‘Munchausen syndrome’ is named after the famous Baron von Munchausen (1720-1797), a German Nobleman who was renowned for telling exaggerated and wild stories upon his return from travels.
Feldman describes a type of ‘virtual’ factitious disorder. The internet offers a vast range of mediums through which patients and their families can find invaluable sources of information and compassion. Chat rooms, discussion forums and social networking sites can offer virtual support groups for individuals.
For those individuals and families genuinely afflicted by illness, this person-to-person interaction can act as a great source of support of comfort. However, there are a number of individuals that manipulate other users and post factitious accounts of illness for their own personal gain.
In these situations individuals gain emotional gratification by embracing the sick role. They feign illness in themselves or others and can attract audiences via the internet on a 24/7 basis. They no longer need to attend hospital to feign illness as now they have the internet which is readily available to aid their quest for attention.
The motivation behind this behaviour is felt to be to gain attention and instant support. Other internet users are manipulated into parting with vast amounts of time and concern, being misled by the deception. False information posted may include personal histories, laboratory and radiological results and even apparent re-creations of their encounters with health-care professionals.
Whilst it must not be doubted that web support groups can act as an invaluable source of information, comfort and support by users sharing experiences and advice, one must be aware of the potential peril of using such a medium. Unfortunately there are individuals who are willing to knowingly mislead and deceive others with the purpose of gaining sympathy and attention by adopting the ‘sick role’.
(Read the original article by Marc D. Feldman ‘ Munchausen by Internet: Detecting Factitious Illness and Crisis on the Internet’. Southern Medical Journal. July 2000. Vol 93, No.7)
Further to the post below on the film ‘Silver Linings playbook’, I strongly advise you all to click the above link and view the video.
Robert De Niro was recently interviewed regarding his role in the film as the father of a son (played by Bradley Cooper) with Bipolar disease. He spoke of the troubles of seeing someone close to you and whom you love struggling with illness:
‘If you’re a father, you certainly understand what it’s like to go through the worry about your kids, especially if they’ve got issues like Bradley’s character has.
‘Sometimes it can be overwhelming. It can be nightmarish and upsetting. There’s nothing much you can do but deal with it.’
As with most severe and chronic illness, the family can struggle to cope with the illness as much as the affected individual. Having to live with seeing someone you love having such a debilitating condition, and knowing there is little you can do to help, can leave many feeling completely hopeless.
I watched this film just before Christmas. I was expecting just a typical American ‘Rom Com’ but was proved wrong. This film was a touching, emotional film focusing on the barriers and stigma associated with mental illness.
Bradley Cooper played the role of former teacher Pat Solitano. It was only after Pat discovered his fiancee having an affair with a fellow colleague and launching a brutal attack on the man that he was eventually diagnosed with Bipolar disorder. Instead of serving his sentence in prison, he was admitted to a psychiatric institue for several months.
The film centres around Pat’s struggle to re-enter society after leaving the mental instute and adjusting to his new diagnosis. He initially appears to lack insight into his condition and believes he does not need to take medication. His focus is reconciling with his ex-fiancee who has obtained a restraining order against him following the brutal attack.
One particular scene shows Pat returning to his old place of work, where one of his old colleagues displays great fear towardshim as he tries to speak to her. He returns to live with his parents where the neighbours soon start discussing him and making derogtory comments about him. Many of his former friends appear uncomfortable and nervous around him. This clearly highlights the stigma and lack of understanding around mental illness, something which I feel this film touches upon beautifully.
Pat soon builds a relationship with Tiffany (played by Jennifer Lawrence). Although initially reluctant to pursue a friendship with her, they soon find that both being social outcasts they soon begin to understand one another and they soon develop an odd friendship based on their shared neuroses.
Pat and Tiffany’s relationship develops further when Pat reluctantly agrees to partner Tiffany in an upcoming dance competition in the hope that Tiffany can help reconcile him with his ex-fiancee. Despite his inital reluctance, Pat regularly attends training sessions. Although not winning the competition, the fact that they worked hard and competed in it was worth so much more.
