Towards the end of the 19th century a publication appeared from the pen of Baron Munchausen giving an account of his worldwide travels and experiences. This included long and eloquent observations of cases of the disease and of the hospitals where they were treated. There were many medical critics who regarded the case descriptions as implausible and ridiculous. Others regarded them as crude and incompetent accounts of real organic illnesses.
Some decades later, Dr Richard Asher (1951), director of the casualty department of the Central Middlesex Hospital, published a paper in which it was plain to large numbers of medical readers that he had captured the essential features of a hitherto unrecognized acute and dramatic 'illness'. These patients had a record of presentation to a large number of casualty departments and frequent admissions to medical and surgical wards. Here the judgement made was that the symptoms and signs had been fabricated and that individuals, who were often homeless, were seeking shelter and protection rather than requiring treatment, and suffering from what was now regarded as some form of 'personality disorder'.
Within a short time observations of such disorders began to appear from all parts of the world. This paper, from an observant and imaginative writer, made it clear that the existence of medical, psychological, and social phenomena in these patients was relatively common in all countries and the high prevalence had escaped notice until attention had been drawn to it.
Until the 19th century novelists and writers had neglected its social and familial repercussions when the danger of death transfigures the perception of the outer and inner worlds of experience and their fate shaped by their illness.
1. Literature and illness 2. Some social and historical associations 3. Case histories 4. Psychopathology of the Munchausen and related forms of personality disorder 5. Concluding remarks1. Literature and illness
During the period since the middle of the 19th century an increasing number of novels and other writings have included sick or disabled persons and their vicissitudes, often emanating from the life history of the author, and playing an important part in the action and its relationship to the inner life of the central characters.
The attitudes of those in the community to the progress of disease and its treatment to an increasing extent brought the medical profession into contact with their potential patients by inviting them to participate in the medical programme. These early contributions to the lives of ill persons and their carers tended to be over-dramatized but they improved in authenticity in later decades.
An early contributor, Virginia Woolf, brought to bear a delicate and insightful sensibility to her representations and her own experiences of disease. In her case this eventually led to her suicide by drowning.
Considering how common illness is, how tremendous the spiritual change that it brings, how astonishing when the lights of health go down, the undiscovered countries that are then disclosed, what wastes and deserts of the soul a slight attack of influenza brings to view, what precipices and lawns sprinkled with bright flowers a little rise of temperature reveals, what ancient and obdurate oaks are uprooted in us by the act of sickness, how we go down into the pit of death and feel the waters of annihilation close above our heads and wake thinking to find ourselves in the presence of the angels and the harpers; when we have a tooth out and come to the surface in the dentist's armchair and confuse his 'rinse the mouth — rinse the mouth' with the greeting of the Deity, stooping from the floor of Heaven to welcome us — when we think of this as we are so frequently forced to think of it, it becomes strange indeed that illness has not taken its place with love and battle and jealousy among the prime themes of literature. Novels, one would have thought, would have been devoted to influenza, epic poems to typhoid: odes to pneumonia; lyrics to toothache.
It will be apparent that some of the effect of these representations can enrich the personality and help in the healing of illness. But in some vulnerable individuals it may generate neurotic or personality disease; what used to be called 'hysterical personality' has now been changed to 'narcissistic personality' or 'borderline personality disorder'.
Characters afflicted with disease have usually been described from the outside in literature, and distance has tended to lend enchantment to the view. For the manner in which they have been depicted has often given to illness an aura of sentiment and romance, and established fashions that have been widely emulated. In the 19th century tuberculosis was a common cause of disease and death: the literature of this love-shackled period endowed the disease with a tragic and spiritual beauty. The heroines of
La Dame aux camélias and
La Bohême die of tuberculosis on the stage. They had been based upon the characters of women loved by the younger Alexandre Dumas and Henri Murger, who had suffered from phthisis. This was the time when Keats wrote 'Youth grows pale and spectre thin and dies', and the imperishable sonnet 'Bright star would I were steadfast as thou art' was composed four months before his death from consumption in Rome. Byron said, 'I should like to die of a consumption because the ladies would all say "look at that poor Byron, how interesting he looks in dying".'
In this manner tuberculosis came to be incorporated into the ideal conception of beauty and artistic sensibility, and good health was almost equated with bourgeois coarseness, materialism, and vulgarity.
Half a century earlier the publication of Goethe's
Werther, whose romantic hero took his own life, let loose an epidemic of yearning and melancholy in Germany and made suicide a fashionable pastime among those who wished to cut a poetic figure. Heroines and high-born ladies swooned and fainted in the reign of Queen Victoria.
