Munchausens syndrome by proxy is a variant of which of the following disorders

5.26.1 Introduction

Factitious disorder, simply put, is the intentional simulation of illness through a variety of false pretenses. This includes reporting exaggerated symptoms, fabricating laboratory results, and actually inducing symptoms through physical means such as ingestion of substances, injection, or suffocation. Factitious illnesses often result in numerous expensive and painful, not to mention unnecessary, laboratory tests, hospitalizations, and surgical procedures for the young “patient” before the charade is finally uncovered.

What is not so simple is the identification and understanding of this disorder, which poses serious challenges in differential diagnosis and effective treatment. Much better represented in the adult literature, often as “Munchausen syndrome,” factitious disorder in youngsters is certainly known to occur, but has yet to be studied in any systematic manner. There is a very limited literature on factitious disorders in children per se, while there is an extensive literature of related disorders, diagnoses, and conditions which may provide intriguing clues to the etiology of this disorder. While this chapter will address factitious illness which involves a child or adolescent as the object of unnecessary medical attention, we will find that the perpetrator can actually be the child him or herself, the parent, the family unit, or a complex pathological collusion between parent and child. The relationships between these different yet similar presentations is still little understood, but poses intriguing clues for fiuture understanding of the development of the many forms of somatization and illness exaggeration throughout the lifespan.

Nonpharmacologic Therapy

Two approaches may be considered by the primary physician:

Nonpunitive diagnostic disclosure by the primary physician and a psychiatrist in collaboration. This is sometimes called “confrontation,” but it is not adversarial. A supportive stance should be maintained and an offer for ongoing support and follow-up made.Box E3 summarizes consensus opinions on the treatment of factitious disease. Features of supportive “confrontation” are described inBox E4.

Avoid overt confrontation with patient but provide him or her with a face-saving way to recover. For example, a therapeutic double bind would involve saying, “There are two possibilities here: One is that you have a medical problem that should respond to the next intervention we do, or two, you have a factitious disorder. The outcome will give us the answer.”

Severe cases may be virtually impossible to treat except to avoid further invasive intervention.

BOX E3

Consensus Opinions on the Treatment of Factitious Disease

Achievement of insight should not be the principal early goal of treatment, because it can weaken the patient’s defenses.

One person should have primary responsibility for patient management.

There should be a comprehensive psychiatric evaluation of the patient, including assessment for suicide risk.

All members of a multidisciplinary team should be aware of the psychiatric assessment and treatment plan.

The treatment plan should be individualized.

Comorbid illness should be treated appropriately.

If confrontational techniques are used, they should be nonpunitive and supportive.

BOX E4

Features of Supportive Confrontation

Tell the patient what you suspect without outright accusation.

Support the diagnosis of factitious disease with facts.

Provide empathetic and face-saving comments.∗

Avoid probing to uncover the patient’s underlying feelings and motivations.‡,†

Assure the patient that the physician will not release the diagnosis to others without the patient’s permission unless required to do so by law.‡

Ensure that the staff demonstrates continued acceptance of the patient.

Encourage psychiatric help, but do not force the issue.

Factitious unresponsiveness

Case 28.4

Factitious disorder

A 53-year-old man on trial for historic charges of child sexual abuse collapsed in court and was admitted to the neurology ward in an apparently comatose state. There was clear evidence of a “functional coma,” with normal response to stimulation of the nasal mucosa with a tuning fork (Harvey's sign, discussed below) and eyes closed with resistance to eye opening. The comatose state lasted 12 hours, following which he rapidly recovered and returned to prison. On recovery he had Ganser-type answers – that is, answering “approximate” answers to very simple questions to which nearly everyone should know the answer, such as “What is two plus two?” “Five” Later he admitted to a prison psychiatrist that he had deliberately faked the episode as he was finding the experience in court intolerable.

The possibility of intentional feigning of unconsciousness should also be considered among the differentials in cases of unexplained unconsciousness and unresponsiveness, although clear evidence of feigning can be difficult or impossible to obtain and positive signs of functional coma do not exclude feigned symptoms. Factitious disorder is differentiated from malingering, in that, where malingering of symptoms is for clear purposes of personal gain, there are no such external rewards in factitious disorder. Our own personal experience across a range of functional disorders is that extreme presentations, such as complete paralysis or coma, whilst often genuine, are a “red flag” for the possibility of factitious symptoms and so a priori we might expect a higher incidence of willful exaggeration in this patient group. On the other hand more extreme symptoms can also be a red flag for more severe comorbidity, especially personality disorder and previous abuse. We have met patients with functional coma who appeared to have an entirely genuine and distressing experience with no obvious potential for material gain. It seems reasonable to assume there may be a spectrum of willful exaggeration that patients may move across over time, even during a single episode. However, it is not reasonable to assume that all patients in a functional coma are willfully exaggerating.

