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Factitious disorder imposed on self

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For cases of feigned illness not driven by a psychiatric disorder, see Malingering.

Factitious disorder imposed on self
Other namesMunchausen syndrome[1]
SpecialtyPsychology, psychiatry

Factitious disorder imposed on self (FDIS), sometimes referred to as Munchausen syndrome, is a complex mental disorder where individuals play the role of a sick patient to receive some form of psychological validation, such as attention, sympathy, or physical care.[2] Patients with FDIS intentionally falsify or induce signs and symptoms of illness, trauma, or abuse to assume this role.[3] These actions are performed consciously, though the patient may be unaware of the motiviations driving their behaviors. There are several risk factors and signs assocaited with this illness and treatment is usually in the form of psychotherapy.

Factitious disorder imposed on self is related to factitious disorder imposed on another, which refers to the abuse of another person in order to seek attention or sympathy for the abuser. This is considered "Munchausen by proxy", and the drive to create symptoms for the victim can result in unnecessary and costly diagnostic or corrective procedures.[3]

Terminology

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Tales from the fictional German character Frieherr Von Munchausen.

The name "Munchausen syndrome" derives from Baron Munchausen, a literary character loosely based on the German nobleman Hieronymus Karl Friedrich Freiherr von Münchhausen (1720–1797).[4] The historical baron became a well-known storyteller in the late 18th century for entertaining dinner guests with tales about his adventures during the Russo-Turkish War. In 1785, German-born writer and con artist Rudolf Erich Raspe anonymously published a book in which a heavily fictionalized version of "Baron Munchausen" tells many fantastic and impossible stories about himself. Raspe's Munchausen became a sensation, establishing a literary exemplar of a bombastic liar or exaggerator.[5][6]

In 1951, Richard Asher was the first to describe a pattern of self-harm, wherein individuals fabricated histories, signs, and symptoms of illness. Remembering Baron Munchausen, Asher named this condition Munchausen's Syndrome in his article in The Lancet in February 1951.[6] Asher's nomenclature sparked some controversy, with medical authorities debating the appropriateness of the name for about fifty years. While Asher was praised for bringing cases of factitious disorder to light, participants in the debate objected variously that a literary allusion was inappropriate given the seriousness of the disease; and that the name's connection to works of humor and fantasy, and to the essentially ridiculous character of the fictional Baron Munchausen, was disrespectful to patients with the disorder.[7] Some healthcare providers avoid this term because it downplays the complexity of the illness and devalues the patient experience. The term "factitious disorder imposed on self" provides a more accurate and encompassing description of this mental disorder; however, both terms may still be used interchangeably in practice.[8]

Risk Factors

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The exact cause of this illness is unknown due to limited research but is likely the result from multiple psychosocial factors. Specific risk factors have been assocaited with developing FDIS, specifically a history of childhood trauma, abandonment, having a serious childhood illness, and certain personality disorders.[9][10] Patients are more likely to be female, middle aged, and work in the healthcare industry.[11] Individuals with this disorder may also have a history of recurrent hospitalizations and frequent visits to multiple different physicians (i.e. doctor shopping). They are also more likely to have underlying depression, though it is unclear if it is a cause or symptom of this illness.[12]

Signs and symptoms

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In factitious disorder imposed on self, the affected person exaggerates or creates physical or psychological symptoms of illnesses in themselves to gain examination, treatment, attention, sympathy or comfort from medical personnel. Because these symptoms can vary depending on how patients induce these symptoms, there is no consistent symptom specific for this illness. However, there are several common themes that may raise suspicion for FDIS. Some of these common themes include:

  • Prolonged, repeated hospital stays[13]
  • Frequent visits to multiple different physicians[14]
  • Opting for unnecessary operations or procedures where the results are generally normal or inconclusive[3]
  • Inconsistencies in past medical history, where illness/procedural history stated by patient is different than their documented history[15]
  • Vague, nonspecific pain unresponsive to normal treatment options[15]

Common examples of commonly induced physical symptoms include intentionally infecting a wound with debris or unsanitary material, taking laxatives to induce diarrhea, and ingesting thyroid hormone replacement medication to simulate a hyperactive thyroid or hyperthyroidism.[14]

Diagnosis

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Due to the behaviors involved, diagnosing factitious disorder is very difficult. If the healthcare provider finds no physical reason for the symptoms, they may refer the person to a psychiatrist or psychologist (mental health professionals who are specially trained to diagnose and treat mental illnesses). Psychiatrists and psychologists use thorough history, physical examinations, laboratory tests, imagery, and psychological testing to evaluate a person for physical and mental conditions. Once the person's history has been thoroughly evaluated, diagnosing factitious disorder imposed on self requires a clinical assessment.[16]

