Speaking of Psychology - Medical Deception: Understanding Munchausen Syndrome/Factitious Disorder, with Marc Feldman, MD, and Janet Cahill, PhD

Episode Date: May 24, 2023

Factitious disorder, more commonly known as Munchausen syndrome, is a mental health disorder in which people fake serious illness to gain sympathy, attention and support. A related disorder, Munchausen by proxy, or factitious disorder imposed on another, is a form of abuse in which caregivers make up or induce illness in their children. Psychiatrist Marc Feldman, MD, and psychologist Janet Cahill, PhD, discuss researchers’ evolving understanding of these disorders, how common they are, the phenomenon of “Munchausen by internet” where people lie to strangers online, and whether there are any effective therapies for these disorders. For transcripts, links and more information, please visit the Speaking of Psychology Homepage. Learn more about your ad choices. Visit megaphone.fm/adchoices

Why would someone lie about being sick or do terrible things to themselves in order to appear sick? Factitious disorder, more commonly known as Munchausen syndrome, is a mental health disorder in which people fake serious illness in order to gain sympathy, attention, and support. A related disorder, Munchausen by proxy, or a factitious disorder imposed on another, is a form of abuse in which caregivers, often mothers of young children, make up or even induce illness in their kids. This is to gain sympathy and support. How common are these disorders? Why do they go by so many different names?

What's the difference between factitious disorder or Munchausen syndrome and simply malingering? Are factitious disorders related to other mental health disorders? Are there effective therapies? Can a person with factitious disorder be cured of it? And what about people who lie to strangers on the Internet about being sick? Is that a form of one of these disorders as well? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life.

I'm Kim Mills. We have two guests today. First is Dr. Mark Feldman, a board-certified psychiatrist, clinical professor of psychiatry, and adjunct professor of psychology at the University of Alabama. He is an international expert in factitious disorder, Munchausen syndrome, Munchausen by proxy, and Malingering. He has authored more than 100 research studies and five books on these topics, including his most recent book, Dying to Be Ill, True Stories of Medical Deception. Dr. Feldman is a distinguished fellow, of the American Psychiatric Association and has spoken to dozens of media outlets about Munchausen syndrome.

Our second guest is Dr. Janet Cahill, a clinical psychologist and professor emerita in the Department of Psychology at Rowan University. Her private practice specializes in assessing abused and neglected children and their families, including evaluations and treatments for factitious disorder imposed on another, or Munchausen by proxy. Dr. Cahill has consulted with many human services agencies, including the New Jersey Division of Child Permanency and Protection, the Nevada Division of Child and Family Services, and the South Carolina and Colorado Departments of Child Protective Services. She also provides workshops and training to human services professionals. Thank you both for joining me today. It's a pleasure.

Thank you. In the introduction, I mentioned that these disorders are known by several different names. Factitious disorder is the official term that's used in the diagnostic and statistical manual of mental disorders, but most people, if they've heard of this disorder, are more familiar with the term Munchausen syndrome. And factitious disorder imposed on another, or Munchausen by proxy, is also sometimes called medical child abuse. Are these terms basically interchangeable? What's the history of these terms? And which do you use for which? Dr. Feldman, maybe you want to grab this one first. Yeah, there's been a lot of complexity because so many terms have been used to refer somewhat to munchausen syndrome, that is, people making themselves sick or lying a bad illness, but really to munchausen by proxy, which I do prefer to call medical child abuse. And the reason I prefer that is it focuses on the fact that this is abuse.

It typically involves a child being victimized. And it's easier to understand. Munchesom by proxy doesn't tell you very much about what the ailment is and what the behavior is, whereas medical child abuse makes it clear, and it also helps focus on the child victim rather than the adult perpetrator, who's usually the mother. But formally, the DSM-5 and DSM-5TR do call these factitious disorder imposed on self in the case of what we used to call Munchausen syndrome. And as you said, factitious disorder imposed on another for what people still tend to know is Munchausen by proxy. Dr. Cahill, does that resonate with you?

