a review of the munchausen syndrome

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Page 1: A review of the Munchausen syndrome

Clinical Psychology Revtew, Vol. 1, pp. 65-78. 1981 Printed in the USA. All rights reserved.

027%7358/81/010065-l4$02.00/0 Copyright o 1981 Pergamon Press Ltd.

A REVIEW OFTHEMUNCHAUSEN SYNDROME

Loren Pankra tz

University of Oregon Health Sciences Center

and VA Medical Center, Portland

ABSTRACT. The Munchausen syndrome is used to describe patients who repeatedly present factitious medical emergencies to obtain hospital admission. Case presentations of the syndrome

in the medical literature during the past decade are identified and reviewed. These patients usually arrive bleeding, in pain, or with other dramatic symptoms. Once on the hospital ward

they are characterized by grandiosity, chronic lies, disruptiveness, and discharge against medical advice (AMAs). Although there are many psychodynamic considerations, more likely etiological considerations include characterological problems, substance abuse, and brain dysfunction. The Munchausen diagnosis provides no certainty against existing medical prob-

lems, either self-induced, iatrogenic, or unrelated to the presenting problem. Therefore, careful medical screening is necessary. Suggestions are made for the identafication of the Munchawen

patient in the emergency room nnd for management on the ward.

Munchausen’s victims must be expected To plague our lives unless detected

-William Bean

The Munchausen syndrome patient is a medical itinerant who presents the symp- toms of an acute illness for the purpose of gaining hospital admission. On exam- ination he may have evidence of multiple surgeries, all explained by a plausible but convoluted history. Once admitted to the hospital, the patient may keep the ward routine in an uproar by demanding service, special medication, and surgery. The patient may have medical problems but deception is at the core of the problem.

One would think that such a dramatic presentation would make the Munchausen syndrome easily recognizable. Unfortunately, the diagnosis is most often made retrospectively or not at all. Furthermore, the histories of these patients suggest that they frequently do obtain the drugs, surgeries, and invasive procedures that they demand. They also leave (often against medical advice-AMA) with their bills unpaid, their charts bulging with noncompliance, and their problems unresolved, ready to invade the next hospital.

Requests for reprints should be sent to Lot-en Pankratz, Ph.D., Psychology Service, Veterans Administration Medical Center, Portland, Oregon 97201.

65

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66 Loren Pankratz

A research assistant of mine (Mark Fischer) documented 106 hospital admissions and 53 emergency room visits of one Munchausen patient, which represented onl) a part of the patient’s search for care in the medical community. The portion of his record that was easily accessible to us weighed 9.8 kg. Even though everyone making entries in the record would have had the same accessibility to it, almost every page contained a note that indicated a lack of reference to the patient’s ongoing care. Laboratory tests were excessively repeated, chronic problems were treated as if they were acute, the patient’s word was taken at face value, analgesics were prescribed liberally, and consults were requested from every known speciality to further fill his chart with fractioned care.

To further understand the scope of this problem, the past ten years of case presentations in the medical literature were reviewed. After discussion of the di- agnosis and the etiology, some suggestions have been provided for the early rec- ognition and control of the syndrome.

HISTORICAL BACKGROUND

Baron von Munchausen (1720-l 797), a local teller of tales about his exploits with the Russian Army, became known through the writings of Rudolf Raspe, a scientist and mining engineer. Raspe lived beyond his means and was forced to flee his native Germany because of embezzlement (Sakula, 1978). Although Raspe contin- ued his scientific pursuits in England, he also published a small anonymous book on the Baron, whom he had probably known as a lad. Raspe was most likely surprised by the popularity of his work. Other volumes about the Baron appeared thereafter, undoubtedly because of their economic value to Raspe, and each tale became more preposterous and absurd (Raspe, 1969). Thus, the fun-loving baron became known as an outrageous liar.

Asher (195 1) formally introduced the medical world to the Munchausen syn- drome, dedicated to the baron because of the similarity in behavior by these patients whose stories also are both dramatic and untruthful. Fifteen years after Asher named the syndrome, Ireland, Sapira, and Templeton (1967) identified 59 cases of Munchausen syndrome presented in the medical literature. They noted that the psychopathology of the condition was still entirely unclear, although they suggested the following possibilities: (1) antisocial behavior, (2) character neurosis, (3) brain damage, and (4) a primitive, presuperego self-aggression.

