By contrast, women with Munchausen’s or Munchausen’s by proxy—often nurses or hospital personnel—are more difficult to diagnose because they usually are agreeable and compliant with medical staff. Staff members tend to ask themselves, “Could such a caring person be putting us on?”
Some persons with Munchausen’s visit disease-specific support groups and draw attention or sympathy by faking illness. Having amassed significant medical knowledge through Web searches and frequent doctor visits, they present themselves as both patient and lofty advisor. Their antisocial tendencies can negatively alter group discussions, and the revelation that a fellow group member is an impostor can distress legitimate participants.3
Ms. J exhibited no evidence of a delusional disorder, which occurs rarely among parents with Munchausen’s by proxy. Her allegedly “clingy” (dependent) behavior toward her daughter and ex-husband, however, indicates borderline personality disorder or antisocial personality disorder, which are common in both forms of Munchausen’s. Like Ms. J, these patients
- have strong fears of rejection and abandonment
- are often impulsive
- exhibit damaging behavior to self or others
- have an unstable sense of self
- are unusually willing to comply with clinical tests or procedures
- and describe feelings of emptiness.
How would you confirm a diagnosis of Munchausen’s? What features in Ms J’s case distinguish Munchausen’s from other factitious disorders?Box
Munchausen’s and allegations of child sexual abuse
- Munchausen’s syndrome by proxy has been reported in women who were sexually abused in their youth. As adults, some of these women become hypervigilant against sexual abuse of their children.
- The disorder has been cited in several legal cases in which a suspect—usually a teacher or religious leader—was falsely accused of sexually molesting a child.4 Psychiatrists involved as expert witnesses or examiners in such cases should consider these allegations as a possible manifestation of Munchausen’s.
- If the accused denies the charges and no evidence is uncovered, the alleged victim’s mother should be interviewed. In some cases the mother was sexually abused and sought help, but the perpetrator was never apprehended. She may harbor resentment toward men and repeatedly ask her child whether he or she has been touched inappropriately. The child—besieged by frequent inquiries or unsure of what constitutes an inappropriate touch—may answer "yes," prompting the mother to press charges against the named individual.
Dr. Messer’s observations
When taking the patient history, look for:
- a pattern of rejection or abuse in youth. In women who have been sexually molested, Munchausen’s by proxy may manifest as allegations that their children have been touched inappropriately (Box).4
- history of multiple surgeries.5 Because Munchausen’s can coexist with genuine physical illness, the psychiatrist and other doctors need to carefully review the findings to determine the existence of medical symptoms or Munchausen’s. Doctors usually choose to operate if there is any suspicion that medical symptoms exist.
- memories of sympathetic and nurturing medical care early in life. A severe emotional crisis can awaken these memories. For example, emotional pain after a divorce or break-up can trigger a Munchausen’s episode in a subconscious attempt to repair this hurt.
Carefully reviewing the history will turn up glaring discrepancies in the patient’s account of his or her illness. Patients with Munchausen’s or Munchausen’s by proxy usually present to numerous clinicians and do not describe their “illness” the same way twice. Sharing information with other members of the care team—many of whom may feel anger after learning that a patient has been feigning illness—is crucial to confirming the diagnosis.
DIFFERENTIAL DIAGNOSIS
Munchausen’s should not be confused with symptoms of other lookalike disorders:
- Hypochondriasis applies to patients who are convinced they have a serious illness despite lack of a medical basis. The person may misinterpret normal bodily functions and suffer severe distress. The symptoms may express inner psychic conflict.
- Somatoform disorder is a physical complaint that cannot be explained as a known medical condition. This may include preoccupation with an imagined defect in appearance or loss of physical capacity. The deficit usually coincides with emotional conflict and—unlike Munchausen’s—there is no fabrication of illness.
- Malingerers purposely fake physical symptoms for specific gain, such as money, hospital care, disability, drugs, or avoiding military duty.
Persons with Munchausen’s have no external incentive for their behavior. Aside from the medical staff’s admiration, Ms. J had nothing to gain from injuring her daughter or portraying her as sickly.
TREATMENT: Coming home
Ms. J’s daughter responded well after being placed in the home of a relative who had a 3-year-old daughter of her own. Ms. J was allowed to see her daughter for 2 hours each day under strict supervision by a retired schoolteacher hired by the family. If Ms. J. violated the agreement, such as by leaving the house with her daughter, she was prohibited from seeing her child the next day.