They showed that having mental illness does not mean that you are incapable of achieving or being successful. They eventually become romantically involved and help each other to start to overcome their issues and problems.
I am happy to hear that this film has been nominated for a number of Academy awards including best actor for Bradley Cooper’s portrayal of Pat. If this film goes anyway to aid the public’s understanding of mental illness and help to reduce the stigma surrounding it then I feel that this would be worth so much more than winning any oscars. However I wish them luck at the Oscars!
Happy New Year from inpsychfulminds.com
All the best for 2013!
Looking forward to exciting new posts to come & site developments in the new year!!!
This is a first hand account from a woman suffering from Bipolar affective disorder. After struggling with self harm, depression and mood swings since the age of 16 she was first diagnosed with depression & anxiety, then clinical depression and eventually receiving a diagnosis of bipolar affective disorder in her early twenties.
Now in her late twenties and on a combination of lamotrigine and venlafaxine she mainly suffers with crippling anxiety and depressive episodes.
(This shall remain anonymous to protect the identity of the individual):
” I worry so much about everything. Everything, everyday! Usually I’m a happy smiling person, often the loudest person in a group and always the one that makes jokes. But this often makes my life harder.When I get down I get really down. Gone is the smile. Gone is the laughter. Gone arethe jokes. But no-one sees how I am feeling on the inside. I haven’t broken my leg. My legs or arms aren’t in a bandage or a sling. No-one can see my illness. But this doesn’t make it any less real.
It affects every aspect of my life….my job, my work, my relationships, my happiness! People see me as the high achiever, the hard worker, the woman who is always so organised and happy. What people don’t know is that this is often a facade. It’s hard to keep this act up. Often all I want to do is curl up in a ball and cry. But I can’t. Everyone else just seems to gets on with their life so why can’t I?People who are affected by mental illness often don’t make their struggles or problems obvious. I have become good at hiding my problems and pretending everything is ok. This isn’t helpful. Sometimes you just can’t carry on. Sometimes you need a break. This isn’t a sign of weakness. This is just me. This is my mental illness. This is what I need. “
Uganda is currently under the spot light because of a curious outbreak that has affected thousands of African children. ‘Nodding Syndrome’ is characterised by uncontrollable head nodding and unresponsive staring, often triggered by food. It affects children between 5 and 15, impairing their physical and cognitive development. Disorientated, these children wander from their homes and they are prone to accidents such as falling into fires or drowning.
Currently, most of the reported cases have been found in northern Uganda and southern Sudan, both war torn territories that have seen a lot of conflict and population displacement. Some psychiatrists believe the syndrome could be a cultural presentation of the psychological effects of protracted mass war trauma in these children. Over the past month I have been treating a child with suspected ‘Nodding Syndrome’ and her story has opened my eyes to this mysterious epidemic that everyone is talking about.
The case: A 14 year old girl with a 2 week history of head nodding, disorientated behaviour and unusual abdominal breathing was referred with ‘Nodding Syndrome’ to Mulago Hospital, Kampala.
On the ward, the girl presented with rapid, continuous head nodding and a strange breathing style which involved fast painful movements of her diaphragm and abdominal muscles.
The fifth of 8 children, this teenager had never been to school because her parents feared she lacks the mental capacity. At the age of 4, her father told us, she spent two days in a coma after developing cerebral malaria. She then regressed: her speech was delayed; she began to misidentify things (e.g. hen for a cow) and she developed poor co-ordination in her right hand and a limp in her right leg.
Over the next ten years, the girl would have regular spells of disorientated behaviour. Every month, her father told us, she undergoes a period lasting a few days, where she would become confused, unresponsive and uncommunicative. Recently, she had become increasingly agitated, talking to herself and apparently responding to voices and noises.
With careful psychiatric assessment, it transpired that at the age of 12, our patient was raped by a man in the neighbourhood. We gradually uncovered all the features of psycho-trauma: intrusive flashbacks, emotional numbing, physiological over-arousal and avoidance of situations that remind her of the rape. We noted that speaking of these experiences could trigger and quicken the head nodding and abdominal breathing.
