Tuesday, August 23, 2011

The Surprising Adventures of Baron Munchausen

Karl Friedrich Hieronymus Freiherr von Münchhausen (1720–1797) was a German nobleman known in his time as a weaver of tall tales and humorous anecdotes. Over the years many anonymous authors republished Münchausen’s stories; then in 1785 Rudolf Erich Raspe published “The Surprising Adventures of Baron Munchausen”, an unflattering collection of Munchausen tales which forever labeled the German story teller as a liar.

Fast-forward to 1951; Dr. Richard Alan John Asher published a paper in the medical journal, "Lancet" describing a particular psychosis whereby patients were intentionally making themselves ill in order to gain attention and sympathy. Dr. Asher named the disorder: Munchausen’s syndrome after the old baron.

At the Skeptic’s Toolbox, forensic psychologist and clinical professor, Loren Pankratz, gave a talk about Dr. Asher and the ramifications of the discovery of this interesting psychosis. Munchausen’s syndrome, and in particular its derivation, Munchausen’s by Proxy (whereby parents cause their children to become ill in order to gain attention and sympathy) has become a controversial topic in recent years. As physicians and social workers became educated about this syndrome, it began popping up with increasing frequency in their practices. So much so that soon child protective services workers were removing children from their parents amid accusations of causing their children’s illnesses.

So were physicians and social workers truly witnessing a monumental increase in child abuse through Munchausen’s by Proxy? As a forensic psychologist, Loren Pankratz has been called as an expert witness in the defense of parents accused of causing their child’s illness. Over the years of treating patients for the Department of Veterans Affairs, Pankratz had encountered significant numbers of patients who lied about their own illnesses. During this time the VA was investing significant mental health resources in treating Vietnam War veterans who claimed they suffered from PTSD resulting from horrific war experiences – only to find, upon reviewing their service records, some had never even served overseas.

Pankratz found that medical professionals were now suddenly diagnosing Munchausen’s by Proxy precisely because they had become aware of it in lectures and journals. However the problem was that the physicians were not adequately trained to conclude such a diagnosis; it was not their field of expertise. The result was that mothers genuinely concerned about the health of their children, and often aggressively advocating for their child sometimes to the point of irritating the doctor, were having charges of Munchausen’s by Proxy leveled at them.

This is yet another way in which intelligent people can go wrong; assuming that if they are competent in their chosen field of study, they will be equally competent in another. It is not uncommon for even scientists to check their rationality at the door when venturing into fields where they lack expertise.

Occasionally possessing a little knowledge, incorrectly applied, can be outright dangerous. Or as the old saying goes: “Sometimes when one has a hammer, every problem begins to look like a nail”.

26 comments:

Elisabeth said...

Thanks, Robert for alerting me to something I already know about, but to a limited extent.

I did not realise that Vietnam Vets were in some some instances falsely illness as a result of war trauma.

To me, these burst of knowledge about new illnesses can cause problems in both directions: either we exaggerate the frequency with which such illnesses -so-called - occur, or we underestimate their significance.

Most people in my view do not falsify their experience. If they claim illness of trauma it's usually because somewhere down the line something's gone wrong, but in some instances people falsify their situation because they don't know how else to ask for help.

DJan said...

That is fascinating. I never heard of anybody making their kids sick like that. Bet it's not really very common, but that was your point, I suspect. I never knew any of this, Robert. I learned something today...

Robert the Skeptic said...

Elizabeth The opposite can be true as well, I know of cases where physicians dismissed a patient's symptoms only to have the patients become very ill, or die, as a result of misdiagnosis.

In my own case I was sent home by a doctor dismissing my symptoms as the flu; only to send me to the ER after I asked him if I was having a heart attack on my third visit. I had endocarditis and was hospitalized for 11 days.

DJan It is not very common at all. But the point, obviously, was that it appeared more common than reality because doctors were made aware of the syndrome but not adequately trained or qualified to diagnose it.

thegoodgreatsby.com said...

