Munchausen syndrome in COVID-19: An unnoticed concern

The COVID-19 pandemic has been associated with numerous mental illnesses such as depression, anxiety and insomnia (Rogers et al., 2020). However, we have not yet focussed on a not-so-apparent but vital psychiatric disorder linked with it, the Munchausen Syndrome (MS).

In MS, a person tries to mimic symptoms of a medical condition to assume the role of a patient and get medical care. Dr Richard Asher first described it in 1951 by linking the factitious behaviour with Hieronymus Karl Friedrich von Münchhausen's mendacity (Asher, 1951). Münchhausen, a German officer who had fought in the Russo-Turkish War, used to tell his wartime experiences with overt exaggerations and hyperbole. However, as the modern medicine tries to do away with the eponyms, MS is now termed as factitious disorder imposed on self. The Diagnostic and Statistical Manual of Mental Disorders (DSM)−5 classifies it under the ‘Somatic Symptom and Related Disorders’ category (American Psychiatric Association, 2013). Based on International Classification of Diseases (ICD)−10, MS (F68.10) is different from person feigning illness (with obvious motivation) or malingering (Z76.5).

It is quite easy to mimic the symptoms of COVID-19 since everybody is familiar with them. People can complain of loss of smell and taste, which can't be denied objectively, just like sore throat and cough. The only catch in a probable MS is that the symptom onset and progression might be vague and incoherent.

It would be quite interesting to understand the reason behind this behaviour in this pandemic – is it because they are worried about themselves or about infecting their families? Is it that they just want to be under the safe monitoring of doctors, to avoid getting infected or receive timely treatment when needed? Or do they want to end the “uncertainty” by getting infected and admitted?

Repetitive wandering from one COVID-19 testing facility to another, in order to get tested and admitted anyhow, would expose them more to the infection and thus, increase their ‘actual’ chances of contracting the disease. So, in case we are denying them tests, we have to counsel them properly.

Cases of forgery and manipulation of laboratory reports have been reported in MS (Zittel et al., 2017). Due to the availability of numerous text editors, it is quite easy to replace the “negative” in a COVID-19 report with a “positive”, thus highlighting the need for healthcare professionals to be vigilant.

On the other hand, we need to be extremely careful in diagnosing someone with MS since seemingly factitious symptoms might hamper our ability to correctly diagnose a possible COVID-19 case. In fact, early deaths have been reported in MS because of missed-diagnosis (Di Lorenzo et al., 2019). In order to exclude MS as a differential diagnosis, some of its commonly associated risk factors such as prolonged hospital admission in childhood or adolescence due to a medical condition, grievances against doctors or healthcare workers or any experience of working in a healthcare facility should be looked for (Burton et al., 2015).

Except for a newspaper article (The Hindu, 2020), we could not find any other scientific literature talking about MS in COVID-19. We strongly believe that a probable MS should not go unnoticed.

Funding

This study has not received any specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Declaration of Competing Interest

The authors declare no conflicts of interest.