Personality and Mental Health 7: 80–83 (2013) Published online 25 January 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/pmh.1223
Complex Case Recovery from chronic factitious disorder (Munchausen’s syndrome): a personal account
CHRISTOPHER BASS AND MICHAEL TAYLOR†, Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK ABSTRACT This case report provides an account by a patient (with permission) of chronic factitious disorder and the factors that led to recovery. Such accounts are extremely rare in the literature. This account also throws into sharp focus current controversies in the classification of factitious disorders. Copyright © 2013 John Wiley & Sons, Ltd. Introduction Factitious disorder (which used to be called Munchausen’s syndrome) is a rare, but important, clinical disorder, which leads to considerable disruption to a person’s life, as well the consumption of substantial healthcare resources. Early identification is important, but the course of the illness is usually chronic because patients are often driven by complex impulses to fabricate symptoms and, once confronted with their deceptions, usually take flight. The results of psychological intervention in patients with factitious disorders are usually very disappointing (Eastwood & Bisson, 2008), and many continue to fabricate symptoms and deceive doctors, often by self-discharging from hospital. In this case report, the patient provides an account of his early background and abnormal illness behaviour (all verified by the author who had sight of his complete medical records) and provides an explanation for why he decided to change his behaviour. The case is of interest not only because recovery from this disorder is extremely rare (to date, there are only three reports in English (Higgins,
Copyright © 2013 John Wiley & Sons, Ltd.
1990; Fehnel & Brewer, 2006; Feldman, 2006)) but also because it highlights diagnostic dilemmas presented by patients who deceive doctors.
Case report (from patient) When I look back and consider the reasons for my behaviour, I think that receiving care and compassion are an important contributing factor. As a 10-year-old boy, I went into a hospital to correct a squint. The care and compassion I received from the nurses and medics were something I had never received from my parents. It was a powerful influence on a nervous and shy 10-year-old. When I was a child, I was frightened to tell my parents that I was ill; I do not know why but I lived in fear of upsetting my father. When I was 19 years old, I began abusing base amphetamine. One day, I could not face going to work so I pretended to have abdominal pain and got admitted to hospital. That was the first time I was given pethidine and I wanted more of it. I was admitted to my local hospital a few times over the
7: 80–83 (2013) DOI: 10.1002/pmh
Recovery from chronic factitious disorder
next few weeks and because the medics were catching on to my need for opiates, I had to travel farther afield to get them. I was first diagnosed as having Munchausen’s syndrome in 1986 (age 20 years) after I had been charged with stealing the ambulance I had been a patient in! During the previous 12 months, I had been hospitalized 15 to 20 times in various parts of the country feigning stomach pains in the hope of being given pethidine, which offered me a way of avoiding the emotional mess that was my life. In those early days of getting myself admitted, it was just as much about the compassion as it was about obtaining opiates at any price, although it was not long before the craving for opiates became the major goal. I could not hold down a job, my relationships with women were very short lived and even the thought of trying to get through a normal day scared me. I started to self harm, and on one occasion, because I knew that just faking pain to get into a general hospital for opiates would not wash, I swallowed some screws and needles thinking they would show up on X-ray and be a good enough excuse. I did not think they would have to operate to remove them! Disappearing in the middle of the night and hitch hiking anywhere with the aim of getting admitted to a hospital seemed to be the only thing I could control. Telling the medics some yarn about just getting off a long flight the previous day often persuaded them to investigate the severe chest pain I was faking and then getting that injection was all I could think about. The only place I wanted to be was in hospital out of my head on opiates. When I was not in hospital, I could not cope. I started abusing other drugs including cannabis, LSD and base amphetamine with no thought to the risks. For many years, that was my life. Every so often, I would go off and get myself admitted to a hospital, even abroad. On one occasion, I faked a car crash in France to get admitted to hospital because of my addiction. Back in the UK, I was registered with three or four different general practitioners using different names. This was the only way I could make sure I had the opiates I needed. I
Copyright © 2013 John Wiley & Sons, Ltd.
