The Times: My Mother, Munchausen’s and Me by Helen Naylor review — the tyrant in the sick bed

I'm glad you say verifiable history, @hibiscuswahine. My guess is that if there really is such a thing as factitious disorder, then people with it would almost certainly be inclined to exaggerate their childhood hardships!

I worry about some of the claims that are made about the causal role of childhood adversity in psychological presentations. Before I came to the world of ME, I didn't realise how tenuous these claims are. It seems that you can take any group with any mental health or medical complaint, and they will report more adverse childhood events than controls.

There could be a number of spurious factors driving this association. One might be that those experiencing difficulties in the present see things more negatively, including their past. Another might be that they are searching more actively for explanations within their own life history (particularly if its a psychological or unexplained problem). Another contribution might be active suggestion, particularly if the person has undergone some form of psychotherapy, and been encouraged to scutinise their past. A whole lot of it is probably the old third variable problem: socioeconomic status. SES is a factor that that is likely to determine both childhood experiences and current health status.

A huge portion of the problem is downright poor research - bad research practices and poorly defined constructs. A few papers I've read carefully use way too many childhood adversity variables, and they often double dip. You can get credit for both extremes of some variable - too much control vs. too little supervision, too demonstrative vs. too cold, too combative vs. too repressed. Then they dig out the one or two positive associations from this great fishing expedition and hide the rest.

It seems like a tiny point, but I think a very important one. I think it really matters that mental health professionals don't over attribute things to people's childhoods, if it is not warranted. It can destroy whole families.

end of rant.

 

@Woolie @Sean. I totally agree there can be false attribution, it can be misused, abused etc. Yes, the literature can be flimsy. No, we can’t change childhood trauma but for some people, psychiatry has helped them. I am happy to say I have and many of my colleagues have. I do not feel the need to provide you with evidence of this.

 

This is all very well, @Trish, but might it not be something completely different.

I think you are talking about people who had known and undisputed trauma. It might be a child physically abused by an alcoholic parent or it might be a spouse grieving over a child who had committed suicide. I have no doubt such people are helped by seeing someone experienced who can help them patch up their lives. Nothing to do with psycho-behavioural therapy. Just sympathy.

The different situation is where someone presents as ill, either with perhaps a depressive illness, maybe with some organic psychotic features, or with what is considered a psychosomatic problem. They are then interrogated to see IF they had childhood or recent trauma. They are then given psycho-behavioural therapy which consists of attributing their illness to this trauma.

This second situation has two major flaws. One has been mentioned - it is very unclear how reliable the evidence is that on a statistical basis there is really an association between trauma and these problems. Reporting of trauma by someone seeing a psychotherapist for an unexplained illness is likely to be seriously biased. The other thing is that the patient having a sense of 'being helped' may be associated both with lifelong misery for others, who may have been wrongly implicated in the trauma, and with a dysfunctional existence for the patient themselves, having been induced into a delusory belief about how life works. And this happens, I can assure you.

One other thing that I think is important to consider, and which I am going to spend some time on in my book, is that attributing illness to trauma in this second scenario is never justified.

The reason it is never justified has to do with a very basic fact about knowledge. We know that A causes B because we have found A followed by B and also not A followed by not B. Without the counterexample there cannot be knowledge. There are subtleties but they do not change the basic structure of how we know. So it might be possible to prove a causal link between trauma and a type of illness in a population type where you first look at one population of this type and then look at another population of this type for which trauma has been eliminated. But you can never know there is a causal link in an individual because that individual will have a life history of A and B and will never have an alternative history of not A and not B. Knowledge is not available at that level.

The only way we can be reasonably sure that A caused B in an individual is if in a population of similar individuals A is followed by B 95%+ of the time and not A is followed by not B 95% of the time. This works for a defective Factor VIII gene and haemophilia. It has no relevance to a vague statistical link between trauma and ill health.

End of my rant.

 

Typically, I have lost the reference to it, but I remember reading a questionnaire that was used to measure childhood trauma. Using a questionnaire rather than a discussion with the patient could be leading to all sorts of problems the same way anxiety and depression are over diagnosed by using them.

It had different questions which each scored the same but were different in awfulness for instance. Then they tried to be all inclusive with sexual abuse but ended up giving the same score for someone who saw a flasher and someone who was repeatedly raped.

A question asked if a parent was imprisoned without taking into account that an abusive father being locked away may have been the best thing that happened rather than a trauma. I could go on.

It is very difficult to put a measure on childhood trauma as each child copes in a different way. Some people will use abuse as an excuse to avoid personal responsibility for anything that goes wrong in adulthood while others will refuse to be bowed down so they struggle too hard to succeed.

The effect on illness is also difficult to measure. Most serious abuse of children has a physical component. A child who is continually slapped round the head is more likely to have neurological problems than psychological ones. The idea that trauma means psychological disease is simplistic, a ladybird book science we find too often in BPS work.

 

Helen Naylor was on Saturday Live BBC Radio 4 this morning. I didn't listen to it. I'd been listening to the Vicky McClure interview but switched off at the introduction as it sounded familiar from this thread as I didn't feel up to facing it over my porridge.

https://www.bbc.co.uk/sounds/play/m0013qs5

 

Wouldn't be be strange for someone with a disorder to reveal the truth in their diaries?

(p.s. I switched off Radio 4 when it felt as if they weren't asking the right questions but that could have changed over the interview)

 

A quick search seems to indicate that people with Munchausen's are aware that they are lying, but that they are also unable to keep themselves from doing so. Admitting, perhaps regretting, an antisocial compulsion in a diary seems pretty common in drama, at least. I not sure how often it happens in real life.

 

Is it possible that some people with a ‘contested’ illness come to the mistaken belief that they have some form of Munchausen’s when in fact they have a genuine illness?

When doctors repeatedly tell someone they have a psychosomatic condition is it possible that an impressionable person comes to the conclusion that they themselves are lying or delusional? There are symptoms that are difficult to understand, for example severe pain in the absence of identified structural damage or disease, or the inability to walk across a room one day contrasted with the ability to walk a couple of miles the next, so when the person is repeatedly told their symptoms don’t exist, they come to believe that they would be lying if they reported these symptoms.

An iatrogenic induced false Munchausen’s in the context of a real but unacknowledged biomedical condition.

 

That would make sense @Peter Trewhitt .

And if CBT really does alter folks beliefs about themselves and their situations etc then surely it is just as possible that some one could have intraogenic Munchausens!

Surely therapists who deliver CBT should have considered (as part of the ethics of CBT delivery perhaps) what might happen if patients were persuaded by CBT to belief something false?