INT’L. J. PSYCHIATRY I N MEDICINE, Vol. 7(3), 1976-77
MEDICAL PSYCHOLOGY FORUM
A CASE OF CHRONIC FACTITIOUS ILLNESS* NORMAN B. LEVY, M.D. Associate Director, Medical-Psychiatric Liaison Service Associate Professor of Psychiatry TR IKANTE RAJAPAKSA, M.D. Assistant Professor of Clinical Medicine State University of New York Downstate Medical Center College of Medicine
ABSTRACT
A twenty-four-year-old woman is presented with multiple previous hospitalizations for joint and muscle pains. Guarded in her description of symptoms, she reports that “lupus” has been diagnosed at several hospitals over the past few years, unable to recall the name of any other than one previous hospital. The medical work-up failed to show any abnormality except that compatible with previously diagnosed von Willebrand’s disease. In the discussion of the case, the patient’s desire to be taken a r e of is seen as a major dynamic, causing her to fabricate illness. The diagnoses of Munchausen Syndrome, malingering, conversion reaction and hypochondriasis are discussed and differentiated from each other, and the treatment of Munchausen Syndrome is discussed.
Dr. Levy: Dr. Rajapaksa will present a patient from the medical service of this hospital. I will interview the patient and then we shall discuss the case. The patient has given us permission to tape record this interview.
*
Medical-Psychiatric Liaison Service Conference, State University-Kings County Hospital Center, Brooklyn, New York. At the time of this conference, Dr. Rajapaksa was Fellow in Psychosomatic Medicine at the State University-Kings County Hospital Center. 257 @
1977, Baywood Publishing Co.. Inc.
doi: 10.2190/W4X3-KPX2-384D-4J7U http://baywood.com
258 1 N. 0 . L E V Y AND T. RAJAPAKSA
Medical History Dr. Rajapaksa: The patient is a twenty-four-year-old, married Jewish woman, admitted to the State University Hospital a week ago with a history of muscle and joint pain and hematuria of two weeks’ duration. She claimed to have developed myalgia and arthralgia six months ago and saw a physician who diagnosed her condition as “lupus” and treated her with steroids and Imuran,’ which she discontinued after a few weeks because there was no improvement. She decided to have herself admitted to the hospital now because of worsening of the muscle pain. She said that she had been diagnosed as having von Willebrand’s disease at age fourteen, and had had excessive bleeding following a tonsillectomy. Nobody else in her family has any bleeding tendencies. Her physical examination was normal. Her hemoglobin was 7.0 gm. on admission. While she gave the nurse small samples of urine containing blood, she was unable to provide large samples of urine. The patient has complained of severe pain for which Talwin’ and Percodan3 have been prescribed. Because of the absence of objective evidence of disseminated lupus erythematosus or any other physical illness, the house staff asked the Medical-Psychiatric Liaison Service to assess the possible psychological component to her pain. When I interviewed her, the patient explained that her illness was of a much longer duration than six months: at age seventeen she had muscle and joint pains and was told then that she had “lupus.” At age eighteen, soon after marrying and leaving home, she was hospitalized in Boston for these same symptoms. Her unsuccessful marriage was annulled within a year, after which she went on a cross-country vacation with a group of friends for about two years. She said she was constantly under medical supervision during this vacation and was hospitalized in several states for the symptoms of “lupus.” She remarried four months ago. The patient is the youngest in a family of five children. Her father died when she was ten years old. Her seventy-one-year-old mother lives in Florida and the patient speaks to her by telephone several times a week. She said she didn’t want to tell the doctors that she had been previously worked up and treated for “lupus” because she wanted them to start afresh. She couldn’t remember the names of hospitals in which previous work-ups were done. Our Rheumatology Service received a call from the New York Hospital “ warning” them that there was a “Lupus-Munchausen” patient going from hospital to hospital in the New York-Metropolitan area. An intern found her handbag stuffed with bills from different hospitals, among them one for $1500
* Azathioprine.
* Pentazocine HCI. Oxycodone HCI.
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OF CHRONIC FACTITIOUS ILLNESS / 259
from the New York Hospital. After contacting some of these hospitals, we learned that one had told her she had lupus based only on her symptoms and a slightly positive anti-nuclear antibody test. Michael Blumenfield, M.D. :4 Was the sedimentation rate elevated? Dr. Rajapaksa: No, everything was normal except for the anemia and red cells in the urine.
Patient Interview Dr. Levy: Can you tell us what it was that brought you here? Patient: Well, originally I was sick in bed for two weeks and if I walked around I couldn’t breathe and I would have heart palpitations and I just couldn’t walk from one end of my apartment to another without having trouble breathing. Finally, since my husband was away, I picked a doctor’s name out of the phone book and I saw him. Dr. Levy: Did he recommend that you come in here? Patient: Well, I just couldn’t breathe. I couldn’t catch my breath, and if I would d o anything I would get heart palpitations, even if I bent down to pick something up. You know, a lot of people get heart palpitations when they are nervous but not when they bend to pick something up and I am not the nervous type-only when I am in front of a lot of people. Dr. Levy: As you are right now? Patient: Like now. [She laughs.] Dr. Levy: Are you anxious about this interview? Patient: No, not really. Dr. Levy: How long have you been having the problem breathing? Patient: I also had trouble with muscle pains since I have been seventeen and I have been to various doctors in New York City and all over the country because I had swelling in my joints. I went to California and a few other places where they told me that I had polymyositis; then most places told me that I had something called lupus. But at this hospital they claim that all my tests are coming back negative and that I don’t have lupus. Dr. Levy: Can you tell us something more about the muscle pains? What were they like? Patient: Well, they would come and go but mostly they were there being very annoying and hard for me to walk and making me very weak. Dr. Levy: What muscles were involved? Patient: Mostly all of them. They would vary. Sometimes it would last for days and then it would go away and come back some other time. They gave me certain drugs that really helped it and I gradually [her voice cracking] stopped taking them because I was getting some side effects. The cortisone Assistant Professor of Psychiatry, State University of New York, Downstate Medical Center, College of Medicine.
