Il
C A S E REPORT
M u n c h a u s e n ' s S y n d r o m e : A n Unusual C a s e R O B E R T
J A M I E S O N , M
H O W A R D
Unlike
most
Munchausen
as a psychiatric, was
possible
as well to engage
It was found, simulate
also,
M.D.f
R O B A C K ,
P H . D . J
Miss
A.
was
as a medical-surgical, her
that Miss
a neurological
cholinergic
patients,
in therapy A. had
disorder
used
eye
had
willing
patient.
in which
and
D.*
M c K E E ,
E M B R Y
to define
to dilate
accidentally
could
it occur.
her pupils
induced
Tenn.
herself
Consequently,
observation
drops,
Nashville,
an
to anti-
delirium.
Munchausen's syndrome is defined as a chronic, factitious illness i n w h i c h patients consciously distort their histories and produce misleading physical a n d / o r laboratory findings for the purposes of deception. Such patients often come to the emergency r o o m late at n i g h t or on weekends, w h e n less experienced physicians are on d u t y . Because they possess a r i c h f u n d of medical i n f o r m a t i o n , they usually present a plausible history w i t h convincing symptoms. 1
2
I f a d m i t t e d to the hospital, these patients are d e m a n d i n g of attention a n d / o r medication. A n g e r increases along w i t h complaints about the treatment received. Patients discovered to be imposters and confronted w i t h t h e i r f r a u d u l e n t behavior usually become i n d i g n a n t and sign out against medical advice or are a n g r i l y discharged by physicians. 3
* C o - c h i e f resident i n P s y c h i a t r y , D e p a r t m e n t of P s y c h i a t r y at V a n d e r b i l t U n i v e r s i t y School of M e d i c i n e . t Associate Professor, D e p a r t m e n t of P s y c h i a t r y at V a n d e r b i l t U n i v e r s i t y School of M e d i cine. ^Professor of P s y c h i a t r y ( P s y c h o l o g y ) at V a n d e r b i l t U n i v e r s i t y School of M e d i c i n e . address: 37232. AMERICAN
616
Mailing
D e p a r t m e n t of P s y c h i a t r y , V a n d e r b i l t U n i v e r s i t y School of M e d i c i n e , N a s h v i l l e , T e n n .
JOURNAL
OF PSYCHOTHERAPY,
Vol.
X X X I I I ,
No.
4,
October
1979
M U N C H A U S E N ' S
S Y N D R O M E
617
T h e patients' involvement w i t h physicians and hospitals does not appear to encompass psychiatrists and psychiatric centers. T h e y define themselves as medical patients and eschew the role of psychiatric patients. Articles describing psychiatric treatment w i t h M u n c h a u s e n patients are rare. T h e psychodynamics of the syndrome r e m a i n unclear. F o r example, B u r s t e n concluded a paper by stating, " W e have never successfully treated a patient w i t h M u n c h a u s e n Syndrome, nor do we k n o w anyone w h o has." A c l i n i c a l l y innovative approach was proposed by H o l l e n d e r and H e r s h w h o stated that a psychiatrist i n dealing w i t h these patients is often forced into the position of being both a confronter and a therapist, or a prosecutor and a helper. I t was their contention that psychiatrists w h o f u n c t i o n i n these dual roles are u n l i k e l y to be accepted as an a l l y by the patient. T h u s , they suggested s p l i t t i n g the roles, w i t h the p r i m a r y physician being the confronter and the psychiatrist the helper. 3
4
T h e patient to be presented here is u n u s u a l i n that she sought the identity of a psychiatric, as w e l l as a medical-surgical, patient. She presented w i t h both organic and f u n c t i o n a l symptoms and a treatment v a r i a n t of the H o l l e n d e r - H e r s h approach was u t i l i z e d .