Florence Nightingale dominated the worlds of public health, nursing, and social welfare and exerted a powerful political influence from her sickbed, while Elizabeth Barrett languished for many years in a state of romantic fragility, suffering from a spinal injury, delicate lungs, and threatened consumption. Medical science was unfortunately insufficiently advanced for anyone to be able to remove a prolapsed intervertebral disc. However, she managed to survive long enough to make her celebrated escape from 50 Wimpole Street and consummate her epic love affair with Robert Browning, whom she married.
The role of helpless invalid, or indeed of affliction with specific disease, is therefore not always repugnant or unwelcome. It may provide an avenue of escape from the turmoils and conflicts of active life. Or it may be conceived as adding an appealing lustre and significance to the personality and ego of the unloved, depressed, and rejected. Here we approach close to the essence of the condition which is a vicarious attempt to resolve conflict that has become insupportable or reached a critical stage, by flight into disease.
The typical neurotic subject is insensible of the true nature of his malady and by a convenient dissociation of mental processes into separate, uncommunicating departments (a device for which the narcissistic personality is specially gifted), the problems from which he has taken refuge are also shelved in some hidden corner of the mind. The narcissistic personality assumes illness for a specific and understandable purpose which may be uncovered by psychological enquiry and is largely unconscious of the escape that disease provides and of the psychological processes that motivate it.
Special interest attaches, however, to those subjects who appear, in full consciousness, to choose disease, mutilation, and physical suffering as a way of life for its own sake. These are the individuals who manage to feign soaring temperatures, or who are brought into hospital with seeming haemorrhages of alarming proportions from a bewildering variety of orifices, who succeed in getting their abdominal walls covered with an intricate pattern of surgical scars, who may get their limbs amputated and their cranial cavities explored. The phenomenon has become notorious under the eponym 'Munchausen syndrome' coined by Asher (1951). The description was unfortunate for it helped to establish a strong hostile bias towards individuals, often endowed with valuable qualities, who are set on a course of self-destruction and whose condition reflects a distorted state of mind that requires early and sustained treatment.
2. Some social and historical associations
It is perhaps relevant that the self-inflicted injuries by patients with Munchausen syndrome figure to some extent in the periods of fasting or self-inflicted pain and deprivation in the practices of many religions in the rituals prescribed for atoning for sin or achieving a higher spiritual tendency.
It would be superficial, as
William James pointed out, simply to explain all such phenomena in terms of an egotistical craving for sympathy and notoriety, but one cannot but suspect that in many instances some important relationship to an inherent personality disorder exists. Some of the early religious activities recorded in ancient history were dominated by services where some shaman or priest engaged in heroic activities such as crossing mountains and rivers, wars with demons and ghosts, acted out in front of an audience who participated in these activities. These were among the earliest religious group activities. In the rites of Dionysus in ancient Greece, the participants enacted the birth, death, and resurrection of a god. The death of the god sometimes took the form of human sacrifice, either of a priest or some substitute. The rites were enacted mainly by women led by a male priest, a description perhaps reminiscent of the wards of a modern hospital.
So when we attempt to use the term 'narcissistic personality' in a pejorative sense, let us remember the ancient lineage and ubiquity of the phenomenon. If we were to dispense with the deviation from the norm that is narcissism, we should have to do without great actresses and actors, opera singers, many executant musicians, journalists, salesmen and women who carry their beauty with panache, and some of the best teachers in medicine.
Nowhere is it more difficult to hold condemnation in check than in the face of the persistent, tale-spinning deceit and exhibitionism of the chronic hospital addict. Nowhere is it more important to maintain a spirit of objectivity, tolerance, and detachment.
3. Case histories
Case 1This case exemplifies both the characteristic natural history and the psychological background of the phenomenon particularly well. It is that of a nun aged 41 who joined an Anglican order at the age of 24 and, when not afflicted with some physical complaint, had been described as serving it with dedication. She was admitted to hospital with a suspected diagnosis of hyperthyroidism, owing to loss of weight and a raised pulse rate. Perplexity and later suspicion were aroused by the fact that although her basal metabolic rate (BMR) was raised, the uptake of radioactive iodine by the thyroid was negligible, a finding thought to be sufficiently bizarre for a psychiatrist to be consulted in the matter. After having noted the thickness of the case records and the combination of reserve and icy hostility with which the psychiatric consultation was greeted, it was thought advisable to survey the history of past disabilities. Her medical history had begun at the age of 16 with bilateral, middle-ear infection which rapidly became chronic. After a number of periods in hospital, a mastoidectomy was carried out followed by a second operation two years later. The purulent discharge from both ears continued. She then developed a thick nasal discharge and pain over the sinuses. Several operations were carried out, including submucus section of the septum.
