What is Munchausen syndrome? Would you recognize a 'self-inflicted' oral disease?
Munchausen syndrome is a severe form of a factitious disorder in which a person has recurrent, feigned, or self-inflicted illness to gain medical attention (Little, 2016). The term "Munchausen syndrome" is named for the German Baron von Munchausen and described by Dr. Richard Asher in an article published in Lancet (1951). In his "Talking Sense" trilogy, Dr. Asher described three typical cases.
As described by Asher (1951), the patient may present with a multiplicity of scars, often abdominal, an immediate history that is always acute and harrowing, an evasive manner, a wallet or handbag stuffed with hospital attendance cards, insurance claims, and litigious correspondence.
The paper was originally written in the early 1950s and admissions have changed greatly since that time. Hospital procedures currently use online documentation in most cases. Hospital personnel would begin to recognize frequent visitors to clinics and emergency rooms. Generally, a patient may attempt to convince health-care providers of an existing disease state to maintain the health-care providers' interest. A self-inflicted injury is usually found, and the patient may invent ways to keep the disease in a worsening state with the goal of managing to be treated again and again.
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In a study by Bass and Jones (2011), over half of the participants had histories of self-harm beginning in adolescence, and some continued into adult life. They are usually women and many have been involved in some type of health-care work themselves. The connection with health care may provide some insight into terms and body/health functions.
Munchausen's is also used in a form of child abuse in which "the care giver intentionally overstates, contrives, and/or creates a physical, emotional, or behavioral problem in the child" (Neville et al., 2016). The abuser presents a contrived effort to make the child appear sick to gain attention with health-care providers. The term used in this case is Munchausen syndrome by proxy (MSBP), also recently named "fabricated or induced illness."
It is believed that many individuals who exhibit these bizarre behaviors in Munchausen as well as MSBP were abused themselves as children. It is a form of child abuse in which the parent presents the child to a health-care provider with false claims of sickness or disease, knowingly falsifying their role in this development. Factitious injury may be either self-induced or deliberately caused either subconsciously or unconsciously.
Little et al. (2016) reported a case in which gossypiboma was reported in a nonhealing patient. Gossypiboma is a cottonoid mass surrounded by a foreign body reaction. The patient was found to have ongoing fragments of "sponge-like material" and exhibited a nonhealing of surgical wounds over time. It is believed that the patient exhibited Munchausen's syndrome.
Some patients may claim medical negligence in leaving a sponge/gauze in the wound as an attempt to cite medical negligence as the cause of their suffering (and sometimes to gain monetary compensation). In this case presented, the patient reported multiple attempts of gossypiboma. However, it was determined that the sponge-like material was not the same type that was used in the surgical procedure that was performed.
An additional finding cited in the dental literature is baby bottle caries; this entity is considered a form of neglect and falls into the category of an inattention to the dental needs of the child. Baby bottle caries may just involve ignorance of the effects on the teeth.
Attention should also be given to "elder abuse" in which a caregiver is the abuser. The elder may exhibit scalp and orofacial lesions, bruising, hair loss due to the abuser grabbing the victim's hair, broken teeth, fractures, and even bilateral contusions of the lip commissures from the placement of a gag (Neville, 2016).
There have been reported cases of the patient claiming injury or disease for financial benefit. Most often, though, the patient is trying to gain attention from the health-care provider and the need to continue to be treated.
Along with the possibility of a patient claiming medical or dental negligence, the condition of the patient is also in jeopardy as the undiagnosed cause is continued long term. There may be rapid deterioration and unneeded medical or dental procedures that place the patient at risk. Tyler et al. (1995) presented a case in which a patient exhibited atypical migratory stomatitis that involved self-inflicted injury (Munchausen syndrome) in which the patient attempted to convince the health-care providers of the true existence of lesions to maintain their interest in continuing treatment.