usually consumed 80 tablets a day of co-proxamol and DF118, and I was also taking three bottles of Benylin daily, which helped me to feel more relaxed. What helped me to change? By this time (age 30 years), I was married with two small children. After an attempted suicide, I was admitted to a local psychiatric unit where I was diagnosed with borderline personality disorder (BPD). Because of the effect my behaviour was having on my family, I was admitted to the Henderson Hospital in London for 6 weeks. But after a weekend leave, my craving for opiates led to me feigning acute chest pain again and getting admitted to hospital. The rules at the Henderson were strict: if you are not there when you should be, you are discharged. I decided prior to the Henderson that if it did not work, then my marriage could not work. It was just so unfair on my children and on my wife. Disappearing for weeks when I would go off and get admitted to some hospital complaining of a pulmonary embolism, or severe neck pain with pins and needles down one side or being bandaged up after self-harming was an awful situation for the children to experience. I realized that if I wanted to continue a relationship with my children and attempt to repair some of the damage that had been done I needed to make some major life changing decisions. The 6 weeks spent at the Henderson helped because I was able to see how living with someone with BPD was awful, never knowing how each day was going to pan out, and also, not knowing whether on any given afternoon you would be able to go on a nice walk in the park or call in the emergency psychiatric team for an assessment. To my then wife’s credit, she tolerated almost 10 years of this. I remember thinking at the time what it must feel like explaining to the children why daddy had not come home that night and not knowing whether he was safe. I felt so ashamed that my wife and children suffered so much because of me.
7: 80–83 (2013) DOI: 10.1002/pmh
81
82
Bass and Taylor
The first glimmer of hope came when I was prescribed methadone. Because I was abusing opiates, my treating psychiatrist approached my local Community Drug and Alcohol Team who commenced a daily methadone programme. This was a catalyst for change, and I knew I had taken the first step. That was 7 years ago. I was going through a messy divorce and fighting for contact with my children. The stress was sometimes awfully painful, and I was tempted numerous times to go off and seek opiates, but two things stopped me going down that route. First, my children deserve better, and second the thought of a relapse scared me. For the first time in my life, I was learning to deal with life without the need for drugs and not needing to fake symptoms. Seeing the delight of my children that their dad was enjoying life was and still is a wonderful joy. Children are a wonderful motivation for change. After spending 20 years of my life out of control, a minimum of 400 admissions to hospital in both the UK and Europe, 10 totally unnecessary surgeries, and the anguish and pain suffered by those close to me, I no longer ask myself could things have been different. Nor do I think how easy it would be to go back to how it was. I look how far I have come but most of all I cherish the time I spend with my children knowing that for them I can accomplish anything. Discussion Patients with chronic factitious disorder of the kind described here are characteristically very intractable and difficult to help, and reports of resolution of this behaviour are extremely rare. In previous case reports, patients have attributed their improvements to finding religious belief (Feldman, 2006) and faith healing at a local church (Higgins, 1990). In this case, M. T. was motivated to change because he realised that to continue with his fabrications in an attempt to satisfy his addiction to drugs he would lose contact with his young children. He was also helped to withdraw from opiate dependence and received in patient treatment
Copyright © 2013 John Wiley & Sons, Ltd.
for personality disorder. His improvement has been sustained for over 8 years, and he remains in good health, but he has struggled to find employment. Diagnostic problems. How does factitious disorder differ from malingering? In factitious disorders, the motivation for the deceptive behaviour is thought to be to achieve the sick role, a so-called internal or psychological motive. In essence, this usually involves the search for care, nurturance and attention. In malingering, the motive is assumed to be ‘external’, which usually involves obtaining drugs such as opiates, or money, or to avoid conscription or conviction (American Psychiatric Association, 2000). It is important to note however that the nosology of these conditions has been the subject of recent controversy (Hamilton, Feldman, & Janata, 2009; Turner, 2006). In the case of M. T., his motivation is complex and involves more than one factor over his life span. When younger, he feigned symptoms in order to receive ‘care and compassion’ from nursing staff that he never received at home. Thus his motivation could be conceived as being internal. By contrast, as an adult, his behaviour was influenced predominantly by ‘external’ factors, which involved feigning symptoms in order to satisfy a craving for drugs. In this sense, his ‘illness affirming behaviour’ displays features of both factitious disorder and malingering. The use of motivation (whether external or internal) as a diagnostic criterion for this disorder has been questioned (Turner, 2006). We have argued elsewhere that illness deception is best conceptualized within a socio-legal or human model (rather than a medical model) that recognizes the capacity of free will and the potential for pursuing the benefits associated with the sick role (Halligan, Bass, & Oakley, 2003). In this case, M. T. changed his behaviour because he realised that if he did not the consequences would be that he lost access to his children. This proved to be a powerful motivator for change.
