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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)
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Physicians Academy May 2008 vol 2 no 5
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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
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Physicians Academy May 2008 vol 2 no 5
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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