Munchausen’s and friends

Psychiatric syndromes like hypochondriasis, somatization disorder and Munchausen’s disorder could be uncharitably characterized by the layman as ‘he’s making it up, innit’.  Not as simple as that alas, which one of the reason you have to train psychiatrists rather than pull them off the street.

Munchausen syndrome (also known as factitious disorder): the patient seeks medical attention by the intentional production or feigning of symptoms.  The motivation for this is considered not to be known to the patient and he/she keeps their stimulation or induction secret.  It was named (1) after Rudolf Raspe’s 1785 fictional German cavalry officer, Baron Karl von Munchausen, who always lied fantastically about his military exploits.  A classic case might have what is called a ‘grid iron’ stomach because of all the scars from numerous abdominal operations.  Also a feature is ‘perigrination’ where a patient will move from hospital to hospital seeking treatment, once rejected from a department.

Munchausen syndrome by proxy: This was first defined by Meadows (2) and has become controversial.  Defined as ‘the deliberate production or feigning of physical or psychological symptoms or signs in another person who is under that individual’s care’.  it is considered to be a form of child abuse.  It is also not unknown for healthcare workers to fabricate health crises in their patients so that they can ‘save’ them. 

Hypochondriasis: the patient is convinced that they have a life-threatening illness, despite evidence to the contrary.  They often misattribute normal bodily sensations as being pathological. 

Malingering: the patient knowingly fabricates a medical illness for known gain.  This is considered to be rare. 

Somatization disorder: With this a patient presents with multiple, medically unexplained symptoms. Originally described as Briquet’s syndrome in the 1960s.  Patients sometimes show a lack of concern for the nature and implications of their symptoms and the presentation may also be illogical for example, the patient may complain of intolerable pain, but still appear calm and composed.

So, in summary, if they’re doing it, but they don’t know why then it’s Munchausen’s syndrome; if they’re doing it to someone else and they don’t know why then that’s Munchausen’s by proxy; if they think they’re going to die and you can’t persuade them otherwise then that’s hypochondriasis; if they’re not doing it, but they feel unwell but are pretty vague about it then they’re somatizing and if they’re doing it, they know why and they want money for it then they’re malingering.  Clear?

Addendum: Jan-Michael has asked about how the above relate to conversion disorders, which is a good question.  Conversion disorders are presumed to be psychogenic in origin.  The patient experiences a conflict or trauma of some kind and the unpleasant affect is transformed (/converted) into symptoms.  Examples are dissociative amnesia, dissociative fugue, dissociative stupor, trance and possession disorders, dissociative disorders of movement and sensation and dissociative convulsions. 

In common with somatisation disorder, both involve physical symptoms and with both there is no evidence of a physical disorder that might explain these symptoms.  The difference is that to diagnose dissociative disorder there should be clear evidence of psychological causation for the symptoms, even if the patient denies it.  There is no need for this to make a somatisation disorder diagnosis.  Also with somatization disorder, the patient tends to present with a variety of vague symptoms whilst in a dissociate disorder the symptoms are more focused. 

In terms of classification, disorders with a predominantly physical or somatic mode of presentation are grouped together.  In ICD-10 F40-48 covers neurotic, stress related and somatoform disorders.  Within this F44 covers Dissociative [conversion] disorders and F45 covers somatoform disorders.  Somatoform disorder is classified within this as F45.0 and hypochondrical disorder is classified as F45.2.  Malingering is classified elsewhere as Z76.5 (Z0-Z99 Factors influencing health status and contact with health services) and Munchausen’s F68.1 ‘intentional production or feigning of symptoms or disabilities either physical or psychological [factitious disorder]‘ (F68 other disorders of adult personality and behaviour)

(1) Asher, R. (1951). Munchausen’s syndrome. Lancet, i, 339–41.

(2) Meadow, R. (1977). Munchausen syndrome by proxy: the hinterland of child abuse. Lancet, ii, 343–5.

13 Responses to “Munchausen’s and friends”

  1. deClerambault says:

    Poor old Baron von Münchhausen, has had his character tarnished forever by the defamation of the scoundrel Raspe. Münchhausen undoubtedly didn’t suffer from his unfortunate eponymous syndrome and reputation as a liar.
    It was Rudolf Raspe who met the Baron after his campaigning in Russia, and, as a largely exploitative exercise of self furtherance, published a pamphlet of the Baron’s “Marvelous Travels” which was a work of fantastic fiction, as was the vogue of the period (contemporary to Gulliver’s Travels.) Unfortunately it painted the perceived Author as a liar and a fantasist.

    Maybe “Münchhausen’s syndrome” should be more accurately be described as “Raspe’s apocrypha”.

  2. Jan-Michael says:

    Can you talk a little about Conversion disorders and how they’re related to the others?

  3. Frontier Psychiatrist says:

    Hi, I’ve added a bit to the article to help explain this – I hope its useful. I’ll add some links in also when I have time!

