Many moons ago, when I was an intern in Boston, I was assigned to do a history and physical on a teenager. She had been hospitalized multiple times for recurrent kidney infections that had spread to her blood stream and nobody could figure out why, so the kidneys were removed as they were chronically infected, and now she was dialysis dependent. She also continued to have mysterious outbreaks of bacteria in her bloodstream. The puzzle had been solved by an astute physician, who found a syringe filled with cloudy fluid that contained the bacteria that she had been infected with in her room. It turned out that the patient's mother, with the patient's knowledge, had been injecting her with the bacteria. This was my introduction to Munchausen's syndrome.
Munchausen's syndrome is one of group of conditions known as "factitious disorders." In this variety, the person intentionally feigns a disease or self-induces an injury reflecting a need to appear sick in order to receive medical attention. It was named after Baron von Munchausen (1720-1797), who told widely exaggerated stories about his life adventures. The condition isn't like hypochondria because hypochondriacs really believe they have a particular disease. People with Munchausen's know they don't; but the risks they take by inducing symptoms, falsifying test results or undergoing invasive procedures justify the emotional support they receive from health care providers and facilities. Munchausen's patients often become so medically knowledgeable that they can produce symptoms that result in costly medical tests, long hospitals stays or even unnecessary operations. So while their physician is trying to diagnose any number of varying and uncontrollable symptoms, the true underlying cause goes undetected.
The cause of Munchausen's syndrome is unknown. Some factors that are commonly associated with it include childhood trauma, experiencing a serious illness during childhood that brought about sympathy and nurturing, poor self-esteem, low coping skills, or early abandonment. Personality disorders, including mood disorders, anxiety disorders or borderline personality disorder, have also been associated with Munchausen's syndrome.
And while dishonesty makes Munchausen's syndrome so difficult to diagnose, there are certain signs that health care professionals can look for. These include a dramatic, almost textbook presentation, but with multiple inconsistencies in the medical history, nonspecific symptoms that continually change, relapses despite apparently appropriate and effective treatment, the presence of multiple surgical scars, an eagerness for tests to be taken, and, if the results are negative, the appearance of new symptoms, and a history of being admitted to many different hospitals "hospital hopping." There is reluctance for the patient to give medical staff access to family members, friends or previous physicians.
Munchausen's symptoms are usually nonspecific, like chest pain, stomach problems or fever. These can indicate a wide range of possible illnesses from acid reflux, allergy and anemia to arthritis, back pain and breathing difficulties. But because the goal of a Munchausen patient is hospitalization or continued care, patients can simulate symptoms for conditions as serious as a heart attack, AIDS, arrhythmia, cancer or lupus. These patients can be very adroit at altering tests, such as heating up a thermometer or putting some blood in a urine sample.
But whichever disease or conditions a Munchausen's patient may choose to feign,
the potential complications are frighteningly real. These include severe injury or even death from self-inflicted medical conditions, damage to or loss of organs from unnecessary surgeries, substance or alcohol abuse, and suicide. Because the need to play the role of "patient" provides comfort and fills a psychological need, Munchausen's syndrome is usually treated with psychotherapy, cognitive (behavioral) therapy or medications for patients with an associated mood, anxiety or borderline personality disorder.
Munchausen's Syndrome by Proxy
As difficult as Munchausen syndrome is to diagnose and treat, Munchausen's syndrome by proxy (MSP) is even more insidious because the real sufferers are young children, generally under the age of six. With MSP, an adult will fake or induce symptoms of illness in his or her child (or in a child under their care) in order to appear devoted, and to develop a relationship with a physician or network of health care professionals. MSP patients are often willing to have their child undergo lengthy hospitalizations or painful or risky tests and treatments in order to get praise and attention. Indeed, the patient and her mother that I described above represented both Munchausen's in the daughter and MSP in the mother.
MSP isn't just a condition; it's child abuse and it's a crime. Even though it's recognized in the Diagnostic and Statistical Manual of Mental Disorders as a mental illness, the American Professional Society on the Abuse of Children defines it as child abuse and encourages health care professionals to watch for some specific signs. Does a child have a history of hospitalizations? Have the symptoms been witnessed by the physician or hospital staff, or only reported by the parent? Do the symptoms agree with the test results?
Because the mortality rate of children victimized by MSP patients can be quite high, when MSP is suspected, the first concern is for the safety and protection of the potential victim and his or her removal from the care of the person practicing MSP. Nevertheless, it is not recommended for the caregiver to be confronted directly, because he or she might move. Anyone who suspects a person might have MSP is advised to keep a journal of the child's symptoms or health care events, talk with a physician about the concerns, or report them to a local child welfare agency, which can also be done anonymously.
Munchausen's by Internet
A condition spawned by the digital age, this permutation of Munchausen's syndrome refers to people who go online to infiltrate support groups in order to fake a condition, emotional trauma, terminal illness or even their own death, in order to receive sympathy from group members, especially in support groups for the terminally ill. Because of its anonymity and lack of accountability, the Internet is the ideal environment to shelter and empower sympathy seekers. Although this disorder was described only 10 years ago, the incidence of it has increased steadily due to the explosion of social networking, online support groups and medical websites that provide all the information needed to perpetuate a hoax.
Fortunately, Munchausen's syndrome is rare. Nevertheless, it is imperative that it be recognized before the patients are subjected to expensive, unwarranted diagnostic and therapeutic activities, both for their sake as well as society's. A national registry of these patients that is readily accessible to hospitals and health care workers would be helpful in this regard.
Follow Glenn D. Braunstein, M.D. on Twitter: www.twitter.com/CedarsSinai