Do you also use factitious disorder rather than Munchausen? So as a psychologist, I use factitious disorder imposed on another. And so that allows us to make that diagnosis. We're really looking at the same stuff, at the same symptoms, at the same problems. But our different professional needs are, if we're going to do it, we need to do it within our own areas. So I would use factitious disorder imposed on another. But honestly, for the most case, we're all looking at the same thing. Well, let me ask you the different.

between factitious disorders and simply malingering, which is basically faking or exaggerating illness, are there cases where people pretend to be sick but they don't have factitious disorder? Yeah, this can occur in, well, let me clarify the difference between factitious disorder and malingering, but also point out that they can coexist. Malingering involves external gains, primarily going after things that are tangible, like feigning or exaggerating illness or even inducing illness to get opioid medications or disability adjudications or not guilty by reason of insanity adjudications or evasion of military service. It's things that when you look at the patient situation, you can sort of understand why they've done what they've done. Whereas in factitious disorders in general, you have to infer psychological processes because they're after things like that aren't tangible, like intention, sympathy, care, and concern that they feel unable to get in other ways. But as I said, we all know motivations can shift over time. They can even coexist.

And so I never hesitate to make the diagnosis of both if that's what's applicable in a given case. Dr. Cahill, let me ask you, how common do you think these disorders are? Do we have any reliable estimates? Well, by definition, an individual who meets the criteria for a factitious disorder is doing this on purpose for their own psychological needs. And so it's very, very hard to catch up with them. We have colleagues now who are doing some research on this. And the more we research it, the more we find it. So I think it's out there more than we expected, but it's also difficult to get a handle on it. I would just add that the recognition also has occurred that munchausen by proxy or factitious disorder imposed on another can also coexist with munchausen syndrome.

so somebody can be feigning illness in themselves and do it in a child as well. Sometimes we find that, and research has borne this out, up to a third of abusive moms in Munchesom biproxy cases have a personal history of feigning illness in themselves. And this is deliberate deception. They know what they're doing. There's often considerable planning involved in executing the behaviors that. deceptive behaviors. And so anyone who says, well, DSM contains these two diagnoses, the mothers can't, and patients can't be held responsible. No, this is deliberate behavior. And I always point out that

pedophilia is also a mental disorder. But we certainly prosecute those who sexually abuse children. And sometimes we have to seriously look at prosecution in the Munchausen cases. especially medical child abuse or munchausen by proxy? It would seem that for someone to manifest either version of factitious disorders, that there must have been some kind of trauma, something happened in a person's life that led them to this behavior. One would think, how much is known about the causes of factitious disorder? Are there common threads?

As Mark was saying, a lot of times they did this, they might have been the victims of that kind of behavior. They might have been exposed to it. So that's possibility. It might be trauma. But generally speaking, it's a psychological need that this parent has. Maybe it could be attention behavior. Maybe it could be they want to be seen as a fantastic mom.

Maybe they have issues of control. They want to control everyone around them. So there's multiple paths to this. But a general way to think about it is this is a parent, and Mark is correct, it's almost all moms who are trying to get to, who are manipulating this child to meet their own psychological needs, whatever those are. Dr. Feldman, let me ask you, how difficult is it to diagnose factitious disorders? I mean, do you think that MDs are sufficiently aware of the syndromes so that they can spot it in patients?

And if people are doctor shopping, which often these people will do, can they go undetected for, long periods of time. I actually believe that the majority of these cases go undetected. And a lot of that has to do with a knowledge deficit and an educational deficit among health care providers. It's actually getting better. But I, for example, did my medical school training at Dartmouth and my residency training at Duke. And I never heard the term. factitious or any discussion of munchesom by proxy throughout my education. The first time I heard of it was when I was confronted with a patient in my office who had feigned terminal breast cancer for a year and a half and I suddenly had to do a lot of research on my own to figure out what was happening.

She did have a full-blown case of factitious disorder imposed on self. We did call it just plain factitious disorder at the time. But if a patient is particularly crafty, we may see no red flags. And again, as I said before, I think the majority of these cases go unrecognized. So how can an expert differentiate between malingering and hypochondria? I mean, they sound very similar. Are these disorders connected? Are they the same thing? Dr. Cahill? Any thoughts on that? Yes. We do have, as a profession, we've gotten better in our ability to do evaluations that separate those things out.

