (21 May 2020). "Pancreatic neuroendocrine tumors: A review of serum biomarkers, staging, and management". World Journal of Gastroenterology. 26 (19): 2305–2322. doi:10.3748/wjg.v26.i19.2305. ISSN 2219-2840. PMC 7243647. PMID 32476795.
  25. ^ Rubinstein G, Osswald A, Hoster E, Losa M, Elenkova A, Zacharieva S, Machado MC, Hanzu FA, Zopp S, Ritzel K, Riester A, Braun LT, Kreitschmann-Andermahr I, Storr HL, Bansal P (1 March 2020). "Time to Diagnosis in Cushing's Syndrome: A Meta-Analysis Based on 5367 Patients". The Journal of Clinical Endocrinology and Metabolism. 105 (3): dgz136. doi:10.1210/clinem/dgz136. ISSN 1945-7197. PMID 31665382.
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  27. ^ "Overactive thyroid (hyperthyroidism) - Symptoms". nhs.uk. 3 October 2018. Retrieved 22 January 2025.
  28. ^ Persani L, dell'Acqua M, Ioakim S, Campi I (May 2023). "Factitious thyrotoxicosis and thyroid hormone misuse or abuse". Annales d'Endocrinologie. 84 (3): 367–369. doi:10.1016/j.ando.2023.03.008. ISSN 2213-3941. PMID 36963754.
  29. ^ CDC (8 January 2025). "Low Blood Sugar (Hypoglycemia)". Diabetes. Retrieved 22 January 2025.
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  31. ^ Sweetser S (June 2012). "Evaluating the Patient With Diarrhea: A Case-Based Approach". Mayo Clinic Proceedings. 87 (6): 596–602. doi:10.1016/j.mayocp.2012.02.015. ISSN 0025-6196. PMC 3538472. PMID 22677080.
  32. ^ Kinns H, Housley D, Freedman DB (1 May 2013). "Munchausen syndrome and factitious disorder: the role of the laboratory in its detection and diagnosis". Annals of Clinical Biochemistry. 50 (3): 194–203. doi:10.1177/0004563212473280. ISSN 0004-5632. PMID 23592802.
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  34. ^ Todd, Belinda (October 21, 2002)."Faking It" Archived 2011-07-17 at the Wayback Machine, New Zealand PC World Magazine. Retrieved on July 29, 2009.
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  37. ^ Weber B, Gokarakonda SB, Doyle MQ (2025), "Munchausen Syndrome", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30085541, retrieved 14 January 2025
  38. ^ Johnson BR, Harrison JA (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.
  39. ^ Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E (4 May 2020). "Psychological therapies for people with borderline personality disorder". The Cochrane Database of Systematic Reviews. 5 (5): CD012955. doi:10.1002/14651858.CD012955.pub2. ISSN 1469-493X. PMC 7199382. PMID 32368793.
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  42. ^ "Guideline Watch: Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 2nd Edition", APA Practice Guidelines for the Treatment of Psychiatric Disorders: Comprehensive Guidelines and Guideline Watches, vol. 1, Arlington, VA: American Psychiatric Association, 2006, doi:10.1176/appi.books.9780890423363.148217, ISBN 0-89042-336-9, retrieved 22 January 2025
  43. ^ www.apa.org https://www.apa.org/depression-guideline/adults. Retrieved 22 January 2025. {{cite web}}: Missing or empty |title= (help)

Bibliography

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