AUTHOR INFORMATION

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Authored by William Ernoehazy, Jr, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Ed Fraser Memorial Hospital

William Ernoehazy, Jr, MD, FACEP, is a member of the following medical societies: American College of Emergency Physicians

Edited by Eric Kardon, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Athens Regional Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert C Harwood, MD, MPH, Program Director, Chair, Department of Emergency Medicine, Christ Hospital and Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago Medical School; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Craig Feied, MD, FACEP, FAAEM, FACPh, Professor of Emergency Medicine, Georgetown University, Director, National Institute for Medical Informatics, Director, Federal Project ER One, Director, National Center for Emergency Medicine Informatics

Author's Email:	William Ernoehazy, Jr, MD, FACEP
Editor's Email:	Eric Kardon, MD, FACEP

eMedicine Journal, February 28 2006, VOLUME 7, Number 2

INTRODUCTION

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Background: Patients who present with overt, demonstrable symptoms who subsequently prove to have factitious disease are particularly challenging to physicians.

Munchausen syndrome is distinguished from other factitious diseases by the lack of overt secondary gain. The patient's primary reason for continuing the deception is not to escape some consequence in life but rather reflects an apparent deep-seated need to be sick.

Richard Asher coined the eponym in 1951. Asher named the syndrome after Karl Friedrich Hieronymus, Baron Munchausen (1720-1797), a man who traveled widely and was renowned in his time for telling fantastic and exaggerated stories about his life.

Pathophysiology: The pathophysiology of this disorder is unknown. Patients with Munchausen syndrome often are noted to have associated personality disorders (eg, poor impulse control, self-destructive behavior, borderline or passive-aggressive personality trait or disorder). The relationship of these constellations of personality disorders to the primary syndrome is unclear; patients with Munchausen syndrome are extremely adept at concealing the fact that their diseases are factitious and are resistant to psychiatric evaluation. Information is often difficult to obtain.

Frequency:

• In the US: Rare

• Internationally: Rare

Mortality/Morbidity: The potential for significant inadvertent morbidity and mortality exists because patients with Munchausen syndrome go to extreme measures to simulate true organic diseases and may cause real disease in the process. For example, injection of exogenous material to produce febrile symptoms may result in local or systemic infection. Morbidity and mortality may also arise from unnecessary medications and procedures when physicians are taken in by the patient’s factitious symptoms.

Sex:

• The majority of patients suffering from Munchausen syndrome are male.

• The typical presentation of Munchausen syndrome is characterized by a restless journey from physician to physician and hospital to hospital, and an ever-changing list of complaints and symptoms, often buttressed by an alarming variety of self-intoxications and self-injuries designed to better portray the illness that the patient asserts he or she has.

• There is a subset of women patients who vary from the classic presentation in that they reproduce a single set of symptoms, repeatedly. Patients in this subset exhibit less evidence of comorbid personality dysfunction than the average patient with Munchausen syndrome, and they have a strong tendency to form personal bonds with a single physician or group of physicians.

Age:

• Incidence of Munchausen syndrome peaks in young–to–middle-aged adults, but it has been reported in patients of all ages (ie, childhood through advanced age).

• Pediatric Munchausen syndrome is a different disease from Munchausen syndrome by proxy (MSBP). MSBP is a syndrome in which an adult simulates or creates symptoms in a child to receive an ill-defined secondary gain from the child's hospitalization.

• MSBP is child abuse and must be dealt with when it is suspected. Because of the dangerous nature of the varied means used to create factitious symptoms, the mortality rate is significant; estimates range from 5-50%. MBSP is currently a topic of intense interest and research, given its potentially dire prognosis for the children who are victims.

CLINICAL

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History:

• Dramatic presentations of apparently severe illnesses

• Reported symptom patterns that fit diagnoses too perfectly and are too much like a textbook presentation

• A history of extensive surgical procedures and inpatient workups for a variety of diseases, particularly when the workup spans multiple hospitals and cities

• Notable vagueness or inconsistency in the details of the medical problems

• Evidence of pathological lying in areas other than the presenting symptoms

Physical:

• Patients with Munchausen syndrome may display any combination of signs and symptoms.

• In an effort to obtain hospitalization, an invasive workup, and therapies, patients with Munchausen syndrome may mimic any severe disease that generates physical findings and symptoms.

• Cardiac presentations of Munchausen syndrome are common enough to have allowed cardiologists to identify cardiac Munchausen syndrome—sometimes referred to as cardiopathia fantastica—as a distinct subset of the Munchausen spectrum.

