The medical case literature provides compelling documentation of patients who have intentionally exaggerated, feigned, simulated, aggravated, or self-induced an illness or injury for the primary purpose of assuming the sick role. These occurrences were documented in the modern medical literature as early as the mid-19th century, and were identified as a distinct psychiatric disorder in 1951 by Asher, who coined the term Munchausen syndrome.
Although many health professionals use the term to describe all persons who intentionally feign or produce illness in order to assume the sick role, Munchausen syndrome is not included as a discrete mental disorder in the World Health Organization’s International Statistical Classification of Diseases, 10th Revision (ICD-10) or in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). In both systems, the official diagnosis in these cases is factitious disorder (FD) (F68.1 in the ICD-10; 300.16 or 300.19 in the DSM-IV-TR). Nevertheless, numerous experts have identified a distinct subset of patients with FD for whom they reserve the term Munchausen syndrome.
The DSM-IV-TR diagnostic criteria for FD are as follows:
The patient intentionally produces or feigns physical or psychological signs or symptoms.
Motivation for the behavior is to assume the sick role.
External incentives for the behavior are absent.
The following subtypes are specified in the DSM-IV-TR.
Patients with primarily physical signs and symptoms (300.16)
Patients with primarily psychological signs and symptoms (300.19)
Combined subtype (300.19)
The subtype referred to as Munchausen syndrome lacks its own code but can be distinguished by the following characteristics:
The factitious illness behavior is particularly chronic and severe and may be practiced to the exclusion of most other activities. The signs and symptoms of illness or injury are intentionally produced through medically dangerous manipulations of the patient’s body (eg, self-inflicted infection, superwarfarin ingestion), thereby virtually guaranteeing hospitalization. These patients willingly, if not eagerly, submit to invasive interventions such as surgery.
Peregrination, also commonly called itinerancy in the professional literature, is observed. The patient may move from hospital to hospital, town to town, and even country to country to find a new audience once his or her ruse is uncovered.
Pseudologia fantastica is present in classic cases. The patient makes false claims about distinguished accomplishments, educational credentials, relations to famous persons, etc.
Some authors invoke additional diagnostic elements in addition to the triad described above. For instance, in relation to peregrination and pseudologia fantastica, the patient may use aliases or adopt false identities. Patients with Munchausen syndrome have little or no significant social contact with anyone other than health care professionals.
The published literature on FD is almost entirely limited to case reports and clinical guidelines based on unsystematic clinical observations (the subjectivist approach). Apparently, only 2 empirical studies of persons with Munchausen syndrome exist. The lack of systematic research is attributable to the reluctance of these patients to admit to their deceit or to cooperate with psychiatric investigations.
The literature on FD and Munchausen syndrome is not based on scientifically established facts so much as anecdotal and single case reports. In either scenario, the terms may have been misapplied. A peculiarity of the case literature on FD is that it reflects a bias toward the more extreme cases and those that pose the greatest medical danger, ie, cases that almost always involve induction of actual severe illness by the patient (eg, suppression of bone marrow through surreptitious use of chemotherapy medications).
No brain defect or dysfunction has been established to cause the behavior patterns that characterize Munchausen syndrome or FD more generally. A study of 5 cases of Munchausen syndrome suggested neurocognitive deficits. One case study reporting on the results of single-photon emission computed tomography (SPECT) analysis found hyperperfusion of the right hemithalamus in a patient with FD. It remains to be seen whether these results are replicable in larger samples, and if so, how these brain dysfunctions are linked to factitious illness behavior.
Epidemiological data on FD are scarce. Patients with FD are generally not open and honest about their medical deceptions. Because epidemiological studies of the general population rely on respondents’ self-reports, estimating the prevalence of FD in the general population is impossible. Patients with Munchausen syndrome, who may not have a fixed address or a telephone number, are unlikely even to be recruited for such studies.
Studies of medical patients suggest that the prevalence of FD is probably in the range of 0.2-1% of hospital inpatients. Although patients with Munchausen syndrome have appeared with almost every medical condition, the prevalence is particularly high in a few select settings. These include patients who present with persistent rashes and nonhealing wounds, unexplained anemia, neurological problems, endocrine-related problems, hematuria, and joint and connective-tissue symptoms.
As might be expected, the prevalence is even higher among patients with unexplained or intractable medical complaints. For example, 9.3% of a sample of persons with fever of unknown origin were determined to have simulated or produced fevers. Another study found that an astounding 40% of brittle diabetics altered their medication compliance or diet to intentionally produce diabetic instability.
