What is Munchausen syndrome

The Munchausen syndrome and Munchausen syndrome by proxy are factitious disorders characterized by fabrication or induction of signs or symptoms of a disease, as well as alteration of laboratory tests ¹. People with Munchausen syndrome pretend that they are sick and tend to seek treatment, without secondary gains, at different care facilities. The term “Munchausen syndrome” was first described in the literature by Asher in 1951 ², to characterize individuals who intentionally produce signs and symptoms of a disease and who tend to seek medical or hospital care. Later, in 1977, Meadow used the term “Munchausen syndrome by proxy” to describe children whose mothers produce histories of illness to their children and who support such histories by fabricated physical signs and symptoms, or even by alter laboratory tests ³. The Munchausen syndrome and Munchausen syndrome by proxy are frequently observed by health teams in clinics, hospital wards and emergency rooms.

The term “Munchausen” is associated with the fictitious Baron von Munchausen, an extravagant raconteur, whose fanciful narrations of his imagined exploits made his name in literature ³. Physicians have borrowed his name to describe a group of patients whose complaints are fabricated but so convincing that they are subjected to needless hospitalizations, laboratory tests, and even surgery. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) refers to Munchausen syndrome as “factitious disorder” as those imposed on self and on other (previously called “factitious disorders by proxy”) ⁴ and motivations for this bizarre behavior continue to puzzle both medical and mental health professionals.

Main characteristics of Munchausen syndrome (factitious disorder imposed on self) are feigning of physical and/or psychological signs and symptoms and induction of injury or disease associated with identified fraud. The diagnosis criteria in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to factitious disorder imposed on self are described in Table 1, and the criteria for factitious disorder imposed on other are described in Table 2 ⁴.

Munchausen syndrome was included in the tenth edition of the International Classification of Diseases ⁵ and classified as intentional production or feigning of symptoms or disabilities either physical or psychological (factitious disorder).

Munchausen syndrome has also been called “hospital addiction”, “polysurgical addiction,” and “professional patient syndrome” ⁵.

Munchausen syndrome (factitious disorder imposed on self) symptoms can range from mild (slight exaggeration of symptoms) to severe. The person may make up symptoms or even tamper with medical tests to convince others that treatment, such as high-risk surgery, is needed.

Munchausen syndrome (factitious disorder imposed on self) is not the same as inventing medical problems for practical benefit, such as getting out of work or winning a lawsuit. Although people with factitious disorder know they are causing their symptoms or illnesses, they may not understand the reasons for their behaviors or recognize themselves as having a problem.

Munchausen syndrome (factitious disorder imposed on self) is challenging to identify and hard to treat. However, medical and psychiatric help are critical for preventing serious injury and even death caused by the self-harm typical of this disorder.

Munchausen syndrome by proxy (factitious disorder imposed on other) is classified in the category of abuse of children, although this term is also used to refer to elderly or disabled person and/or dependent adults whose signs or physical symptoms are created by a caregiver and whose laboratory tests were altered ⁶.

Table 1. Diagnostic criteria for Munchausen syndrome (factitious disorder imposed on self)

A. The patient feigns psychological and physical signs and symptoms, or induction of lesion or disease; factitious disorder
B. The individual presents him/herself to others as ill, impaired or injured
C. Fraudulent behavior is evident even in the absence of obvious external rewards
D. Individual’s behavior is no longer well explained by a disorder, such as delirium or other psychotic condition
Specify:
	Single episode
	Recurrent episodes (two or more events of feigning diseases and/or induction of injury)

[Source ⁴]

Table 2. Diagnostic criteria for Munchausen syndrome by proxy (factitious disorder imposed on other)*

A. Psychological and physical signs and symptoms, or induction lesion or disease on other are feigned in association with identified fraud
B. Individual presents the other (victim) as ill, impaired or injured
C. Fraudulent behavior is evident even with absence of obvious external rewards.
D. Individual’s behavior is no longer well explained by a disorder, such as delirium or other psychotic condition
	Single episode
	Recurrent episodes (two or more events of feigning a disease and/or induction of an injury)

^*The agent, not the victim, receives the diagnosis.

[Source ⁴]

People with Munchausen syndrome (factitious disorder imposed on self) may be well aware of the risk of injury or even death as a result of self-harm or the treatment they seek, but they can’t control their behaviors and they’re unlikely to seek help. Even when confronted with objective proof — such as a videotape — that they’re causing their illness, they often deny it and refuse psychiatric help.

If you think a loved one may be exaggerating or faking health problems, it may help to attempt a gentle conversation about your concerns. Try to avoid anger, judgment or confrontation. Also try to reinforce and encourage more healthy, productive activities rather than focusing on dysfunctional beliefs and behaviors. Offer support and caring and, if possible, help in finding treatment.

If your loved one causes self-inflicted injury or attempts suicide, call your local emergency number for emergency medical help or, if you can safely do so, take him or her to an emergency room immediately.

Munchausen syndrome vs Hypochondria

Hypochondria is also known as health anxiety, or illness anxiety disorder, or hypochondriasis. Hypochondria is a type of anxiety disorder. If someone is often very worried about their health, even when their doctor tells them that nothing is seriously wrong, they might be affected by hypochondria. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) ⁴, no longer includes hypochondria — also called hypochondriasis — as a diagnosis. Instead, people previously diagnosed with hypochondriasis may be diagnosed as having illness anxiety disorder, in which the focus of the fear and worry is on uncomfortable or unusual physical sensations being an indication of a serious medical condition.

On the other hand, somatic symptom disorder ― a related disorder ― involves focusing on the disabling nature of physical symptoms, such as pain or dizziness, without the worry that these symptoms represent a specific illness.

The person with hypochondria may have no physical symptoms. Or he/she may believe that normal body sensations or minor symptoms are signs of severe illness, even though a thorough medical exam doesn’t reveal a serious medical condition.

It is normal for people to worry about their health now and again. But people who experience hypochondria get very worried that they are seriously ill, or are about to become seriously ill. This can occur even if they have no symptoms, or their symptoms are very mild. They might even mistake normal sensations for symptoms of a serious illness.

