In the eighteenth century, Baron Hieronymous Karl von Munchausen went to Russia to fight the Turks as a cavalry officer. A mercenary, he became famous for entertaining friends (usually over a bottle or two) with wild and dramatic tales of brave exploits and narrow escapes. In one of these the Baron told how - after an exhausting flight - he fell asleep in deep snow, tying his horse to a convenient post. Nothing else was visible. The following day, to his astonishment he found himself in a village, his unfortunate horse dangling by its bridle from the church steeple - the whole scene revealed by the now melted snow. Such stories became a bench mark for creative lying; a collection of them was later written by RE Raspe in "The Singular Travels, Campaigns and Adventures of Baron Munchausen".

In 1951, an imaginative and alert physician, Dr R Asher, borrowed the Baron to describe an extraordinary psychiatric condition which he had been studying. Consider the following examples:

Susie (not her real name) was a mousey young woman who suffered badly from asthma as a child. In her office, Susie kept to herself. She had a boyfriend, Steve, to whom she was devoted. One day, Steve announced that he was leaving town, and incidentally leaving her as well. Susie was devastated. She called in sick for a while. When she returned, she had shaved off all her hair, and had lost over 10kg of weight. She looked pale and gaunt. She told horrified colleagues that she had been diagnosed with incurable breast cancer. Susie also joined a breast cancer support group. It was only after some time that the group leader, Jo, discovered Susie's story to be a pack of lies. Susie had never been diagnosed with cancer. Sensitively and gently, Jo confronted Susie and persuaded her to go for counselling. Within a few months, Susie was doing well and had a new job. She has not again resorted to feigning illness to get attention.

Robert (not his real name) was a former engineering student who had dropped out of college. He was admitted to a special ward for investigation of a dreadful rash all over his body. The rash itched, oozed blood and showed signs of infection. For over a week, staff tried to treat the rash and discover its cause. Eventually, a chance discovery occurred: Robert had a large bottle of a skin lotion to which he was allergic in his bag. Confronted, Robert yelled at hospital staff, calling them incompetent. He discharged himself at once, threatening to call his lawyer. Some time later, Robert turned up in another hospital in a different provice, covered from head to foot in a dreadful rash.

Beverly Allitt (her real name) was a nurse working at Grantham and Kesteven Hospital in the British Midlands. Aged 23, she was arrested for causing the deaths of four children and babies in her care, attempted to kill three more (one of whom, Katie Phillips, was badly brain damaged) and attacking a further six children. Allitt had injected the children with insulin or attempted to suffocate them. At the trial, it was argued in mitigation that Allitt had done this in order to play a central role in the drama that ensued when a child - unexpectedly - was found dead or nearly so. She was given 13 life sentences and committed to a hospital for the criminally insane.

An inquiry set up by the health authority later denied that Allitt was suffering from a mental disorder called "Munchausen Syndrome by Proxy", but the popular press has continued to associate her with this label. Munchausen Syndrome is the only psychiatric disorder which is said to occur "by proxy", meaning that helpless others are used to get attention, sympathy and play a role in a satisfying drama.

Thabo ( not his real name) sat in the hospital cubicle, mumbling. His mouth drooped, his right arm was held to his chest, palm outward, and his right leg limped. He was 19 years old, and a week before his mother had discovered mandrax tablets in his belongings and forbidden him to see his friends. When asked about football, his speech temporarily returned. Thabo's elderly uncle had suffered a stroke previously and caring for this relative had taken up a lot of his mother's attention.

Lastly, consider John (not his real name) who taught in a school of nursing. One day, he presented his son at the casualty; crying and said to be ill. He handed over a urine sample which he said he had collected himself, suspecting severe infection. The path lab was astounded to find that there was, indeed, blood in the urine, but the urine itself came from an animal, possibly a dog. Could this be another case of "Munchausen Syndrome by Proxy"?

Factitious disorders

The correct term for Munchausen Syndrome is Factitious Disorder - part of a group of disorders characterised by physical or psychological symptoms that are feigned, exaggerated, or self induced, with the objective of being admitted to hospital or granted the "sick role" by others. Once considered rare, it is now thought that factitious illness is in fact widespread - as many as 9% of patients admitted to hospitals could be faking some or all or their symptoms.

Factitious illness is not malingering - feigning illness for material gain or to escape responsibilities. As in the above cases, there is no external gain to the patient, and sometimes there is (self inflicted) real discomfort. An essential aspect of the problem is the person's familiarity with medical matters which makes it possible for them to fool even experienced practitioners.

Types of illnesses which can be faked

Dr Asher divided Munchausen patients into three groups: the abdominal, the neurological, and the bleeders.

Abdominal fakers may present pain, nausea and vomiting, dizziness, weakness and diarrhoea. They frequently undergo surgery or investigations and can end up with a "hot cross bun" or "gridiron" abdomen, criss-crossed and dotted by scars. It is likely that these may be passed off as war wounds in a Baron-like manner.

Bleeders may swallow anticoagulant drugs in order to produce ready bleeding - blood from a self induced nosebleed can come in handy, but they may resort to more extreme methods, causing orifices to bleed or swallowing pigs' blood in order to vomit up in a dramatic way.

