Monday, December 5, 2011
Medical Mondays: Münchausen Trifecta!
Today, Laura Diamond, Sarah Fine and I are tackling a topic together. It's called Münchausen syndrome.
It's a psychiatric, factitious disorder whereby people fake illnesses for attention and sympathy.
Ever heard of it? It's named after Baron Von Münchausen (1720-1797), who told many fantastic and untruthful tales about his adventures. His stories were later told in a novel by Rudolf Erich Raspe, and also in a 1988 film, The Adventures of Baron Von Munchausen. (Remember Uma Thurman as the Goddess Venus?)
Sarah Fine is going to tackle Münchausen's by Proxy, which occurs when parents sicken their own children to get attention as the "concerned parent."
Laura Diamond is going to tackle the psychiatric aspects of Münchausen's syndrome.
And I'll tackle some of the medical aspects of Münchausen's.
First of all, Münchausen's is different from malingering.
Malingering is when people fake their illness for secondary gain. Secondary gain can include money (for a lawsuit), getting out of military duty, getting out of prison for the "nicer" environment of the prison hospital, getting out of school (see Ferris Bueller's Day Off), getting out of prison ("I swear I was crazy when I killed that guy!"), getting prescription drugs, etc. Also, see my vomiting chicken blood post.
It's also different from Somatoform Disorders, when people have physical symptoms without any overt abnormalities on tests. These people aren't faking their suffering.
In Münchausen's, the person fakes an illness because they find the attention of medical personnel and the medical environment comforting and pleasant. From the doctor's side of this, it can be extremely frustrating.
Here's a story that I heard when I was a medical student.
A man came to the hospital with excruciating abdominal pain. He was at a party the night before when he clinked glasses with guests. After drinking his champagne, he realized his glass had broken during the toast and splinter-sized shards were at the bottom of his glass. He was convinced he'd swallowed some splinters.
Though normally glass should be seen on an X-ray, tiny shards might be missed. He had an endoscopy, which revealed nothing. He was ready to have an exploratory surgery to remove the possible glass shards from his gut when my attending (who I believe was a rotating resident at the time) said, "Hey. You look very familiar. Didn't you come to the ER at another hospital with the same problem last month?"
The patient immediately left and never came back.
Yes, he was willing to have an unnecessary, major surgery. And needle pokes, and endoscopies, and radiation. But he also got a load of concerned doctors, nurses, and staff who thought, "This poor man! He needs our help!"
Here's another one.
A woman came in with fevers and signs of a blood bacterial infection gone out of control. After antibiotics and an ICU stay, she recovered. There was no obvious cause for the infection, and doctors were confused as to why several types of bacteria grew in her blood. (Normally in blood infections, there is just one bacteria involved.)
After a second bout of sepsis with multiple bacteria, the hospital staff suspected Munchausen's. The patient was then observed surreptitiously injecting herself intravenously with a liquid mixture made from her own feces.
And on, and on, and on. There are thousands of stories like these, sadly. People injecting themselves with insulin to get hypoglycemic; people rubbing dirt and spit into their wounds to prolong a hospital stay...sounds impossible? It's not. I've seen a bunch of them myself.
Many patients with Munchausen's will go to several doctors and/or hospitals for treatment ("doctor hopping"). They may move to different states so they can do it again, or change their names. And they're willing to undergo unnecessary, even dangerous, evaluations to do so and put their very lives at risk.
From the medical side, the key to finding out someone has Munchausen's is part science, and part luck. Doctors have an obligation to make sure there truly isn't a dangerous medical condition before they blame something on Munchausen's--because that kind of accusation is extremely serious. But when the data doesn't add up (like the multiple bacteria in the blood, above) or suspicious behavior is found, then we suspect Munchausen's. I have heard that video cameras can be used to prove cases of Munchausen's by proxy, but I'm not sure about regular Munchausen's.
It can be particularly difficult to diagnose if the patient already has real medical problems, and/or has educated themselves about certain illnesses--how they present, what "alarm" words to use to make doctors sit up and take notice.
Can you imagine what's it's like to have Münchausen's? Can you imagine having one of your characters with this syndrome?