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gave me diabetes and that runs in my family, so I had to be very careful with that and then they stopped it and then I started taking it again. That was the only drug that would really help. Dr. Levy: What was the occasion for the travel that you mentioned before? Patient: Well, when my first marriage broke up my mother gave me some money and told me to go travel, so I did with a group of friends. I went to California, Colorado and quite a few other places. My parents live in Florida so I was there for a while too. . . . Dr. Levy: How is the muscle pain now? Patient: It hasn’t gone away. It’s more or less constant all the time. Lately I am taking Talwin. It helps it a little. Dr. Levy: How often do you take it? Patient: I suppose whenever I ask for it, they give it to me. Dr. Levy: How often does that turn out to be? Patient: About every five or six hours. Dr. Levy: How long have you been taking Talwin? Patient: On and off for the past three or four years plus I was on other drugs but they were a little bit stronger, like Percodan. At times they gave me Demerol.’ Dr. Levy: Which one was the most effective? Patient: Of course the Demerol was the best, but I don’t want to keep taking that. It makes me very sleepy and I was always sleeping with it. Dr. Levy: Was there any other reason why you didn’t want t o take it? Patient: No. Dr. Levy: Would you tell us a little bit about your background? Patient: Well, I have two sisters and two brothers. My parents live in Florida and my sisters and brothers all live in New York State and New Jersey. We are a very close family. My mother moved to Florida about three years ago. She got married again and she bought a condominium in Florida. Dr. Levy: Were your parents divorced orPatient: No, my father died. [Long pause.] Dr. Levy: Would you tell us about this? Patient: He died when I was ten years old, so I really can’t tell you very much. He died of a heart attack. Dr. Levy: How did that affect you? Patient: It really didn’t affect me in any way because I was quite young and I really didn’t know exactly what was going on. Dr. Levy: Do you have any memories of your father? Patienf: Not very much. I was very young. It’s been quite a long time. Dr. Levy: What did your mother do after his death? Patient: My mother only started working after my father died. She became Meperidine HCl.
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a private secretary of some kind and it worked out fine. I went t o school. I went t o college, I think for five months, and then that’s when I started getting sick. Dr.Levy: After you were there for five months what happened? Patient: I met somebody and I got married and I went back t o work. I got a job and I was working to put him through college. [Long pause.] Dr. Levy: Would you tell us something more about this? Patient: I met him in a hotel somewhere and we got married a couple of months later. I was in love with him and, you know, I was willing t o go t o college for him-I mean t o work for him t o put him through college and then it only lasted a year. I was putting him through college and then I found out he wasn’t going t o school and was just taking money and a lot of little things occurred-fights-and then we just broke up. Dr. Levy: He was taking your money and not going t o school? Patient: Well, I was giving him money for tuition and books and he wasn’t going t o class. Dr. Levy: What was he doing? Patient: To this day I really don’t know and I don’t care. Dr. Levy: How did you react when you discovered this? Patient: Well, I almost killed him, not literally, but I got very upset and we had big fights. We got an annulment after a year and a half of marriage. Then I met somebody else three months later and then I started traveling with my girl friends. When I was in California he came there and he got me. He wanted to get married, so I got married. Dr. Levy: Would you tell us something more about him? Patient: Well [patient starts stuttering], he’s good t o me. He understands my illness. He understands when I have t o go t o a doctor, when I have to be in a hospital and to me those are very important things. Dr. Levy: Could you tell us something more about him? Patient: He works for the State. He makes a good living and is able ro support me and give me almost everything I want. Dr. Levy: How has your illness affected your marriage? Patient: Well, I think it’s only normal for it t o affect it in some way but he accepts it because he knew everything about it before we got married. Dr. Levy: How does it affect the marriage even though he accepts it? Patient: It’s a pretty good marriage. It’s pretty stable. It’s better than it was at this point in the first marriage. Dr. Levy: Were you having trouble at this point in time in the first marriage? Patient: I was having trouble after three months and now it’s three months since I’ve been married again. . . . Dr. Levy: Have you been sick before? Patient: When I was fourteen I had my tonsils out. It didn’t go too well because I had bleeding and they told me that I had von Willebrand’s disease.
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Dr. Levy: How did von Willebrand’s disease affect you? Patient: I have to be careful in case of surgery. But I haven’t had surgery since then. So it doesn’t affect me. I have bleeding in my urine. I also had a blood clot once. I blacked out and I had severe chest pains and I couldn’t breathe and they took some tests in the emergency room and they told me I had a blood clot in my lung. Dr. Levy: What were you doing at the time that you blacked out? Patient: I was just walking in the street with a friend. We were in a strange city so she didn’t know what to do, so she just called the police. It just felt like everything was going around and I leaned against somethmg SO I wouldn’t fall and hurt my head, like a car and I slid down. I was out for like three or four seconds. I couldn’t breathe. I had chest pains in the center, in the upper part of my chest. Dr. Levy: What kind of pain was it? Patient: A very sharp pain, like a knife. . . . Dr. Levy: In what hospitals have you been treated for your illnesses? Patient: I really don’t remember any of them. The only ones I remember were the ones in New York because when I traveled I didn’t remember the names of the doctors or anything because my friends usually took me there. Dr. Levy: You mentioned hospitals in New York. Can you tell us about them? Patient: All I remember is when I first got sick I was in Kingsbrook. I don’t remember any others except this one and Kingsbrook. Dr. Levy: I would like to ask the other doctors here if they have any questions for you. Will that be all right with you? Patient: Yes. Melvyn Schoenfeld, M.D.:6 How do you handle stress in general? Patient: I just handle it the best I c a n . I try to discuss it with a friend or somebody that’s around. Dr. Schoenfeld: What about problems with your husband? Patient: My first husband? Dr. Schoenfeld: Either one. Patienf: Well, I don’t have problems with my second one. My first one is the one I had problems with and that I kept in-I think it was a big mistake. Jorge Steinberg, M.D.:’ I don’t have a clear picture of you as a person. Are YOU a sad person, a happy one, do you get moody? Can you describe yourself to us? Patient: It’s kind of a hard thing. Well, I [stutter], I handle things the best way I can. I make the most of my own decisions. No matter what they say I 6
Clinical Assistant Professor of Psychiatry, State University of New York, Downstate Medical Center, College of Medicine. I Assistant Professor of Psychiatry, State University of New York, Downstate Medical Center, CoUege of Medicine.
