Psychiatric Munchausen's syndrome. Literature review with case reports

The present study reviews the literature on Munchausen's syndrome. In a psychiatric hospital, out of a total of 775 admissions under the age of 65 in 1986, four patients were diagnosed as having Munchausen's syndrome (0.5%). The underlying pathology of these cases is discussed and suggestions for management and further research made.     

Factitious disorders with psychological symptoms.

BACKGROUND: Factitious disorders with psychological symptoms have been underdiagnosed and hence undertreated. Historically, the literature has focused on factitious disorder with physical symptoms, particularly Munchausen's syndrome. METHOD: The authors report three cases of factitious disorder with psychological symptoms that had diverse clinical presentations. RESULTS: Two of the patients had features of a psychiatric Munchausen's syndrome--being middle-aged, aggressive men who falsified their symptoms, treatments, and backgrounds. The third patient was a younger woman with comorbid substance abuse, dysthymia, and borderline personality disorder. CONCLUSION: The authors feel that there is a need for refinement of diagnostic criteria, greater awareness, and evaluation of treatment approaches for this condition.     

The diagnosis and treatment of Munchausen's syndrome

Patients with Munchausen's syndrome--a syndrome characterized by the intentional production of physical symptoms to gain the sick role-present a variety of challenges to health care providers. Their treaters quickly become frustrated by their demanding interpersonal styles, by deception and manipulation, and by multiple unrevealing diagnostic procedures. These difficulties can lead to poor outcomes for patients and staff alike. We present the case of a young woman whose presentation and subsequent evaluation led to significant distress among the hospital staff responsible for her care, and discuss the epidemiology, diagnosis, and management of patients with Munchausen's syndrome. The most important role of the psychiatrist in the treatment of Munchausen's syndrome is to help the primary treatment team manage the patient in the safest and most appropriate way. Such management includes avoiding unnecessary procedures, preventing further self-harm, and avoiding angry or threatening interactions with the patient. The prognosis for patients with Munchausen's syndrome appears to be poor; flexible and creative approaches that emphasize consistency of care and regular outpatient psychiatric treatment have had the greatest success.     

The onset of Munchausen's syndrome

Although Munchausen's syndrome is well known, its mode of onset and development are poorly understood. The authors describe an individual whose developmental history was notable for dyslexia and pathological lying from early childhood, and who later developed Munchausen's syndrome following an explosive separation from his terminally ill father. The patient's simulated genitourinary problems related directly to his father's renal malignancy. The development of his Munchausen syndrome is discussed with reference to his traumatic separation from his father as well and to his preexisting character pathology and probable central nervous system dysfunction.     

Further notes on Munchausen's syndrome: a case report of a change from acute abdominal to neurological type

Summary A rare case of Munchausen's syndrome beginning in early childhood is described. The diagnosis of Munchausen's syndrome was made at the age of 29 years, after the symptoms had changed from acute abdominal to neurological complaints, with feigned loss of consciousness, first ascribed to an encephalitis. Insight into the psychopathology of this patient is given by his biography, by assessment of a psychotherapist, who had treated him some years before, and by his observed profile in some psychological tests.     

Exaggeration of Symptoms or Psychiatric Munchausen's Syndrome by Proxy?

Prompt and accurate diagnosis of Munchausen's syndrome by proxy is essential in order to minimise the risk of iatrogenic and parentally-induced harm to the child. However, inaccurate diagnosis of MSBP may have devastating consequences for the child, family and professionals involved. 'Psychiatric' Munchausen's syndrome by proxy, which involves the presentation of signs and symptoms suggestive of a psychiatric disorder in the child, is even more difficult to diagnose and requires an unbiased and full assessment by the appropriate multidisciplinary team.     

The Munchausen patient in a forensic facility

The many reports in the literature of chronic factitious illness (Munchausen's Syndrome) have emphasized the difficulty of treating these patients because of their propensity to leave medical facilities as soon as the factitious nature of their symptoms is discovered, and because of their disinclination to accept psychiatric help. The authors report on their treatment of such a patient who was incarcerated for over ten years under a criminal commitment, and discuss methods for overcoming resistances to treatment in Munchausen's patients.     

Epileptic Munchausen's syndrome: a form of pseudoseizures distinct from hysteria and malingering

A young woman with seizures and status epilepticus sought and obtained hospitalization in at least 25 hospitals in the province of Quebec between 1980 and 1987. She was thought to have uncontrolled epilepsy; her treatment led to intoxication with anticonvulsants and once to anesthesia for three consecutive periods of 7 days each. The nonepileptic nature of her attacks was proven and a diagnosis of Munchausen's syndrome made. She was transferred to a psychiatric center where she committed suicide. We found no documented cases of epileptic chronic factitious disorder in the literature.     

Paleodigms and paleodigmatics: a new theoretical construct applicable to Munchausen's syndrome by proxy, child-abuse dwarfism, paraphilias, anorexia nervosa, and other syndromes

A paleodigm is a formulation of ancient folk wisdom that encodes a causal explanation in a saying or story that penetrates the idiom of everyday language and influences behavior. Although paleodigms are not, per se, causative, they have diagnostic, prognostic, and therapeutic significance in syndromes like Munchausen's syndrome by proxy.     

Dual factitious disorder

The DSM-III classification of factitious disorders encourages artificial separation into disorders with physical and those with psychologic symptoms. Despite documented examples of similar patients who present with psychiatric complaints, Munchausen's syndrome is usually considered a form of chronic factitious physical disorder. Three patients with both factitious physical and psychologic symptoms are presented. These patients illustrate the importance of focusing on the fundamental behavior of assuming the patient role, rather than on the specific category of symptoms. We recommend that the category of symptoms be used as a modifying statement, rather than defining separate disorders.     