A year later Spiro (1968) also published a review of the syndrome, identifying only 38 cases. He noted that the terminology used to describe these patients was characterized more by its color than its clarity, even though the syndrome had now been known for more than 16 years. Agreeing with Barker (1962), he implied that the Munchausen label was a misnomer, and he suggested the title “chronic factitious illness.” Asher’s catchy label of Munchausen syndrome has remained popular, although the Diagnostic and Statistical Manual of Mental Disorders (third edition) uses chronic factitious disorder (American Psychiatric Association, 1980).

A REVIEW OF CASE REPORTS

More than a decade has passed since the reviews of Ireland et al. (1967) and Spiro (1968). For an update, only those cases presented since 1968 were sought. A decision was made to include all case study examples where the author of that article, who was in the best position to know, concluded that the Munchausen syndrome was

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Munchamen Syndrome 67

TABLE 1. Distribution of Sex and Age of

Munchausen Patients.

Study 7r Mean Age of Adults Age Range

Ireland et al. (1967) Males 76 Females 24

40.1 (23-62) 32.8 (19-52)

Pankratz (1981) Males 66 Females 33

39.0 (infant-64) 30.9 3-53

Table 2. Geographic distribution of 59 Munchau-

sen patients identified by Ireland et al. (1967) and

of 115 Munchausen patients identified since then.

Studv

Country Ireland et al. (1967) Pankratz (198 1)

% %

England 66 18 North America 16 68 Scandinavia 12 2 Other 6 12

a proper diagnosis. In some cases these Munchausen patients were identified under titles relating to malingering, factitious or fraudulent illness, or self-inflicted con- ditions. But in each instance the author of the case presentation concluded that the patient was best described by the Munchausen label. Some articles mentioned Munchausen patients but were not included because they were too brief to allow analysis or were not clinically oriented, such as those in Hospitals, designed to alert hospital administrators. The brief reports on feigned bereavement were not in- cluded here, although the clinician should be aware of this important Munchausen variant (Mann, 1979; Snowden, 1978). Only articles in the English language were included.

One hundred four adult patients and 11 children were identified. The mean age, range of age, and sex ratios are presented in Table 1. Means were based on the reported ages of 55 male and 33 female adult subjects; the ages of the 11 children were omitted from this measure. Table 2 illustrates the shift of cases from England to the United States and Canada during the past decade, which may reflect an awareness of the syndrome in North America. Ireland et al. (1967) suggested that Munchausen patients flourish with the accessibility of free services in the more socialized countries. And if that is correct, the growing number of cases may be an increasingly important problem in the future.

Presenting Problems

Pain, the most frequent symptom, was mentioned in 77 cases (75%). The next most common complaint was bleeding, found in 32 cases (31%). Only 15 patients made

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68 Loren Pankratz

no mention of pain or bleeding. Eight of these 15 patients presented with psychiatric problems or suicidal gestures, and the remaining presented with unconsciousness, delirium, seizures, blackout spells, vomiting, infection, and frothing at the mouth. Thus, the Munchausen patients presented in this sample sought medical aid with a dramatic presentation, as suggested by Asher.

More than one-fourth of all patients reported genito-urinary tract disorders, some with kidney stones, and almost all with pain and hematuria. Another one- fourth of the patients presented with cardiac problems, most typically precardial pain. These two categories both have disorders with a symptom complex that can be simulated fairly easily. Kidney stones and ischemic heart disease are not directly observable, and in some instances it may take several days to provide objective corroboration of the patient’s complaint. In the meantime the physician is expected to provide analgesics. He cannot dismiss the patient easily even if he suspects deception because the consequences of both conditions are serious.

Pa lien t Characteristics

All adult case reports were evaluated on behavioral and social characteristics con- sidered a part of the syndrome. These features are presented in Table 3. This table should be considered with caution because of the inadequacy of many reports. However, most of these estimates are probably low because all judgments were made in a conservative direction.

The Munchausen syndrome patients were characterized by multiple hospitali- zations over a wide geographic area (perigrination). They had histories of multiple surgeries and invasive diagnostic procedures. Although many had completely feigned or self-induced symptoms, a sizable number had some positive medical findings. On the wards they were socially disturbing and disruptive. Two-thirds of these patients were characterized by lying, grandiosity, hostility, or AMA’s. One-

TABLE 3. Characteristics of 104

Adult Munchausen Patients.