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make up my own mind like, for instance, in my first marriage. My family was against it but I married him anyway and when problems came up I handled them the best way I could. I went to people for advice but I made mostly my own decisions. I am very seldom sad. Most of the time when I have problems I take them the best way I can. Dr. Steinberg: What does it feel like inside when you are by yourself, alone and you are thinking about yourself, your life? Patient: I never really even thought of any of those. The only time I was alone was when I was traveling. I really enjoyed it. Dr. Steinberg: And you’re saying that you never get sad? Patient: Very seldom. The only time I get sad is when I have a lot of pain. When I have a lot of pain the only thing I want to do is just go to sleep. I want to be alone and just do anything to make the pain go away. Charlotte Nadel, M.D.:8 How does your husband feel about your being sick? Patient: He convinced me that it didn’t matter. He didn’t care and would help me the best way he could emotionally and physically. He is understanding. He understands how I feel when I have pain. I want to just lie down and be left alone. Dr. Blumenjield: What are your memories of your father? Patient: I was a change-of-life child and I was something very special. I think he was a wonderful person. Dr. SchoenfeM: Do you feel like you could use somebody to talk to about how hard it has been for you-somebody professional, like a psychiatrist or a psychologist? Patient: No. I think about it but I never really pursued it. I have a friend who was a neighbor that I speak to. Dr. Levy: Have you ever seen a psychiatrist? Patient: No, never until now. Dr. Levy: We do have to stop now. Is there anything you wish to ask us? Patient: No. Thanks for listening to me.
Discussion Dr. Rajapaksa: The patient’s older sister reported that she is a “spoiled brat” and a person who lies for no reason. She said that the patient has not traveled out of New York at all except to Las Vegas for five days over five years ago, and that there was no trip from state to state over a two year period, as was reported. The tonsillectomy and the diagnosis of von Willebrand’s disease happened two and a half years ago and not at age fourteen. The sister describes their family as an ‘‘unusual’’ one. Their father Clinical Assistant Professor o f Psychiatry, State University of New York, Downstate Medical Center, College of Medicine.
264 I N. B. LEVY AND T. RAJAPAKSA
was extremely “health conscious.” He had food fads and was obsessive about clean air and exercise. He was a construction worker who had several jobrelated accidents and finally died of a pulmonary embolus. The sister said the patient took their father’s death “very badly,” that she cried a lot and used to dream of him and wake up crying in the night for at least several months after his death. Some of this information is quite disparate from what the patient just told us. Julian J. Clark, M.D.:9 Did the sister speak of the patient’s first marriage? Dr. Rajapaksa: Yes, she said the patient was first married to a “sadistic, psychotic man.” She knows nothing about the second husband. Dr. Levy: Dr. Rajapaksa, I assume that you do not believe that this woman has organic disease other than von Willebrand’s disease, if even that. If I am correct in that assumption, how do you explain the hemoglobin of 7.0 grams and the hematuria? Dr. Rajapaksa: You are correct. As I mentioned, the patient produces only small quantities of urine which has blood in it. She may be putting blood into her urine. 1 would not accept the finding of hematuria unless the urine was obtained by catheterization or in the presence of a nurse. As to the low hemoglobin, a hematology consultant postulates that it could be explained by multiple venipunctures in a menstruating woman. I am dubious of that explanation, however, and will be very interested in the findings of her hematological work-up. Howard Berkowitz, M.D.:“ The patient is a very secretive person. She responded to Dr. Levy’s questions hesitantly and often failed to give a definite answer that might provide us with more concrete information. At times the answer given was not to the question asked. At the beginning of the interview when asked about her breathing problem, she responded by talking about her muscle pains and her trip to California. Dr. Steinberg: When I asked her a few questions about what kind of person she is, she could not really focus down and give any particulars. We tried in many ways to get to know her, but she told us very clearly that she is not going to tell us much about herself. Dr. Blumenfield: Consciously, she obviously withholds the truth about various aspects of her life including her hospitalizations. Her story is full of untruths: her vacation, the onset of her symptoms, and her never having seen a psychiatrist before. As to the last untruth, I saw her in psychiatric consultation when she was in Kingsbrook Hospital about six months ago. I was asked to see her because she had tachycardia and there was some question of a cardiac conduction defect. I thought her symptoms were those of conversion reaction. She made an appointment with me as an outpatient but didn’t keep Assistant Professor of Psychiatry, State University of New York, Downstate Medical Center, College of Medicine. Resident Physician in Psychiatry, State University-Kings County Hospital Center.