Some people with hypochondria have a medical condition that they worry about excessively. Other people with hypochondria are healthy, but have an overwhelming fear about their health in the future. For example, they might think: “What if I get cancer?”

People with hypochondria can become so distressed and so anxious that they have trouble doing everyday things.

Caring for a loved one with hypochondria (illness anxiety disorder)

Significant health anxiety can cause real distress for the person, and reassurance isn’t always helpful. Sometimes, providing reassurance can make things worse. This can be frustrating and cause stress on families and relationships. Encourage your loved one to consider a mental health referral to learn ways to cope with illness anxiety disorder.

Hypochondria treatment

A doctor who is treating someone for hypochondria would examine them to look for physical problems. Their options then include:

• giving a clear and honest appraisal of the causes of concern
• providing the person affected with advice and self-help resources
• cognitive behavioral therapy (CBT)
• referring the person to a counselor or psychologist, especially if they think depression or anxiety might be making the symptoms worse
• prescribing medication such as antidepressants to reduce anxiety.

Exercise, sleep, and a healthy diet can help reduce stress.

Hypochondria symptoms

Symptoms of hypochondria (illness anxiety disorder) involve preoccupation with the idea that you’re seriously ill, based on normal body sensations (such as a noisy stomach) or minor signs (such as a minor rash).

Signs and symptoms of hypochondria may include:

• Thinking a lot about having a serious illness
• Seeing a doctor many times, but not accepting reassurances
• Seeking out lots of medical tests
• Talking about health a lot with friends and family
• Spending hours on the internet studying for causes of symptoms or possible illnesses
• Having problems sleeping
• Having problems with family, work and social lives because of concerns about their health
• Being preoccupied with having or getting a serious disease or health condition
• Worrying that minor symptoms or body sensations mean you have a serious illness
• Being easily alarmed about your health status
• Finding little or no reassurance from doctor visits or negative test results
• Worrying excessively about a specific medical condition or your risk of developing a medical condition because it runs in your family
• Having so much distress about possible illnesses that it’s hard for you to function
• Repeatedly checking your body for signs of illness or disease
• Frequently making medical appointments for reassurance — or avoiding medical care for fear of being diagnosed with a serious illness
• Avoiding people, places or activities for fear of health risks
• Constantly talking about your health and possible illnesses

What causes hypochondria?

It is not clear why people have hypochondria (illness anxiety disorder), but it is more common in people who:

• have had major stress, illness or a death in the family
• were neglected or abused as a child
• have a serious physical illness
• have a mental health issue such as anxiety, depression, a compulsive disorder or a psychotic illness
• have a personality that tends to make everything seem worse than it is.

These factors may play a role:

• Beliefs. You may have a difficult time tolerating uncertainty over uncomfortable or unusual body sensations. This could lead you to misinterpret that all body sensations are serious, so you search for evidence to confirm that you have a serious disease.
• Family. You may be more likely to have health anxiety if you had parents who worried too much about their own health or your health.
• Past experience. You may have had experience with serious illness in childhood, so physical sensations may be frightening to you.

Certain activities can trigger an episode of serious concern in someone who is susceptible to hypochondriasis (illness anxiety disorder), including:

• reading about diseases on the internet
• watching something on television
• knowing someone with a serious medical condition
• feeling unwell or noticing lumps or bumps

Risk factors for developing hypochondriasis

Hypochondria (illness anxiety disorder) usually begins in early or middle adulthood and may get worse with age. Often for older individuals, health-related anxiety may focus on the fear of losing their memory.

Risk factors for hypochondria (illness anxiety disorder) may include:

• A time of major life stress
• Threat of a serious illness that turns out not to be serious
• History of abuse as a child
• A serious childhood illness or a parent with a serious illness
• Personality traits, such as having a tendency toward being a worrier
• Excessive health-related internet use

Hypochondria Complications

Hypochondria (illness anxiety disorder) may be associated with:

• Relationship or family problems because excessive worrying can frustrate others
• Work-related performance problems or excessive absences
• Problems functioning in daily life, possibly even resulting in disability
• Financial problems due to excessive health care visits and medical bills
• Having another mental health disorder, such as somatic symptom disorder, other anxiety disorders, depression or a personality disorder

Hypochondria Prevention

Little is known about how to prevent hypochondria (illness anxiety disorder), but these suggestions may help.

• If you have problems with anxiety, seek professional advice as soon as possible to help stop symptoms from getting worse and impairing your quality of life.
• Learn to recognize when you’re stressed and how this affects your body — and regularly practice stress management and relaxation techniques.
• Stick with your treatment plan to help prevent relapses or worsening of symptoms.

Hypochondria Treatment

The goal of treatment is to help you manage anxiety about your health and improve your ability to function in daily life. Psychotherapy — also called talk therapy — can be helpful for illness anxiety disorder. Sometimes medications may be added.

Psychotherapy

Because physical sensations can be related to emotional distress and health anxiety, psychotherapy — particularly cognitive behavioral therapy (CBT) — can be an effective treatment. Cognitive behavioral therapy (CBT) helps you learn skills to manage illness anxiety disorder and find different ways to manage your worries other than excessive medical testing or avoidance of medical care.

The Royal College of Psychiatrists defines cognitive behavioral therapy as a way of talking about:

• How you think about yourself, the world and other people
• How what you do affects your thoughts and feelings.

They say that cognitive behavioral therapy (CBT) can help you to change how you think (the cognitive part) and what you do (the behavioral part). These changes can help you to feel better. Unlike some of the other talking treatments, it focuses on the “here and now” difficulties. Instead of focusing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now.

Other therapies such as behavioral stress management and exposure therapy also may be helpful.