Characteristic R of Cases

Multiple hospitalizations 95

Peregrination 77

Multiple surgeries 61

Feigned illness 39

Self-induced illness or injury 39

Substance abuse 48

Chronic Lies 36

Grandiositv 28

Disruptive’on ward Y4

AMA (against medical advice) 42

Prison record 9

Early parental disruption 1x

Relationship to medical profession 22

Iatrogenic problems 6

Psychiatric diagnosis or admission 25

Poor use of’the term 14

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Munchausen Syndrome 69

fourth of the patients were given a psychiatric diagnosis or had a history of previous psychiatric admission.

The high percentage of prison records noted in the Ireland et al. (1967) study was not found in the present group. Only nine cases in our sample had any mention of prison or reform school.1 The famous Indiana Cyclone (Kinch, 1969), the only patient included in the study of Ireland et al. as well as the present study, also had a prison record. This prison record was noted (Chapman, 1957), but has not been mentioned thereafter. Both prison records and substance abuse may have been underestimated, although substance abuse was reported or clearly implied in 49% of all cases. The most frequently abused drugs were analgesics.

These Munchausen syndrome patients gleaned from medical journals are prob- ably representative of those who will be seen in emergency rooms. This conclusion seems warranted based on a review of professional patients described in Hospitals for the purpose of administrative awareness. Thirty-four patients were cited be- tween 1972 and 1975. In that sample, 82% had pain as a complaint, most commonly with a presentation of cardiac pain, kidney stones, or abdominal pain. These brief reports similarly contained clear evidence for the common characteristics of drug- seeking behavior, multiple scars, grandiosity, chronic lying, and AMA’s.

Patients with Multiple Reports

Of particular interest were seven patients who appeared to be the subject of more than one article. These patients provided interesting profiles because more com- plete behavioral descriptions emerged with each report. There were six separate reports on the young Italian man 2; five articles on the British laboratory technician who conquered two continents, and four articles within the past ten years on Leo Lampere, the famous Indiana Cyclone, who terrorized hospitals since at least 1943. There are nine articles on the black “nuclear physicist” who claims 48 surgeries, and he has a “gridiron abdomen” which suggests that on this topic he is not being grandiose. Other patients with multiple reports included the young cardiac patient, the Australian lady with “pulmonary embolism,” and the patient with filariasis who orders his own medication by imitating a physician.

There were some striking similarities among the patients in this select group. All were skillful in the use of medical terminology, and they showed a technical knowledge beyond the reach of the average layman. All had serious medical prob- lems and underwent repeated surgery. It seemed apparent that many of their medical problems should have resolved but did not because of the patient’s life style. They kept their illnesses active. Their hospital admissions generally followed a pattern, varying each time only in minor detail or with the embellishment of an additional symptom. Finally, all were drug abusers, and they were able to maintain their supply of medicines by skillful ploys on the hapless physician.

‘In my first interview with the black “nuclear physicist,” he emphatically denied the prison record attributed to him by Puzzuoli (1978). He stated that he stays only in the finer hotels to avoid police and the possibility of a forced withdrawal from his addiction in ajail. However, he does have a history of convictions, mostly relating to his use of hospitals during the past 30 years. He is now attempting to establish a less destructive life in the Northwest.

*A complete list of references on Munchausen syndrome patients may be obtained from Loren Pankratz, Psychology Service, Veterans Administration Medical Center, Portland, Oregon 97201.

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70 Loren Pankralz

THE DIAGNOSIS

unfortunately, the diagnosis of the ~~unchaus~n syndrome will not be made through laboratory tests as suggested by an eager hematology department (Weaver, McMillan, Longmire, Yam, & Crosby, 1974). Their facetious article is a reminder that this syndrome is not a disease entity but a cluster of behaviors. Before con- sidering what the Munchausen syndrome is, it may be easier to consider further what it is not. At least some attempt should be made to differentiate the syndrome from other abnormal illness behaviors. Some authors, for example, failed to provide convincing evidence that they had considered orher alternatives, such as malin- gering, sociopathy with substance abuse, emotional disturbance with factitious ill- ness, factitious illness without peregrination, unusual traits, and outrageous be- havior.

I estimated that about 14% of the adult cases in my review presented insufficient evidence that a more common diagnosis would nut be more appropriate than the diagnosis of Munchausen syndrome. The most distressing use of the syndrome, however, was not in those cases with the fewest syn~ptoms or with inadequate differentiation. Rather, in some cases the Munchausen label seemed to be used as a method for referring the patient to another service or as a method for denying service to the patient.

