A 17th century German baron had a thing for embellishing stories about his exploits. His heroic narratives of his military career when he fought in the Russo-Turkish war were outrageous, even outlandish. But, far from being ridiculed for his yarns, Baron von Münchausen became a kind of minor celebrity within German aristocratic circles, gaining fame as a raconteur of extraordinary tales.
Fast forward to 1951 when the British physician, Richard Asher, published an article inThe Lancet describing patients who suffered from a mental disorder that caused them to feign illness, and to fabricate case histories and symptoms. Asher proposed to call the disorder “Münchausen’s syndrome”, commenting, “Like the stories attributed to the famous Baron von Münchausen, the stories told by the affected persons are both, dramatic and untruthful. Accordingly, the syndrome is respectfully dedicated to the baron, and named after him”.
Fast forward to 21st-century India. A 16-year old girl, coming from an under-privileged background in rural North India, arrives at a psychiatric facility. For a year and a half she has been visiting a clinic in a nearby town, accompanied by family members. Her presenting symptoms: infected wounds and pain in the forearms, arms, thighs and knees. The wounds had been caused by the “spontaneous extrusion” of copper wires from all her limbs, with X-rays confirming the presence of thin metallic wires in the muscle bulk. The wires would be surgically removed and given to the family members who would dispose of them near their home. In a few days, the symptoms would recur. Unsurprisingly, the girl found herself in the spotlight of brief media attention which she liked, and which the family would talk about with pride. Eventually, she was refused further surgery at the clinic, and referred instead to a psychiatric centre.
Examination showed that, although she had multiple scars on all accessible limbs, there were no scars on inaccessible areas like the back. She was wary while being interviewed at the centre; when asked non-judgementally about the possible source of the wires in her body, she became aggressive and challenging. She was tidy and kempt, spoke normally, showed no abnormalities of thought, and showed normal levels of higher mental functioning such as memory and attention. When asked about possible psychological stressors in her life, she reacted with obvious displeasure and shifted the focus back to her physical symptoms. Despite repeated attempts, she refused personality and other psychological testing.
On being questioned, the family revealed that, since childhood, Ms. S. (the name under which her case was published in The Indian Journal of Psychological Medicine) had experienced difficulty in emotional control. She would get angry easily, was stubborn, inconsiderate towards her younger siblings, and sought the attention of others. She would refuse to do her share of work, refuse food and walk out of the house without informing the family.
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Interestingly, no new instances of wire formation occurred during her stay in the hospital ward. When additional surgery was refused because of the danger of further tissue scarring, she began demanding a discharge. The doctors then tried to confront her in a supportive manner, attempting to redefine her illness as being not a physical disease but psychological distress, and assuring her that the information would not be communicated to her family. But she turned aggressive again, and then stopped communicating with the team in charge of her case. Putting the facts together, a diagnosis was made: “Factitious Disorder”, the modern-day medical term for Münchausen syndrome.
But attempts to get the cooperation of the family in working out a therapy plan failed because the family clung to its belief that the problem was attributable to supernatural powers, and that it was certainly not the girl herself who had inserted the wires in her body. Eventually, they all left the hospital against medical advice.
The case of Ms S. may seem like a rare instance of a bizarre disorder. In fact, it is not quite so rare. A 2014 study published by NIMHANS (The National Institute of Mental Health and Neurosciences) estimated that, at the time, India had about 1.3 million people with Factitious Disorder (FD).
What FD is, and what it is not
FD is not about faking an upset tummy to avoid going to school or to the office, or for obtaining financial compensation. These are cases of so-called malingering; the person is prompted by some clear external reward, and is well aware of what this external motivation is. Those with FD, on the other hand, while they are aware that they are feigning illness, are not aware of why they are doing it. There is no material gain. So, why do they do it? Why do they play the sick role? Because they are starved for and are strenuously seeking attention and sympathy. But these motivations, embedded in psychological distress, are generally sub-conscious.
However, FD and malingering can sometimes overlap. External incentives may not drive the initial make-believe illness, but can follow once the person realizes that there are material benefits to be gained.
FD is also a different kettle of fish from garden-variety malingering in that people not only feign illness but go to extreme and bizarre lengths to do so.
The things they do
People with FD engage in a wide variety of ruses and stratagems in order to arouse concern and gain sympathy from their family and from doctors and nurses. For instance, they may:
» Fabricate an extensive medical history to narrate to the doctor
» Pretend to have physical symptoms – for example, claiming to have chest pain or head-splitting migraines.
» Pretend to have psychological symptoms – for example, claiming to hear voices or claiming to see things that aren’t really there
» Actively try to get ill – for instance, by taking something to cause themselves to vomit; deliberately infecting a wound by rubbing dirt into it, injecting faeces into their veins to induce sepsis, eating rotting food to perforate the bowels
» Divert all attention to themselves in the emergency room by dramatic enactments such as faking sustained seizures.
» Fake test results by, for instance, adding blood, a food dye or some other substance to their urine, which will cause the urine to get tinted red, blue, green or some other colour, and have their doctor scrambling around to investigate them for a whole range of possible ailments from kidney stones to enlarged prostate to cancer to pseudomonas to a metabolic disorder, to an inherited condition like familial hypercalcemia.
