Munchausen's Syndrome

Baron von Munchausen

I was first introduced to the psychiatric malady known as 'Munchausen's Syndrome' back in the late 80's. I understand it's name comes from Baron von Munchausen, a widely travelled adventurer who would regale those who would listen of his fantastical experiences...

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Munchausen's Syndrome: "A chronic factitious disorder with physical symptoms.", "A plausible presentation of factitious physical symptomatology of such a degree that he is able to obtain and sustain multiple hospitalizations. The frequency of hospitalizations will be so extensive that the individual spends the majority of his days either seeking or maintaining hospitalization". 1.

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A dishevelled young man, I'll call 'Joshua', approached the E.R. triage desk with a complaint of moderate abdominal pain subsequent to an approximate 15ft  fall from the roof of a house. He was carrying a bag and a down-filled coat. It was August. In Texas. My inner "Bullshit Detector Alarm" sounded. Loudly.

But, having a high index of suspicion of possible internal injuries, our patient was efficiently triaged. During the primary assessment, he began to complain of sudden, excrutiating diffuse abdominal pain. Drawing up his legs and guarding his abdomen from further examination, his level of acuity was immediately cranked up a notch or two and our walk-in-fall-injury became a high level trauma patient with all the necessary bells and whistles... Trauma Team activated.

• Oxygen 100% via non-rebreather mask
• C Collar/Backboard
• 2 large bore IV's w/NS
• Multiple diagnostic labs including Type and Cross for 4 units of blood on hold.
• Heavy duty narcotics
• Stat CT Scan - abdomen & pelvis.
• Nasogastric tube (NGT) to low suction.
• Foley catheter.

Your basic Trauma Team

Before I go on, for those of you not in the health care biz, there are two tubes most people really don't like....

1. Nasogastric tubes (NGT)
2. Foley catheters

Why?

1. NGT are long tubes that are inserted into your nostril and advanced until they reach your stomach.
2. Foley catheters are placed into your urethra and are advanced until they reach your bladder.

'nuff said.

'Joshua' was a champ. Submitting to the barrage of tubes and needles coming his way simultaneously, he sucked it up and "took it like a man", so to speak. I was impressed. Even our drugged and/or drunken patients have a hard time with the NGT. He was stoic.

Now stable, vital signs within normal limits, Joshua and I went to CT.

It was upon his exit from the CT Scanner that he had the first of his many "seizures".

I had been an ER Nurse for about 10 years at this point and had seen my share of seizure activity. And although this was by far the best seizure performance I had ever witnessed, my "Bullshit Detector" alarmed yet again.


I shared my skeptism with the ER doc.

He shrugged.

Little known fact: Many nurses beat themselves up for thinking bad thoughts about people. I was no different. The poor guy was traumatized physically and emotionally. Here I was thinking it was all B.S. What kind a a nurse was I anyway? Had I become jaded? One of those crusty, old, acerbic ER nurses who could care less about you or the horse you rode in on?

All of Joshua's lab and radiology reports came back within normal limits. He was being kept in the hospital for further observation as his level of consciousness was deteriorating. At the change of shift I began reporting off to the oncoming night shift nurse..."This is Joshua X, patient of Dr. Y's, chief complaint; fall injury...." she interrupted me. "That's not Joshua X, that's Tony B. - I took care of him last month after he fell off of an escalator."; "He's faking".  Suddenly, upon hearing our report, and as if by divine intervention, 'Tony', my 'semi-conscious' trauma patient sat up, pulled out his NGT and demanded to be discharged.

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"Features associated with this disorder, as described by Sussman and Hyler include pathological
lying, extensive knowledge of medical terminology and hospital routines, demanding and disruptive behavior, substance abuse, shifting complaints and symptoms, equanimity regarding invasive procedures and operations, wandering, discharge against medical advice, deception regarding identity, evidence of prior treatment, and intermittent time in jail or psychiatric hospitals." 2.

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A few months later our ER doc recieved a call from another hospital's ER asking if we knew a "Tony B." Apparently, he had been 'found down' after reportedly falling down a staircase at the mall. He was unsconscious but had a card in his wallet from our ER...

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"Although the precise motivation for Munchausen's syndrome is unknown, several explanations
have been offered, such as underlying organic problem, substance abuse, resentment of physicians,
childhood deprivation and rejection, subintentional death wishes, castration fantasies, relief of aggression and guilt through operations, and seeing the physician as a father figure. It is currently
believed that different motives operate in different patients and even in the same patients on
separate occasions." 3.

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Reflecting back on Joshua/Tony, I wonder where he might be today? I guess it would be a safe bet to think (unless he has had extensive psychiatric treatment), he's occupying an ER stretcher somewhere, messing with the minds of his health care team.

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References;

1. Committee on Statistics and Nomenclature. Diagnostic and Statistical Manual of Mental Disorders,  3rd   ed.American Psychiatric Association, Washington, DC, 1980.
 
2. Sussman N, Hyler SE. Factitious Disorders. In: Comprehensive Textbook of Psychiatry, 3rd ed. Kaplan H,Freedman A, Sadock B, eds. Baltimore: Williams & Wilkins,1980.
 
3. Howe, G.L. Munchausen's Syndrome or Chronic Factitious Illness: A Review and Case Presentation. Journal of The National Medical Association, Vol. 75, No. 2, 1983.