Cognitive behavioral therapy (CBT) can help you:

• Identify your fears and beliefs about having a serious medical disease
• Learn alternate ways to view your body sensations by working to change unhelpful thoughts
• Become more aware of how your worries affect you and your behavior
• Change the way you respond to your body sensations and symptoms
• Learn skills to cope with and tolerate anxiety and stress
• Reduce avoidance of situations and activities due to physical sensations
• Reduce behaviors of frequently checking your body for signs of illness and repeatedly seeking reassurance
• Improve daily functioning at home, at work, in relationships and in social situations
• Address other mental health disorders, such as depression

If you are not sure you want to commit to a long course of sessions with a clinical psychologist, there are various resources on the Internet which will provide an introduction to CBT or even a course of computer-aided CBT sessions:

• Developed by the Australian National University, MoodGYM (https://moodgym.com.au/) is a fun, free interactive web program that teaches the principles of CBT using flashed diagrams and online exercises. MoodGYM (https://moodgym.com.au/) demonstrates the relationship between thoughts and emotions, and works through dealing with stress and relationship break-ups, as well as teaching relaxation and meditation techniques. It consists of five modules (why you feel the way you do, changing the way you think, changing ‘warped’ thoughts, knowing what makes you upset, assertiveness and interpersonal skills training), an interactive game, anxiety and depression assessments, downloadable relaxation audio, a workbook and feedback assessment. Scientific trials have shown that using two or more modules is linked to significant reductions in depression and anxiety symptoms. These benefits last after 12 months. MoodGYM has won several IT and health awards, and has over 1,000,000 users worldwide. MoodGYM (https://moodgym.com.au/)

• Living Life to the Full (https://llttf.com/) is a free online life skills course for people feeling distressed. It aims to provide easy access to CBT skills in a way that cuts through jargon. It helps you understand why you feel as you do, and to learn new ways of improving how you feel, by making changes in your thinking, activities, sleep and relationships. The course is based on the idea of helping you to help yourself. It is supported by a series of CBT self-help workbooks that can be used between the e-learning sessions. These encourage you to put what you are learning into practice, and to stop, think and reflect on what you are learning. Living Life to the Full (https://llttf.com/)

• FearFighter (http://www.fearfighter.com/) delivers CBT over the internet, useful for those who may be concerned about the stigma associated with seeing a therapist. Taking only three months to complete, with minimal telephone support, FearFighter helps you improve even if you have virtually no computer skills. You are encouraged to use FearFighter as often as you wish but for at least once a week. It helps you identify specific problems, work on realistic treatment goals, and monitor achievement of those goals by repeated self-exposure. You get scheduled brief helpline support to a total of one hour over 10 weeks. FearFighter helps you to work out exactly what brings on your fear, so you can learn how to face it until it subsides. This is called exposure therapy. It consists of nine steps that need to be worked through one by one to obtain the greatest benefits. Like a therapist, FearFighter asks you to return every week to report on how you’ve been doing. You can ask it to print out questionnaires and graphs of your progress. It guides you through CBT as much as a therapist does.
  • Step 1: Welcome to FearFighter – Introduces the system, asks you to rate your problem on the Fear Questionnaire (FQ) and Work & Social Adjustment Scale (WSA), and asks about suicidal feelings and alcohol misuse.
  • Step 2: How to Beat Fear – Explains the principles of CBT, with case examples. You are asked to keep a daily record of your triggers.
  • Step 3: Problem Sorting – Helps you identify your triggers, shows you scenarios relevant to your problem, and helps you personalise your triggers and rate them on a 0-8 scale.
  • Step 4: How to Get a Helper – Explains the value of recruiting a CBT co-therapist and gives hints on how to find one.
  • Step 5: Setting Goals – Guides you through the process of setting good goals and tests them. You record and rate these on the system and can print personalised homework diaries.
  • Step 6: Managing anxiety – Offers a menu of coping strategies for use during CBT homework.
  • Step 7: Rehearsing Goals – Guides you on how to practise personal coping strategies during both imagined and live CBT homework.
  • Step 8: Carrying On – Reviews progress with the help of graphs, allows new goals to be devised, and offers feedback and advice.
  • Step 9: Troubleshooting – Offers a menu of tips on overcoming common sticking points in treatment.

You may have found that when you avoid things that make you panic or feel uncomfortable, the situation tends to get worse and worse. FearFighter can teach you how to face your fear until you adapt and no longer want to run away from it. It helps you learn to face the things that make you panic, such that, with time, you’ll find that, one by one, they’ll get easier.

Self-exposure therapy guided by computer is as effective as clinician-guided therapy and both are superior to relaxation to improve phobia/panic. FearFighter has been tested in four clinical trials and is as effective as the best CBT therapists.

Approved by the National Institute of Clinical Excellence (NICE), free access can only be prescribed by your doctor in England and Wales. FearFighter (http://www.fearfighter.com/)

Medications

Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), may help treat illness anxiety disorder. Medications to treat mood or anxiety disorders, if present, also may help.

Talk with your doctor about medication options and the possible side effects and risks.

What is Munchausen syndrome by proxy

Munchausen syndrome by proxy (factitious disorder imposed on another) is a mental illness and a form of child abuse involving both physical abuse and medical neglect ⁷. Munchausen syndrome by proxy occurs in the medical setting when a parent or caregiver causes injury to a child by seeking or administering unnecessary and possibly harmful medical treatment for the child. Although Munchausen syndrome by proxy is a rare circumstance, physicians need to consider it when treating a child with seemingly inexplicable findings or failed treatments. For a child whose illness is fabricated by a caregiver, the prognosis may be poor if the abused child is left in the home ⁷. The American Academy of Pediatrics ⁷ has identified factors that may help physicians recognize this form of child abuse and has provided recommendations on when to report a case to their state child protective services agency.

Continuing unnecessary medical care may become abusive to the child if the parent or caregiver is consistently misrepresenting or making up symptoms, manipulating laboratory tests, or intentionally inflicting harm on the child to create symptoms. The American Academy of Pediatrics ⁷ advises physicians to consider three questions that may help diagnose this condition:

1. Are the history, signs, and symptoms of disease credible?
2. Is the child receiving unnecessary and harmful or potentially harmful medical care?
3. If so, who is instigating the evaluations and treatment?

In determining whether signs and symptoms have been fabricated, physicians need to gather relevant information from everyone involved and report concerns to other health care professionals and social service workers. A thorough evaluation of medical charts and clear communication among medical professionals are important in making a proper diagnosis.

