Sawbones: Munchausen Syndrome

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Hello everybody and welcome to Sawbones, a marital tour of misguided medicine.

I'm your co-host, Justin Tyler McElroy.

Then I'm your other co-host, Sidney, formerly and now Smurl McElroy.

And

can I still have my middle name, even though legally I don't have that anymore?

Well, as your husband, I feel compelled to grant you this.

Yes.

Yes, around the house, I believe you can refer to yourself with your former former name.

Do you know sometimes I regret that decision?

When I changed my name when we got married, I changed it to Sidney Smurl McElroy from Sidney Ann Smurl so that I could keep my maiden name in there somewhere.

But having Sidney Ann Smurl McElroy, it felt kind of ostentatious at the time.

Like I felt like, I mean,

I don't know.

Am I allowed to have teachers?

I will say this: as somebody who's known you your entire adult life, you are a four-name woman, if not five.

You, you deserve it.

You deserve all the noms you can plume on there.

Can I go back?

I need to go, but see, now I'd have to go petition a court, I think.

I think I'd have to go like ask a judge to legally change my name to Sidney Ann Smarrel McElroy, like to get the ann back.

And that feels wrong that I'd have to pay to get my and back.

That's true.

We would have just didn't think through it.

So this week is about names and what they mean to us.

No, that's not accurate.

It's just kind of.

Yeah, a little bit.

Okay.

Well, Justin, we got a lot of eponyms in medicine.

stuff named for people.

Yes.

Okay, right?

Yes.

And I'll be honest, it's really interesting.

And I think people who have gone through medical training would probably agree with me.

There are those who practice medicine who really like to know those.

They like to memorize them.

They like to quiz you on them.

They like to impress maybe students with them.

And then there are those of us like me who sometimes remember them, but always, I mean, I remember the thing.

I know the diagnosis.

I know the disease.

I know what it does.

But I often forget like the person it was named for.

It's just never been my interest.

Most of the things that are named for people are named for like who discovered it.

So, like, Bell's palsy is named for Charles Bell, who was a physician who described it.

Dupatron's contracture, you may be shocked to know, was named for a Dr.

Dupatron.

Kawasaki disease is named for Dr.

Kawasaki.

Allison Wonderland is a nice name.

Kawaasaki jet skis, too, actually.

It's crazy.

That guy was into jet skis and medical stuff.

Alice in Wonderland Syndrome is not named for who described it because Alice in Wonderland is a fictional character.

Yes.

And that's similar to Munchausen's.

So thank you.

Coda recommended this topic because of who Munchausen's is named for and the interesting backstory.

And then right as we were about to record, I saw I also got the recommendation from Laura.

So I'm going to give you both credit, even though technically Laura, I had already researched the episode.

So, but we were on the same wavelength yeah Laura Coda and I so we'll all we'll all take credit

so munchausen's do you I've never thought about this I've never I mean and again eponym this has never really been my kind of interest in medicine what what is stuff named for can can I tell you part of why yeah

in medicine there are a lot of things named for people we wish we hadn't named it for

yeah and like they were a bad like a bad person and then there's it's so bad sometimes all y'all are like let's change it and then a few people are like i'm not so sure and then everyone else is like yes no we're changing it okay thank you for the most part if it was named for a nazi which unfortunately there are quite a few things in medicine that are we have all decided to cast off that former name and not use it anymore.

You will find, though, there are just physicians who have been practicing a really long time and maybe they don't know and they're still using it.

And we all have to be like, yeah, we don't really call it that.

We don't say that.

Anyway, I did not know who Munchausen's was named for.

And it's interesting because it is named primarily for a fictional character,

Baron Munchausen,

who was based on a real person with the last name Munchausen.

But the reason we call it Munchausen's syndrome is not because of the real guy as much as the fictional character.

So this is, I think this is interesting, right?

So who is this person?

Who is the real person?

Who's the the character?

Why is their name forever going to be linked with something that I think is, when we talk about like popular medicine stuff, people find interesting, I think Munchausen's is something that people really find fascinating, right?

Like you and I listened to a podcast about it not too long ago.