Physical examination and blood tests were fairly unremarkable but crucially, the electroencephalogram revealed mild epilepsy in the left temporal lobe. Given her long history of unusual ‘spells’ we decided that the cerebral malaria she suffered as a child was the likely cause of her epilepsy.
Our diagnosis was Temporal Lobe Epilepsy and Complex Post Traumatic Stress Disorder (PTSD) leading to a conversion disorder. After initiating her on an anticonvulsant, we gave her Childhood Accelerated Trauma Therapy (CATT). CATT is a form of cognitive behavioural therapy, developed for children with psycho-trauma. It involves encouraging the child to tell the story both forwards and backwards using craft materials. Through repetition and reframing techniques the child learns to explain their traumatic event without becoming emotionally aroused.
Thankfully, our patient responded extremely well to both Carbamazepine and CATT. The therapy also revealed higher cognitive abilities which opened up an opportunistic discussion with her father about her potential for education. The head nodding and abdominal breathing stopped completely. By the time she left hospital, she was sleeping and eating well with no nightmares, intrusive flashbacks or avoidant behaviour.
Discussion: Some studies of Nodding Syndrome have proposed that the hallmark head nodding occurs when abnormal brain activity causes a brief lapse in neck muscle tone, causing the head to fall forwards. Electroencephalograms (EEGs) of some of these children have shown subtle, sub-clinical seizures but in many, the EEG is entirely normal. This mixed picture suggests that Nodding Syndrome may have many different subtypes.
Epidemiologists from the Centre of Disease Control (CDC) have revealed that the children affected by Nodding Syndrome tend to be from the very poorest backgrounds, usually living beside fast flowing rivers. This finding has implicated Onchocerca volvulus, the parasitic worm of the blackfly that is well known for causing river blindness, as a possible cause. Our patient had high eosinophil levels, suggesting possible O. Volvulus infection, although we were unable to confirm its presence.
This case illustrates a complex mixture of neuropsychiatric symptoms that have been lumped under the dubious diagnosis of Nodding Syndrome. Our patient’s long standing, untreated epilepsy predisposed her to poor verbal and cognitive skills, making her ill equipped to manage the intrusive flashbacks and physiological arousal associated with the rape. Head Nodding was her way of communicating unresolved emotional pain.
In conclusion, Nodding Syndrome is likely to umbrella lots of different subtypes with many different causes. In fact, the term ‘Nodding Syndrome’ might be a complete misnomer. Perhaps we should be simply talking about ‘Children who head nod.’
Film: One Flew Over the Cuckoo’s Nest
Venue: Ugandan National Theatre, Kampala
Last week, more than 80 Ugandan mental health workers and service users gathered in the Ugandan National Theatre to watch and discuss the film, One Flew Over the Cuckoo’s Nest. The lead in this classic sixties film is Randle McMurphy (Jack Nicholson) a free-spirited criminal, who ends up in a psychiatric hospital to get out of jail. Crammed with anti-psychiatry themes, the film explores the controversial role of psychiatry in policing society and defining social norms. I was interested to hear what Uganda, a famously conservative nation, thought of this Oscar winning counterculture film, so close to my heart.
During the post film discussion, a Ugandan service user stood up early on and commented that if McMurphy had been more compliant with his medications, he would have got better and things would not have ended so badly. Had we been watching the same film? I suddenly wondered whether the audience had been institutionalised and feared that the film’s anti-psychiatry messages had been lost in translation. However, I needn’t have worried because quickly a diverse range of insights were aired. Most people who spoke commented on Nurse Ratchet’s controlling and inflexible personality. They kept returning to the fact that she did not listen to the patients and thus failed them as a care provider. I was impressed by the service users’ confidence and bold opinions.
One audience member from Heart Sounds, the Ugandan service user group, was particularly shocked at the film’s depiction of ECT. He admitted that ECT had ‘saved’ him from severe depression in the past but in the film he saw it used as a form punishment. Dr Dave Baillie, a consultant psychiatrist from the UK who facilitated the discussion, commented that in the sixties before the discovery of many antidepressants and antipsychotics, ECT was used more routinely for many psychiatric disorders. Nowadays, there is a clear evidence base for the role of ECT in life threatening depression, for example, or puerperal psychosis, but not schizophrenia and certainly not personality disorder. He tried to reassure the audience that he did not know anyone in the UK or Uganda who would use ECT as a punishment.