  4. Graeme G says:

    Do you really mean “hypercondraisis”?
    Always thought it was due to the common presenting complaint of pain in the hypochondrium.

  5. Frontier Psychiatrist says:

    No I don’t, I can’t spell. This is very embarrassing…. Actually someone else pointed this out to me and I thought I’d corrected it.

    A quick websearch on ‘hypercondriasis’ reveals that I’m not the only moron out there:

    http://www.medicine.utas.edu.au/teaching/year3_4/cam410/tutorials/intro_cbt.html

    http://www.echeat.com/essay.php?t=31788

    according to a cancer dictionary on
    http://cancerweb.ncl.ac.uk/cgi-bin/omd?-iasis

    -iasis means ‘a condition or state, normally an unhealthy one’ pain in the hypercondrium would probably fit the bill for the true definition for ‘hypercondriasis’

    Right, now back to beating myself with a stick.

  6. karen says:

    i suffer from this disorder and i am no malingerer your definition of somatization disorder is totally way off it is a recognized illness. but some doctors don’t recognize it, until it has gone on for several years. yes the disorder is real, after going through several arduous tests the medical specialist eventually finds the cause, i personally have had several operations due to this condition, i was thought to have irritable bowel syndrome which turned out to be gall stones and i was infact given an apology from the consultant
    this condition requires the sufferer to have at least 4 symptoms

    therefore your diagnosis of the disorder is your own Munchausen syndrome

  7. karen says:

    Disorder Information Sheet Mental Health Information from PsychNet-UK
    Multi Search
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    Refer to conditions of use

    Somatization Disorder

    The most common characteristic of the somatoform disorder is the appearance of physical symptoms or complaints for which they have no organic basis. Such dysfunctional symptoms tend to range from sensory or motor disability, hypersensitivity to pain. Four major somatoform disorders exist: conversion disorder (also known as hysteria), hypochondriasis, somatization disorder, and somatoform pain disorder. Somatization disorder is also known as Briquet’s Syndrome.

    Starting before age thirty, the patient has had many physical complaints occurring over several years and has sought treatment for these symptoms, or they have materially impaired social, work or personal functioning. The patient has at some time experienced a total of at least 8 symptoms from the following list for which the symptoms need not be concurrent.

    PAIN SYMPTOMS (4 or more) related to different sites, such as head, abdomen, back, joints, extremities, chest or rectum, or related to body functions such as menstruation, sexual intercourse or urination.

    GASTROINTESTINAL SYMPTOMS (2 or more, excluding pain) such as nausea, bloating, vomiting (not during pregnancy), diarrhea, intolerance of several foods.

    SEXUAL SYMPTOMS (at least 1, excluding pain) including indifference to sex, difficulties with erection or ejaculation, irregular menses, excessive menstrual bleeding or vomiting throughout all nine months of pregnancy.

    PSEUDONEUROLOGICAL SYMPTOMS (at least 1) including impaired balance or coordination, weak or paralyzed muscles, lump in throat or trouble swallowing, loss of voice, retention of urine, hallucinations, numbness (to touch or pain), double vision, blindness, deafness, seizures, amnesia or other dissociative symptoms, loss of consciousness (other than with fainting). None of these is limited to pain.

    For each of the above symptoms, one of these conditions must be met:

    Physical or laboratory investigation determines that the symptom cannot be fully explained by a general medical condition or by substance use, including medications and drugs of abuse, or

    If the patient does have a general medical condition, the impairment or complaints exceed what you would expect, based on history, laboratory findings or physical examination.

    The patient doesn’t consciously feign the symptoms for material gain (Malingering) or to occupy the sick role (Factitious Disorder).

    Symptoms:

    Vomiting.
    Abdominal Pain.
    Nausea.
    Bloating.
    Diarrhea.
    Pain in the arms or legs.
    Back Pain.
    Joint pain.
    Pain during urination.
    Headaches.
    Shortness of breath.
    Palpitations.
    Chest Pain.
    Dizziness.
    Amnesia.
    Difficulty swallowing.
    Vision changes.
    Paralysis or muscle weakness.
    Sexual apathy
    Pain during intercourse
    Impotence
    painful menstruation
    Irregular menses
    Excessive menstrual bleeding
    Discussion of other aspects of life may cause anxiety

    Note: A variety of symptoms may be present at any given time.

    Associated Features:

    Many somatic complaints and long, complicated medical histories.
    Psychological distress and interpersonal problems are prominent>
    Medical histories are often circumstantial, vague, imprecise, inconsistent and disorganized.

    Differential Diagnosis:

    Some disorders have similar or even the same symptoms. The clinician, therefore, in his/her diagnostic attempt, has to differentiate against the following disorders which need to be ruled out to establish a precise diagnosis.

    None psychiatric medical conditions that may explain the symptoms.

    Causes:

    The cause is not specific but symptoms begin or worsen after losses (for example, job, close relative, or friend). A greater intensity of symptoms often occurs with stress.