Causes:

• Once a determination has been made that a disease presentation is factitious, the absence of a clear source of primary or secondary gain is the hallmark that distinguishes Munchausen syndrome from other factitious illnesses. No convincing explanation of secondary gain has yet been described in patients with Munchausen syndrome.

• In contrast to Munchausen syndrome, malingering patients have a clear primary gain in their efforts to escape some task or obligation.

• Conversion and somatoform disorders also are driven by a secondary gain. Treating the underlying stressor often can alleviate the presenting symptoms.

• In contrast, a patient with Munchausen syndrome actively seeks hospitalization and invasive painful procedures as a primary goal.

• Munchausen syndrome afflicts the patient who presents with the complaint. Munchausen syndrome by proxy involves inflicting injury on a child or other dependent person in order to simulate symptoms. There is no obvious or plausible secondary gain to the caretaker who performs these actions. Munchausen syndrome by proxy is a form of abuse and must promptly be acted upon when suspected.

DIFFERENTIALS

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Conversion Disorder
Munchausen Syndrome
Munchausen Syndrome by Proxy

Other Problems to be Considered:

Malingering

WORKUP

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Lab Studies:

• Depending upon the presenting complaint, any laboratory test used in the ED may be indicated in the initial evaluation of patients with underlying Munchausen syndrome.

• Laboratory results that are atypical in pattern (eg, dramatically positive results, paradoxically normal results) may be an early indication of the presence of a factitious illness. Efforts may then be made to refine the diagnosis.

Imaging Studies:

• As with laboratory testing, almost any imaging technique used in the ED may be indicated in the initial workup.

Procedures:

• If the initially credible impression suggests severe enough disease or the attempts the patient has made to mimic organic illness have themselves produced sufficient illness and/or injury, appropriate procedures for workup and/or treatment must be undertaken.

• Clinicians often become frustrated at the thought of performing invasive procedures on healthy people.

• Persons with Munchausen syndrome often develop remarkable skill in inducing or duplicating symptoms. Further, the ED physician has a duty not to ignore organic disease where it is plausibly believed to exist. These factors, in concert, often make the performance of such procedures unavoidable.

TREATMENT

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Prehospital Care: Emergency medical services (EMS) care will be directed at the initial presenting symptoms. It is unlikely that prehospital teams will be able to effectively establish a diagnosis of Munchausen syndrome, they should not attempt to do so.

Emergency Department Care: Initial care and stabilization of patients with Munchausen syndrome is driven by the presenting symptoms.

The fact that symptoms may well be the result of sophisticated lying or of self-injury or self-intoxication by the patient does not make the workup and treatment of those symptoms any less necessary.

Consultations:

• If in doubt, consult the appropriate specialist for the purported illness and arrange for admission to the hospital.

• If the diagnosis of Munchausen syndrome is clear, psychiatric consultation and referral should be offered to the patient even if admission for the patient's medical problems is declined.

• The patient nearly always declines such referrals, and a refusal should be documented in the patient's record.

• Although not intuitively obvious, persons with Munchausen syndrome generally do not meet criteria for involuntary admission to hospital. They are neither homicidal nor suicidal, and their mental illness does not incapacitate them (in most cases) sufficiently to impair their ability to carry out their activities of daily living. They thus fail statutory criteria for involuntary commitment as it is set forth in many states' laws. Psychiatric consultation should be sought if the issue is unclear in the state or province of the physician.

MEDICATION

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Drugs that may be proposed for a patient with Munchausen syndrome fall into 2 categories, (1) drugs used to treat the presenting symptoms, and (2) antipsychotic medications, which are used to treat the underlying condition.

The first category is necessarily broad because patients with Munchausen syndrome have portrayed nearly every disease known to medicine.

No good evidence exists that antipsychotic drugs have any effect on the course or prognosis of Munchausen syndrome.

FOLLOW-UP

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Further Inpatient Care:

• Inpatient admission will be indicated by the presenting symptoms.

• As mentioned in Procedures, there will come a time in the care of a patient with Munchausen syndrome when the suspicion of factitious illness has arisen, but evidence is insufficient to be certain of that diagnosis.

• Physicians have a duty not to miss authentic pathologies in the patient with a factitious illness, and the observation of such patients actually taking the steps to feign a symptom in a controlled environment often is the final step in securing the diagnosis of Munchausen syndrome.

Further Outpatient Care:

• At least one report exists of a patient being placed under legal restraint, house arrest, and mandatory outpatient psychiatric therapy in an attempt to deal with the patient's persistent disease.

