Psychiatry was my last rotation as a junior interne. I had completed all the required rotations in medicine, surgery, pediatrics, and obstetrics and considered myself, with justification, a savvy and battle hardened young doctor, within a month of receiving my certificate to practice.
I had seen it all: pathos, mayhem and violence, and self-mutilation. I had witnessed nobility and courage in some patients and helpless defeat in others. I was ready for the world of medicine, not just the clinical challenges but the challenge of reading patients – their needs, their fears, their intentions and above all, what they were hiding.
A month of psychiatry was almost like ending my internship with a vacation. Since I was the only interne I would be on-call 24/7, but the case load would be light and emergencies infrequent. Unlike my previous services, a week-end on call would be a week-end of loafing at home.
The first call from emergency came about 10 pm on my first Friday. It was a common week-end incident, ‘attempted suicide’. The patient, Reginald R., had been brought to the ER by the police. Their story was simple and brief. The man in their custody had been standing on Portage Avenue, at the bus stop in front of the Eaton Centre, chatting amicably with one of Winnipeg’s finest when he suddenly threw himself in front of a bus approaching the stop.
The policeman, both quick witted and nimble, pulled him back but our patient fought him off and tried to scramble under the wheels of the bus, now stopped and loading late night passengers. He ignored the advice freely offered by both the officer and the commuters – who only wanted to get home – and loudly declared his right to end his life.
Since he had to be physically extricated from under the bus, which was already behind schedule, the policeman was stuck with him. And, since it was also near the end of the officer’s shift, he probably made a quality-of-life decision – quality of his life that is, certainly not mine. If he took Reggie to the ER of the Winnipeg General Hospital he could turn him over to the constable on duty, and go home; if he charged Reggie and locked him up he would be stuck with two or three hours of paper work.
Such were the life-or-death decisions that led to my summons to the ER at 10:00 on a Friday night to admit an attempted suicide. I wasn’t particularly distressed; it was my only call of the evening and attempted suicide was a legitimate admission. Once we got Reggie to the ward it took a rather large dose of Valium to sedate him but he soon went quietly to sleep and I quickly followed suit.
I had the whole week-end to sort Reggie out, my first real psychiatric patient. Admittedly, I had some reservations that psychiatry was a real medical specialty but I wanted to make a good impression for my last month so I did a thorough medical examination as well as a psychiatric history. Reggie was a small, middle aged man of no particular distinction. His manner was diffident, almost apologetic, his voice soft and pleading, and he paused after each statement as if judging its effect. He had the remarkable knack of watching you without staring. The only notable feature of his physical examination were his abdominal scars, evidence of multiple surgical attempts to explore his innards, for reasons I could not immediately discover.
Reggie was more than willing to talk, he was downright eager. He told me about his abusive father, his thankless employer, his cheating wife and his difficult childhood. He had been brought up in a poor family with a mother who did house-cleaning, an older sister who went out every evening (he didn’t know where) dressed mainly in mascara and hot pants, and a father who did odd jobs and drank. Most evenings his father would beat his mother until she surrendered her day’s pay, and beat Reggie even more when he tried to defend her.
Reggie left home at age 16, after his mother died tragically, and joined the air force at the outbreak of WWII. During the war he was a tail gunner in Lancaster bombers and had many harrowing experiences, which he would be happy to relate later. After demobilization, he worked his way up from shipping clerk to dispatcher in a large trucking firm. Life was going well until he developed serious medical problems. He had no medical or disability insurance but his doctor insisted he have a laparotomy (surgical intra-abdominal exploration) to diagnose his pain. After the operation he was worse and his misery was compounded – no job, no savings, no severance pay, no benefits.
That was when he discovered his wife was cheating with his best friend. One afternoon, exhausted from his fruitless search for work – “any job,” as he put it – he came home early and found his wife and friend in bed together. She was unapologetic, berating Reggie for being sick and out of work. He left and had been trying to get himself straightened out ever since but struggled with his depression. He had found very few people who were willing to help him and medical people had proven particularly disappointing.
He had been diagnosed, he informed me, with gastric epilepsy and the conspicuous scars on his abdomen were evidence of fruitless surgical attempts to relieve his agony. When the attacks came, the pain was excruciating, only tempered by large doses of Demerol. But some doctors – and here he became bitter and resentful – rejected him just as his wife had done. They treated his attacks with placebos, injections of normal saline. He could tell the difference immediately and could hardly believe that trained doctors and nurses, who had taken the Hippocratic oath, would let another human suffer as he suffered. He hoped that I was not of that ilk.