The state child protective services agency should be informed if the parent or caregiver is harming the child and will not cooperate with the child’s physician in limiting the amount of medical care to an appropriate level. Medical child abuse should be reported in the same way as physical and sexual child abuse if the parent or caregiver continues to harm the child. Care of the abused child may include a multidisciplinary approach that involves primary care physicians, medical subspecialty consultants, dietitians, physical therapists, and social service workers. Treatment considerations include ensuring the child’s future safety and allowing treatment to occur in the least restrictive setting possible.

Munchausen syndrome by proxy symptoms

Munchausen syndrome by proxy (factitious disorder imposed on another) is when someone falsely claims that another person has physical or psychological signs or symptoms of illness, or causes injury or disease in another person with the intention of deceiving others.

People with Munchausen syndrome by proxy (factitious disorder imposed on another) present another person as sick, injured or having problems functioning, claiming that medical attention is needed. Usually this involves a parent harming a child. This form of abuse can put a child in serious danger of injury or unnecessary medical care.

There is no typical presentation for this condition. Suspicions may arise when parents misinterpret or exaggerate normal behaviors, and true cases range from apparent fabrication of reported symptoms to outright fabrication of signs of disease. Caregivers may report signs and symptoms that are undetectable to the medical observer, or the child may demonstrate signs that defy medical interpretation.

In case reports, a wide variety of situations have been called, appropriately or inappropriately, Munchausen syndrome by proxy (factitious disorder imposed on another), including the following examples:

• A mother takes her child to the doctor for frequent evaluations for sexual abuse, even in the absence of objective evidence or history of abuse ⁸
• Mothers insist their children be treated for attention-deficit/hyperactivity disorder (ADHD) although there is no evidence to make the diagnosis ⁹
• A parent starves her child because she wrongly believes he has multiple food allergies ¹⁰
• Physicians suspect an unusual hematologic disorder after a mother repeatedly and secretly bruises her child with a hammer ¹¹
• A parent purposely suffocates her child and kills him during a hospitalization for “apnea” ¹²

It is difficult to imagine how such varied conditions can be included in the definition of a syndrome. In some cases, the caregiver has merely exaggerated the child’s symptoms; in others, the caregiver has imagined them. In the worst cases, the signs and symptoms of illness have been induced by the caregiver’s intentional actions. In some patients, the consequences are minor; in others, the consequences are fatal. Indeed, the only things common to the presentations catalogued above are the caregivers’ insistence that something was wrong, an absence of pathologic findings sufficient to explain the described signs or symptoms, and consequent harm to the child.

One needs 2 circumstances to make the diagnosis in this form of abuse: harm or potential harm to the child involving medical care and a caregiver who is causing it to happen.

The motive of the caregiver, although useful to the therapist, is unimportant in making the diagnosis of abuse. In no other form of child abuse do we include the perpetrator’s motives as a diagnostic criterion. For example, a man can sexually abuse a child for a variety of reasons, but his motivation is irrelevant; the child still carries the diagnosis of sexual child abuse. A mother might violently physically assault her infant because she is fed up with the child crying, she is intoxicated or drugged, or she earnestly thinks that is the way to get the infant to behave and start eating, but it is still called physical child abuse.

Child abuse is a pediatric diagnosis, one that describes what is happening to the child. Motivation of the perpetrator often becomes an issue when society considers incarceration, treatment, or reunification but not when the physician makes the medical diagnosis of child abuse.

Munchausen syndrome by proxy diagnosis

Diagnosis of fabricated disease can be especially difficult, because the signs and symptoms are undetectable (when they are being exaggerated or imagined) or inconsistent (when they are induced or fabricated). Researchers may differentiate between exaggeration and fabrication or induction of symptoms, but action taken by the clinician must be determined by the perception of harm or potential harm to the child.

Regardless of the exact nature of the duplicity, health care professionals can be seduced into prescribing diagnostic tests and therapies that are potentially injurious. This is easier than one might think. After all, absolute certainty is a rare thing in medical diagnosis, and physicians have all known empirical therapy to be effective. On occasion, though, the well-meaning but misguided pursuit of an ever-more-elusive diagnosis or effective treatment can lead medical staff into an ethical dilemma. Potentially harmful medical care can range from a diagnostic search that subtly encourages and enables a caregiver’s delusion through a full spectrum of invasive tests and medical or even surgical interventions. Alternatively, a child may present to the doctor with a common diagnosis but one that seems resistant to an increasingly aggressive array of treatment regimens. The common factor in all is the failure to consider factitious disease in the differential diagnosis, although it is often more likely than the arcane diagnoses being pursued so assiduously.

Child abuse is not a diagnosis of exclusion. On the contrary, when a clinician suspects that a disease has been falsified, this hypothesis must be pursued vigorously and the diagnosis must be confirmed if the child is to be spared further harm. In seeking to determine if signs and symptoms of a disease have been fabricated, the physician should make every effort to gather information from all those involved and make other professionals aware of the concerns. Care of children who are victims of factitious disorder by proxy often involves a variety of medical personnel, from primary care physicians and medical subspecialty consultants to dietitians, physical therapists, and social service workers, and each has a unique perspective. Nursing and support staff can frequently contribute to making the correct diagnosis by reporting their observations of, and experiences with, the child and family to the supervising physician. It should be stressed, however, that the falsification of a medical condition is a medical diagnosis. Although multidisciplinary input can be very helpful in diagnosis and essential in treatment, psychologists, social workers, and others are not in a position to make or confirm this diagnosis.

Occasionally, more information about the maltreatment is needed before a diagnosis can be reached. When it is suspected that no true disease exists and it is felt that harm to the child is imminent, the use of covert videotape surveillance has been recommended.15–17 Such surveillance may capture a parent’s misbehavior, as when a child is being physically abused in the hospital. It may fail to confirm reported symptoms when they are being exaggerated or exonerate a suspected caregiver when a disease truly exists. In any event, video surveillance cannot be considered a gold standard or held as the only way of diagnosing this insidious form of child abuse. When videotaping is used, adequate safeguards such as continuous surveillance and a well-understood plan of action must be present to prevent further injury.

