Fake’s progress: A beginner’s guide to Münchausen syndrome

One of the most interesting psychological disorders is Münchausen Syndrome (MS) and is sometimes referred to more colloquially as ‘hospital addiction syndrome’, ‘hospital hopper syndrome’ and ‘thick chart syndrome’. MS is currently classified in the most recent International Classification of Diseases under ‘other disorders of adult personality’. The primary characteristic of people suffering from MS is that they deliberately pretend to be ill in the absence of external incentives (such as criminal prosecution or financial gain). MS has been called a factitious disorder because sufferers feign illness, pretend to have a disease, and/or fake psychological trauma typically to gain attention and/or sympathy from other people. Doctors often nickname such people as ‘frequent flyers’. The name of the syndrome was coined in 1951 by Dr. Richard Asher (in a paper he published in The Lancet about people who fabricated illnesses) and derives from German Karl Friedrich Hieronymus Freiherr von Münchhausen (aka Baron Münchausen), a renowned eighteenth century nobleman, who was reported as telling many fantastical and impossible stories about himself.

A related condition is Münchausen Syndrome by Proxy refers to the abuse of someone else (quite often a child son or daughter), also as a way of seeking attention and/or sympathy for the sufferer. Some members of the medical community believe that this related MS condition should simply be re-named ‘medical abuse’). There are also some specific sub-types of MS. For instance, a 2011 paper in the Journal of Electrocardiology, by Dr. Joseph Vaglio reported a female case of Arrhythmogenic Münchausen Syndrome who intentionally simulated and stimulated irregular cardiac activity to gain medical attention by drinking (and overdosing) on caffeine.

According to Dr. A.J. Giannini and Dr. H.R. Black in the Psychiatric, Psychogenic and Somatopsychic Disorders Handbook, one of the most common signs among MS sufferers is that they may have multiple scars on their abdomen because of repeated exploratory or emergency operations. Other ‘warning signs’ listed on the Web MD website of MS include: (i) dramatic but inconsistent medical history, (ii) predictable relapses following improvement in the condition, (iii) detailed knowledge of hospitals and/or medical terminology, (iv) appearance of new or additional symptoms following negative test results, (v) willingness or eagerness to have medical procedures, (vi) history of seeking treatment at numerous hospitals, clinics, and doctors offices, possibly even in different cities, and (vii) problems with identity and self-esteem.

There has been a debate about whether MS should have been re-classified in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. For instance, in a 2008 issue of the journal Psychosomatics, Dr. Lois Krahn and her colleagues argued that MS should be classed as a somatoform disorder because MS sufferers may not be conscious that they are drawing attention to themselves. [According to Wikipedia, a somatoform disorder “is a mental disorder characterized by symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder”]. More specifically, Krahn and her colleagues noted:

“Factitious and somatoform-disorder patients are alike in that they both organize their lives around seeking medical services in spite of having primarily a psychiatric condition. In DSM–IV, the key difference is that factitious-disorder patients feign illness, and somatoform disorder patients actually believe they are ill. Although patients may not be conscious of their motivation or even their behaviors, deliberately embellishing history or inducing symptoms exemplifies behaviors designed to enhance a self-concept of being ill. For DSM–V, we propose reclassifying factitious disorder as a subtype within the somatoform-spectrum disorders or the proposed physical-symptom disorder, premised on our belief that deliberate deceptions serve primarily to portray to treaters the sense of being ill”.

This appears to be part of the same debate that says MS is distinct from hypochondriasis in that MS patients are said to be aware that they are exaggerating their illness or disease, whereas hypochondriasis sufferers actually believe they have an illness or disease. Another way of looking at it is that MS sufferers want to be a patient whereas those with hypochondriasis don’t. One of the more unusual consequences of MS is that the affected individual will often undergo unnecessary medical procedures, treatments and/or exploratory operations to prolong hospital stay and gain sympathy and attention from those around them including the medical and nursing staff. It is also known that some MS patients have very good medical knowledge and use this as a way of creating and/or producing symptoms of known medical conditions.

