The psychiatrist João Carlos Melo has just released another book, this time co-authored with one of his patients, a young woman affected by three of the “most painful and disturbing” mental illnesses that can afflict a person: Borderline Personality Disorder, Pathological Lying, and Factitious Disorder, also known as Munchausen Syndrome.
In an interview, the specialist, who is also a psychotherapist, group analyst, and works at the Fernando Fonseca Hospital (known as Amadora-Sintra), discussed the “incalculable suffering” of these individuals, which leads “about 70% to commit suicide,” as well as the impact of these disorders on their relationships, families, and loved ones.
For the case of Maria C. (a fictional name), who has been in treatment with the professional since 2021, there has been a clear improvement. Although she continues psychotherapy with João Carlos Melo, she is one of the “very rare cases of Factitious Disorder recovery recorded worldwide.” This success owes much to her determination “to endure whatever was necessary to improve.”
‘Renascer das Cinzas’ offers a ‘raw portrait’ of these three mental illnesses, still unknown to many, though it is estimated they affect thousands of people in Portugal alone.
On one hand, we have the account of a psychiatrist diagnosing three of the “most devastating and intriguing diseases.” Dealing with lies, without giving up. Providing tools, without criticizing. Being trustworthy to understand the true extent of the problem facing the person.
On the other hand, we have Maria C., who, besides Borderline Personality Disorder—a personality disorder characterized, among other things, by fear of abandonment and feelings of emptiness—also suffers from Pathological Lying, where the person lies extensively, almost uncontrollably, and feels relief in lying, as if it were a drug, and from Munchausen Syndrome, where one lies about illnesses seeking comfort, affection, and attention.
Since 2013, Maria reportedly visited hospital emergency services at least 200 times and attended consultations in 20 specialties and subspecialties, being seen by around 300 health professionals. For her, those were “the only moments in life when she was assured she wouldn’t be abandoned.” But the scenario has changed.
Recently, ‘Renascer das Cinzas’ was launched, a book co-written with Maria C., a young patient affected by three mental illnesses: Borderline Personality Disorder, Pathological Lying, and Factitious Disorder. Whose idea was it to write this book?
The idea came from each of us independently, and then, gradually, we started talking about it. Not about writing a book, but to document what was happening. Then it gradually evolved this way. The document initially served as a testimony to Maria C.’s recovery process, but after a certain point, it also started to serve another purpose: as an incentive to continue fighting—each of us with our tasks.
In the book, it is revealed that you met Maria C. via LinkedIn after she sent you a message seeking help. Do you still accompany her?
Yes. The support started in 2021 and will continue. Even after recovering from the main symptoms. In the case of Pathological Lying and Munchausen Syndrome, which mainly manifest through behaviors, those, at this time, do not exist. However, what lies beneath—the suffering, emptiness, anxiety typical of Borderline Personality Disorder, though improved—has not disappeared, as it is part of the disorder’s condition. It is part of the person’s basic functioning. The characteristics and severity are attenuating, but that emptiness, that anxiety, that suffering continues, sometimes overtly, other times latently. Currently, it manifests in Maria in a much less severe form. At this point, if for any reason, I were to end the psychotherapy, she would certainly have many more tools to handle life, but it would be much more difficult, so it makes more sense, is more logical, for the psychotherapy to continue. Now not in such an intensive, dramatic form, in terms of dealing with very serious problems. It is more a kind of maintenance. But, anyway, it continues and will continue.
Is that a problem?
No, it’s not a problem because the dependency that might have existed is changing. At the beginning of the process, the therapeutic relationship manifested with a lack of trust from her side—it’s so difficult to trust someone, to open up, to share deep anxieties—and there’s a management process that is not easy. After a certain point when the person is really connected, there is some degree of dependency, which is natural. We can draw an analogy with a child’s development. A baby is very dependent at first. As they grow, what’s desirable is for this dependency to slowly evolve into lesser dependency and greater autonomy. The relationship with Maria is not as intense as in the beginning, but it continues and must continue.