Munchausen syndrome by proxy treatment

By recognizing that this problem is a form of child abuse taking place in a medical setting, a clear role is delineated for the system that is currently in place in our states to protect children. Child protective services agencies are mandated to keep children who are abused—sexually, physically, or psychologically—safe regardless of whether the abuse occurs in the home or the hospital.

When considering treatment for child abuse taking place in a medical setting, the basic principles used in any other type of child abuse case should be applied:

1. Make sure the child is safe.
2. Make sure the child’s future safety is also assured.
3. Allow treatment to occur in the least restrictive setting possible.

For example, if an overanxious mother who has insisted on too much medical care for her child is willing to cooperate with the physician and learn when it is appropriate to seek care, the child can safely be treated within his or her family setting. In contrast, if a mother has repeatedly suffocated her child, the “least restrictive setting” that would guarantee the child’s safety would most likely be permanent out-of-home placement.

If the parent’s care-seeking is harming the child but the parent refuses to cooperate with the physician in limiting the amount of medical care to an appropriate level, the state child protective services agency should be informed. If the parent persists in harming the child, medical child abuse should be reported in the same way as physical and sexual child abuse. Any time that a dependent child is being hurt by an adult’s action, child protective services should become involved.

A list of possible interventions follows, from the least restrictive to the most restrictive. Some of these options require action by outside agencies (child protective services, private counselors, law enforcement, etc).

1. Use individual and/or family therapy while depending on a primary care physician to be “gatekeeper” for future medical care utilization.
2. Monitor ongoing medical care usage by involving people or institutions outside the medical practice to alert the physician gatekeeper about health care issues. For example, in the event of a child protective services investigation, or with the parent’s consent, the insurance provider can be alerted to inform the primary care physician or medical home about visits to other professionals. Another example would be having the parent authorize the school to call the physician any time the child is absent or have school officials agree not to excuse any absence without the physician’s approval.
3. Admit the child to an inpatient hospital setting or a partial hospital program, where his or her actual signs and symptoms can be monitored (as opposed to the signs and symptoms reported by the parent). This admission is a very important resource if the parent tends to exaggerate or lie about the child’s pain or disability. A program that treats the whole family can then work to define the child as normal in the parents’ eyes.
4. Involve child protective services to obtain dependency, either in or out of the home, to control overuse of medical resources and gradually reintroduce the child to the caregiver’s home while monitoring the child’s safety.
5. Place the child in another family setting permanently.
6. Prosecute the offending parent and incarcerate him or her, thus eliminating access to the child.

The physician’s role in options 4 through 6 would be to report the case to the appropriate authorities, carefully document the abuse, and, if needed, testify on the child’s behalf in courts of law. Obviously, options 3 through 6 will be required only in the most extreme or persistent cases of medical abuse.

Munchausen syndrome symptoms

Munchausen syndrome (factitious disorder imposed on self) symptoms involve mimicking or producing illness or injury or exaggerating symptoms or impairment to deceive others. People with Munchausen syndrome (factitious disorder imposed on self) go to great lengths to hide their deception, so it may be difficult to realize that their symptoms are actually part of a serious mental health disorder. They continue with the deception, even without receiving any visible benefit or reward or when faced with objective evidence that doesn’t support their claims.

In general, individuals with Munchausen syndrome (factitious disorder imposed on self) report their story dramatically, but they are quite vague and inconsistent when asked to provide further details. Munchausen syndrome (factitious disorder imposed on self) patients frequently have a history of pathological lies about any aspect of their history or symptoms (i.e., pseudologia fantastica), and they can even have extensive knowledge on medical terminology, routines, and hospital protocols ¹. Students or health professionals have been described, and there is a question of whether the increased incidence of Munchausen syndrome (factitious disorder imposed on self) among this population ¹³.

Munchausen syndrome (factitious disorder imposed on self) signs and symptoms may include:

• Clever and convincing medical or psychological problems
  • Extensive knowledge of medical terms and diseases
  • Vague or inconsistent symptoms
  • Conditions that get worse for no apparent reason
  • Conditions that don’t respond as expected to standard therapies
  • Seeking treatment from many different doctors or hospitals, which may include using a fake name
  • Reluctance to allow doctors to talk to family or friends or to other health care professionals
  • Frequent stays in the hospital
  • Eagerness to have frequent testing or risky operations
  • Many surgical scars or evidence of numerous procedures
  • Having few visitors when hospitalized
  • Arguing with doctors and staff

Reports of nonspecific pain and other nonspecific symptoms and request for analgesics are also quite common. If, after extensive investigation complaints, no clear evidence exist that the individual is facing a true clinical condition, such patients may report other somatic and/or psychological problems and produce other nonspecific signs and/or symptoms. Individuals with Munchausen syndrome (factitious disorder imposed on self) can be submitted to multiple unnecessary procedures, including frequent and invasive surgery, without achieving an accurate diagnosis or successful therapy.

In the hospital environment, many of these patients receive few or no visits during hospitalization. Eventually, the fraudulent nature of these signs and symptoms is revealed (e.g., the patient is recognized by some professional who previously assisted him/her, or other hospital confirm previous admissions of the patient due to the same health problem and whose diagnosis was Munchausen syndrome (factitious disorder imposed on self). However, when these individuals with Munchausen syndrome (factitious disorder imposed on self) are informed that evidences show that symptoms are fraudulent and confronted, they often deny or leave the hospital without formal discharge. Commonly, later on, they end up seek another hospital or health service to be admitted ¹⁴.

In Munchausen syndrome (factitious disorder imposed on self) with predominant psychological signs and symptoms, as shown in Table 3, patients can provide approximated answers to simple questions (e.g., 8 times 8 equals 65). The individual can discretely use psychoactive substances to produce symptoms that suggest mental disorder (e.g., stimulatants to produce uneasiness or insomnia, hallucinogens to alter perception, analgesics to induce euphoria and hypnotics to cause lethargy). The combinations of psychoactive substances can produce extremely uncommon clinical pictures ¹⁵.