The Professor of Psychiatry from Mulago Hospital, Kampala, stood up at this point: ‘Medicine is often abused,’ he said, ‘And it’s not just in psychiatry. Just look at what happened to Michael Jackson, who died at the hands of a doctor.’ He went on to compliment the film for exploring challenging questions about how people with behavioural or personality disorders, like McMurphy, should be managed in society. ‘There are no straight answers to these questions,’ he mused, ‘but we have to keep trying.’ He then quipped, ‘At least on their ward, there was one nurse to 20 patients. Here in Uganda, its one nurse for 60 patients!’
A service user called Daniel told us he could relate to the lead character. ‘I once fell into the cuckoo’s nest like McMurphy’, he told us, ‘But my friends, my faith and my family helped me get better.’ He then questioned why the film showed no visitors on the ward. The isolation of the patients in the film was a theme that the Ugandan audience returned to again and again. It reminded me of a conversation I’d had with Richard – the head Occupational Therapist at Butabika –about his time working in London. ‘The people in the UK are very alone,’ he told me thoughtfully. ‘And they spend a lot of time with their pets. You ask people about their weekend and they just talk about taking their dog to the park, or feeding their cat. I often wondered: Where are these people’s families? Where are their friends? To be honest Kate, I found it all very odd.’
Yesterday I met an 11 year old boy who appeared to have sustained a serious head injury from being hit by a ball in sports class. I was shocked to discover that his speech was now delayed, his memory impaired and he could barely walk. The consultant psychiatrist gently asked the child to tell me exactly what happened. Slowly, the child described the fateful incident and how he had since developed movement difficulties and painful headaches. His mother told us he had become increasingly absent, staring blankly into space and five days after the incident, she went to wake him for breakfast but found him foaming at the mouth and was unable to rouse him.
The boy was rushed to hospital to scan his head and a series of EEGs were conducted to check if he had developed seizures after the head injury. All the tests came back normal but given the severity of his symptoms, his mother was still extremely worried. When I met them, the mother was considering how she might finance an MRI scan, which could reveal more subtle brain damage. Listening to the boy’s slurred and stumbling tale was painful to hear and convinced me initially that the family may need to fund further tests. However, when I listened carefully, I realised there were a few details that did not add up. The child remembers the second the ball hit his head and subsequently ‘waking up’ in the gym, but if this had caused true brain damage, he is likely to have suffered amnesia. What’s more, it was unclear whether he had lost consciousness at the time of injury at all.
The consultant, of course, was about one hundred steps ahead of me and asked the mother to leave, whilst she continued her line of gentle questioning. Tearfully, the child revealed that he misses his father who works in Maluwi and he is anxious about his exams. Once he had calmed down, the consultant asked the boy to walk back to his bed. He got up, clutching the furniture and staggered to the door. At one point, he fell dramatically to the ground. Instinctively, I moved to help him but the consultant gently blocked me, ‘Leave him. He will get up.’ Eventually the child picked himself up and stumbled off to the bed
After he had left, Dr Joyce told me all about conversion disorders. She realised fairly quickly that the boy’s symptoms were not consistent with the history and wondered whether he was converting emotional problems into physical symptoms. She told me that conversion disorders are extremely common in African children and usually belie an underlying psychosocial difficulty. ‘When I worked in the UK,’ she told me, ‘I would see young people cut their arms as a cry for help. This is extremely uncommon in Africa. Here, children tend to communicate their stress through physical problems, usually subconsciously, in order to be noticed and cared for by adults.’
A few days later, the boy was walking and talking fluently. Dr Joyce had a quiet word with the parents and even organised a meeting with the boy’s school teachers to ensure a smooth recovery. Impressed by her expertise and sensitivity, Dr Joyce has given me a memorable introduction into childhood conversion disorders.
