Nina J. Karlin - Dartmouth Medical School
Class of 1996

Munchausen Syndrome by Proxy Described

In Munchausen Syndrome by Proxy, a perpetrator assumes the sick role indirectly (i.e., by proxy) by feigning or producing illness in another person. Usually, the perpetrator is a mother who produces the symptoms or illness in her child of under six years of age (Kahan & Yorker, 1991). However, cases have been reported with adults as both perpetrators and victims. The syndrome is well known to veterinarians. In such cases, a pet's owner fabricates signs and symptoms in the animal (Sigal et al., 1989).

MSBP is not uncommon; however its prevalence has not been established. Rosenberg (1987) considered 117 cases in a review. Schreier and Libow (1993) postulated that this syndrome is more common than previously believed, and that many of the cases are not diagnosed.

MSBP ranges from diseases that are completely imagined to diseases that are fully induced in the child. The means by which MSBP mothers most frequently fabricate disease are suffocation, induced seizures, bleeding, chronic poisoning with ipecac (leading to vomiting), chronic poisoning with phenolphthalein (leading to diarrhea), and excrement injection.

Types of MSBP Perpetrators

Libow and Schreier (1986) described three major types of MSBP perpetrators: Help Seekers, Active Inducers, and Doctor Addicts.

Help Seekers are mothers who seek medical attention for their children in order to communicate their own anxiety, exhaustion, depression, or frank inability to care for the child. Case examples of Help Seekers include homes studded with domestic violence, marital discord, unwanted pregnancies, or single parenthood.

Active Inducers induce illness in their children by dramatic methods. These mothers are anxious and depressed, and employ extreme degrees of denial, dissociation of affect, and paranoid projection. Secondary gain for these mothers includes a controlling relationship with the treating physician and acknowledgment from medical staff as outstanding caretakers.

The Doctor Addicts are obsessed with obtaining medical treatment for nonexistent illnesses in their children. The falsifications of Doctor Addicts consist of inaccurate reporting of history and symptoms. Such mothers believe their children are ill, refuse to accept medical evidence to the contrary, and then develop their own treatment for their children. The children usually are older than six years, and the mothers are suspicious, antagonistic and paranoid. These mothers tend also to be distrustful and angry.

Theories of MSBP

Many theories exist as to why a woman may fabricate illness in her child. Common to most theories is a traumatic loss earlier in the mother's life; such a loss may be represented by maternal rejection and the lack of love and attention as an infant. It may also be representative of the "loss of a parent, loss of a parent's love through neglect or abusive treatment, or loss of self through childhood illness or traumatic disillusionment" (Bach, 1991).

Help Seekers are thought to be making an uncomplicated cry for help. Unlike the more typical MSBP parent, who will shun therapy and refuse placement of her child in a protective agency, these mothers readily acquiesce to both measures.

Active Inducers and Doctor Addicts use the relationship with the doctor to attempt to repair earlier traumatic losses (Libow & Schrier, 1986). These mothers express rage engendered by the earlier loss by devaluing and deceiving physicians and medical staff in a game of false illness. By devaluing the physician, these mothers create for themselves protection, recognition, and security, all of which they violently crave. In other words, such mothers use their "sick" children to create a relationship, cemented by lying, with a physician. However, it is this very relationship which provides them with nurture and "protects them from despair" (Schreier, 1992).

Warning Signs of MSBP

Typical features and warning signs of MSBP include one or more of the following: a prolonged, unusual multi-system illness with incongruent symptoms; signs and symptoms disappear when the parent is absent; one parent (usually the father) is absent during the hospitalizations; the general health of the patient clashes with results of lab tests; and a history of SIDS in siblings (Leonard & Farrell, 1992). The usual victim is a child less than six years old (Crouse, 1992).

The characteristic behavior of the parent is pleasant, cooperative, and supportive of the medical staff; eager to be in the hospital, overly attentive to her child (takes temperature, administers medication, attempts to exclude medical support staff); and able to arouse sympathetic interest and involvement of hospital staff. In addition, the mother may have a nursing or medical background, have her own history of Munchausen syndrome, have a history of marital discord, deny deception, lack the usual parental concern, and have suicidal ideation or attempt suicide before or after discovery of the syndrome (Meadow, 1982). The mother may thrive in the medical environment and enjoy the attention and care she receives from the health care staff. She may have a history of frequent use of emergency rooms and ambulances.

Other classic warning signs include separation anxiety in the child and parental over-protectiveness. The child may cling to the mother and not demonstrate age-appropriate behavior (Crouse, 1992). The child may initially display fear, negativism, and anxiety, and later progress to a passive, helpless state.

Effects on the Child

MSBP is not without grave danger to the child victim. The impact is psychological and physiological, both short-term and long-term. The more acute consequences include physical harm induced by the mother or resulting from multiple medical tests and treatments. For example, one six year old boy suffered "thirteen months away from school, five months in the hospital, one month of IV fluids, and the following procedures: barium meal (2), IV urogram, skeletal survey, brain scan, EEG (2), biopsies of bone, kidney, and skin. In addition, he had endoscopy of the upper GI tract, and over one hundred and twenty venopunctures, "At the time the deception was revealed he was being considered for plasmapheresis" (Meadow, 1982).

Cases have been reported where children developed destructive skeletal changes, limps, mental retardation, brain damage (from anoxia), immune-mediated nephritis, and cortical blindness. Often, these children require multiple abdominal surgeries, each with the risk for future medical problems (Rosenberg, 1987). The mortality rate is significant. At the least, it is ten percent (Kahan & Yorker, 1991).

