Munchausen's Syndrome: Causes, Risk Factors, and Theory

Biological Basis and Genetic Predisposition

There remains a paucity of timely and relevant studies concerning the biological basis for Munchausen's syndrome. In this regard, Cohen notes that "it has been difficult to assemble patients to study in more detail, since — once confronted — they usually become defensive and leave, only to seek medical care elsewhere" (p. 389). Although the precise basis for developing Munchausen's syndrome remains unclear, what is known is that men are at higher risk of acquiring the syndrome than women (Jacoby & Youngson, 2005; Gomez, 1993). Likewise, Trask and Sigmon (1997) report that "Munchausen syndrome patients may have an organic pathology that accounts for their physical symptoms, even though the physical condition is self-induced" (p. 346).

Because the condition is chronic, an individual's temperament may play a role in the escalation of Munchausen's syndrome, as current and future efforts to manipulate healthcare providers are typically more amplified and exaggerated than previous ones (Turvey, 2002). People who develop Munchausen's syndrome appear to be motivated by the need for some type of unconscious psychological gain rather than a tangible reward for their behaviors (Cohen, 2003). Regarding the basis for predisposition, Cohen advises that "personality testing often reveals a mixture of histrionic, narcissistic, impulsive, and dependent traits" (2003, p. 389).

Biological Stressors and Developmental History

Although the specific causes of Munchausen's syndrome remain unclear and understudied, "some doctors believe the condition dates from a long history of medical treatment in childhood. Some think it is a manifestation of a longstanding and severe grudge against doctors" (Jacoby & Youngson, 2005). In addition, Cohen reports that "past histories of childhood abuse and abandonment are common [in Munchausen's syndrome sufferers]" (p. 389).

Environmental and Interpersonal Influences

Interestingly, there may be a link between an individual's profession and the development of Munchausen's syndrome. According to Jacoby and Youngson, "although it is comparatively rare, the syndrome often seems to occur in people working in health-related jobs" (2005, p. 1286). This link may be due to the availability of medical texts that provide these individuals with accurate descriptions of medical condition symptoms, which sufferers then use to manipulate and deceive healthcare providers.

For instance, Ford notes that "lying and deception may be so pervasive for an individual that they take over much of that person's life. People who have factitious disorder (Munchausen's syndrome) represent an extreme example; these people spend most of their energy in fooling physicians and other health care professionals" (1996, p. 61).

Life Stressors, Malingering, and Vulnerability Factors

Some authorities suggest that Munchausen's syndrome is a form of compulsive disorder that develops in response to various environmental stressors in people's lives (Murray, 1997). Other authorities cite a potential connection between dysfunctional relationships and substance-abusing behaviors in the development of Munchausen's syndrome (Gomez, 1993). In contrast to malingering, Munchausen's syndrome sufferers do not respond to life stressors by faking illness for financial gain or to avoid employment — behaviors that are more indicative of malingering (Trask & Sigmon, 1997). According to Murdach (2006), "malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms in pursuit of external incentives, such as escaping criminal prosecution, receiving financial compensation, or gaining access to drugs or medication" (p. 155). Cohen (2003) also notes that various interpersonal stressors may play a role in the development of Munchausen's syndrome.

Generally speaking, women are at lower risk of developing Munchausen's syndrome than men. However, the incidence of a limited form of the syndrome that involves dermatitis artefacta — a condition wherein sufferers damage their own skin while adamantly denying the practice — appears to be as common in women as in men (Gomez, 1993). There are also other factors that may make an individual more vulnerable to developing the disorder. For instance, even though the condition is rare, Munchausen's syndrome is more common in the United Kingdom and other countries that provide free medical care than in the United States (Jacoby & Youngson, 2005). The prevalence of the syndrome may therefore be related to an individual's desperate need for attention, which translates into assuming the sick role in ways facilitated by the availability of requisite healthcare resources.

In this regard, Trask and Sigmon report that "diagnostic criteria [for Munchausen's syndrome] include the intentional production or feigning of physical signs or symptoms, the motivation for which is to assume the sick role, with the absence of any external incentives for the behavior (e.g., economic gain, avoiding legal responsibility, or improving physical well-being)" (1997, p. 346). Likewise, Murray (1997) emphasizes that "unlike malingerers who have something to gain from their illness (e.g., to miss military service or jury duty), Munchausen's syndrome patients are uncomfortable unless a great desire to deceive others and live for the sake of lies compensates them" (p. 343). Despite these distinctions, some patients who suffer from Munchausen's syndrome may also exhibit behaviors that, at least on occasion, reflect signs of malingering, since the outcomes of their behaviors may involve some type of external gain separate from any unconscious psychological gain accruing from self-inflicted injuries and deceptive interactions with healthcare providers (Cohen, 2003).