Neurological fakers may simulate any condition from a stroke to a seizure or epileptic fit, headaches, dizziness and so on.

In addition to these, we may include a large group who present with factitious psychiatric symptoms such as hearing voices, depression, conversion symptoms, or just generally bizarre behaviour. We may also, perhaps, add those people like John and even perhaps criminals like Beverly Allitt, whose medical-drama fantasies involve children - although as we shall see, this is rightly controversial.

Who gets Munchausen's syndrome and how is it caused?

The illness usually begins in early adult life, though some have a history of faking illness in childhood. As with Susie, there is often a trigger incident involving loss, rejection or abandonment. Most have been in hospitals before, for a genuine illness, or have a close relative who was hospitalised; the more experience of hospitals, the better the faking.

People with factitious disorders usually have a normal, or even above average IQ. Their childhood history may reveal early deprivation of love, serious illness or disability which made doctors and nurses their major caregivers, and often a mother or father who is perceived by the patient as rejecting them.

By seeking the love of hospital staff, but also inevitably their rejection when faking is exposed, the person revisits or repeats the scene of his or her childhood experience. (Freud called this the "repetition compulsion"). So although the behaviour is voluntary, it has a compulsiveness about it too.

More men than women are diagnosed with Munchausen Syndrome. The person with a factitious disorder often has the kind of personality that is regarded as problematic by others, with poor personal relationships, perhaps a weak sense of identity, or a tendency to identify with the people around them.

In a few cases, persons other than the patient may assist him or her in simulating an illness. This was the case with John. His little boy went along with him so far as to pretend to have a stomach ache, and his wife was also complicit.

Like John and Allitt, many people with factitious illness have an association with the medical profession. Their experience assists them in effective faking and their choice of a paramedical job may both contribute to and reflect their fascination with doctors, while obviously holding a deep grudge against the medical profession. Like Robert, Munchausen Syndrome patients often abuse medical staff, sneering at their failures, accusing them of incompetence, threatening to sue, and becoming generally abusive.

Course and outcome

Unless factitious illness discovered before unnecessary surgical procedures are done or medication given, the long term outlook can be grim. It is quite possible that many Munchausen patients die of complications of surgery, perhaps without anyone realising the true nature of their illness. Chronic hospitalisation prevents them from achieving satisfaction in work or in relationships. In general, the outlook is likely to be poor, except in cases like Susie's where prompt and sympathetic recognition of the true problem was forthcoming. It is especially gloomy if - as often happens - the person is feigning psychotic symptoms or has taken to crime, or shows other signs of an antisocial personality.

There is no specific treatment that is effective in factitious disorders, mainly because patients avoid it by discharging themselves from medical care as soon as they think the game may be up - hoping to try their luck elsewhere. At the moment, the best hope for sufferers of Munchausen Syndrome is prevention by early recognition of the disorder, and a sympathetic, non-judgemental approach when that happens.

It is certainly difficult for doctors who may feel justifiably aggrieved that the patient has wasted their time and or tried to make a fool of them, but setting up any kind of dramatic "unmasking ceremony" in order to humiliate the patient in return will simply increase hostility and inspire immediate flight from the hospital.

We need to recognise that people who do these things, while they appear to be in control of their actions, are at another level seriously out of control and even in the grip of panic - panic that if they are not ill, nobody will love or care for them. They only feel truly alive when they are the focus of a medical drama, and are being nursed.

Munchausen by proxy

What of Munchausen Syndrome By Proxy (MSBP)? This is another kettle of fish, much more controversial. Despite wide coverage in the popular press, MSBP does not exist in either of the two major systems for psychiatric diagnosis - the American DSM-IV or the World Health Organisation's ICD-10.

There can be little doubt that Beverley Allitt, and the dozen or so British mothers who allegedly suffocated or poisoned their own babies because of MSBP, are mentally disturbed. But the nature of the disturbance and its possible relation to factitious disorders remains uncertain.

Munchausen syndrome by proxy is not regarded by courts as a reason to relieve the accused of responsibility in a case of murder, although as in the case of Beverly Allitt, it may be considered more appropriate for the sentence to be served in a medical facility.

The horribly sad truth is that the Allitt case could be seen as the ugly tip of the iceberg of institutionalised child abuse in hospitals, children's homes and schools. In the same way, parents or caregivers who kill or sicken their children in order to adopt a tragic or heroic role themselves, merely reflect one aspect of the vast amount of use and abuse to which the human race subjects its helpless children for its own ends. It is difficult to see how it helps the children or anyone else to invent a new psychiatric label to explain their suffering in medical terms.

Perhaps the poet Elizabeth Barrett-Browning said it best when she wrote the following:

I think it frets the saints in heaven to see
How many desolate creatures on the earth
Have found the simple dues of fellowship
And social comfort, in a hospital

Further interesting reading:

"Ailments through the Ages: An alarming history of famous difficult patients", by Richard Gordon. (ISBN: 1854793675).

For more on factitious disorders, treatment, and support try the following websites:

Munchausen syndrome, Munchausen's syndrome by proxy and factitious disorders.