I believe there are two viable options for defining the Munchausen syndrome. The first option would be to accept the diagnostic criteria of chronic factitious illness as outlined in the psychiatric manual. The two terms would then be consid- ered synonymous. The second option would be to use the Munchausen syndrome in its historical use, as one variation of many possible abnormal illness behaviors.

The diagnostic criteria for chronic factitious illness with physical symptoms in- cludes: a. Presentation of physical symptoms apparently under the individual’s control

that result in multiple hospitalizations. b. The individual’s goal is apparently to assume the “patient” role and is not

otherwise easily understandable. Many authors have attempted to define the Munchausen syndrome. However,

after reviewing the set of patients identified in this study, I conclude that Asher (195 1) has best captured the spirit of the syndrome in a few brief paragraphs. Diagnostic criteria for the more historical use would include these additional items: C. Peregrination (itinerancy) to avoid follow-up or commul~ication among care-

takers. d. A presentation or personal style characterized by dramatics, grandiosity, or

the extraordinary. Carney (1980) has un~~ittingly provided a comparison of these two possible

definitions by dividing a group of artifactual illness patients into wanderers and non-wanderers. Interestingly, the non-wanderers were less dramatic in their pres- entation, more expressive of personal problems, and harder to detect as having artifactual problems. The wanderers, on the other hand, were more frequently aggressive, abused drugs and alcohol, had long histories of social maladjustnlent, dnd had more records of criminal activity. The majority of these patients were not the colorful men who wandered from hospital to hospital but rather were a group whose personalities were staid and symptomatology prosaic. The lesson should be

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Munchawen Syndrome 71

clear that if one only looks for Munchausen syndrome patients (in the historical sense), many other patients with illness behaviors might be missed.

ETIOLOGICAL AND DEVELOPMENTAL CONSIDERATIONS

The cause of the Munchausen syndrome is uncertain, and it probably does not arise from any single one. It is possible there may be different subtypes of Mun- chausen patients just as there are different subtypes of alcoholics.

Psychodynamics and Social History

Ford (1973) provided a comprehensive analysis of the psychodynamic factors in- volved in the development of the Munchausen syndrome. It is clear that many of these patients have experienced parental sadism, loss, or rejection, as well as ex- posure to chronic illness and institutionalization. Clearly, these early social situations are ideal for learning deviant methods of gaining attention, avoiding responsibility, maintaining a dependent role, and causing conflict with authority and parental figures.

Although a few authors have provided some developmental data on their pa- tients, there is virtually nothing known about the level of functioning of the patient outside the hospital. For example, little is known about the social support network, marital relationships, or social skill repertoire. Although a sizable number are identified as a part of the medical or paramedical profession, little is known about their job history, occupational attainment, or job competency. Extensive efforts have been made to track the itinerary of their hospitalizations, but virtually no effort has been made to interview informants outside the hospital to understand the social history. It is unclear if the Munchausen behaviors of deception, gran- diosity, lying, and dependency persist outside the hospital.

Substance Abuse and Personality Problems

Mendel (1974) suggested that psychiatrists, in an attempt to avoid pejorative epi- thets such as “deadbeats” or “professional hospital bums,” have placed these patients into diagnostic categories. These patients do not, however, fit the regular psychiatric categories, and Mendel suggested that the common theme was the longstanding (characterological) demanding and manipulative behavior. Furthermore, he em- phasized the long history of drug abuse in Munchausen patients and suggested that it was merely a variant of the drug-dependent personality.

Indeed, there does appear to be a number of addicts who are out to manipulate the physician for the sake of manipulation, and these patients are devastating to detoxification programs (Hayward, 1977). Nevertheless, most reports on Mun- chausen patients with drug abuse do not provide adequate histories for differen- tiating the styles of abuse. For example, a patient may demand drugs for sensation seeking, peer approval, and defiance of society; whereas another patient may seek drugs for coping with anxiety, avoiding conflict, and managing his isolation. These two different types of patients, both with drug-seeking behavior, can be sorted out by a careful developmental history. It would be helpful to know which type of drug abuse the patient has, not merely that he abuses drugs. In most cases we do not even know if the drug abuse occurred before or after the onset of the Munch; usen activities.