Furthermore, the fact that Munchausen's syndrome is more common in countries with free healthcare services supports the assertion that an individual who presents with the syndrome in the United Kingdom would be less likely to engage in such behaviors if those healthcare resources were unavailable. This observation suggests that disabled veterans in the United States, for example, may be at higher risk for developing Munchausen's syndrome than the general population given their free access to healthcare services — making this an important area for future research.

Psychodynamic Theory as the Explanatory Framework

In reality, the diathesis-stress model could be used to explain and understand the development of Munchausen's syndrome. According to Windle, "the diathesis-stress model is consistent with the general model adopted in psychiatric research of the interaction between a person's constitutional predisposition to acquire a certain disorder (i.e., diathesis) and outside stressors" (1997, p. 185). In other words, the diathesis-stress model accounts for the relationship between an individual's personal attributes and environmental stressors that may contribute to the development of the condition (Windle, 1997).

This observation is congruent with Zuckerman's discussion of how some people respond to external stressors based on genetic predispositions to certain conditions. In addition, the tenets of the diathesis-stress model hold that the excuses people routinely make for their failures affect how they react to such failures in the future, creating self-fulfilling prophecies (Buchanan & Seligman, 1995). Moreover, the model recognizes that a wide range of personal and environmental factors can influence the manner in which people respond to external events in their lives (Buchanan & Seligman, 1995).

Nevertheless, given its mysterious origins and baffling manifestations, psychodynamic theory appears to represent the superior theoretical model for explaining the development of Munchausen's syndrome. In this regard, Revelle notes that "psychodynamic theories with an emphasis on cognitive representations rather than biological drives (i.e., object relations theory) are more compatible with the research paradigms of social cognition" (p. 295). Furthermore, psychodynamic therapy can help sufferers of Munchausen's syndrome better understand their condition in ways that may help them avoid future recurrences. Holmes (1993) notes that psychodynamic therapy is "more concerned with meanings than mechanism, in which patient and therapist collaboratively develop a coherent narrative about the patient's experience. Such objectification and coherence are in themselves therapeutic, irrespective of the validity or otherwise of the meanings that are found" (p. 8).

According to Holmes, attachment theory has two main strengths that make it useful for understanding conditions such as Munchausen's syndrome. The first relates to its focus on using direct observation instead of retrospective reconstruction of an individual's past; the second is that attachment theory begins with the observation of normal development, which can serve as a benchmark for understanding psychopathological conditions (Holmes, 1997). Moreover, Zepf (2006) emphasizes that attachment theory has been applied effectively to conditions such as Munchausen's syndrome: "the application of attachment theory concepts to clinical phenomena has contributed substantially to an understanding of the origins of various forms of psychopathological developments, including anxiety, depression and personality disorders" (p. 1529). Linked to but distinct from attachment theory, cognitive theories focus on identifying deficient or distorted cognitive structures and processes that may contribute to a disorder (Mash & Barkley, 2003). Taken together, these findings suggest that both attachment theory and cognitive theory can help identify internal and external factors that may contribute to the development of Munchausen's syndrome.

References

Buchanan, G. M., & Seligman, M. E. P. (1995). Explanatory style. Hillsdale, NJ: Lawrence Erlbaum Associates.

Ford, C. V. (1996). Lies! Lies!! Lies!!! The psychology of deceit. Washington, DC: American Psychiatric Press.

Gomez, J. (1993). Psychological and psychiatric problems in men. London: Routledge.

Holmes, J. (1993). John Bowlby and attachment theory. London: Routledge.

Jacoby, D. B., & Youngson, R. M. (2005). Encyclopedia of family health. New York: Marshall Cavendish.

Mash, E. J., & Barkley, R. A. (2003). Child psychopathology. New York: Guilford Press.

Murdach, A. D. (2006). Social work and malingering. Health and Social Work, 31(2), 155–156.

Murray, J. B. (1997). Munchausen syndrome/Munchausen syndrome by proxy. Journal of Psychology, 131(3), 348.

Revelle, W. (1995). Personality processes. Annual Review of Psychology, 46, 295–296.

Trask, P. C., & Sigmon, S. T. (1997). Munchausen syndrome: A review and new conceptualization. Clinical Psychology: Science and Practice, 4, 346–358.

Turvey, B. E. (2002). Criminal profiling: An introduction to behavioral evidence analysis. San Diego, CA: Academic Press.

Windle, M. (1997). Concepts and issues in COA research. Alcohol Health and Research World, 21(3), 185–186.

Zepf, S. (2006). Attachment theory and psychoanalysis. International Journal of Psychoanalysis, 87, 1529–1531.