So if we have enough information, we can make a distinction between somebody who really feels like their child is having this problem. I'm usually coming from the child perspective, but Mark is right. This can also be just an individual with factitious disorder. So what we need then is we need to get tons of records, and we need to get lots and lots of information, and we have to compare what the potential perpetrator is saying versus what the records are doing. And if we're careful about that and we get enough of the records and we have enough time, we can make the distinction between someone who just is really concerned about their child and messing up to someone who is doing this on purpose.

So, for example, sometimes if a nurse has a concern, they'll put a camera in the room where the mom is with the child, and we've had a number of these. So you have to get a court agreement for that. You just can't start putting cameras in the hospitals. But let's say we have a camera in the hospital with a mom who says that her child keeps throwing up and he's vomiting and he can't focus anymore. So we look at that after a while and we see that the child is not focusing, but literally the mom is putting a pillow over the case. kid's head and blocking it happens. So there we go. We're set. We know what we're doing. We saw it with our own eyes. Even with that, they will deny to the end of time. It's very difficult to get them to admit they did this. But we have now better protocols where by using the information

we have, it doesn't have to be a camera, but it could be a lot of records, having someone, just a quick example, said her kid keeps throwing up when she goes to school all the time. Talk to the teacher who's there to guard the kids at the school going across the street, she said the kid never throws up. So if we can build a pattern of that, it can't just be one thing, we can make that diagnosis with some accuracy. Dr. Feldman, I want to ask you a question. Back in the 1990s, you coined the term Munchausen by Internet. How has the Internet changed how this disorder presents itself? And is Munchausen by Internet as common as regular Munchausen syndrome, or is it even more common at this point. Well, I coined the term because people, when I lecture it, would often come up to me

after the lecture and tell me about online cases. Some of them were so extreme. It was hard to believe that anyone else believe them, but they tend to impart this catastrophic information about illness or crisis in a gradual way that becomes believable because who would think some somebody would go online and lie about their child's health or their own health. And many of the support groups they would log on to are explicitly supportive. They're there to provide health information and health support. They're not there to question anything that goes on. But it can be explosive when it's discovered that a person has lied online, whether about themselves or children.

and it can often lead to the end of the group because the group members divide into camps of the believers, those who still believe the stories are true, and those who were finished with the group because they know they're not. I think there are way more Munchausen by Internet cases these days than real-life Munchausen cases. Because it used to be that people would have to go to medical libraries, study up about illnesses, then go to an emergency room or a doctor's office and act, really, act out in illness. They had to have acting skills and not everybody does. So sometimes they were detected, sometimes quite easily.

But Munchausen by Internet is different in that it just involves the gift of using words. And you can become an expert in almost any medical ailment by special. spending 20 minutes on Wikipedia. It can include ailments that doctors themselves don't know that much about. And I think, again, if they're discovered, they simply go elsewhere on the internet and may continue the same kind of deception or go into a completely different group, research that one, and try to be credible as they post online. Yeah, Dr. Cahill. Let me add also. I agree everything's Mark Singh, and I think also the Internet has made this more, has increased the number of people who are doing this. Now we have people who have a GoFundMe page for kids' illnesses saying, oh, the kid can't eat, and he has a gastric tube, and he has this and that. They get a lot of attention and positive feedback from people on social media who's saying, oh, you poor thing, we're so sorry.

pictures of the kids with masks on and in wheelchairs, those kinds of things. I think it gives them access to a bigger audience that gives them the love and the support that they need. And it's harder in some ways to track them, but in other ways it's easier to track them because we can go on to that website and see what's going on. So I think it's actually increased the number of people who are using or who are doing this against their children because it's another medium that can be very effective for. there's been research in fact that shown that if you compare the child in the hospital and some doctors have done this with what the mother has posted online about the child in the hospital they grossly exaggerate so doctors themselves in hospital staffs if you think it's ethical to look at what the mother is posted online can often make the diagnosis based upon

the prose and those pictures that Janet referred to. Some people refer to it as medical pornography. I mean, if you have a desperately ill child, why would you post pictures coming out of orifice, every orifice you can mention, to a group of strangers? Maybe you know a few people, but you don't know others. It's perverse, and it can be an important warning sign. But how can you differentiate between a person who's posting fake information about medical conditions on the internet in order to make money, right? You mentioned a GoFundMe campaign, Dr. Cahill. I mean, but do all of these people really have factitious disorder or are they con artists trying to make money? How can you tell the difference?