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72 Loren Pankratz

Similarly, it is difficult to sort through the personality or characterological issues, although an attempt may be worthwhile. Primary and secondary gains are not easy to distinguish, and many authors point out that the painful operations and invasive procedures these patients demand can hardly be considered a personal gain.

Munchausen patients are frequently labeled with a variet.y of personality disorder types, such as histrionic, antisocial, passive-dependent, and borderline. However, most often an interesting developmental incident is related rather than specifying the criteria used to make the diagnosis. A personality disorder is not established by the distastefulness of the patient’s behavior but through a careful history. The diagnostic manual is clear that personality disorders must begin with specified behavioral patterns in the developmental years.

Mental Function Consiciera tions

Developmental and characterological factors may best explain the Munchausen syndrome; however, another consideration is central nervous system dysfunction. Although Ireland et al. (1967) indicated that brain damage was evident in their patient and in many of those they reviewed, few authors have actively pursued the question of brain dysfunction. Three of the four cases presented by Cramer, Gersh- berg, and Stern (197 1) appeared to have evidence of brain dysfunction; neverthe- less, the issue was ignored in their discussion in favor of describing primary and secondary gain, relationships with physicians, and other dynamic considerations. Only a few authors have presented even the most rudimentary descriptions of a neurological exam, EEG, mental status exam, or intellectual or neuropsychological testing.

Brain dysfunction could account for Munchausen behaviors such as pseudologia phantastica, those outrageous lies that are practically the pathonomonic foundation of the syndrome. Stern (1980) suggested that the pseudologia is actually a coun- terphobic attempt to establish superiority and control, but Munchausen patients seem strangely unaware of the illogicality of their story. Any person intent on deception or acting out some illusion ought to be able to make a more subtle and believable presentation.

A patient with grandiosity, confabulations, p~eu~olo~c~l p~~l~~a.~t~c~, or a confusing presentation should be evaluated for brain dysfunction, especially of the right hemisphere. Lezak (Note 1) suggested that right hemisphere damaged patients show: (1) defects in organization, (2) fragmented awareness, and (3) illogicality without generally impaired verbal reasoning. This right hemisphere impairment may well explain the strange presentation of some Munchausen patients. Indeed, such confabulations and dramatic symptoms are known to occur after brain injury (Levin & Grossman, 1978; Lezak, 1978; Weinstein & Lyerly, 1966, 1968).

An example of brain dysfunction was provided by a 29-year-old Munchausen syndrome patient who was quite facile with medical terminology. Although his verbal skills suggested adequate intelligence, his direct copy of the Rey-Osterrieth Complex Figure (Figure 1) revealed severe problems in perceptual organization. He stated that he was not much of an artist, but he produced his copy (Figure 2) with a startling lack of critical evaluation of his performance. It was easier to understand the reason why he made such outrageous conclusions about his medical condition once his defects in perceptual organization were observed on this and other neuropsychological tests.

Page 9: A review of the Munchausen syndrome

Munchausen Syndrome

FIGURE 1. Rey-Osterrieth Complex Figure Test.

FIGURE 2. Copy of the Rey-Osterrieth Figure by a 29-year-old Munchausen

syndrome patient.

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74 Loren Pankratz

In summary of the etiological factors, it must be said that we are a long way from any clear understanding of the etiology of the syndrome. Vale (1962) rightly stated that “no formulations come close to explaining.. what such behavior is all about.” Indeed, the most erudite explanations seem “thin as the emperor’s clothes.” It is difficult to construct one theory that can explain the self-destructiveness of injecting oneself with parrot feces, the grandiosity of claiming to be an oceano- graphic physicist working with Jacques Cousteau, the passivity of submitting to 48 lumbar punctures, the skill to stop breathing to unconsciousness, and the wander- lust for 423 admissions.

PHYSICAL SYMPTOMS

Asher (195 1) carefully emphasized that Munchausen patients are often quite ill, although their illness is shrouded by duplicity and distortion. As previously noted, the diagnosis of Munchausen syndrome is made without reference to the physical condition of the patient, but this is easily forgotten or denied. The Munchausen patient is probably at high risk for both primary and secondary medical problems.