C L I N I C A L REPORT Miss A., a 28-year-old, licensed practical nurse, appeared at the emergency room of a university hospital late one evening. She reported that one-half hour after taking two Sominex tablets she experienced both visual (long black snakes coming out of faucets, and laughing faces in cups of coffee) and auditory (voices telling her how horrible her life situation was) hallucinations. I n addition, she had dilated pupils. She was disoriented for time, place and person. She was wearing a neck brace and a left forearm cast, claiming to have broken her left radius and to have sprained her neck in a car accident resulting from an unidentified man's attempt to force her off the interstate. (During subsequent interviews, she reported that her ulna was fractured, later the radius and ulna and still later the radius, ulna and metacarpals). X-rays of the left forearm revealed no evidence of fractures, and a check with the police revealed no record of a car accident. Both pupils remained dilated and fixed following the administration of 1% pilocarpine eye drops. Based on the history and physical findings, the medicine and neurosurgery residents concluded that the patient was delirious. A perusal of the patient's hospital folder revealed six previous hospitalizations over a five-year period. The first four hospitalizations were for investigation of a seizure disorder. Porphobilinogens, coproporphyrins, uroporphyrins, urine protein electrophoresis, brain scan, 17-hydroxysteroids, 17-hydroxyketosteriods, P B I , E E G , and skull films were within normal limits. No evidence was found for Addison disease, polycystic disease or hypoadrenalism. The patient was described as a hysterical personality. Miss A. entered the psychiatric system when she and her husband sought marital
618
A M E R I C A N
J O U R N A L
OF
P S Y C H O T H E R A P Y
therapy. However, her husband terminated treatment prematurely and left the state. Miss A. then became increasingly depressed with suicidal ideation and was referred to D r . E . M . She was hospitalized on a psychiatric inpatient unit on two occasions for severe depression. Each hospitalization was for approximately six weeks, and each was followed by outpatient care. Prior to and while under psychiatric care, Miss A. made numerous emergencyroom visits. On one such occasion, she presented with a number of superficial lacerations on her face and reported that she had been sexually attacked by a 6'11" man. Examination for spermatozoa was negative. The patient claimed that the attacker had poured bleach into her eyes; she later changed this story to 2 or 3 attackers. She also stated that she scratched and fought with them—but her nails were long, unbroken and clean. Miss A.'s chart revealed that she had also been seen as an outpatient and inpatient in most hospitals in Nashville as well as in other cities (including Atlanta, M i a m i , and Minneapolis) for similar complaints. She had consulted numerous physicians including ophthamologists, internists, endocrinologists, orthopedic surgeons, neurosurgeons, and psychiatrists. Based on the records and recent psychiatric findings, the diagnosis of borderline personality with chronic factitious illness was made. Family
and Social
History
Miss A. was an only child of an academic family. Materially her early life was comfortable. She had many friends, and she had attended private schools. Her parents' 32-year marriage was described as "an ideal one" although it ultimately ended in divorce. T w o days following the divorce, her father remarried a young woman with a remarkable resemblance to Miss A. Before the divorce, the patient described the relationship with her father as being "very close." After the divorce, she refused to see him for one year and invited him to her wedding only on the condition that he come without his new wife. Her mother had always treated her as a child, but she reported having grown closer to her mother since the divorce. There was no history of psychiatric illness in the family. Miss A. related that her first sexual experience occurred at age 18, when she was raped four times by two men. She stated that there were no other sexual contacts prior to her marriage at the age of 22. Her husband had been divorced two months prior to their marriage. He was described as being very patient with her and not making sexual demands. She thought their sexual relationship was healthy until he had a psychotic episode three years after the marriage. Then, according to the patient, he began to demand more and more information about her previous rape experience, and he would awaken her in the middle of the night demanding to have sexual relations. He would also tie her down and, according to the patient, attempt to reenact the rape scene. He refused to be seen in individual psychotherapy but was willing to enter marital therapy. As noted earlier, he ultimately fled treatment and was divorced by Miss A. Miss A. met her present manfriend one year after her divorce. She described this relationship as friendly with no sexual overtones. She did not tell him about her prior experiences with men. He was divorced and had no children. He periodically
M U N C H A U S E N ' S
S Y N D R O M E
619
moved into her apartment, staying with her for a week at a time but in separate bedrooms. His main attribute as far as she was concerned was that he was not sexually demanding, although he had recently asked her to obtain an I U D . Hospital
Course