We've listened to a few at this point.

Yeah.

Yeah.

So there's a lot of, yes, there are a lot of cases.

There's a lot written in not just like medical journals, but in popular medical literature about

why does this happen?

So before we talk about Baron Munchausen, who's the fictional character that really inspired the name, we need to talk about the guy who inspired the fictional character, Baron Munchausen.

So Hieronymus Carl Friedrich von Munchausen.

And I'm going to guess it should be

Munchausen.

Oh boy, the way you're stretching your neck like that.

You okay?

It's got the thing over the U.

Yeah, you're giving the umlaut inch in your neck there.

Yeah.

How would you say it, Justin?

Would you like to do it?

Baron Munchausen.

But I was born and raised in Hunter West, Virginia City.

I'm not ashamed.

Okay.

And I will say that in terms of what we call the actual, like the medical term, we often, we don't say munchausens.

We say munchausen.

Yeah.

So he was born on May 11th, 1720 in Hanover.

He was in an aristocratic family, and he had a military career.

He fought for the Russian Empire during the Russo-Turkish War.

He spent most of his life kind of advancing through the ranks and serving in Riga and like that.

He was a military guy.

This is the guy we're talking about.

He has nothing to do with medicine.

Yeah.

We're not there yet.

Can I ask you a question real quick?

When you're, you say the birthdays of these people all the time.

Are you mentally clocking what their astrological sign is

and you just don't mention it?

Or

do you not think about it?

Do you think about it when you do these?

I'm just curious.

I'll be honest.

No, I don't.

Which it feels like I should because it is something I'm interested in.

I don't know.

It just never occurred.

I don't know.

I was thinking about their birthday.

Like, I wonder what the, I wonder, I don't know what that occurred to me.

What?

A Taurus.

A Taurus, I believe.

Interesting.

You tell me.

90.

Oh, now, see, listen, I'm really good with this stuff, but then, like, I'll get it wrong on a podcast and everybody's going to see, yeah, I'm right.

No, it's a Taurus.

It's after me.

I'm an Aries.

It's the one that comes next.

All right.

A Taurus.

I'm not going to get into the characteristics of a Taurus.

This is a science podcast.

Yeah, but we should do an episode sometime where we talk about, we talk the signs of some of our favorite people and see if we can like read into it a little bit.

That would be fun to do an astrology.

Do you want me to invite my mom as a special guest?

Your mom is a special guest to like, she could

read the cards.

Do their, yeah, do their nativity charts and everything.

At this, okay, so he settles down at this point in his life.

In 1760, he retires, and him and him and his wife, Jacobine, and he embarks on a new pastime, storytelling.

So he was famous at this point in his life for hosting elaborate dinners at

his home, at his big, fancy, aristocratic, whatever mansion.

Probably, yeah, it's a big mansion, his big house.

And he developed this reputation for having these big dinners where he would tell these fantastic stories

about his own military career, but

greatly exaggerated.

They were funny, and

there were obvious elements that probably weren't true.

Like,

you know,

people, I mean, that was kind of his thing.

You go there and he will tell you these fantastic stories about his life.

And the whole time you're going,

that can't be real.

Kind of like the Chuck Norris thing on Twitter for a while when people would say, like, you know,

I don't know the Chuck Norris thing.

Well, it's like, okay, this is actually,

I'm going to,

I'm not going to do it because it makes me

feel old to talk about Chuck Norris jokes.

Like Paul Bunyan, a real guy that a legend grew out of.

So

that was kind of what he did, but he wasn't, I will say, it wasn't like people said, like, oh my gosh, he's such a liar.

Like, people had a lot of respect for him because the way that he would tell these stories.

He would tell these stories of incredible experiences.

Man, this really reminds me of my early mentor, Dr.

Walden.

These incredible experiences that he had and these things he did.

And he would say it very matter of factly.

That's what he was known for.

Specifically, as one person described it, he would tell these stories cavalierly, indeed with military emphasis, yet without any concession to the whimsicality of the man of the world, describing his adventures as one would incidents which were in the natural course of events.