Some of the reported risk factors for individuals that develop MS include (i) a history of childhood traumas and (ii) emotional deprivation (e.g., having parents or guardians that were emotionally unavailable due to illness and/or emotional problems while the individual was a child). In relation to treatment and prognosis, the Wikipedia entry on MS asserts:

“Providers need to acknowledge that there is uncertainty in treating suspected Münchausen patients so that real diseases are not under-treated. Then they should take a careful patient history and seek medical records, to look for early deprivation, childhood abuse, or mental illness. If a patient is at risk to himself or herself, inpatient psychiatric hospitalization should be initiated…Therapeutic and medical treatment should center on the underlying psychiatric disorder: a mood disorder, an anxiety disorder, or borderline personality disorder. The patient’s prognosis depends upon the category under which the underlying disorder falls; depression and anxiety, for example, generally respond well to medication and/or cognitive-behavioral therapy, whereas borderline personality disorder, like all personality disorders is presumed to be pervasive and more stable over time, thus offers the worst or best prognosis”.

Unfortunately there are no reliable statistics regarding the number of people who suffer from MS. Research suggests that both males and females are affected in roughly equal numbers and that the mean age of presentation is 36-years old. This is certainly one behaviour that we could do with more empirical research.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Asher, R. (1951). Munchausen’s syndrome. The Lancet, 1, 339–341.

Bhugra D. (1988). Psychiatric Munchausen’s syndrome. Literature review with case reports. Acta Psychiatrica Scandinavica, 77, 497–503.

Feldman, M.D., Hamilton, J.C & Deemer, H.N. (2001). Factitious Disorder. In K.A. Phillips (Eds.), Somatoform and Factitious Disorders. Washington D.C.: American Psychiatric Association.

Giannini A.J. & HR Black, H.R. (1978). Psychiatric, Psychogenic and Somatopsychic Disorders Handbook (pp.194-195). New Hyde Park, NY. Medical Examination Publishing.

Krahn, L.E., Bostwick, J.M. & Stonnington, C.M. (2008). Looking toward DSM-V: Should factitious disorder become a subtype of somatoform disorder? Psychosomatics, 49, 277–282.

Vaglio, J. C., Schoenhard, J. A., Saavedra, P. J., Williams, S. R., & Raj, S. R. (2011). Arrhythmogenic Munchausen syndrome culminating in caffeine-induced ventricular tachycardia. Journal of Electrocardiology, 44, 229-231.

Wikipedia (2013). Münchausen syndrome. Located at: http://en.wikipedia.org/wiki/Münchausen_syndrome

An eye for an I! A beginner’s guide to auto-enucleation

I have to say that I have no idea what it must be like to lose an eye (i.e., enucleation) but one thing I can’t possibly begin to imagine is what it must like is to remove my own eye (i.e., auto-enucleation). However, there are many clinical and medical reports of people that self-mutilate by stabbing or removing their eye(s). Arguably the most infamous auto-enucleator was Oedipus (in Sophocles’ play) who removed both his eyes after he realized he had unwittingly slept with his own mother and killed his own father.

The psychiatrist Dr. Armando Favazza defines self-mutilation as “the deliberate, direct, non-suicidal destruction or alteration of one’s body tissue”. Dr. Niraj Ahuja and Dr. Adrian Lloyd writing in the Australian and New Zealand Journal of Psychiatry also add that self-mutilation relates to bodily self-damage without wishing to die. Dr. Favazza also believes there are three fundamentally different types of self-mutilation. Enucleation is included in the first type (major self-mutilation) and is the least common. Other forms of self-mutilation in this category include self-castration, penectomy (cutting off one’s own penis) and self-limb amputation.

The second type includes “monotonously repetitive and sometimes rhythmic acts such as head-banging, hitting, and self-biting” (which according to Dr Favazza occur mostly in “moderate to severely mentally retarded persons as well as in cases of autism and Tourette’s syndrome”). The final and most common forms of bodily self-mutilation are moderately superficial and include a compulsive sub-type (e.g., hair-pulling, skin scratching and nail-biting), as well as an episodic/repetitive sub-type (e.g., skin-cutting, skin carving, burning, needle sticking, bone breaking, and wound picking). Many of these self-harming behaviours are a symptom and/or an associated feature in a number of mental personality disorders (e.g., anti-social, borderline, and histrionic personality disorders).

Reports of auto-enucleation in the medical literature were first described in the 1840s. By the early 1900s, the act of removing one’s own eye was actually termed ‘Oedipism’ by Blonel. Auto-enucleation is (of course) exceedingly rare although a couple of studies in the American Journal of Ophthalmology (in 1984) and an analysis of 1,146 enucleations between 1980 and 1990 in the British Journal of Ophthalmology (in 1994) estimated there were 2.8 to 4.3 per 100,000 in the population. However, some papers (such as those by Dr. Favazza) on major self-mutilation have put the incidence as low as one in 4 million.

