Basics
Description
- A neurotic disorder in which the patient fakes signs or symptoms without tangible personal benefit other than to experience the sick role.
- Most dramatic form of chronic factitious disorder with a predominance of physical findings.
- The nature of the disorder resists rigorous study but possible risk factors include:
- Males
- Less severe factitious disorders are more common in women
- Unmarried
- Age in the forties
- Personality disorder
- A history of sadistic and rejecting parents
- A history of chronic childhood illness
Etiology
- Factitious disorder:
- 3 DSM-IV diagnostic criteria:
- Intentional production of physical or psychological signs
- Motivation to assume the sick role
- Absence of external incentives
- Predominance of symptoms rather than physical findings
- Classic Munchausen syndrome:
- Most severe and chronic form of factitious disorders
- Predominantly physical findings
- Clinical clusters:
- Self-induced infection
- Simulated specific illnesses with no actual disorder
- Chronic wounds
- Self-medication
- Munchausen by proxy:
- The patients illness is caused by the caregiver, not the patient
- The motivation for the caregiver's behavior is to assume the sick role by proxy
- The caregiver inflicts injury or induces illness in their charge, usually a child
- Commonly parents (mostly mothers)
- May simulate injury and disease in a number of ways:
- Inflicts injury
- Induces Illness
- Fabricates symptoms
- Exaggerates symptoms of the child's illness causing overaggressive medical interventions
- The perpetrator usually refuses to acknowledge the deception
- Cessation of the symptoms when the patient and caregiver are separated
Caregivers of elderly patients may also be perpetrators in Munchausen by proxy
Diagnosis
Signs and Symptoms
History
- Inappropriate or bizarre use of the ED
- Frequent visits
- Numerous hospital admissions
- Peregrination: Travel from hospital to hospital
- Pseudologia fantastica:
- Intricate and colorful stories associated with the presentation
- Alteration of biographical information:
- Use of aliases
- Change date of birth by 1 digit
- Escalating demands for diagnostic testing and therapeutic interventions
- Hostility toward the health care providers when questioned
- Evasiveness regarding details of the presenting complaint
- The patient provides excessive medical documentation
- Masochistic acceptance of painful procedures
- The patient appears more comfortable than is likely considering the disease
- The patient demonstrates unusually strong medical knowledge
- Frequent homelessness and significant wandering between cities and states
- An absence of close interpersonal relationships
- Self-medication
- Abdominal complaints with history of repeated negative laparotomies (laparotomaphilia migrans)
- Witnessed intentional acts to fake illness:
- Inappropriate ingestion of medication to reproduce physical findings
- Injection of contaminants (feces, bacteria, sputum, corrosives)
- Self-induced wounds
- Swallowing blood to simulate a GI hemorrhage
- Self-phlebotomy
- Instrument tampering
Physical Exam
- Fever:
- Factious from manipulation of thermometer
- Induced from injection of contaminants
- Self-induced wounds
- Chronic wounds
- Multiple scars
- Foreign bodies in wounds, ear canals, urethra
Essential Workup
- Diligent detective work is needed:
- Retrieval of records from other hospitals
- Call on family members to discuss past history for inconsistencies and excessive use
- Call personal physician for background and to coordinate information
- Search patients room and belongings to establish the method of deception
- Conclusive proof of faking disease is needed to make the diagnosis
Diagnosis Tests & Interpretation
Lab
- Direct observation of the patient when obtaining tests to prevent faking results
- Commonly faked lab results:
- Hemoccult positive stool
- Hematuria (intentionally dripping blood into urine sample)
- Hypoglycemia (self-administration of insulin)
- Abnormal results from self-medication:
- Low hematocrit (ingestion of warfarin or self-phlebotomy)
- Elevated INR (ingestion of warfarin)
- Thyroid function tests (ingestion of thyroxine)
- Low serum glucose (injection of insulin or ingestion of sulfonylurea)
