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Munchausen’s Syndrome: A difficult diagnosis?

Munchausen’s syndrome is described as a factitious disorder where a person falsely overstates his/her physical or mental illness without the perception of acquiring any financial gain.

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Baron Munchausen. The Horse At The Fountain

However, such a person strongly possesses an inner desire of seeking sympathy from others. This psychological condition was named by Richard Asher (1951) after the renowned fictional character, Baron von Munchausen. The reason being that the latter was famous for sharing fabricated accounts of his life experiences with the public. Although extremely difficult to diagnose, Munchausen’s syndrome has been associated with around 1-2% of hospitalized individuals.

Munchausen’s syndrome has been considered as an immense diagnostic challenge and remains to be a diagnosis of exclusion. The presenting complaints of such patients are mostly pertinent to gastrointestinal, neurological and skin diseases. In a majority of cases, the patient would be a young female and it is very likely that the patient’s occupation would be somehow related to healthcare. It may be possible that the person has visited the hospital numerous times in his/her lifetime and possesses a lot of credible information about rare medical ailments.

In some rare instances, patients have even been observed to perform self-venesection so as to induce a fictitious anaemia. Since these patients are capable of exceeding any limits when it comes to falsifying their medical records, there is a potential risk that their recklessness might cause any serious complications, especially if such patients are planning to undergo any unneeded surgical procedure.

As a nurse, I have seen literally hundreds of known Munchausen patients. Many present with esoteric neurological syndromes that defy all investigation, pseudo-epilepsy, pseudo-asthma, razor blade swallowing, “skin popping” petrol to cause abscesses, self-injection of faecal matter, over-hydration to cause electrolyte imbalance and so on. Many are well known through multiple hospital departments and multiple hospitals, sometimes with a number of identities.

Of course, initially, it may not be apparent that the patient is faking it. In such circumstances, it is fairly common for the attending physician to find it extremely challenging to correlate the incoherent symptomatology of the patient and to establish a firm clinical diagnosis. Therefore, a step-by-step approach has to be adopted before labelling a patient as a confirmed case of Munchausen’s. It is noteworthy that a prevailing medical disorder might manifest itself through an uncommon presenting complaint. Therefore, any such possibility must be prudently excluded through a thorough medical check-up. If possible, an interdisciplinary approach can be followed to help reach a final diagnosis.

In addition, it is equally essential to identify any possibility of somatoform disorders (e.g., hypochondriasis). In such cases, the presenting symptoms are rather authentic, however, the physician would find it difficult to attribute these features to a generalized medical disorder. In clinical practice, differentiating Munchausen’s syndrome from somatoform disorders is an arduous deal as the boundaries between the two conditions are quite vague.

Once diagnosed, it is advised that such patients should be adequately counselled and then encouraged to seek psychiatric care as soon as possible. This not only helps save the doctor’s time but also prevents the loss of valuable medical resources. Lastly, it is important for the physician not to behave too bluntly with such individuals as it may lead to an emotional breakdown or even cause fits of rage among them. This invariably leads to them taking flight and simply moving on to a different hospital or department.

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