Fake patients in need of real help
by Robert Fulford

(The National Post, 31 July 2004)

The dark fascination of Munchausen Syndrome grows out of its peculiar status as both a warped form of folk narrative and an insoluble medical mystery. We've all heard about lonely people who flagrantly waste health care resources by showing up at hospitals with fictitious symptoms, at first puzzling and then enraging the doctors. We know that some of them exhibit a truly vicious tendency, Munchausen Syndrome by proxy, which means attracting medical attention by making their children appear sick or even causing them to be become sick.

We assume this happens because the pseudo-patients want attention and yearn for control over their lives. They have discovered the power of skilful storytelling and the force of a clever lie.

But that doesn't begin to explain the most amazing aspect of Munchausen, the spectacular mental energy and long-range determination demonstrated by many in the Munch Bunch (the nickname Britain gives its national registry of suspected Munchausen patients). Consider their extraordinary patience, their hidden creativity, the endless hours studying symptoms.

Some years ago Wendy Scott, a working-class woman from Scotland, became the Munchausen queen of the world. She managed over 12 years to get herself hospitalized 800 times in several countries. Her abdomen carried dozens of scars, evidence of the occasions when she persuaded surgeons to operate. The lines connecting her imagination and ego were snarled, but not snarled enough to hamper her ingenuity.

What finally broke her pattern was acquiring a kitten. She realized that if she were hospitalized again, no one would look after it.

Apparently that brought her to her senses, and soon she was running a Munchausen support group. Eventually she developed real colon cancer, but doctors viewed her with such suspicion that she didn't get treated until it was too late.

People like her, loony as they may be, are the true contrarians of this era. While many of us work desperately hard to stay out of hospital, the Munch Bunch lie to get admitted. Surgery they consider a major bonus.

Karl Friedrich Hieronymus Munchhausen (1720-1797) was a German baron who served with the Russian army and spent his retirement lying about his exploits. He entered medical textbooks in 1951, when Richard Asher, a British doctor, gave his name (with spelling changed) to medical trickery.

In The Lancet, Asher described a syndrome most doctors had seen: "Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories ... are both dramatic and untruthful." Ever since, medicine has been trying to deal with Munchausen. But apparently it continues to spread.

Marc D. Feldman, an Alabama psychiatrist who has made it his specialty, puts together in Playing Sick? (Routledge) a collection of stories about Munchausen and related conditions, which he groups under the term "disease forgery." He argues that patients exhibiting Munchausen behaviour deserve the help rather than the disdain of psychiatrists. These are patients and pretenders. He's had some clinical success, but he acknowledges that it's hard to treat people for a condition they don't think they have.

By the end of Playing Sick? we know Munchausen is even more complicated than we imagined. One patient tells Feldman, "The first time I saw a therapist, I don't know why but I began to act out having multiple personality disorder." Over time she developed 12 different personalities and couldn't figure out how to bring her story under control. Another patient reported that when she actually became sick it was hard to remember that she wasn't just working another scam.

Feldman, introducing us to on-line Munchausen, describes a young man who signed on to a Usenet group for migraine sufferers. He described at great length his long struggle with migraines, also his haemophilia and his seizure disorder, also his drunken stepfather and his blind mother. Still, he was getting good marks in fourth year of medical school and paying for his medication by working nights as a drummer in bar. Finding this all a bit much, other members of the group began gently questioning him. When they asked what medical school he was attending, he denounced them for unkindness -- and vanished.

That's what usually happens when a Munchausen patient is exposed.

And that's one of two reasons why (as Feldman notes) this subject remains little understood. The other reason is that there's no lobby promoting research, as there is for AIDS, breast cancer and many other conditions.

Patients are in no position to demand help, since their main interest is in denying that they could possibly have any such illness.

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