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Factitious disorder

Page last reviewed: 13/07/2011

Munchausen's syndrome is a psychological and behavioural condition where someone pretends to be ill, or sometimes induces symptoms of illness in themselves. Munchausen's syndrome is also known as factitious disorder.

Munchausen's syndrome is named after a German aristocrat, Baron Munchausen, who became famous for telling wild, unbelievable tales about his exploits and past.

The cause of Munchausen's syndrome is largely unknown. Most people who have been diagnosed with the condition refuse to accept any sort of psychiatric treatment, meaning little is known about their motives or thought processes.

Types of behaviour

People with Munchausen's syndrome can show different types of behaviour, such as:

  • Pretending to have psychological symptoms: for example, claiming to hear voices or claiming to see things that are not really there.
  • Pretending to have physical symptoms: for example, claiming to have chest pain or stomach ache.
  • Actively seeking to make themselves ill: such as deliberately infecting a wound by rubbing dirt into it.

Some people with Munchausen's syndrome may spend years travelling from hospital to hospital faking a wide range of illnesses. When it is discovered that they are lying, they may suddenly leave hospital and move to another district.

People with Munchausen's syndrome can be very manipulative and, in the most serious cases, a person with the condition may undergo painful and sometimes life-threatening surgery, even though they know it is unnecessary. There have been several cases where people have died due to complications arising from treatment that was not actually necessary.

How common is Munchausen's syndrome?

It is not known exactly how common Munchausen's syndrome is. Some experts believe that Munchausen's syndrome is under-diagnosed because many people with the condition may succeed in deceiving medical staff. But it is also possible that cases of Munchausen's syndrome are over-diagnosed because the same person could travel from hospital to hospital.

A fairly large study that was carried out in a Canadian hospital estimated that, out of 1,300 patients, 10 were faking the symptoms of illness.

Who is affected

There appear to be two distinct groups of people who are affected by Munchausen's syndrome:

  • women who are 20 to 40 years of age, who often have a background in healthcare, such as working as a nurse or a medical technician
  • unmarried white men who are 30 to 50 years of age

It is unclear why this is the case.

Outlook

The outlook for Munchausen's syndrome is mixed. Some people (usually women) with the condition will experience one or two episodes before admitting that they need medical help. However, others (usually men) will deny that they have a problem and therefore never get the medical help that they need.


Munchausen's syndrome by proxy

There is a variant of Munchausen's syndrome called Munchausen's syndrome by proxy (also known as fabricated or induced illness), in which an individual fabricates or induces illness in a person who is under their care. Most cases involve a mother and her child.

See the Health A-Z topic about Munchausen's syndrome by proxy for more information about this condition.

Hypochondria and malingering

Munchausen's syndrome should not be confused with hypochondria and malingering. These are defined as:

  • Hypochondria: a psychiatric disorder where a person has a fear of illness and interprets normal bodily functions, such as sweating, or minor abnormalities, such as aches and pains, as indications of major illness.
  • Malingering: where a person fakes illness to gain some sort of benefit, such as to avoid military duty or to try to obtain compensation.

Page last reviewed: 13/07/2011

Warning signs

There are several warning signs that someone may have Munchausen's syndrome. Someone with the condition may:

  • make frequent visits to hospitals in different areas
  • claim to have a history of complex and serious medical conditions with little documentary evidence to support this (people often claim that they have spent a long time out of the country)
  • have symptoms that do not correspond to test results
  • have symptoms that get worse for no apparent reason
  • have a very good medical knowledge
  • receive few or no hospital visitors (many people with Munchausen's syndrome adopt a solitary lifestyle and have little contact with any friends or family)
  • be willing to undergo often painful or dangerous tests and procedures
  • report symptoms that are vague and inconsistent, or report a pattern of symptoms that are 'textbook examples' of certain conditions
  • tell highly unbelievable and often very elaborate stories about their past, such as claiming to be a decorated war hero or that their parents are fantastically rich and powerful

Patterns of behaviour

There are four main ways that people with Munchausen's syndrome can fake or induce illnesses. These are outlined below.

  • Lying about symptoms. They often choose symptoms that are difficult to disprove, such as having a severe headache or pretending to have a seizure (fit) or to pass out.
  • Tampering with test results. For example, they may heat a thermometer to suggest a fever or add blood to a urine sample.
  • Self-infliction. They may cut or burn themselves, poison themselves with drugs or an overdose of medication, or eat food that has been contaminated with bacteria.
  • Aggravating pre-existing conditions. For example, they may rub dirt or dog faeces (stools) into wounds to cause an infection or reopen previously healed wounds.

Munchausen's by internet

A relatively new condition has been labelled Munchausen's by internet. This is where a person joins an internet support group for people with a serious health condition, such as cystic fibrosis or leukaemia, and then claims to have the illness themselves.

While these actions may only be confined to the internet, they can have an incredibly destructive effect on support groups and online communities. People with genuine health conditions have reported feelings of betrayal and anger upon discovering that they have been lied to.

One expert on Munchausen's by internet has compiled a list of warning signs that indicate that someone may be affected by the condition:

  • They report experiencing symptoms that appear to be much more severe than most people would experience, such as having a constant blinding headache in a support group for people with migraines.
  • They claim to have near-fatal bouts of illness followed by a miraculous recovery.
  • They make fantastic claims which they later contradict or which others disprove at a later date. For example, they may claim to be attending a certain hospital that does not actually exist. 
  • They claim to have continual dramatic events in their life, such as loved ones dying or being the victim of a violent crime, particularly when other group members have become a focus of attention.
  • They feign an attitude of unconcern when they talk about serious problems, probably to attract attention and sympathy.
  • Other 'people' claim to post on their behalf, such as a parent or partner, but they use exactly the same pattern of writing.