Table 3. Indications of Munchausen syndrome (factitious disorder imposed on self) with psychological conditions

Worsening of symptoms after hospital discharge

Symptoms not consistent with those found in a syndrome

Consistent response to treatment

Reports about physical and emotional trauma, but no one can confirm them

Pseudologia fantastica (pathological liar)

Intense relationship with other patients and health care team

Symptoms similar to other patients that appear during hospitalization

[Source ¹⁶]

Individuals with Munchausen syndrome (factitious disorder imposed on self) with predominant physical sign and symptoms can also be seen as substance abusers, particularly of analgesics and prescribed sedatives. Multiple hospitalizations often lead to iatrogenic general medical conditions (e.g., multiple scars because of unnecessary surgeries or adverse drug reactions). Individuals with the chronic form of this disorder can have a “gridiron abdomen” caused by multiple surgical scars. In general, individuals with Munchausen syndrome (factitious disorder imposed on self) have difficulty to maintain their job, create family ties, and stable interpersonal relationships. The most common Munchausen syndrome (factitious disorder imposed on self) in medical and surgical clinic are shown in Table 4.

Table 4. Most common factitious disorders in medical and surgical clinic

Abdominal pain or recurrent pain in multiple sites

Unexplainable metabolic and hydroelectrolytic disorders

Hard-to-heal wounds and pathological bleeding in different sites

Unexplained bleeding

Repetitive urinary tract infections, hematuria and proteinuria

Repetitive infections in different sites

Genital injuries

Convulsions

Skin injuries and repetitive ocular conditions

Subcutaneous emphysema

No accidental poisoning in children, elderly patients or disabled persons

[Source ¹⁶]

How those with Munchausen syndrome (factitious disorder) fake illness

Because people with Munchausen syndrome (factitious disorder imposed on self) become experts at faking symptoms and diseases or inflicting real injuries upon themselves, it may be hard for health care professionals and loved ones to know if illnesses are real or not.

People with Munchausen syndrome (factitious disorder imposed on self) make up symptoms or cause illnesses in several ways, such as:

• Exaggerating existing symptoms. Even when an actual medical or psychological condition exists, they may exaggerate symptoms to appear sicker or more impaired than is true.
• Making up histories. They may give loved ones, health care professionals or support groups a false medical history, such as claiming to have had cancer or AIDS. Or they may falsify medical records to indicate an illness.
• Faking symptoms. They may fake symptoms, such as stomach pain, seizures or passing out.
• Causing self-harm. They may make themselves sick, for example, by injecting themselves with bacteria, milk, gasoline or feces. They may injure, cut or burn themselves. They may take medications, such as blood thinners or drugs for diabetes, to mimic diseases. They may also interfere with wound healing, such as reopening or infecting cuts.
• Tampering. They may manipulate medical instruments to skew results, such as heating up thermometers. Or they may tamper with lab tests, such as contaminating their urine samples with blood or other substances.

Munchausen syndrome complications

People with Munchausen syndrome (factitious disorder imposed on self) are willing to risk their lives to be seen as sick. They frequently have other mental health disorders as well. As a result, they face many possible complications, including:

• Injury or death from self-inflicted medical conditions
• Severe health problems from infections or unnecessary surgery or other procedures
• Loss of organs or limbs from unnecessary surgery
• Alcohol or other substance abuse
• Significant problems in daily life, relationships and work
• Abuse when the behavior is inflicted on another

Munchausen syndrome causes

The cause of Munchausen syndrome (factitious disorder imposed on self) is unknown. However, Munchausen syndrome (factitious disorder imposed on self) may be caused by a combination of psychological factors and stressful life experiences.

Possible predisposing factors for Munchausen syndrome (factitious disorder imposed on self) can include presence of other mental disorders or medical conditions in childhood or adolescence that lead to long-term treatments and hospitalizations, resentment against medical professionals, experience in a position related to health area, presence of personality disorders, and important relationship with a physician in the past ¹⁷.

Risk factors for Munchausen syndrome

Several factors may increase the risk of developing Munchausen syndrome (factitious disorder imposed on self), including:

• Childhood trauma, such as emotional, physical or sexual abuse
• A serious illness during childhood
• Loss of a loved one through death, illness or abandonment
• Past experiences during a time of sickness and the attention it brought
• A poor sense of identity or self-esteem
• Personality disorders
• Depression
• Desire to be associated with doctors or medical centers
• Work in the health care field

Munchausen syndrome (factitious disorder imposed on self) is considered rare, but it’s not known how many people have the disorder. Some people use fake names to avoid detection, some visit many different hospitals and doctors, and some are never identified — all of which make it difficult to get a reliable estimate.

Munchausen syndrome prevention

Because the cause of Munchausen syndrome (factitious disorder imposed on self) is unknown, there’s currently no known way to prevent it. Early recognition and treatment of Munchausen syndrome (factitious disorder imposed on self) may help avoid unnecessary and potentially dangerous tests and treatment.

Munchausen syndrome diagnosis

Diagnosing Munchausen syndrome (factitious disorder imposed on self) is often extremely difficult. People with Munchausen syndrome (factitious disorder imposed on self) are experts at faking many different diseases and conditions. And often they do have real and even life-threatening medical conditions, even though these conditions may be self-inflicted.

The person’s use of multiple doctors and hospitals, the use of a fake name, and privacy and confidentiality regulations may make gathering information about previous medical experiences difficult or even impossible.

Diagnosis is based on objectively identifying symptoms that are made up, rather than the person’s intent or motivation for doing so. A doctor may suspect Munchausen syndrome (factitious disorder imposed on self) when:

• The person’s medical history doesn’t make sense
• No believable reason exists for an illness or injury
• The illness does not follow the usual course
• There is a lack of healing for no apparent reason, despite appropriate treatment
• There are contradictory or inconsistent symptoms or lab test results
• The person resists getting information from previous medical records, other health care professionals or family members
• The person is caught in the act of lying or causing an injury

To help determine if someone has Munchausen syndrome (factitious disorder imposed on self), doctors:

• Conduct a detailed interview
• Require past medical records
• Work with family members for more information
• Run only tests required to address possible physical problems
• May use the criteria for Munchausen syndrome (factitious disorder imposed on self) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (see Table 1 above).

