Rare and Unusual Psychiatric Syndromes: A Primer

Christoph U. Correll, MD; Bret S. Stetka, MD; Ariel Harsinay

Disclosures

July 23, 2018

Munchausen Syndrome/Factitious Disorder

Often called "Munchausen syndrome" after Baron von Munchausen (1720-1797), a German officer who was known for embellishing the stories of his life and experiences, factitious disorder involves the falsification and/or fabrication of (even medically dangerous) physical or psychological signs or symptoms, with no obvious external reward for doing so. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the condition is covered in the section on somatic symptoms and related disorders and is divided into two subtypes: that imposed on one's self and that directed at someone else, known as "factitious disorder/Munchausen syndrome by proxy." The condition differs from hypochondriasis in that patients with Munchausen syndrome are aware that they are exaggerating or inducing signs and symptoms of illness, but lack awareness of the underlying psychological reasons or "gains," whereas persons with hypochondriasis believe that they actually have a disease.

People affected by factitious disorder deliberately produce or exaggerate symptoms in several ways. They might lie about or fake symptoms, hurt themselves (which can even lead to amputations), or tamper with diagnostic tests. Possible warning signs include a dramatic but inconsistent medical history; seeking treatment at numerous hospitals; extensive knowledge of hospitals and/or medical terminology; eagerness to have medical tests or interventions; new symptoms after negative test results; presence of symptoms only when the patient is alone or not being observed; and problems with identity and self-esteem. Patients often have a history of abuse or neglect as a child, and personality disorders are common in individuals with factitious disorder.

Clinicians who suspect factitious disorder should rule out early-stage medical conditions. The first treatment goal is to modify the person's behavior and reduce misuse or overuse of medical resources. In addition, any underlying psychiatric disorder should be identified and treated. Finally, the primary treatment for factitious disorder is psychotherapy, including cognitive-behavioral therapy and family therapy.

Munchausen Syndrome by Proxy/Factitious Disorder by Proxy

Persons with Munchausen syndrome by proxy/factitious disorder by proxy act as if an individual for whom they are caring, most often a young child, has a physical or mental illness when the person is not really sick. People with the condition might lie about symptoms; alter diagnostic tests; falsify medical records; or induce symptoms through various means, such as poisoning, suffocating, starving, and causing infection.

People with factitious disorder by proxy are often parents or the adult children of an elderly patient or are healthcare professionals. They may be very friendly and cooperative with the healthcare providers, be quite concerned (sometimes overly so) about the child or designated patient, and might also have factitious disorder themselves. One clinical pointer is that the illness symptoms and signs do not occur when the person the patient cares for is alone for a longer period. The fabrication is not done to achieve an external benefit, such as financial gain, other than perhaps sympathy and attention from others.

Etiologic and treatment considerations are similar to those in factitious disorder, with the added concern about the safety of the potential victim. Management often requires a team that includes social workers, foster care organizations, and law enforcement in addition to the healthcare providers.

Apotemnophilia and Acrotomophilia

Apotemnophilia, also known as "body integrity identity disorder" or "amputee identity disorder," is most likely a neurologic disorder in which a person has the overwhelming desire to amputate healthy parts of their body. In extreme cases, persons with this condition amputate their own limbs or ask others to do this for them. Because few surgeons are willing to amputate healthy limbs, patients often attempt to irrevocably damage the limb in question themselves, necessitating formal amputation. After amputation, most report being happy with their decision.

Apotemnophilia is thought to be related to right parietal lobe damage, as the disorder has features in common with somatoparaphrenia, a type of monothematic delusion secondary to parietal lobe injury where the afflicted person denies ownership of a limb or an entire side of one's body. The major problem in providing treatment is that most people with apotemnophilia do not seek professional treatment for their condition. Cognitive-behavioral and aversion therapies have been tried. A related disorder is acrotomophilia, a form of sexual fetishism whereby a person without amputation has a strong erotic interest in people who are missing limbs.

Recent research in apotemnophilia was conducted in which subjects were shown virtual renderings of their ideal body (featuring the amputation of their desired healthy limb) versus images of their undesired body state (nonamputated limb). Brain activity was recorded, and it was observed that apotemnophilia can be objectively predicted based on neuronal activity in visual processing regions of the brain. The aim of this study was to find therapeutic approaches to treating apotemnophilia, such as using virtual reality for patients to be able to achieve their desired body state without an amputation[13]

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