A half-hour after I left the ward I had a call from the nurse in charge. Reggie was having one of his seizures, clutching his abdomen in agony, crying for help. I immediately went back to examine him and found him, as described, writhing with pain. When I examined his abdomen he complained of excruciating tenderness wherever I probed, but he didn’t have the rigidity, guarding and lack of bowel sounds of an acute abdominal crisis.
He hoped I would not leave him in unbearable pain for the whole night as others had done. My first inclination was to get a second opinion, a surgical consult, but the surgical residents were busy exploring a knife wound and then had a perforated appendix to deal with before they could even consider my patient. I gave Reggie intravenous Demerol and only after an remarkably large dose did he relax, and with a satisfied smile he fell asleep. There were two more such episodes between then and Monday morning but adequate doses of Valium and Demerol ensured that both of us got some sleep.
My psychiatric consultant was a hardened veteran of encounters with the inner-city residents. After my detailed presentation, it took him less than 15 minutes to assess Mr. Reginald R. His instructions were terse, “discharge him with no medications.” I was amazed at his penetrating perception, but he had some information he neglected to share with me. Last week, before I joined the service, a city wide psychiatric conference had discussed a case with many of the features exhibited by Reggie. Perhaps it was the same patient. It was labelled “Munchausen’s syndrome” and all psychiatrists were cautioned to be wary.
I went back, rather chagrined, to break the bad news to Reggie. He had already packed his meager belongings and left. He saw it coming, probably not for the first time!
Munchausen’s syndrome is one of the oddities of human nature and its etymology has colorful origins. The first and still the best description of the condition was by a British physician, Dr. Richard Asher, who in an article published in The Lancet in 1951 described patients who “Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly, the syndrome is respectfully dedicated to the baron, and named after him.” (Asher 1951) The official label now is Factitious Disorders (DSM-5), a rather bland descriptor, and I prefer the old term.
The famous Baron Munchausen that Asher refers to is a fictional character invented by an 18th Century German author, Rudolph Erich Raspe. In Raspe’s accounts the Baron is a braggart soldier who entertains his friends with implausible stories. But legend holds that he was a real person, a German aristocrat who served with the Russians during the Russo-Austro-Turkish War of 1735-39 and later became a raconteur of some notoriety. He is still remembered in parts of Europe though his popularity in North America has faded.
Munchausen’s patients are ingenious in concocting factitious symptoms. They baffle their caretakers in numerous ways: by contaminating lab tests (putting sugar in urine samples for example), by self-inflicted injury, often very difficult to distinguish from real injury, by injection of fecal material into the skin to produce abscesses, by tampering with surgical incisions, by insertion of foreign bodies in various body orifices (including the urethra), by ingestion of drugs or chemicals and much more.
The syndrome is not widely reported in the medical literature; it does not excite young doctors who are trying to bolster their academic credentials. The largest review – 455 cases – was compiled by GP Yates and MD Feldman in 2016. (Yates and Feldman 2016) They found that about two-thirds of reported cases were females (average age 34 years) and many had a psychiatric history. Unfortunately, most reports are simply descriptive and there is little insight into their bizarre behavior.
Munchausen’s syndrome is a perplexing mental disorder in which the patient craves medical attention (even surgery), not just material gain. Their needs are complex and probably include dependency issues and drug addiction. Munchausen’s can be confused with malingering, but malingering stems from different motivation; malingerers feign illness for material gain, for example to avoid work or military service. Munchausen’s and malingering are both different from hypochondria. A hypochondriac truly believes that she – most are women – has a serious or even fatal disease and no amount of reassurance or negative tests will convince her otherwise.
To make matters even more complicated there is also a Munchausen by proxy syndrome in which the symptoms are feigned or induced in a child, often by the child’s mother. This gets attention since the victims are young and vulnerable and likely to become adult Munchausen’s.
It is not surprising that Munchausen patients elicit little sympathy. They are viewed as malingerers and their caregivers are offended by their deceptive and manipulative behaviour. There is no charitable foundation canvassing on behalf of Munchausen’s patients, no trust to fund research into its cause.
No effective treatment has been reported and, in any case, they show no interest in being cured. They are elusive, adept at deceiving young doctors and nurses and at vanishing as soon as their deceptions are revealed. They are the phantoms that haunt Emergency Rooms, lurking in the shadows at the fringes of society and disappearing as soon as the light is shone on them. Like the Baron Munchausen of old, they are itinerant story tellers, playing to a credulous audience and attempting to keep one step ahead of discovery.
Asher, R. (1951). “Munchausen’s syndrome.” Lancet 1(6650): 339-341.
Yates, G. P. and M. D. Feldman (2016). “Factitious disorder: a systematic review of 455 cases in the professional literature.” General hospital psychiatry 41: 20-28.