Munchausen syndrome

Definition

Munchausen syndrome is a psychiatric disorder that causes an individual to self-inflict injury or illness or to fabricate symptoms of physical or mental illness in order to receive medical care or hospitalization . In a variation of the disorder, Munchausen by proxy (MSBP), an individual, typically a mother, intentionally causes or fabricates illness in a child or other person under her care.

Description

Munchausen syndrome takes its name from Baron Karl Friederich von Munchausen, an eighteenth century German military man known for his tall tales. The disorder first appeared in psychiatric literature in the early 1950s when it was used to describe patients who sought hospitalization by inventing symptoms and complicated medical histories, and/or inducing illness and injury in themselves. Categorized as a factitious disorder (a disorder in which the physical or psychological symptoms are under voluntary control), Munchausen syndrome seems to be motivated by a need to assume the role of a patient. Unlike malingering, there does not seem to be any clear secondary gain (e.g., money) in Munchausen syndrome.

Individuals with Munchausen by proxy syndrome use their child (or another dependent person) to fulfill their need to step into the patient role. The disorder most commonly victimizes children from birth to eight years old. Parents or caregivers with MSBP may only exaggerate or fabricate their child's symptoms, or they may deliberately induce symptoms through various methods, including poisoning , suffocation, starvation, or introducing bacteria into open wounds . They often display an extraordinary depth of medical knowledge and may even be in the medical profession themselves.

Demographics

Both Munchausen syndrome and Munchausen syndrome by proxy are thought to be rare, but there are no solid statistics on the frequency of either diagnosis. Data on Munchausen syndrome in children and adolescents specifically are very limited. In 2000 one review found that among the 42 cases reported in the medical literature, 71 percent were female and the mean age was 14 years of age. Children age 14 and younger were more likely to admit to falsifying symptoms when confronted than those between the ages of 15 and 18.

Munchausen syndrome by proxy is also hard to quantify due to the number of undetected or undiagnosed cases. The incidence of the condition in the United States is not known, but a 1996 study of children in Ireland and the United Kingdom estimated that Munchausen syndrome by proxy occurred annually in 0.5 of every 100,000 children under age 16, and in 2.8 of every 100,000 children under the age of one.

Causes and symptoms

The exact cause of Munchausen syndrome is unknown. It has been theorized that Munchausen patients are motivated by a desire to be cared for, a need for attention, dependency, an ambivalence toward doctors, or a need to suffer. Factors that may predispose an individual to Munchausen include a serious illness in childhood or an existing personality disorder. Some research indicates that children and adolescents who develop Munchausen syndrome are more likely to have been previous victims of Munchausen syndrome by proxy.

The Munchausen and Munchausen by proxy patient can appear to have a wide array of physical or psychiatric symptoms, usually limited only by their (or their caregiver's) medical knowledge. Many Munchausen patients are very familiar with medical terminology and symptoms. Some common complaints include fevers, rashes , abscesses, bleeding, and vomiting . Common Munchausen by proxy symptoms include apnea (cessation of breathing), fever , vomiting, and diarrhea . In both Munchausen and MSBP syndromes, the suspected illness does not respond to a normal course of treatment, and diagnostic tests turn up nothing out of the ordinary. Patients or parents may push for invasive procedures and display an extraordinary depth of knowledge of medical therapies.

Diagnosis

Because Munchausen sufferers often go from doctor to doctor, gaining admission into many hospitals along the way, diagnosis can be difficult. They are typically detected rather than diagnosed. During a course of treatment, they may be discovered by a hospital employee who encountered them during a previous hospitalization. Their caregivers may also notice that symptoms such as high fever occur only when the patient is left unattended. Occasionally, medication used to induce symptoms is found with the patient's belongings. When the patient is confronted, they often react with outrage and check out of the hospital to seek treatment at another facility with a new caregiver.

A diagnosis of Munchausen syndrome may be even more difficult in children and adolescents. A physician may be able to recognize a pattern of symptoms (e.g., those that occur only when the child is alone or that begin only when the parent is present with the child) or the child may admit to fabricating or self-inflicting symptoms upon questioning. Surveillance video may record the child or the child's caregiver inducing symptoms.

Treatment

There is no clearly effective treatment for Munchausen syndrome. Extensive psychotherapy may be helpful with some Munchausen patients. If Munchausen syndrome coexists with other mental disorders, such as a personality disorder, the underlying disorder is typically treated first. Children who develop the syndrome may respond more favorably to therapy than adults, particularly if they are diagnosed at an early age.

Children who are victims of Munchausen syndrome by proxy are usually removed from the offending caregiver immediately and placed in protective custody. Therapy may also be beneficial to these children in recovering from the emotional trauma of MSBP.

Prognosis

The infections and injuries Munchausen patients self-inflict can cause serious illness. Patients often undergo countless unnecessary surgeries throughout their lifetimes. In addition, because of their frequent hospitalizations, they have difficulty holding down a job. Further, their chronic health complaints may damage interpersonal relationships with family and friends.

Children victimized by sufferers of MSBP are at a real risk for serious injury and possible death. A UK study published in 1998 found that although the majority of children with MSBP studied (90 percent) were placed in child protection care at diagnosis, at two-year follow up the number had fallen to 32 percent. A reported 17 percent of children who were victims of MSBP and who were eventually returned to an abusive caregiver suffered further abuse. Those who survive physically unscathed may suffer developmental and emotional problems.

Prevention

Because the cause of Munchausen syndrome is unknown, formulating a prevention strategy is difficult. Some medical facilities and healthcare practitioners have attempted to limit hospital admissions for Munchausen patients by sharing medical records. While these attempts may curb the number of hospital admissions, they do not treat the underlying disorder and may endanger Munchausen sufferers that have made themselves critically ill and require treatment. Children who are found to be victims of persons with Munchausen by proxy syndrome should be immediately removed from the care of the abusing parent or guardian.

Parental concerns

Parents who suspect that their child may be deliberately hurting themselves or falsifying symptoms should contact their pediatrician immediately for assessment. Children who are thought to pose potentially life-threatening danger to themselves may require hospitalization, and a referral to a child psychologist or therapist will be necessary. It is important to remember that properly treating the condition requires addressing the motives and emotions behind the disorder, not simply punishing the behavior.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders , 4th ed., text revision (DSM-IV-TR). Washington, DC: American Psychiatric Press Inc., 2000.

Feldman, Marc. Playing Sick?: Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York: Brunner-Routledge, 2004.

Mart, Eric G. Munchausen's Syndrome by Proxy Reconsidered. Manchester, NH: Bally Vaughn, 2002.

PERIODICALS

Libow, Judith. "Child and Adolescent Illness Falsification." Pediatrics 105, no. 2 (February 2000): 336.

Schreier, Herbert. "Munchausen by Proxy Defined." Pediatrics 110, no. 5 (November 2002): 985.

ORGANIZATIONS

American Psychiatric Association. 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209. Web site: http://www.psych.org.

American Psychological Association (APA). 750 First St. NE, Washington, DC 20002–4242. Web site: http://www.apa.org.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201–3042. Web site: http://www.nami.org.

National Institute of Mental Health (NIMH). Office of Communications, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892–9663. Web site: http://www.nimh.nih.gov.

Paula Ford-Martin