Episode 108: Munchausen Syndrome, Factitious Disorder, Malingering, and Munchausen Syndrome by Proxy
Amanda Shim, David Puder MD
There are no conflicts of interest for this episode.
This episode does not offer CME credit.
There are several disorders so branded with taboo, stigma, and legal consequences that they are almost never diagnosed and very little research has been done on them. My role (Dr. Puder) in the MEND program has given me case after case of firsthand experience with these disorders. These patients are literally seen by every specialty, often without knowing it, and without a good solution. I am hoping this podcast brings awareness to this important topic and gives providers insight into the power of empathy in helping these patients.
The disorders are:
Malingering
Factitious Disorder imposed on another, also called Munchausen syndrome by proxy or Factitious Disorder by Proxy
Factitious Disorder, also called Factitious Disorder imposed on self; when severe it is called Munchausen syndrome
What Is Malingering?
Malingering is when someone lies about an illness to gain external benefits (compensation from an insurance company, money from a disability claim, avoid the military, avoid a criminal conviction, etc.). To call someone malingering is to call them a liar, so as a medical professional it is prudent to document exactly what happened, record quotes of what was said, and make sure all of it supports the diagnosis.
As I write this, multiple patients come to mind:
One wanted me to sign off on his inability to work because of depression, then the week after told me he was working under the table for a friend.
Another case was a woman suing her work for an injury she claimed happened at work, when she had absolutely nothing wrong with her (except for flagrant narcissism).
Countless cases of patients wanting clear documentation of how severely ill they were, only to tell me later that they wanted these notes because it was helping them finish a court case.
My approach to malingering is setting boundaries until they move on or move them on immediately. No benzos. No adderall. Nothing addicting. In one man’s case that I followed for years, I saw his anger improve. I might add that they are always angry when you confront them and angry when they leave. If you are seeing this type of patient as a provider, seek counsel from a colleague to extend empathy to you for the difficult place this puts you in!
I specifically try to scare these clients away with my introduction letter that states:
For me the therapeutic relationship is a very important aspect that I seek to protect. I do so by not giving legal testimony for my clients. I require that you employ independent forensic psychiatric services should this type of evaluation or testimony be required.
If I sense even a hint of malingering I make requirements that lead to them leaving:
ADHD - get a neuropsych eval before any treatment with amphetamines
Wanting Benzos- check what they are actually on vs what they report (pharmacy records, cures report). Then, if they are lying, recommend immediate detox. If their dosage is too high, taper them down once a month. If they don’t follow recommendations send them immediately to detox.
Factitious Disorder Imposed on Another
Next, let’s discuss Factitious Disorder imposed on another, formerly known as Munchausen by proxy. This is when caretakers induce illness in their child for some sort of gain. I have also seen this disorder too many times and it is hard to witness. Nothing angers me more than actually being so close to child abuse (and there is always profound abuse and neglect in these cases). The innocence of every child is damaged. Watching the person who should have loved the child the most act in a narcissistic, psychopathic, Machiavelian way is very challenging.
Rather than talk about my own cases, here are some I have heard about:
A mother forced her daughter to use a wheelchair and undergo unnecessary medical procedures (the daughter ended up killing her mother) (Keegan, 2021)
After poisioning her infant daughter, a mother was arrested for child abuse after the baby was diagnosed and treated for nine different rare infections (Pham, 2011)
By age 8, a young boy had been to the hospital 323 times and undergone 13 major surgeries based on his mother’s claims that he had cancer or a degenerative disorder affecting his oxygen supply (Eiserer, 2017)
Until age 17, a mother convinced her daughter that she had Lyme Disease, which resulted in years of alternative treatment (homeopathy, laser treatments, electric bands) that made her weak to the point of requiring a wheelchair (Gladwell, 2020)
A mother starved her 13-year-old son until he weighed only 51 pounds to convince healthcare professionals to give him a feeding tube, central line, colostomy bag, and several pain medications (Rogers, 2020)
Following the death of her daughter, a mother was arrested for fraudulently portraying her as terminally ill and seeking donations to cover medical care (Slevin, 2020)
Some things to look for (Feldman 2004, Rogers 2020):
“Episodes of illness begin when the mother is or has recently been alone with the child, or the child has symptoms that only the mother has observed.