People really liked him because he would just matter of factly be like,

and so then I, I don't know, met this king and we did this, and then I saved someone's life who was falling off a cliff.

Oh, you just said it, yeah, as if, like, whatever, yeah, and people were really fascinated by it.

So, he wasn't seen as like, oh man, that's that liar who tells these.

People, I mean, people traveled far and wide to come sit at his table and hear his non-whimsical tales.

So,

you

so this is interesting, Sid, because when you're saying this to me, what occurs to me is reality TV.

Because if you think about it we know

it's not real we're watching and we know that these are very carefully narrow constructed narratives that have been built by producers who are asking people targeted questions and are crafting a story we know the story isn't real but we watch it and play along because we like the narrative we like the fun right it's like this is no different than whatever like yeah i bet the kardashians just happened to be crab fishing today you know like yeah i'm i'm certain that was you're on your all's agenda.

Well, and, you know, the thing is, too, I think it is, it is sort of, there is something very humanizing to present.

I'm like, we all have had fantastic experiences for the most part.

We all have had a moment.

I think so.

I think most of us have had some moment in our life.

We've all been touched by wonder.

Which, yeah, which we could dramatize into something very,

you know, shocking and tell in some way that would elicit a lot of, I don't know, gasps or something.

But to just present it as the mundane, I think it highlights something kind of beautiful, which is that the human experience is weird and wonderful and wild and incredible.

And I don't know,

some people connected with that, right?

And maybe it reminded us of the maybe the big fibs reminded us of the little ways that we all do this to try to spice up our stories and polish off the rough edges and make them work better as a a narrative

so at some point it is possible that there was a german uh writer scientist rudolf erich rasp who he was actually also known as a con artist um

see he later like stole a lot of stuff and tricked people but anyway he may have actually been at one of these centers it's possible at some point he met munchausen

and he began to write a collection of stories that were basically based on the stories he heard from Munchausen and stories that probably were being passed around, right?

Like Munchausen said that

he began to collect some of these anecdotes.

Now, not all of it came from Munchausen.

There were quite a bit of it that were based on like other sort of like legends and folk stories and things, right?

So like he kind of is taking, he's taking from Munchausen, he's taking from other sources, and he puts together a collection in German of stories.

And he calls the collection

S N

stories is the English translation.

It's M H S nisch Geis.

It's stories in German.

I'm not going to do it.

It's okay, but I'm not going to butcher German for you.

No.

But the point is, like, it was very clearly, like, if you look at the letters, like, it's very clearly a reference to Munchausen.

Like, it's very clearly, these are Munchausen stories.

But he doesn't say Munchausen story.

But it is.

He kind of did the Tumblr thing.

Yeah.

Right.

It's like,

this particular work of literature has this really kind of wild course where he publishes this in German.

And I mean, it would go on to tons of different revisions and republications.

And as different people translated it and recopied it in different parts of the world, they would add and subtract stories.

They changed the tone a lot.

Like if you look at the English version, it's it's a lot, it's a very different sort of tonally than the German version.

I mean, like, there was a lot of changes in the stories and what was done as the book spread.

So,

any relation between whatever the actual guy Munchausen said at his dinner table and literally said to people and what was printed in this book, it's hard to say if there was truth left there or what it was, right?

Right.

But it was definitely connected to Munchausen.

It went through, like I said, it was reprinted in multiple languages and throughout Europe and the U.S.

Rasp never admitted to authoring it, by the way.

It was always anonymous.

It was credited to a lot of different people.

It wasn't until 30 years after he died that they even proved that he was the one who wrote the original book.

And

for his part,

Munchausen hated it.

Really?

Yes, as it grew in popularity and was reprinted, these fantastic stories, who then were very much, you know, from that initial title he then went on to just say these are munchausen stories like that's what was recorded these are stories

oh my god and this is like this dude no no this is this i'm on munchhausen's team here munchhausen had his his um like frigging like uh a prototype podcast going right he had his podcast where he told fake stories about his life and he loved it and then some of these dorks are like i'm gonna write these podcasts down and adapt them on my own and like put them out no way man absolutely not well and not only that in in doing so because the stories

red bubble this guy's name should be red bubble that's why i think of this guy red bubble because the stories were so fantastic the character baron munchausen in the book version not the real guy but in the book became

kind of this like braggart

liar yeah you know who like oh you know he likes to sit and talk about like all the wild stuff he he did.