No epidemiological studies address the rate of FD or Munchausen syndrome in countries and cultures outside the United States and western Europe. Case reports indicate that the diagnosis of FD has been made in eastern Europe, Mediterranean countries, Asia, Africa, and South America.
Four features of FD that are particularly prominent in Munchausen syndrome significantly increase morbidity and mortality risk.
The first is dangerous manipulations of the patient’s own body, including the ingestion of chemical toxins, self-infection, aggravation of wounds, and so on. Although patients with Munchausen syndrome are generally medically knowledgeable and sophisticated, their manipulations sometimes result in unintended serious injury, permanent disability, or death.
Second, the patients place themselves at risk for iatrogenic illness and injury by repeatedly engaging in deceptions that cause medical care providers to perform risky diagnostic and treatment procedures. In some cases, the resultant damage is part of the patient’s plan. For example, a patient who pretends to have a malignancy may desire the adverse effects of chemotherapy, or a patient may simulate adrenal gland dysfunctions with the intention of having an adrenal grand removed. In other cases, the iatrogenic damage results from unintended medical accidents such as adverse medication effects, allergic reactions, or surgical complications. Because patients with Munchausen syndrome subject themselves to so many medical procedures, their lifetime risk of experiencing an unintended adverse medical event is many times greater than that of the average person.
Third, patients with Munchausen syndrome frequently provide incomplete or false medical history information that intentionally or accidentally causes increased morbidity or mortality risk. For example, they may experience dangerous adverse medication effects because they withhold information about known drug allergies, or they may suffer surgical complications because they fail to inform the medical staff that they have taken anticoagulant medications.
Finally, although patients with FD or Munchausen syndrome are more likely than typical patients to claim illness or injury, they are no less likely than anyone else to actually become ill or injured. However, for genuinely ill patients with a known history of factitious medical complaints, medical staff may delay or withhold necessary tests and treatments to minimize unnecessary iatrogenic risks and to avoid reinforcing patients’ inappropriate behavior. As with the boy who cried wolf in Aesop’s famous tale, patients with Munchausen syndrome may be unable to mobilize the serious attention of medical staff when they truly need it.
The case literature clearly shows that most patients with Munchausen syndrome are white. In the absence of demographic data describing the racial/ethnic composition of the patient populations in which these cases were identified, it is currently impossible to know whether race represents a significant risk factor.
Among Munchausen syndrome cases described in published reports, there are many more cases of male patients than female. This observation is particularly noteworthy in light of the fact that the literature on FD and the somatoform disorders suggests a much higher prevalence among women than men.
The published cases of Munchausen syndrome generally describe patients aged 30-50 years. Infants and toddlers whose medical problems reflect intentionally produced signs of illness or injury are typically abused by a parent or other custodial adult (see Munchausen Syndrome by Proxy). The diagnostic picture is much less clear in cases of older children and young adults, who may be feigning illness on their own but who also may be encouraged to adopt the sick role by a parent or other custodian.
The self-reported medical history of patients with Munchausen syndrome might be extensive. In these cases, the lack of medical documentation to substantiate the self-reported medical history is notable, and the patient might claim that the previous injuries or illnesses occurred in a foreign country or that the records of the treating physician were destroyed in a fire. They often decline to sign releases of information and give odd excuses in denying access to relatives and friends.
Alternatively, the patient may lie and deny an extensive medical history. Such reports are sometimes contradicted by surgical scars, other evidence from the physical examination, or the laboratory, radiologic, or other test findings that suggest a significant medical/surgical history (eg, the presence of benign surgical clips). The patient’s description of his or her current problem and medical history may be overly dramatic or inconsistent. The literature is replete with tales of patients who diverted all attention to themselves in the ED by appearing to be spewing blood or having sustained seizures. At the same time, the patients might be surprisingly vague or guarded about the details of their medical history, especially regarding details of prior treatments.
The case literature describes cases in which the patients repeatedly simulated or self-induced a single medical problem (eg, nonhealing wounds) and a roughly equal number of cases in which individual patients presented over time with a wide diversity of medical problems. Although a history involving diverse symptoms and organ systems has been regarded by a few authors as an important indicator of FD and Munchausen syndrome, this feature is not a sensitive indicator.
Patients with Munchausen syndrome are seldom willing to admit that they have feigned or caused their own medical or emotional problems. When confronted by medical and nursing staff or with policies they find offensive (eg, no leaving the unit at will), they often become angry and discontinue their care at that particular facility. Against-medical-advice (AMA) discharges are common, as are threats of retribution through lawsuits or physical attacks.
