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5 Munchausen Syndrome by Proxy Shehzad A Khan, MD Introduction: In 1977 the term Munchausen syndrome by proxy (MSBP) was first coined by pediatrician Roy Meadow, an Englishman, when he published a report on a new form of child abuse after the syndrome had been first reported by Asher in 1951.It describes the deliberate production, or feigning, of physical or psychological symptoms in another person who is under the individual's care. This pattern of behavior frequently involves a mother and young child; though, there have been cases of MSBP involving illness produced or feigned in other adults and even in pets (1, 2). Such a behavior causes the physician to perform unnecessary diagnostic procedures that do not result in any specific diagnosis. Pediatricians should have a high index of suspicion for this entity since it often produces a diagnostic dilemma in clinical practice. The disorder may be mild where a false medical history is provided or severe where the parent may actually induce the symptom in the child. The fabrication of a pediatric illness is a form of child abuse and not merely a mental health disorder, and there is a possibility of an extremely poor prognosis if the child is left in the home (3). In our Valley though statistics are not available but it seems that a mild form of MSBP does exist. Till somebody like Bryk will narrate her own plight at the hands of her mother. Bryk had suffered from MSBP and narrated the story to her doctors. This is an important article for anybody who is interested in this strange disorder(4). Definition: MSBP is classified as a factitious disorder by proxy in Appendix B (Criteria Sets and Axes Provided for Further Study) of the Diagnostic and Statistical Manual (DSM) IV-TR (5) .The definition includes the following: • • • • Intentional production of or feigning of physical or psychological symptoms in a person under one's care; The motivation for the perpetrator's behavior is to assume the sick role by proxy. External incentives for the behavior, such as economic gain, avoiding legal responsibility, or improving physical well-being, are absent; Behavior is not better accounted for by another disorder(5) Etiology: Though the exact cause of MSBP is not known, some researchers hold both biological and Khan SA. Munchausen Syndrome by Proxy psychological factors responsible for the development of this disorder. There are some theories which suggest that a history of abuse or neglect as a child or the early loss of a parent might be factors in its development. Some evidence suggests that major stress, such as marital problems, can trigger an MSBP episode (1) Types: Based on the frequency and intensity of behaviors, Schreier and Libow describe different subtypes of MSBP (6). Chronic Munchausen by proxy is characterized by the constant pursuit of attention by inducing symptoms in another person. Individuals displaying chronic MSBP are compulsive, and the behavior consumes most of their lives. Episodic Munchausen by proxy occurs in spurts where the person experiences symptoms of MSBP only episodically. In mild Munchausen by proxy the perpetrators fabricate medical histories for their children and lie about their children being sick rather than actively causing sickness. Their motivation is the emotional gratification they receive from medical attention. In intense Munchausen syndrome by proxy, the person actually induces symptoms such as vomiting, poisoning, removing blood from the child, and suffocation. The individual is able to induce severe illness in his or her own child, yet remain cooperative, concerned, and compassionate in the presence of healthcare providers. (6) Incidence: In our Valley there are no statistics available as of now, the commonest reason being that many cases go undetected due to a low suspicion index. In the US, estimates suggest that about 1,000 of the 2.5 million cases of child abuse reported annually are related to MSBP. Motive: People with MSBP often need the other person (often his or her child) to be seen as ill or injured. It is not done to achieve a concrete benefit, such as financial gain. Such people are even willing to have the child or other patient undergo painful or risky tests and operations in order to get the sympathy and special attention given to people who are truly ill and their families. A person with MSBP uses the many hospitalizations as a means to earn praise from others for her dedication to the child’s care, often using the sick child as a way for developing a relationship with the doctor or other health care provider(1) www.physicians-academy.com Physicians Academy May 2008 vol 2 no 5 6 Presentation: There is no single typical presentation of this condition and symptoms can be quite variable. Victims are generally children aged between fifteen to seventy two months. The classic characteristics of the perpetrator are female, white, being very attentive to the child, having some medical knowledge and history of marital discord and psychiatric disorder/abuse (7). In as many as 98% of cases the perpetrator is the biological mother (8). Typical presentations of MSBP include the following (7,8): • • Bleeding from Coumadin poisoning, phenolphthalein poisoning, exogenous blood exsanguination of child, and use of colored substances to simulate bleeding Seizure activity that does not respond to medication and that is only witnessed by the caretaker; • Recurrent apparent life-threatening events (ALTE) • Poisoning with phenothiazines, hydrocarbons, salt, and imipramine Apnea produced via carotid sinus pressure and suffocation - Covert video surveillance in cases of suspected child abuse has demonstrated that in many cases parents were inflicting abuse by suffocation. CNS depression produced via drugs (eg, insulin, barbiturates, aspirin, tricyclic antidepressants, acetaminophen,) Diarrhea and vomiting secondary to ipecac, laxatives, and salt administration Fever via falsification of chart records or actual temperature Rash from