R. YASSA, M.D.
Munchausen's syndrome: A successfully treated case ABSTRACT: A case history of a 33-year-old woman with a diagnosis of Munchausen's syndrome is presented with a review of the literature about this bizarre syndrome. We recommend that patients so diagnosed be committed to mental hospitals and treated in a structured program combining behavior modification and dynamic therapy, which proved to be an effective tool in the patient we describe. We believe this form of treatment is warranted because patients incur heavy expenses and lose many work hours when treated as outpatients for this otherwise intractable condition.
There is a group of patients who, despite neither medical nor surgical need, wander from hospital to hospital, and are admitted with what appears to be an acute illness that is supported by a plausible, dramatic, and often elaborate history. Because the history turns out to be untrue, these patients are usually discharged, often against medical advice. Their condition is called Munchausen's syndrome, a term coined by R. Asher in 1951,1 who named it after Baron von MOnchausen (1720-1797), a retired German cavalry officer. The baron related fantastic anecdotes very similar to those that are told by these extraordinary patients.
Since Asher, however, this condition has been called by many other names: peregrinating problem patients2 ; hospital hoboes3 ; chronic factitious illness4; and hospital addiction syndrome.s All these designations are unfortunate because they do not indicate the nature of the patients' illness, but rather the anger these patients tend to provoke in many of the physicians who treat them. Manifestations Asher described three main types of patients with this syndrome: the acute abdominal type; the hemorrhagic type; and the neurologic type. To these were subsequently
added the cutaneous type2; and the cardiac and endocrinologic typeS.6 Few of these patients have been examined by a psychiatrist because they do not stay in the hospital long enough and because it usually takes a long time for a physician to determine that they really need psychiatric care, by which time they may have left the hospital. When these patients are examined, however, diagnoses have ranged from schizophrenia2,7,8 to other psychoses7; hysteria2,7.9,IO to psychopathic personality. 1.8.1 1,12 Case history This is a case history of a patient with this fortunately rare, usually intractable syndrome, whom we treated successfully, using a behavioral-dynamic approach. A 33-year-old female who had been a patient in our hospital almost continuously from 1963 until her discharge in 1975, had a long history of provocative behavior, including hysterical fainting spells, fire-setting, and what was described as "atypical epileptic fits." As a PSYCHOSOMATICS
result, the patient was confined in a structured environment and treated by operant conditioning, which gradually helped to control her behavior. Subsequently, a number of new symptoms appeared: headaches, "gallbladder aching," pain on micturition (with no evidence of infection), and nosebleeds. On a few occasions, the woman was caught picking at her nose or putting substances into her urethra and subsequently bleeding or complaining of pain. Repeated laboratory tests and cholecystograms were performed, but all were negative. Although she was in a locked ward, she still managed to escape from the hospital. Every time she escaped, a symptom "developed" and she went to another hospital: abdominal pain, fainting, "gallbladder abdominal-type pain," and symptoms of urinary tract infection. On two different occasions, she was actually admitted under a fictitious name to the same hospital, and had four operations performed, all with no positive findings. In a few instances, she ran away to a different province but soon was discovered and sent back to our hospital. This patient was hospitalized over a period of 12 years, and accumulated 44 accident reports, 27 unauthorized leaves from the hospital, and 30 consultations, mostly for symptoms simulating diseases of the gallbladder and urinary tract. She was diagnosed as having a hysterical neurosis. Discussion Treatment of this intractable condition has varied throughout the years, and has ranged from blacklisting lO,13 to hypnosis;4 to insulin coma and group therapy,1S to supAPRIL 1978 • VOL 19· NO 4