    Treatment:

    The goal of treatment is to help the person learn to control the symptoms.

    A supportive relationship with a sympathetic health care provider is the most important aspect of treatment. Regularly scheduled appointments should be maintained to review symptoms and the person’s coping mechanisms.

    Acknowledgment and explanation of test results should occur. It is not helpful to tell the people with this disorder that their symptoms are imaginary. People with a somatization disorder rarely acknowledge that their illness has a psychological component and will usually reject psychiatric treatment.

  8. ETP says:

    My mom is currently being diagnosed in Rehab for Somatization disorder, but I am convinced she has munchausen. Can someone with SD manifest into Munchausen. Or Munchausen bi-proxy if there condition goes undiagnosed for a long time. She has had every disease in the book from pancreotic cancer (that misteriously turned into a cyst and disappeared), MS, fibromyalsia, chronic fatique, hep B, hysterectomy due to cervical cancer, degenerative disks in spine etc……… from my childhood experiences I am convinced she had MBPS, but she is so good at lying the doctors are calling it somatization disorder.

    What are your thoughts on relatedness and manifestation of the 2 illnesses

  9. Harvey J. says:

    I agree, the you tube videos are confusing of this cheerleader. What’s NOT confusing; however is the factual discoveries of her pyschogenic disorder. In short, she really thinks she has dystonia, thus presents as such. Similar cases are seen in the case of psychogenic autism (factitious disorders) where the persons either deliberately feign being autistic or they really believe they are autistic. Normally, you find this in people who have taken large amounts of LSD type drugs, combined with a severly abusive past, thus resulting in a very mixed presentation of whatever it is they feel will bring them the most attention and nurturing. Autism is popular today, so many mentally ill persons are adopting this persona. Mainly, because few, if any professionals or media will challenge such a diagnosis after even a less than competant professional duped by the complexity of the presentation—validates it. Ooops, than it becomes a save face issue, where neither the media or the professionals (not to forget publishers who publish stories that later turn out not to be autistic people) involved in the faulty diagnosis want to be embarrassed. This is unfortunate, as this does a great disservice to the autism community in general. Recall the Amanda Baggs controversy and the case of Ms. Donna Williams. You Tube has a recent video out discussing some of this I’ve mentioned. It is on you tube under the name, “autism spectrum seems out of control” and another video named, “autism epidemic out of control.” The video has most definately hit on something few outside psychoanalytical or psychiatric circles, have even noticed.

  10. Seth says:

    The reason it is called hypochondriasis is that many of the presenting symptoms are located in that area. The patients, who can be demanding and time-consuming, were dehumanized by referring to them derogatorily by their presenting symptom.

  11. amandabaggsucks says:

    Amanda Baggs is NOT autistic. Nor was or is Jenny McCarthy’s son autistic. What in the heck is wrong with the media? Have they lost their minds? How stupid can they get? CNN Dr. Gupta should be fired for his utter failure to discern the fraud of amanda baggs, though baggs is probably brain damaged from taking so much LSD in past, and thinks she really is autistic. Jenny McCarthy on otherhand, knows the truth about her son, and doesn’t even have the class or integrity to admit he has Landau Kleffner Sydrome, which explains why he “was cured by her” or “improved” after he started taking seizure meds. Duh.

  12. amandabaggsucks says:

    Yep it’s true. Donna Willaims, the high profile adult with “autism” has now been recently diagnosed with a mulitple personality disorder. Oh my. That must make all her publishers of her books a bit nervous. What a scam. Now don’t get us wrong, donna is a nice woman who has a gift of extreme intellect and insight into autism, but she is NOT autistic. Just like jenny mccarthy’s on was never autistic. Time to wake up folks. You’ve been mislead on what autism is.

  13. SexyKitten says:

    Yep. Yep. Yep. Agreed. Amanda Baggs is not autistic. Never was. Is not autistic. Baggs is a mentally ill person with drug induced autistic traits. ASK Amanda about her drug past. She took a lot of LSD and then, after scrambling her brain, got “autism.” OKAYYYYYYYYYYYYY sure. All rightly then….c’mon folks use critical thinking skills here. Check out Amanda’s background and come to a conclusion. You’ve been DUPED. Amanda Baggs is not autistic. She’s a drug induced presentation posing as autistic. She should be evaluated by a psychiatrist, not a medical doctor who has no experience dealing with this type of person. She’s very bright. Very deceitful. Very crazy. Wired Magazine, New York Times reporters and the embarrassing CNN medical guy, Dr. Gupta (aka, goofed up) need to seriously understand the difference between mental illness caused by drugs that lead a person to THINK they’re autistic, and real autism. You are born with real autism. it is NOT an acquired drug induced condition, as seen in Amanda Baggs. Now, that’s in my language. Truth. Amanda Baggs Exposed, should be the title of the next media coverage.

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