'Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories, like those attributed to him, are both dramatic and untruthful".
This is the opening statement by Dr Richard Asher in his classical description of Munchausen's syndrome, published in the Lancet in 1951. Munchausen's syndrome is an extreme form of facititious disorder, in which a person fabricates physical signs and symptoms and/or psychiatric ones with no apparent motivation other than to adopt the role of being a patient. Munchausen's probably accounts for fewer than 10 per cent of all factitious disorders seen in a hospital setting. To make the diagnosis the following features must be present: simulated illness, pathological lying and wandering from place to place.
Dr Asher's nomenclature is based on the true story of Baron von Munchausen, a German cavalry captain who lived in the 18th century. He was renowned for fabulous anecdotes about his life and adventures, some of which were subsequently published as Baron Munchausen's narrative of his marvellous travels and campaigns in Russia.
Although it helped bring attention to a particular disorder, Asher's use of Munchausen's name has been criticised in view of the absence of a medical theme to the Baron's exaggerated self-promotion. Alternatives have been suggested - "hospital hoboes" or "addiction syndrome" - but, lacking the ring of Dr Asher's original description, none has persisted.
A typical Munchausen's syndrome patient is usually male and makes multiple, often dramatic presentations to hospital, using different names. A fictitious medical history is usually good enough to gain the initial sympathy of staff.
The patient might feign bleeding by presenting a urine specimen which he has contaminated with blood. He might self-induce disease by eating contaminated food. Simulated seizures are another way of seeking medical attention. Psychological complaints can include factitious memory loss and hallucinations.
Once admitted, the patient allows himself to undergo investigations and even invasive procedures such as an exploratory operation. He then discharges himself whether or not his deception is discovered, before setting off on his travels to repeat the entire exercise at a different hospital.
The typical Munchausen patient has a criminal record and a history of lifelong anti-social behaviour. Patients with a generalised factitious disorder are often female, socially conforming, pleasant and compliant in their dealings with hospital staff. They are also easier to treat and will usually show some reduction in their abnormal behaviour after the involvement of a sympathetic psychiatrist.
Munchausen's syndrome by proxy is a related condition in which a care-giver fabricates signs and symptoms in another person - usually children in their charge. They often report breathing problems in toddlers, and diarrhoea and vomiting in older children. Patients diagnosed with this condition often have an underlying personality disorder.
Dr Asher was famous for his descriptive powers, which reflected his concern that medicine was becoming lost in a morass of obscurity and overspecialisation. His sharp writing is evident in his paraphrasing of Churchill when he somewhat unkindly said of patients with Munchausen's syndrome: "Never in the history of medicine have so many annoyed so few."
E-mail Dr Muiris Houston, Medical Correspondent, at mhouston@irish-times.ie or leave a message at 01-6707711, ext. 8511. He regrets he cannot reply to individual medical problems.