Would I Lie to You?

Munchausen’s syndrome was first described and named in a seminal article by Richard Asher  in 1951. It is also known as Factitious Disorder (FD), and is described in DSM-5 as ‘a psychiatric disorder in which sufferers intentionally fabricate illness, injury or impairment in order to gain hospital admission and undergo medical procedures, without obvious gain’.

Although the exact incidence is unknown, estimates of incidence vary around 1%, and it is likely that most doctors will encounter at least one patient with Munchausen’s syndrome.

A recent review article found that 66.2% of reported patients were female with a mean age at presentation of 34.2 years. Healthcare and laboratory professionals were overrepresented. There is considerable variation in the presentation in cases, and patients may gravitate towards signs and symptoms leading to fast-track admissions such as chest pain.  The internet has enabled patients to research their presentation of choice, forge medical reports or referral letters and even purchase prescription medications such as insulin, anticoagulants and thyroid hormones in order to induce illness.

A Tribunal prosecuted a nurse in 2014 who impersonated a medical practitioner and provided a false medical history in order to procure the insertion of a venous infusaport where there was no clinical justification for one being inserted.

The cost of unnecessary investigations, treatments and hospital admission on the healthcare system can be significant, and there may be considerable psychological impact on medical staff involved in the patient’s care.

The authors of the review suggest that health practitioners should consider Munchausen’s syndrome early when encountering patients whose complaints appear unsupported by physical examinations, and the results of investigations.  

Other clues to this diagnosis include:

• dramatic and unlikely medical history
• refusal to grant access to information from external sources, and family and friends
• evasiveness and inconsistent history
• tests and procedures are eagerly accepted, or requested
• investigations normal or inconclusive
• course of illness is unusual with resolution of symptoms soon after admission to hospital, and inconsistent or poor response to standard treatments.

Management can be challenging, and should involve a multidisciplinary approach, including psychiatry. Unfortunately patients may respond by lodging complaints, becoming disruptive, and leaving against medical advice.

Although the majority of your patients will be honest with you, it is prudent to check directly with primary sources (previous doctors, hospitals or laboratories) and keep an open mind if your suspicions are raised regarding your patient’s presentation. It may also be helpful to seek advice from your MDO when dealing with a patient with Munchausen’s syndrome.