Didn't this same thing happen with the spike of high profile child molestation cases in the 80s? Psychologists were seeing molestation everywhere but it turned out to be a result of new attention on the issue and new methods for questioning children.

John Myste said...

I tried to read this. I was very interested, but I could not pronounce any of the names. I don't want to have to sound words out again. I am too old for that.

Can you re-post, but change all instances of: "Rudolf Erich Raspe" To Earl and all instances of: Munchausen’s to "Freddie," etc.

Antares Cryptos said...

Exceptionally rare and probably overdiagnosed.

The same is happening with teachers "diagnosing" ADD, when all they need is less sugar, more exercise.

I think misdiagnosis (dismissing a serious physical illness) is much more common.

Interesting topic.

Robert the Skeptic said...

Greatsby You are correct, most famously the McMartin Preschool trial where investigators essentially manipulated the children's testimony to support the allegations though later forensic investigations showed their stories to be false.

John I know... but big words are good for you and give your mouth needed exercise.

Robert the Skeptic said...

Cryptos It should, of course, not be teachers diagnosing ADD, though there is more mythology and little fact behind the concept of the "sugar high". But indeed kids generally are exposed to excessive sugar in processed foods and pop (which I term a "liquid candy bar") which can lead to obesity and type-II diabetes. Exercise is part of the prevention plan for those two medical issues.

Nance said...

I got to see one bona fide case of M. by Proxy, referred to me by the child psychiatrist in our practice. There was an extraordinary degree of anxiety in the mother in that case; these things are never as simple as they seem on teevee. You'd have thought the Munchausens were coming out of the woodwork, though, to judge by the brouhaha in the press over that diagnosis.

It's always been that way since the press got hold of a Diagnostic and Statistical Manual: there's Diagnosis of The Year and everybody's got it. Back in the eighties, it was Multiple Personality Disorder (wildly over-diagnosed and misdiagnosed. The nineties were all about OCD. Now, thanks to the hot new read, Anti-Social Personality Disorder is the thang.

Keep your eyes peeled. The new DSM-V is due out...well, the date keeps changing, but, any day now. Honest. And then there'll be a new flavor of the month.

adrielleroyale said...

Yup! I go to the doctor as rarely as possible, both for me and my daughter because a.) I can't afford to be going in for every sneeze and hiccup and b.) 9 times out of 10, it is exactly what I thought...nothing!
I would much rather prevent illness rather than have to react/deal with it. So I go the more natural route, which has had GREAT results and significantly helps lower the risk of misdiagnosis, I think! :)

Cognitive Dissenter said...

I wonder if misapplication of knowledge and facts is a common human problem even for experts and is sometimes the result of personal biases, egos, and experiences rather than a lack of knowledge?

For example, consider how many people have been convicted of crimes they did not commit primarily because police and investigators developed a predisposition that someone was guilty. Investigators sometimes ignore compelling evidence if it does not accord with their theories.

I've also seen experts with the same impressive level of expertise examine the same evidence, apply the same knowledge, and reach opposite conclusions, often depending upon which side they are on.

You've given me much to think about, Robert. Great post.

Robert the Skeptic said...

Nance Indeed, I had an ASPD following the blog for a while, but he gets summarily deleted. But yes, the press has already seized on the newest quirks that will be coming out in the DMS-V.

Adrielle Our parent's generation used to avoid going to the doctor as well, but for different reasons - back then you didn't want to burden the doctor with your problems. That unusual lump usually didn't get treated until it was, well... untreatable. Something again to be said for a national health care plan.

Dissenter Smart people do/think stupid things PRECISELY for those reasons you state; personal bias, ego, even peer pressure. I read recently that with the advent of all these CSI crime shows, juries believe forensic science can accomplish more than it can actually deliver.

Indeed in a court room or legislative body, people can look at the same facts and figures and come to different conclusions based on their own vested interests. Example: Tax cuts create jobs -- tax cuts do not create jobs... the list is long.

Paul said...

