Tales of the Unexpected

The term “Munchausen syndrome” originates from the storybook character created by Rudolph Erich Raspe, which was based on a real 18th century Prussian cavalry officer, Karl Friedrich Hieronymus, Freiherr (Baron) von Munchhausen. Throughout his adventures, Baron Munchausen performs incredible feats and goes on amazing journeys; he travels to the moon, rides on a cannonball, and saves himself from drowning by pulling on his own hair...

The term was coined by physician Richard Asher in 1951, who said: “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. Accordingly, the syndrome is respectfully dedicated to the baron, and named after him.”

Munchausen syndrome is an extreme subtype of factitious disorder (FD), which is defined by the Diagnostic Statistical Manual–5 of Mental Disorders as being characterized by the following behaviors:

• Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. 
• The individual presents himself or herself to others as ill, impaired, or injured. 
• The deceptive behavior is evident even in the absence of obvious external rewards. 
• The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Some ophthalmologists could potentially go through their entire careers without encountering a patient with FD. But if you do, it’s hugely helpful to be able to recognize them.

Fact or fiction?

Patients with FD can be hugely challenging to treat – they may exaggerate, lie, mimic medical or psychological symptoms, interfere with attempts at diagnosis, induce illness or even injure themselves.

These patients are not working towards obvious external gains, such as to obtain financial aid or to avoid work. Rather, their goal is often unclear, but may be to assume the “patient” or “victim” role to gain attention and sympathy from healthcare providers and others – or it may be because they get a “rush” from undergoing medical procedures. It could also be because they derive satisfaction from duping medical professionals (1).

Take, for example, the case of a woman who feigned deafblindness (see Case Study 1). It might sound fantastical, but these patients do exist. Some go even further – in one case, a women introduced alkaline chemicals into her eyes, causing corneal burns. She then used atropine eyedrops to dilate her pupils and then stared at the sun to produce retinal burns – resulting in self-inflicted blindness (2).

Although Munchausen syndrome, FD, malingering and conversion disorder patients may all display some of the same behaviors, there are important differences to be aware of.

Munchausen syndrome describes a triad of behaviors: recurrent hospitalizations, peregrination (in other words, the patient travels from one provider to another to seek care), and pseudologia fantastica (pathological lying). Munchausen syndrome describes the most severe and chronic individuals (around 10 percent of all such patients). Patients with FD, on the other hand, will display some of these behaviors but are more stable geographically, have some social network, will engage in FD only intermittently, and are more amenable 
to treatment.

Hysteria or duplicity?

When comparing FD with the other reasons people feign illnesses, the two key differences are whether they are conscious of what they are doing and what their motive is for doing it.

Conversion disorder (previously known as hysteria) is the loss of motor or sensory ability, and is produced unconsciously in response to a mental or emotional crisis. Malingering, on the other hand, is the deliberate fabrication and exaggeration of symptoms for clear external gain, such as avoiding work or gaining financial compensation. In FD and Munchausen syndrome cases, the symptoms are consciously produced, but the motivation is usually unconscious.

It may not necessarily be within the purview of the ophthalmologist to distinguish between these patients – but being able to spot a patient who is feigning illness could result in the patient being directed to psychiatric services for more appropriate treatment, rather than time being spent trying to treat an illness that doesn’t exist. In conversion disorder, the patient’s symptoms can improve with treatment, as they are likely to be susceptible to the suggestion that they are improving. In FD and malingering cases, the patient is deliberately choosing to present as unwell, and will not be so susceptible (see Indicators of FD or malingering).

If the patient goes undetected, it can come at great expense, with multiple unnecessary tests, procedures and medications needing to be paid for. If they are later discovered, it can have an impact on the hospital team too – staff may feel cheated out of limited time and resources, or feel that they have been “duped” (3).

Spotting tall tales

But if you think you have spotted one of these patients, what exactly can you do? Valerie Purvin provides some further advice on conversion disorder and malingering in her article “Truth, Lies, and Ophthalmology.” When it comes to FD, there are some maneuvers that can be tried in the eye office: for example, aside from feigned blindness, factitious keratoconjunctivitis is a more common case for an ophthalmologist to encounter (see Case Study 2). In a case like this you could give the patient a pressure patch with subtle markings on it. This can tell you if they’ve removed and replaced the patch, and if they improve once they don’t have access to the eye.

