Medical condition
Factitious disorder imposed on self | |
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Other names | Munchausen syndrome |
Specialty | Psychology, 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. Patients with FDIS intentionally falsify or induce signs and symptoms of illness, trauma, or abuse to assume this role. 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.
Terminology
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). 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.
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. 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. 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.
Risk factors
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. Patients are more likely to be female, middle aged, and work in the healthcare industry. 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.
Signs and symptoms
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
- Frequent visits to multiple different physicians
- Opting for unnecessary operations or procedures where the results are generally normal or inconclusive
- Inconsistencies in past medical history, where illness/procedural history stated by patient is different than their documented history
- Vague, nonspecific pain unresponsive to normal treatment options
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.
Diagnosis
Due to the behaviors involved, diagnosing factitious disorder is very difficult. Because induced symptoms may mimic those of a real disease or disorder, physicians must first rule out genuine disease. Therefore, FDIS is usually a diagnosis of exclusion. To rule out genuine illness, lab tests may be required, including complete blood count (CBC), urine toxicology, drug tests, blood cultures to rule out infection, coagulation tests, assays for thyroid function, or DNA typing, depending on the mimicked disease. In some cases CT scan, magnetic resonance imaging, psychological testing, electroencephalography, or electrocardiography may be required. A more extensive list of how organic illness is differentiated from FDIS is provided below.
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 and to distinguish between feinged versus real illness. Once the person's history has been thoroughly evaluated, diagnosing factitious disorder imposed on self requires a clinical assessment, typically performed by a psychiatrist.
For a person to be diagnosed with factitious disorder imposed on self, they must meet the following criteria:
- The patient presents as sick or injured motivated by a primary gain, or internal reward of validation/attention as opposed to a secondary gain, which usually involves external benefits.
- There is evidence that the patient is inducing or falsifying their symptoms
- There is no alternative explanation, mental disorder, or illness to explain the patient's symptoms
Common Manifestations
There are common methods for inducing certain symptoms and mimicking specfic diseases. As mentioned earlier, it is important ot first rule out true disease. Physicians usually must have a high suspicion for FDIS to pursue it as a likely diagnosis based on abnormal patient behaviors and medical history. Some examples of these are listed in the table below, along with how to differentiate them from real versus mimicked disease using medical laboratory tests or imaging.
Disease Mimicked | Method of Imitation | Laboratory/diagnostic confirmation |
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Bartter syndrome |
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Catecholamine-secreting tumor (i.e. Carcinoid tumor) |
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Chromogranin A, a tumor marker for Carcinoid tumor, blood levels will be increased for a tumor and normal in those with FDIS. |
Cushing's syndrome |
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Urine test to detect use of steroids |
Hyperthyroidism |
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Hypoglycaemia |
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Chronic diarrhea |
|
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Haematuria (bloody urine) |
|
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Treatment
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. Then they may take a careful history and seek medical records to look for early deprivation, childhood abuse, or mental illness. If a person is at risk to themself, psychiatric hospitalization may be initiated.
Healthcare providers may consider working with mental health specialists to help treat the underlying mood or other disorder as well as to avoid countertransference. 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
Main article: Auto-trollingMunchausen 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. 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. New Zealand PC World Magazine called Munchausen by Internet "cybermunch", and those who posed online "cybermunchers".
A person may attempt to gain sympathy from a group whose sole reason for existence is to support others. Some 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.
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. Online interaction has only been possible since the 1980s, steadily growing over the years.
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.
Such dramatic situations can polarize online communities. Members may feel ashamed for believing elaborate lies, while others remain staunch supporters. Feldman admits that an element of sadism may be evident in some of the more egregious abuses of trust.
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.
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.
See also
References
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{{cite book}}
: CS1 maint: location (link) - 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. ISSN 1758-1001. PMID 23592802.
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- Leila Schneps and Coralie Colmez (2013). " Math error number 1: multiplying non-independent probabilities. The case of Sally Clark: motherhood under attack". Math on trial. How numbers get used and abused in the courtroom. Basic Books. ISBN 978-0-465-03292-1.
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