Illness abates when the child is separated from the mother.
Other children in the family have had unexpected illnesses.
The mother has provided false information about the child.
Physiological or laboratory parameters are consistent with induced illness.
The suspected disease or disease pattern is extremely rare.
Signs and symptoms do not respond to appropriate treatment.
The child has been to numerous medical care providers without a cure or even a clear diagnosis.
The mother has medical or nursing training or access to illness models.
The mother has a personal history of somatic symptom disorder(s).
The mother is unresponsive to the child’s needs when unaware of being observed.”
I could go on, but basically the mother brainwashes her kid into taking on a sick role while she gains some combination of attention, power, and financial benefit. The kid often believes it deeply for a long time, causing horrific damage.
Factitious Disorder Imposed on Self
We concluded the previous podcast with an exploration of the Hero’s Journey. We see the hero venture into the unknown to face conflict and adversity and return transformed. I talked about how in Factitious disorder imposed on another (also known as Munchausen syndrome by proxy), the mother keeps the child from launching into the quest. Alternatively, with factitious disorder imposed on self, or Munchausen syndrome, if the patient is considered the hero then they do not follow their own journey. Rather, they craft a false narrative of a hero’s journey as to engender guides to provide psychological empathy for a real psychological need.
Factitious disorder imposed on self is a psychiatric disorder involving the fabrication of illness, injury, or impairment to get psychological needs met. Oftentimes, a motivation includes the need to adopt the role of a patient. Common underlying and often unconscious driving forces could include a desire to receive care and support, to escape from the reality of a current situation, to experience the thrill of undergoing medical procedures, or to maintain a sense of control by puzzling healthcare professionals. People with factitious disorder are taking on the sick role to get their psychological needs met and do this consciously, unlike other somatic disorders like somatic symptom disorder or conversion disorder.
Munchausen syndrome used to be thought of as an extreme variant of the factitious disorder. Accounting for less than 10% of all cases (Turner 2002), it is characterized by feigning illness, habitual lying, and multiple hospitalizations in multiple locations. I think it is more useful to think of them as the same thing.
A typical factitious disorder or Munchausen patient will make frequent visits to various hospitals, sometimes under different names. He/she will provide a fake history as well as simulate symptoms to gain the attention, empathy, and comfort from the staff. This ranges from consuming contaminated food to self-inducing a disease to using non-human blood in order to fake bleeding. Following admission, they willingly undergo multiple diagnostic tests. Often the testing itself generates real problems (lines get infected, surgeries lead to abdominal adhesions). These patients often discharge themselves with or without the discovery of their deception. If you report that nothing was found during the diagnostic tests, they often get angry, which can be a red flag that triggers the involvement of more subspecialists to make sure nothing is really going on. Ultimately, this leaves the patient getting some psychological needs met, but they also have physical consequences from unnecessary medical procedures, as well as costs associated with repeated hospital admissions. Due to its nature, this disorder is extremely challenging to the medical provider and often leaves them feeling frustrated and/or guilty for being deceived and cheated of their time, energy, and resources.
Further, the setting for factitious disorder and Munchausen syndrome is often not fully lived out in the medical hospital. It could be faking illness to engender kindness, empathy, or attachment needs in a religious center or school. Telling fake stories of rape, cancer and deaths in the family and heroic events are often part of these stories. Imagine the psychological turmoil this might cause to an empathic priest or caring teacher. With malingering, the person is motivated by financial reward, whereas in Munchausen they are motivated by psychological needs.
Key facts about factitious disorder:
It is statistically about 33.8% men and 66.2% women (Yates 2016)
57% of patients report an occupation related to healthcare or laboratory (Yates 2016)
Most common profession described was nursing (Yates 2016)
Common disorders identified with factitious disorder (Yates 2016):
Depression (41.8%)
Personality disorder (16.5%)
Substance abuse (15.3%)
Anxiety (14.7%)
Functional neurological symptoms (5.3%)
Eating disorders (4.1%)
Current suicidal ideation of history of suicide attempt (14.1%)
Absence of comorbid psychopathology (17.1%)
DSM-5 Criteria:
Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
The individual presents himself or herself to others as ill, impaired, or injured.
The deceptive behavior is evident even in the absence of obvious external rewards.
