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.     

A bewitching case of factitious disorder in Zimbabwe

A rural Zimbabwean man attributed the appearance of needles in his leg to witchcraft, but medical practitioners suspected that the needles were self-introduced. Psychiatric evaluation revealed no major mental illness. The patient met criteria for the Euro-American diagnosis of factitious disorder, persisting in his claim that he had been the victim of witchcraft. The patient's claim cannot be considered delusional because belief in witchcraft is culturally sanctioned within Shona culture. The case appears to be one of factitious disorder with both physical and psychological symptoms. Differential diagnoses must be broadened to consider culturally specific phenomena such as witchcraft.     

Malingering and associated syndromes

Malingering is the false and fraudulent simulation or exaggeration of physical and/or psychological symptoms. It is not a mental disorder, but rather a behavior pattern that may coexist with objectively diagnosed disease. Whatever form it takes, malingering is defined as conscious, voluntary, goal-directed behavior; the presence of a clearly definable goal differentiates malingerers from those with other forms of factitious illness.     

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.     

Psychiatric and behavioral correlates of factitious blindness

In factitious disorder, an individual feigns, exaggerates, or actually self-induces physical or psychiatric illness to achieve ends such as mobilizing care and concern, ventilating aggression, diminishing guilty feelings, or gratifying dependency wishes. We present 2 new cases of factitious binocular blindness, which has rarely been reported but readily illustrates the dramatic range of factitious illness behaviors. Psychiatric and behavioral correlates culled from these cases include extravagant claims about the impairment and ludicrous claims for nonvisual sensory abilities. These patients typically refuse psychiatric care, but earlier detection can help abort the illness deceptions and forestall iatrogenic complications.     

A case report of comorbid eating disorder and factitious disorder

A review of the literature on comorbid eating disorder and factitious disorder reveals that they are very rare. In this report the authors present the case of a 26-year-old Japanese female, who, in the midst of treatment for eating disorder, was found to be fabricating her physical symptoms, by injecting unclean water into her intravenous bottle. As a result she was diagnosed with factitious disorder.     

A pediatric case of factitious disorder with unexplained bleeding symptoms

Factitious disorder is characterized by deliberate production or imitation of physical or psychological symptoms in order to adopt the sick role. The disorder can be seen as factitious bleeding. Factitious bleeding is a rare disorder in pediatric population. The concomitant appearance of hemoptysis and hematuria in the same patient has not been previously reported. In this case report, we present a pediatric case of factitious disorder with both hemoptysis and hematuria.     

Conversion syndromes in neurology. A psychopathological and psychodynamic differentiation of conversion disorder, somatization disorder and factitious disorder

Conversion syndromes are frequent among medically unexplained somatic symptoms in neurology. A careful differential diagnosis must be carried out in a psychiatric consultation service. In a prospective study lasting for over four years 169 patients with pseudoneurological signs of conversion were included. From a clinical point of view the following conversion syndromes were presented: astasia/abasia: 27.2%, paresis/plegia: 24.3%, aphonia: 1.8%, hyp-/anaesthesia: 21.9%, blindness: 5.3%, non-epileptic seizures: 19.5%. According to the diagnostic criteria of DSM-III-R three subgroups were differentiated: conversion disorder (n = 132), somatisation disorder (n = 28), factitious disorder (n = 9). Intermittent courses of illness were prevailing in conversion disorder, whereas chronic courses predominated in the other two subgroups. High rates of psychiatric comorbidity were typical signs of somatisation disorder. Frequent autodestructive motives (suicidality, deliberate and covert self-harm, chronic pain, high rate of operations) in illness behaviour had to be registered in somatisation and factitious disorder. Both subgroups were characterised by frequent traumatic events during early development. Important socio-economic aspects of illness behaviour above all in somatisation and factitious disorder were underlined. The results are discussed in terms of psychiatric differential diagnosis and psychiatric comorbidity, psychodynamic evaluation, illness behaviour and therapeutic options in a C/L-service.     

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.     

Physical complaints and symptoms of somatizing patients.