It's not real.

That's what Munchausen was doing.

But

it was.

He was trying to do something nuanced and the book made it very,

it was kind of appealing to the lowest common denominator sort of thing.

Like, let's just make them as ridiculous as possible because everybody will connect with this.

And you don't have to be, you don't have to get the nuance.

You don't have to get the joke.

The joke is that it's a silly story.

Right.

So.

Anyway, Munchausen was very angry.

There were a lot of people who thought he had written it and he spent a lot of time saying like, like that insults my honor.

Like I would never.

I'm an aristocrat.

I'm not going to write a book of my stories.

You get to come to my dinner and bask in the glory of this, but I'm not going to write a, that was, it was, it would be low in his mind to like write it all down and publish it.

It made him really famous,

but as a liar and somebody who brags about his military service.

Tricky.

And eventually, like he even tried to bring a lawsuit against the guy.

There was a guy, Berger, who who they thought had written it for a while.

This was the guy who got

credited with the work for quite a while before they realized he really wrote it.

He even tried to sue him

and a publisher who translated it because he wanted this book gone.

He eventually, it would lead him to become a recluse.

He stopped hosting parties.

He stopped.

telling stories.

I mean, it really, like, the book kind of ruined the real Munchausen's life, even as it gave his name and sort of kind of his thing fame forever.

I mean, because because we, the word Munchausen is connected to an idea.

Yeah.

Yeah, right.

I understand.

Forever.

Right.

It will be.

That's his.

But that's the idea he got stuck with.

And it wasn't, it wasn't really his thing.

If you read the book, it really, like I said, he was, he, he brags about stuff.

He does things that are absurd or superhuman.

He travels to the moon.

He rides a cannonball.

He's swallowed by a fish.

There's one really classic story where he claims that he saved himself from drowning by pulling himself up by his own hair.

So it's obviously ridiculous and exaggerated.

And there isn't really evidence that his stories were like that.

Like, I can't sit here and tell you, like, well, you did tell those anecdotes.

No, I mean, he told fantastic stories, but there's no evidence that he told lies to this degree.

And so that, you know what I mean?

Like, it really removed it.

So the character

Baron von Munchausen or Baron Munchausen then took on a life of its own.

And there have been books and TV and radio and film and video games

on Baron Munchausen or where he is a character in there, where this sort of like lying, silly, arrogant military baron would be a character.

The thing that we're like...

The thing that is probably a touchstone for a lot of, for some people, I don't know, in the late 80s, there was a Terry Gilliam movie, The Adventures of Baron Munchausen, that was like,

you know, my dad, like all dads of a certain age, you know, loved all the Monty Python guys.

And this is definitely a film that was like on at our house sometimes.

It was a little bit adult.

So I didn't watch it myself, but I knew of it because it was a massive flop.

It was a made like $8 million bucks the box office, and it was a huge disaster.

Well, I think that people have attempted to use this character as like a,

I don't know, like a lot of classic classic characters that get into a lot of foibles, silly.

I don't know.

I think Mr.

Bean or something.

You know what I mean?

Like gets into sort of like

weird, funny situations.

And it just didn't, it hasn't worked as well with Munchausen.

I think in part probably because what we connect the word with now commonly.

So how did this funny,

you know, funny anecdote book, Munchausen, how did it become something that we now think of as a medical condition, as a, it's a factitious disorder?

It, you know, how did that happen?

So I'm going to tell you how we got to what we think of as Munchausen's now, but first we got to go to the billing department.

Let's go.

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Sid, before I forget, I just wanted to tell you that the extraordinary adventures of Baron Munchausen is a multiplayer

tabletop role-playing game where you collaboratively tell stories in the style of Baron Munchausen.

So it's like a storytelling game.

Well, that's very cool.

Published by Fantasy Flight and Design by James Wallace.

