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Munchausen syndrome is a subset of factitious disorders with a number of distinguishing characteristics. This article presents three case reports and brief discussions to facilitate recognition. Management techniques are also presented.
The term "Munchausen by proxy" denotes a special form of factitious disorder and a rare kind of child abuse. We present the case of a 12-year-old boy, whose mother's manipulations culminated in his immobilization in a wheelchair and the implantation of a pacemaker. Problems of diagnosis and clinical management of Munchausen by proxy are discussed.
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In recent years factitious disorders have gained increasing significance in all medical specialties although in child psychiatry publications on this topic are rare. In this article these and other somatoform disorders are discussed with reference to a case report on a 14-year-old girl. Psychodynamic aspects of this syndrome are presented and differentiated from simulation. Conversion syndromes and hysterical neurosis and comparisons are made with other publications on this topic. Treatment of these patients, who repeatedly succeed in subjecting themselves to invasive and sophisticated diagnostic procedures is difficult because of minimal compliance. The prognosis is affected by the extent to which changes in personality structure and development of alternative problem-solving mechanisms can be achieved.
Munchausen's syndrome, a chronic factitious disorder, is appropriately named after an 18th century German nobleman who was noted for his story-telling ability. The disorder is an interesting oddity; however, it may not be as uncommon as most think. Behavioral motivations and clinical presentations of the illness are variable and make diagnosis difficult. Approaches to treatment vary widely and success remains elusive. As a result of their manipulative behavior and their desire not to "respond" to medical intervention, these patients are extremely frustrating to treat. The illness represents an emotional and economic stress on an already stressed medical system. If the diagnosis is suspected, efforts should be made to direct the patient toward expert sources for further evaluation and treatment.
A 46-year old female nursing sister was admitted to three different hospitals because of blood pressure crises of 300/150 mmHg which occurred up to six times a day. The rises in blood pressure were accompanied by headache, tachycardia and outbreaks of sweating. Raised catecholamine concentrations were repeatedly measured in the 24-hour urine and in the blood. The diagnosis of pheochromocytoma could therefore be regarded as confirmed. The investigations to establish the localization (including MIBG scintigrams carried out several times) showed negative results. Octreotide scintigraphy finally revealed a raised concentration of nuclides in the right adrenals. Selective venous blood samples showed markedly raised concentrations of adrenaline and noradrenaline in all regions investigated. After removing the right adrenal, which was of normal histological appearance, there was an improvement for six months. Afterwards, up to six blood pressure crises per day were observed once more. Fresh determination of catecholamines at various levels demonstrated the highest concentrations in the left iliac vein. It was then shown that the patient injected catecholamines intravaginally even during the angiographic investigation. A search of the patient s room revealed several ampoules containing noradrenaline and adrenaline as well as syringes and needles. - This case shows that in clinical pictures with typical clinical symptoms and negative results of repeated investigations a factitious disorder must be considered in terms of differential diagnosis especially when female patients with medical knowledge who have ready access to drugs are involved with a history comprising several stays in hospital which have not produced any clarification of their condition.
The historical uniqueness of the Vietnam War produced an unusually high rate of psychiatric dysfunction among veterans, particularly in the form of posttraumatic stress disorder (PTSD). Now, in the wake of unprecedented media coverage of PTSD and the growth of veteran outreach centers documenting and publicizing the difficulties of some veterans, a heretofore unrecognized variant of PTSD-factitious PTSD--has arisen. The authors present seven cases of factitious PTSD, a classic example of clinical deception found among veterans who were never in combat and, in some cases, were never in Vietnam. The authors discuss the etiologies of the disorder and the underlying psychopathology, which suggests either factitious syndromes, such as Munchausen's, or malingering. They conclude with recommendations for diagnosis and treatment.
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OBJECTIVE: The goal of this study was to determine the frequency of dissociative disorders in Dutch psychiatric inpatients. METHOD: During a period of 12 months, 122 consecutively admitted adult psychiatric patients were screened with the Dissociative Experiences Scale. Patients scoring 25 and higher and a random selection of patients scoring lower than 25 were blindly interviewed with the Structured Clinical Interview for DSM-IV Dissociative Disorders, Revised. Interviews were scored independently by a blind rater. RESULTS: Ten (8%) of the 122 patients were diagnosed as having a dissociative disorder; two (2%) were diagnosed as having a dissociative identity disorder. Two patients (2%) had factitious dissociative identity disorder. CONCLUSIONS: The rate of dissociative disorders in this group of Dutch patients is comparable to the rates reported in other European studies but lower than rates reported in North American studies.
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A 24-year-old man presented with a convincing history of Post Traumatic Stress Disorder (PTSD). He claimed to be the victim of a widely publicized 'human bomb' attack by the IRA in Northern Ireland when he was serving with the armed forces. Psychometric tests for PTSD confirmed his symptoms. A subsequent check of public and military records demonstrated that he was a serviceman at that time, but showed conclusively that he could not have been present at the terrorist incident.
OBJECTIVE: To review the current state of knowledge on factitious illness in children and adolescents to help clarify the relationship of this phenomenon to a range of somatizing disorders in children and factitious disorder by proxy. DESIGN: The literature of the past 30 years was reviewed for cases describing children <18 years old who have intentionally falsified symptoms of illness, without known parental involvement. Cases in which a parent was involved, the child acknowledged a credible motive, the deception was identified after age 18, or which appeared in foreign languages were excluded. Data on age, gender, factitious symptoms, method, duration of deception, and outcome of confrontation, where available, were gathered from case studies. RESULTS: Forty-two cases of illness falsification by children were identified, with a mean age of 13.9, and a range from 8 to 18 years. The majority of patients were female (71%), and the gender imbalance was greater for the older children. The most commonly reported falsified or induced conditions were fevers, ketoacidosis, purpura, and infections, and the fabrications ranged from false symptom-reporting to active injections, bruising, and ingestions. The mean duration of the falsifications was almost 16 months before detection. Many of the children admitted to their deceptions when confronted, and some had positive outcomes at follow-up. The descriptions of some of these children as bland, depressed, and fascinated with health care were remarkably similar to adults with factitious disorders. CONCLUSIONS: Medical conditions fabricated by children may go undetected for a variety of reasons, or diagnosed as somatization. Further study of children who falsify symptoms may in some cases help identify earlier experiences of Munchausen by proxy abuse or covert parental coaching of illness falsification, and provide more effective interventions. Better understanding and identification of these children is likely to help prevent the development of more chronic adult factitious disorders.
A series of 224 patients with organic mental deterioration, including 129 patients with presumptive Alzheimer dementia, is described chiefly from the neuropsychological standpoint. Several methodological problems arising from research on dementia are discussed.
OBJECTIVE: To study the illness characteristics of Dhat syndrome, which has been widely regarded as a culture-bound syndrome. METHODS: The sample was selected from a general hospital and included 29 patients with Dhat syndrome and 32 medical controls. Somatization Screening Index (SSI), Illness Behaviour Questionnaire (SIBQ), Somatosensory Amplification Scale (SAS), Whitley Index (WI) and Chalder Fatigue Scale were administered to both groups. RESULTS: Patients with Dhat syndrome scored significantly higher on all the measures except the SAS. DISCUSSION: The results indicate that patients with Dhat syndrome have significantly different illness beliefs and behaviours compared to controls and have similarities with other functional somatic syndromes (FSSs).
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