portive therapy}6 Most of the treatment modalities indicate the frustration that the physician usually feels when treating these patients. The only definite conclusion each one individually has reached is to commit them to mental hospitals. We decided to try a dynamic behavior modification program with this patient. We used a system that reinforced positive attributes by rewarding acceptable social behavior with approval and praise. A list of unwanted symptoms such as pains, acting-out behavior, "epileptic fits," and passive-aggressive behavior was negatively reinforced by denying privileges. To accomplish this, a weekly one-hour session was organized with the author and a social worker on the ward. Day-to-day problems were discussed and the patient was allowed to express her frustrations. A focus on future plans and constructive use of time were the main themes of the therapy. During this period she was given supportive psychotherapy in 30-minute sessions once a week and encouraged to work, which was also rewarded with approval, praise, and money. To lessen the possibility of sabotage, one particular nurse was assigned to the patient for specific problems. The program lasted three years. Over a period of one year the patient improved gradually, during which time testing and acting-out occurred frequently. In our weekly sessions the patient was frequently confronted by me or by the nurse in charge, with her acting-out behavior. She began working in the ward
and gradually moved to work in other areas of the hospital, eventually maintaining a steady job for two years, without missing a day of work. The patient was discharged from the hospital two years ago. Since then, she has been doing very well outside. Only once has she been to a nearby hospital for symptoms of abdominal pain of a fictitious nature. She later mentioned that she just needed to see a physician to discuss some domestic problems. To our knowledge, this was her last visit to a hospital. 0
REFERENCES 1. Asher R: Munchausen's syndrome. Lancet 1:339, 1951. 2. Chapman JS: Peregrinating problem pa· tients-Munchausen's syndrome. JAMA 165:927, 1957. 3. Clarke EJ, Melnicke SC: Munchausen's syn· drome or the problem of hospital hoboes. Am J Mad 25:6,1958. 4. Spiro H: Chronic factitious illness. Arch Gen Psychiatry 18:569, 1968. 5. Barker JC: The syndrome of hospital addiction (Munchausen's syndrome). J Ment Sci 108:167, 1962. 6. Gorman CA, Wahner HW, Tauxe WN: Meta· bolic malingerers. Patients who deliberately induce or perpetuate a hyperrnetabolic or hypometabolic state. Am J Med 48:708, 1970. 7. Petersdorf AC, Bennett IL Jr: Factitious lever. AnnlntemMed46:1039,1957. 8. Vail OJ: Munchausen returns. Psychiat Ouart 38:317, 1967. 9. Herndon AF: Non-peregrinating hysteria of Munchausen. 11/ Mad J 116:25, 1959. 10. Williams CG: Peripatetic pseudoporphyria: A report of a case. N Engl J Med 264:925. 1961. 11. Small A: Munchausen's syndrome. 8r Med J 2:1207,1955. 12. Bursten B: On Munchausen's syndrome. Arch Gen Psychiatry 13:261, t 965. 13. Gattenby PBB: A case of Munchausen's syndrome. J Irish Moo Ass 30: t 02, t 952. 14. Salinger S: A case of malignant recurring nasal haemorrhage of undetermined etiology. Ann Otol53:583, 1944. 15. Brody S: Value of group psychotherapy in patients with poly-surgery addiction. Psychiat Ouart 33:260,1959. 16. Shaw AS: Pathologic malingering. N Engl J Med271:22,1964.
Dr. Yassa is coordinator of undergraduate education, Douglas Hospital Centre, Verdun, Canada. Reprint requests to Dr. Yassa, 6875 LA Salle Blvd., Verdun H 4H I R3, Quebec, Canada. 243
Munchausen's syndrome: A successfully treated case ABSTRACT: A case history of a 33-year-old woman with a diagnosis of Munchausen's syndrome is presented with a review of the literature about this bizarre syndrome. We recommend that patients so diagnosed be committed to mental hospitals and treated in a structured program combining behavior modification and dynamic therapy, which proved to be an effective tool in the patient we describe. We believe this form of treatment is warranted because patients incur heavy expenses and lose many work hours when treated as outpatients for this otherwise intractable condition.
There is a group of patients who, despite neither medical nor surgical need, wander from hospital to hospital, and are admitted with what appears to be an acute illness that is supported by a plausible, dramatic, and often elaborate history. Because the history turns out to be untrue, these patients are usually discharged, often against medical advice. Their condition is called Munchausen's syndrome, a term coined by R. Asher in 1951,1 who named it after Baron von MOnchausen (1720-1797), a retired German cavalry officer. The baron related fantastic anecdotes very similar to those that are told by these extraordinary patients.