Munchausen lives on.

Yeah.

But not the actual Munchausen, the fictional character Munchausen.

Okay, we have known about factitious disorders.

So a patient is exaggerating or maybe even like causing symptoms and signs and themselves doing things to their body that might show up on a physical exam or in a lab or something like that, or telling you things that aren't really happening.

We have known about that since the time of Galen.

Galen wrote a book called On Feigned Diseases and the Detection of Them.

So

this was in the second century CE.

And there were things like a patient, and a lot lot of this, I will say, in the early descriptions, we were not pulling apart Munchausen's or what was at the time called factitious disorder from

malingering and somatiform disorder.

I think it's really important.

I'm going to go over what those three things mean very quickly because I think it's important to distinguish between them.

I know malingering is faking it.

Yes.

Malingering is faking it.

You're not allowed to say faking it, but that is the mean one.

If you say malingering, that sounds mean, actually.

It sounds meaner than faking it, I I think, just sonically.

It does sound kind of mean.

It's like loitering.

Loitering.

And I will say that, like, what Galen wrote about really was malingering by today's standards.

So there was a patient who pretended that his stomach was upset, so he didn't have to go to a meeting.

It's like, we've all done that.

And another who was like, I don't want to, I don't want to go on this long journey, so I'm going to pretend my knee hurts.

So like those are malingering, right?

Like that's not, that means I am intent.

I know I'm doing this.

I'm intentionally doing it.

I'm trying to get out of something or get some secondary gain.

I'm trying to get something from someone by pretending.

And it's very conscious.

Somatiform disorder is completely, you don't know.

So someone who has a somatophorm disorder, the symptoms they're reporting and the things that are happening,

they believe it.

This is not a conscious attempt to trick anyone.

Okay.

And that's an entirely different thing.

The thing about factitious disorder is that while the person doesn't know why they do it, like if you ask them, like, why did you, I don't know, eat that stuff and give yourself massive diarrhea for a week and then tell us that you had diarrhea and let me do 30 tests to try to figure out why when really it was just because you took a bunch of laxatives or something, right?

They couldn't tell you why they did that.

But if you said straight up, did you take a bottle of laxatives?

Yeah, they know they did.

They know they did it.

They're doing it consciously.

I'm going to take this bottle of laxatives and give myself a ton of diarrhea.

But why then did I do that?

And then go to a doctor and go, I don't know why I have diarrhea.

Help me.

And I got admitted to a hospital and I had to have tests run and all this stuff.

Like, why did I do that?

They can't tell you that part.

Okay, would that count for, this is a really nuanced question, and I hope that the asking of it isn't offensive, but like, would that be the first time?

that happened and then you tell them like you had like i'm not saying the first time but like is this something that you could learn like oh wait this is something i have or are you going to go through that experience of doing that thing as a compulsion like is it a compulsion or is it like something where you could recognize and like i don't know it's so i mean it's very complex this is it is it is hard the patient themselves does not understand why they do this and confronting them with the idea that you have factitious disorder you don't have uh this is not a gastrointestinal problem causing this symptom This is something you have done to yourself to do that.

And so we need to work on the psychiatric diagnosis that I have made.

Confronting a patient with that is very difficult and often

doesn't necessarily lead to them accepting and moving forward.

It's not as easy as you have this thing.

Just like every mental condition, like literally ever.

It's not as easy as recognizing it.

Yeah, I got you.

It's much more complicated than that.

But I think it's really important to understand those distinctions.

Right.

Because they're different things and you handle them differently.

Somebody who's malingering, you just say like

you did that.

You're lying.

Nice try.

Somebody who has factitious disease,

you don't just say you're lying and discharge them.

It's more complex than that.

So anyway,

the term factitious disease dates back to 1843.

There was a Scottish physician, Hector Gavin, who talked about some soldiers and seamen who had mimicked illness mainly not to get out of anything, but they wanted like

compassion.

The idea that somebody might lie about symptoms or produce symptoms.

Because sometimes, I mean, you don't have to do something as dramatic as, like I said, take a bunch of laxatives.

