Factitious Disorder, Munchausen Syndrome, & Munchausen by Proxy: Dr. Marc Feldman

PlayingSickOur guest today is Dr. Marc Feldman who is the leading international expert on Factitious Disorder, Munchausen Syndrome, Munchausen by Proxy, and Malingering.  After personal experience with a young mother afflicted with this disorder and the aftermath on her child, the quest to interview an expert was important.  Join Kristin Walker, Melanie Vann, and Dr. Marc Feldman as they discuss the nature of these mental illnesses, his work in this field, and why he was compelled to make these particular syndromes his field of expertise.      


What is factitious disorder?

Factitious disorder (FD) is a recognized mental disorder that refers to people who feign, exaggerate, or induce illness in themselves to gain emotional satisfaction. The ailments they fabricate can involve medical problems and/or behavioral-mental health problems. Unlike malingering, in which people do the same thing but in the pursuit of external goals such as disability payments or narcotics, FD patients seek attention and sympathy or seek to control others through the use of illness.

Dr.MarcFeldmanWhat is Munchausen syndrome?

Munchausen syndrome is the term applied since 1951 to the most severe and chronic patients with FD. Approximately 10 percent of FD patients have Munchausen syndrome, in which they evolve a lifestyle of traveling from hospital to hospital to obtain medical care. Many Munchausen patients subject themselves to surgery that they know they really do not need, and may exhibit what is called “pseudologia fantastica.” Pseudologia fantastica is pathological lying that tends to combine truth and fiction—and therefore makes for the most compelling type of lie.

Why are so many people aware of the term “Munchausen syndrome”, even if they don’t know precisely what it means?

In the 1700s, a writer in England named Raspe appropriated the name of a real-life military hero, Baron Munchausen, for a book of wild adventure stories. Baron Munchausen had been a well-known raconteur but not a pathological liar; however, Raspe’s stories were so exaggerated that people thought he was. The book, “The Adventures of Baron Munchausen,” was instantly popular, and variations of the book have been published continuously ever since. In 1951, physician Dr. Richard Asher applied the Baron’s name to a syndrome in which people lied about illness to gain attention (“Munchausen’s syndrome”) and that term has entered the public’s awareness.

What are examples of the manipulations in which FD patients engage?

Most patients with FD do not induce actual illness, though some do. In general, these individuals merely lie about illness, misleading others into providing care and concern that they feel are lacking in their lives. Cancer is an illness that is commonly portrayed because people are loath to question someone who reports a cancer diagnosis. Pain (of any part of the body) is probably the single most common symptom that is falsely reported. It is rather easy to feign pain because everyone has had the experience of pain and knows its features; people also readily empathize with those who are ostensibly experiencing severe pain. Overall, virtually any illness, symptom, or sign can be reported or induced by a FD patient who is motivated, reasonably knowledgeable, and creative.

Occasionally my partner or child will feign a mild illness to avoid a stressor such as work or school for a couple of days. Does this mean that they have FD?

No. We call such behavior the “benign use of illness” or “normal illness behavior”, and probably everyone has done it at some point in their lives. Unlike FD, the behavior is displayed only infrequently, involves minimal gains, and does not represent an enduring pattern in the person’s life.

How common is FD?

The American Psychiatric Association reports that approximately one percent of hospitalized medical/surgical patients have FD.  However, we know that FD is more common in highly specialized and advanced medical settings, where these patients often wind up because of the enigma their signs and symptoms have previously presented to health care professionals in general medical settings.  In one early study, over 9 percent of patients with fevers of undetermined origin were found actually to be falsifying or producing their fevers, apparently for the medical attention and treatment it would compel physicians to offer.

What are some of the factors predisposing people to develop FD?

Though some of the information FD patients provide can be suspect, they commonly claim to have been victims of abuse and/or neglect in childhood. Emotional neglect is particularly frequent, with patients stating that the only time their parents provided attention was when they appeared to be ill. Thus, feigning illness became a way of life that developed and festered, even after they had separated from their families of origin.

What is “Munchausen by Internet”?

In 1997, I became aware of the fact that some individuals were going online to health-related support groups and falsely claiming to be seriously ill with the ailment under discussion. I published an article about it in 1998, then another in 2000 in which I explicitly used the term “Munchausen by Internet” to apply to this phenomenon. Since then, I have learned of many dozens of similar cases, and any online social media can be used to access the attention that most FD patients seek in doctor’s offices, emergency departments, and hospitals. If the goal of the online deceptions is setting up GoFundMe or other accounts to solicit money, we call this behavior “malingering by Internet.” Unlike pure Munchausen by Internet, malingering by Internet can be criminally prosecuted.

Are individuals with FD truly “patients”? After all, their behavior is willful and volitional.

Since 1980, the American Psychiatric Association has formally included FD in its list of mental disorders. While FD involves purposeful deception, these individuals may not know precisely why they are doing what they are doing, and they may continue the behavior even after experiencing serious adverse consequences. Some FD patients refer to their FD as a “compulsion” or “addiction,” and it does seem as if they commonly cannot resist their impulses despite a desire to do so.

How did you become so interested in FD, Munchausen syndrome, malingering, and similar diagnoses?

I had never even heard the term “factitious disorder” when I was assigned my first FD patient early in my career. I received an urgent referral involving a young woman who had been faking terminal cancer for a year and a half. She had shaved her head to mimic chemotherapy-induced hair loss, dieted to lose 50 to 60 pounds as an authentic cancer patient might, and joined a breast cancer support group. The support group leaders found out only incidentally that she had never seen any of the doctors whom she claimed were treating her. When confronted, she became tearful and depressed, and admitted to her deceptions. Unlike many FD patients, she was eager for psychiatric care and she did very well during a six-week hospitalization on a psychiatric unit. I wrote an article about her case for a medical journal, and that led to an invitation to write my first book on the subject, “Patient or Pretender.” I have since published two more books on the topic. The most recent is entitled, “Playing Sick: Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder.”

Dr. Marc FeldmanMarc D. Feldman, M.D. is Clinical Professor of Psychiatry and Adjunct Professor of Psychology, the University of Alabama (UA), Tuscaloosa, Alabama. A Distinguished Fellow of the American Psychiatric Association, he is the author of more than 100 peer-reviewed, published articles in the professional literature. Dr. Feldman is an international expert in factitious disorder, Munchausen syndrome, Munchausen by proxy, and malingering.  He is the author of four books which can be purchased on his website at www.munchausen.com.

Dr. Feldman’s work has been the subject of stories in more than 200 magazines and newspapers, including The New York Times, The Los Angeles Times, The Chicago Tribune, the Philadelphia Inquirer, and USA Today. Among Dr. Feldman’s television and radio appearances are Good Morning America, Larry King, Dateline, 20/20, ABC World News Tonight, Court TV, CNN, Discovery Health, MSNBC Nightly News, Fox News, CBC News, CBS News, Donahue, Dr. Phil, and National Public Radio. He is listed in The Best Doctors in America. He is an Honors graduate of Dartmouth College and Dartmouth Medical School, and the psychiatric residency at Duke University Medical Center, where he later joined the faculty. He was formerly Vice Chair and Medical Director in the Department of Psychiatry and Behavioral Neurobiology at the University of Alabama at Birmingham (UAB) and has served as Regional Medical Director of United Behavioral Health, Inc., a managed care company. He is board-certified in psychiatry and psychosomatic medicine.

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