• Given the current poor success rate of psychiatric interventions in Munchausen syndrome such an approach seems appropriate only as a last resort.

Transfer:

• Even if Munchausen syndrome is suspected, ordinary care must be provided until the patient is fully diagnosed. As with any other patient, if (1) a constellation of symptoms has placed, or appears to have placed, the patient in need of certain therapies, and (2) the initial hospital lacks the resources or staffing to deal with the symptoms in question, then transfer to a secondary or tertiary referral center should be arranged, in accordance with federal law and established clinical practice.

Complications:

• Manifold complications may occur from the simulation of symptoms, depending upon the technique that the patient used to induce such symptoms. The severity of complications may range from trivial to lethal.

Prognosis:

• The prognosis for patients with Munchausen syndrome generally is poor.

• There is no substantial understanding of the psychopathology of this disorder.

• Patients generally are unwilling to undergo therapy. Even if they are willing, no good therapeutic strategy exists.

Patient Education:

• Patients with Munchausen syndrome may even present in self-help groups; reports are now surfacing of such patients using Internet-based patient support groups to fulfill their need to "be sick." Physicians who assist such groups may run across such cases, or their colleagues may ask about such things, having become frustrated when dealing with such people.

• For excellent patient education resources, visit eMedicine’s Mental Health and Behavior Center. Also, see eMedicine’s patient education article Munchausen Syndrome.

MISCELLANEOUS

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Medical/Legal Pitfalls:

• Rushing to a diagnosis of a factitious disorder and, as a result, missing the presence of an authentic organic disease, may result in litigation.

• Other pitfalls that might delay or adversely affect the care of the patient, causing morbidity and mortality include the following:

• Inadequate effort to distinguish Munchausen syndrome, malingering, and conversion disorders

• Misdiagnosing patients as having any of the factitious illness syndromes because of unpleasant personality traits

• Attributing symptoms to the Munchausen syndrome without proper investigation (Patients with documented Munchausen syndrome are as susceptible to develop true disease as any other patient.)

TEST QUESTIONS

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CME Question 1: A 6-year-old girl has a history of mysterious and recurrent urinary tract infections, which have led to 12 hospital admissions, multiple major procedures (eg, intravenous pyelograms, cystoscopies, pelvic examinations under anesthesia), and antibiotic-induced drug reactions. Although her mother was described by nurses as cooperative, concerned, and loving, the mother was eventually discovered to be contaminating her daughter’s urine specimens. The child’s examination findings were normal and her urinary tract infections disappeared when she was separated from her mother. Which of the following is a true statement?

A: The mother has Munchausen syndrome and the daughter has Munchausen syndrome by proxy.
B: The mother has Munchausen syndrome by proxy.
C: The child has Munchausen syndrome by proxy.
D: Munchausen syndrome by proxy is a mental illness, and it is not child abuse.
E: None of the above statements are true.

The correct answer is C: The child has Munchausen syndrome by proxy. This is a form of child abuse. The mother does have a psychiatric illness.

CME Question 2: An 80-year-old woman who has Alzheimer disease and lives with her son has a history of multiple admissions to several different hospitals for genitourinary sepsis. Despite his questionable ability to provide her with appropriate care, the son repeatedly declines offers for nursing home placement. Investigation reveals that her admissions correspond to her son’s vacation trips to Las Vegas and the Caribbean. On her discharge date, her son again flies back into town. The use of a hidden camera discovers the son injecting the patient’s feces into her Foley catheter. Which of the following statements is true?

A: By definition, Munchausen syndrome by proxy only involves pediatric patients.
B: Although atypical, this example is a case of Munchausen syndrome by proxy.
C: This is a case of Munchausen syndrome, but it is not a factitious disorder by proxy.
D: This is a case of factitious disorder by proxy, but it is not Munchausen syndrome because there is an identifiable secondary gain for the caregiver.
E: None of the above statements are true.

The correct answer is D: This is a case of abuse and factitious disorder by proxy. It cannot be considered Munchausen syndrome by proxy because the son appears to receive primary benefit from his mother’s illnesses. By keeping her out of a nursing home, he is able to control more of her retirement income. By making her sick, he is able to let the hospital care for her while he has the freedom to travel. In Munchausen syndrome by proxy, the abuser’s primary motivation is unclear, but it usually involves relishing the role of a sick person by proxy. The abuser may have suffered from Munchausen syndrome sometime in the past. The abuser enjoys being a star. For example, in this case the abuser may enjoy hearing someone say, “I have never seen a son so dedicated towards his mother” or “Your mother’s illness has stumped 10 different consultants.” In some cases, the abusers are addicted to medical care. Munchausen syndrome by proxy is not limited to children. Any dependent adult (eg, elderly, handicapped, disabled) can be victimized.