Has the human race gone mad ? One wonders what other "illnesses" doctors will come up with. We are besotted with medical mumbo jumbo.

Robert the Skeptic said...

Paul Doctors didn't "come up with" Munchausen’s syndrome, it is a very real condition. When my wife was doing child protective services she had one Munchausen’s syndrome by Proxy case where the mother was putting things in the child's food. The point of my post is that intelligent people can make mistakes led by their bias or other subconscious motivations; being objective takes much more cognitive ability. The disorder is not fictitious, but the diagnosis can be if not conducted with conscious effort.

Jayne said...

Lordy, it makes me sick to think that any parent would deliberately make their child ill. It seems to me that their is a more ominous diagnosis that falls upon the parent.

Poor Münchhausen.

Paul said...

I am overwhelmed by maladies - Give me a day in the country ! Doctors are loving it as are gurus et al...A great Scottish Psychiatrist one Ronnie Laing once said that a fair amount of what is labeled as "mental illness" is actually people acting out if they don't get their way.

Robert the Skeptic said...

Jayne We find it inconceivable that a parent would hurt their child in any manner, yet it is all too common an occurrence and child welfare agencies are overwhelmed with such cases.

Paul Laing is probably referring to people with what are termed "personality disorders", behaviors which cause them to be at odds in their dealings with other people. Some of this can be overcome. On the other hand, physiological and chemical aberrations of the brain are clearly beyond the individual's control.

Jerry said...

I have nothing to contribute to the conversation. I just want to note that the entry and commentary was interesting and informative.

secret agent woman said...

I remember when there was a wave of multiple personality disorder (now dissociative identity disorder) diagnoses. Sometimes, people learn a bright shiny new disorder and star seeing it everywhere.

Robert the Skeptic said...

Jerry Your comment appreciated none the less. Thanks.

SecretAgent You are correct. The same thing happened with PTSD following Vietnam; Psychiatrists and psychologists were finding it everywhere after it hit lecture circuit. This is where Pankratz did most of his definitive work when some of these patients didn't respond to treatment - they were never in combat.

billy pilgrim said...

i seem to remember seeing a few cop shows with munchausen by proxy being a central theme. of course the cops figured it out and solved the crime.

cops are good at solving crimes when family members are involved. not so good when strangers are involved.

Murr Brewster said...

I'm still trying to figure out what fibromyalgia used to be before we had that name and diagnosis.

Robert the Skeptic said...

Billy I love how the crimes in cop shows are ALWAYS solved.

Murr Fibromyalgia used to be referred to as Malingering. The recommended treatment was tincture of Cocaine. It worked back then.

KleinsteMotte said...

I remember well those stories. My grandpa used to tell them and I once had a small book of some of those stories. We knew that they were just grossly over exaggerated works. Fun though. My book had illustrations and one was of himself being shot from and riding a canon ball.

alwaysinthebackrow said...

This is a very interesting post. My personal experience has been with the misdiagnosis. My 18 month old son was sent home with me by one doctor who clearly felt I was an overreacting mother. Turns out he had meningitis and spent 4 days in children's ICU and 6 more days in the hospital. My sister was dismissed as overreacting to a friend's death by heart attack and was sent home by the doctor on a Friday. My sister died of a massive heart attack the following Friday.
Dealing with child protection cases in court for over twenty years, I often see county social workers who become angry with parents for "doctor shopping" when the parents seek second or third opinions about their child's medical issues, and for disagreeing with doctors' recommendations for medications which are not approved to be prescribed for children.

Robert the Skeptic said...

KleinsteMotte The character must have been a European thing, I had never heard of him until Terry Gilliam came out with his movie about him.

BackRow What you describe is exactly the type of case that my friend Pankratz has been called in as an expert witness to defend. In fact, he states specifically a case where the child had been removed from a home because the mother sought a second opinion from another doctor.

Conversely, the case my wife had on her caseload, the mother was actually putting things in their child's food to make the child sick. You would think the physicians would be able to delineate the difference. Apparently not.