Miss A. was admitted to the psychiatric service from the emergency room for evaluation of her dilated pupils and treatment of her Munchausen's syndrome. The dilated and fixed pupils brought up the possibility of an accidental atropine overdose from the use of mydriatic eye drops. Miss A. probably intended to simulate a neurological condition much as she had at other hospital visits. Such an overdose, producing an anticholinergic delirium, would explain her auditory and visual hallucinations. The right pupil was fixed and 9 mm; her left pupil was mildly reactive and 7 mm. A urine drug screen was negative. A n Adie's pupil was ruled out by normal reflexes. T w o bottles of a short-acting mydriatic (Mydriacyl) were found in the patient's hospital room. The treatment variation of the Hollender-Hersh technique 4 for patients with factitious disorders consisted of one psychiatrist ( E . M . ) being the helper and a second psychiatrist (R.J.) being the confronter. Both therapists met with Miss A. daily to establish rapport before D r . R. J . confronted her with the fact that she had self-administered mydriatic drops. She was told that a dilated pupil not responding to pilocarpine could only be caused by eye drops. After initial denial, she soon broke into tears and acknowledged that she had used them. Five days following the discontinuation of the eye drops her pupils were equally round, reactive to light and accommodated normally. She continued, however, to complain of visual hallucinations throughout the remainder of the hospitalization. Following the initial confrontation, Miss A. became severely depressed and was considered suicidal. When she recovered from the depression, she was confronted with the fact that there was no radiological evidence for a fracture or a neck injury. She became very upset and screamed that there was also no evidence for any rapes or car accidents in the past. She accused D r . R. J . of enjoying the confrontation. T w o days prior to discharge, her lack of motivation to change was discussed. A meeting of the patient, her mother, and both therapists was held prior to discharge, and arrangements were made for her to live with her mother until she could secure employment. Miss A. was seen regularly by both therapists for four months until she left the city to take a new job. Follow-up with both the patient and her mother one and one-half years after discharge revealed that she was functioning socially and professionally without the need for further psychiatric or medical treatment. She expressed satisfaction over her present life style and verbalized positive feelings about herself. She also acknowledged again her role in the production of her factitious symptoms but reported no longer feeling compelled to produce them. However, approximately two years later, the patient contacted one of the author's claiming she was in town and "wanted to say hello." During the meeting, Miss A. "confessed" that after leaving the city two years previously she immediately started producing her symptoms again
620
A M E R I C A N
J O U R N A L
O F
P S Y C H O T H E R A P Y
and that no physician whom she had contacted wanted to have her as his patient. Thus, she hoped that D r . E. M . would help her locate a physician who would be willing to "treat" her.
COMMENT M i s s A . fulfills the three c r i t e r i a described by Bürsten for the diagnosis of M u n c h a u s e n ' s syndrome. H e r presentation was d r a m a t i c , her symptoms escalated i n numbers a n d complexity w i t h each r e t e l l i n g (pseudologia fantastica), a n d she traveled f r o m hospital to hospital a n d f r o m city to city seeking medical attention. T h e d e l i r i u m itself, complete w i t h both a u d i t o r y and visual hallucinations was secondary to the accumulated effects of four anticholinergic drugs: M y d r i a c y l (short-acting m y d r i a t i c ) , c h l o r p r o m a z i n e , a m i t r i p t y l i n e , a n d Sominex (scopolamine). W i n s l o w stated that an a t r o pine-induced dilated p u p i l can be differentiated f r o m a neurologically dilated p u p i l by a p p l y i n g t w o or three drops of 1 % pilocarpine (a p a r a s y m p a t h o m i metic agent acting directly o n the postganglionic fibers of the p a r a s y m p a thetic nerve endings of the iris a n d c i l i a r y body) w h i c h w i l l constrict a neurologically dilated p u p i l w i t h i n ten to fifteen minutes b u t has no effect o n an atropine dilated p u p i l . 3
5
6
I t is t e m p t i n g to speculate on M i s s A . ' s vascillation between caregiver ( L P N ) a n d care-receiver (patient role). G r a m m e r et a l discussed the identification problems of nurses whose professional role often prevents t h e m f r o m meeting their o w n n o r m a l dependency cravings. Also, the patient's view of sexuality as dangerous b u t fascinating m a y have played a p a r t i n her M u n c h a u s e n ' s syndrome. 7
Because of the patient's fragile psychological state, D r . E. M . ' s approach was h i g h l y supportive a n d crisis-oriented, a n d he avoided psychodynamic interpretations. D r . R. J . conducted a confrontative approach w i t h i n a n o n a n g r y , nonretaliatory atmosphere, u n l i k e that sometimes presented by physicians w h o challenge these patients. T h u s , the treatment effort was specifically aimed at f o r m i n g a supportive alliance w i t h M i s s A . , strengtheni n g her reality testing, h e l p i n g her overcome day-to-day crises i n an a p p r o p r i a t e m a n n e r , a n d p r o v i d i n g her w i t h sufficient support to reassume a h e l p - g i v i n g rather t h a n help-seeking role. U n d e r no circumstance were her self-destructive (both physical a n d psychological) urges reinforced. I t is difficult to k n o w w h e t h e r the treatment described here for patients w i t h factitious illness w o u l d have been successful i f the patient h a d remained i n treatment for a longer period of t i m e . I t appears to have made an impact over a f o u r - m o n t h period a n d then collapsed w h e n the patient left t o w n ( a n d the treatment agents). T h i s case also indicates the necessity for more objective criteria t h a n merely the patient's self-report i n f o l l o w i n g u p on the treatment effectiveness of a given procedure.
