Munchausen syndrome

Disease Description (Causes and Symptoms)

• Definition: Munchausen syndrome is a severe form of factitious disorder in which a person deliberately creates or exaggerates symptoms and assumes the sick role despite not actually having a disease, motivated by a desire to receive attention or care from others without external rewards (such as money or legal benefits). Munchausen by proxy refers to deliberately making another person (usually a child or dependent) ill or pretending that they are ill in order to obtain care and attention.
• Causes and pathophysiology:
  • The causes are multifactorial, and no definitive mechanism is known.
  • Factors involved include attachment problems in childhood, overprotection, experiences of abuse or neglect, emotional deprivation, and problems with self-identity.
  • The psychological motivation to obtain emotional rewards (attention and sympathy) through the “sick role” is considered a key mechanism.
  • Some patients have medical knowledge, making their deception sophisticated by manipulating tests and treatments or presenting fabricated medical histories.
• Main symptoms:
  • Inconsistent medical history and discrepancies between test results and clinical findings
  • Repeatedly changing hospitals and doctors (doctor shopping)
  • Requesting unnecessary tests or procedures, or inducing symptoms through self-harm
  • Reproduction of symptoms when there is no objective evidence or when they cannot be explained by the diagnosis
  • In the proxy form, repeated hospitalization, testing, and treatment of the dependent person, with unexplained worsening of symptoms

Treatment Methods

• General principles:
  • There is no standard treatment that “removes” the symptoms with medication; psychosocial approaches are central.
  • The goals are to prevent iatrogenic harm (injury caused by unnecessary tests or procedures), treat the underlying psychological causes, and treat coexisting mental disorders.
• Psychotherapy:
  • Establishment of an ongoing trusting relationship (designation of a consistent primary physician and care team)
  • Cognitive behavioral therapy (CBT): improving symptom distortion and coping strategies, and managing urges to self-harm
  • Psychodynamic therapy or interpersonal therapy: addressing early attachment and emotional deprivation
  • In cases involving borderline personality traits or similar pathology, DBT (dialectical behavior therapy), mentalization-based therapy, and other treatments may be considered
• Behavioral management and medical strategies:
  • Use of consultation with other departments, documentation, and a single point of contact to avoid more tests or surgeries than necessary
  • If symptoms are harmful or there is a risk of self-harm, inpatient treatment (to ensure safety) may be considered
  • In the proxy form, immediate protective measures (such as reporting to child protective services) and legal and ethical responses are necessary
• Medication:
  • There is no specific medication indication for factitious disorder itself
  • If coexisting depression, anxiety, impulse-control problems, or psychotic symptoms are present, medications appropriate for those symptoms (such as antidepressants, anxiolytics, or antipsychotics) may be used
• Precautions (during treatment):
  • Direct and hostile accusations should be approached with caution because they may destroy the therapeutic relationship
  • Prevent duplicate procedures and adverse effects by systematizing information sharing among the treatment team and referral records
  • If legal or ethical issues arise, consult the hospital ethics committee and legal department

Checklist Before an Outpatient Visit (Including Preparation Materials and Example Questions)

• Preparation materials and information:
  • List of currently used medications and health supplements (including dosage and duration of use)
  • Copies or summaries of past hospital treatment records and test results (if available)
  • A record of when symptoms occur, their characteristics, aggravating factors, and relieving factors (symptom diary)
  • History of hospitalizations, surgeries, and procedures, and a list of visits to other hospitals (including contact information if possible)
  • Past mental health diagnoses and treatment records (such as psychotherapy and hospitalization records)
• Items that may be helpful to prepare before the outpatient visit:
  • A record of recent changes in stressors (such as at home or work)
  • Sleep, eating, and alcohol or drug use habits
• Example questions that may be asked during the outpatient visit:
  • When did the symptoms first begin, and how have they progressed?
  • How do the symptoms affect your daily life?
  • What tests and treatments have you received at other hospitals?
  • Have you ever caused self-harm or injury to another person?
  • Does a similar problem exist among your caregivers or family members?

Examples of General Questions to Ask a Doctor

• “What are the diagnostic criteria for this condition? What additional tests do I need in my case?”
• “What treatment options (psychotherapy and medication) do you recommend, and what are the expected effects and duration of each?”
• “When tests are unavoidably needed during treatment, how can I avoid unnecessary procedures?”
• “What are the risk of recurrence and the prognosis? What can I do to prevent recurrence?”

Examples of Condition-Specific Questions

• Questions specific to Munchausen syndrome (self-directed):
  • “When my symptoms cannot be medically explained, how can I work with the medical staff to reduce unnecessary tests?”
• Questions specific to the proxy form (Munchausen by proxy):
  • “When the dependent person has been repeatedly hospitalized or undergone procedures, what are the procedures for ensuring the safety of the child (or dependent person)? How are legal protective measures carried out?”

Additional Information:

• Munchausen syndrome is difficult to diagnose and treat. Treatment is long-term and requires a multidisciplinary approach (including psychiatry, internal medicine or surgery, social work, and legal support). If symptoms lead to self-harm or become life-threatening, emergency intervention is necessary.