Page last reviewed: 13/07/2011

Many people with Munchausen's syndrome refuse to co-operate with any sort of psychiatric treatment or psychological profiling. Because of this, there is little available evidence about the possible causes of the condition.

Theories

There are two main theories about the root cause of Munchausen's syndrome. The condition may be the result of:

  • emotional trauma (deeply upsetting experiences) that occurred during a person's childhood
  • a personality disorder: a mental health condition that causes patterns of abnormal thinking and behaviour

The two theories are discussed in more detail below.

Childhood trauma

Some experts have suggested that many cases of Munchausen's syndrome may be the result of parental neglect and abandonment, resulting in feelings of considerable childhood trauma.

As a result of this trauma, a person may have unresolved issues with their parents that cause them to fake illness. They may do this for a number of reasons, for example because they have:

  • a compulsion to punish themselves (masochism) by making themselves ill because they feel unworthy
  • a need to feel important and be the centre of attention
  • a need to pass responsibility for their wellbeing and care onto other people

There is also some evidence to suggest that people who have had extensive medical procedures, or received prolonged medical attention during childhood or adolescence, are more likely to develop Munchausen's syndrome when they are older.

This may be because they associate their childhood memories with a sense of being cared for. As they get older they try to obtain the same feelings of reassurance by pretending to be ill.

Personality disorders

There is some evidence that many people with Munchausen's syndrome have a personality disorder.

Personality disorders are a type of mental health condition where an individual has a distorted pattern of thoughts and beliefs about themselves and others. This leads them to behave in ways that most people would regard as disturbed and abnormal.

One theory is that there may be people with Munchausen's syndrome who have an antisocial personality disorder that causes them to take pleasure in manipulating and deceiving doctors. They may see doctors as authority figures and by tricking them it may give them a sense of power and control.

Page last reviewed: 13/07/2011

Diagnosing Munchausen's syndrome can be very challenging for medical professionals. People with the condition are often accomplished liars and are skilled at manipulating and exploiting a doctor's concern for their patient, and a doctor's natural interest in investigating unusual medical conditions.

Investigating claims

If a health professional does suspect that a person may have Munchausen's syndrome they will usually make a detailed study of that person's health records to look for any inconsistencies between their claimed and actual medical history. They may also attempt to talk to their family and friends to see if their claims about their past are true.

Health professionals can also run a number of clinical tests to check for evidence of self-inflicted illness or tampering of clinical tests. For example, the person's blood can be checked for traces of medication that the person should not be taking, but which could explain their symptoms.

Doctors will also want to rule out other possible motivations for their behaviour, such as faking illness for financial gain, or because they want access to strong painkillers.

A diagnosis of Munchausen's syndrome can usually be confidently made if:

  • there is clear evidence of fabricating or inducing symptoms
  • the person's prime motivation is to be seen as sick
  • there is no other likely reason or explanation for their behaviour

Page last reviewed: 13/07/2011

Treating Munchausen's syndrome can be very difficult because most people refuse to admit that they have a problem and will not co-operate with suggested treatment plans.

Non-confrontational approach

As a result of this, some experts have suggested that healthcare professionals adopt a gentle, non-confrontational approach. Therefore, rather than directly accusing the person of lying, they may suggest to them that they have complex health needs and may benefit from a referral to a psychiatrist. However, this suggestion is often rejected.

Other experts argue that a person with Munchausen's syndrome should be confronted directly with a question about why they have lied and whether they suffer from stress and anxiety.

One of the biggest ironies surrounding Munchausen's syndrome is that people with this condition have a mental health condition and are genuinely ill, but they will often only admit to having a physical illness. 

If a person admits to their behaviour, they can be referred to specialist psychiatric services for further treatment (see below).

If the person does not admit to lying, most experts in the field argue that the doctor in charge of their care should minimise any future medical contact with them. This is because the doctor-patient relationship is based on trust, so if a doctor has compelling evidence that they can no longer trust a patient, they are unable to continue as that person's doctor.

Psychiatric treatment

If someone admits that they have a problem, and co-operates with treatment, it may be possible to help them to control the symptoms of Munchausen's syndrome.

There is no standard treatment for the condition, but a combination of psychoanalysis and cognitive behavioural therapy (CBT) has shown some success in helping people to control their symptoms.

Psychoanalysis

Psychoanalysis is a type of psychotherapy that is based on the theories of Sigmund Freud. Freud suggested that unconscious beliefs or motivations, often formed during early childhood, can be the cause of many psychological conditions. Psychoanalysis attempts to uncover and resolve these unconscious beliefs and motivations.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) works by helping people to identify unhelpful and unrealistic beliefs and behavioural patterns that they may have. A specially trained therapist teaches the person receiving CBT ways of replacing the unrealistic beliefs with more realistic and balanced ones.

Family therapy

People with Munchausen's syndrome who are still in close contact with their family may also benefit from having family therapy. Family therapy involves the person with Munchausen's syndrome and their close family members discussing how the condition has affected the family and the positive changes that the person and their family can make.

Members of the family can also be advised about effective ways to avoid 'reinforcing' the person's abnormal behaviour. For example, they can be taught to recognise when the person is trying to play 'the sick role' and then avoid showing them concern or offering support.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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