Objective. - In line with the work by Alain Abelhauser, we would like to reappraise the psychoanalytic approach to the Munchhausen syndrome. The authors present two clinical cases, which could provide answers to four fundamental questions: what is the psychic mechanism at play in the subject's characteristic demand for surgery? To what kind of logic does the subject's reluctance towards psychotherapy obey, widely reported in the literature, precluding any kind of psychotherapeutic demand and aiming solely for recognition of his status as a medical patient? Is it true that this reluctance is systematic? Are the reasons for this refusal of words of a psychopathological nature, or is the refusal induced by the structure of the medical discourse received? Method. - We present two clinical cases in detail, one from institutional practice in a hospital, the other from private practice. We offer a synthesis of the main contributions of the literature on the subject. Finally, an analysis of the development of medicine and of the place of words in medical discourse shows the reasons for the deadlock into which these patients take their doctors. Results. - The presentation of the first clinical case shows that an approach that no longer bases itself on the realist paradigm "truth or lie?" is well founded. By taking the subjective position into account, the authors show how a demand for surgery is articulated on an unconscious logic in which the question of the lost object is central. A proposal is made according to which the Munchhausen syndrome is often related to grieving, which is symbolically impossible, but which resurfaces in the subtracting of something from the reality of the body. The second case is extraordinary for its wealth of clinical material gathered from a female patient in the unusual setting of a lengthy cure with a psychiatrist-psychoanalyst outside hospital. This female subject developed the desire to decipher the meaning of her behaviours, and this resulted in the disappearance of her requests for mutilation and for exclusive nomination by the medical Other. This second case shows that a psychoanalytic treatment can prove relevant for these subjects, normally considered to be resistant to putting things into words. Discussion. - This article, through the discussion of the second case, refutes the general belief that subjects who have developed a Munchhausen syndrome flee from any offer of help or verbal exchange from medical teams. An inductive reflection follows on the role played by the medical discourse itself on this classically observed closure of the spoken word. As the medical position, which is always complex, bases itself solely on the patient's truth or lie strategy, we show why this "forcing" approach cannot but produce an acting-out in the form of flight. The "technician" evolution of modern medicine is thus questioned for its role in the misreading of psychic causality, despite the fact that it is often involved in somatic symptoms. Conclusion. - A number of proposals are made in this article to help doctors apprehend this clinical issue in a different way from the supposed "deceiving-deceived" mode, which makes the Munchhausen syndrome an ongoing challenge to nursing staff. This involves taking into account the transference relationship between doctor and patient, knowing the particular place of the body in the psychotic structure, distinguishing between demand and desire, as variations of the death drive. (C) 2015 Elsevier Masson SAS. All rights reserved.
