Sick in the head? Part 1

This is the first of a planned three-post series about Munchausen syndrome. In this post I'll talk about the classic syndrome. In the second post I'll talk about Munchausen syndrome by proxy, and in the final post about a newly described variant, Munchausen syndrome by internet.

I used to know someone in meatspace who constantly told lies. About the tiniest, most unimportant things. One minute she was a dental nurse, the next she was working for MI5 (neither was true). It was like her real life wasn't interesting enough, so she had to make up another one to get more attention. We constantly called her out on it (apart from anything else, she wasn't consistent in her lies) but it didn't seem to bother her. Getting attention was the important thing, even if it was negative.

Many people need attention, but for those of us who have serious physical illnesses, and have to take multiple medications and undergo medical procedures to remain moderately stable (note: I didn't say well!), it seems truly bizarre that anyone would deliberately exaggerate or create illness symptoms to get it. People who do this may be suffering from Munchausen's syndrome. These symptoms can in some cases be as credible and measurable as heart arrhythmias, and people with Munchausen's may undergo multiple hospital admissions, treatments and operations. Typically someone with Munchausen's may:

• invent psychological symptoms such as hearing voices or seeing things that are not really there
• pretend to have physical symptoms such as chest pains or stomach ache
• deliberately aggravate an existing illness
• heat a thermometer to suggest fever, contaminate a samples of urine etc
• actively make themselves physically ill: for instance by rubbing dirt into a minor wound to cause infection

People with Munchausen's are aware that they are exaggerating or inventing their symptoms. This makes it distinct from hypochondriasis. Hypochondriacs genuinely believe that they are ill. Although it has always been the case that people with Munchausen's have tended to be very well-informed about the symptoms of the conditions they are mimicking, there is now evidence that the use of the internet has increased this knowledge still further.

The name derives from Baron Karl Friedrich Hieronymus Freiherr von Münchhausen, an 18th Century German nobleman who reputedly told many tall tales about himself. His feats apparently included riding cannonballs, travelling to the moon, and escaping from a swamp by pulling himself out by his own hair.

Although the person with it is aware of what they are doing, Munchausen's is a genuine illness - or perhaps, to be more accurate, a symptom: generally of a mood disorder, an anxiety disorder or a borderline personality disorder. There seem to be two groups generally affected, though nobody knows why: women aged 20-40, often with a background in healthcare; and men aged 30-50. It's not known how common Munchausen's is, though a fairly large study in a Canadian hospital estimated that out of 1300 patients 10 were faking their symptoms, a rate of 0.8% or nearly one in every 100. It's thought to be more common in men than in women.

Munchausen's syndrome is not included as a separate condition in the WHO's International Statistical Classification of Diseases, 10th revision (ICD-10) or in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The official diagnosis in these classifications is 'factitious disorder' and Munchausen's is seen as an extreme version of this. The DSM-IV-TR criteria for factitious disorder are:

• The patient intentionally produces or feigns physical or psychological signs or symptoms.
• Motivation for the behaviour is to assume the sick role.
• External incentives for the behaviour are absent.

The sick role is a term used in medical sociology. It is a concept created by Talcott Parsons, and concerns the social aspects of falling ill, and the privileges and responsibilities that accompany it. To simplify his theory, an individual who falls sick is not only functionally sick, but must now adhere to the socially patterned role of "being sick". This role contains within itself certain customary rights and obligations:

Rights

• The sick person is exempt from normal social roles
• The sick person is not responsible for their condition

Obligations

• The sick person should try to get well
• The sick person should seek technically competent help and cooperate with the medical professional

So, by mimicking or exaggerating symptoms, someone with Munchausen's syndrome both gains attention and becomes exempt from their normal social roles such as going to work. For someone in the grips of a mood disorder such as severe depression, this could be very tempting bait.

There is little evidence as to what causes Munchausen's. One theory is that people with the condition have an anti-social personality disorder which leads them to take pleasure from manipulating doctors and other healthcare professionals. Another theory is that Munchausen's is an attempt to form relationships and become more socially acceptable, by people who previously have been "loners" with few friends and little family contact. Many people with Munchausen's claim to have experienced physical or sexual abuse as children, though these claims are impossible to verify. Many also seem to have experienced serious illness as children.

In the next post in this series, I will be looking at Munchausen's by proxy - where the individual harms others rather than themself.