Some time later, while working as a probationer nurse, she was diagnosed as having scarlet fever and to have tachycardia and swollen ankles. She was kept for four months on her back and after dental extractions she suffered a recurrence of the sinus infection. She then developed an infection of the left thumb, resistant to treatment, necessitating amputation. She was thereafter given short-wave therapy for a period. A further flare-up of infection in the stump was treated by penicillin but the responsible organism proved extremely resistant and, following infections in several fingers, a number of nails were removed. However, the monotonous recurrence in her case records of the words 'a pure culture of
E. coli' in the bacteriological reports provided an important clue.
She suffered further sinus troubles and a massive epistaxis which required blood transfusion. She then went abroad where frequent epistaxes, often necessitating blood transfusion, gave rise to considerable perplexity. There followed a recurrence of E. coli infection, this time in the left knee joint, followed by a further admission for tachycardia, sweating, and loss of weight. It is of interest that she was carrying out nursing duties at this time and had responsibility for dispensing a wide range of drugs. Some years later there was a recurrence of septic arthritis and also a rectal fissure for which she was admitted to hospital for the eighteenth time.
After completion of the psychiatric interview it was felt advisable to carry out a careful inspection of the patient's locker. In it were found two syringes, numerous needles, two catheters, Price's
Textbook of Medicine, a textbook of nursing, and several hundred tablets of various kinds, including thyroid extract. Marked thermometers failed to return, indicating that she was secreting one or more of them on her person. This provided an apparently logical explanation for the swinging temperature which had meanwhile appeared, until this was traced to a number of gluteal abscesses subsequently admitted to have been self-induced by injections of bath water. Study of the bacteria of the contents of the abscesses made it certain that the fluid which had been injected by her had been contaminated.
Subsequently the patient admitted to having simulated many of the disabilities of recent years. It was not possible to get her to admit that the early haemorrhages, sinus infections, and the chronic infection of the left thumb had been self-inflicted. As her cooperation in treatment had been obtained it became clear that further confessions would have proved humiliating, and there did not seem any purpose in eliciting them.
Her father was a general practitioner working in private practice, and during the patient's childhood the family lived in close proximity to a nursing home owned by him. Able, energetic, but cantankerous, impatient, and prone to bursts of explosive temper, the children were terrified of him. The mother was an efficient and conscientious woman, but poorly gifted in expressing affection or tenderness and most of her energies, like those of her husband, seemed to be absorbed in the management of the nursing home. The patients were, in other words, highly privileged members of the community in which our nun had grown up. Noise or high spirits tended to be discouraged and at an early age the patient was sent to a convent school.
One can perhaps best convey what conclusions were eventually reached in respect of the most likely psychological starting point for the patient's disabilities by recounting the story of a man and wife, both working in the medical profession. They had only one child. All day long the father and mother would be busy working in the same private hospital and nursing home. When the little child was asked one day what she would like to do when she grew up, she replied without hesitation, 'I would like to be a patient'.
Case 2This man was a highly capable, charming, widely respected citizen, successful in life, a devoted husband and father. His many commercial contacts had led him to an early stage of his life into increasingly heavy drinking and, as alcohol was for him a social lubricant, he found himself, in his early 30s, getting drunk before the usual boost to wit and eloquence could take effect, and this was happening in the middle of the day. He had, in other words, become a chronic alcoholic. He dealt with the situation with unusual courage and energy, sought treatment, went off alcohol, and became a teetotaller and a leading light in Alcoholics Anonymous. Seven or eight years later he suffered a mysterious malady which led to numerous admissions to hospital in a state of profound coma. Detailed neurological and metabolic studies proved largely negative and it was eventually decided that he was suffering from some slowly developing, diffuse neoplasm of the midbrain on account of the recurrent attacks of prolonged coma and the intermittent abnormality in his
EEG, which took the form of high-voltage, bilaterally synchronous, slow activity. Before this conclusion had been reached, however, he had had several lumbar punctures, some twelve EEGs, an air encephalogram, and, in the course of a severe depressive episode between admissions for coma, a course of electroconvulsive treatment. All these measures he endured with a resignation and good humour which everyone regarded as stoical and astonishing.
After eighteen months of fruitless investigations, he suddenly developed a state of acute confusion, becoming disoriented in hospital and insisting that he was being criticized, accused, and insulted by a number of people shouting at him from an adjoining room. He was voluble, excited, and aggressive and was restrained with great difficulty from leaving hospital to seek the help of the police. It was decided that his condition could be due only to an acute toxic state or some toxin he had been taking regularly and had been suddenly withdrawn. He was admitted to a mental hospital where, after the clearing of his confusion, he was allowed to go freely into town. Twenty-four hours later he was, as anticipated, lying comatose on his bed. Underneath his mattress was found a litre bottle half full of chloral, which had been prescribed for his insomnia some five years previously and to which he had become increasingly addicted.