M U N C H A U S E N ' S
621
S Y N D R O M E
SUMMARY U n l i k e most M u n c h a u s e n patients, M i s s A . was w i l l i n g to define herself as a psychiatric, as w e l l as a medical-surgical patient. Consequently, i t was possible to engage her i n a u n i q u e f o r m of psychotherapy i n v o l v i n g t w o therapists: one serving a supportive role and the other being a confronter. P r i o r to admission the patient had used eye drops to dilate her p u p i l s to simulate a neurological disorder w h i c h accidentally induced an a n t i c h o l i n e r gic d e l i r i u m .
REFERENCES 1. S p i r o , H .
C h r o n i c Factitious Illness.
2. C l a r k , E . and M e l n i c k , S . 25:6,
Gen. Psychiatry
18:569, 1968. Am. J.
Med.
1958.
3. Bürsten, B . 4. H o l l e n d e r ,
O n Munchausen's Syndrome. M.
Psychiatry, 5. A M A Drug
a n d H e r s h , S.
Arch.
Impossible
Gen. Psychiatry,
Consultation M a d e
13:261, 1965. Possible.
Arch.
Gen.
2 3 : 3 4 3 , 1970.
Evaluations,
6. W i n s l o w , R . L . 7.
Arch.
T h e M u n c h a u s e n S y n d r o m e or H o s p i t a l Hoboes.
T h i r d E d . , 1977, P S G P u b l i s h i n g C o m p a n y , L i t t l e o n e , M a s s .
A t r o p i n e P u p i l s , i n letters to the editor, JAMA,
C r a m e r , B . , G e r s h b e r g , M . and S t e r n , M .
229:1863,
Malingering, H y s t e r i a , and Physician-Patient Relationship. 2 4 : 5 7 3 , 1971.
1974.
M u n c h a u s e n S y n d r o m e — I t s R e l a t i o n s h i p to Arch.
Gen.
Psychiatry
C A S E REPORT
M u n c h a u s e n ' s S y n d r o m e : A n Unusual C a s e R O B E R T
J A M I E S O N , M
H O W A R D
Unlike
most
Munchausen
as a psychiatric, was
possible
as well to engage
It was found, simulate
also,
M.D.f
R O B A C K ,
P H . D . J
Miss
A.
was
as a medical-surgical, her
that Miss
a neurological
cholinergic
patients,
in therapy A. had
disorder
used
eye
had
willing
patient.
in which
and
D.*
M c K E E ,
E M B R Y
to define
to dilate
accidentally
could
it occur.
her pupils
induced
Tenn.
herself
Consequently,
observation
drops,
Nashville,
an
to anti-
delirium.
Munchausen's syndrome is defined as a chronic, factitious illness i n w h i c h patients consciously distort their histories and produce misleading physical a n d / o r laboratory findings for the purposes of deception. Such patients often come to the emergency r o o m late at n i g h t or on weekends, w h e n less experienced physicians are on d u t y . Because they possess a r i c h f u n d of medical i n f o r m a t i o n , they usually present a plausible history w i t h convincing symptoms. 1
2
I f a d m i t t e d to the hospital, these patients are d e m a n d i n g of attention a n d / o r medication. A n g e r increases along w i t h complaints about the treatment received. Patients discovered to be imposters and confronted w i t h t h e i r f r a u d u l e n t behavior usually become i n d i g n a n t and sign out against medical advice or are a n g r i l y discharged by physicians. 3
* C o - c h i e f resident i n P s y c h i a t r y , D e p a r t m e n t of P s y c h i a t r y at V a n d e r b i l t U n i v e r s i t y School of M e d i c i n e . t Associate Professor, D e p a r t m e n t of P s y c h i a t r y at V a n d e r b i l t U n i v e r s i t y School of M e d i cine. ^Professor of P s y c h i a t r y ( P s y c h o l o g y ) at V a n d e r b i l t U n i v e r s i t y School of M e d i c i n e . address: 37232. AMERICAN
616
Mailing
D e p a r t m e n t of P s y c h i a t r y , V a n d e r b i l t U n i v e r s i t y School of M e d i c i n e , N a s h v i l l e , T e n n .