7: 80–83 (2013) DOI: 10.1002/pmh
Recovery from chronic factitious disorder
References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, (4th ed.), text revision). Washington DC: APA. Eastwood, S., &Bisson, J. (2008). Management of factitious disorders: a systematic review. Psychotherapy and Psychosomatics 77, 209–18. Fehnel, C., & Brewer E. (2006). Munchausen’s syndrome with 20-year follow-up. American Journal of Psychiatry 163, 547. Feldman, M. (2006). Recovery from Munchausen syndrome. Southern Medical Journal 99, 1398–1399. Halligan, P., Bass, C., and Oakley, D. (2003). Wilful deception as illness behaviour. In P. Halligan, C. Bass, & D. Oakley (Eds). Malingering and Illness Deception. Oxford: Oxford University Press.
Copyright © 2013 John Wiley & Sons, Ltd.
Hamilton, J., Feldman, M., & Janata, J. (2009). The A, B, and C’s of factitious disorder: a response to Turner. Medscape Journal 11(1), 27 Epub 2009 Jan 27. Higgins, P. (1990). Temporary Munchausen’s syndrome. British Journal of Psychiatry 157, 613–616. Turner, M. (2006). Factitious disorders: reformulating the DSM-IV criteria. Psychosomatics 47, 23–32.
Address correspondence to: Christopher Bass, Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK. Email: c.bass1@ btinternet.com † Michael Taylor is a pseudonym.
7: 80–83 (2013) DOI: 10.1002/pmh
83
Complex Case Recovery from chronic factitious disorder (Munchausen’s syndrome): a personal account
CHRISTOPHER BASS AND MICHAEL TAYLOR†, Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK ABSTRACT This case report provides an account by a patient (with permission) of chronic factitious disorder and the factors that led to recovery. Such accounts are extremely rare in the literature. This account also throws into sharp focus current controversies in the classification of factitious disorders. Copyright © 2013 John Wiley & Sons, Ltd. Introduction Factitious disorder (which used to be called Munchausen’s syndrome) is a rare, but important, clinical disorder, which leads to considerable disruption to a person’s life, as well the consumption of substantial healthcare resources. Early identification is important, but the course of the illness is usually chronic because patients are often driven by complex impulses to fabricate symptoms and, once confronted with their deceptions, usually take flight. The results of psychological intervention in patients with factitious disorders are usually very disappointing (Eastwood & Bisson, 2008), and many continue to fabricate symptoms and deceive doctors, often by self-discharging from hospital. In this case report, the patient provides an account of his early background and abnormal illness behaviour (all verified by the author who had sight of his complete medical records) and provides an explanation for why he decided to change his behaviour. The case is of interest not only because recovery from this disorder is extremely rare (to date, there are only three reports in English (Higgins,
Copyright © 2013 John Wiley & Sons, Ltd.
1990; Fehnel & Brewer, 2006; Feldman, 2006)) but also because it highlights diagnostic dilemmas presented by patients who deceive doctors.