CASE OF CHRONIC FACTITIOUS ILLNESS / 265
it. I had no idea that she had been to other hospitals for other symptoms. One of the things that stood out most in my mind about that consultation is that she never paid her bill. [The group laughs.] Dr. Levy: Her object relations are very primitive. In response to my question about her present husband, she said that he was good to her, he understands her and doesn’t expect much from her. She described him only in relationship to herself. Dr. Steinberg: This is quite typical of a narcissistic personality. The egosatisfying quality of the object becomes the most important issue. Dr. Blumenfield: But why does this patient lie so much about her medical history? She may think that if we knew she was in other hospitals, we wouldn’t take care of her as well as we would otherwise. Dr.Clark: It is interesting that she is very successful in getting doctors t o focus on every little abnormality they can find. She was quite able to get us to do that too. Dr. Levy: This patient has been presented to us as a possible case of Munchausen Syndrome, referring to a chronic factitious illness with a special pattern. Munchausen patients tend to wander from hospital to hospital and from city to city consciously often creating a myriad of bizarre and fantastic symptoms. The origin of the name of the syndrome is interesting. Baron Karl von Munchausen was a real person who lived during the 18th century and went from tavern to tavern in different cities telling tall tales. According to Spiro [ l ] , however, it was another German confabulator, Rudolph Raspe, who in publishing a book purporting to tell of the Baron’s adventures [2] created an even bigger hoax. In 1951 Asher coined the term Munchausen Syndrome, colorfully equating certain patients with the best known hoaxer [3]. The underlying diagnosis of such patients varies. In Spiro’s extensive review [ l ] of the literature on this subject in 1968, he found only thirty-eight cases of chronic factitious illness-twenty-five men and thirteen women. For the sixteen of them seen by a psychiatrist, the following diagnoses were listed: psychopathic personality disturbance in five cases, schizophrenia in three cases, other psychoses in two cases, hysterical neuroses in five cases and, in one, no psychiatric illness. Irrespective of diagnosis, these patients as a group tend to have poor ego strength with poor object relationships, as in the case of today’s patient. Franz Reichsman, M.D.:’ In regard to patients with Munchausen Syndrome, when a physician likes such a patient, it is usually a patient who is able to use her helplessness in a very successful manner. Some patients have that gift. Then, even though the “malingering” is known, the physician continues to want to help.
’
’
Director, Medical-Psychiatric Liaison Service and Professor of Medicine (Assigned from Psychiatry), State University of New York, Downstate Medical Center, College of Medicine.
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N. B.
L E V Y AND T. RAJAPAKSA
’
Joseph Berry, M.D..’ Dr. Reichsman, how does one distinguish the following from each other: Munchausen Syndrome, conversion reaction, malingering and hypochondriasis? Dr. Reichsman: By Munchausen Syndrome we mean a chronic factitious illness with fantastic, bizarre elements in the symptomatology. As Dr. Levy has mentioned, that is how the term was originally derived. Similarly, in malingering the patient consciously tries to “get out from under.” Malingering, unlike Munchausen Syndrome, is only rarely seen in “civilian” medicine, but seems to occur much more often in the armed forces in wartime. Hypochondriasis, in my experience, is often a sub-form of conversion with the main differences being: 1. the symptoms in hypochondriasis shift very much from one bodily area to another, much more than is usual in conversion reactions, or are present in many areas at the same time; 2. the hypochondriacal patient has a preoccupation with bodily symptoms and sensations which assumes in some patients a persecutory quality. In a minority of these patients, the symptoms may be indistinguishable from the psychotic with somatic delusions. In many hypochondriacal patients one can elicit the symbolic meaning of at least some of the symptoms and thus the similarity to conversion reaction. As you know, in patients with conversion, psychological conflict is not admitted into consciousness and the wish or fantasy is expressed in body language by body symptoms. Thus, the conflicts leading to symptom formation in patients with conversion and hypochondriasis are unconscious ones. I continue to make the fundamental difference between conversion and hypochondriasis on the one hand and Munchausen Syndrome and malingering on the other. In the latter two, there is conscious fabrication of symptoms and/or signs; in conversion and hypochondriasis the symptoms are due to unconscious processes. Some physicians in their management of all these patients tend to reinforce the symptoms of the given illness by wanting to prove the presence of “organic” disease: ordering all too many laboratory tests and paying much attention to minor deviations in these tests [4]. Dr. Steinberg: To become a psychiatric patient is the last resort of those with Munchausen Syndrome, is it not? Dr. Reichsman: Yes, they see a psychiatrist only very reluctantly. Furthermore, since the object relationships of these patients are very shallow, they are usually unable to make meaningful relationships to physicians. This makes psychotherapy an unpromising procedure [5] . Dr. Schoenfeld: It makes insight psychotherapy unpromising, but if these patients can find a therapist who will meet with them regularly in a supportive
’*
Fellow in Psychosomatic Medicine and Assistant Instructor, Department of Medicine, State University of New York, Downstate Medical Center, College of Medicine.
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way and gratify their dependency needs, it may reduce their visits t o nonpsychiatrist physicians or general hospitals and prevent unnecessary and harmful procedures being done. If this can be accomplished, their adaptation to the outside world may also improve. Dr. Levy: Although Munchausen Syndrome is an uncommon diagnosis, these patients belong to the large group about whom consultation-liaison physicians are asked t o advise. I am referring to that group of patients who present symptoms of physical illness but who are not physically ill. The nonpsychiatrist physician is frequently vexed by such patients and often looks to us for our help in diagnosis and treatment. As Dr. Reichsman mentioned, it is important that such patients be evaluated as to the differential diagnosis of conversion reaction, hypochondriasis, malingering and Munchausen Syndrome. As to their therapy, patients with all four of these diagnoses are usually quite attached to their physical complaints. Psychotherapy is usually not feasible for them. For the vast majority, the primary care physician may be in the best position to render help if he can establish good rapport with them. An empathetic listening ear and reassurance may be therapeutic.’ ACKNOWLEDGEMENT
We wish to thank Dr. Franz Reichsman for his help in editing this manuscript. REFERENCES
1. H. R. Spiro, Chronic Factitious Illness: Munchausen’s Syndrome, Arch. Gen. Psychiat., 18, pp. 569-579, 1968. 2. R. E. Raspe et al., Singular Travels, Campaigns and Adventures of Baron Munchausen, Dover Publications, New York, 1960. 3. R. Asher, Munchausen’s Syndrome, Lancet, 1 , pp. 339-341, 1951. 4. L. G . Chertok, Mania Operativa: Surgical Addiction, Int. J. Psychiat. in Med., 3, pp. 105-118, 1972. 5. C. V. Ford, The Munchausen Syndrome: A Report of Four New Cases and a Review of Psychodynamic Considerations, Int. J. Psychiat. in Med., 4, pp. 3146,1973. The diagnostic work done subsequent to this interview failed to show persistence of red cells in the patient’s urine. The anemia was probably due to iron deficiency and was of a lesser degree than indicated by the admission hemoglobin. Direct reprint requests to : Norman B. Levy, M.D. Box 127 Downstate Medical Center 450 Clarkson Avenue Brooklyn, N.Y. 11203
MEDICAL PSYCHOLOGY FORUM
A CASE OF CHRONIC FACTITIOUS ILLNESS* NORMAN B. LEVY, M.D. Associate Director, Medical-Psychiatric Liaison Service Associate Professor of Psychiatry TR IKANTE RAJAPAKSA, M.D. Assistant Professor of Clinical Medicine State University of New York Downstate Medical Center College of Medicine
ABSTRACT
A twenty-four-year-old woman is presented with multiple previous hospitalizations for joint and muscle pains. Guarded in her description of symptoms, she reports that “lupus” has been diagnosed at several hospitals over the past few years, unable to recall the name of any other than one previous hospital. The medical work-up failed to show any abnormality except that compatible with previously diagnosed von Willebrand’s disease. In the discussion of the case, the patient’s desire to be taken a r e of is seen as a major dynamic, causing her to fabricate illness. The diagnoses of Munchausen Syndrome, malingering, conversion reaction and hypochondriasis are discussed and differentiated from each other, and the treatment of Munchausen Syndrome is discussed.