JOURNAL
OF PSYCHOTHERAPY,
Vol.
X X X I I I ,
No.
4,
October
1979
M U N C H A U S E N ' S
S Y N D R O M E
617
T h e patients' involvement w i t h physicians and hospitals does not appear to encompass psychiatrists and psychiatric centers. T h e y define themselves as medical patients and eschew the role of psychiatric patients. Articles describing psychiatric treatment w i t h M u n c h a u s e n patients are rare. T h e psychodynamics of the syndrome r e m a i n unclear. F o r example, B u r s t e n concluded a paper by stating, " W e have never successfully treated a patient w i t h M u n c h a u s e n Syndrome, nor do we k n o w anyone w h o has." A c l i n i c a l l y innovative approach was proposed by H o l l e n d e r and H e r s h w h o stated that a psychiatrist i n dealing w i t h these patients is often forced into the position of being both a confronter and a therapist, or a prosecutor and a helper. I t was their contention that psychiatrists w h o f u n c t i o n i n these dual roles are u n l i k e l y to be accepted as an a l l y by the patient. T h u s , they suggested s p l i t t i n g the roles, w i t h the p r i m a r y physician being the confronter and the psychiatrist the helper. 3
4
T h e patient to be presented here is u n u s u a l i n that she sought the identity of a psychiatric, as w e l l as a medical-surgical, patient. She presented w i t h both organic and f u n c t i o n a l symptoms and a treatment v a r i a n t of the H o l l e n d e r - H e r s h approach was u t i l i z e d .
C L I N I C A L REPORT Miss A., a 28-year-old, licensed practical nurse, appeared at the emergency room of a university hospital late one evening. She reported that one-half hour after taking two Sominex tablets she experienced both visual (long black snakes coming out of faucets, and laughing faces in cups of coffee) and auditory (voices telling her how horrible her life situation was) hallucinations. I n addition, she had dilated pupils. She was disoriented for time, place and person. She was wearing a neck brace and a left forearm cast, claiming to have broken her left radius and to have sprained her neck in a car accident resulting from an unidentified man's attempt to force her off the interstate. (During subsequent interviews, she reported that her ulna was fractured, later the radius and ulna and still later the radius, ulna and metacarpals). X-rays of the left forearm revealed no evidence of fractures, and a check with the police revealed no record of a car accident. Both pupils remained dilated and fixed following the administration of 1% pilocarpine eye drops. Based on the history and physical findings, the medicine and neurosurgery residents concluded that the patient was delirious. A perusal of the patient's hospital folder revealed six previous hospitalizations over a five-year period. The first four hospitalizations were for investigation of a seizure disorder. Porphobilinogens, coproporphyrins, uroporphyrins, urine protein electrophoresis, brain scan, 17-hydroxysteroids, 17-hydroxyketosteriods, P B I , E E G , and skull films were within normal limits. No evidence was found for Addison disease, polycystic disease or hypoadrenalism. The patient was described as a hysterical personality. Miss A. entered the psychiatric system when she and her husband sought marital
618
A M E R I C A N
J O U R N A L
OF
P S Y C H O T H E R A P Y
therapy. However, her husband terminated treatment prematurely and left the state. Miss A. then became increasingly depressed with suicidal ideation and was referred to D r . E . M . She was hospitalized on a psychiatric inpatient unit on two occasions for severe depression. Each hospitalization was for approximately six weeks, and each was followed by outpatient care. Prior to and while under psychiatric care, Miss A. made numerous emergencyroom visits. On one such occasion, she presented with a number of superficial lacerations on her face and reported that she had been sexually attacked by a 6'11" man. Examination for spermatozoa was negative. The patient claimed that the attacker had poured bleach into her eyes; she later changed this story to 2 or 3 attackers. She also stated that she scratched and fought with them—but her nails were long, unbroken and clean. Miss A.'s chart revealed that she had also been seen as an outpatient and inpatient in most hospitals in Nashville as well as in other cities (including Atlanta, M i a m i , and Minneapolis) for similar complaints. She had consulted numerous physicians including ophthamologists, internists, endocrinologists, orthopedic surgeons, neurosurgeons, and psychiatrists. Based on the records and recent psychiatric findings, the diagnosis of borderline personality with chronic factitious illness was made. Family
and Social
History