In seven out of 25 reviewed cases there was evidence of willful exaggeration (Hopkins, 1973; Henry and Woodruff, 1978; Albrecht et al., 1995). However, two of these articles were published with titles including terms such as pretending and factitious, suggesting bias within the selection and interpretation of the presented cases. In these cases evidence for conscious simulation was either derived from the observation that patients were looking around when felt unwatched or on the basis of the patients’ comments after regaining consciousness. One patient even admitted that she produced the fits of unconsciousness when faced with stress (Henry and Woodruff, 1978).

Principles

Patients may present to the emergency department (ED) with symptoms that are simulated or intentionally produced. The reasons that cause this behavior define two distinct varieties: factitious disorders and malingering.

Factitious disorders are characterized by symptoms or signs that are intentionally produced or feigned by the patient in the absence of apparent external incentives.1,2 Factitious disorders have been present throughout history. In the second century, Galen described Roman patients inducing and feigning vomiting and rectal bleeding.3 Hector Gavin sought to categorize this behavior in 1834.3 These patients constitute approximately 1% of general psychiatric referrals, but this percentage is lower than that seen in emergency medicine because these patients rarely accept psychiatric treatment.1,4 Of patients referred to infectious disease specialists for fever of unknown origin, 9.3% of the disorders are factitious.5 Between 5% and 20% of patients observed in epilepsy clinics have psychogenic seizures, and the number reaches 44% in some primary care settings.6 Among patients submitting kidney stones for analysis, up to 3.5% are fraudulent.7

TheDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies factitious disorders into two types: factitious disorder imposed on self (FDIS) and factitious disorder imposed on another (FDIA).

Munchausen syndrome, the most dramatic and exasperating of the FDIS, was originally described in 1951.8 This fortunately rare syndrome takes its name from Baron Karl F. von Munchausen (1720 to 1797), a revered German military officer and noted raconteur who had his embellished life stories stolen and parodied in a 1785 pamphlet.3 The diagnosis applies to only 10% to 20% of patients with factitious disorders.1,9 Other names applied include the “hospital hobo syndrome” (patients wander from hospital to hospital seeking admission), peregrinating (wandering) problem patients, hospital addict, polysurgical addiction, and hospital vagrant.4,10

FDIA, an especially pernicious variant that involves the simulation or production of factitious disease in children by a parent or caregiver, was first described in 1977.2,11 There are approximately 1200 estimated new cases of FDIA per year in the United States.3 The condition excludes straightforward physical abuse or neglect and simple failure to thrive; mere lying to cover up physical abuse is not FDIA.3,11 The key discriminator is motive: the mother is making the child ill so that she can vicariously assume the sick role with all its benefits. The mortality rate from FDIA is 9% to 31%.12 Children who die are generally younger than 3 years old, and the most frequent causes of death are suffocation and poisoning.13 Permanent disfigurement or permanent impairment of function resulting directly from induced disease or indirectly from invasive procedures, multiple medications, or major surgery occurs in at least 8% of these children.13,14 Other names applied includePolle's syndrome (Polle was a child of Baron Munchausen who died mysteriously),factitious disorder by proxy, pediatric condition falsification, Munchausen syndrome by proxy, andMeadow's syndrome.3,8,10,12

DIFFERENTIAL DIAGNOSIS

Factitious illness and MBP exist on a spectrum ranging from situations of caretaker underinvolvement (i.e., child neglect) to excessive involvement, the extreme of which is MBP.5 The MBP caretaker has a pattern of repeatedly seeking medical evaluation for “unexplained” episodes. In contrast, in cases of non-MBP abuse or neglect, although the caregiver may attempt to obscure the real story, he or she is typically not trying to elicit a prolonged evaluation of the child.

One can also differentiate factitious illness from the more extreme MBP. In cases of factitious illness, the caretaker may “overreport” or “pathologize” symptoms that are in fact unremarkable, leading to inappropriate testing or treatment. The crucial difference is that the non-MBP caretaker does not intend to deceive. Factitious disorders that are not MBP can also be seen when the caregiver is psychotic and in children with somatoform disorder and some eating and feeding disorders.2 Regardless of the terminology, such caretaker behavior places the child's overall health and well-being at risk.

Epidemiology

Factitious disorders are relatively uncommon but, like many conditions remain largely based on patient feedback, and probably remains underdiagnosed. A survey of referrals to a psychiatric liaison service in a North American general hospital found that 0.8% had factitious disorder (Sutherland and Rodin, 1990). Surveys of physicians demonstrate a wide range of prevalence estimates, with a mean estimated prevalence of 1.3%, with dermatologists and neurologists giving the highest estimations (Fliege et al., 2007).