I sat in children’s psychiatric clinic today with Florence, the psychiatric clinical officer – essentially an experienced nurse who can prescribe. Virtually all of the children that come to outpatients clinic here have epilepsy, a condition treated by psychiatrists in Africa. Today we met a 15 year old girl, accompanied by her older sister, who describes having regular seizures for over 3 years. She speaks very quietly but mentions that after a seizure she sometimes has a pain in her neck and points to a lump, which she fears may be connected. I examine her neck, asking her to swallow and decide that it could be a growth on the thyroid. Asking about symptoms of hyper/ hypothyroidism, I begin to wonder if she’s underactive.
Thyroid problems are clearly underdiagnosed around here as I’ve noticed a child on the ward with severe exopthalmus (huge eyes that bulge out of their sockets, a complication of chronic hyperthyroidism). The poor boy looks like a cartoon, a tragedy really because thyroid problems are easy to treat but his eyes are now irreversibly damaged. With this in mind, I mention that a blood test would be appropriate. Florence flips out a blood test card but when I discover that a thyroid function blood test will cost the family 90,000Ush, a huge sum for most rural families who might earn 30,000Ush a week, I wonder whether they will get it.
After taking a history, we discover that the girl’s seizures are classic primary tonic clonic type, where she loses consciousness, foams at the mouth her eyes roll back, and her whole body convulses. Florence tells me, sadly, that the hospital has an EEG machine, and there are nurses to operate it, but there are no doctors to interpret the results. She has to decide whether to treat purely on history and given her very limited resources, she appears to be extremely well formed and sensitive to the girl’s fears.
The girl is happy to take medication but sad when we suggest she may have epilepsy. Florence explains to me that epilepsy carries a huge stigma. People believe that demons have entered the body and they fear it to be infectious. Often epileptics will seizure in the street and no one will go to their aid. Florence prescribes lamotrigine 25mg OD for 14 days, followed by 50mg OD for 14 days. The patient is asked to come back in 1 month, with the blood test results.
My Ugandan colleagues have warned me that as a Mzungo doctor, patients will often be blindly trusting, assuming some kind of superior knowledge and integrity. Recently, an Englishman was caught stealing a mobile phone in Kampala and it generated huge discussion in the local press and disbelief within the communities. Ugandans could not comprehend why a rich white man would behave dishonestly.
The encounter has made me wary of slipping into a clinical role here. In the UK, I would order a thyroid function test with no qualms, but here a doctor must always be mindful of money. Maybe it will teach me to rely more on my clinical acumen than reach for expensive tests. Finally, I’ve realised I must keep my somewhat pathological desire to please people in check. This kind of trust in Mzungo medicine is inherently very flattering, but ultimately leads to unrealistic expectations.
“Mzungo” is what Africans call white people. It comes from a Kiswahili word which literally means “to move around in circles”. Some think it dates back to the missionaries who were constantly on the move, spreading the gospel, but I think its because Westerners don’t know how to sit still and relax the African way.
Winston Churchill described Uganda as the “Pearl of Africa”. Perhaps because the most striking thing about this country is the light. It is almost hallucinogenic, as if the Ugandan’s beloved creator was over zealous with photoshop on this little patch of the dark continent. The trees are truly lushious and the sky so bright and expansive that the terracotta mud looks like marker pen.
Kampala at rush hour is scary, particularly when you already have a fear of cars. (I was hit by a car at the age of ten and have since behaved like a health and safety inspector when crossing the road). Saying this, i’m rather enthralled by the deliciously dangerous boda boda motobike taxis which whizz around the frustrated stationary traffic. I felt a pang of envy when i saw a couple of Mzungos (white people) on the back of boda bodas, they looked at ease and confident, so different from me and Jo in our smart work clothes, sweating anxiously at the side of the road.
Already, I can see that progress here is slow and its easy to feel demoralised. The small ‘book shops’ down the Kampala side streets, for example, are packed with Oxford English dictionaries, rainbow text books and stationary, clearly gifts from western NGO s that have been stolen to sell on. Also, the continual expectation that as a Mzungo you should offer money can wear you down. But just as you wonder what on earth you are doing, a playful but polite child beams their big white nashers, grabs your hand and asks: “Mzungo! How are you today my friend?”