Miss A. was an only child of an academic family. Materially her early life was comfortable. She had many friends, and she had attended private schools. Her parents' 32-year marriage was described as "an ideal one" although it ultimately ended in divorce. T w o days following the divorce, her father remarried a young woman with a remarkable resemblance to Miss A. Before the divorce, the patient described the relationship with her father as being "very close." After the divorce, she refused to see him for one year and invited him to her wedding only on the condition that he come without his new wife. Her mother had always treated her as a child, but she reported having grown closer to her mother since the divorce. There was no history of psychiatric illness in the family. Miss A. related that her first sexual experience occurred at age 18, when she was raped four times by two men. She stated that there were no other sexual contacts prior to her marriage at the age of 22. Her husband had been divorced two months prior to their marriage. He was described as being very patient with her and not making sexual demands. She thought their sexual relationship was healthy until he had a psychotic episode three years after the marriage. Then, according to the patient, he began to demand more and more information about her previous rape experience, and he would awaken her in the middle of the night demanding to have sexual relations. He would also tie her down and, according to the patient, attempt to reenact the rape scene. He refused to be seen in individual psychotherapy but was willing to enter marital therapy. As noted earlier, he ultimately fled treatment and was divorced by Miss A. Miss A. met her present manfriend one year after her divorce. She described this relationship as friendly with no sexual overtones. She did not tell him about her prior experiences with men. He was divorced and had no children. He periodically
M U N C H A U S E N ' S
S Y N D R O M E
619
moved into her apartment, staying with her for a week at a time but in separate bedrooms. His main attribute as far as she was concerned was that he was not sexually demanding, although he had recently asked her to obtain an I U D . Hospital
Course
Miss A. was admitted to the psychiatric service from the emergency room for evaluation of her dilated pupils and treatment of her Munchausen's syndrome. The dilated and fixed pupils brought up the possibility of an accidental atropine overdose from the use of mydriatic eye drops. Miss A. probably intended to simulate a neurological condition much as she had at other hospital visits. Such an overdose, producing an anticholinergic delirium, would explain her auditory and visual hallucinations. The right pupil was fixed and 9 mm; her left pupil was mildly reactive and 7 mm. A urine drug screen was negative. A n Adie's pupil was ruled out by normal reflexes. T w o bottles of a short-acting mydriatic (Mydriacyl) were found in the patient's hospital room. The treatment variation of the Hollender-Hersh technique 4 for patients with factitious disorders consisted of one psychiatrist ( E . M . ) being the helper and a second psychiatrist (R.J.) being the confronter. Both therapists met with Miss A. daily to establish rapport before D r . R. J . confronted her with the fact that she had self-administered mydriatic drops. She was told that a dilated pupil not responding to pilocarpine could only be caused by eye drops. After initial denial, she soon broke into tears and acknowledged that she had used them. Five days following the discontinuation of the eye drops her pupils were equally round, reactive to light and accommodated normally. She continued, however, to complain of visual hallucinations throughout the remainder of the hospitalization. Following the initial confrontation, Miss A. became severely depressed and was considered suicidal. When she recovered from the depression, she was confronted with the fact that there was no radiological evidence for a fracture or a neck injury. She became very upset and screamed that there was also no evidence for any rapes or car accidents in the past. She accused D r . R. J . of enjoying the confrontation. T w o days prior to discharge, her lack of motivation to change was discussed. A meeting of the patient, her mother, and both therapists was held prior to discharge, and arrangements were made for her to live with her mother until she could secure employment. Miss A. was seen regularly by both therapists for four months until she left the city to take a new job. Follow-up with both the patient and her mother one and one-half years after discharge revealed that she was functioning socially and professionally without the need for further psychiatric or medical treatment. She expressed satisfaction over her present life style and verbalized positive feelings about herself. She also acknowledged again her role in the production of her factitious symptoms but reported no longer feeling compelled to produce them. However, approximately two years later, the patient contacted one of the author's claiming she was in town and "wanted to say hello." During the meeting, Miss A. "confessed" that after leaving the city two years previously she immediately started producing her symptoms again
620
A M E R I C A N
J O U R N A L
O F
P S Y C H O T H E R A P Y
and that no physician whom she had contacted wanted to have her as his patient. Thus, she hoped that D r . E. M . would help her locate a physician who would be willing to "treat" her.
