Biology 202
2004 Second Web Paper
On Serendip

You don your white overcoat and grab a stethoscope, expecting to conduct a routine examination. Your young, female patient enumerates a variety of complaints including painful swelling over her right breast. You notice multiple scars on her torso, question her about her medical history, and learn that "she has a history of similar recurrent swellings over the abdominal wall, which needed repeated surgical drainage on about 20 occasions". Her problem had started at the age of 17 when she was first diagnosed with immune deficiency. Soon after medication was administered, she developed symptoms suggestive of deep vein thrombosis in one leg. Since medication was given under supervision, she was thought to have developed a resistance to the drug. "She soon complained of bilateral painful swellings associated with weakness of the lower limbs and consistent with bilateral femoral nerve palsy and hematoma. Surgical evacuation was rapidly carried out but recurrent abscesses remained a problem." The list continues, each item more spectacular than the last. And yet, the cause of her illness remains undiagnosed. Baffled and confused you consult your fellow doctors and order a battery of tests, determined to detect the cause. Would it ever occur to you that your patient is really a pretender? In his case report(2)summarized above, Aamer Aleem, a doctor in the UK, illustrates a typical scenario a Munchausen patient presents.

Munchausen Syndrome is an extremely disturbing medical condition-often going undetected for decades. Not to be confused with hypochondriacs who experience physical symptoms of illnesses and visit doctors truly believing they are ill (4), those with Munchausen's make "capitalizing on, exploiting, exaggerating or feigning illness, injury, or personal misfortune"(1). a habit in order to gain the attention they feel cannot be gained by any other means. Named after a German soldier renowned for exaggerated tales, the disease is deemed a factitious disorder, and is predominant in females (71% of cases).(5). The disorder is relatively rare and incredibly difficult to treat. Awareness and early detection are crucial factors. Those afflicted with Munchausen Syndrome rely on the fact that a doctor will trust history and symptoms reported in order to fabricate an intricate web of deception.

Aleem's report continues to illustrate the difficulties faced by the medical community in properly diagnosing and treating the disorder. Although routine questioning reveals that her mother had suffered from breast cancer and that no near relatives were involved in the medical field, "suspicion is raised regarding a possible factitious nature of her problem because of an inability to explain the cause of her abscesses and the growth of multiple organisms from the lesions"(2). A high level of suspicion is required to detect Munchausen, and doctors need to be on the look out for one of these essential features: "pathologic lying (pseudologia fantastica), peregrination, and recurrent, feigned or simulated illness"(2). Supporting features include borderline and/or antisocial personality traits, deprivation in childhood, knowledge/experience in the medical field, multiple hospitalizations, and multiple scars coupled with an unusual or dramatic presentation.(2)

Ironically, those with Munchausen Syndrome really are sick, yet they rarely seek the right kind of medical advice. When confronted, they vehemently deny any claims and ingenuity is required to catch them. In this student's case, a psychiatric consultation was conducted (without giving the patient any hints about the suspected factitious disorder) during which she was judged very defensive and conflicted when responding. Soon after, when the patient was not in bed, the nurses found a syringe full of fecal material along with needles-the source behind the mysterious swelling and cultures. When the patient returned, she was informed and became very hostile. Finally, against medical advice, she left the hospital and was lost to follow-up(2).

In researching this intriguing disease, I was struck with the realization that Munchausen's highlights many issues of neurobiological importance. It is very much an extension of the mind-body riddle for within the seemingly physical nature of the victims' symptoms, there lies a neurological cause. What is it that any individual could possibly gain by harming themself? Research suggests that women who have led emotionally deprived childhoods and who may themselves have been physically abused or even victims of Munchausen's, are the most likely to be afflicted. Presenting oneself as a false victim is very much a Munchausen trait. Often suffering from "narcissistic tendencies, low self-esteem, and a fragile ego"(1), they crave the attention and sympathy a grave illness or seriously ill child, immediately elicits. Sufferers also relish the status of power and control that accompanies being the only person who "knows" while an intellectual medical community remains baffled. The real question remains-do they knowingly deceive, or are they themselves deceived?

A related disease, Munchausen Syndrome by Proxy (MSBP) is illuminating because in this case, the victim is not the MSBP sufferer. In fact, in this more dangerous variation of the disease, it is usually a very young child who will be targeted. Often the MSBP sufferer will assume a caregiver role, working as a nurse, perhaps in a ward for sick children or in a home for the elderly, or with severely handicapped people-"the common thread is a victim who is vulnerable, whose verbal skills or emotional state or mental condition prevents them from explaining what the MSBP person is doing to them and whose hold on life may already be precarious"(1). It has been estimated that one in five cot deaths (SIDS) is really a murder resulting from a mother with MSBP (1). Sufferers become adept at inflicting harm upon others in a manner that leaves little or no forensic evidence. Methods employed include restricting breathing by 'placing a hand over the mouth, lying on top of the baby, smothering, placing plastic or cling film over the person's face, withholding food and medicine, over-medicating or medicating when unnecessary, or delaying calling for medical assistance when an emergency arises". Then "when the victim reacts with a fit, breathing difficulties, collapse, etc the MSBP sufferer can-after ensuring the condition is sufficiently life-threatening-rush to the rescue and later be hailed as a hero for being such a wonderful, kind, caring, compassionate person for having saved this person's life" (1). Sadly MSBP is rarely suspected because very often the abuser appears to be an ideal caretaker-attentive, knowledgeable about their child's condition, and extremely interested in the medical field.

In closing, the calculative mentality needed to perpetrate a crime on a child in order to elicit sympathy suggests that the perpetrator is "conscious" of their actions. It is clear that premeditation is needed to research medical data and falsify symptoms, all the while outwardly placing oneself in a sorrowful situation. However many symptoms reveal a psychiatric origin. Those with Munchausen illustrate how very fine the distinction between pleasure and pain really is. Often they exhibit sadistic/masochistic behaviors exploiting their victim's pain for their own pleasure. Must the I-function be involved, or is this behavior pathological and uncontrollable? These are questions that remain to be grappled with within the medical and legal community. The debate over deliberate child abuse vs. psychological disorder remains unresolved. Coupled with the needs for early detection and appropriate treatment, these issues remain a priority.

References

1Bully Online, A detailed report on the two syndromes.

2)Case Report:Munchausen Syndrome, A very comprehensive case report and review of literature surround Munchausen.

3 The Merck Manual Site on Psychiatry in Medicine,

4Page Wise,gives overview of syndrome.

5)WebMD,Article by Daniel DeNoon entitled "Some Kids Cry Out in the Language of Illness"

6)Village Voice,Cybersickness: Article on Munchausen and the Internet

7)Feldman, Marc, MD. Munchausen by Internet, Southern Medical Journal. Vol. 93, No. 7, July 200.


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