Case report (from patient) When I look back and consider the reasons for my behaviour, I think that receiving care and compassion are an important contributing factor. As a 10-year-old boy, I went into a hospital to correct a squint. The care and compassion I received from the nurses and medics were something I had never received from my parents. It was a powerful influence on a nervous and shy 10-year-old. When I was a child, I was frightened to tell my parents that I was ill; I do not know why but I lived in fear of upsetting my father. When I was 19 years old, I began abusing base amphetamine. One day, I could not face going to work so I pretended to have abdominal pain and got admitted to hospital. That was the first time I was given pethidine and I wanted more of it. I was admitted to my local hospital a few times over the
7: 80–83 (2013) DOI: 10.1002/pmh
Recovery from chronic factitious disorder
next few weeks and because the medics were catching on to my need for opiates, I had to travel farther afield to get them. I was first diagnosed as having Munchausen’s syndrome in 1986 (age 20 years) after I had been charged with stealing the ambulance I had been a patient in! During the previous 12 months, I had been hospitalized 15 to 20 times in various parts of the country feigning stomach pains in the hope of being given pethidine, which offered me a way of avoiding the emotional mess that was my life. In those early days of getting myself admitted, it was just as much about the compassion as it was about obtaining opiates at any price, although it was not long before the craving for opiates became the major goal. I could not hold down a job, my relationships with women were very short lived and even the thought of trying to get through a normal day scared me. I started to self harm, and on one occasion, because I knew that just faking pain to get into a general hospital for opiates would not wash, I swallowed some screws and needles thinking they would show up on X-ray and be a good enough excuse. I did not think they would have to operate to remove them! Disappearing in the middle of the night and hitch hiking anywhere with the aim of getting admitted to a hospital seemed to be the only thing I could control. Telling the medics some yarn about just getting off a long flight the previous day often persuaded them to investigate the severe chest pain I was faking and then getting that injection was all I could think about. The only place I wanted to be was in hospital out of my head on opiates. When I was not in hospital, I could not cope. I started abusing other drugs including cannabis, LSD and base amphetamine with no thought to the risks. For many years, that was my life. Every so often, I would go off and get myself admitted to a hospital, even abroad. On one occasion, I faked a car crash in France to get admitted to hospital because of my addiction. Back in the UK, I was registered with three or four different general practitioners using different names. This was the only way I could make sure I had the opiates I needed. I
Copyright © 2013 John Wiley & Sons, Ltd.
usually consumed 80 tablets a day of co-proxamol and DF118, and I was also taking three bottles of Benylin daily, which helped me to feel more relaxed. What helped me to change? By this time (age 30 years), I was married with two small children. After an attempted suicide, I was admitted to a local psychiatric unit where I was diagnosed with borderline personality disorder (BPD). Because of the effect my behaviour was having on my family, I was admitted to the Henderson Hospital in London for 6 weeks. But after a weekend leave, my craving for opiates led to me feigning acute chest pain again and getting admitted to hospital. The rules at the Henderson were strict: if you are not there when you should be, you are discharged. I decided prior to the Henderson that if it did not work, then my marriage could not work. It was just so unfair on my children and on my wife. Disappearing for weeks when I would go off and get admitted to some hospital complaining of a pulmonary embolism, or severe neck pain with pins and needles down one side or being bandaged up after self-harming was an awful situation for the children to experience. I realized that if I wanted to continue a relationship with my children and attempt to repair some of the damage that had been done I needed to make some major life changing decisions. The 6 weeks spent at the Henderson helped because I was able to see how living with someone with BPD was awful, never knowing how each day was going to pan out, and also, not knowing whether on any given afternoon you would be able to go on a nice walk in the park or call in the emergency psychiatric team for an assessment. To my then wife’s credit, she tolerated almost 10 years of this. I remember thinking at the time what it must feel like explaining to the children why daddy had not come home that night and not knowing whether he was safe. I felt so ashamed that my wife and children suffered so much because of me.