Persons with factitious disorder can end up doing things and creating symptoms that are off-the-wall, such as non-healing wounds caused by mouthwash, and self-inserted needles in finger joints. Which is why the disorder has shown up in almost every medical drama on TV. In Grey’s Anatomy, a patient of FD is also a medical professional with a degree in neuropharmacology, and she knows exactly what drugs and other substances she needs to take to induce the symptoms of ventricular arrhythmia.
It is interesting that, in real life, too, it has been documented that many people with FD work in the healthcare field. Even those with FD who are not doctors are often very knowledgeable about the symptoms they are trying to pass off as real. The Internet has played a decided role here. In fact, one contemporary version of FD is called “Münchausen by Internet” in which people with FD feign illness online, using Internet-based patient support groups to fulfil their need to “be sick”. They are known as “sickness bloggers”, and Münchausen by Internet is now a recognised medical condition.
While factitious disorder can occur as a single episode, more commonly people with this disorder make repeated doctor visits, undergo a number of tests and procedures, and may even be hospitalized several times – sometimes under a variety of aliases.
For those who are living with FD, the consequences can be much more severe than a scathing tongue-lashing from a doctor who sees what’s going on.
Some of them can be harmed by unnecessary medical procedures such as lumbar puncture (spinal tap). They may put themselves at risk for serious injury or even death, and may sometimes have to be institutionalized for their own protection. In one study that followed 20 persons with the disorder, four of them died because of behaviour related to the disorder.
On a different level, they can find themselves bankrupted by medical bills and by enforced leave of absence from work.
Diagnosis can be tricky
Diagnosing the disorder involves a tricky balance: obviously, doctors don’t want to perform risky procedures on people who don’t need them -- but they also don’t want to withhold them from people who do. So, it’s complicated. But there are certain clues that can help detect a case of FD. They include:
» A dramatic or atypical presentation of symptoms by the person
» A description of symptoms that sounds like an extract from a medical textbook
» Employment or education in a medically-related field
» Arrival at the Emergency Department on a day when experienced staff are less likely to be present – for instance, on a Sunday or a public holiday
» An overly-long medical record, with multiple admissions in a stream of hospitals in different localities, sometimes in different cities
» Inconsistent findings in the course of clinical examination or diagnostic checks. For instance, a person may report persistent vomiting and diarrhoea, but show no signs of dehydration; or, a person may report paralysis of a limb, but may show normal muscle tone in the affected limb
» Symptoms or behaviours that are present only when the person is aware of being observed
» Multiple surgical scars, reflecting numerous exploratory surgical procedures
» Calm acceptance of the discomfort and risks of diagnostic procedures and / or of high-risk surgery
» Inconsistencies between the medical history provided by the person and the findings from tests
» The fact that the pattern of symptoms does not match a known syndrome or diagnostic category. For instance, a person feigning the manic phase of bipolar disorder may display the euphoric mood and the rapid speech that are well-known characteristics of this phase, but may not have the sleep disruption which also typifies this phase.
» The rapid development of complications or of a new set of symptoms if the initial tests show up negative.
» Persistent hostile, defensive, disruptive or attention-seeking behaviour during hospitalization.
Is this a treatable disorder?
Not much is known as yet about the roots of factitious disorder, which would be the first step towards laying down a therapy protocol. One school of thinking is that it is rooted in childhood deprivation or trauma, leading to a pathological need to assume the sick role as a way of getting the attention and sympathy that will bandage the emotional wounds. But early trauma is not easy to verify.
Most persons with this disorder have normal to high IQ, but the majority have also been found to suffer from one or other of the personality disorders. In the most extreme cases, this takes the form of what is colloquially called sociopathy – formally known as anti-social personality disorder. The hallmark of this disorder is a pervasive pattern of disregard for and a violation of the rights of others. Its characteristics include deceitfulness, manipulation, predatory behaviour and a lack of remorse.
FD can be impossible to treat if a person refuses to acknowledge the deception in the first place, let alone see a mental-health professional. Confronting him with the allegation that he is faking his illness appears to be counter-productive. He will rarely acknowledge it; more likely, he will simply go off to another doctor or medical facility.
The best approach seems to be to offer an alternative that will encourage the person to seek psychological help without having to admit that he faked his symptoms. He would be told that, while the doctors work on his condition, a psychologist might also help him get better. That way, his therapist can work with him on understanding the underlying distress that caused him to seek the “sick role” in the first place. Psychotherapy, a type of counselling, is the primary treatment for FD. It focuses on changing the thinking and behaviour of the person so as to reduce the felt need to fake symptoms of illness.
Concurrently, it is also helpful for family members to be counselled so that they understand the illness and the motivations underlying it, and also the importance of not rewarding or reinforcing deceitful behaviour by the person with the disorder.
There are no medications to treat factitious disorder, but medications may be prescribed to treat anxiety, depression or the symptoms of personality disorder if such disorder has been diagnosed.
(The author is a former editor of 'Health & Nutrition' magazine, and now works as a counseling therapist)