Since Asher, however, this condition has been called by many other names: peregrinating problem patients2 ; hospital hoboes3 ; chronic factitious illness4; and hospital addiction syndrome.s All these designations are unfortunate because they do not indicate the nature of the patients' illness, but rather the anger these patients tend to provoke in many of the physicians who treat them. Manifestations Asher described three main types of patients with this syndrome: the acute abdominal type; the hemorrhagic type; and the neurologic type. To these were subsequently
added the cutaneous type2; and the cardiac and endocrinologic typeS.6 Few of these patients have been examined by a psychiatrist because they do not stay in the hospital long enough and because it usually takes a long time for a physician to determine that they really need psychiatric care, by which time they may have left the hospital. When these patients are examined, however, diagnoses have ranged from schizophrenia2,7,8 to other psychoses7; hysteria2,7.9,IO to psychopathic personality. 1.8.1 1,12 Case history This is a case history of a patient with this fortunately rare, usually intractable syndrome, whom we treated successfully, using a behavioral-dynamic approach. A 33-year-old female who had been a patient in our hospital almost continuously from 1963 until her discharge in 1975, had a long history of provocative behavior, including hysterical fainting spells, fire-setting, and what was described as "atypical epileptic fits." As a PSYCHOSOMATICS
result, the patient was confined in a structured environment and treated by operant conditioning, which gradually helped to control her behavior. Subsequently, a number of new symptoms appeared: headaches, "gallbladder aching," pain on micturition (with no evidence of infection), and nosebleeds. On a few occasions, the woman was caught picking at her nose or putting substances into her urethra and subsequently bleeding or complaining of pain. Repeated laboratory tests and cholecystograms were performed, but all were negative. Although she was in a locked ward, she still managed to escape from the hospital. Every time she escaped, a symptom "developed" and she went to another hospital: abdominal pain, fainting, "gallbladder abdominal-type pain," and symptoms of urinary tract infection. On two different occasions, she was actually admitted under a fictitious name to the same hospital, and had four operations performed, all with no positive findings. In a few instances, she ran away to a different province but soon was discovered and sent back to our hospital. This patient was hospitalized over a period of 12 years, and accumulated 44 accident reports, 27 unauthorized leaves from the hospital, and 30 consultations, mostly for symptoms simulating diseases of the gallbladder and urinary tract. She was diagnosed as having a hysterical neurosis. Discussion Treatment of this intractable condition has varied throughout the years, and has ranged from blacklisting lO,13 to hypnosis;4 to insulin coma and group therapy,1S to supAPRIL 1978 • VOL 19· NO 4
portive therapy}6 Most of the treatment modalities indicate the frustration that the physician usually feels when treating these patients. The only definite conclusion each one individually has reached is to commit them to mental hospitals. We decided to try a dynamic behavior modification program with this patient. We used a system that reinforced positive attributes by rewarding acceptable social behavior with approval and praise. A list of unwanted symptoms such as pains, acting-out behavior, "epileptic fits," and passive-aggressive behavior was negatively reinforced by denying privileges. To accomplish this, a weekly one-hour session was organized with the author and a social worker on the ward. Day-to-day problems were discussed and the patient was allowed to express her frustrations. A focus on future plans and constructive use of time were the main themes of the therapy. During this period she was given supportive psychotherapy in 30-minute sessions once a week and encouraged to work, which was also rewarded with approval, praise, and money. To lessen the possibility of sabotage, one particular nurse was assigned to the patient for specific problems. The program lasted three years. Over a period of one year the patient improved gradually, during which time testing and acting-out occurred frequently. In our weekly sessions the patient was frequently confronted by me or by the nurse in charge, with her acting-out behavior. She began working in the ward
and gradually moved to work in other areas of the hospital, eventually maintaining a steady job for two years, without missing a day of work. The patient was discharged from the hospital two years ago. Since then, she has been doing very well outside. Only once has she been to a nearby hospital for symptoms of abdominal pain of a fictitious nature. She later mentioned that she just needed to see a physician to discuss some domestic problems. To our knowledge, this was her last visit to a hospital. 0
REFERENCES 1. Asher R: Munchausen's syndrome. Lancet 1:339, 1951. 2. Chapman JS: Peregrinating problem pa· tients-Munchausen's syndrome. JAMA 165:927, 1957. 3. Clarke EJ, Melnicke SC: Munchausen's syn· drome or the problem of hospital hoboes. Am J Mad 25:6,1958. 4. Spiro H: Chronic factitious illness. Arch Gen Psychiatry 18:569, 1968. 5. Barker JC: The syndrome of hospital addiction (Munchausen's syndrome). J Ment Sci 108:167, 1962. 6. Gorman CA, Wahner HW, Tauxe WN: Meta· bolic malingerers. Patients who deliberately induce or perpetuate a hyperrnetabolic or hypometabolic state. Am J Med 48:708, 1970. 7. Petersdorf AC, Bennett IL Jr: Factitious lever. AnnlntemMed46:1039,1957. 8. Vail OJ: Munchausen returns. Psychiat Ouart 38:317, 1967. 9. Herndon AF: Non-peregrinating hysteria of Munchausen. 11/ Mad J 116:25, 1959. 10. Williams CG: Peripatetic pseudoporphyria: A report of a case. N Engl J Med 264:925. 1961. 11. Small A: Munchausen's syndrome. 8r Med J 2:1207,1955. 12. Bursten B: On Munchausen's syndrome. Arch Gen Psychiatry 13:261, t 965. 13. Gattenby PBB: A case of Munchausen's syndrome. J Irish Moo Ass 30: t 02, t 952. 14. Salinger S: A case of malignant recurring nasal haemorrhage of undetermined etiology. Ann Otol53:583, 1944. 15. Brody S: Value of group psychotherapy in patients with poly-surgery addiction. Psychiat Ouart 33:260,1959. 16. Shaw AS: Pathologic malingering. N Engl J Med271:22,1964.
Dr. Yassa is coordinator of undergraduate education, Douglas Hospital Centre, Verdun, Canada. Reprint requests to Dr. Yassa, 6875 LA Salle Blvd., Verdun H 4H I R3, Quebec, Canada. 243
