Is there a cure for Muenchhausen Syndrome

Artificial Disorders: Mysterious and Dangerous

If patients regularly fake symptoms and illnesses, it is often caused by a mental illness. However, these are difficult to spot and difficult to treat.

Munchausen Syndrome - instead of harming themselves, some affected people harm other people. The victims are mostly toddlers and babies. Photo: Fotolia

Hardly any other mental illness pushes doctors and psychotherapists to their limits as much as the artificial disorder. Because it is basically based on deception and fraud and is very likely to lead to an ethical dilemma. The artificial disorder (also: simulated disorder) is actually a disorder group to which the artificial disorder in the narrower sense, the Munchausen syndrome and the Munchausen-by-proxy syndrome are counted.

Symptoms are simulated

A common feature of these disorders is the deliberate creation or pretense of physical or psychological symptoms and disabilities, either in oneself or in other people. The self-harming or self-harming behavior is carried out secretly and presumably occurs in a dissociative state of consciousness. Medical treatments and interventions are then requested.

Since those affected do not derive any easily recognizable benefits, such as financial advantages or increased physical well-being, from their behavior, the motive seems puzzling at first. Various assumptions can be found in the specialist literature, which, however, have so far hardly been empirically proven. For example, it is assumed that patients with artificial disorders use their behavior to create feelings of uniqueness, attention and care. It may also serve to regulate affects and tensions. Psychodynamic interpretations are based on re-enactments of traumatic experiences, approaches based on family dynamics assume that the focus on a supposedly ill child serves to regulate and stabilize conflict-ridden relationships.

Patients with artificial disorder in the narrower sense are predominantly female, often living alone or separately and with average education. In addition, they suffer from personality and psychological disorders. They often work as a medical assistant.

In Munchausen syndrome, patients with invented or staged complaints move from one practice or clinic to the next ("treatment wandering") and provoke diagnostic and therapeutic interventions with dramatic and imaginatively embellished disease stories. Most of these are socially disintegrated male patients.

Children are often the victims

Munchausen-by-proxy syndrome occurs when one person harms another person instead of harming himself. It mostly affects mothers, grandmothers and female babysitters, and their victims are usually infants and young children. These women often feel inferior, lonely, and isolated, have distant but dominant relationships, experience little support, and also display self-destructive aggression. But there are also adults who on their behalf cause injuries to other adults.

Patients with artificial disorders have often experienced trauma in childhood from violence, abuse, neglect, and social deprivation and suffered from a hostile and unreliable family atmosphere. For this reason, among other things, their relationships with other people often have traits of mistrust, deception and betrayal, and those affected are hardly able to build emotionally stable and trusting relationships. Many also had to endure numerous medical treatments or have seen family members often sick and in need of treatment. Because of such experiences, your relationship with your body is disturbed, divided and rather negative. The body is neither a home nor a part of the self for them, but only serves as a means to achieve their goals, even if these are mostly unconscious. Although they have often experienced a lot of pains in life themselves, they react noticeably with empathy and mercilessness to other people's expressions of suffering, even to that of their children. The trivialization of suffering and the lack of empathy can be explained by the fact that, according to their own feelings, they were not shown empathy when they had to endure pain; here there are parallels to the ignoring, empathetic behavior of mothers who tolerate the abuse of their children by male perpetrators.

Comorbidities often occur

The high comorbidity with personality disorders is also noticeable. Munchhausen syndrome, for example, is often associated with dissocial personality disorders, whereas patients with artificial disorder in the narrower sense and Munchhausen-by-proxy syndrome more often have depressive syndromes as well as eating, borderline, narcissistic and histrionic personality disorders.

It is not easy to find out about patients with artificial disorders. They are masters of deception and know how to deceive even specialists for years. Since they show great interest in medicine and have often even taken up relevant professions, they are very familiar with the symptoms and can simulate them convincingly. They benefit from the fact that there are numerous physical illnesses that cannot be objectively measured, such as headaches; Even psychological symptoms can sometimes be easily simulated or asserted. In addition, they benefit from the general attitude of believing the sick, helping them, sparing them, and feeling sorry for them. Their deceptions are also fueled by doctors' fear of overlooking a rare disease and by a health system in which a high degree of professional specialization is common and frequent changes of doctors and clinics are easily possible. In this way, patients can evade as soon as they are suspected and avoid any confrontation. The only telltale thing is that there are usually no organic causes for the complaints, that an “accident” or “mistake” is not plausible and that a large number of different practitioners are used and frequently changed.

