570 Am J Psychiatry 1 41 :4, April 1984 Munchausen Syndrome, Depression, and the Dexamethasone Suppression Test Dwight Landis Evans, M.D., M.S., John K. Hsiao, M.D., and Charles B. Nemeroff, M.D., Ph.D. The authors describe two patients with Munchausen syndrome who met DSM-IIl criteria for major depression. Both patients exhibited evidence of nonsuppression of serum cortisol by dexamethasone. Although many patients with Munchausen syndrome have been reported to be depressed, only a few have received a diagnosis of major depression. Because the physical and psychiatric symptoms of the Munchausen patient are so complex, clinical assessment may stop at a diagnosis of Munchausen syndrome, and major depression may be overlooked. A diagnosis of major depression should be considered in the evaluation of these patients; the dexamethasone suppression test may enhance clinical assessment. (AmJ Psychiatry 141:570-572, 1984) M unchausen syndrome, a poorly understood, gen- erally untreated chronic psychiatric disorder with a poor prognosis, was first described and named by Asher (1), who felt that the stories told by these patients resembled the fictionalized exploits of the 18th century German, Baron von Munchausen. These patients suffer from chronic factitious illnesses that have physical and at times psychological symptoms. A review of the literature suggests that this syn- drome is associated with a broad range of psychiatric diagnoses from psychoses and neuroses to personality disorders. A considerable number of patients diag- nosed as having Munchausen syndrome appear to have been suffering from major depression. We report two patients with Munchausen syndrome (DSM-III diagnosis, chronic factitious illness with physical symptoms), each of whom also fulfilled DSM- III criteria for major depression. Both patients exhibit- ed evidence of early escape from dexamethasone. Received Sept. 8, 1982; revised Feb. 15, 1983; accepted June 15, 1983. From the Department of Psychiatry and the Biological Sci- ences Research Center, University of North Carolina School of Medicine. Address reprint requests to Dr. Evans, Department of Psychiatry, University of North Carolina School of Medicine, Cha- pci Hill, NC 27514. Supported by NIMH grant MN-33127 and National Institute of Child Health and Human Development grant HD-03110. Copyright C 1984 American Psychiatric Association. These findings support the view that certain Munchau- sen patients may have a major affective disorder; the dexamethasone suppression test (DST) may be useful in the identification of these patients. The DST was performed essentially as described by Carroll and associates (2). Dexamethasone (1 mg orally) is administered at 11:00 p.m. (and ingestion is documented in nursing notes), and serum cortisol is measured at 4:00 p.m. and 11:00 p.m. the following day by a specific nadioimmunoassay (Amerlex TM, Amensham-Searle, Arlington Heights, Ill.). Serum con- tisol concentrations greater than S p.g/dl at either time point are considered to be nonsuppression. CASE REPORTS Case 1 . Mr. A, a 3 1-year-old man admitted to our inpatient psychiatry service for evaluation and treatment of depression, claimed that he had been depressed since the death of his wife exactly I month before his admission. He appeared very sad and reported suicidal ideation. His medi- cal history included insulin-dependent diabetes, gout, and migraine headaches. Results of a physical examination and laboratory studies were unremarkable except for a mild iron deficiency anemia (hematocnit, 37.5%; serum iron, 15 p.g/dI). Mn. A’s diabetes was in very good control throughout the hospitalization; his fasting blood glucose was consistent- ly around 100 mg/dl. He fulfilled DSM-III criteria for major depression and exhibited cortisol nonsuppnession; his 4:00 p.m. serum cortisol level was 13.2 p.g/dl. An 11:00 p.m. serum cortisol level was not obtained because Mr. A began complaining of symptoms suggestive of renal colic. The urology service was consulted, and an evaluation for renal colic was negative. The apparently factitious renal complaints led us to inves- tigate Mr. A’s identification. All the information he had provided was false. When confronted with this, he became quite indignant, but after a few days he confided that he had been wandering the country from hospital to hospital with factitious renal colic. We independently verified two hospi- talizations in the previous week. He said his peregrinations began 3 years before admission, shortly after he and his wife divorced. He claimed to have had 300 admissions during this time. We were able to verify neither the divorce nor the admissions, as Mr. A refused to comment further. We agreed to discharge Mr. A and intended to provide him with anti- depressant medication and outpatient psychotherapy with one of us (J.K.H.), but he failed to return for his follow-up appointment, and we have been unable to contact him.