Phony Cancers and Self-Inflicted Acid Attacks: A National Outbreak of Munchausen’s?

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The stories boggle the mind: in August, a 28-year-old Washington woman claimed to be the victim of a mindless acid attack, and almost won the ultimate prize in attention-seeking — an appearance on Oprah — before admitting she had actually disfigured herself. Another woman, a 23-year-old Canadian, faked terminal cancer. She shaved her head, starved herself, tattooed “won’t quit” on her fingers and solicited thousands of dollars in donations for a fake charity, before turning herself over to police this summer.

But, wait, there’s more: another woman in New York City recently faked leukemia to wheedle the community into paying for her dream wedding — complete with a honeymoon in Aruba — before she was revealed as a fraud and lost her husband, too. (More on Why City Life Adds to Your Risk of Psychosis)

And September saw the revelation of another case in Colorado, a woman who also pretended to have cancer and raised some $60,000 from friends and neighbors before being unmasked.

What’s going on? Is the tanked economy creating incentives for scammers? Or are we in the midst of a national outbreak of Munchausen syndrome?

Munchausen’s is the most severe type of a group of illnesses known as factitious disorders, whose sufferers fake illnesses to gain goodies or attention. I spoke with Dr. Marc Feldman, a clinical professor of psychiatry at the University of Alabama and one of the world’s leading experts on these disorders. According to Feldman, who runs and has written several books and numerous scientific papers on the topic, factitious disorders are far more common than you might think. Experts believe they account for billions of dollars in unnecessary health spending.

Q: Why would a woman [Bethany Storro] throw caustic fluid on her own face? Do you think she has Munchausen syndrome?

A: My gut tells me that this is a combination of malingering — which is feigning, exaggerating or self-inducing an ailment to get money or drugs — as well as Munchausen’s. There’s probably a dual motive. She said it was partly a suicide attempt and partly that she wanted to have her face redone.

I wouldn’t take that at face value, so to speak. There are probably deep-seated issues that she’s only barely aware of that made her resort to such drastic behavior rather than just seeking help.

Q: Is the risk of permanent disfigurement an unusually extreme ploy to get attention?

A: It’s certainly uncontrollable when you use a caustic substance. But a lot of people do it. Feigning an attack *is* unusual. [However], a lot of people show up at dermatologists’ offices with strange rashes that they have induced themselves. It’s one of the more common of manifestations of Munchausen’s.

Q: What’s the difference between Munchausen’s and malingering to get money or a dream wedding?

A: The difference is in some cases very subtle. In malingering, people [are] after some external gain. Typically, that’s disability payments or donations of money or narcotics. In Munchausen syndrome … the goal is purely emotional satisfaction, often involving getting attention and sympathy.

According to the American Psychiatric Association, you can only have one or the other. But I’ve been [studying] this for 20 years and I almost always find the two together — at least when a case reaches the public eye or court, then you see the combination routinely.

Q: How common are these disorders exactly?

A: In hospital [studies], it’s estimated that between 1% and 5% of patients have to some extent faked or exaggerated their illnesses. In psychiatric hospitals, it’s a little higher: 6% to 8%. In the general population, the only good study was one where in a family practice clinic, they asked 350 consecutive patients to fill out anonymous questionnaires in which they were asked questions like “Have you ever done anything to deliberately prolong an illness?” Seven percent said they had, including doing things like exposing themselves to substances they were allergic to. [One expert] has said that manufactured illnesses take $20 billion from the health care economy.

Q: Are factitious disorders becoming more common? If so, why?

A: We seem to have a mini-epidemic right now. There are at least four cases that I know of in the last month that have reached national attention. The Internet has [also] affected it massively; I’ve written about “Munchausen’s by Internet.” I think with the advent of so many specific interest groups and health-based support groups, this behavior has really reached new heights. (More on Photos: Portrait of Schizophrenia)

I think it is increasing because it’s so easy to do now. If you are bored, you can assume a new identity. If you decide you’ve got cystic fibrosis, [there are groups that] will instantly accept you because their very reason for being is to offer support. So you’re guaranteed acceptance and everyone goes along. If you are discovered to be lying, you can sign out and click on a new group and decide you have anorexia.

Q: Do you think people with Munchausen’s are responsible for their behavior?

A: Sometimes people will ask, “Are these patients or criminals?” The answer is often both. You can be a patient and a criminal at the same time. For example, pedophilia is certainly a mental disorder, but [molesting children] is certainly a crime. The [responsibility] ultimately lies with the patient. But Munchausen’s in theory could be a mitigating factor. They still need to be punished, but maybe not quite so severely if Munchausen syndrome is involved. Munchausen’s is often described by sufferers as addictive or compulsive. They feel that it’s truly irresistible. There’s a need to explore that further: is that an excuse or is it really the case?

Q: What causes it?