Clinicians should be aware that those presenting with symptoms (or persons reporting for that person) may exaggerate, and caution should be taken to ensure there is evidence for a diagnosis.[16] Lab tests may be required, including complete blood count (CBC), urine toxicology, drug levels from blood, cultures, coagulation tests, assays for thyroid function, or DNA typing. In some cases CT scan, magnetic resonance imaging, psychological testing, electroencephalography, or electrocardiography may also be employed.[16] A summary of more common and reported cases of factitious disorder (Munchausen syndrome), and the laboratory tests used to differentiate these from physical disease is provided below:[17]

Disease Mimicked Method of Imitation Laboratory/diagnostic confirmation
Bartter syndrome
  • Surreptitious intake of diuretics
  • Self-induced vomiting
  • High performance liquid chromatography (HPLC) analysis of urine
  • Urine chloride analysis
Catecholamine-secreting tumor Injection of epinephrine into urine or blood stream Adjunct analysis of increased chromogranin A
Cushing's syndrome Surreptitious steroid administration HPLC to differentiate endogenous and exogenous steroids
Hyperthyroid Surreptitious thyroxine administration Blood tests for thyroglobulin to differentiate endogenous versus exogenous thyroid hormone.
Hypoglycaemia Exogenous insulin or insulin secretagogues Simultaneous blood analysis of insulin, C-peptide, proinsulin, and insulin secretagogues
Sodium imbalance Intake large quantities of salt Measure fractional sodium excretion to differentiate intentional salt overload from dehydration.
Chronic diarrhea
  • Watered down stool samples
  • Laxative abuse
Induced vomiting Although many alternatives possible, ipecacuanha ingestion HPLC measurement of serum or urine for elevated creatine kinase, transaminases and ipecacuanha
Proteinuria Egg protein injection into bladder, albumin (protein) addition to urine samples Urine protein electrophoresis analysis
Haematuria Blood introduction to urine samples, deliberate trauma to the urethra Imaging to rule out insertion of a foreign body, monitor sample collection, analysis of red blood cell shape in samples

There are several criteria that together may point to factitious disorder, including frequent hospitalizations, knowledge of several illnesses, frequently requesting medication such as pain killers, openness to extensive surgery, few or no visitors during hospitalizations, and exaggerated or fabricated stories about several medical problems.

People may fake their symptoms in multiple ways. Other than making up past medical histories and faking illnesses, people might inflict harm on themselves by consuming laxatives or other substances, self-inflicting injury to induce bleeding, and altering laboratory samples.[18] Many of these conditions do not have clearly observable or diagnostic symptoms and sometimes the syndrome will go undetected because patients will fabricate identities when visiting the hospital several times. Factitious disorder has several complications, as these people will go to great lengths to fake their illness. Severe health problems, serious injuries, loss of limbs or organs, and even death are possible complications.[medical citation needed]

Treatment

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Because there is uncertainty in treating suspected factitious disorder imposed on self, some advocate that health care providers first explicitly rule out the possibility that the person has another early-stage disease.[19] Then they may take a careful history and seek medical records to look for early deprivation, childhood abuse, or mental illness.[16] If a person is at risk to themself, psychiatric hospitalization may be initiated.[20]

Healthcare providers may consider working with mental health specialists to help treat the underlying mood or other disorder as well as to avoid countertransference.[21] Therapeutic and medical treatment may center on the underlying psychiatric disorder: a mood disorder, an anxiety disorder, or borderline personality disorder. The patient's prognosis depends upon the category under which the underlying disorder falls; depression and anxiety, for example, generally respond well to medication or cognitive behavioral therapy.

Munchausen by Internet

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Main article: Auto-trolling

Munchausen by Internet is a term describing the pattern of behavior in factitious disorder imposed on self, wherein those affected feign illnesses in online venues. It has been described in medical literature as a manifestation of factitious disorder imposed on self.[22] Reports of users who deceive Internet forum participants by portraying themselves as gravely ill or as victims of violence first appeared in the 1990s due to the relative newness of Internet communications. The specific internet pattern was named "Münchausen by Internet" in 1998 by psychiatrist Marc Feldman.[22] New Zealand PC World Magazine called Munchausen by Internet "cybermunch", and those who posed online "cybermunchers".[23]

A person may attempt to gain sympathy from a group whose sole reason for existence is to support others. Some[who?] have speculated that health care professionals, with their limited time, greater medical knowledge, and tendency to be more skeptical in their diagnoses, may be less likely to provide that support.[22][24][25]

In an article published in The Guardian, Steve Jones speculated that the anonymity of the Internet impedes people's abilities to realize when someone is lying.[26] Online interaction has only been possible since the 1980s, steadily growing over the years.[27][28][29]