Dr. Levy: Dr. Rajapaksa will present a patient from the medical service of this hospital. I will interview the patient and then we shall discuss the case. The patient has given us permission to tape record this interview.
*
Medical-Psychiatric Liaison Service Conference, State University-Kings County Hospital Center, Brooklyn, New York. At the time of this conference, Dr. Rajapaksa was Fellow in Psychosomatic Medicine at the State University-Kings County Hospital Center. 257 @
1977, Baywood Publishing Co.. Inc.
doi: 10.2190/W4X3-KPX2-384D-4J7U http://baywood.com
258 1 N. 0 . L E V Y AND T. RAJAPAKSA
Medical History Dr. Rajapaksa: The patient is a twenty-four-year-old, married Jewish woman, admitted to the State University Hospital a week ago with a history of muscle and joint pain and hematuria of two weeks’ duration. She claimed to have developed myalgia and arthralgia six months ago and saw a physician who diagnosed her condition as “lupus” and treated her with steroids and Imuran,’ which she discontinued after a few weeks because there was no improvement. She decided to have herself admitted to the hospital now because of worsening of the muscle pain. She said that she had been diagnosed as having von Willebrand’s disease at age fourteen, and had had excessive bleeding following a tonsillectomy. Nobody else in her family has any bleeding tendencies. Her physical examination was normal. Her hemoglobin was 7.0 gm. on admission. While she gave the nurse small samples of urine containing blood, she was unable to provide large samples of urine. The patient has complained of severe pain for which Talwin’ and Percodan3 have been prescribed. Because of the absence of objective evidence of disseminated lupus erythematosus or any other physical illness, the house staff asked the Medical-Psychiatric Liaison Service to assess the possible psychological component to her pain. When I interviewed her, the patient explained that her illness was of a much longer duration than six months: at age seventeen she had muscle and joint pains and was told then that she had “lupus.” At age eighteen, soon after marrying and leaving home, she was hospitalized in Boston for these same symptoms. Her unsuccessful marriage was annulled within a year, after which she went on a cross-country vacation with a group of friends for about two years. She said she was constantly under medical supervision during this vacation and was hospitalized in several states for the symptoms of “lupus.” She remarried four months ago. The patient is the youngest in a family of five children. Her father died when she was ten years old. Her seventy-one-year-old mother lives in Florida and the patient speaks to her by telephone several times a week. She said she didn’t want to tell the doctors that she had been previously worked up and treated for “lupus” because she wanted them to start afresh. She couldn’t remember the names of hospitals in which previous work-ups were done. Our Rheumatology Service received a call from the New York Hospital “ warning” them that there was a “Lupus-Munchausen” patient going from hospital to hospital in the New York-Metropolitan area. An intern found her handbag stuffed with bills from different hospitals, among them one for $1500
* Azathioprine.
* Pentazocine HCI. Oxycodone HCI.
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from the New York Hospital. After contacting some of these hospitals, we learned that one had told her she had lupus based only on her symptoms and a slightly positive anti-nuclear antibody test. Michael Blumenfield, M.D. :4 Was the sedimentation rate elevated? Dr. Rajapaksa: No, everything was normal except for the anemia and red cells in the urine.
Patient Interview Dr. Levy: Can you tell us what it was that brought you here? Patient: Well, originally I was sick in bed for two weeks and if I walked around I couldn’t breathe and I would have heart palpitations and I just couldn’t walk from one end of my apartment to another without having trouble breathing. Finally, since my husband was away, I picked a doctor’s name out of the phone book and I saw him. Dr. Levy: Did he recommend that you come in here? Patient: Well, I just couldn’t breathe. I couldn’t catch my breath, and if I would d o anything I would get heart palpitations, even if I bent down to pick something up. You know, a lot of people get heart palpitations when they are nervous but not when they bend to pick something up and I am not the nervous type-only when I am in front of a lot of people. Dr. Levy: As you are right now? Patient: Like now. [She laughs.] Dr. Levy: Are you anxious about this interview? Patient: No, not really. Dr. Levy: How long have you been having the problem breathing? Patient: I also had trouble with muscle pains since I have been seventeen and I have been to various doctors in New York City and all over the country because I had swelling in my joints. I went to California and a few other places where they told me that I had polymyositis; then most places told me that I had something called lupus. But at this hospital they claim that all my tests are coming back negative and that I don’t have lupus. Dr. Levy: Can you tell us something more about the muscle pains? What were they like? Patient: Well, they would come and go but mostly they were there being very annoying and hard for me to walk and making me very weak. Dr. Levy: What muscles were involved? Patient: Mostly all of them. They would vary. Sometimes it would last for days and then it would go away and come back some other time. They gave me certain drugs that really helped it and I gradually [her voice cracking] stopped taking them because I was getting some side effects. The cortisone Assistant Professor of Psychiatry, State University of New York, Downstate Medical Center, College of Medicine.