A: At the root of most cases are personality disorders, particularly borderline personality disorder [a condition characterized by wildly unstable emotional states, interpersonal relationships, self-image and behavior — think Glenn Close’s character in the film Fatal Attraction]. These are people who have long-term maladaptive ways of getting their needs met or handling stress. They use action instead of words, typically self-defeating actions. Often, they have been hospitalized in childhood for legitimate medical problems and unexpectedly found that the hospital was a warm and nurturing place. They go on to seek opportunities to get medical attention over and over. In other cases, they may have grudge against the medical profession and see this as a way of getting even.

Q: How do you treat Munchausen’s?

A: We know from clinical experience that heavy-handed confrontation leads only to denial, to the patient eloping from the hospital, or to threats. It’s been tried for eons and almost never works. People have instead recommended supportive confrontation where you say, “We agree with you that there’s a serious problem here, but it’s not a physical problem. It’s an emotional problem, which we want to work with you on.” That fails less often [than tough confrontation]. (More on Invisible Wounds: Mental Health and the Military)

There’s also face-saving strategies that may work. You can say this: “We’ve applied every possible treatment except one. Unfortunately, if we apply the last one and you fail to improve, we will know that you’re doing it to yourself.” [That sometimes allows them to accept help.]

[Not many treatments have really been studied]. I usually recommend very frequent psychotherapy, 45 minutes twice a week [and sometimes use medications to treat co-existing problems].

Q: It seems patients with Munchausen’s tend to pick particular diseases to fake, like cancer.

A: It’s [because] in cases of cancer, there is this heroic quality to the cancer survivor, and we view with admiration those who fight hard. It’s laudable. For these patients, it’s an enviable ailment to have. They know they’re not going to die, so they get the benefits without the drawbacks. Another favorite, believe it or not, is AIDS.

Q: What happens if someone has a real disorder that doctors can’t diagnose and is mistakenly labeled Munchausen’s?

A: The most famous case involved a patient of mine named Wendy Scott. She always asked me to use her real name. She’s deceased now because her legitimate medical problem was misunderstood to be further evidence of Munchausen’s.

She’d had 650 hospitalizations throughout Europe and Scandinavia and 42 abdominal operations. She had Munchausen’s but she’d gotten over it and hadn’t done anything to herself in more than 10 years. Then, she started to have belly pain. She went from doctor to doctor. Many said that they could feel a mass but most believed it was scar tissue [from all those operations] and sent her on her way. They figured they were being duped. We got her here in Birmingham at the university and discovered immediately that she had metastatic carcinoma of the bowel.

It may sound unbelievable, but [here’s how she beat the Munchausen’s]: for four years, Wendy did nothing but get hospitalized. She was in the U.K., living in a homeless shelter and she adopted a kitten. She was an intense pet lover and she realized that if she were hospitalized again, none of other residents would take care of her kitten. So she didn’t get hospitalized again. When we had her here [in the hospital], we brought in a kitten in defiance of policy. [Her pet] had been the cure for her.

Q: What’s the most extreme case you’ve ever seen?

A: Probably Wendy’s. I guess the most extreme ones are those that result in death. There was a patient who created nodules under her skin by injecting talcum powder. She was found dead in an ER bathroom [because it got into her bloodstream and] traveled to her lungs and killed her.

I also had a patient in a legal case [who had been] pepper-sprayed by the police when she resisted going to a psychiatric hospital. She went on for two years, scabbing and scarring her face [claiming that this was caused by scratching in reaction to the spray]. She sued the police and the pepper-spray manufacturer.

[For some reason] she then decided to drill a hole into her skull. She used a plant mister to spray week-old urine and saliva into her brain matter, creating a brain abscess. She [eventually] admitted the truth. [But it wasn’t the brain abscess that killed her]. She died because she was seeing 21 different doctors. She took her medications as prescribed [and the combination] killed her.

Q: Why does it seem like most people with Munchausen’s are women?

A: Women and nurses are particularly high-risk groups. There are a few theories. One comes from a feminist perspective and suggests that women are negated and their needs are frequently ignored and so some decide that the only way that they can get their needs met is by appearing to be ill.

[The only study on this] came out almost 20 years ago. It says that the ratio of men to women in terms of factitious disorders — the milder cases — is three women for every one man. When it comes to full-blown Munchausen’s, it’s 2-to-1, male to female.

But in my experience, which is considerable, I have very, very rarely encountered a Munchausen’s patient who wasn’t female. Maybe they are more willing to come forward. But I’ve seen two to three male Munchausen’s patients, compared with hundreds of females. I’m not sure that that old research reflects reality.

Q: Do you think we’d see less of this if mental illnesses were less stigmatized? It seems as though these people are creating physical illnesses because they don’t want to be seen as mentally ill, to some extent.

A: Our society understands the language of physical distress much more than it understands emotional distress. If you call your boss and ask for a few days off for your emotional [health, you’re not likely to get them]. If you cough into the receiver and say you’ve got the flu and don’t want to infect everyone else, you will get days off.

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