If the suspicion is confirmed that a patient or family member is only pretending to be illnesses and disabilities or has created them himself, this initially causes irritation among the practitioners. The thought that you have invested a lot of time and effort and have only been lied to and deceived undermines the joy and motivation of the job. Most of the time, there is also considerable tension and differences in the treatment teams because one part believes the patient while the other does not. In addition, there are self-doubts because you have been deceived despite your own expertise. It must also be borne in mind that patients with artificial disorders place a considerable burden on the health system and take away treatment places from other patients.

Despite one's own disappointment and hurt, it must be taken into account that patients with artificial disorders are ill and need help, but with other means than those requested by the patient. The consequence of this is that patients may not be held morally responsible for their behavior, or only partially. However, since they are usually neither aware of wrongdoing nor suffering, nor are they capable of understanding, it is extremely difficult to win them over to psychotherapy.

Avoid confrontation

If it still succeeds, the essential step is to build a stable doctor-patient relationship. During initial psychotherapeutic contact, it is advisable not to take an accusatory attitude and direct confrontation, e.g. by disclosing evidence of fraud. "This often leads to a sudden break in the relationship on the part of the patient, or at least to a considerably reduced willingness to cooperate", says Prof. Dr. Harald Freyberger from the University of Greifswald and Prof. Dr. Rolf-Dieter Stieglitz from the Psychiatric University Policlinic Basel. In a kind of indirect confrontation work one should instead try to address the symptoms without explicit mention of the pretense. The patient should be able to feel the empathy of the psychotherapist for his difficult, painful life situation and previous history and learn to understand the intrapsychic mechanisms of the disorder and their biographical embedding.

If possible, patients with artificial disorders should be hospitalized. Experience has shown, however, that a single inpatient stay is not enough to change the clinical picture. Interval therapy with repeated inpatient admissions and intervening outpatient therapy phases seems to be more effective. So far, however, there is no tailored therapy for the affective disorder. Among other things, there are experience reports on behavioral approaches in which the functionality of the disease behavior was processed and positive reinforcers were used. Insightful psychotherapy and psychoeducational supportive behavior therapy have also been suggested. In addition, conflict-oriented therapy work can be a treatment option; however, only about a quarter of those affected meet the entry requirements for inpatient conflict-processing psychotherapeutic procedures. The much larger part has to be treated in the context of psychiatric-psychotherapeutic crisis intervention, since this group of patients is often admitted with acute illnesses and tends to suicide or kill others. Overall, the prognosis is assessed as rather unfavorable, as the numerous hospital stays with invasive interventions lead to increasing disability and severe impairment of social and professional performance. Comorbidity with personality disorders and addictions also worsen the prognosis.

Affected people are overprotective

Treatment is also challenging because patients with artificial disorders tend to involve doctors and psychotherapists in a complex network of relationships. They present themselves as ideal patients in that they show professional expertise, a high level of tolerance and tolerance and always full, uncritical approval even for complex examinations and serious interventions. Mothers with Munchausen-by-proxy syndrome are on the one hand particularly caring, self-sacrificing and symbiotic with their children and get on well with the practitioners (especially with nurses). You quickly develop intimate relationships with the nursing staff and other parents and obviously feel comfortable in the infirmary. On the other hand, they are far less worried about serious interventions on their children than the treatment team - on the contrary, they demand invasive treatments and get angry when concerns are raised about them; Their cold feeling and indifference when a child dies is also noticeable.

However, if a doctor or psychotherapist questions the supposedly ideal-typical, over-adjusted behavior, patients react with artificial disorders through strong relationship tensions, immediate break-offs or confrontation denial in the sense of undoing. The split-off tendencies towards self-harm or harm to others that are inaccessible or barely accessible to conscious experience can barely remain tangible for the patient, so that they feel misunderstood, rejected or humiliated by the doctor or psychotherapist. As a rule, immediately after breaking off the relationship, they look for a new contact with another practitioner, and the relationship pattern is repeated here in a similar sequence.