Munchausen syndrome treatment

Treatment of Munchausen syndrome (factitious disorder imposed on self) is often difficult, and there are no standard therapies. Because people with Munchausen syndrome (factitious disorder imposed on self) want to be in the sick role, they’re often unwilling to seek or accept treatment for the disorder. However, if approached in a gentle, nonjudgmental way, a person with Munchausen syndrome (factitious disorder imposed on self) may agree to be treated by a mental health professional.

Nonjudgmental approach

Direct accusations of Munchausen syndrome (factitious disorder imposed on self) typically make the affected person angry and defensive, causing him or her to abruptly end a relationship with a doctor or hospital and seek treatment elsewhere. So the doctor may try to create an “out” that spares your loved one the humiliation of admitting to faking symptoms and offer information and help.

For example, the doctor may reassure your loved one that not having an explanation for medical symptoms is stressful and suggest that the stress may be responsible for some physical complaints. Or the doctor may ask your loved one to agree that, if the next medical treatment doesn’t work, they’ll explore together the idea of a possible psychological cause for the illness.

Either way, the doctor will try to steer your loved one toward care with a mental health professional. And both doctors and loved ones can reinforce healthy productive behaviors without giving undo attention to symptoms and impairments.

Treatment options

Treatment often focuses on managing the condition, rather than trying to cure it. Treatment generally includes:

• Having a primary care doctor. Using one doctor or gatekeeper to oversee medical care can help manage needed care and the treatment plan and reduce or eliminate visits to numerous doctors, specialists and surgeons.
• Psychotherapy. Talk therapy (psychotherapy) and behavior therapy may help control stress and develop coping skills. If possible, family therapy also may be suggested. Other mental health disorders, such as depression, also may be addressed.
• Medication. Medications may be used to treat additional mental health disorders, such as depression or anxiety.
• Hospitalization. In severe cases, a temporary stay in a psychiatric hospital may be necessary for safety and treatment.

Psychotherapy

Psychotherapy — particularly cognitive behavioral therapy (CBT) — can be an effective treatment. Cognitive behavioral therapy (CBT) helps you learn skills to manage Munchausen syndrome (factitious disorder imposed on self) and find different ways to manage your worries other than excessive medical testing or avoidance of medical care.

The Royal College of Psychiatrists defines cognitive behavioral therapy as a way of talking about:

• How you think about yourself, the world and other people
• How what you do affects your thoughts and feelings.

They say that cognitive behavioral therapy (CBT) can help you to change how you think (the cognitive part) and what you do (the behavioral part). These changes can help you to feel better. Unlike some of the other talking treatments, it focuses on the “here and now” difficulties. Instead of focusing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now.

Other therapies such as behavioral stress management and exposure therapy also may be helpful.

Cognitive behavioral therapy (CBT) can help you:

• Identify your fears and beliefs about having a serious medical disease
• Learn alternate ways to view your body sensations by working to change unhelpful thoughts
• Become more aware of how your worries affect you and your behavior
• Change the way you respond to your body sensations and symptoms
• Learn skills to cope with and tolerate anxiety and stress
• Reduce avoidance of situations and activities due to physical sensations
• Reduce behaviors of frequently checking your body for signs of illness and repeatedly seeking reassurance
• Improve daily functioning at home, at work, in relationships and in social situations
• Address other mental health disorders, such as depression

If you are not sure you want to commit to a long course of sessions with a clinical psychologist, there are various resources on the Internet which will provide an introduction to CBT or even a course of computer-aided CBT sessions:

• Developed by the Australian National University, MoodGYM (https://moodgym.com.au/) is a fun, free interactive web program that teaches the principles of CBT using flashed diagrams and online exercises. MoodGYM (https://moodgym.com.au/) demonstrates the relationship between thoughts and emotions, and works through dealing with stress and relationship break-ups, as well as teaching relaxation and meditation techniques. It consists of five modules (why you feel the way you do, changing the way you think, changing ‘warped’ thoughts, knowing what makes you upset, assertiveness and interpersonal skills training), an interactive game, anxiety and depression assessments, downloadable relaxation audio, a workbook and feedback assessment. Scientific trials have shown that using two or more modules is linked to significant reductions in depression and anxiety symptoms. These benefits last after 12 months. MoodGYM has won several IT and health awards, and has over 1,000,000 users worldwide. MoodGYM (https://moodgym.com.au/)

• Living Life to the Full (https://llttf.com/) is a free online life skills course for people feeling distressed. It aims to provide easy access to CBT skills in a way that cuts through jargon. It helps you understand why you feel as you do, and to learn new ways of improving how you feel, by making changes in your thinking, activities, sleep and relationships. The course is based on the idea of helping you to help yourself. It is supported by a series of CBT self-help workbooks that can be used between the e-learning sessions. These encourage you to put what you are learning into practice, and to stop, think and reflect on what you are learning. Living Life to the Full (https://llttf.com/)

• FearFighter (http://www.fearfighter.com/) delivers CBT over the internet, useful for those who may be concerned about the stigma associated with seeing a therapist. Taking only three months to complete, with minimal telephone support, FearFighter helps you improve even if you have virtually no computer skills. You are encouraged to use FearFighter as often as you wish but for at least once a week. It helps you identify specific problems, work on realistic treatment goals, and monitor achievement of those goals by repeated self-exposure. You get scheduled brief helpline support to a total of one hour over 10 weeks. FearFighter helps you to work out exactly what brings on your fear, so you can learn how to face it until it subsides. This is called exposure therapy. It consists of nine steps that need to be worked through one by one to obtain the greatest benefits. Like a therapist, FearFighter asks you to return every week to report on how you’ve been doing. You can ask it to print out questionnaires and graphs of your progress. It guides you through CBT as much as a therapist does.
  • Step 1: Welcome to FearFighter – Introduces the system, asks you to rate your problem on the Fear Questionnaire (FQ) and Work & Social Adjustment Scale (WSA), and asks about suicidal feelings and alcohol misuse.
  • Step 2: How to Beat Fear – Explains the principles of CBT, with case examples. You are asked to keep a daily record of your triggers.
  • Step 3: Problem Sorting – Helps you identify your triggers, shows you scenarios relevant to your problem, and helps you personalise your triggers and rate them on a 0-8 scale.
  • Step 4: How to Get a Helper – Explains the value of recruiting a CBT co-therapist and gives hints on how to find one.
  • Step 5: Setting Goals – Guides you through the process of setting good goals and tests them. You record and rate these on the system and can print personalised homework diaries.
  • Step 6: Managing anxiety – Offers a menu of coping strategies for use during CBT homework.
  • Step 7: Rehearsing Goals – Guides you on how to practise personal coping strategies during both imagined and live CBT homework.
  • Step 8: Carrying On – Reviews progress with the help of graphs, allows new goals to be devised, and offers feedback and advice.
  • Step 9: Troubleshooting – Offers a menu of tips on overcoming common sticking points in treatment.