When I started my internship, I noticed a situation while attending my supervisor’s consultations. There was a woman who had been his patient for more than 20 years, and that intrigued me somewhat—used to the more practical, pragmatic side of medicine, where the goal is to solve problems, the problem is solved, the person is discharged. And when he said: ‘there are patients we will have until the first of us dies’. That scared me. But naturally, with experience, you start to relativize things and realize that’s just how it is, it’s natural, it doesn’t affect me. It would be complicated, even for me, to interrupt the process with Maria. I wouldn’t feel good because the person would still need it. So, things are going really well, as expected. Initially with a more dependent relationship and now with progressive autonomy that connects to her increasing trust and ability to face life.
Why do you consider these disorders—Borderline Personality Disorder, Pathological Lying, and Factitious Disorder (or Munchausen Syndrome)—to be some of the “most painful and disturbing” that can affect a human?
More well-known disorders like schizophrenia, bipolar disorder, obsessive-compulsive disorder, etc., are sufficiently recognized to understand their progression and there are specific therapies and medications for them. There aren’t for these disorders. Although there are evidence-based specific psychotherapies for Borderline Personality Disorder that help immensely and in which the person improves a lot. However, there’s a problem: the stigma still exists. Namely, from a portion of psychology and psychiatry regarding Borderline Personality Disorder. Pathological Lying is not yet officially considered a disorder, but it will be soon, according to ongoing research. Factitious Disorder is very little known even though it is much more common than people think.
Why is it little known?
The primary reason it is still very little known is that people do not allow themselves to be treated. When people start to realize that the doctor is beginning to understand the lies being told, they switch hospitals, switch doctors, it is exceptionally rare for them to be treated. However, Pathological Lying is very serious, and Factitious Disorder as well. Both have a compulsive nature. The behaviors end up being a ‘solution’ to the immense suffering these people have. A satisfactory analogy can be drawn with drug addiction. A drug-dependent person, whenever there’s a psychological problem, a moment of anxiety, of despair, of immense suffering, which they do not know how to handle, resorts to drugs to soothe those symptoms. With Factitious Disorder and Pathological Lying, it’s the same. It’s very hard for a person to give up on these behaviors, as I write in the book, with a specific example that happened. The person might be better, but if at a certain point in their life, there are severe problems causing immense suffering, immense anxiety, immense despair, what the person ends up doing is resorting to these behaviors again.
Just as if it were an addiction…
Yes, as if it were in a drug addict, the person feels withdrawal symptoms. It’s a cold suffering. So immense that it leads, as estimated, to 70% of people with Factitious Disorder committing suicide. No other psychiatric disorder has such a dire prognosis.
And, just like an addict, they also lie… Maria C. even started by lying to you, as you recount in the book. How did you handle that?
Yes, she lied from the beginning. When she came to me, it was similar to what happens to hundreds and hundreds of people, especially young women, who read ‘Reféns das Próprias Emoções’, about Borderline Personality Disorder. She started by saying she had been seen by psychiatrists who diagnosed Borderline Personality Disorder but, as it wasn’t their specialty, suggested finding another professional. However, she already knew very well that she also suffered from Pathological Lying. She knew she lied a lot. And regarding Factitious Disorder or Munchausen Syndrome, she had been aware for years because she is an intelligent person and researched what was happening to her. Furthermore, many doctors told her and even mistreated her somewhat because of it. But she didn’t tell me about it. Then, gradually, I began to understand—through colleagues who talked to me, through her family—what was actually happening.
Initially, I even thought it wasn’t true, that they were exaggerating, which is normal because I thought this person with whom I had established a therapeutic relationship, which was going well, couldn’t have such a serious disorder. So, gradually, we began to talk about it. But she always denied it. Always. And progressively, it became possible to discuss it. But again, very slowly. I was hoping that one day she would open up, that there would come a point when she would explain everything… and that never happened. Never. What happened was she would admit a lie in favor of another, constantly. That is, indirectly, admitting the first had been a lie but now this was true, and this happened a third, fourth, fifth time, and so on. And this happened very gradually. Meanwhile, psychotherapy continued to develop well, and at a certain point, it became natural to talk about the lies, the fictitious behaviors as symptoms.