Yeah, that's a very good question. And right, so again, with factitious disorder, the motivation has to be their psychological. needs. If on top of that, they're malingering and getting some money, so they say their kid has ADHD, so they get, you know, they get to send the kid to a certain school or something like that. Or they have nurses. We've had cases where nurses are there 24-7 taking care of the kid for them. We've had cases where they have wheelchairs and they go to, they say the kid is dying, so they get paid to go to Disneyland. These are all real cases. I know. But again, I think we're better with a protocol where we can begin to discriminate those things.

I'll give you a quick example in a case where I had a mom who's telling me that the kid can't eat. He had autism and had all these problems, but he couldn't eat. So he had go through a number of surgeries and he had a gastric tube and those kinds of things. And the casework I was working with, we did a surprise visit and we walked into the house and we see this kid eating the biggest sandwich we've ever seen in our lives right in front of us. And immediately, oh, yeah. And the mom's like trying to dig herself out of that stuff. So we need to look at what the mom is saying, or the perpetrator,

it can be the father and other people, it can be grandparents. And then we have to compare that to other sources of information. And if we're lucky and if we persevere, we often find those differences. And that's how I would make that diagnosis. I let him finish the sandwich to see you now. I'm sure he thanks you. He appreciates that. There have been cases of mothers starving their children to death.

There's a famous case in Colorado of a victim who died named Olivia Gant. And there, the mother made up a failure to thrive scenario and made the child sound like she couldn't absorb nutrients. ultimately the child went to hospice and died based upon the mother's instructions that no effort should be made to feed the child. It all is so suspicious as I'm presenting it now, and there were suspicions in the hospital and among a host of health care providers, but they never took the step as mandated reporters to alert child protective services or the police. They kept to quiet. And now they have had, now with the death of the child, they have had to pay millions of dollars for their negligent care that culminated in death and the mother's in prison.

Dr. Feldman, I listened to a podcast interview you did with a woman who had factitious disorder, but seems to have overcome it. She hasn't made up any illnesses in years. Is that common? And what are the treatments that mental health providers have when they're working with patients who have factitious disorder. Well, it's a challenge. And many people told me when I encountered my first munchausen syndrome or a factitious disorder imposed on self patient that I should just drop the case because that they're needy, they're clingy, they have no desire to get better. That is true in some cases. But I was impressed with the fact that some patients did respond really well. we were able to break through the denial.

And I found that my lack of overjudgment of them, my sitting with them for two times a week in an hour-long psychotherapy, led them to trust that there, in fact, was a health care provider who cared about them and would be very consistent and not fire them from practice. fire them from the therapy if they happen to slip up. And that's the biggest mistake that therapists make. They tend to say at the beginning, if you do this one more time, harm your child or harm yourself, you're out of here. I'm not going to treat you any further. That never works. It's like saying to a schizophrenic patient, if you have one more hallucination, you're out of here. I mean, it makes no sense. It's just crazy. So in the case I think you're referring to, there were slip-ups where she got hospitalized, but I was there for her. And in fact, she came to recognize that the more she got medical treatment and hospitalizations, the less she could meet with me.

It was actually interfering with something she was benefiting from. So she gradually abandoned the behavior and is done splendidly. I stay in touch with her, even though it was torn. years ago and she's free of the behavior. So does something like cognitive behavioral therapy work with people who have the disorder, Dr. Cahill? So I'm going to talk specifically about monchasm by proxy. So now we have the parent doing it to the child.