The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
How Factitious Disorder Presents
It is important to realize that factitious disorder presents to every specialty. Here are some examples of factitious disorder presentations by medical specialty (either reported, stimulated, or induced) (Yates 2016, Rogers, 2020):
Allergy and Immunology:
Allergic emergency
Signs of immune deficiency
Cardiology:
Hypertension
Syncopal episodes
Retrosternal chest pain
Myocardial infarction
Dermatology:
Generalized lesions
Lesions of face, arms, legs, genitals
Pyoderma gangrenosum
Endocrinology:
Recurrent hypoglycemia
Cushing's syndrome
Thyrotoxicosis
Diabetic ketoacidosis
ENT:
Facial swelling
Airway distress
Bleeding from mouth, nose, ears and eyes
Gastroenterology:
Diarrhea
Hematemesis
Epigastric pain
Hematology:
Anemia
Purpura
HIV and Sexual Health:
History of HIV
History of AIDS
Microbiology and Infection:
Sepsis
Septic arthritis
Necrotizing fasciitis
Neurology:
Chronic pain
Paralysis or weakness
Unconsciousness
Seizures
Obstetrics and Gynecology:
Vaginal discharge
Vaginal bleeding
Menorrhagia
Oncology:
Breast cancer
Ovarian cancer
Uterine cancer reported
Ophthalmology:
Keratoconjunctivitis
Corneal damage
Anterior scleritis
Diplopia
Oral and Maxillofacial:
Swelling of mandibular region
Abrasion of oral mucosa
Orthopedics and Trauma:
Subcutaneous emphysema
Severe trauma
Joint dislocation
Plastic and Reconstructive Surgery:
Skin ulceration
Deep muscular abscess
Wound deterioration following surgery
Pulmonary and Respiratory:
Asthmatic episodes
Acute respiratory distress
Hemoptysis
Rheumatology:
Lobular panniculitis
Systemic lupus erythematosus
Urology and Nephrology:
UTI
Hematuria
Proteinuria
Factitious Disorder and Fabricated Mental Health Complaints
The second category of factitious complaints and issues are mental health. This can be estimated at 40% of the total factitious complaints (Yates 2016).
Alcohol abuse
Hallucinations
Suicidal and homicidal ideation
PTSD (made up traumas)
Bereavement
Childhood sexual abuse
Sexual assault (may use foreign bodies to fabricate “evidence”)
Pain disorders
Stockholm syndrome
Dissociative identity disorder
Cult brainwashing
Factitious symptoms are stronger around physicians and hospital staff than when they are alone. I often have my therapists tell me that patients with factitious disorder display a bright affect in group settings and that they laugh and have a good time with their peers, only to express to me exaggerated sorrow without emotional blunting, 10/10 depression, 10/10 anxiety when in person. They actually like psychiatric hospitalization, partial programs and high levels of treatment. They often use a history of trauma and loss to stir up empathy from their peers, while not expressing any dissociation while telling the story, sometimes even a half smile is on their face.
But at times, patients with factitious disorder muddy the water by using substances to change their affect:
Simulants produce restlessness and insomnia
LSD- may looked altered
Opioids produce euphoria
Benzos and Barbs produce lethargy
Factitious disorder patients induce the altered state to mislead you, rather than as an end in and of itself.
As someone who has studied microexpression, I can perceive small flashes of emotion that are true to their inner experience that do not match their story. So I follow the emotion and what I actually see. If you have not, check out episodes 1, 2, and 3 of my microexpression series to dive into this as a tool for detecting the truth (start here).
A Journey Through Munchausen: Jane’s Story
In this interview, we will dive into a person’s experience who was able to break through and start a real hero’s journey by moving from fake stories to real ones, and by moving from gaining connection through falsehoods to creating connection through vulnerability and being 100% honest with her inner experience. It is my experience that people who make up stories for empathy are never satisfied by this, which is why the stories get bigger and the hole they are trying to fill remains empty. By being 100% honest with our experience and approaching it with empathy, we can achieve real psychological growth and transformation.
In order to keep our guest’s identity anonymous, we will be referring to her as “Jane.” We also had our audio engineer change her voice. She knows there might be other risks to her identity being found out, as she also has a podcast where she details her story.