Enucleators are also known to be at increased risk of further self-harming, and (predictably) are more likely to be living in psychiatric institutions when the auto-enucleation event occurs. They are also at increased risk of removing the second eye at a later date if they didn’t pull out both eyes to start with. A review by Dr. H.R. Krauss and colleagues in a 1984 issue of the Survey of Opthalmology examined 50 cases of self-enucleation and reported that 19 of them had bilateral auto-enucleation (i.e., had removed both of their eyes). A 2007 paper by Dr. Alireza Ghaffari-Nejad and colleagues in the Archives of Iranian Medicine examined the many theories behind self-harming behaviour. They briefly overviewed theories ranging from Fruedian psychoanalytic theory to biologically-based theories. They wrote:

Psychoanalytically self-injurious behaviour has been linked to castration and explained as a process of failure to resolve oedipal complex, repressed impulses, self punishment, focal suicide and aggression turned inwards especially in cases of depression. [Other authors] have postulated interpersonal loss preceding self-injurious behaviour and linked it to rejection sensitivity…Biologically serotonergic depletion preceding self-mutilation has been linked to aggression and depression…Some authors have claimed strong moral, religious and delusional component”

A recent literature review by Dr. Alexander Fan in the journal Psychiatry reported that the vast majority of auto-enucleation cases suffer from psychotic illness (particularly schizophrenia) although other medical and/or psychiatric conditions associated with auto-enucleation include obsessive-compulsive neuroses, severe depression, post-traumatic stress disorders, drug-induced psychoses, bipolar mania. There are also case studies where auto-enucleation has been linked with structural brain lesions, Down Syndrome, epilepsy, neurosyphilis, and Lesch-Nyhan syndrome (juvenile gout). These are similar to other forms of extreme self-mutilation. For instance, self-mutilation in schizophrenia in response to auditory hallucinations has often been described as Van Gogh Syndrome (in reference to the painter’s self-excision of his own left ear)

Other reviews of the psychiatric literature have reported that those who remove their own eyes commonly have delusions (typically sexual and/or religious) and that when asked about motivations for self-harming include reasons such as guilt, atonement, sin, evil, etc. Although some authors have noted that enucleators with religious beliefs are often Christian, other case studies have made reference to other religious faiths (e.g., Muslims). Finally, another paper by Favazza in Hospital and Community Psychiatry concluded that:

“Males in a first episode of a schizophrenic illness that is characterized by delusions associated with a body part or religious delusions are at the greatest risk for MSM [major self-mutilation]. However, MSM of this severity is so rare that it cannot be predicted accurately unless there has been a previous attempt at self-injury or the patient has spoken about wanting to remove or injure an organ. Threatened ocular mutilation deserves special mention because it may occur in a hospital setting, and the case histories suggest that one-to-one nursing is not always be sufficient to prevent enucleation”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Berguaa, A., Sperling, W. & Kuchlea M. (2002). Self-enucleation in drug-related psychosis. Ophthalmologica, 216, 269-271.

Eric, J.C., Nevitt, M.P., Hodge, D. &  Ballard, D.J. (1984). Incidence of enucleation in a defined population. American Journal of Ophthalmology, 113, 138-44.

Fan, A.H. (2007). Autoenucleation: A case report and literature review. Psychiatry, October, 60-62.

Favazza, Armando (1998) ‘Introduction’, in Marilee Strong A Bright Red Scream: Self-mutilation and the Language of Pain. New York: Viking.

Favazza, A. & Rosenthal R. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44, 134-140.

Field, H. & Waldfogel, S. (1995). Severe ocular self-injury. General Hospital Psychiatry, 17, 224-227.

Gamulescu, M.A., Serguhn, S., Aigner, J.M., Lohmann, C.P., & Roider J. (2001). Enucleation as a form of self-aggression, two case reports and review of the literature. Klin Monatsbl Augenheilkd, 218, 451-454.

Ghaffari-Nejad, A., Kerdegari, M., & Reihani-Kermani, H. (2007) Self-mutilation of the nose in a schizophrenic patient with Cotard Syndrome. Archives of Iranian Medicine, 10, 540-542.

Gottrau, P., Holbach, L.M. & Nauman, G.O. (1994). Clinicopathological review of 1,146 enucleations (1980-90). British Journal of Ophthalmology, 78, 260-5.