Sometimes you just say something hurts, right?

And that's, that could be the entire presentation.

Which is very much like, I mean,

I kind of wonder this is, I kind of feel like kids maybe fall into this category sometimes, right?

Where we spend a lot of time talking about in kids

like the concept of functional abdominal pain, which is a whole other topic in and of itself.

But the idea that

especially young children can have difficulty at times expressing their emotional needs or if they're in pain from an emotional standpoint, you know what I mean?

So, like, I'm anxious, I'm worried, I'm sad, I'm, you know, in some way hurting, and I don't know how to express that.

And I'm expressing that in a way that is very understandable to you, my tummy hurts.

And then some of that is related to like a misunderstanding of, I don't know, sometimes if you eat a lot, you feel kind of full and my tummy hurt.

I don't know.

So some or like you have to go to the bathroom, my tummy hurts.

Anyway, yes, similar to what kids do and similar to kind of what we all do at times.

I'm a little bit sick, but I don't feel well enough to do things.

So I'm really going to not exaggerate, but really emphasize that I'm sick so that people won't think I'm trying to shirk my responsibilities, which is a capitalist problem.

But anyway,

everything's capitalism's fault.

But we didn't call it Munchausen's yet.

That wasn't until 1951.

Dr.

Richard Asher published an article in The Lancet about factitious disorders.

So he described a bunch of cases, or well, three cases.

He described a bunch of information about like how this presents and what he had observed and that kind of thing, which is a very classic thing to do in medicine to try to like fully describe a condition and then give some case reports to illustrate the things you have just described, right?

So he did this in 1951.

And in it, he wrote, like the famous Baron von Munchausen, the persons affected have always traveled widely and their stories, like those attributed to him, are both dramatic and untruthful.

So very colorful article.

When he wrote this, he gave it the name Munchausen's.

And that was the first time we connect Munchausen with factitious disorder as opposed to just the guy who told fantastic stories.

In the three-page article, Dr.

Asher talks about, he names the disorder.

He points to different types of presentation.

At the time, the most common, and this is really like, if we fast forward to today, a lot of this, because of technology and the internet and lots of things, a lot of this has changed.

But at the time, he said that most of these patients present either with abdominal pain.

Abdominal pain is pretty vague and can be hard to diagnose at first.

There's a lot of stuff in there.

You know, medically speaking, there's a bunch of stuff in there.

Well, this is the dance you always have to do.

Like, what kind of, is it a squishing?

Is it like a stab?

Yes, a squishing is what we usually say.

A squishing pain.

No, but you, I mean, it can be very vague and it can also require a lot of different kinds of tests.

And some of these patients, I don't want to say they're seeking a lot of diagnostic procedures, but they certainly are

accepting of, like open to, and continuing to go to doctors and hospitals, agreeing to get not just like some blood drawn, but an x-ray, a CAT scan, an MRI, endoscopy, meaning we're going to put a scope up your butter, down your throat.

Maybe we're going to even do a surgery, like an exploratory laparotomy where we will actually open you up and look around inside to try to figure out what's hurting.

So, I mean, they're...

They're definitely receiving these procedures in many cases.

Bleeding is a very common thing.

Someone will come in and say, I just, you know, had a bunch of blood in my bowel movement.

I just vomited a bunch of blood.

Something like that.

Bleeding was a very common thing people would say.

And then he talks about like a variety of neurology, what he classifies as neurological symptoms.

Someone will come in and say, I keep fainting.

Someone will come in and say, I'm having seizures.

Somebody will come in with a headache that nothing fixes.

And then he outlines like warning signs.

He says, like, if you see a lot of scars from past surgeries, if they're evasive about like exactly their medical history, like if they don't want to tell you about different doctors or hospitals they've been to, or if it's particularly harrowing, you know, this is a particularly wild course of events that you have presented me with.

He says these are all reasons you should suspect.

You should begin to maybe do a little more digging.

And that's kind of what he, as he goes through the cases,

he becomes like a detective.

So the patient comes in,

nothing's really making sense.

They can't find a diagnosis.

Nothing's fixing it.