Pearl Question 1 (T/F): Munchausen syndrome, like other factitious illnesses, occurs in association with some source of secondary gain for the patient.

The correct answer is False: The hallmark of Munchausen syndrome is the presence of ominous symptoms that are factitiously produced by the patient in the absence of any plausible secondary gain or psychological benefit other than receiving invasive studies and/or hospitalization. All other factitious illnesses are driven by some kind of secondary gain.

Pearl Question 2 (T/F): Persons with Munchausen syndrome do not present with real illnesses.

The correct answer is False: The most dangerous error in the management of the patient with Munchausen syndrome is the assumption that a patient with known or suspected Munchausen syndrome is presenting a factitious complaint. Organic disease does occur in patients who are prone to factitious illness, and ignoring such a disease can result in fatality.

Pearl Question 3 (T/F): Munchausen syndrome by proxy is reportable abuse.

The correct answer is True: Munchausen syndrome afflicts the patient who presents with the complaint. Munchausen syndrome by proxy involves inflicting injury on a child or other person in order to simulate symptoms so that hospitalization occurs; furthermore, there is no obvious or plausible secondary gain to the caretaker who performs these actions. Munchausen syndrome by proxy is abuse and must promptly be acted upon when suspected.

Pearl Question 4 (T/F): Antipsychotics play a key role in the ED treatment of patients with Munchausen syndrome.

The correct answer is False: No antipsychotic medication or psychotherapeutic intervention has proven to be effective in ablating the self-injuring impulses of the patient with Munchausen syndrome. Despite this, psychiatric follow-up should be offered to a patient with Munchausen syndrome when the diagnosis can be established.

BIBLIOGRAPHY

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• Asher R: Munchausen's syndrome. Lancet 1951 Feb 10; 1(6): 339-41[Medline].
• Bretz SW, Richards JR: Munchausen syndrome presenting acutely in the emergency department. J Emerg Med 2000 May; 18(4): 417-20[Medline].
• Elmore JL: Munchausen syndrome: an endless search for self, managed by house arrest and mandated treatment. Ann Emerg Med 2005 May; 45(5): 561-3[Medline].
• Falagas ME, Christopoulou M, Rosmarakis ES, et al: Munchausen's syndrome presenting as severe panniculitis. Int J Clin Pract 2004; 58(7): 720-2[Medline].
• Feldman MD: Munchausen by Internet: detecting factitious illness and crisis on the Internet. South Med J 2000 Jul; 93(7): 669-72[Medline].
• Hall DE, Eubanks L, Meyyazhagan LS: Evaluation of covert video surveillance in the diagnosis of munchausen syndrome by proxy: lessons from 41 cases. Pediatrics 2000 Jun; 105(6): 1305-12[Medline].
• Huffman JC, Stern TA, Huffman JC, Stern TA: The diagnosis and treatment of Munchausen's syndrome. Gen Hosp Psychiatry 2003; 25(5): 358-63[Medline].
• Ifudu O, Kolasinski SL, Friedman EA: Brief report: kidney-related Munchausen's syndrome. N Engl J Med 1992 Aug 6; 327(6): 388-9[Medline].
• Lad SP, Jobe KW, Polley J, et al: Munchausen's syndrome in neurosurgery: report of two cases and review of the literature. Neurosurgery 2004; 55(6): 1436[Medline].
• Olry R: Baron Munchhausen and the syndrome which bears his name: history of an endearing personage and of a strange mental disorder. Vesalius 2002 Jun; 8(1): 53-7[Medline].
• Park TA, Borsch MA, Dyer AR, et al: Cardiopathia fantastica: the cardiac variant of Munchausen syndrome. South Med J. 2004 Jan;97(1):48-52; quiz 53 2004; 97(1): 48-52[Medline].
• Rabinerson D, Kaplan B, Orvieto R, et al: Munchausen syndrome in obstetrics and gynecology. J Psychosom Obstet Gynaecol 2002; 23(4): 215-8[Medline].
• Smith MS: Factitious illness, malingering, and conversion disorder. In: Harwood-Nuss AL, Linden CH, Luten RC, et al, eds. The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1996:986.
• Zuger A, O'Dowd MA: The baron has AIDS: a case of factitious human immunodeficiency virus infection and review. Clin Infect Dis 1992 Jan; 14(1): 211-6[Medline].

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