A certain superficiality of emotion and a capacity for dissociation of consciousness had no doubt helped him to hoodwink himself and others about what was happening, to the point where he permitted ventriculography to be carried out. Why had he not behaved with the determination and forthrightness that had enabled him to achieve the rare feat of an effective and lasting cure from alcoholism some years previously? To some extent probably because chloral provided oblivion for him, and possibly he obtained a certain satisfaction from the high drama his admission to hospital had provided. However, perhaps his chronic intoxication, which was far worse than anything he had suffered during the period of alcoholism, made it impossible for him to hold his tendencies to self-display in check. There is evidence that hospital addiction and self-mutilation sometimes appear for the first time after brain injury or disease. Hence, even in the oddities of conduct which look so like wilful misdemeanours, we cannot get completely away from the brain and its preformed patterns of response. That there may be something in this explanation is suggested by the fact that this patient made an excellent response to treatment and has, over a period of five years, remained a successful, respected, and valuable member of the community.
4. Psychopathology of the Munchausen and related forms of personality disorder
From the facts outlined is it possible to infer any explanations for the deliberate simulation of illness or disability? Clearly any complete explanation would require much more knowledge than we possess at present and the field is worthy of research by the psychiatrist, the physician, and the social scientist. But there are certain consistent themes which run through the lives of their patients and it is on these themes that attention should be focused.
The craving for the special care and attention, the concern and the high drama that are all available in the medical or surgical ward and at home seems commonly to have been the starting point in the early stages of childhood when the affection and tenderness which are indispensable for healthy development appear often to have been lacking, or when conditioning to a role of extreme helplessness and dependence has occurred.
The condition is commoner in women than men, and some of the phenomena under the heading of the syndrome Munchausen-by-proxy, in which the mother or female care person is responsible for imitating the syndrome or inflicting a serious feeding disorder, such as anorexia nervosa, has some factitious element. In this condition the transfusion of blood or some other fluid being injected into the child is contaminated by the addition to it of some toxic or poisonous substance. Those who undertake these dangerous and illicit acts prove, in most cases, to be mothers or carers of the child.
Young persons with personality disorder engaged in antisocial behaviour such as burglary, violence, and antisocial conduct in a setting of drug dependence are mainly male. These are, of course, two completely different populations.
The phenomenon of hospital addiction appears therefore to be an escape into illness for a specific purpose: to achieve vicariously the love, pity, or sense of significance of which the familial and social background has, for one reason or another, deprived these individuals in their formative years. If this is correct the condition must, despite the distinction drawn earlier, be related to underlying
borderline personality disorder (DSM-IV).
For persons whose life history and presenting features reveal some positive assets of emotional strength, stability, intelligence, and achievements in personal relationships, it is possible for psychotherapy to achieve considerable success. Treatment in such cases is quite often rewarding, particularly after one has succeeded in bringing the patient to the point where he admits to his deceptions and prevarications.
5. Concluding remarks
The desire to be ill is a relatively common human failing and possibly connected with that willingness to undergo or to exhibit physical suffering that has played an important part in the history of some cultures and religions. In cultures where the fakir excites admiration and miracles are considered everyday events, there are perhaps outlets which our society provides only within the confines of the hospital. Yet in seeking for explanations one is in danger of explaining them away. It would be naive and shallow to overlook the fact that those who have been prepared to accept martyrdom in a cause have written some of the noblest chapters in history. It would be just as unfortunate if the doctor were to be too ready to suspect a breach of the contract of mutual trust and candour by his patient as if he failed to be alive to the possibility that illness might be exaggerated or feigned in an appeal for compassion or understanding.
Bringing the law into the situation is contraindicated and can make matters worse. It would be most tragic of all if we failed to react to a diagnosis of a 'desire to be ill' with sympathy and imagination.
In Molière's
Le Malade imaginaire Béralde remonstrated with his hypochondrical brother for his foolish infatuation with doctors and medicines. 'Doctors', he insisted, 'know their classics, talk Latin freely, can give the Greek names of all the diseases, define them and classify them, but as for curing them, that is a thing they know nothing about.' And again, 'all that their art consists of is a farrago of high sounding gibberish, specious babbling which offers words in place of sound reasons and promises instead of results'. The words you will agree have a contemporary ring. The only thing that has altered is that it is not to general medicine that they are commonly applied nowadays. Ironically enough, Molière collapsed and died after taking part in his play: for some years his enemies had been ridiculing him as a hypochondriac.
(Published 2004)— Martin Roth
Bibliography- Asher, R. (1951). 'Munchausen's syndrome'. Lancet.
- American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders DSM-IV (4th edn.).