Jane’s journey began when she got her first IUD. A nurse practitioner taught her about her body, how she could have boundaries with boys, and also gave her warmth and empathy. After having the IUD placed she had a legitimate, severe reaction to it involving vomiting and diarrhea. While in this extremely vulnerable state, with vomit everywhere and the horrible stench, the nursing team showed her warmth and kindness as they cared for her. She recalled that this was the first time she experienced being taken care of.
For weeks after she fantasized about receiving that kindness again. She became obsessed with thinking of herself as sick and being comforted. She described these as fantasies that played over and over in her head. As a result, she began to research different scenarios in which she could elicit care from others and began acting on those impulses.
In one of these situations, Jane recalled a scenario in which she went to see a neurologist about a legitimate tremor in her left hand. He admitted her to the hospital for further testing. After undergoing several imaging studies as well as a diagnostic lumbar puncture, she was subsequently diagnosed with an infection and prescribed antibiotics. During her admission, she felt deeply cared for by the attentiveness and kindness shown by the healthcare professionals. For the medical staff this was simply another day at work, but for Jane it awakened her unconscious desire for connection. Her time in the hospital was a reprieve from the constant confusion and chaos in her life. It was a moment of feeling “okay,” which stirred a yearning for attention and a resolve to further reinforce the feeling.
During routine blood work for her tremors, Jane decided to mix honey with her urine sample. The mystery and complexity of her case led physicians to perpetuate this cycle Jane had created. She even began taking insulin to induce seizures, which eventually led to a false diagnosis of a pancreatic tumor. These acts of self-harm culminated in multiple visits to the emergency room and eventually an admission to the ICU.
While in the ICU, Jane was struck by the seriousness of her illness. Fear began to set in that she may accidentally kill herself through these fabrications. Despite understanding the gravity of her situation, she felt powerless against the obsession and compulsions. Her online research only left her further in despair after reading about the negative depiction of patients with Munchausen Syndrome. Jane felt she was beyond help because there were too many aspects of this disorder that needed to be acknowledged and addressed. After a failed attempt to take her life, she was eventually admitted to a psychiatric hospital.
One day while in the psychiatric hospital, Jane decided to be fully transparent with her nurse. Despite the overwhelming shame she felt, she shared her story from start to finish. The nurse listened with the same attentiveness she had first received from the nurses at the IUD clinic. In the end the nurse said, “Okay, we can go from here.” The nurse did not shame her, was not overwhelmed by her but was able to be present and give her empathy. This was the turning point for Jane. She openly named her shame and others were able to receive it. They were not overwhelmed by her Munchausen syndrome. She was not too broken and she was not alone.
Jane returned from her journey with the understanding that she is more than her illness. Through the help of several mental health professionals and medications, she became aware of the factors that play a part in her Munchausen syndrome. Most notably, she discovered how she turned to self-harm to fill the void of emotional neglect and physical disconnection of her childhood. Jane has since learned to meet those needs on her own by investing in relationships, reflecting and journaling, or even enjoying time in nature. For her, healing began with a willingness to accept that it was a problem, along with a desire to extend herself grace and compassion. Her journey continues with a sense of grief, gratitude, and peace about her experiences that have shaped her into the woman she is today. She faces her diagnosis with courage by helping others as a social worker and continuing to bring awareness to this disorder through her podcast, “I am Munchausen.”
If you know someone who has something similar to Jane’s and wants help, I run an IOP/Partial in Redlands, California, for people with this issue. Our nurse, Ann Morris, can be reached at 909-651-4954, to discuss the program at more length. You can learn more about the program here.
Further Reading:
Yates, G. P., & Feldman, M. D. (2016). Factitious Disorder: A systematic review of 455 cases in the professional literature. General hospital psychiatry, 41, 20–28.https://doi.org/10.1016/j.genhosppsych.2016.05.002
Turner, J., & Reid, S. (2002). Munchausen syndrome. Lancet (London, England), 359(9303), 346–349. https://doi.org/10.1016/S0140-6736(02)07502-5
Feldman, M. D. (2013). Playing sick?: Untangling the web of Munchausen syndrome, Munchausen by proxy, malingering, and factitious disorder. Routledge.
Feldman, M. D., & Smith, R. (2004). Playing sick?: untangling the web of Munchausen syndrome, Munchausen by proxy, malingering & factitious disorder (pp. 18-32). New York: Brunner-Routledge.