For unilateral visual impairments, you can use a phoropter to fog rather than close their eye, so that the patient thinks they are seeing out of their good eye, when in fact they’re seeing out of the “bad” one. For bilateral visual impairment, you can create an obstacle course from your office to your examination room, and watch how they make their way to their chair – also have someone else watch them when they’re not aware they are being observed.

Other approaches include the use of Snellen charts; isolate the lines as though you are showing them to someone with amblyopia, and provide the patient with no reference as to the size. You can then suggest that a very tiny letter is actually very large, and then go larger and larger until the patient finally admits to being able to see at 20/40, thinking it might be 20/400. These are just some practical suggestions on how to spot these patients (see Factitious visual impairment: some clues).

Once you have ruled out other causes to your satisfaction (and if not, a referral to neuroophthalmology may be appropriate, and allow for objective testing to be done) you can plant the idea in the patient’s mind that they will get better. If they are suffering from conversion disorder, this suggestion could help them improve. If it’s a situation where the patient is malingering or has FD, it will help them save face – confronting patients with their dishonesty does not, in my experience, prove to be very effective.

Simply being aware of the warning signs can help to identify patients whose problem is psychiatric rather than physical, lead to earlier intervention, and potentially prevent side effects from unnecessary treatments. As I have said previously, the deceptions in FD are limited only by the patient’s creativity, knowledge, motivation and skill. Although the eyes may not be a common target for such patients, I believe that practitioners in every area of healthcare, including ophthalmology, need to be aware that these audacious deceptions are possible.

Marc Feldman is Clinical Professor of Psychiatry and Adjunct Professor of Psychology at the University of Alabama, Tuscaloosa, Alabama, USA. A Distinguished Fellow of the American Psychiatric Association, Feldman is the author of more than 100 peer-reviewed articles in the professional literature. He is an international expert on factitious disorder, Munchausen syndrome, Munchausen by proxy, and malingering – and has authored four books on the subject.

Case Study 1: Factitious Deafblindness

Ms. A, a 50-year-old woman, was evaluated at a rehabilitation facility for the deaf and blind. She arrived escorted by a blindness counselor and her guide dog. She stated that she had become blind at a young age and deaf more recently, but simply refused to answer specific questions. She denied the staff access to next-of-kin and identified no close friends. Available records were notably vague. For example, an ophthalmologist had written, “[Ms. A] has asked me to write this note stating that she is deaf and blind. I cannot comment because I have not examined her.” Her audiology report showed no response to sound at any level, but she would not permit testing that was any more objective than a standard audiogram.

Ms. A reported having graduated from college with a double degree in accounting and journalism, but would not provide the dates of university attendance. Other unconfirmed claims included her working in the pit on racing cars and on portable jet propulsion devices. She stated that one of her current career goals was to become a lighting technician at a television station. When told that this goal was obviously impractical, she stated, “You only see my disabilities, not my abilities.” She continually emphasized the “special needs” of her dog, such as strictly organic food. It was observed that, in fact, the animal was no longer functioning as 
a guide.

The patient’s lack of concern about becoming deaf after already being blind was considered perplexing and unconvincing. The eventual consensus was that Ms. A was neither deaf nor blind. The patient precipitously withdrew from rehabilitation services because pain she attributed to a car accident made it impossible for her to participate. She was not confronted about the dubious information she provided or her refusal to allow confirmatory testing. Just before discharge however, when Ms. A was unaware of being observed during a meal, she neatly arranged her food on the plate and speared her peas with great accuracy. She was lost to follow-up.

Case Study 2 – Factitious Keratoconjunctivitis

• A case involving a 17-year-old female “fish processor”
• Intense conjunctivitis was observed in the left eye; then later, in the right eye
• Swabs taken were negative for bacteria, viruses, and chlamydia
• The patient showed no response to steroids and antibiotics, either preserved or unpreserved
• Eventually she went through a conjunctival biopsy, which showed only nonspecific chronic inflammation
• When finally admitted, tissue paper was found in her fornix

Tales of the Unexpected

Truth, Lies, and Ophthalmology