COMMENT M i s s A . fulfills the three c r i t e r i a described by Bürsten for the diagnosis of M u n c h a u s e n ' s syndrome. H e r presentation was d r a m a t i c , her symptoms escalated i n numbers a n d complexity w i t h each r e t e l l i n g (pseudologia fantastica), a n d she traveled f r o m hospital to hospital a n d f r o m city to city seeking medical attention. T h e d e l i r i u m itself, complete w i t h both a u d i t o r y and visual hallucinations was secondary to the accumulated effects of four anticholinergic drugs: M y d r i a c y l (short-acting m y d r i a t i c ) , c h l o r p r o m a z i n e , a m i t r i p t y l i n e , a n d Sominex (scopolamine). W i n s l o w stated that an a t r o pine-induced dilated p u p i l can be differentiated f r o m a neurologically dilated p u p i l by a p p l y i n g t w o or three drops of 1 % pilocarpine (a p a r a s y m p a t h o m i metic agent acting directly o n the postganglionic fibers of the p a r a s y m p a thetic nerve endings of the iris a n d c i l i a r y body) w h i c h w i l l constrict a neurologically dilated p u p i l w i t h i n ten to fifteen minutes b u t has no effect o n an atropine dilated p u p i l . 3
5
6
I t is t e m p t i n g to speculate on M i s s A . ' s vascillation between caregiver ( L P N ) a n d care-receiver (patient role). G r a m m e r et a l discussed the identification problems of nurses whose professional role often prevents t h e m f r o m meeting their o w n n o r m a l dependency cravings. Also, the patient's view of sexuality as dangerous b u t fascinating m a y have played a p a r t i n her M u n c h a u s e n ' s syndrome. 7
Because of the patient's fragile psychological state, D r . E. M . ' s approach was h i g h l y supportive a n d crisis-oriented, a n d he avoided psychodynamic interpretations. D r . R. J . conducted a confrontative approach w i t h i n a n o n a n g r y , nonretaliatory atmosphere, u n l i k e that sometimes presented by physicians w h o challenge these patients. T h u s , the treatment effort was specifically aimed at f o r m i n g a supportive alliance w i t h M i s s A . , strengtheni n g her reality testing, h e l p i n g her overcome day-to-day crises i n an a p p r o p r i a t e m a n n e r , a n d p r o v i d i n g her w i t h sufficient support to reassume a h e l p - g i v i n g rather t h a n help-seeking role. U n d e r no circumstance were her self-destructive (both physical a n d psychological) urges reinforced. I t is difficult to k n o w w h e t h e r the treatment described here for patients w i t h factitious illness w o u l d have been successful i f the patient h a d remained i n treatment for a longer period of t i m e . I t appears to have made an impact over a f o u r - m o n t h period a n d then collapsed w h e n the patient left t o w n ( a n d the treatment agents). T h i s case also indicates the necessity for more objective criteria t h a n merely the patient's self-report i n f o l l o w i n g u p on the treatment effectiveness of a given procedure.
M U N C H A U S E N ' S
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S Y N D R O M E
SUMMARY U n l i k e most M u n c h a u s e n patients, M i s s A . was w i l l i n g to define herself as a psychiatric, as w e l l as a medical-surgical patient. Consequently, i t was possible to engage her i n a u n i q u e f o r m of psychotherapy i n v o l v i n g t w o therapists: one serving a supportive role and the other being a confronter. P r i o r to admission the patient had used eye drops to dilate her p u p i l s to simulate a neurological disorder w h i c h accidentally induced an a n t i c h o l i n e r gic d e l i r i u m .
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