Some form of abuse

In particular, dealing with patients with Münchhausen-by-proxy syndrome can not only lead to an ethical dilemma, it can also raise forensic questions and require legal consequences. By producing symptoms and inflicting serious injuries, those affected commit a form of child abuse that can go as far as infanticide. If the child is withdrawn from them, they go on to harm their other children; Sometimes, several children are mistreated at the same time or one after the other. The deceptions and manipulations range from the description of non-existent symptoms (e.g. cardiac arrest and respiratory arrest, epileptic seizures) to the falsification of body substrates and measurement data (e.g. temperature curves) to the generation of real symptoms (e.g. from drugs, poisons or suffocation ). As a rule, the perpetrators are women who present themselves as particularly good mothers, but sometimes harbor the delusional idea that their children are sick and can only survive through them. Despite a presumably intermittently impaired perception of reality, they are often aware that they are harming their children, but do not know their own motives and feel an urge to carry out the behavior. When confronted with the suspicion of targeted child abuse, they quickly change the practitioner and thus evade further critical observation and persecution.

Should a doctor, psychotherapist or treatment team in a clinic manage to collect evidence of targeted external damage, for example through the detection of non-prescribed medication in the child's body or through direct observations, the most important thing is to protect the affected child and the child To substantiate suspicion with further evidence. To this end, the youth welfare office should be involved, a complaint should be filed and the child should be legally separated from the person causing the child's welfare and placed in a foster family. "The mothers must not be confronted with the abuse allegation too early, as they often deny the manipulation and try to quickly remove the child from medical care," says Prof. Dr. Martin Krupinski from the Würzburg University Neurological Clinic. In addition, the confrontation can lead to psychological decompensation in the mothers, which is not infrequently accompanied by suicide attempts and acts of self-harm. In this situation, the mothers need psychotherapeutic help, which should, if possible, lead to therapy. Above all, however, the affected children must be protected effectively and in the long term with all available means.

Even if it seems hard to separate a child from the family of origin for a long time and place it in a foster family, this can be justified by the fact that the mothers continue the abuse of the affected child and siblings, provided that they are (again) unrestricted Have access to the children and no psychiatric-psychotherapeutic intervention takes place. Children of mothers with Munchausen-by-proxy syndrome also have a relatively high risk of death and mostly suffer permanent physical and psychological damage and trauma as a result of the abuse.

A residue of doubts remains

Even if enough evidence has been gathered, there is usually a residual of doubt. The dilemma consists on the one hand of doing the parents injustice and inflicting great damage on the family and the children through a separation, on the other hand, failure to pursue a Munchausen-by-proxy abuse leads the child victim back to a dangerous and damaging family situation has to return, has to endure years of torture-like manipulation and may even die as a result. In addition, doctors often feel like co-abusers and accomplices and therefore feel shame, feelings of guilt and resignation.

Artificial disorders, especially the Munchausen-by-proxy syndrome, therefore not only require therapy, but also always careful observation and weighing of the human, social and legal consequences.

Dr. phil. Marion Sonnenmoser

Contact: Prof. Dr. Martin Krupinski, Department of Forensic Psychiatry, University Hospital Würzburg, Füchsleinstraße 15, 97080 Würzburg, email: [email protected]

@Literature on the Internet:
www.aerzteblatt.de/pp/lit0910

Subtypes in Munich hausen-by-proxy syndrome

  • Help seekers: They introduce their children to practices and clinics less often than the other types. After confronting the suspicion, they are more willing to communicate and respond more easily to offers of help and treatment than the other two subtypes.
  • Active inducers: Most common type. Characteristic are repeated dramatic staging of symptoms and a high degree of denial, so that manipulations are not admitted even under threat of punishment. After confrontation, the relationship with the practitioner is broken off.The victims are mostly younger children.
  • Doctor addicts: They are not very friendly and cooperative, but rather suspicious. They do not or rarely actively produce symptoms, but insist on treating non-existent diseases. They dramatize minor abnormalities in children and insist on sustainable treatment or protect the children so that they develop an outsider position or considerable behavioral problems through isolation. The affected children are more likely to be older.

Evidence of Munchausen-by-proxy syndrome

  • Persistent and recurring symptoms in the child without a plausible explanation or organic cause
  • No improvement despite professional treatment; common complications
  • Symptoms and complaints, which are reversible in principle, disappear during the hospital stay or when the child is separated from the caregiver, but occur again and again in the home environment (even intensified or with additional symptoms).
  • No assignment to a known clinical picture is possible; Discrepancy between anamnesis and findings; Discrepancy between maternal reports and direct observations.
  • The child has already been introduced to other doctors on various occasions; however, the parents mostly disagreed with the therapy; frequent changes of doctors and therapists.
  • Other children in the family are also often introduced to doctors and therapists; there have been deaths of children in the family.
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