7: 80–83 (2013) DOI: 10.1002/pmh
81
82
Bass and Taylor
The first glimmer of hope came when I was prescribed methadone. Because I was abusing opiates, my treating psychiatrist approached my local Community Drug and Alcohol Team who commenced a daily methadone programme. This was a catalyst for change, and I knew I had taken the first step. That was 7 years ago. I was going through a messy divorce and fighting for contact with my children. The stress was sometimes awfully painful, and I was tempted numerous times to go off and seek opiates, but two things stopped me going down that route. First, my children deserve better, and second the thought of a relapse scared me. For the first time in my life, I was learning to deal with life without the need for drugs and not needing to fake symptoms. Seeing the delight of my children that their dad was enjoying life was and still is a wonderful joy. Children are a wonderful motivation for change. After spending 20 years of my life out of control, a minimum of 400 admissions to hospital in both the UK and Europe, 10 totally unnecessary surgeries, and the anguish and pain suffered by those close to me, I no longer ask myself could things have been different. Nor do I think how easy it would be to go back to how it was. I look how far I have come but most of all I cherish the time I spend with my children knowing that for them I can accomplish anything. Discussion Patients with chronic factitious disorder of the kind described here are characteristically very intractable and difficult to help, and reports of resolution of this behaviour are extremely rare. In previous case reports, patients have attributed their improvements to finding religious belief (Feldman, 2006) and faith healing at a local church (Higgins, 1990). In this case, M. T. was motivated to change because he realised that to continue with his fabrications in an attempt to satisfy his addiction to drugs he would lose contact with his young children. He was also helped to withdraw from opiate dependence and received in patient treatment
Copyright © 2013 John Wiley & Sons, Ltd.
for personality disorder. His improvement has been sustained for over 8 years, and he remains in good health, but he has struggled to find employment. Diagnostic problems. How does factitious disorder differ from malingering? In factitious disorders, the motivation for the deceptive behaviour is thought to be to achieve the sick role, a so-called internal or psychological motive. In essence, this usually involves the search for care, nurturance and attention. In malingering, the motive is assumed to be ‘external’, which usually involves obtaining drugs such as opiates, or money, or to avoid conscription or conviction (American Psychiatric Association, 2000). It is important to note however that the nosology of these conditions has been the subject of recent controversy (Hamilton, Feldman, & Janata, 2009; Turner, 2006). In the case of M. T., his motivation is complex and involves more than one factor over his life span. When younger, he feigned symptoms in order to receive ‘care and compassion’ from nursing staff that he never received at home. Thus his motivation could be conceived as being internal. By contrast, as an adult, his behaviour was influenced predominantly by ‘external’ factors, which involved feigning symptoms in order to satisfy a craving for drugs. In this sense, his ‘illness affirming behaviour’ displays features of both factitious disorder and malingering. The use of motivation (whether external or internal) as a diagnostic criterion for this disorder has been questioned (Turner, 2006). We have argued elsewhere that illness deception is best conceptualized within a socio-legal or human model (rather than a medical model) that recognizes the capacity of free will and the potential for pursuing the benefits associated with the sick role (Halligan, Bass, & Oakley, 2003). In this case, M. T. changed his behaviour because he realised that if he did not the consequences would be that he lost access to his children. This proved to be a powerful motivator for change.
7: 80–83 (2013) DOI: 10.1002/pmh
Recovery from chronic factitious disorder
References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, (4th ed.), text revision). Washington DC: APA. Eastwood, S., &Bisson, J. (2008). Management of factitious disorders: a systematic review. Psychotherapy and Psychosomatics 77, 209–18. Fehnel, C., & Brewer E. (2006). Munchausen’s syndrome with 20-year follow-up. American Journal of Psychiatry 163, 547. Feldman, M. (2006). Recovery from Munchausen syndrome. Southern Medical Journal 99, 1398–1399. Halligan, P., Bass, C., and Oakley, D. (2003). Wilful deception as illness behaviour. In P. Halligan, C. Bass, & D. Oakley (Eds). Malingering and Illness Deception. Oxford: Oxford University Press.
Copyright © 2013 John Wiley & Sons, Ltd.
Hamilton, J., Feldman, M., & Janata, J. (2009). The A, B, and C’s of factitious disorder: a response to Turner. Medscape Journal 11(1), 27 Epub 2009 Jan 27. Higgins, P. (1990). Temporary Munchausen’s syndrome. British Journal of Psychiatry 157, 613–616. Turner, M. (2006). Factitious disorders: reformulating the DSM-IV criteria. Psychosomatics 47, 23–32.
Address correspondence to: Christopher Bass, Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK. Email: c.bass1@ btinternet.com † Michael Taylor is a pseudonym.
7: 80–83 (2013) DOI: 10.1002/pmh
83
