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IN PRACTICE

A patient's tragic tale didn't add up

The young woman came looking for treatment. But she refused to own up to her real problem.

April 14, 2008|Sandeep Jauhar | Special to The Times

Deception by patients assumes many different guises. One is what the diagnostic bible of psychiatry calls malingering: "the intentional production of false or grossly exaggerated physical or psychiatric symptoms" motivated by the desire to avoid work, evade prosecution, obtain drugs and so on. I believe my patient was suffering from a different disorder, called Munchausen syndrome. In this syndrome, patients will often intentionally produce or distort symptoms because of a need to be seen as ill or injured. They will undergo painful tests or diagnostic procedures if necessary to maintain the lie.

Named after Baron Munchausen, a German military officer in the 18th century who was known for telling tall tales, Munchausen syndrome most often affects young adults and usually involves physical symptoms, such as chest pain, stomach problems or fever. Diagnostic clues include dramatic but inconsistent medical history; eagerness to undergo medical tests, operations or other procedures; history of seeking treatment at numerous hospitals; and reluctance by the patient to allow doctors to meet with or talk to family, friends or prior healthcare providers.

Although a person with Munchausen syndrome actively seeks treatment for the various disorders he or she invents, the person often is unwilling to admit to and seek treatment for the syndrome itself. The outlook for recovery is usually poor.

"There's nothing you can really do in these situations," Dr. Alberto Goldwaser, a forensic psychiatrist at NYU Medical Center, told me. "We need acknowledgment from a patient that something is wrong to make them better. Patients with Munchausen don't have that insight."

He added that despite the proliferation of psychiatric medications, drug therapy is usually ineffective. "There are many diseases in psychiatry motivated by unconscious conflicts that are not amenable to treatment," he said. "This unfortunately is one of them. She'll end up going somewhere else, finding someone to give her what she needs. These patients are bound to repeat their mistakes."

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Dr. Sandeep Jauhar, director of the Heart Failure Program at Long Island Jewish Medical Center, is author of the new memoir "Intern: A Doctor's Initiation."

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