Within days of starting an EMT-basic course, students are introduced to the concept of the ABCs – verifying if the patient:
- A. Has an airway
- B. Is breathing
- C. Has a pulse
When a clinician obtains advanced certifications, these same ABCs become more in-depth. Coupled with the question, “What is my general impression of the patient,” clinicians make their first, doorway impression. Prehospital clinicians should fall back on these basic concepts when treating patients with suspected factitious disorders.
Perhaps the most well-known, Munchausen syndrome is a psychological disorder, which manifests as someone pretending to be ill or deliberately producing symptoms of illness. Their main intention is to assume the sick role so that people care for them, and they are the center of attention, according to a report published by the Mayo Clinic.
The condition, a factitious disorder, is a serious mental disorder in which someone deceives others by appearing sick, by purposely getting sick or by self-injury. Factitious disorders can also involve a family member or caregiver falsely presenting others, such as children, as being ill, injured or impaired.
Symptoms can range from a mild, slight exaggeration of symptoms, to severe, known as Munchausen syndrome. The person may make up symptoms or even tamper with medical tests to convince others that treatment, such as high-risk surgery, is needed.
Factitious disorders are not the same as inventing medical problems for practical benefit, such as getting out of work or winning a lawsuit. People with a factitious disorder know they are causing their symptoms or illness, but they may not understand the reasons for their behaviors or recognize themselves as having a problem.
Signs and symptoms of Munchausen syndrome
Munchausen syndrome is challenging to identify and hard to treat. Medical and psychiatric help are critical for preventing serious injury and even death caused by the self-harm typical of this order.
Factitious disorder signs and symptoms include:
- Clever and convincing medical or psychological problems
- Extensive knowledge of medical terms and diseases
- Vague or inconsistent symptoms
- Conditions that get worse for no apparent reason
- Conditions that don’t respond as expected to standard therapies
- Seeking treatment from many different doctors or hospitals, which may include using a fake name
- Reluctance to allow doctors to talk to family, friends or other healthcare professionals
- Frequent hospital stays
- Eagerness to have frequent testing or risky operations
- Many surgical scars or evidence of numerous procedures
- Having few visitors when hospitalized
- Arguing with doctors and staff
Munchausen syndrome by proxy
Factitious disorder imposed on another, previously called Munchausen syndrome by proxy, is when someone falsely claims that another person has physical or psychological symptoms of illness, or causes injury or disease in another person with the intention of deceiving others.
People with this disorder present another person as sick, injured or having problems functioning, claiming that medical attention is needed. Usually, this involves a parent harming a child. This form of abuse can put a child in danger of injury or unnecessary medical care.
In these emergency situations, prehospital clinicians who suspect a patient is being abused or their life is in danger should report the behavior to the appropriate agency. Remember, your immediate notification should be to the person receiving care at the accepting facility. Additional notifications should include Child Protective Services for children and Adult Protective Services for at-risk adults. Local protocols may include notifying a law enforcement agency. If there is a question of who to notify, clinicians should check with their immediate supervisor or chief.
faking symptoms
People with factitious disorders become experts at faking symptoms and disease or inflicting real injuries upon themselves. It may be difficult for healthcare professionals and loved ones to know if illnesses are real or not.
People with a factitious disorder make up symptoms or cause illness in several ways, such as:
- Exaggerating existing symptoms. Even when an actual medical or psychological condition exists, they may exaggerate symptoms to appear sicker or more impaired than is true.
- Making up histories. They may give loved ones, healthcare professionals or support groups a false medical history, such as claiming to have had cancer or AIDS. Or they may falsify medical records to indicate an illness.
- Faking symptoms. They may fake symptoms, such as stomach pain, seizures or passing out.
- Causing self-harm. They may make themselves sick, for example, by injecting themselves with bacteria, milk, gasoline or feces. They may injure, cut or burn themselves. They may take medications, such as blood thinners or drugs for diabetes, to mimic diseases. They may also interfere with wound healing, such as reopening or infecting cuts.
- Tampering. They may manipulate medical instruments to skew results, such as heating thermometers. Or they may tamper with lab tests, such as contaminating their urine samples with blood or other substances.
The cause of factitious disorders is not known. The Mayo Clinic reports the disorder may be caused by a combination of psychological factors and stressful life experiences. Factors that may increase the risk of developing the disorder include:
- Childhood trauma, such as emotional, physical or sexual abuse
- A serious illness during childhood
- Loss of a loved one through death, illness or abandonment
- Past experiences during a time of sickness and attention it brought
- A poor sense of identity or self-esteem
- Personality disorders
- Depression
- Desire to be associated with doctors or medical centers
- Work in the healthcare field
Risks of Munchausen syndrome
People with Munchausen syndrome are willing to risk their lives to be seen as sick. They frequently have other mental illnesses as well. As a result, they face many possible complications, including:
- Injury or death from self-inflicted medical conditions
- Severe health problems with infections or unnecessary surgery or other procedures
- Loss of organs or limbs from unnecessary surgery
- Alcohol or other substance abuse
- Significant problems in daily life, relationships and work
- Abuse when the behavior is inflicted on another
EMS clinicians should maintain high situational awareness on all incidents in which Munchausen syndrome is suspected. This practice will allow you to provide detailed information to the investigating agency.
Both the Cleveland Clinic and Mayo Clinic report obtaining accurate statistics about factitious disorder frequency is difficult because of dishonesty. People with Munchausen syndrome may use different names and change between different geographical areas and the hospitals in those areas. A national hospital discharge survey in 2013 recorded 6.8 cases of a factitious disorder per 100,000 patients. It is unclear how many of those patients had Munchausen syndrome, specifically.
Researchers have noted that females who work in the healthcare community are most at risk for Munchausen syndrome, according to the Cleveland Clinic report. Having borderline or histrionic personality traits or disorders put you more at risk.
Diagnosing Munchausen syndrome
Patients’ dishonesty and the multiple care providers involved also complicates diagnosing Munchausen syndrome. Healthcare providers must rule out any possible physical and mental illnesses, and often use a variety of diagnostic tests and procedures before considering the diagnosis.
Documentation in these cases is extremely important, especially in situations with children and vulnerable adults. Clinicians should document:
- Dispatch information
- What you see on arrival at the scene – your general impression of the patient, including anything suspicious around a child who is sick, such as bottles or containers
- All the information the patient tells you. Use quotation marks when necessary to ensure you are capturing the most important information. This information could include reasons why a patient needs to be transported to a specific facility, even though it is out of your normal transport area. Additionally, if you are transporting a child, document any conversations you have with the patient and any pertinent conversations with the caregivers.
- Who you transfer care to at the receiving facility
- Who you speak with at CPS or APS
Prehospital clinicians should conduct a complete assessment on all patients, even if it is believed that the patient is suffering from a factitious disorder. It is the responsibility of a clinician, with diagnostic tools, to ensure that the patient is not suffering from a life-threatening, treatable or correctable condition. Ask yourself, “does the patient look sick?” If the answer to this question is yes, continue a treatment pathway.