And unfortunately, our track record is very poor. We do have a protocol that was developed by the Apsack group, which is very good. And so it says what we need to do is go through these steps. and trying to treatment them. So ordinary protocols like cognitive behavioral therapy or supportive counseling or behavior therapy does not work with this population. And the problem with the one protocol we have,

which we've had some very mild successes with, is that the very first step in that protocol is they have to acknowledge that they abuse their child. And we often, and so far, where we get stuck at that one. We can't get past that one. They will not agree that they did something wrong to the child. And there's actually some thoughts out there that if they did it, they really didn't have

bunchhousin. So if they said, yes, I'm sorry, I did this. They probably don't have bunchhousin. But that's our problem. So the treatment is normal treatment, a really good therapist and the situation that Marchist explained with someone with factitious disorder. Yeah, that's great. But for individuals who truly meet the criteria for proxy, where they're doing this or there's kid, the one protocol we have is not effective because the person will not admit they did anything.

And we can't get past that. If we can get past it, then we can help them to find ways to meet their psychological needs without hurting their children. And there's a few cases where that did happen, but the majority of them, it doesn't work. Yeah, I've done this for 32 years or so and have only had perhaps three patients, or I should say perpetrators who admitted to me what they had done. And they all came through anonymous internet information. I ultimately fanned out their identities. But part of the barrier is what they're doing is illegal in every case. And I think part of the resistance to breaking through the denial is they realized by acknowledging what they're,

done, they may find themselves criminally prosecuted. So it's a real dilemma. And I'll date myself here. Back in 1994, I published an article called Denial in Munchausen Syndrome by proxy, the consulting psychiatrist dilemma. And we're no further along in having techniques to crack through that denial than we did, honestly, back in 1994. It's getting better. There are lots of ideas, but still, I would totally agree with Janet, that that is a problem that is almost intractable. Is factitious disorder limited to humans, or are there cases where people mistreat their pets, for example? And why would someone do that? I've written quite a bit about that in veterinary journals because I wanted to alert veterinarians,

and this could happen, and I sent out reprints of the articles, to a bunch of vets that I know. They may indeed, and do, victimize their pets and kill their pets, to extract attention, sympathy, concern. I had one case where the motive was a little bit different. The human taking care of the pet had fallen in love with their vet, and keeping the pet perennially ill allowed her to stay in touch with the the vet. But in other cases, they love the attention or they may get medications prescribed for

the pet like opioids or benzodiazepines, sedating agents, relaxing agents, and use them themselves. And that becomes a case of malingering by animal proxy. Wow. A few months ago, we did a podcast on pathological lying, and I'm wondering whether people with Munchausen syndrome are dishonest in other parts of their life, and does it co-occur with other mental health disorders? Well, by definition, they are lying and they are doing it on purpose. And often that will spread to other things. They'll, you know, they'll make up other stuff. But most of the energy is towards the child. And but yeah, so they're definitely lying in terms of other things.

things, yeah, the thing that we have most commonly comorbid, which means the two things occur together, are personality disorders. And so there's a number of those we would use. About 50% of the people who we see who meets criteria for monochasein bioproxy will also have a personality disorder. And we can do both, so we can diagnose both, so we can't, you know, but in terms of, if they have that, let's say, oh, I don't know. example, but let's say they have some depression or anxiety, we would target that secondarily.

So first order of business is to see if we can make sure this child is okay, and we would try to treat that, and then we might have to go after the personality disorder later. But generally speaking, again, we don't get there because we can't get past the child abuse. But almost always they'll come in with something else. Dr. Feldman, if you suspect that someone you know may have factitious disorder, and this is for our listeners, what can you do? Are there resources people can go to for help? There really are resources available. I established a website called munchausen.com back in 1993. Again, I'm dating myself more than I intended to. And starting in 1996, I introduced an email capacity. Every day, I hear from people who have one concern or another about medical deception. It is usually a dad or a new wife or the fiancé of the dad who's divorced from his spouse,

looking for munchausen by proxy information and a consultant perhaps to help them along with that. but I do hear from some patients with factitious disorder imposed on self, and I can refer them to a variety of sources. The links on my website help. There are books on the subject, such as my own, Dying to Be Ill and some other earlier ones that I wrote. Dying to Be Ill has the advantage of including personal accounts, tons of personal accounts, from patients who have worked through this or who are experiencing it. And it's written in their own words, so it resonates tremendously with patients.