Factitious hemiplegia and Munchausen's syndrome.

We report a case of a thirty-year-old woman suffering from chronic factitious disorder with hemiplegia. Such a pathomimia is very uncommon in Munchausen's syndrome. Indeed, most often, the clinical picture is characterised by acute abdominal pain, fainting, haemoptysis, precordialgia, hematemesis or dermatological lesions.     

Munchausen's syndrome: a reconceptualization of the disorder

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) delineates three categories of factitious disorders: chronic with physical symptoms (Munchausen's syndrome); factitious disorder with psychological symptoms; and other factitious disorders with physical symptoms. Munchausen's syndrome served as the prototype for all factitious disorders at the time DSM-III was drafted, partly due to the disproportionate attention given to this variant of the disorder. Clinical experience suggests that existing categories do not adequately provide for commonly seen forms of factitious illness. It is now recognized that factitious disorder is the result of a complex interaction of personality factors and psychosocial stressors that often present with both medical and psychiatric symptomatology. Proposed changes in the revised edition of the diagnostic manual DSM-III-R include separate categories of factitious disorder with psychological, physical, and both psychological and physical symptoms. A case report of a patient for whom extensive records and thorough psychological assessment were available is exemplary of a more common course of the disorder (both psychological and physical symptoms) that by current classification would be considered "atypical." A reconceptualization of the disorder that gives emphasis to course and clinical features is suggested.     

Munchausen's syndrome with hematuria and sepsis: an unusual case

An unusual case of Munchausen's syndrome is described in which a former microbiology technician was suspected of inoculating himself with contaminated material to produce sepsis and ingesting warfarin in the form of rat poison to cause hematuria. This combination of factitious disorders has rarely been reported. Other unusual features included a nonemergent presentation through the hospital emergency room and a clinical profile not typical of previously published cases.     

An adolescent in Istanbul with Munchausen's syndrome

This article presents the treatment period for a 16-year-old girl with Munchausen's syndrome. She was initially referred to the hospital with emphysema of the face, which turned out to be due to self-injection of air. She had an eight-month hospitalization period for the diagnosis of her condition. After the diagnosis was established she was treated by our psychiatric team and followed for 21 months successfully without recurrence.     

Hypernatremic thirst deficiency and memory disorders following hypothalamic lesions

Summary This report describes two patients with a hypodipsic-hypernatremic syndrome and memory disorders associated with hypothalamic lesions. The literature is reviewed. Pathophysiologic mechanisms underlying the syndrome and the therapeutic approach to these patients are discussed.     

The effects of a suspected case of Munchausen's syndrome by proxy on a pediatric nursing staff

Munchausen's syndrome by proxy is a relatively new diagnosis for a unique form of child abuse that involves a parent who creates or feigns illness in his or her child, and presents a “sick child” to the medical profession for assessment and treatment. Typically, while creating or feigning the child's illness, the parent usually appears to be “ideal” (i.e., especially attentive, caring, supportive, and close to the medical staff). The present study assessed the effects of a suspected case of Munchausen's syndrome by proxy on 20 pediatric nurses in a large midwestern children's hospital. After the child had left the hospital, the staff was given a ten-item open-ended questionnaire covering how they felt about the case, how the case affected their interactions with other parents, and how they professionally and personally coped with the physician's presumptive diagnosis. Only 10% of the staff had had previous experience with such a case, and 55% had not even heard of such a diagnosis. More than 70% of the staff felt they were professionally and personally unprepared for the case. Their initial reaction to the suspected diagnosis ranged from shock and disbelief to nausea and anger. The majority of the staff had perceived the parent as supportive, loving, and concerned. Yet, now they were confronted with information that suggested that the parent had nearly killed the child while on the unit, in order to keep that child in the hospital. Although almost every nurse eventually accepted the diagnosis, they felt their relationships with parents in general had changed. At first, the majority of nurses reported they were less trusting and more observant with the parents. Further, 40% of the staff felt they would continue to be more vigilant, and perhaps less trusting. The possible long-term staff effects are both positive and negative. While on the one hand, the staff now has greater knowledge and expertise in recognizing and treating such cases, at least a few of the nurses may continue to be less trusting and more cautious with other parents.     

A 3-year-old boy's chronic diarrhea and unexplained death.

The fatal case of a three year-old boy hospitalized for chronic diarrhea is described. The diagnosis of Munchausen's by Proxy is discussed, and the approach to such cases is explored.     

Capgras syndrome in adolescence.

Capgras syndrome, the delusion of substitution, has rarely been reported in adolescents. The etiology is unknown, and intense controversy surrounds the debate over the relative importance of biological versus psychological factors. Presented here are two cases of Capgras syndrome in adolescents and a review of the relevant biological, neuropsychological, and psychodynamic literature. The authors suggest that the psychological processes underlying the Capgras delusion are mediated by neuroanatomical connections between various brain areas and hypothesize that the fundamental lesion in Capgras syndrome may be the patient's inability or failure to acknowledge the authenticity of a person they clearly recognize.     

Juvenile Pearson syndrome

The clinical and magnetic resonance imaging findings of a 14-year-old boy with Pearson syndrome are presented. The patient represents the oldest living survivor of the original four patients described by Pearson and associates. This syndrome has recently been found to be associated with an mtDNA deletion. The patient reported here has a deletion similar but not identical to that reported in the literature. Several mitochondrial myopathies have been associated with mtDNA deletions, with considerable overlap between and among the phenotypes and underlying mtDNA deletions. The same may well prove to be true for Pearson syndrome.