There may also be a failure of the health-care provider to either recognize the syndrome or delay a diagnosis of Munchausen syndrome. The occurrence of factitious injuries may be intentionally self-induced with an ulterior motive, as appeared true for this case presented. The authors cautioned that familiarity of variations in stomatitis migrans and Munchausen syndrome is needed so that the clinician does not delay needed treatment and present unnecessary patient anxiety and expense. Although most cases appear in the medical literature, dental diagnosis has been reported as well. Scully et al. (1995) presented two cases of Munchausen syndrome.
An oral medicine perspective
Although Munchausen syndrome in oral medicine exists, it is rare. The clinician must evaluate the possibility that a misdiagnosis or no diagnosis long term is a reality as well. Kondori (2011) found that many patients were either misdiagnosed with oral diseases or that they were totally missing a correct clinical disease diagnosis in 43% of submitted biopsies.
Evaluation of clinical lesions is not always so clear when just typed clinically. With the addition of misdiagnosis in oral conditions, the patient may truly believe that they have not been given the answers they need, do not see improvement in the condition, and may begin to look to another practitioner that results in multiple evaluations. This change in health-care providers can occur multiple times and may be legitimate.
The clinician should be aware of Munchausen syndrome but, at the same time, weigh the differential diagnosistic possibilities and consider all elements including the patient's total profile. It is known that patients may spend anywhere from 10 months to many years searching for a complete diagnosis of their symptoms.
The International Pemphigus and Pemphigoid Foundation reports that many patients have been seen/treated by as many as five to 10 different health-care providers before receiving a proper diagnosis of their disease.
In a study in October 2011, 80% of patients sought treatment within the first three months of their symptoms. Dentists were one of the top health-care providers, and oral symptoms (mouth, gums, and throat lesions) were the specific reason that the patients consulted a dentist.
Over 46% of the patients surveyed felt that the dentist was not knowledgeable about their disease; and 83% reported a negative experience, and 60.1% believed that it took much too long for a diagnosis. The International Oral Lichen Planus Support Group also reports a delay in a diagnosis or misdiagnosis in some reported cases as well.
There is the possibility of Munchausen's syndrome in some rare cases. Early recognition is necessary to assist patients in getting the care that they need and protecting those patients who may be under the care of a person who exhibits Munchausen's syndrome. Knowledge about oral lesions is key to differentiating various causes of disease states.
As always, continue to ask good questions and always listen to your patients!
What are the signs of Munchausen syndrome?
- Unexplained course of a disease
- Evidence of prior treatment, possibly scars or surgical evidence
- Multiple health-care providers
- Hospital and clinic visits at various locations, or recognition as a frequent patient to various facilities by health-care workers
- Eagerness to undergo surgery
- An apparent desire to continue the role of sickness
- Unemployment or employment as a health-care worker
- History of assault
- Other psychiatric diagnosis4
Originally published in 2017 and updated regularly.
References
1. Asher R, Lond MRCP. Munchausen's syndrome. The Lancet; 1951; 1:6650:339-341.
2. Bass C, Jones D. Psychopathology of perpetrators of fabricated or induced illness in children: case series. Br J Psychiatry. 2011; 199(2): 113-118.
3. Kondori l, Mottin RW, Laskin DM. Accuracy of dentists in the clinical diagnosis of oral lesions. Quintessence Int. 2011; 42:7: 575-577.
4. Little A, Curtis H, Kellogg B, Harrington M. Munchausen syndrome disguised as gossypiboma: An interesting case. Eplasty 2016; Sep 9;16:ic39.eCollection.
5. Neville BW, Damm DD, Allen CM, Chi AC. Oral and Maxillofacial Pathology. 4th ed. Elsevier, St. Louis. 2016.
6. Scully C, Eveson JW, Porter SR. Munchausen's syndrome: oral presentations. Br Dent J. 1995; 178:65-67.
7. Tyler MT, Bentley KC, Cameron JM. Atypical migratory stomatitis and Munchausen syndrome presenting as periorbital ecchymosis and mandibular subluxation. Oral Surg Oral Med Oral Pathol Oral Radiol, Endod. 1995; 80:414-419.
