Psiquiatria - Faculdade de Medicina - UFMG

diagnositc methods used in roentgenology, endoscopy, biopsy
and laboratory chemistry an organic disease was never found. On
each admission he was free of symptoms a few days later; in adulthood
he always left the hospital very soon, against medical advice.
Since the age of 22, a severe abuse of analgesics was documented;
on admissions at age 25 and 26 the patient presented with druginduced
ileus, which disappeared after he stopped the selfadministration
of drugs. Reasons for the repeated hospital treatments
were the always very dramatic symptoms on admission, but
also frequent changes of physicians. Furthermore, their preliminary
diagnoses of chronic remitting diseases (colitis ulcerosa or
Crohn's disease) were contributive, although the patient knew
they were false.
Detailed history of the admission due to suspected encephalitis
revealed the following. That evening he and his wife were to
visit some friends of hers whom the thought to be very disagreeable.
When his wife phoned and asked him to meet her in the car
as arranged, in order to pay the visit, he complained about diarrhoea,
but his wife did not believe him, whereupon he cried:
“Help, I can't see any longer!” Reevaluation showed that pleocytosis
and increased protein in the CSF were caused by haemorrhagic
lumbar puncture and that the EEG changes were due to
clouded consciousness caused by sedatives. On the basis of the
above history, the diagnosis of Munchausen's syndrome was
made.
Personal development
The patient's records indicated that he had grown up in a
superficially intact family and had attended a school for educationally
subnormal children. At age 12 he had told a psychologist
that he thought his parents rejected him. At that time, the
umbilical colics were interpreted as symptoms of the search for
contact and as expression of feelings of displeasure. At age
15 he started work as an unskilled labourer, frequently changed
jobs afterwards, and had several periods of unemployment. At
age 20 he married; in two medical reports his wife was described
as being dominant and bossy. From age 18 to 22 considerable
alcohol abuse was documented. At age 21 he wrote to the head of
a psychosomatic clinic: “My parents constantly treat me as if I were
a child and all important decisions are taken by them. If I try to get
my own way, my parents threaten to commit suicide... My convulsions
occur especially after arguments with my parents...
Furthermore, I was an unwanted child and had to witness how my
brother was preferred...”
The patient stopped several outpatient psychotherapy courses
soon after starting them, only to be admitted to the hospital as an
emergency shortly after. At age 26 hospital admissions ceased for
a period of three years after he had taken a permanent position as
an unskilled labourer. The head of the company had been
acquainted with the patient and his problems since early childhood;
the foreman was his father. His present family doctor
judged the patient to be “hardly capable of living on his own and
needing the supervision of parents and wife”. The last consulted
psychosomatic doctor characterized him as follows: “He showed
addictive behaviour with wishes for plenty of strong medication
that were expressed as imperative requests for direct and immediate
help. If his wishes were not fulfilled, his helpless and demanding
behaviour turned immediatly into aggressive and de preciative
acting out. In depth psychological terminology he can be described
as having a low selfesteem and is in constant danger of descompensating
with paranoid cathexis of his own body. Motivation for
longterm psychotherapy was very poor, since his possibilities of
obtaining relief from inner tensions through acting out were too
numerous. Family therapy failed because it brought about shifts in
the marital and familial balance, whereupon the patient reacted
with a distinct deterioration of symptoms”.
Psychological testing
In the Hamburg-Wechsler-Intelligenztest für Erwachsene
(Hamburg- Wechsler Inntelligence Test for Adults) our patient
achieved a total IQ of 79 (verbral IQ 74, performance IQ 85).
With respect to the test profile a subaverage intellectual capacity
with lack of educa-tion close to intellectual inadequacy was
observed (verbal part), giving no indication of an acquired organic
impairment due to cerebral pathology (performance part).
Considering the maximum stanine value of 1 on scale 9 (the socalled
lie score) and the normal values on all other scales of the
Freiburg Persönlichkeits-Inventar (Freiburg Personality Inventory)
the only interpretation of these results is that the patient intentionally
gave wrong answers. In the Minnesota Multiphasic
Personality Inventory (MMPI), however, he had normal values on
the validity scales, thus allowing evaluation. The T-scores of the
scales “hypochondria” and “hysteria” were 75 and 71 respectively,
the T-scores of all other scales lying between 45 and 60.
Discussion
Psychiatric patients not suffering from Munchausen's syndrome
but showing the same MMPI profile as our patient are
well known to present somatic complaints without organic reasons.
They mostly receive a neurotic (hysterical, hypochondriacal)
diagnosis. Their underlying personality is described as
“rather immature, egocentric and selfish. They are insecure and
have a strong need for attention, affection and sympathy. They
are very dependent, but they are uncomfortable with the dependency
and experience conflict because of it. They pre-sent themselves
as normal, responsible without fault... by making excessive
use of denial, projection and ratio-nalization. They prefer
medical explanations for their symptoms, and they lack insight
into psychological factors underlying their symptoms. Because of
their unwillingness to acknowledge psychological factos, they are
difficult to motivate in traditional psychotherapy...”.6 This
abstract description of a test profile corresponds nearly perfectly
to the earlier written self-portrait, biography and present way-of
life of our patient as well as with the judgements of consulted
physicians and our own assessment.
Remarkably, our patient started his career at the age of four
years. Except for the very few cases with socalled Munchausen by
proxy,7,8 which means that parents feign or cause illness in their
children in order to obtain medical attention for them, we have
not found a documented case beginning in early childhood.
Casos Clin Psiquiat 1999; 1(1):40-42 41