And I found that that's been a really helpful tool. And then for Munchausen by proxy cases or medical child abuse cases, there's a website called Munchausen Support.com that was more recently developed and has a wealth of information for anyone, whether professional or not, who might come across one of these cases in their lives. So it includes legal individuals, guardians ad litem, lawyers, but also patients themselves, their families, their friends. So I think that's an important resource.

It doesn't come up easily on Google searches. But again, munchausen Support.com is the site. And Dr. Cahill, what about cases? where somebody thinks a child is being a victim of basically this type of child abuse? My best advice, if you're worried, go do something about it because they're out there. I also just mentioned to the American Professional Society on the Abuse of Children, Apsack, is a very good resource for people to get in touch with. There's a group of people, there's a committee that has expertise in this area.

So that's another place to go to get some help if you need it. I think it's really important. I think people need to get past the idea that how is it possible a parent could do this to their child? It's really hard to get over that bump because how could that possibly happen? So I think one thing to really emphasize is it happens. It's happening out there. So if you have suspicion about that, you should either go to one of the websites that Mark just said or you should call child protection anonymously and not mess around with it and really try to follow up.

on it. And now I think, you know, child protection is getting more sophisticated about these things. They're following up longer. But don't let it go. If they feel you, if you feel something's going on with that child, call child protection, go on one of these websites. Try to protect that child as any way you can. And if you're wrong, you're wrong. Okay, no problem. If you're right, you're saving that kid's life or they're saving their ability to have a reasonable adulthood. I would also go to the police pretty routinely if it appears that will rise to the level where the police will help. They often know nothing about medical child abuse or factitious disorder, but sometimes there's been grossly illegal behavior. And there is a consultant who's a member of the Apsack team who is a police investigator and international expert in.

medical child abuse in particular. And he's always willing to consult for free with police departments that might encounter a case. And he tells them exactly what to do every step of the way. It's good to know there are resources out there. So last question, Munchausen syndrome and Munchausen by proxy have been dramatized in TV and movies probably because so many of these stories are compelling, if not downright horrifying. Do you think these portrayals are giving the public an accurate picture of these disorders, or are they misleading? Okay.

I think they're helpful overall, if they're well done, in educating the public. And they've particularly shown cases of Munchausen by proxy. But they do, as you might expect on a true crime program on TV, or a fictionalized case of Munches and By proxy stressed the most extreme and dramatic cases like the Gypsy Rose Blanchard case where she had her boyfriend kill her mother as a way to finally escape

the abuse she had encountered for 19 or 20 years as a result of Munchesom by proxy and having to play along with her mother's efforts to depict her. as ill. And obtaining money was a big piece of that. Jipsy Rose, the daughter, is now in prison, but we'll probably get out next year or the year after. She was convicted of second-degree murder, even though she didn't wield the knife. Her boyfriend, who did, is sentenced to life in prison, I think, without the possibility of parole. But Gypsy Rose has said that her life in prison

is much more liberating and free than what she encountered under her mother and that she doesn't really regret what happened. Yeah, I would add to that, yeah. I mean, I think getting over the hump that this could happen, I'm all for that. I agree that some of these are pretty dramatic and pretty crazy, and they're missing the little ones where they're not just doing these dramatic things. But anything that encourages people to understand that it is possible that this disorder exists I think is helpful for us.

Well, I want to thank you both for joining me today. This is an absolutely fascinating topic. I really appreciate you taking the time. Thank you so much for having us. My pleasure. Thanks for having us. You can find previous episodes of Speaking of Psychology on our website at www. www. speakingof psychology.org or on Apple, Stitcher, YouTube, or wherever you get your favorite podcasts.

If you have comments or ideas for future podcasts, you can email us at Speaking of psychology at APA.org. Speaking of psychology is produced by Lee Weinerman. Our sound editor is Chris Kondyenne. Thank you for listening. For the American Psychological Association, I'm Kim Mills.