You may have found that when you avoid things that make you panic or feel uncomfortable, the situation tends to get worse and worse. FearFighter can teach you how to face your fear until you adapt and no longer want to run away from it. It helps you learn to face the things that make you panic, such that, with time, you’ll find that, one by one, they’ll get easier.

Self-exposure therapy guided by computer is as effective as clinician-guided therapy and both are superior to relaxation to improve phobia/panic. FearFighter has been tested in four clinical trials and is as effective as the best CBT therapists.

Approved by the National Institute of Clinical Excellence (NICE), free access can only be prescribed by your doctor in England and Wales. FearFighter (http://www.fearfighter.com/)

Treatment may not be accepted or may not be helpful, especially for people with severe Munchausen syndrome (factitious disorder imposed on self). In these cases, the goal may be to avoid further invasive or risky treatments. In cases where the Munchausen syndrome (factitious disorder imposed on self) is imposed on others, the doctor assesses for abuse and reports the abuse to the appropriate authorities, if indicated.

In 2008 a systematic review on factitious disorders, which included 32 case reports and 13 case series, showed insufficient evidence to evaluate the effectiveness of any management technique for factitious disorders, including psychotherapy, drug treatment, behavioral therapy and multidisciplinary techniques ¹⁸. So far, no biologic or psychological therapy has shown efficacy based on reviews and empiric reports of clinicians with experience on this field. No comparative analyses have been carried out between different types of therapeutic approach, although a number of techniques have been described, such as psychodynamic and behavioral techniques.

Some authors stated that involuntary psychiatric hospitalization has been used for patients who put himself/herself at risk and who cannot be treated on an outpatient unit. Such approach is need because most patients, although willing to assume the position of an ill person or put others in this position, do not recognize themselves as having mental disorder, they often do not adhere to treatment, and sometimes run away from their hometown to try to be admitted in another health service by reporting previous clinical features he/she had produced intentionally. Treatment of these patients is extremely difficult; presents very low rates of adherence, poor prognosis; and few cases have improvements. It should be emphasized that most of the treatments reported in case studies or literature reviews were conducted in hospital settings, with few weeks or months of treatment, which could be an important bias in these studies ¹⁵.

References

1. De Sousa D, Kanomata EY, Feldman RJ, Maluf A. Munchausen syndrome and Munchausen syndrome by proxy: a narrative review. Einstein. 2017;15(4):516-521. doi:10.1590/S1679-45082017MD3746. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875173/
2. Munchausen’s syndrome. ASHER R. Lancet. 1951 Feb 10; 1(6650):339-41. https://www.ncbi.nlm.nih.gov/pubmed/14805062/
3. ABC of child abuse. Munchausen syndrome by proxy. Meadow R. BMJ. 1989 Jul 22; 299(6693):248-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1836924/pdf/bmj00242-0040.pdf
4. American Psychiatric Association, DSM-5 Task Force . Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. American Psychiatric Association: Arlington, VA; 2013.
5. World Health Organization (WHO) The ICD-10 Classification of Mental and Behavioural Disorders. Diagnostic criteria for research. Geneva: WHO; 1993
6. Recurrent hypoglycaemia in multiple myeloma: a case of Munchausen syndrome by proxy in an elderly patient. Ben-Chetrit E, Melmed RN. J Intern Med. 1998 Aug; 244(2):175-8. https://www.ncbi.nlm.nih.gov/pubmed/10095805/
7. Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting. John Stirling, and the Committee on Child Abuse and Neglect. Pediatrics May 2007, 119 (5) 1026-1030; DOI: 10.1542/peds.2007-0563 http://pediatrics.aappublications.org/content/119/5/1026.full
8. Rand DC. Munchausen syndrome by proxy: integration of classic and contemporary type. Issues Child Abuse Accusations.1990;2 :83– 89. http://www.ipt-forensics.com/journal/volume2/j2_2_4.htm
9. Ayoub CC, Schreier HA, Keller C. Munchausen by proxy: presentations in special education. Child Maltreat.2002;7 :149– 159
10. Warner JO, Hathaway MJ. Allergic form of Meadow’s syndrome (Munchausen by proxy). Arch Dis Child.1984;59 :151– 156
11. Bryk M, Seigel PT. My mother caused my illness: the story of a survivor of Munchausen by proxy syndrome. Pediatrics.1997;100 :1– 7
12. Meadow R. Suffocation, recurrent apnea, and sudden infant death. J Pediatr.1990;117 :351– 357
13. Yonge O, Haase M. Munchausen syndrome and Munchausen syndrome by proxy in a student nurse. Nurse Educ. 2004;29(4):166–169.
14. Cheng TO. Munchausen syndrome. J Intern Med. 1999;245(5):544–545
15. Burton MC, Warren MB, Lapid MI, Bostwick JM. Munchausen syndrome by adult proxy: a review of the literature. J Hosp Med. 2015;10(1):32–36. Review.
16. De Sousa D, Kanomata EY, Feldman RJ, Maluf A. Munchausen syndrome and Munchausen syndrome by proxy: a narrative review. Einstein. 2017;15(4):516-521. doi:10.1590/S1679-45082017MD3746. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875173
17. Munchausen syndrome by adult proxy: a review of the literature. Burton MC, Warren MB, Lapid MI, Bostwick JM. J Hosp Med. 2015 Jan; 10(1):32-5.
18. Management of factitious disorders: a systematic review. Eastwood S, Bisson JI. Psychother Psychosom. 2008; 77(4):209-18. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0025496/