Jeffreys, S. (2000). ‘Body art’ and social status: Cutting, tattooing and piercing from a feminist perspective Feminism and Psychology, 10, 409-429.

Krauss, H., Yee, R. & Foos, R. (1994). Autoenucleation. Survey of Ophthalmology, 29, 179-87.

MacLean, C. & Robertson, B.M. (1976). Self enucleation and psychosis. Archives of General Psychiatry, 33, 242-249.

Patil, B. & James, N. (2004). Bilateral self-enucleation of eyes. Eye, 18, 431-432.

Patton N. (2004). Self-inflicted eye injuries: A review. Eye, 18, 867-872.

Rao, K.N. & Begum, S. (1996) Self enucleation in depression; A case report. Indian Journal of Psychiatry, 38, 267-70

Witherspoon, D., Feist, F., Morris, R. & Feist, R. (1989). Ocular self-mutilation. Annals of Ophthalmology, 21, 255-259.

Spare fib: Should pathological lying be considered a mental disorder?

In a previous blog on weird addictions, compulsions and obsessions, I briefly looked at pathological lying. Writings relating to pathological lying first appeared in the psychiatric literature over 100 years ago and have been given names such as ‘pseudologia fantastica’ and ‘mythomania’ and often used interchangeably. There is some consensus that Dr. Anton Delbruck, a German physician was the first person to describe the concept of pathological lying in 1891 after publishing an account of five of his patients. Despite the long history of research, pathological lying is not included in either the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) or the World Health Organization’s International Classification of Diseases (ICD-10). The only mention of pathological lying in the DSM-IV is in association with Factitious Disorder (discussed below), However, many psychologists and psychiatrists claim that it is a distinct psychiatric disorder as highlighted in the many papers that have been published on the topic over the last two decades.

At a very simplistic level, pathological lying refers to a person that incessantly tells lies. However, Dr Charles Dike and his colleagues at Yale University define it as “falsification entirely disproportionate to any discernible end in view, may be extensive and very complicated, and may manifest over a period of years or even a lifetime, in the absence of definite insanity, feeble-mindedness or epilepsy”. However, there are other psychiatric conditions (such as people with Manipulative Personality) that may also engage in pathological lying as part of a wider set of behaviours and symptoms. In fact, there is a lot of debate as to whether the behaviour is really a discrete and unique entity or whether it typically manifests itself as an adjunct to other recognized psychological and/or psychiatric conditions. Dr Dike and colleagues note that:

“Pathological liars can believe their lies to the extent that, at least to others, the belief may appear to be delusional; they generally have sound judgment in other matters; it is questionable whether pathological lying is always a conscious act and whether pathological liars always have control over their lies; an external reason for lying (such as financial gain) often appears absent and the internal or psychological purpose for lying is often unclear; the lies in pathological lying are often unplanned and rather impulsive; the pathological liar may become a prisoner of his or her lies; the desired personality of the pathological liar may overwhelm the actual one; pathological lying may sometimes be associated with criminal behavior; the pathological liar may acknowledge, at least in part, the falseness of the tales when energetically challenged; and, in pathological lying, telling lies may often seem to be an end in itself. However, it is evident that no single descriptive tableau of a pathological liar settles all the nosological and etiological questions raised by the phenomenon of pathological lying” (p.344)

Dike and colleagues then went on to list a wide range of psychiatric conditions that have been associated pathological lying in an attempt to contextualize how the lying behaviour is manifested within these known conditions. The list of psychological and psychiatric conditions included: (i) Malingering, (ii) Confabulation, (iii) Ganser’s Syndrome, (iv) Factitious Disorder, (v) Borderline Personality Disorder, (vi) Antisocial Personality Disorder, (vii) Histrionic Personality Disorders. Arguably it is these last three disorders with which pathological lying is most associated with. The following briefly describes the symptoms and context of each of these conditions as outlined by Dr Dike and his colleagues:

• Malingering: This is deliberate lying where the person grossly exaggerates or totally lies about physical and/or psychological symptoms. Unlike ‘archetypal’ pathological liars, malingerers are typically motivated to tell lies for a specific purpose such as to obtain financial compensation, to avoid working, to avoid military service, to avoid criminal prosecution, etc.
• Confabulation: This is where people tell lies incessantly as a way of covering up memory lapses caused by specific memory loss conditions (e.g., organically derived amnesia). In ‘archetypal’ pathological liars, the condition is psychological (rather than organic) in origin.
• Ganser’s Syndrome (GS): GS is a rare dissociative disorder (only 101 recorded cases ever) characterized by affected people giving nonsensical answers to questions (and goes under many other names including ‘nonsense syndrome’ and ‘balderdash syndrome’). Unlike the elaborate and sometimes fantastical stories told by ‘archetypal’ pathological liars, the lies told by those with GS are very simplistic and approximate.
• Factitious Disorder (FD): FD is the deliberate use of lies and/or exaggerations concerning psychological and/or physical symptoms solely for the purpose of assuming the role of a sick person (formerly known as Munchausen’s Syndrome). In contrast, the ‘archetypal’ pathological liar doesn’t want to appear sick to other people.
• Borderline Personality Disorder (BPD): BPD is the condition where people have long-term patterns of unstable and/or turbulent emotions. Pathological lying and being deceitful are core characteristics of BPD and lies are typically told for personal profit or pleasure. Although. BPD patients typically have contradictory views about themselves and lack a consistent self-identity. A lack of impulse control may facilitate the distortions and lies told.
• Antisocial Personality Disorder (APD): APD is the condition in which the sufferer has a long-term pattern of manipulating, exploiting, or violating the rights of others (and is often criminal). Those with APD often lie repeatedly and consistently for personal satisfaction alone. Although those with APD are often pathological liars, ‘archetypal’ pathological liars rarely have disordered antisocial personalities.
• Histrionic Personality Disorder (HPD): Those with HPD act in a highly emotional and dramatic way to draw attention to themselves. They often lie as a way to enhance and/or facilitate their dramatic and attention-seeking behaviour. In contrast, ‘archetypal’ pathological liars do not constantly seek attention.

Based on the list above, it is evident that the symptom of pathological lying can occur in some mental disorders (e.g., FD, BPD) and could be called secondary pathological lying. However, it is much less clear whether it can occur independently of a known psychiatric disorder and be seen as primary pathological lying. Unlike other the other forms of lying outlined above, Dr Dike says pathological lying appears to be unplanned and impulsive. Despite all the speculation, there is still relatively little known although it’s thought to affect men and women equally with an onset in late adolescence. There are no reliable prevalence figures although one study estimated that one in a 1000 repeat juvenile offenders suffered from it.

On a biological and neurological level, a paper published in the Journal of Neuropsychiatry and Clinical Neurosciences reported the case of a pathological liar who was given a brain scan. Results showed that his condition was associated with right hemithalamic dysfunction. This supported the hypothesized roles of the thalamus and associated brain regions in the modulation of behavior and cognition.

A study published in the British Journal of Psychiatry reported differences in brain structure between pathological liars and control groups. Pathological liars showed a relatively widespread increase in white matter (approximately one-quarter to one-third more than controls) and the authors suggested that this increase may predispose some individuals to pathological lying.

Those working in the mental health system need to pay attention to pathological lying so that they can inform legal practitioners about whether pathological liars should be held responsible for their behaviour. Whether pathological liars are aware of the lies they tell has major implications for forensic psychiatry practice. Dr Dike says it could help determine how a court deals with pathological liars who provide false testimony while under oath.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Delbruck, A (1891). Die pathologische Luge und die psychisch abnormen Schwindler: Eine Untersuchung uber den allmahlichen Uebergang eines normalen psychologischen Vorgangs in ein pathologisches Symptom, fur Aerzte und Juristen. Stuttgart, 1891, p 131.

Dike, C.C., Baranoski, M. & Griffith, E.E.H. (2005). Pathological lying Revisited. Journal of the American Academy of Psychiatry and Law 33, 342-349.

Healy W, Healy MT: Pathological Lying, Accusation, and Swindling. Boston: Little, Brown, 1926

King, B.H. & Ford, C.V. (1988). Pseudologia fantastica. Acta Psychiatrica Scandinavica, 77, 1-6.

Miller, P., Bramble, D., & Buxton, N. (1997). Case study: Ganser syndrome in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 112-115.

Modell, J.G., Mountz, J.M. & Ford, C.V. (1992). Pathological lying associated with thalamic dysfunction demonstrated by [99mTc]HMPAO SPECT. Journal of Neuropsychiatry and Clinical Neurosciences, 4, 442-446.

Yang, Y., Raine, A. Narr, K.L., Lencz, T., LaCasse, L., Colletti, P. & Toga, A.W. (2007). Localisation of increased prefrontal white matter in pathological liars. British Journal of Psychiatry, 190, 174-175.