A Munchausen patient known to the present author presented over the years factitious neurological symptoms, genito-urinary problems, abnormal endocrine tests, gastro-intestinal problems, depression, and drug abuse. His chest pain com- plaints were largely ignored until coronary angiography revealed triple artery dis- ease. Even these results were disputed because of his Munchausen diagnosis, his age (35 years), and his penchant for unnecessary surgery. All three vessels were in fact seriously diseased, and a bypass operation was performed.

Another concern is the problem of the surreptitious continuation of an existing medical problem. Physicians are well acquainted with self-inflicted conditions such as those caused directly by self-mutilation, or indirectly as through the abuse of alcohol. However, symptoms are expected to resolve (temporarily) during the hos- pital stay. This expectation was well described by Parsons (1951), who discussed the demand upon the patient to seek professional help and cooperate in the process of getting well. ‘I‘he Munchausen patient may violate the rule of the sick role by maintaining the symptoms that brought him to the hospital. This may be done by continually presenting the appearance of the symptom, such as factitious fever or hematuria, by maintaining the symptom in an active state such as reintroducing stones into the bladder, by ingesting medications surreptitiously, or by self-injecting harmful substances. A variation of this problem is the passive neglect of proper care as in failure to take required medication or living as if a serious condition did not exist.

Finally, physicians should be aware of the iatrogenic problems that exist (and can be caused to exist) in the Munchausen patient. Justus and Kitchens (1976) reported on a man who had symptoms of exotic diseases and filariasis. He was discovered to have leukemia that probably resulted from many years of needless radiographic exposure. Repeated X-ray exposure has also been implicated as the cause of leukopenia and alopecia. Some surgeries are followed by adhesions, ab- cesses, or loss of function, as in the case of the lady who had a leg amputated because of pain (Laudadio, Eickenberg, 8c Amin, 1979).

A medical illness is the ticket by which the hlunchausen syndrome patient is admitted and maintained in the hospital. Thus, one should expect the Munchausen syndrome patient to have a medical illness that needs care. It is important to remember that a Factitious illness does not necessarily mean “imaginary” but means “arising from an artificial source.” Although some patients entirely feign their

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Munchausen Syndrome 75

symptoms, such as pretending to have a fever by manipulating the thermometer, an equal number of patients created serious symptoms, such as causing a fever by self-injection of a harmful substance. Therefore, the Munchausen syndrome patient cannot be easily ignored or referred away.

The state of health is not at issue in the diagnosis. The presenting problem may be self-induced, feigned, or a properly presented medical emergency beyond the control of the patient. Indeed, one patient had a bona fide stroke while hospitalized, and he rightly retained his Munchausen diagnosis.

IDENTIFICATION AND TREATMENT CONSIDERATIONS

The Emergency Room

An ounce of prevention in the emergency room is worth a pound of cure on the ward. The early identification of the Munchausen patient is essential for the pre- vention of unnecessary medical intervention, which merely serves to entrench the patient further into the illness role. The first line of defense is an educated ad- missions staff that can properly identify the level of evaluation and care needed. Many of these patients arrive at night when less experienced staff are more likely to provide an admission to the hospital, rather than attempt the complex diagnostic procedures or search for alternative dispositions when needed consultants, labo- ratory services, and social service agencies are unavailable.

How are Munchausen patients identified in the emergency area? Suggestions have been made for a blacklist, rogue’s gallery, a registry with photographs and fingerprinting. Hospitals dropped their “professional patients” section but will prob- ably renew this feature. Hospitals that have the mechanisms for communication (such as the Veterans Administration Hospitals) should consider the issue. One resourceful hospital used a variation of the register by giving a Munchausen patient a medical alert bracelet with the diagnosis carefully inscribed. Unfortunately, most patients will not arrive so well labeled. Furthermore, a blacklist may provide a false sense of security. Deaths have been reported where the doctor was unwilling to believe in an underlying organic condition (Berney, 1973), illustrating again that the Munchausen diagnosis says nothing of the medical status.

Clearly, data gathering and sorting cannot be completed in an emergency room setting. Nevertheless, certain basic screening should be completed before the patient is admitted. For example, in a recent study one-third of the patients in an emergency room for psychiatric reasons were in the midst of concurrent therapy (Kass, Karasu & Walsh, 1979), and the same may be true of patients with physical symptoms. Elsewhere I have outlined a series of screening strategies and alternatives to im- mediate hospitalization (Pankratz & Lipkin, 1978). Although the suggestions were for transient psychiatric patients, many of the procedures would be the same for patients with unusual, undocumented, or persistent medical conditions. The basic strategy is to avoid conflict over the veracity or seriousness of the symptom and work toward collection of more information and toward agreement about how to attain the best outcome.

