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Munchausen Syndrome, Emergency Medicine

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Munchausen Syndrome, Emergency Medicine

Basics

Description

Caregivers of elderly patients may also be perpetrators in Munchausen by proxy

Do not rely on imaging brought by the patient

Avoid unless clear objective findings indicate the necessity of a procedure

Treatment should be limited to stabilization of life or limb threats caused by acts of self-harm

Maintain contact between the patient and an identified provider for that patient.

  • 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:MalesLess severe factitious disorders are more common in womenUnmarriedAge in the fortiesPersonality disorderA history of sadistic and rejecting parentsA history of chronic childhood illness
  • 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 signsMotivation to assume the sick roleAbsence of external incentivesPredominance of symptoms rather than physical findings
  • Classic Munchausen syndrome:Most severe and chronic form of factitious disordersPredominantly physical findings
  • Clinical clusters:Self-induced infectionSimulated specific illnesses with no actual disorderChronic woundsSelf-medication
  • 3 DSM-IV diagnostic criteria:Intentional production of physical or psychological signsMotivation to assume the sick roleAbsence of external incentivesPredominance of symptoms rather than physical findings
  • Intentional production of physical or psychological signs
  • Motivation to assume the sick role
  • Absence of external incentives
  • Predominance of symptoms rather than physical findings
  • Most severe and chronic form of factitious disorders
  • Predominantly physical findings
  • 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 patientThe motivation for the caregiver's behavior is to assume the sick role by proxyThe caregiver inflicts injury or induces illness in their charge, usually a childCommonly parents (mostly mothers)
  • May simulate injury and disease in a number of ways:Inflicts injuryInduces IllnessFabricates symptomsExaggerates 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
  • 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)
  • Inflicts injury
  • Induces Illness
  • Fabricates symptoms
  • Exaggerates symptoms of the child's illness causing overaggressive medical interventions

Diagnosis

Signs and Symptoms

  • 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 aliasesChange 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 findingsInjection of contaminants (feces, bacteria, sputum, corrosives)Self-induced woundsSwallowing blood to simulate a GI hemorrhageSelf-phlebotomyInstrument tampering
  • Intricate and colorful stories associated with the presentation
  • Use of aliases
  • Change date of birth by 1 digit
  • 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
  • Fever:Factious from manipulation of thermometerInduced from injection of contaminants
  • Self-induced wounds
  • Chronic wounds
  • Multiple scars
  • Foreign bodies in wounds, ear canals, urethra
  • Factious from manipulation of thermometer
  • Induced from injection of contaminants

Essential Workup

  • Diligent detective work is needed:Retrieval of records from other hospitalsCall on family members to discuss past history for inconsistencies and excessive useCall personal physician for background and to coordinate informationSearch patients room and belongings to establish the method of deception
  • Conclusive proof of faking disease is needed to make the diagnosis
  • 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

Diagnosis Tests & Interpretation

  • Direct observation of the patient when obtaining tests to prevent faking results
  • Commonly faked lab results:Hemoccult positive stoolHematuria (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 abuseSerum C-peptide with high insulin levels:Low C-peptide: Exogenous administration of insulinElevated C-peptide: Endogenous hypoglycemia or sulfonylurea ingestion
  • Hemoccult positive stool
  • Hematuria (intentionally dripping blood into urine sample)
  • Hypoglycemia (self-administration of insulin)
  • 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)
  • Testing stool for phenolphthalein may detect laxative abuse
  • Serum C-peptide with high insulin levels:Low C-peptide: Exogenous administration of insulinElevated C-peptide: Endogenous hypoglycemia or sulfonylurea ingestion
  • Low C-peptide: Exogenous administration of insulin
  • Elevated C-peptide: Endogenous hypoglycemia or sulfonylurea ingestion

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 retardationSecondary to diagnostic and therapeutic procedures
  • Malingering:Clear-cut secondary gain
  • 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:AnxietyDepression
  • Primary illness unrelated to a psychiatric disorder
  • Secondary to self-destructive acts in patients with dementia, psychotic disorders, or mental retardation
  • Secondary to diagnostic and therapeutic procedures
  • Clear-cut secondary gain
  • Deficits of the voluntary motor or sensory neurologic system that are not consciously produced
  • Symptoms that involve multiple organs, that varies over time, and are not consciously produced
  • Anxiety
  • Depression

Treatment

Initial Stabilization/Therapy

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

  • 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
  • When the diagnosis is suspected but there is not enough evidence to have child protective services take custody
  • May also allow setting to rule out rare organic etiologies
  • Medical stability
  • Not an active threat to harm self
  • Appropriate referral for medical and psychiatric follow-up arranged
  • 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

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)

Codes

ICD9

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