by Cheong Pak Yean
Munchausen syndrome by proxy, also termed factitious disorder imposed on others, is the deception of illness not in the protagonist but rather in someone under that person’s care. Like the classical Munchausen syndrome, this diagnosis is seldom made in a family doctor’s clinic. In truth, however, experienced family physicians have encountered many patients with this disorder.
Lucy* consulted her regular family doctor for headache and fatigue. She was exhausted from caring for James*, her hospitalized twelve-year-old son, and her new-born baby.
James was Lucy’s son from her first marriage. James’ father had died of a brain tumor seven years ago, and James was under the care of his paternal grandmother when Lucy remarried. Grandma believed that brain diseases ran in the family genes, as her own husband — James’ paternal grandfather — had died of a haemorrhagic stroke many years ago.
With this projected vulnerability to brain diseases, coupled with the pressure of the Primary Six promotional examinations, James started to display many medically unexplained neurological symptoms. On grandma’s insistence, James was admitted to the hospital for investigation.
All investigations turned out normal. Who is the patient?
*Names have been changed.
The medical students caption their drawing The Unseen Patient. The registered patient is the elderly woman in the wheelchair. The doctor asks whether the patient is taking her anti-depressants as prescribed. At this, her carer, the younger woman, confesses in a flash of candor that she takes them instead. The carer has imposed her own symptoms upon the elderly woman to obtain medication for herself.
The accompanying vignette is familiar to family physicians. We often see how illness is projected onto another family member. Superficially, the diagnosis for Lucy’s consultation is given as influenza-like illness. This is technically correct, as under the strain of anxiety and lack of sleep, her resistance to viral infections has decreased. Technical correctness, unfortunately, may not be sufficient to help Lucy in this case.
—-A/Prof Cheong Pak Yean
A/Prof Cheong Pak Yean is an Internal Medicine/Family Practice physician and psychotherapist practising in the community. He is an Adjunct Associate Professor in NUS and past president of the College of Family Physicians and the Singapore Medical Association.
The commentary and vignette were reproduced with permission from the book “Being Human, Stories from Family Medicine” edited by Cheong Pak Yean and Ong Chooi Peng and published in 2021 by the College of Family Physicians Singapore. Pictures of illness experiences were drawn by NUS medical students in workshops conducted from 2012-2017 by A/Prof Cheong Pak Yean. Senior family physicians subsequently shared vignettes and commentaries based on the pictures.