The symptoms are persisting despite all of the efforts.

And then they begin calling other hospitals.

That's always kind of where it leads to.

And then we called this place and we called this place.

And this patient had been to, you know, every hospital in the area 30 times in the last month, had already had all of these tests and procedures done, had already been told that this is not a problem.

You know what I mean?

And so, like, that's kind of what the rest of his thing is, is, is all of this detective work.

Why does he think people do it?

He talks about, I mean, basically, he's like, I'm not sure.

Sometimes it's very straightforward.

They, they want pain medication.

Yeah.

You know, sometimes it's that.

Sometimes they are looking for room and board.

They don't have anywhere to stay and they're trying to get a bed for the night.

He thinks sometimes that they hate doctors, so they're trying to trick them.

Okay.

It's an interesting motivation.

That would not be my first thought.

Sometimes it's attention.

You know, somebody's taking care of you and worrying about you, fussing over you.

He thinks that there is a group that's trying to escape from police, which I would say like, like somebody who is in jail and then does something to themselves to go spend time in a hospital, which probably we're overlapping with malingering in some of those cases.

And then mental illness.

He mentions like, and then I don't know, maybe there's mental illness.

This is the 50s.

We really didn't understand mental illness well yet.

Right?

It's possible.

The name was controversial then and continues to be now because people think it kind of made it funny.

Like we're poking fun at people who suffer from this was the thought from other medical professionals.

Like,

this isn't about humor.

It's not about fantasy.

these people are sick

help they're not sick from the thing maybe they're telling you like they're not sick like they're maybe their belly isn't the problem it's also but they are it's also a silly sounding name if the name was something different maybe it would feel different but it is it does sound very silly to say it does um but it really stuck and that's to this day The term munchhausen's is used widely both in popular medical literature by lay people and by people within medicine I mean I hear that word used by other healthcare providers commonly and I would say you know even

the term factitious disorder if we had not recently listened to a podcast about it would you know that term no right I don't I mean it sounds like you're coming

it sounds like you're coming up with a nice way of saying lying like that it is how it sounds but they but they're but they're used interchangeably and I mean I think that there's a good case here like hearing the the background of it that we probably should use factitious disorder and not use munchausen's if for no other reason than the poor guy who it's named for hated that this was his legacy yeah and it is it is reductive it is reductive that this is this is a silly thing right or that the stories are always fantastic um it's very difficult to diagnose for a few reasons first the pay while the patient is

at times possibly doing things taking things substances or

taking doing something to elicit a sign or symptom, something that you could find on exam, or you do a lab and things do look wrong.

Even though they're doing that, they don't know why.

They know it's not good.

They know I shouldn't do this because I might hurt myself and because I'm tricking a doctor.

They know that.

And they know that you're going to be upset if you figure it out.

And they know that society looks on that,

you know, that they feel guilt.

They feel shame, right?

So they're not going to tell you.

And when you confront them with it, typically they're going to be very resistant to it.

They might get upset.

They might leave against medical advice.

They might become very sad.

It can be kind of complex in that maybe someone does have an actual,

like that their stomach does hurt sometime.

Maybe that maybe the complaint is real, but then they've done other things to try to get the attention of a medical provider so that they'll take them seriously.

So it can be,

yeah, it can be nuanced.

And overall, it's a diagnosis of exclusion, which means if you even begin to think this patient has factitious disorder, you have to prove it by ruling out every possible thing it could be.

Which you can't do.

It's pop, you can't prove it.

It's hard.

It's really difficult.

And it also involves a lot of testing, some of which is invasive if you're going to, you know, uncover, if we're going to turn over every stone.

And so it can be really hard to do enough testing that you feel confident saying this is what it is.

And then once you've labeled a patient with that, the stigma and I mean, against mental illness in general, but then specifically against this can be extreme.

So you really want to be cautious before you just say, well, I think it's factitious disorder.

Yeah.

In more recent years, there have been talk of things like Munchausen's by internet or what I saw was referred to in some press as cyber munchers.

Cyber munchers is amazing, but it's too funny to be related to anything real.