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gave me diabetes and that runs in my family, so I had to be very careful with that and then they stopped it and then I started taking it again. That was the only drug that would really help. Dr. Levy: What was the occasion for the travel that you mentioned before? Patient: Well, when my first marriage broke up my mother gave me some money and told me to go travel, so I did with a group of friends. I went to California, Colorado and quite a few other places. My parents live in Florida so I was there for a while too. . . . Dr. Levy: How is the muscle pain now? Patient: It hasn’t gone away. It’s more or less constant all the time. Lately I am taking Talwin. It helps it a little. Dr. Levy: How often do you take it? Patient: I suppose whenever I ask for it, they give it to me. Dr. Levy: How often does that turn out to be? Patient: About every five or six hours. Dr. Levy: How long have you been taking Talwin? Patient: On and off for the past three or four years plus I was on other drugs but they were a little bit stronger, like Percodan. At times they gave me Demerol.’ Dr. Levy: Which one was the most effective? Patient: Of course the Demerol was the best, but I don’t want to keep taking that. It makes me very sleepy and I was always sleeping with it. Dr. Levy: Was there any other reason why you didn’t want t o take it? Patient: No. Dr. Levy: Would you tell us a little bit about your background? Patient: Well, I have two sisters and two brothers. My parents live in Florida and my sisters and brothers all live in New York State and New Jersey. We are a very close family. My mother moved to Florida about three years ago. She got married again and she bought a condominium in Florida. Dr. Levy: Were your parents divorced orPatient: No, my father died. [Long pause.] Dr. Levy: Would you tell us about this? Patient: He died when I was ten years old, so I really can’t tell you very much. He died of a heart attack. Dr. Levy: How did that affect you? Patient: It really didn’t affect me in any way because I was quite young and I really didn’t know exactly what was going on. Dr. Levy: Do you have any memories of your father? Patienf: Not very much. I was very young. It’s been quite a long time. Dr. Levy: What did your mother do after his death? Patient: My mother only started working after my father died. She became Meperidine HCl.
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a private secretary of some kind and it worked out fine. I went t o school. I went t o college, I think for five months, and then that’s when I started getting sick. Dr.Levy: After you were there for five months what happened? Patient: I met somebody and I got married and I went back t o work. I got a job and I was working to put him through college. [Long pause.] Dr. Levy: Would you tell us something more about this? Patient: I met him in a hotel somewhere and we got married a couple of months later. I was in love with him and, you know, I was willing t o go t o college for him-I mean t o work for him t o put him through college and then it only lasted a year. I was putting him through college and then I found out he wasn’t going t o school and was just taking money and a lot of little things occurred-fights-and then we just broke up. Dr. Levy: He was taking your money and not going t o school? Patient: Well, I was giving him money for tuition and books and he wasn’t going t o class. Dr. Levy: What was he doing? Patient: To this day I really don’t know and I don’t care. Dr. Levy: How did you react when you discovered this? Patient: Well, I almost killed him, not literally, but I got very upset and we had big fights. We got an annulment after a year and a half of marriage. Then I met somebody else three months later and then I started traveling with my girl friends. When I was in California he came there and he got me. He wanted to get married, so I got married. Dr. Levy: Would you tell us something more about him? Patient: Well [patient starts stuttering], he’s good t o me. He understands my illness. He understands when I have t o go t o a doctor, when I have to be in a hospital and to me those are very important things. Dr. Levy: Could you tell us something more about him? Patient: He works for the State. He makes a good living and is able ro support me and give me almost everything I want. Dr. Levy: How has your illness affected your marriage? Patient: Well, I think it’s only normal for it t o affect it in some way but he accepts it because he knew everything about it before we got married. Dr. Levy: How does it affect the marriage even though he accepts it? Patient: It’s a pretty good marriage. It’s pretty stable. It’s better than it was at this point in the first marriage. Dr. Levy: Were you having trouble at this point in time in the first marriage? Patient: I was having trouble after three months and now it’s three months since I’ve been married again. . . . Dr. Levy: Have you been sick before? Patient: When I was fourteen I had my tonsils out. It didn’t go too well because I had bleeding and they told me that I had von Willebrand’s disease.
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Dr. Levy: How did von Willebrand’s disease affect you? Patient: I have to be careful in case of surgery. But I haven’t had surgery since then. So it doesn’t affect me. I have bleeding in my urine. I also had a blood clot once. I blacked out and I had severe chest pains and I couldn’t breathe and they took some tests in the emergency room and they told me I had a blood clot in my lung. Dr. Levy: What were you doing at the time that you blacked out? Patient: I was just walking in the street with a friend. We were in a strange city so she didn’t know what to do, so she just called the police. It just felt like everything was going around and I leaned against somethmg SO I wouldn’t fall and hurt my head, like a car and I slid down. I was out for like three or four seconds. I couldn’t breathe. I had chest pains in the center, in the upper part of my chest. Dr. Levy: What kind of pain was it? Patient: A very sharp pain, like a knife. . . . Dr. Levy: In what hospitals have you been treated for your illnesses? Patient: I really don’t remember any of them. The only ones I remember were the ones in New York because when I traveled I didn’t remember the names of the doctors or anything because my friends usually took me there. Dr. Levy: You mentioned hospitals in New York. Can you tell us about them? Patient: All I remember is when I first got sick I was in Kingsbrook. I don’t remember any others except this one and Kingsbrook. Dr. Levy: I would like to ask the other doctors here if they have any questions for you. Will that be all right with you? Patient: Yes. Melvyn Schoenfeld, M.D.:6 How do you handle stress in general? Patient: I just handle it the best I c a n . I try to discuss it with a friend or somebody that’s around. Dr. Schoenfeld: What about problems with your husband? Patient: My first husband? Dr. Schoenfeld: Either one. Patienf: Well, I don’t have problems with my second one. My first one is the one I had problems with and that I kept in-I think it was a big mistake. Jorge Steinberg, M.D.:’ I don’t have a clear picture of you as a person. Are YOU a sad person, a happy one, do you get moody? Can you describe yourself to us? Patient: It’s kind of a hard thing. Well, I [stutter], I handle things the best way I can. I make the most of my own decisions. No matter what they say I 6
Clinical Assistant Professor of Psychiatry, State University of New York, Downstate Medical Center, College of Medicine. I Assistant Professor of Psychiatry, State University of New York, Downstate Medical Center, CoUege of Medicine.