Recognizing simulation remains largely a function of experience and the predisposing attitudes of the observer, especially neurologists (Miller and Cartilidge, 1972). In a review of factitious disorders in neurology, Kanaan and Wessely (2010b) found that neurology patients were strikingly different from those in other specialties in terms of their demographics. Considering 90 patients from a total of 45 published reports, they found a wide range of neurologic presentations, the most common of which was functional motor symptoms/simulated strokes, and seizures/blackouts. They found that proportionately more of the patients were male (56%) and only 17% were healthcare workers, which was surprising, given that the majority of patients with factitious disorders are women and many are involved in the healthcare professions. The authors speculated that “factitious nurses” (or, more properly, nurses presenting with factitious disorders) are typically diagnosed with conversion disorder. They also speculated that there was evidence that neurologists preferentially diagnosed factitious presentations in nurses as “hysterical,” presumably to avoid the stigma of simulated illness.

5.27.2.1 Factitious Disorder in the Context of Related Conditions

FD belongs to a family of medical and psychological conditions in which signs or symptoms of medical illness appear to be excessive relative to a patient's objective medical condition. The signs and symptoms are commonly referred to as unexplained medical complaints, medically unexplained symptoms, or functional somatic symptoms, and these are common in both adults and children (Eminson, 2007; Fink, 2017). In the medical setting, unexplained symptoms are observed as single functional symptoms (e.g., non-epileptic seizures) or broader functional somatic syndromes (Fink, 2017). These syndromes include fibromyalgia, complex regional pain syndrome, non-cardiac chest pain, chronic fatigue, and irritable bowel syndrome. They are common in the medical specialties that address them, and they have been observed in children and adolescents (Rask et al., 2013).

In mental health settings, there is a family of DSM and International Classification of Diseases (ICD) psychiatric disorders that are defined by persistent reports of unexplained medical concerns. The category is called somatic symptoms and related disorders. These disorders include illness anxiety disorder (previously termed hypochondriasis), somatic symptom disorder (previously called somatization disorder) and conversion disorder. These disorders are thought to be common in adult primary care, though they may not be officially diagnosed (Swanson et al., 2010), and they are also observed in children and adolescents (Schulte and Petermann, 2011).

Collectively, people in these categories may represent 10%–15% of primary care patients or higher (de Waal et al., 2004), and the rates may be closer to 30% in specialty care settings. The boundaries across these conditions are not clear. There is vigorous debate about whether they should be regarded as discrete medical and psychiatric conditions, or whether all the various categories and labels have more to do with what type of provider is seeing the patient than the type of patient the provider is seeing (Fink, 2017).

All of these phenomena have in common the assumption that the patient genuinely experiences either anxiety over their health or actual bodily distress; that is, they are not intentionally lying or exaggerating their complaints. They are distinguished from FD (and the specification of malingering) by the fact that in FD that the patient is actively falsifying their complaint for the purpose of deceiving others. In fact, this criterion is the singular defining feature of FD.

It is important to note how the DSM criteria for the somatic symptom and related disorders are constructed. In short, to diagnose FD, the DSM requires affirmative proof that the patient falsified their claims of illness and that they did so for the purpose of deceiving others. In contrast, the other disorders (illness anxiety, somatic symptom disorder, and conversion disorder) and cases of functional somatic syndromes are assumed to reflect unconscious psychological processes that result in genuine worries or bodily distress, but the diagnostic criterion do not require affirmative proof of that. The instructions for diagnosing FD require that these other disorders be “ruled out” before FD can be diagnosed, but make no symmetrical requirement that deliberate falsification must be ruled out before a non-FD disorder can be diagnosed.

There is no psychological test or procedure for detecting the medical deception that distinguishes FD from other cases involving medically unexplained or puzzling complaints. Clinicians who make the diagnosis of FD usually do so in response to direct forensic evidence (e.g., catching someone in the act of self-harm, or discovering physical evidence of illicit drugs or poisons that can explain puzzling test results), or overwhelming circumstantial evidence (e.g., the seizure never starts when someone else is around). An important consequence of the way the DSM criteria are structured is that FD can only be diagnosed in cases in which the medical deception is severe and audacious. Only in such cases will there be a chance of gathering the types of evidence required to affirm medical deception. This requirement virtually ensures that FD will appear to be a rare and extreme form of psychopathology simply because subtler cases of medical deception are much harder to prove. Thus, FD, as a disorder, along with the motivational mechanisms that define it, are nosologically segregated and minimized. We believe that this results in the unfortunate neglect of the possible contributions of intentional falsification in more pedestrian cases of unexplained illness.