Factitious disorder imposed on self (FDIS), commonly called Munchausen syndrome, is a complex mental disorder in which an individual imitates symptoms of illness in order to elicit 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 their motivations. There are several risk factors and signs associated with this illness and treatment is usually in the form of psychotherapy, but may depend on the specific situation, which is further discussed below. Diagnosis is usually determined by meeting specific DSM-5 criteria after ruling out true illness as described below.
Factitious disorder imposed on self is related to factitious disorder imposed on another, the abuse of another person in order to seek attention or sympathy for the abuser. This is "Munchausen by proxy", and the drive to create symptoms for the victim can result in unnecessary and costly diagnostic or corrective procedures. Other similar and often confused syndromes and diagnoses are discussed in the "Related diagnoses" section.
History and terminology
That patients can exaggerate or inflict symptoms on themselves has been recognized since antiquity, with the second century manuscript attributed to Galen titled On Feigned Diseases and the Detection of Them. In 1843, the Scots physician Hector Gavin invented the term "factitious disease" to describe persons who faked medical symptoms for sympathy, attention or "some inexplicable cause". In the 1930s, the psychiatrist Karl Menninger noted some patients compulsively insisted on medically unnecessary surgeries, often seeking out a physician with a powerful or dynamic personality.
In 1951, Richard Asher coined "Munchausen syndrome" for a pattern of self-harm where individuals fabricated histories, signs, and symptoms of illness. The name alludes to Baron Munchausen, a fictional character who tells many fantastic and impossible stories about himself. Asher's article was published in The Lancet in February 1951. The name 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 neutral description of the 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 of multiple psychosocial factors. Specific risk factors have been associated 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. Some researchers suggest other various psychiatric disorders may coincide, namely Histrionic personality disorder or Borderline Personality Disorder. The comorbidity of these psychiatric disorders with FDIS can be termed a Tripolar Syndrome.
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, or 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 feigned 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 specific diseases. As mentioned earlier, it is important to first rule out true disease. Oftentimes this requires multiple lab tests as a form of differential diagnosis, especially when the disease is mimicked closely in patients with existing medical knowledge. 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 manifestations are listed in the table below, along with how to differentiate real versus mimicked disease using medical laboratory tests or imaging. Disease mimickedMethod of imitationLaboratory/diagnostic confirmationBartter syndrome Taking diuretics to urinate excessively or self-induced vomiting Termed "pseudo-Bartter syndrome" Creates an electrolyte imbalance in the body Measure blood or urine diuretic levels to detect medication as the cause Urinary chloride levels will be high in true Bartter syndrome vs. low in pseudo-Bartter syndromeCatecholamine-secreting tumor (i.e., carcinoid tumor) Injection of epinephrine into urine or blood stream Causes diarrhea, facial flushing, wheezing, heart palpitations, weight loss Chromogranin A is a tumor marker for carcinoid tumors; blood levels are typically elevated in the presence of a tumor but remain normal in individuals with FDIS.Cushing's syndrome Secret steroid medication (e.g., prednisone) administration (note: patients admitting that they are prescribed steroids for another medical condition will experience this, but this would not be considered FDIS since the patient is not deceitful or withholding information or intending to have Cushing's syndrome) Over time, patients will experience weight gain, easy bruising, rounding of the face, increase in blood pressure, and increase in infections Urine test to detect use of steroidsHyperthyroidism Secret thyroxine, a thyroid hormone, administration (note: patients may be prescribed this medication for low thyroid levels) Produces symptoms of heart palpitations, weight loss, hot flashes, diarrhea, and abnormal menstrual cycles Low radioactive iodine thyroid uptake, which would be elevated in true hyperthyroidism Low thyroglobulin levels, which should be elevated in true hyperthyroidismHypoglycaemia Secretly using more insulin than prescribed and acting as though they are not Produces symptoms of low blood sugar, including shaking, sweating, dizziness, confusion, and an irregular heartbeat C-peptide, a byproduct of normal insulin production in the human body, will be low in patients with FDIS C-peptide is not found in medical insulin but is found in the body, as it is produced at the same time as insulinChronic diarrhea (Factitious diarrhea) Excessive intake of laxatives to produce diarrhea and acting like it's from an unknown cause Produces electrolyte imbalances in the body and dehydration Many cases may mimic inflammatory bowel disease or malabsorption syndromes Stool analysis to detect laxative use Stool osmolality >600 mOsm/kg or <290 mOsm/kg may indicated FDIS Colonoscopy may show brown discoloration of the colon, called melanosis coli, often seen in laxative abuseProteinuria (protein in urine) Surreptitious addition of protein, usually albumin, to sample Perform urine protein electrophoresis Investigate corresponding transferrin levels, albumin rarely exceeds 75% of total urine protein Use of antibodies and band detection on various alpha, beta, and gamma regions can differentiate between human and non-human proteins Haematuria (bloody urine) Deliberately contaminating urine sample with blood Intentionally causing trauma to the urethra Imaging to rule out insertion of a foreign body Monitor sample collection Analysis of red blood cell shape in samples, which will show excessively destroyed red blood cells in FDIS
Munchausen by Internet Munchausen by internet is a term describing the feigning of illness online to garner sympathy and support. Described in medical literature as a manifestation of FDIS, it is not an independent diagnostic classification. 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".Todd, Belinda (October 21, 2002)."Faking It" , New Zealand PC World Magazine. Retrieved on July 29, 2009. More recently, online forums such as snark subreddits have labelled these individuals as "illness fakers" or "munchies".