The purpose of the study was to describe the physical complaints and symptoms of persistent somatization patients. Individuals in the general population (age 17-49 yr) with at least 10 general admissions during an 8-yr period were studied. Persistent somatizers (i.e. patients with more than six medically unexplained general admissions) were compared with patients whose admissions could be ascribed to well-defined somatic disorders. Somatizers were characterized by multiple symptoms from many organ systems, and their physical complaints simulated most types of somatic disorder. Although some symptoms were more common than others, none were infrequent, so neither 'classic' conversion symptoms nor pain symptoms were found to be especially characteristic of the persistent somatizer. Gender had no influence on number of registered symptoms, whereas the number increases with age. The finding question the use of a predefined symptom checklist in the diagnostic criteria for somatizing disorder. The major part of the somatizers present a different illness picture when admitted with medically unexplained disorders compared with admission for which no adequate medical explanation could be found. However, one fifth had, when admitted with a medically explained diagnosis, also been admitted with the diagnosis medically unexplained at another admission. One fifth of the persistent somatizers had been admitted at least once for factitious illness, but apart from the fact that they had more symptoms and admissions, they did not differ from the other persistent somatizers.     

A case of factitious disorder involving menstrual blood smeared on the face

This article presents a case of factitious disorder in which a female smeared menstrual blood on her face. The patient was admitted to our otolaryngology clinic complaining of bleeding from the mouth, nose, ears and eyes. This event reportedly occurred three to four times on a daily basis. She acknowledged nine prior admissions to different specialists over the last two years. Following psychiatric consultation, we diagnosed factitious disorder with predominantly physical signs and symptoms. She was started on Fluoxetine 20 mg/day and supportive interviews were organized. After diagnosis, we observed that her symptoms decreased over two months. The symptoms did not reoccur three to nine months after treatment. This case report outlines two important features. The first is that a case of this type has not been reported before, and the second feature is that this case demonstrates the effect of cultural factors greatly different from those seen in classical factitious disorder.     

Patients with medically unexplained symptoms: DSM-III diagnoses and demographic characteristics

This study reports DSM-III diagnoses and demographic characteristics of 100 patients consecutively referred to a university hospital consultation-liaison service for evaluation of medically unexplained symptoms suggesting physical disorders. Thirty-seven percent of patients received diagnoses of somatoform, dissociative, or factitious disorders, and 14% were felt to have psychologic factors affecting physical conditions. Although black and male patients were less often referred for medically unexplained symptoms, once referred they were more likely than white and female patients to receive diagnoses of somatoform, dissociative, or factitious disorders. Among patients with somatoform disorders, those with conversion disorder and somatization disorder tended to be young women, whereas those with psychogenic pain disorder were older and equally likely to be male or female.     

Identifying and Managing Malingering and Factitious Disorder in the Military

Malingering is the intentional fabrication of medical symptoms for the purpose of external gain. Along similar lines as malingering, factitious disorder is the intentional creation or exaggeration of symptoms, but without intent for a concrete benefit. The incidence of malingering and factitious disorder in the military is unclear, but likely under reported for a variety of reasons. One should be aware of potential red flags suggesting malingering or factitious disorder and consider further evaluation to look for these conditions. A deliberate and intentional management plan is ideal in these cases. Furthermore, a multi-disciplinary team approach, a non-judgmental environment, and the use of direct but dignity sparing techniques will likely be most “successful” when confronting the patient with malingering or factitious disorder.     

Behavioural and psychological management of somatic symptom disorders: An overview

Abstract

The number of patients who seek help at primary and secondary care for somatic symptoms which cannot be explained by any known medical condition is enormous. It has been proposed to rename ‘somatoform disorders’ in DSM-IV as ‘somatic symptom disorders’ in DSM-5. This is supposed to include disorders such as somatization disorder, hypochondriasis, undifferentiated somatoform disorder, pain disorder and factitious disorder. The reason for the renaming and grouping is that all these disorders involve presentation of physical symptoms and/or concern about medical illness. In the literature, there is considerable variation adopted with respect to diagnosis and in the approaches adopted for intervention. However, the common feature of these disorders is the chronicity, social dysfunction, occupational difficulties and the increased healthcare use and high level of dissatisfaction for both the clinician and the patient. A number of behavioural and psychological interventions for somatic symptoms have been carried out at primary, secondary and tertiary care settings and recently there have been more attempts to involve the primary care physicians in the psychological interventions. This review aims at giving an overview of the components of the behavioural and other psychological interventions available for addressing medically unexplained somatic symptoms and to present their efficacy.     

Ethical and management considerations in factitious illness: one and the same

The literature on factitious illness raises many ethical problems regarding diagnosis and treatment. The author briefly reviews ethical issues in factitious illness and argues for viewing these patients as autonomous citizens, capable of accepting responsibility for their behavior. Some factitiously ill patients psychologically resemble those with borderline personality disorder, and ethical implications are developed. In a case example, the author illustrates how good clinical management assists with the resolution or prevention of these ethical dilemmas.     

