The Truth Behind Stories

We watched the Tim Burton-directed movie “Big Fish” (based on the book by Daniel Wallace about a man trying to get to know the truth about his tall tale telling father) and we got to talking about the difference between history and fiction and whether we can say the main difference between them is the presence or absence of truth, which reminded me of other things. The “iceberg” scene in which Will Bloom confronts his raconteur father about his “lies” is thought-provoking.

Incidentally, as kids we used to spin stories to each other and if someone fell for them, we’d act like we were reeling in a big one and say, “Fished you in!” or “Caught a big fish that time!” I couldn’t find that definition for “fishing” on line, even in the Urban Dictionary. It must have been a local thing, I guess.

I tend to fall back on what one of my undergraduate college English professors, Artie, told me about the truth or fiction dichotomy. Artie taught that fiction isn’t necessarily untrue as long as we remember to include in the story the totality of our lived experience along with our emotions and its meaning to us. In that sense, tall tales often contain at least a kernel of truth.

One of the other things the movie reminded me of is what I occasionally encounter in the general hospital in my role as a psychiatric consultant and that is the patient who has Factitious Disorder, formerly called Munchausen’s Syndrome. In the Diagnostic and Statistical Manual (DSM)-5, the disorder is now subsumed under the Somatic Symptom Disorder Category and the diagnostic criteria are:

Factitious Disorder Imposed on Self

  • A. Falsification of physical or psychological signs or sxs, or induction of injury or dz, assoc. w/identified deception
  • B. Presenting oneself to others as ill, impaired, injured
  • C. Deceptive behavior evident even in absence of obvious external rewards
  • D. Not better accounted for by another mental d/o like delusional d/o or other psychosis

The importance of deception is emphasized differently than it was in the DSM-IV, partly because motivation for the behavior is virtually impossible to discern, with malingering clearly evident in some cases:

  • A. Intentional production or feigning of physical/psychological signs/symptoms
  • B. Motivation for the behavior is to assume the patient role
  • C. External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent.

One of the better examples of the difficulty in determining motivation is the very real story of The Indiana Cyclone, a patient with what we would nowadays call Munchausen’s Syndrome in the sense of it being the most extreme form of Factitious Disorder, in which it is a way of life. The story about the Indiana Cyclone was published in JAMA in 1957 by John Chapman, detailing the first case ever published about the disorder at The University of Iowa Hospitals and Clinics [1]. The story was later converted into a very long poem by a former head of the University of Iowa department of internal medicine, William B. Bean [2].

THE MUNCHAUSEN SAGA 

by Dr. William Bennett Bean

In the summer of Nineteen and Fifty-four
At Iowa City, our hospital door,-
Mecca for hundreds every day-
A merchant seaman came our way-
A part time wrestler, in denim jacket
Crashed through the door with a horrible racket,
Two hundred sixty pounds at least,
He was covered with blood like a wounded beast.
Told us, with gestures, his chest was stricken-
His coughed-up blood made the residents quicken
To bring him assistance and ease his anguish.
Residents don’t let “an emergency” languish.
When examined, his legs were red and swollen,
The large blue veins were easily rollen;
“Thrombophlebitis, then clot to the lung”
The resident knew this, although they were young.

And the tall tales told by those with Factitious Disorder often contain a kernel of truth. They may have a genuine health condition which they can influence, thereby getting attention from health care professionals.

The name Munchausen is based on a literary character, Baron Munchausen, who was loosely based (some would say very loosely) on a German nobleman, Hieronymus Karl Friedrich, Freiherr von Münchhausen (1720–1797). The baron was a raconteur or colorful storyteller. However, late in the 18th century, a German writer and con artist named Rudolph Erich Raspe anonymously published a book of fiction which exaggerated the storytelling aspect of the baron, presenting him as telling a lot of whoppers about himself–sort of like Edward Bloom in Big Fish.

Whopper tall tales usually aggrandize the teller. The irony of the deceptions of the patient with Factitious Disorder is that they often lead to a steady diminishing effect, sometimes in the form of multiple surgeries and amputations, eventually culminating in genuine medical problems just from treatment complications.

One of the earliest papers written about Factitious Disorder is the classic by Richard Asher, who was the first to call it Munchausen’s Syndrome [3]. However, his paper has also been suspected of being at least partly facetious (and thereby also possibly factitious in the made up sense). The latinized variants are said to be examples implicating his sense of humor and inventiveness: laparatomophilia migrans (abdominal), neurologica diabolica (neurologic), and hemorrhagica histrionica (bleeding). Another author suggests that a closer reading of Asher’s paper reveals he speculated about the motive behind the patient’s behavior being a search to be the center of attention, even suggesting “Walter Mitty Syndrome” as a variant name for the syndrome, recalling James Thurber’s central character in “The Secret Life of Walter Mitty,” who lives out the role of a hero [4]. However, the patient with Factitious Disorder lives out the role of a patient.

Amirault’s paper is about the pathologic lying feature of Factitious Disorder and makes for fascinating reading, highlighting the literary side of the issue. He also mentions the philosophical consideration of the nature of the syndrome by citing a paper published in the New England Journal of Medicine by a couple of residents, purporting to be  a case report of “Factitious Munchausen’s Syndrome” in which they claimed to have evaluated a man named Norman U. Senchbau in the emergency room. Norman reportedly claimed to have Munchausen’s Syndrome and showed off his gridiron abdomen, covered with surgical scars–which washed off with soap and water. You get the joke, especially after you unscramble Norman’s name..to spell Baron Munchausen. The writers eventually confessed to having spun this tall tale.

Not every expert thinks medical liars are substantially different from ordinary liars, presidential candidate liars–or even from damn liars and challenge the notion that lying should be considered a specific feature of Factitious Disorder. The motivation for the deceptive behavior may be more complex than many believe, as some researchers contend, paradoxically leading to the conclusion that the truth may be stranger than fiction [6].

Which circles back to Big Fish. Edward Bloom’s colorful stories in the end turn out to be an amalgam of fiction and history…mostly true.

References:

1. Chapman, J. S. (1957). “Peregrinating problem patients; Munchausen’s syndrome.” J Am Med Assoc 165(8): 927-933.
2.Bean, W. B. (1959). “The Munchausen syndrome.” Perspect Biol Med 2(3): 347-353.

3.Asher, R. “MUNCHAUSEN’S SYNDROME.” The Lancet 257(6650): 339-341.

4.Amirault, C. (1995). “Pseudologica fantastica and other tall tales: the contagious literature of Munchausen syndrome.” Lit Med 14(2): 169-190.

5.Gurwith, M. and C. Langston (1980). “Factitious Munchausen’s syndrome.” N Engl J Med 302(26): 1483-1484.
6.Lawlor, A. and J. Kirakowski (2014). “When the lie is the truth: Grounded theory analysis of an online support group for factitious disorder.” Psychiatry Research 218(1–2): 209-218.
Factitious disorder (FD) is poorly understood because of the elusiveness of sufferers. What is known is based on speculation from observational case studies and this is evident by the manifold diagnostic and treatment issues associated with FD. This study sought to fill the gap in the literature and overcome the elusiveness of FD sufferers by analysing their text communications in two online communities. One hundred twenty four posts by 57 members amounting to approximately 38,000 words were analysed using grounded theory. The analysis showed that contrary to current theories of FD, motivation is conscious and not unconscious, members did experience symptoms associated with the disorder, and they were also upset by their behaviour and wanted to recover but were deterred by fear. Furthermore, using the excessive appetitive model by Orford (2001) it is hypothesised that the characteristics of FD described by the members were congruent with those associated with addiction.

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