Few patients agree to accept psychiatric consultation or psychological assessment. Among those who do, many report a history of physical, emotional, or sexual abuse or physical or emotional neglect. Many describe having been separated from the family for extended periods or note that, at a young age, a spontaneous illness (eg, appendicitis) introduced them to the care and concern elicited by the sick role.
Unlike the latter, a pattern of claims of childhood abuse and neglect is also observed among the wider population of patients who present with chronic unexplained medical complaints. Abuse and neglect have been linked to the development of personality disorders, particularly the more florid and dramatic ones (cluster B), especially borderline personality disorder. These personality disorders are frequently comorbid with Munchausen syndrome. Whether a unique link exists between abuse and factitious illness behavior that is independent of their mutual relation to these personality disorders is unknown.
Note that patients who truly have Munchausen syndrome engage in chronic lying. Their reports of childhood abuse might be spurious, even if detailed and elaborate. This potential indicator is supported by case studies of persons who presented with various sorts of factitious victimization complaints such as false reports of rape, stalking, battery, or sexual harassment. Given the extent of the lies and deceptions that are a central component of Munchausen syndrome, it is not surprising that a particularly strong connection apparently exists between Munchausen syndrome and antisocial personality disorder.
The physical examination of the patient with Munchausen syndrome frequently suggests an extensive history of illnesses and injuries. Older patients might show evidence of multiple surgical scars on the abdomen, indicating numerous exploratory surgeries. As in conversion disorder, the neurological examination may reveal inconsistent findings.
For example, patients with paralysis may have normal muscle tone in the affected limb, or anesthesias might not follow the anatomical distribution of peripheral nerves. Other physical inconsistencies include an absence of signs of dehydration in patients complaining of persistent diarrhea and vomiting. Clinicians should look to case reports in their medical specialties to acquaint themselves with the types of factitious complaints that have been observed by their colleagues and the means by which these deceptions were carried out and eventually uncovered.
Patients with FD with psychological signs and symptoms, or those simulating neuropsychological problems, often present with patterns of symptoms that do not match known syndromes or diagnostic categories. For example, they may portray the euphoric mood and pressured speech characteristic of a manic episode but show no disruptions in sleep.
Specific symptoms might be presented in an atypical manner. For example, a patient feigning dementia might perform poorly on both recent and remote memory tests, or a patient feigning a closed head injury might show more errors than would be expected by chance on a visual discrimination test.
Psychological and neurocognitive symptoms might appear worse when the patient is undergoing active examination then when the patient is casually interacting with staff members or other patients. The patient with dementia who could not remember any of 3 items after 5 minutes might later complain that the cafeteria served the same entrée 2 nights in a row.
The causes of Munchausen syndrome are unknown. These patients are so elusive that it is nearly impossible to conduct systematic empirical research on them. Psychoanalytic hypotheses have been put forth to explain Munchausen syndrome, but the volume of this work is quite small compared to the pertinent literature on the psychodynamics of the somatoform disorders.
False illness experiences in the somatoform disorders are regarded as unconsciously produced and are therefore amenable to traditional psychoanalytic explanations involving the notion of defense against unacceptable wishes or unspeakable fears. Because the false illness behavior in FD is conscious and intentional, explanations involving unconscious processes are less compelling when applied to FD. Nevertheless, some psychoanalytic writers have argued that whereas the illness behavior of FD patients is conscious, the reasons for the behavior are not.
Several authors have regarded factitious illness behavior as a primitive defense mechanism against sexual and aggressive impulses. Others have hypothesized that patients with FD subject themselves to painful medical procedures as a form of self-punishment. It has also been hypothesized that the cruel and embarrassing deception of physicians is an expression of oedipally based hostility toward authority figures.
More contemporary theorizing has focused on gratuitous sick-role behavior as a reflection of problems with object relations. These authors have focused on the high degree of comorbidity with the cluster B personality disorders and have suggested that the sick-role behavior of patients with FD might serve as a means of establishing or stabilizing the patient’s sense of self and their relations to others. Enactment of the sick role confers unconditional acceptance and concern, and admission to a hospital gives patients a clearly defined role in a social network. This automatic sense of importance and belonging might be difficult for patients with Munchausen syndrome to secure in more routine social contexts.
Case studies support the role of social learning mechanisms in factitious illness behavior. Many patients with FD have either personally experienced a severe illness in childhood or as a child had a family member who experienced a severe illness. Through these experiences, the child is introduced to the various benefits and dispensations attached to the sick role, and these experiences may predispose persons with other psychological vulnerabilities to engage in factitious illness behavior.