But not everyone copes well with these lies…
Indeed. For example, these individuals provoke attitudes of rejection from doctors, as is natural. If people were deceived as they deceive others, they would be very angry. Nobody likes to be fooled, nobody likes being lied to. Being deceived is more severe than a lie. A lie is someone saying something that isn’t true, but it might not affect the relationship. But a person who makes another believe that reality is a certain way, when in fact the reality is otherwise, is deceiving. For these individuals and, particularly for Maria, what happened is that she was abandoned and mistreated by many people. Curiously, what has happened throughout the process? She is reclaiming people who were part of her life, whom she had deceived and from whom she has been seeking forgiveness. And that is very interesting and important for her and offers hope to others.
Despite any trust she had in you, why was it so difficult to admit she was lying?
Because they were lies about everything and, in part, related to Factitious Disorder, Munchausen Syndrome, with diseases. The image that comes to mind is: ‘people are like houses made of bricks and she was like a house of cards. The problem is that many of those cards were lies. You couldn’t remove one lie without another emerging right away. The possibility of her being confronted with a lie left her distraught. She became so upset because they were lie after lie. It was a very complex situation; she lied to cover other lies. Admitting a lie would be so devastating, such incalculable suffering, that she tenaciously defended those lies.
Does that suffering relate to the pain she could cause the other? Or is it suffering that, say, affects her alone?
What triggers these behaviors associated with Pathological Lying and Factitious Disorder is the immense internal suffering the person has. An incalculable suffering. No one knows what it’s like. To the extent that so many people commit suicide, it must be incalculable. But there’s a fundamental distinction to be made about these lies: psychopaths also lie a lot and manipulate a lot. The difference is that the psychopath does this without any guilt. Without any remorse. Without feelings for the other person.
In these cases, and specifically in Maria’s case, she suffered because she knew she was causing pain. She had empathy for others, suffered a sense of guilt for deceiving and hurting them. This was a crucial question for me at the beginning of the psychotherapy. If she wasn’t a good person, if she had psychopathic traits, I wouldn’t have continued the psychotherapy because there were very difficult periods, as is natural and as described in the book. The fact that she was a very good person, had a very good character, and was very determined to endure whatever she had to, to improve, to be treated, to recover, also contributed to my decision to continue helping her.
In summary, what is Factitious Disorder?
When making a differential diagnosis in terms of classification systems and diagnostic criteria, there are certain symptoms common to more than one disorder. One of these situations is with simulation. It’s in the diagnostic criteria, even with the term simulation. People with Factitious Disorder simulate, but Factitious Disorder is one thing, and Simulation in this context is another. Let’s imagine someone who is starving, undertakes a radical diet to lose a significant weight, applies makeup to appear with dark circles and pale skin, shaves their head and eyebrows, and says they have cancer and are undergoing chemotherapy. If this person tells this only to doctors and family, it is purely Factitious Disorder. But there are people who use this to gain material benefits, donations, pensions, likes on social media, sell books, become a brand. These other dividends already configure another situation, which is Simulation, and it’s important to distinguish the two because both deceive others. However, people with Factitious Disorder do not have these material goals.
What is the motivation then? What drives them?
The only way these individuals have to get a little attention, concern, affection in life is to pretend to have illnesses. We should not view this lightly. We all need attention, affection. It’s not surprising. Many people claim to be ill to receive care from others. This is normal. A child who doesn’t want to go to school says they have a stomach ache. This is normal. In this case, it is not just to escape a difficult situation or to get a little attention. No. It is to feel that only with this attention do they feel they exist, that they have life, that they have existence, that they can be minimally functional in this life, because otherwise, they can’t manage.
One of the major anxieties behind Factitious Disorder is the anxiety of abandonment, which is common to Borderline Personality Disorder, pathologies that are often associated. Maria explained that very well in the book. As long as there was a doctor in a consultation, an emergency room, concerned, who didn’t know what was happening, they wouldn’t abandon her. Those were the only moments in her life when she was assured she wouldn’t be abandoned. No matter how many people these individuals have in their lives, family, friends, nothing and no one provides that assurance.