So I'm going to ask that you never, you and every other medical professional, never use cyber munchers as a a way to describe an actual thing.

I will say it here on this podcast for posterity, and then I'll never say it again.

I'm not going to say it.

It's in the transcript now.

You know that, right?

I know.

Hello to our transcriptions.

By the way, we never say hello.

I'm happy you got to type cyber munch today.

And there it is.

I forget about that.

So the thought being that with the rise of the internet, and this has been since the 90s, this isn't brand new.

that it was if you already have factitious disorder, it's easier to like gain sort of a lot of sympathy and compassion because one, anybody who follows you or reads what you write or whatever can interact with you, not just the healthcare provider.

Two, it's easier to tell people about your symptoms on the internet than it is in person.

I mean, nobody needs any visual proof, right?

Like you can provide that, but you don't have to.

So they're seeing more of that.

There's also things like mass psychogenic illnesses that are related to that that we've seen on like, which is a whole other thing, but they've connected to TikTok with like after COVID, there were a lot of cases of tick disorders and Tourette's that were questionable.

And it was a, again, these social media platforms are

helpful for reaching a large audience.

And if what you,

whether it's conscious or subconscious, and in factitious disorder, it's subconscious.

If you're subconsciously trying to get empathy and compassion and attention and care and love, if that's what you're seeking, what, and you don't know that, the internet's useful for that, right?

Makes sense.

And so I will say that when it comes to treating it, therapy is the mainstay of treatment.

I mean, it's, you know, it is a psychiatric condition.

This is something we need to figure out the motivations and how can we express those and get the, meet our needs, meet all of our psychological needs in ways that are not dangerous to ourselves or are taking, I mean, I think that's why doctors react, I would guess, so strongly to this.

It's taking the time and attention and energy of a healthcare system that, especially in this country, is so completely broken, is so completely overwhelmed, is so completely inadequate to meet the needs of every person in an equitable fashion, that I think healthcare providers can get really resentful if they feel like they've spent a ton of time and energy on something and the patient knew why it was happening and they kept it from us.

I think that you get resentment there.

And it's not fair, right?

It's a mental illness.

This person is not, they're not malicious, but I think that it is hard for healthcare providers to take their feelings out of it.

You know, I could have seen five other patients in the time it took me to do this and the whole time you didn't tell me that you took this pill or something.

You know what I mean?

So I think it's hard in that way.

And I will say, I know that whenever you talk about Munchausen's, people want you to talk about Munchausen's by proxy,

which is a whole other syndrome that probably should be an episode unto itself.

So

I don't want to get into it too much.

But the idea of Munchausen's by proxy, just to separate it out, it's a factitious disorder where you are

the person who has the factitious disorder is eliciting those symptoms in someone else.

The classic example is usually like a parent and child situation.

The parent has Munchausen's by proxy and they are doing things

subconsciously to their child, but knowingly,

but why they don't know, in order to elicit symptoms in their child.

Or it doesn't have to be parent and child, but that's just sort of your classic example.

But that is the difference of Munchausen's and Munchausen's by proxy, which, I mean, a factitious disorder by proxy is what we should call that, right?

So I don't know.

It's a very difficult thing to understand.

The patient themselves

understand why they do the things they do.

And it can take a really long time to untangle enough history and do enough.

you know, sort of investigations on your own as the healthcare provider to know that's what's happening.

And then it's even more difficult difficult then to treat it if you can convince the patient to engage with treatment to make sure they get the right kind of therapy and that they stick with it and that the behavior ceases at some point for their own sake.

Right.

It's a very difficult thing to tackle.

But yeah, so let's, there's my, we should call it factitious disorder.

There's my, I'm promoting that.

But but if we call it that, no one will listen to this episode.

Listen to this episode, and then after that,

okay.

Yes.

Hey, thank you so much for listening thanks to the taxpayers for the use of their song medicines as the intro and outro of our program thanks to you for listening thanks to max fun having us as a part of their network and uh thanks again i appreciate it be sure to join us again next time until then my name is justin mcroy and i'm sydney mcroy and as always don't drill a hole in your head

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