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make up my own mind like, for instance, in my first marriage. My family was against it but I married him anyway and when problems came up I handled them the best way I could. I went to people for advice but I made mostly my own decisions. I am very seldom sad. Most of the time when I have problems I take them the best way I can. Dr. Steinberg: What does it feel like inside when you are by yourself, alone and you are thinking about yourself, your life? Patient: I never really even thought of any of those. The only time I was alone was when I was traveling. I really enjoyed it. Dr. Steinberg: And you’re saying that you never get sad? Patient: Very seldom. The only time I get sad is when I have a lot of pain. When I have a lot of pain the only thing I want to do is just go to sleep. I want to be alone and just do anything to make the pain go away. Charlotte Nadel, M.D.:8 How does your husband feel about your being sick? Patient: He convinced me that it didn’t matter. He didn’t care and would help me the best way he could emotionally and physically. He is understanding. He understands how I feel when I have pain. I want to just lie down and be left alone. Dr. Blumenjield: What are your memories of your father? Patient: I was a change-of-life child and I was something very special. I think he was a wonderful person. Dr. SchoenfeM: Do you feel like you could use somebody to talk to about how hard it has been for you-somebody professional, like a psychiatrist or a psychologist? Patient: No. I think about it but I never really pursued it. I have a friend who was a neighbor that I speak to. Dr. Levy: Have you ever seen a psychiatrist? Patient: No, never until now. Dr. Levy: We do have to stop now. Is there anything you wish to ask us? Patient: No. Thanks for listening to me.
Discussion Dr. Rajapaksa: The patient’s older sister reported that she is a “spoiled brat” and a person who lies for no reason. She said that the patient has not traveled out of New York at all except to Las Vegas for five days over five years ago, and that there was no trip from state to state over a two year period, as was reported. The tonsillectomy and the diagnosis of von Willebrand’s disease happened two and a half years ago and not at age fourteen. The sister describes their family as an ‘‘unusual’’ one. Their father Clinical Assistant Professor o f Psychiatry, State University of New York, Downstate Medical Center, College of Medicine.
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was extremely “health conscious.” He had food fads and was obsessive about clean air and exercise. He was a construction worker who had several jobrelated accidents and finally died of a pulmonary embolus. The sister said the patient took their father’s death “very badly,” that she cried a lot and used to dream of him and wake up crying in the night for at least several months after his death. Some of this information is quite disparate from what the patient just told us. Julian J. Clark, M.D.:9 Did the sister speak of the patient’s first marriage? Dr. Rajapaksa: Yes, she said the patient was first married to a “sadistic, psychotic man.” She knows nothing about the second husband. Dr. Levy: Dr. Rajapaksa, I assume that you do not believe that this woman has organic disease other than von Willebrand’s disease, if even that. If I am correct in that assumption, how do you explain the hemoglobin of 7.0 grams and the hematuria? Dr. Rajapaksa: You are correct. As I mentioned, the patient produces only small quantities of urine which has blood in it. She may be putting blood into her urine. 1 would not accept the finding of hematuria unless the urine was obtained by catheterization or in the presence of a nurse. As to the low hemoglobin, a hematology consultant postulates that it could be explained by multiple venipunctures in a menstruating woman. I am dubious of that explanation, however, and will be very interested in the findings of her hematological work-up. Howard Berkowitz, M.D.:“ The patient is a very secretive person. She responded to Dr. Levy’s questions hesitantly and often failed to give a definite answer that might provide us with more concrete information. At times the answer given was not to the question asked. At the beginning of the interview when asked about her breathing problem, she responded by talking about her muscle pains and her trip to California. Dr. Steinberg: When I asked her a few questions about what kind of person she is, she could not really focus down and give any particulars. We tried in many ways to get to know her, but she told us very clearly that she is not going to tell us much about herself. Dr. Blumenfield: Consciously, she obviously withholds the truth about various aspects of her life including her hospitalizations. Her story is full of untruths: her vacation, the onset of her symptoms, and her never having seen a psychiatrist before. As to the last untruth, I saw her in psychiatric consultation when she was in Kingsbrook Hospital about six months ago. I was asked to see her because she had tachycardia and there was some question of a cardiac conduction defect. I thought her symptoms were those of conversion reaction. She made an appointment with me as an outpatient but didn’t keep Assistant Professor of Psychiatry, State University of New York, Downstate Medical Center, College of Medicine. Resident Physician in Psychiatry, State University-Kings County Hospital Center.