On the Ward

Once on a hospital ward, the data gathering and sorting must continue in an attempt to understand the patient and his symptoms. Treatment of the medical

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76 Lorrn I’ankratz

symptoms and of the Munchausen syndrome behaviors are two separate problems, easily confounded by the demanding behavior of the patient. Beginning with a clear problem list, the primary care physician must find a balance between providing a rapid “medical clearance” and conducting an extensive search for low probability disorders. Clearly, non-invasive diagnostic tests are preferred. For example, a strat- egy has been described for the assessment of any sensory deficit (Pankratz, 1979).

Symptoms are important to the Munchausen patient. New or unresolved symp- toms are needed to maintain the hospital stay. ~I‘he wise physician will avoid struggle over the cause or seriousness of a symptom while completing the evaluation. Then the patient and doctor can focus on the agreement of purpose, even though they may disagree openly over the method of obtaining the outcome. Far worse problems result when the physician avoids interaction with the patient, leaving opportunity for the patient to undermine the physician’s credibility, creating an uproar with nurses and other patients.

Disposition and Follow-up

Thus far the discussion has focused on management of the patient during assess- ment. Once the workup is completed, however, some disposition must be made. Of the cases reviewed, the two most common responses were confrontation and referral for psychiatric services. Ferguson and Maki (1978) recommend confron- tation so the patient may be apprised of the danger of the behavior. Others, such as Sendbuehler and Nemeth (1967), suggest that “confrontation leads to quick departure and repetition of the play-acting in another locality.”

My review shows that the response to confrontation varies widely. Some patients show outrage, quick departure, denial, a peculiar bland denial, relief, and re- pentance. One patient became confused and psychotic when confronted; another became depressed and suicidal. Interestingly, some of those who were repentant after confrontation continued to act out whereas some who initially responded with denial were subsequently able to benefit some from therapy (Fras & Coughlin, 1971; Fries, Norlen, SC Danielson, 1977; Meadow, 1977; Seijffers & Welner, 1969).

Similarly, patients referred for psychiatric care showed a variety of responses. Some patients threatened legal action for insinuating a psychiatric problem. Others quickly departed, refused care, accepted the referral, but were unable to benefit from therapy. And again, others responded with a more positive outcome (Pat- terson, Schatz, & Horton, 1974; Sneed & Bell, 1975; Tucker, Hayes, Viteri, 8c Lieberman, 1979; TEC, 1975; Yassa, 1978). Although there are more reports with a hopeful outcome than generally recognized, more objective criteria than the patient’s self-report is clearly needed (J amieson, McKee, 8c Roback, 1979).

It may be presumptuous to give much advice on the follow-up of these patients. We planned an outpatient CT-scan on one Munchausen patient to corroborate some of our nemopsychological findings. However, he failed to return even after calls and letters. It was ironic that a man who had injured himself, opened and infected wounds, and brought himself to the edge of death for the purpose of obtaining hospital admission would not return when asked to do so. Such elusive behavior is typical of this frustrating syndrome.

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Munchuwen Syndrome 77

CONCLUSIONS

The proper identification of Munchausen syndrome patients must rely on knowl- edgeable clinicians who attempt to understand all illness in a broad context. Thus, it is not necessary to be suspicious of every patient. Rather, all patients must be carefully interviewed, and past records must be sought. When no records are immediately available, it is generally easy to telephone others who have knowledge of the patient. Such calls are worth the cost because a high percentage provide important data. Legitimate patients are flattered by the thoroughness of such an approach. Even patients alienated from their family are cooperative with such efforts. imposters, transients, and Munchausen syndrome patients survive on an- onymity and secrecy, hiding their records and the context of their illness.

The clinician does not merely gather the patient’s history to avoid deception by the patient; he also seeks an understanding of the illness for the proper level of intervention. Patients with thick charts or repeated admissions may have social problems, secondary depression, difficulty following prescribed treatments, or other problems that are important to consider. The patient who is struggling with illness and the patient who is pretending illness both need special attention.

REFERENCE NOTES

1. Lezak, M. D. Behavioral concomitants of configurational disorganization in right hemtiphere damaged patients. Paper presented at the meeting of the International Neuropsychological Society, New York City, February, 1979.

REFERENCES

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