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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Case report
 ::  Investigations
 ::  Discussion
 ::  Acknowledgement
 ::  References

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ARTICLE
Year : 1977  |  Volume : 23  |  Issue : 2  |  Page : 95-98

Munchausen's syndrome - (a case report with a review of the literature)


Department of Psychiatry, L.T.M.G.Hospital, Sion, Bombay 400022, India

Correspondence Address:
D A D'Souza
Department of Psychiatry, L.T.M.G.Hospital, Sion, Bombay 400022
India
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Source of Support: None, Conflict of Interest: None


PMID: 614422

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 :: Abstract 

This is a case of Munchausen's syndrome which presented in an atypical manner, viz. cessation of menstruation. The patient had been to 25 doctors and had been investigated with great zeal. The case is published along with a review of the literature, with a view to make clinicians more aware of this rare entity.



How to cite this article:
D'Souza D A, Bharucha M, Shah M V. Munchausen's syndrome - (a case report with a review of the literature). J Postgrad Med 1977;23:95-8

How to cite this URL:
D'Souza D A, Bharucha M, Shah M V. Munchausen's syndrome - (a case report with a review of the literature). J Postgrad Med [serial online] 1977 [cited 2020 Feb 22];23:95-8. Available from: http://www.jpgmonline.com/text.asp?1977/23/2/95/42802



 :: Introduction Top


Munchausen's Syndrome [1] is named after Baron Hieronymus Karl Fried­rich von Munchausen (1720-1791) who lived in Bodenwerder, Hanover, Ger­many. The persons affected have always travelled widely and their stories like those attributed to Munchausen are both dramatic and untruthful.

The patient showing the syndrome is admitted to hospital with an apparent acute illness supported by a plausible and dramatic history usually made up large­ly of falsehoods. He is found to have at­tended and deceived an astounding num­ber of other hospital doctors and he nearly always discharges himself against medical advice, after quarrelling violent­ly with both doctors and nurses.

It is almost impossible to be certain of the diagnosis at first and it needs a bold casualty officer to refuse admission. Usually, the patient seems seriously ill and is admitted unless someone who has seen him before is here to expose him.

Publicizing the histories in journals has been suggested as the only way to cope with such patients. [3]


 :: Case report Top


B.W.S., a nineteen year old female patient, came to the psychiatric O.P.D. of the L.T.M.G. Hospital with the chief complaints of cessation of menstruation, pain in the abdomen, backache, weakness and tingling and numbness of the ex­tremities for the last one and a half years. She was apparently alright 1½ years ago when she started having dull continuous abdominal pain. The pain in­creased after food, during menstruation and when she moved. It was relieved by pressing the abdomen with the hand. There was no history of fever, vomiting, Loose motions, trauma or contact with tuberculosis. The patient felt that a ball was moving around in her abdomen from the right to the left side and then all over the abdomen. She was convinced that a gall existed in her abdomen. She was unable to mensturate for the past 1 years, used to worry a lot about it and was willing for an operation to get re­lieved. Information gathered from rela­tives revealed that the patient was not well for the past three years and had been to about 25 doctors. She had been thoroughly investigated; these investiga­tions (more than 50 in number and in­cluding sigmoidoscopy and rectal biopsy) had all been negative. She had been hospitalised in March 1974 for a sudden inability to pass urine. At that time it was claimed that she was unable to pass urine for 15 days. The patient was kept on diuretics and it was then detected that she was lying. A month after that she presented with bleeding per rectum and on examination broken needles and pebbles were found in her rectum.

The patient's father had been suffer­ing from mental illness for the last five years and had been treated with E.C.T.s and anti-psychotic drugs. Her elder brother was an epileptic. No other re­levant features were found in the history.

On psychiatric examination, no dis­order of mood, perception or thought could be found. On general examination, no abnormality was detected. On examination of the abdomen, there was a vague tenderness all over the abdomen.

The patient was kept under observa­tion and was given an injection of estrogen-progesteron combination after admission. On the fourth day she had withdrawal bleeding which was observ­ed in the form of staining of her clothes. However, the patient denied having men­struated.


 :: Investigations Top


Routine blood, urine and stool exami­nation, plain X-rays of the skull and ab­domen were normal.

This case was diagnosed as one of Munchausen's Syndrome.


 :: Discussion Top


According to Barker, [2] there are about 40 reported cases of this syndrome in the literature mostly in the non-medical literature. There is gross reporting of the same cases and one case has been re­ported 7 times. Barker [2] criticised the term "Munchausen's Syndrome" which was originally coined by Asher [1] on the basis that it focuses attention on the pseudologia. The pseudologia of the Baron was that of a flamboyant adven­turer and is different from that seen in this syndrome. This term thus casts ridicule upon these patients and a prefer­able term is "the Syndrome of Hospital Addiction". [2] Other terms which have been used are "Hospital Hoboes", [4] "Pere­grinating Problem Patients " , [3] and "Kopenickiades". [4] The last term origi­nates after the German town Kopenick where a famous hoax occurred in 1906.