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it. I had no idea that she had been to other hospitals for other symptoms. One of the things that stood out most in my mind about that consultation is that she never paid her bill. [The group laughs.] Dr. Levy: Her object relations are very primitive. In response to my question about her present husband, she said that he was good to her, he understands her and doesn’t expect much from her. She described him only in relationship to herself. Dr. Steinberg: This is quite typical of a narcissistic personality. The egosatisfying quality of the object becomes the most important issue. Dr. Blumenfield: But why does this patient lie so much about her medical history? She may think that if we knew she was in other hospitals, we wouldn’t take care of her as well as we would otherwise. Dr.Clark: It is interesting that she is very successful in getting doctors t o focus on every little abnormality they can find. She was quite able to get us to do that too. Dr. Levy: This patient has been presented to us as a possible case of Munchausen Syndrome, referring to a chronic factitious illness with a special pattern. Munchausen patients tend to wander from hospital to hospital and from city to city consciously often creating a myriad of bizarre and fantastic symptoms. The origin of the name of the syndrome is interesting. Baron Karl von Munchausen was a real person who lived during the 18th century and went from tavern to tavern in different cities telling tall tales. According to Spiro [ l ] , however, it was another German confabulator, Rudolph Raspe, who in publishing a book purporting to tell of the Baron’s adventures [2] created an even bigger hoax. In 1951 Asher coined the term Munchausen Syndrome, colorfully equating certain patients with the best known hoaxer [3]. The underlying diagnosis of such patients varies. In Spiro’s extensive review [ l ] of the literature on this subject in 1968, he found only thirty-eight cases of chronic factitious illness-twenty-five men and thirteen women. For the sixteen of them seen by a psychiatrist, the following diagnoses were listed: psychopathic personality disturbance in five cases, schizophrenia in three cases, other psychoses in two cases, hysterical neuroses in five cases and, in one, no psychiatric illness. Irrespective of diagnosis, these patients as a group tend to have poor ego strength with poor object relationships, as in the case of today’s patient. Franz Reichsman, M.D.:’ In regard to patients with Munchausen Syndrome, when a physician likes such a patient, it is usually a patient who is able to use her helplessness in a very successful manner. Some patients have that gift. Then, even though the “malingering” is known, the physician continues to want to help.
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Director, Medical-Psychiatric Liaison Service and Professor of Medicine (Assigned from Psychiatry), State University of New York, Downstate Medical Center, College of Medicine.
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Joseph Berry, M.D..’ Dr. Reichsman, how does one distinguish the following from each other: Munchausen Syndrome, conversion reaction, malingering and hypochondriasis? Dr. Reichsman: By Munchausen Syndrome we mean a chronic factitious illness with fantastic, bizarre elements in the symptomatology. As Dr. Levy has mentioned, that is how the term was originally derived. Similarly, in malingering the patient consciously tries to “get out from under.” Malingering, unlike Munchausen Syndrome, is only rarely seen in “civilian” medicine, but seems to occur much more often in the armed forces in wartime. Hypochondriasis, in my experience, is often a sub-form of conversion with the main differences being: 1. the symptoms in hypochondriasis shift very much from one bodily area to another, much more than is usual in conversion reactions, or are present in many areas at the same time; 2. the hypochondriacal patient has a preoccupation with bodily symptoms and sensations which assumes in some patients a persecutory quality. In a minority of these patients, the symptoms may be indistinguishable from the psychotic with somatic delusions. In many hypochondriacal patients one can elicit the symbolic meaning of at least some of the symptoms and thus the similarity to conversion reaction. As you know, in patients with conversion, psychological conflict is not admitted into consciousness and the wish or fantasy is expressed in body language by body symptoms. Thus, the conflicts leading to symptom formation in patients with conversion and hypochondriasis are unconscious ones. I continue to make the fundamental difference between conversion and hypochondriasis on the one hand and Munchausen Syndrome and malingering on the other. In the latter two, there is conscious fabrication of symptoms and/or signs; in conversion and hypochondriasis the symptoms are due to unconscious processes. Some physicians in their management of all these patients tend to reinforce the symptoms of the given illness by wanting to prove the presence of “organic” disease: ordering all too many laboratory tests and paying much attention to minor deviations in these tests [4]. Dr. Steinberg: To become a psychiatric patient is the last resort of those with Munchausen Syndrome, is it not? Dr. Reichsman: Yes, they see a psychiatrist only very reluctantly. Furthermore, since the object relationships of these patients are very shallow, they are usually unable to make meaningful relationships to physicians. This makes psychotherapy an unpromising procedure [5] . Dr. Schoenfeld: It makes insight psychotherapy unpromising, but if these patients can find a therapist who will meet with them regularly in a supportive
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Fellow in Psychosomatic Medicine and Assistant Instructor, Department of Medicine, State University of New York, Downstate Medical Center, College of Medicine.
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way and gratify their dependency needs, it may reduce their visits t o nonpsychiatrist physicians or general hospitals and prevent unnecessary and harmful procedures being done. If this can be accomplished, their adaptation to the outside world may also improve. Dr. Levy: Although Munchausen Syndrome is an uncommon diagnosis, these patients belong to the large group about whom consultation-liaison physicians are asked t o advise. I am referring to that group of patients who present symptoms of physical illness but who are not physically ill. The nonpsychiatrist physician is frequently vexed by such patients and often looks to us for our help in diagnosis and treatment. As Dr. Reichsman mentioned, it is important that such patients be evaluated as to the differential diagnosis of conversion reaction, hypochondriasis, malingering and Munchausen Syndrome. As to their therapy, patients with all four of these diagnoses are usually quite attached to their physical complaints. Psychotherapy is usually not feasible for them. For the vast majority, the primary care physician may be in the best position to render help if he can establish good rapport with them. An empathetic listening ear and reassurance may be therapeutic.’ ACKNOWLEDGEMENT
We wish to thank Dr. Franz Reichsman for his help in editing this manuscript. REFERENCES
1. H. R. Spiro, Chronic Factitious Illness: Munchausen’s Syndrome, Arch. Gen. Psychiat., 18, pp. 569-579, 1968. 2. R. E. Raspe et al., Singular Travels, Campaigns and Adventures of Baron Munchausen, Dover Publications, New York, 1960. 3. R. Asher, Munchausen’s Syndrome, Lancet, 1 , pp. 339-341, 1951. 4. L. G . Chertok, Mania Operativa: Surgical Addiction, Int. J. Psychiat. in Med., 3, pp. 105-118, 1972. 5. C. V. Ford, The Munchausen Syndrome: A Report of Four New Cases and a Review of Psychodynamic Considerations, Int. J. Psychiat. in Med., 4, pp. 3146,1973. The diagnostic work done subsequent to this interview failed to show persistence of red cells in the patient’s urine. The anemia was probably due to iron deficiency and was of a lesser degree than indicated by the admission hemoglobin. Direct reprint requests to : Norman B. Levy, M.D. Box 127 Downstate Medical Center 450 Clarkson Avenue Brooklyn, N.Y. 11203