When discovered, forum members are frequently banned from some online forums. Because no money is exchanged and laws are rarely broken, there is little legal recourse to take upon discovery of someone faking illness.[30]

Such dramatic situations can polarize online communities. Members may feel ashamed for believing elaborate lies, while others remain staunch supporters.[22][31] Feldman admits that an element of sadism may be evident in some of the more egregious abuses of trust.[32][24][33][27]

Other perpetrators react by issuing general accusations of dishonesty to everyone, following the exposure of such fabrications. The support groups themselves often bar discussion about the fraudulent perpetrator, in order to avoid further argument and negativity. Many forums do not recover, often splintering or shutting down.[24][33]

In 2004, members of the blog hosting service LiveJournal established a forum dedicated to investigating cases of members of online communities dying—sometimes while online. In 2007 The LiveJournal forum reported that, of the deaths reported to them, about 10% were real.[34]

See also

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References

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  1. ^ Ray WJ (2016). Abnormal Psychology. SAGE Publications. p. PT794. ISBN 978-1-5063-3337-3.
  2. ^ Kay J, Tasman A, eds. (2007). Essentials of psychiatry. West Sussex, England Hoboken, NJ: Wiley. ISBN 978-0-470-03099-8.
  3. ^ a b c Ray WJ (2021). Abnormal psychology (Third ed.). Los Angeles London New Delhi Singapore Washington DC Melbourne: SAGE. ISBN 978-1-5443-9920-1.
  4. ^ Tatu L, Aybek S, Bogousslavsky J (2018). "Munchausen Syndrome and the Wide Spectrum of Factitious Disorders". Frontiers of Neurology and Neuroscience. 42: 81–86. doi:10.1159/000475682. ISSN 1662-2804. PMID 29151093.
  5. ^ McCoy ML, Keen SM (2013). Child Abuse and Neglect: Second Edition. Psychology Press. p. 210. ISBN 978-1-136-32287-7.
  6. ^ a b Olry R (June 2002). "Baron Munchhausen and the Syndrome Which Bears His Name: History of an Endearing Personage and of a Strange Mental Disorder" (PDF). Vesalius. 8 (1): 53–7. PMID 12422889.
  7. ^ Fisher JA (2006). "Investigating the Barons: Narrative and nomenclature in Munchausen syndrome". Perspectives in Biology and Medicine. 49 (2): 250–62. doi:10.1353/pbm.2006.0024. PMID 16702708. S2CID 12418075.
  8. ^ Yates GP, Feldman MD (1 July 2016). "Factitious disorder: a systematic review of 455 cases in the professional literature". General Hospital Psychiatry. 41: 20–28. doi:10.1016/j.genhosppsych.2016.05.002. ISSN 0163-8343.
  9. ^ Jafferany M, Khalid Z, McDonald KA, Shelley AJ (22 February 2018). "Psychological Aspects of Factitious Disorder". The primary care companion for CNS disorders. 20 (1): 17nr02229. doi:10.4088/PCC.17nr02229. ISSN 2155-7780. PMID 29489075.
  10. ^ Repper J (1995). "Munchausen Syndrome by Proxy in health care workers". Journal of Advanced Nursing. 21 (2): 299–304. doi:10.1111/j.1365-2648.1995.tb02526.x. ISSN 1365-2648.
  11. ^ Weber B, Gokarakonda SB, Doyle MQ (2025), "Munchausen Syndrome", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30085541, retrieved 14 January 2025
  12. ^ Yates GP, Feldman MD (1 July 2016). "Factitious disorder: a systematic review of 455 cases in the professional literature". General Hospital Psychiatry. 41: 20–28. doi:10.1016/j.genhosppsych.2016.05.002. ISSN 0163-8343.
  13. ^ Sousa Filho Dd, Kanomata EY, Feldman RJ, Maluf Neto A (2017). "Munchausen syndrome and Munchausen syndrome by proxy: a narrative review". Einstein (Sao Paulo, Brazil). 15 (4): 516–521. doi:10.1590/S1679-45082017MD3746. ISSN 2317-6385. PMC 5875173. PMID 29364370.
  14. ^ a b "Overview - Munchausen syndrome". nhs.uk. 16 February 2021. Retrieved 17 January 2025.
  15. ^ a b Sousa Filho Dd, Kanomata EY, Feldman RJ, Maluf Neto A (2017-12). "Munchausen syndrome and Munchausen syndrome by proxy: a narrative review". Einstein (São Paulo). 15 (4): 516–521. doi:10.1590/S1679-45082017MD3746. ISSN 2317-6385. Archived from the original on 2025-01-09. {{cite journal}}: Check date values in: |date= (help)
