Recovery from Munchausen syndrome.

To the Editor: In 1998, I published an article in the SMJ entitled, "Breaking the Silence of Factitious Disorder." (1) Through the article, a patient, dubbed "Cathy," sought to inform physicians not only about the range of factitious illness behaviors in which she had engaged, but also about her reasons for doing so. She noted that she had been hospitalized 30 to 40 times, undergone innumerable surgeries and diagnostic procedures, and been prescribed literally hundreds of medications by physicians who never suspected that she was the cause of her own illnesses. She conservatively estimated the costs of her care to date at $400,000. This brief letter reports on her recovery and provides further insights into the psychology of factitious disorder.

Cathy had stated in the original report, "I know that my actions seem utterly inexplicable, and yet I just didn't seem to have any other options.... My goal in being sick was not to cause myself pain or create permanent injury. These outcomes were just the necessary inconveniences along the road to my real destination--receiving that little bit of caring ... that would energize me and enable me to go on with my life." Cathy continues to regard her deceptions as having been a necessary evil, intended to obtain the nurturance and attention lacking in all other domains of her life, rather than a primary effort to mislead others. The desire for care and concern was not "an insatiable need" (2) but a response to a near-total lack of human connectedness in her life. Although Cathy originally did not specify precisely all the illnesses she feigned or induced, she is now willing to have me note that they included self-induced burns, bacterial and fungal sepsis, interstitial cystitis, lead poisoning, esophageal and gastric ulcers, and frostbite as well as fabricated sexual assault. The mechanisms by which she falsified or produced these ailments were, respectively, applying oven cleaner to her arms, injecting herself with feces, instilling clog remover into her bladder, boiling lead items and drinking the water, swallowing kitchen cleansers, exposing herself to bitter cold, and lacerating her vagina.

Cathy has now been entirely free of her factitious illness behaviors for five years. She has abandoned her pseudologia fantastica (gratuitous but engaging lying that mixes fact and falsehood), has successfully pursued additional education, is well-established in a career, and has stable housing as reflected in medical and work records and the statements of friends.

Components of this patient's treatment are important to discuss briefly. The patient relocated from another state to enter psychotherapy in the South. Psychotherapy was eclectic: supportive, cognitive-behavioral, or psychodynamic depending on the patient's presentation at each session. It became evident that the patient suffered from a severe avoidant personality disorder that contributed to her inability to seek care and support in appropriate ways. This issue was discussed with the patient and alternative thoughts and behaviors were suggested. She declined an empiric trial of fluoxetine. The patient felt that the respect and acceptance shown to her during the sessions, and consistency in the scheduling of appointments, were vital to her improvement and the sessions proved to be a useful substitute for medical contacts based on contrived illness.

As the therapy proceeded, the patient also obtained medical treatment from an area internist who was fully aware of her history. Medical appointments occurred on a regular basis to avoid creating a contingency between active illness and medical attention. The psychotherapy ended after two years, the patient and therapist having felt that she had reached maximal benefit, but the medical visits continued. One episode of hospitalization for factitious infection occurred after the end of therapy, but none since then.

Importantly, the patient herself believes that the central element in her recovery was her having been "born again" after the conclusion of psychotherapy, with her religious faith and regular church attendance being pivotal. She was particularly moved by the New Testament passage, "Do you not know that your body is a temple of the Holy Spirit, who is in you, whom you have received from God? You are not your own; you were bought at a price. Therefore, honor God with your body" (1 Cor. 6:19-20). Seeking to share her story, she has made herself available to assist another Munchausen patients actively engaged in factitious illness behavior, and consented to publication of this update.

Recovery from Munchausen syndrome is rarely reported. Most patients flee when confronted, perhaps only to repeat the deceptive behaviors elsewhere. (3) Those who remain have only infrequently responded to psychotherapy, although face-saving techniques have proved promising. (4) Medications have been helpful for patients with co-morbid diagnoses such as major depression. This case counters the common belief that Munchausen syndrome is untreatable. It suggests that factitious disorder functions to compensate for unmet interpersonal needs, and suggests that helping patients meet these needs in healthier ways--religious involvement, for example--may be a decisive factor in the recovery of select patients.

Marc D. Feldman, MD

Department of Psychiatry & Behavioral Medicine

University of Alabama 

Tuscaloosa, AL

References

1. Feldman MD. Breaking the silence of factitious disorder. South Med J 1998;91:41-42.

2. Schlesinger RD, Daniel DG, Rabin P, et al. Factitious disorder with physical manifestations: pitfalls of diagnosis and management. South Med J 1989;82:210-214.

3. Feldman MD. Playing Sick?: Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York, Brunner-Routledge, 2004.

4. Eisendrath SJ. Factitious physical disorders: treatment without confrontation. Psychosomatics 1989;30:383-387.