- Evidence of intent to fake illness:
- Testing stool for phenolphthalein may detect laxative abuse
- Serum C-peptide with high insulin levels:
- Low C-peptide: Exogenous administration of insulin
- Elevated C-peptide: Endogenous hypoglycemia or sulfonylurea ingestion
Imaging
Do not rely on imaging brought by the patient
Diagnostic Procedures/Surgery
Avoid unless clear objective findings indicate the necessity of a procedure
Differential Diagnosis
- True illness:
- Primary illness unrelated to a psychiatric disorder
- Secondary to a comorbid condition associated with factitious disorders:
- Secondary to self-destructive acts in patients with dementia, psychotic disorders, or mental retardation
- Secondary to diagnostic and therapeutic procedures
- Malingering:
- Conversion disorder:
- Deficits of the voluntary motor or sensory neurologic system that are not consciously produced
- Somatization disorder (hysteria, Briquet syndrome):
- Symptoms that involve multiple organs, that varies over time, and are not consciously produced
- Other neurotic disorders:
Treatment
Initial Stabilization/Therapy
Treatment should be limited to stabilization of life or limb threats caused by acts of self-harm
Ed Treatment/Procedures
- Identify objective physical illness and treat as appropriate
- Document history and findings suggestive of factitious illness
- List of all the aliases, addresses, and date of births that the patient is known to use
- Summarize the patients known modus operandi (the factitious histories and behaviors that he or she has presented with)
- Ensure that the information will be communicated or available to all doctors who are likely to come into contact with the patient
- Confrontation of the patient in the ED is controversial and should only occur when unambiguous evidence is gathered
- Report Munchausen syndrome by proxy to child protective services
Follow-Up
Disposition
Admission Criteria
- Injuries and disease caused by self-harm
- Munchausen by proxy:
- When the diagnosis is suspected but there is not enough evidence to have child protective services take custody
- Observation to collect evidence of faking disease:
- May also allow setting to rule out rare organic etiologies
- To establish a long-term plan to prevent future self-harm and iatrogenic adverse events
- Psychiatric admission may be of benefit, but it is rarely accepted by the patient
Discharge Criteria
- Medical stability
- Not an active threat to harm self
- Appropriate referral for medical and psychiatric follow-up arranged
Issues for Referral
- May offer psychiatric referral as a method of dealing with stress caused by illness
- Psychiatric providers located directly in medical settings (e.g., primary care physician office) may be more accepted. Overall, this is a chronic illness with poor prognosis
Followup Recommendations
Maintain contact between the patient and an identified provider for that patient.
Additional Reading
- Kenedi CA, Shirey KG, Hoffa M, et al. Laboratory diagnosis of factitious disorder: A systematic review of tools useful in the diagnosis of Munchausens syndrome. N Z Med J. 2011;124:66 " 81.
- Mehta NJ, Khan IA. Cardiac Munchausen syndrome. Chest. 2002;122(5):1649 " 1653.
- Robertson MM, Cervilla JA. Munchausen's syndrome. Br J Hosp Med. 1997;58(7):308 " 312.
- Souid AK, Keith DV, Cunningham AS. Munchausen syndrome by proxy. Clin Pediatr (Phila). 1998;37(8):497 " 503.
- Steel RM. Factitious disorder (Munchausen's syndrome). J R Coll Physicians Edinb. 2009;39:343 " 347.
- Stern TA. Munchausen's syndrome revisited. Psychosomatics. 1980;21:329 " 336.
- Walker EA. Dealing with patients who have medically unexplained symptoms. Semin Clin Neuropsychiatry. 2002;7:187 " 195.
See Also (Topic, Algorithm, Electronic Media Element)
Abuse, Pediatric
Codes
ICD9
301.51 Chronic factitious illness with physical symptoms
ICD10
- F68.11 Factitious disorder w predom psych signs and symptoms
- F68.12 Factitious disorder w predom physical signs and symptoms
- F68.13 Factitious disord w comb psych and physcl signs and symptoms
- F68.10 Factitious disorder, unspecified
- F68.1 Factitious disorder
SNOMED
- 21586000 Munchausens syndrome
- 95637005 Munchausen's by proxy