drug poisoning, scratching, caustics, or skin painting Hypoglycemia from insulin or hypoglycemic agents Hyperglycemia reports (from testing other individuals with diabetes) Hematuria or guaiac positive stools produced by traumatic injury to the urethra or anorectal area Multiple infections with varied and often unusual organisms • • • • • • • • • associate getting attention to being sick and develops Munchausen syndrome him or herself. MSBP is considered a form of child abuse, which is a criminal offense (1). Diagnosis: It is very difficult to diagnose MSBP because of the dishonesty that is involved. In addition the victim's signs and symptoms are undetectable (when exaggerated or imagined) or inconsistent (when induced or fabricated)( 3). A thorough review of the child’s medical history, as well as a review of the family history and the mother’s medical history (many have Munchausen syndrome themselves) might provide clues to suggest MSBP. It has to be borne in mind that it is the adult, not the child, who is diagnosed with MSBP. Review of all old records can be very useful. Often, this laborious, but critical, task is forgotten and the diagnosis is missed (1). Doctors must rule out any possible physical illness as the cause of the child’s symptoms, and often use a variety of diagnostic tests and procedures before considering a diagnosis of MSBP (1) Warning signs that are suggestive of MSBP include the following (8): • • • • • • • • • • • • • Illness is multisystemic, prolonged, unusual, or rare. Symptoms are inappropriate or incongruent. Patient has multiple allergies. Symptoms disappear when parent or caretaker is absent. In children, one parent, usually the father, is absent during hospitalization. A history of sudden infant death syndrome in siblings may be present. Parent is overly attached to the patient. Parent has medical knowledge/background. Patient has poor tolerance of treatment (eg, frequent vomiting, rash, problems with intravenous lines). Parent encourages medical staff to perform numerous tests and studies. General health of the patient is inconsistent with results of laboratory tests. Parent shows inordinate concern for feelings of the medical staff. Seizure activity is unresponsive to anticonvulsants and is witnessed only by parent or caretaker. Complications: MSBP can lead to complications like continued abuse, multiple hospitalizations, and the death of the victim. Research has shown that the death rate for victims of MSBP is about 10 percent. Sometimes, a child victim of MSBP learns to Khan SA. Munchausen Syndrome by Proxy www.physicians-academy.com Physicians Academy May 2008 vol 2 no 5 7 Tests that emergency physicians include the following: (8) may consider 2. • • • • • • • Urine toxicology screening Chemistry panels Electrocardiography (ECG) Drug levels for suspected poisoning agents (eg, aspirin, acetaminophen, anticonvulsants) Cultures Coagulation tests Head CT scan Admission and consultation usually becomes necessary before the diagnosis can be confirmed. Hospitalization may also help to keep the child safe from further abuse. It is recommended to use covert video surveillance in the hospital room to capture a parent's misbehavior when physical abuse of the child is suspected. In cases where symptoms have been exaggerated, hidden cameras may confirm that these symptoms do not exist. Conversely, video surveillance can also exonerate a suspected caregiver when the disease does, in fact, exist. Cameras should only be used in conjunction with carefully developed protocols that define the roles of child protective agencies, police, and hospital security in coordinating the use of covert surveillance systems (9). Management: Managing a case of MSBP involves a team effort with social workers, foster care organizations, and law enforcement, as well as the health care providers working in liaison. The first concern in cases of MSBP is to ensure the safety and protection of victims. The child may be needed to be placed in care of another. Successful treatment of people with MSBP is difficult because those with the disorder often deny there is a problem and in fact tend to be accomplished liars. Psychotherapy generally focuses on changing the thinking and behavior of the individual with the disorder (cognitive-behavioral therapy). The goal of therapy for MSBP is to help the person identify the thoughts and feelings that are contributing to the behavior, and to learn to form relationships that are not associated with being ill (1). As for the prognosis, since it is a difficult disorder, it often requires years of treatment and support. 3. 4. 5. 6. 7. 8. 9. info/docs/2800/2822.asp?index=9834&src= news. Munro H, Thrusfield MV. 'Battered pets': Munchausen syndrome by proxy (factitious illness by proxy). J Small Anim Pract. 2001;42:385-389. Abstract Stirling J and the Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics. 2007; 119:1026-1030. Bryk M, Siegel PT. My mother caused my illness: the story of a survivor of Münchausen by proxy syndrome. Pediatrics. Jul 1997;100(1):17. [Medline]. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000 Schreier H, Libow J. Hurting For Love: Munchausen by Proxy Syndrome. New York, NY; The Guilford Press, 1993 Lieder HS, Irving SY, Mauricio R, Graf JM. Munchausen syndrome by proxy: a case report. AACN Clin Issues. 2005;16:178-184. Mason J, Poirier M. Munchausen syndrome by proxy. eMedicine, 2007. Available at: http://www.emedicine.com/emerg/topic830 .htm Muscari Marie E. How can I recognize Munchausen syndrome by proxy? Letter posted 4.08.2008. Medscape Nurses 2008 Conflict of Interest: None Author Information: Shehzad Ahmed Khan, MD Senior Consultant Internal Medicine Health Services Srinagar, Kashmir, India Pin: 190008 Email: [email protected] References 1. Cleveland Clinic. Munchausen syndrome by proxy. Cleveland Clinic Foundation, 2005. Available at: http://www.clevelandclinic.org/health/healt h- Khan SA. Munchausen Syndrome by Proxy www.physicians-academy.com Physicians Academy May 2008 vol 2 no 5