Munchausen's syndrome - (a case report with a review of the literature)DA D'Souza, MPE Bharucha, MV Shah
Department of Psychiatry, L.T.M.G.Hospital, Sion, Bombay 400022, India
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.
Munchausen's Syndrome  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. 
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.
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.
According to Barker,  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  criticised the term "Munchausen's Syndrome" which was originally coined by Asher  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".  Other terms which have been used are "Hospital Hoboes",  "Peregrinating Problem Patients " ,  and "Kopenickiades".  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.  Unfortunately, the diagnosis is almost impossible at first because of the dramatic presentation. The useful points are , : -
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. 
(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. ,, These include: -
1. A grudge against doctors and hospital due to previous misdiagnosis and maltreatment when they had a genuine illness in the past. 
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  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  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  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".  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.  Unfortunately, these patients are only infrequently referred to psychiatrists and have a deep mistrust of them.
We thank the Dean, L.T.M.G. Hospital for allowing us to report the Hospital data.