How should family members and friends act if they suspect a loved one suffers from these issues, without alienating or further harming them?
People, in general, tend to confront and seek the truth. If someone lies to me, I will do everything to get the person to admit they lied. To start from a base of honesty. But that’s not possible. It isn’t possible because the person won’t admit it. Given this, there are two options: buy a battle and both lose, or accept that the person lied, but do not confront them about it. And that is the only way. We could say, ‘then I’m fostering the lie’. No. As difficult as it is to understand, as little logical as it seems, we have to accept that the person is doing that because it’s the only way they have. And provide attention, understanding, affection.
And seek help?
One should seek help because the individual often lacks the courage to ask for help. The goal should be to treat the person, and the sooner, the better. Because when Factitious Disorder is established, it is very hard to change it. However, I have had some cases of young individuals where the disorder was just beginning, and it was possible to halt it at the outset. What the person needs is attention, care, trustful relationships. And others need patience and resilience to endure the lies, the resistances, and all that. From the individual themselves, there must be an effort and an attitude of wanting to improve. Many people want to improve, they just don’t know how. They’re afraid of being rejected. One of the book’s primary goals is precisely that: to give hope to many people who had lost it, as was Maria’s case. Once she realized it was possible to improve and that she was already improving, she decided she wanted to help others.
Is it possible to quantify the number of people suffering from Factitious Disorder in Portugal?
It’s very hard to determine because individuals don’t cooperate in the sense that, when they are about to be diagnosed, they disappear. A clinical idea I have is that all doctors have come across patients with Factitious Disorder. Just that very rarely do they realize it, and when they begin to, they lose access to the patient because the patient disappears. What two international studies show is that it encompasses about 0.1% of the population, another 0.3% to 0.8%. Even if it’s the minimum, this equates to 10,000 people in Portugal, which is significant, but most doctors never diagnose them. People live in secrecy, hidden.
Despite Maria C.’s recovery, you highlight that recovery cases are very rare worldwide. What was different in this case? What contributed to the success here?
The main reasons for a lack of recovery are that most individuals don’t seek help. They fear being criticized, mistreated, abandoned, and then there are some who do not want to give up that seduction. Drawing another analogy with drug addiction. Some people, knowing that drugs harm them, see no alternative to their suffering but to continue using drugs. So, precisely to not give it up, individuals continue these behaviors.
What can trigger these types of disorders? Traumas?
There has to be an underlying suffering, a core temperament often associated with Borderline Personality Disorder, anxiety of abandonment, inner void, and emotional dysregulation. Individuals exhibit these behaviors to soothe this suffering. Those with Factitious Disorder have experienced one or more highly transformative events. They themselves or someone very close was treated well, for example, in a consultation, an emergency, a simple operation. And, at that moment, they had a sensation that some people describe, for example, as transcendent spiritual experiences. When a person has a good feeling for the first time in their life, they then seek that sensation again. The problem is, it then becomes dependent in nature and even brings withdrawal symptoms like irritation and anxiety, which only abate, for example, when visiting an emergency room. Sometimes, merely signing up at the emergency makes them feel better.
What are the early signs of these disorders to watch out for?
They go unnoticed and sometimes are interpreted differently. Many people, known to the public, who appear on shows, perceived as great heroes, who overcame hardships, who supposedly recovered from incurable diseases, aren’t questioned about the veracity. Within a family, among friends, when someone frequently appears ill or reports certain symptoms or says things that don’t align with the truth, when they undergo a treatment and it doesn’t result, sometimes exhibiting symptoms and other times different ones, when there’s incongruence between complaints, signs, exams, and analyses, we should be alert.
But not confront them…
Yes, but not confront them directly. There’s an internist, who was Maria’s doctor, who played a crucial role in helping and there was a time when he knew and she knew that he knew [laughs]. And he never gave up on her receiving support. What she expresses, very emotionally and with gratitude, is that the most extraordinary thing he did, which helped and saved her, was: even knowing it was a lie, he didn’t abandon her. That is the most important thing of all. Would it be easier if she didn’t lie? The lying becomes impulsive, and there’s always this present factor: ‘the anxiety of abandonment’.