The syndrome is of considerable im­portance as can be seen by the finding that one single case had spent upto 23 years continuously in hospital, had 124 admissions and cost the National Health Service in U.K. £6000. [2] Unfortunately, the diagnosis is almost impossible at first because of the dramatic presentation. The useful points are [1],[2] : -

1. Multiple scars over the abdominal wall.

2. No doctor's letter.

3. A wallet or hand bag stuffed with hospital attendance cards, insurance claim forms and litigious correspondence.

4. Presentation at a time when junior doctors are likely to be present (late at night or at the weekend).

5. An acute and harrowing history with inconsistencies.

6. Discrepancies between symptoms and signs.

7. A glim, facile and evasive manner in responding to questions.

8. A marked capacity for relentless self-destruction which reveals itself in a keenness to have unpleasant investiga­tions and operations.

Certain well defined patterns of pre­sentation have been outlined. [1]

(a) Laparotomophilia migrans-Presentation with acute abdominal symp­toms.

(b) Haemorrhagical histrionica-Also known as Hemoptysis and Haematemeis merchants.

(c) Neurologica diabolica-Presenta­tion with acute neurological features such as coma, blackouts and headaches.

(d) Dermatitis autogenetica-Self induced skin lesions and

(e) Pyrexia of unknown origin.

Despite these diagnostic aids, the patient often gets the better of the doctor because:­

(1) They have an extensive knowledge of medicine based on a study of case re­cords, text books, observing physicians and by discussions with other patients.

(2) Some patients have a real organic lesion resulting from a previous illness which has left signs which confuse the doctor.

(3) Dramatic and acute mode of pre­sentation.

(4) Departmental system in hospitals

It is really puzzling to consider why patients make hospitalisation, which is for most of the people an unpleasant process and a way of life. Several theories have been advanced. [1],[3],[4] These include: -

1. A grudge against doctors and hospi­tal due to previous misdiagnosis and mal­treatment when they had a genuine illness in the past. [7]

2. A desire for narcotic drugs.

3. A desire to escape from the police or steal hospital property.

4. A desire to get free boarding and lodging.

5. Fun out of hoodwinking doctors.

6. A desire to be the centre of interest and attention.

7. A previous unfulfilled leaning to­wards medicine or nursing as a profes­sion.

However, Menninger [6] feels that the problem cannot be understood without considering the deeper unconscious motives. Amongst these, he considers satisfaction of erotic needs or fantasies or child birth, or castration through surgi­cal or other investigative procedures. An organic basis (antecedent cerebral damage) has been invoked by Barker [2] on the basis of a past history of head in­jury/meningitis,/surgery in 3/7 cases studied by him. This could be correlated with the finding of Lidz et al [5] that pseudologia phantastica has been observ­ed in hypoglycaemia.

Management of this problem is general­ly unsatisfactory. It has been suggested that it could be circumvented by main­taining black lists or "an International Rogues Gallery". [8] However, such a procedure is not only unethical, but is also detrimental to the patient's interests, as it would prevent him seeking help.

The mental hospital is considered to be the best place for treatment. [2] Unfor­tunately, these patients are only infre­quently referred to psychiatrists and have a deep mistrust of them.


 :: Acknowledgement Top


We thank the Dean, L.T.M.G. Hospital for allowing us to report the Hospital data.

 
 :: References Top

1.Asher. R.: Munchausen's Syndrome. Lancet. 1: 339-341, 1951.  Back to cited text no. 1    
2.Barker, J.: The Syndrome of Hospital Addiction (Munchausen's Syndrome); a report on the investigation o` seven cases. J. Ment. Sci. 108: 167-182, 1962.  Back to cited text no. 2    
3.Chapman, J.: Peregrinating Problem Patients-Munchausen's Syndrome. J. A. M. A. 165: 927-933, 1957.  Back to cited text no. 3    
4.Clarke, E. and Melnick, S.: The Mun­chausen Syndrome or the Problem of Hospital Hoboes. Am. J. Med. 25: 6-12, 1958.  Back to cited text no. 4    
5.Lidz, T., Miller, J. M., Padget, P. and Stedem, A. F. A.: Muscular Atrophy and pseudologia fantastica associated with islet cell adenoma of the pancreas. Arch. Neurol. and Psychiat. 62: 304-313, 1949.  Back to cited text no. 5    
6.Menninger, K.: Man Against Himself. George, C. Harrap and Co. Ltd., London, 1938.  Back to cited text no. 6    
7.Short, I. A.: Munchausen's Syndrome. B.M.J. 2: 1206-1207, 1955.  Back to cited text no. 7    
8.Small, A.: Munchausen's Syndrome. B.M.J. 2: 1207, 1955.  Back to cited text no. 8    




 

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