A review of the EEG literature on Ganser's syndrome

Ganser's syndrome has been classified as a histrionic disorder, a psychotic illness, a dissociative disorder, a factitious disorder, and an organic illness. The possibility of an underlying organic component to Ganser's syndrome is often implicated. A case which includes CT scan and EEG tests is presented and the EEG data in patients with Ganser's syndrome are reviewed. The majority of EEG data was not suggestive of any specific organic illness.     

A case of factitious homicidal ideation

Homicidal ideation is often fabricated or embellished by psychiatric patients in both the emergency room and inpatient settings. Typically, this symptom is malingered to achieve short-term hospital admission and temporary relief from complications of substance abuse, homelessness, and illicit activities. Very rarely, a patient may feign homicidal intent for the primary purpose of remaining in the role of patient (factitious disorder). Although factitious disorder with psychological symptoms has been described in a variety of circumstances, the psychiatric literature lacks any reports of factitious homicidal ideation. This is a report on the case of a patient who was civilly committed on numerous occasions for protracted periods based solely on his self-professed homicidal ideation. The case raises both forensic and clinical questions and reinforces the authors' belief that further investigation is needed to develop more sophisticated methods of detection, evaluation, and treatment of factitious disorder with psychological symptoms.     

False allegations of child physical abuse: a case of Münchausen by proxy-like syndrome?

The diagnosis of factitious disorder by proxy is still under investigation. Few studies have researched the psychological status and potential underlying psychopathology of the perpetrator, as well as the impact on the child's development and the pathological reactions of rearing a child within the context of a distorted reality. In this article, we present the case of a 12-year-old boy where this diagnosis was suspected. Both he and his parents brought forth false allegations of repeated physical abuse induced by his schoolteacher. The parents presented with shared psychosis and the child presented with conduct disorder, factitious disorder, and emotional problems. We suggest that this case represents a Münchausen by proxy-like syndrome involving both the legal and medical systems. Hypotheses regarding the pathogenesis of symptoms in the child are noted, underscoring the differences between Münchausen by proxy syndrome appearing in infancy with that appearing in older children.     

Patients who strive to be ill: factitious disorder with physical symptoms

OBJECTIVE: Factitious disorder with physical symptoms characterizes patients who strive to appear medically ill and assume the sick role. Clinical suspicion is highest for female health care workers in the fourth decade of life. This study was designed to analyze the diagnosis of factitious disorder, the demographics of affected patients, and intervention and treatment. METHOD: Retrospective examination was of 93 patients diagnosed during 21 years. Two raters agreed on subject eligibility on the basis of DSM-IV criteria and absence of a somatoform disorder and a plausible medical explanation. RESULTS: The group included 67 women (72.0%); mean age was 30.7 years (SD=8.0) for women and 40.0 years (SD=13.3) for men. Mean age at onset was 25.0 years (SD=7.4). Health care training or jobs were more common for women (65.7%) than men (11.5%). Most often, inexplicable laboratory results established the diagnosis. Eighty had psychiatric consultations; 71 were confronted about their role in the illness. Only 16 acknowledged factitious behavior. Follow-up data were available for only 28 patients (30.1%); maximum duration of follow-up was 156 months. Two patients were known to have died. Few patients pursued psychiatric treatment. Eighteen left the hospital against medical advice. CONCLUSIONS: Factitious disorder affects men and women with different demographic profiles. Diagnosis must be based on careful examination of behavior, motivation, and medical history and not on a stereotype. Laboratory data and outside medical records help identify suspicious circumstances and inconsistencies. Confrontation does not appear to lead to patient acknowledgment and should not be considered necessary for management.     

Psychogenic movement disorders

All varieties of movement disorders may be mimicked by a psychogenic disorder, most commonly tremor, dystonia, and myoclonus. Approximately 3% of patients seen in specialty clinics have a psychogenic movement disorder (PMD). The diagnosis of a PMD depends on not just ruling out an organic movement disorder, but moreover, recognizing features from the history and examination that are inconsistent or incongruous with an organic movement disorder. Most PMDs represent a conversion disorder, sometimes as part of a somatoform disorder; less common diagnoses include a factitious disorder or malingering. Co-morbid psychiatric illness is prevalent in patients with PMD including depression, anxiety, and personality disorders. Many PMDs remain chronic, but a multidisciplinary approach centering on psychiatric intervention can be successful. A shorter duration of symptoms and a co-existent treatable psychiatric disorder portend a better prognosis, whereas compensation and pending litigation are associated with a poorer prognosis.