  16. ^ a b c d Brannon GE (11 November 2015). "Factitious Disorder Imposed on Another: Practice Essentials, Background, Pathophysiology". Medscape.
  17. ^ Kinns H, Housley D, Freedman DB (May 2013). "Munchausen syndrome and factitious disorder: the role of the laboratory in its detection and diagnosis". Annals of Clinical Biochemistry. 50 (Pt 3): 194–203. doi:10.1177/0004563212473280. PMID 23592802.
  18. ^ Kinns H, Housley D, Freedman DB (May 2013). "Munchausen syndrome and factitious disorder: the role of the laboratory in its detection and diagnosis". Annals of Clinical Biochemistry. 50 (Pt 3): 194–203. doi:10.1177/0004563212473280. PMID 23592802.
  19. ^ Bursztajn H, Feinbloom RI, Hamm RM, Brodsky A (1981). Medical Choices, medical chances: How patients, families and physicians can cope with uncertainty. New York: Delacourte/Lawrence.[page needed]
  20. ^ Johnson BR, Harrison JA (2000). "Suspected Munchausen's syndrome and civil commitment". The Journal of the American Academy of Psychiatry and the Law. 28 (1): 74–6. PMID 10774844.
  21. ^ Elder W, Coletsos IC, Bursztajn HJ. Factitious Disorder/Munchhausen Syndrome. The 5-Minute Clinical Consult. 18th Edition. 2010. Editor. Domino, F.J. Wolters Kluwer/Lippincott. Philadelphia.[page needed]
  22. ^ a b c d Feldman MD (July 2000). "Munchausen by Internet: detecting factitious illness and crisis on the Internet". South. Med. J. 93 (7): 669–72. doi:10.1097/00007611-200093070-00006. PMID 10923952.
  23. ^ Todd, Belinda (October 21, 2002)."Faking It" Archived 2011-07-17 at the Wayback Machine, New Zealand PC World Magazine. Retrieved on July 29, 2009.
  24. ^ a b c Shreve, Jenn (June 6, 2001). "They Think They Feel Your Pain", Wired.com. Retrieved on July 28, 2009.
  25. ^ Stephenson J (21 October 1998). "Patient Pretenders Weave Tangled "Web" of Deceit". Journal of the American Medical Association. 280 (15): 1297. doi:10.1001/jama.280.15.1297-JMN1021-3-1. PMID 9794296. Archived from the original on 15 December 2004. Retrieved 28 July 2009.
  26. ^ Jones, Steve Computer-Mediated Communication and Community: Introduction Archived 1999-08-24 at archive.today: Introductory chapter to CyberSociety (1995), SAGE Publications. Retrieved on August 16, 2009.
  27. ^ a b Joinson Adam, Dietz-Uhler Beth (2002). "Explanations for the Perpetration of and Reactions to Deception in a Virtual Community". Social Science Computer Review. 20 (3): 275–289. doi:10.1177/08939302020003005.
  28. ^ See also Danet, B., Ruedenberg, L., & Rosenbaum-Tamari, Y. (1998). " 'Hmmm ... Where's that smoke coming from?' Writing, Play and Performance on Internet Relay Chat. In F. Sudweeks, M. McLaughlin, & S. Rafaeli (Eds.), Network and Netplay: Virtual Groups on the Internet (pp. 41-76). Cambridge, MA: MIT Press.
  29. ^ Caspi Avner, Gorsky Paul (2006). "Online Deception: Prevalence, Motivation, and Emotion". CyberPsychology & Behavior. 9 (1): 54–59. doi:10.1089/cpb.2006.9.54. PMID 16497118.
  30. ^ Feldman Marc, Peychers M.E. (2007). "Legal Issues Surrounding the Exposure of 'Munchausen by Internet'". Psychosomatics. 48 (5): 451–452. doi:10.1176/appi.psy.48.5.451-a. PMID 17878508.
  31. ^ Kruse, Michael (February 28, 2010). "Death and Betrayal in Chat Room", The St. Petersburg Times (Florida), p. 1A.
  32. ^ Swains, Howard (March 25, 2009). "Q&A: Munchausen by Internet" Archived 2010-01-10 at the Wayback Machine, Wired.com. Retrieved on July 28, 2009.
  33. ^ a b Russo F (26 June 2001). "Cybersickness: Munchausen by Internet Breeds a Generation of Fakers". The Village Voice. Archived from the original on 1 December 2008.
  34. ^ Swains, Howard (March 5, 2007). "Fake deaths thriving: Online tragedy can be greatly exaggerated", The Gazette (Montreal), p. D1.

Bibliography

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