The psychological ramifications are chronic and long-standing. These children may learn to view love from their mother as dependent on their being ill. Thus, they may help in the deception, or even use self-abuse, in order to protect themselves against fear of abandonment. Having learned to identify with illness and to use it as a means of expression and communication, many victims of MSBP become Munchausen patients. Thus, factitious illness may be perpetuated and an intergenerational cycle may develop.

Other significant sequelae include persistent "intense anxiety, hyperactive behavior, and a sense of helplessness" (Sigal et al., 1988). The experience of symbiosis and complicity between mother and child may affect the child's future behavior. Children under six years of age may believe that they are responsible for their illness, i.e., that it is a punishment. This may alter their self concept and ego strength. Being chronically sick may impinge on the child s ability to test reality. "It may not be possible to tell when and if illness is actually present, or if the symptoms are imagined and/or fabricated" (Sigal et al., 1989). Finally, in older children, the school absenteeism that results from multiple hospitalizations brings with it loss of education and loss of social interactions with peers their own age.

Diagnosis

Because of the consequences for the child, it is important to confirm or rule out a case suspicious for MSBP. Meadow (1982) suggests the following guidelines for diagnosing MSBP:

(1) study the history to determine which events are real and which are fabricated,

(2) look for temporal associations between illness events and the mother,

(3) scrutinize the personal, social, and family history that the mother has given,

(4) contact other family members,

(5) contact the mother's physician about a possible history of Munchausen's or unexplained illnesses,

(6) ensure that the hospital laboratory stores samples from the child for possible future screenings,

(7) more carefully monitor mother and child, possibly by video surveillance,

(8) consider a search of the mother and her possessions for possible poisons or substances,

(9) most important, exclude the mother for a day or two and observe whether the symptoms disappear.

A diagnosis of MSBP can be safely made when objective evidence (e.g., lab confirmation, video surveillance) has been collected, when medical and social histories are characteristic of the disorder, and when clinical findings are absent or suggest induced illness (Jones et al., 1986).

American Psychiatric Association Diagnostic Criteria

The American Psychiatric Association (1994) criteria for a diagnosis of MSBP are intentional production of physical or psychological signs and symptoms in a person under the individual's care, motivation for perpetrator's behavior is to assume the sick role by proxy, external incentives for the behavior are absent (e.g., economic gain), and the behavior is not better accounted for by another mental disorder.

Management

Once MSBP is confirmed, the case should be reported to social services and state authorities, and the physician should request court-ordered supervision of the case. If the mother repeatedly denies the allegations, the child must be placed out of the home. Rosenberg (1987) suggests obtaining court orders for long-term psychiatric evaluation and treatment of the child and family, and for review of medical records of all the siblings. Multidisciplinary management by medical staff, a child protection team, social services personnel, hospital administration, prosecutors, and law enforcement administrators is warranted. In court, it is important to elucidate the risk to the child of permanent handicap or death, and the psychiatric effects of multiple hospitalizations (Meadow, 1985).

Successful psychotherapy for MSBP perpetrators is difficult to achieve. First, the mother s denial is often so strong that she may not admit to the act. Second, it is difficult to gain access to the emotional life of patients who enact rather than verbalize their feelings. Third, in a therapeutic relationship the patient must tell the truth. For an MSBP patient, the boundary between truth and non-truth, between reality and fantasy is greatly blurred (Spivak et al., 1994).

Psychotherapy should help the patient to identify and articulate emotional experiences, to form a relationship no longer based on simulated illness, and to develop a more authentic and consolidated sense of self (Spivak, 1994). Psychotherapy for MSBP mothers may have a place in cases where the patient is reasonably well motivated in trying to confront her difficulties, is of average intelligence, and is not beset with family and social problems (Nicol and Eccles, 1985). Prognosis in MSBP

Prognosis in MSBP

What happens to the child depends to a large extent upon the mother's reaction upon confrontation. If she agrees to treatment and therapy, her child may be placed temporarily in a protective agency. If she is cemented in denial, legal action should be enacted on behalf of the child, and the child should be monitored well into the future. In some cases the mother may refuse treatment, deny the allegation, and even relocate to another state or town (only to continue with her previous behavior). One MSBP perpetrator was convicted in Texas for inducing cardiorespiratory arrest in her two children, and later was reported in Florida for inducing vomiting episodes in her children (personal communication, Dr. Frost).

Extreme caution should be taken in returning a child to the custody of the perpetrating mother. Even after the involvement of the Children's Protective Services, these children continue to be victims of maternal abuse (McGuire & Feldman, 1989). The possibility for reoccurrence should always be considered in these situations, and the safety of the child should have first priority.

Potential for Prevention

Feasible measures for preventing MSBP include a nation-wide registry of MSBP parents; training for pediatric and psychiatric residents about this syndrome; a national electronic network to track and flag MSBP mothers; and, finally, encouraging school attendance officers to identify children with a significant number of absences due to "illness" to the child s pediatrician (Schreier, 1992).

Conclusion

MSBP victimizes children, with widespread social ramifications. Health care professionals who work with children play a pivotal role in detecting possible cases of MSBP. It is important to be cognizant of this syndrome and to be familiar with steps taken in confirming a case. The earlier this syndrome is detected, the better the outcome for the child, the ultimate victim.