Munchausen Syndrome by Proxy
What is Munchausen syndrome by proxy?
Munchausen syndrome by proxy (MSP), a type of factitious disorder, is a
mental illness in which a person acts as if an individual he or she is caring
for has a physical or mental illness when the person is not really sick. The
adult perpetrator has MSP and directly produces or lies about illness in another
person under his or her care, usually a child under 6 years of age. It is
considered a form of abuse by the American Professional Society on the Abuse of
Children. However, cases have been reported of adult victims. (The term "by
proxy" means "through a substitute.")
People with MSP have an inner need for 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. People with MSP are even
willing to have the child or 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. Factitious disorders are considered mental
illnesses because they are associated with severe emotional difficulties.
The Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (Text Revision DSMIV-TR), which is the standard
reference book for recognized mental illnesses in the United States, organizes
factitious disorders into four main types: those with mainly psychological
symptoms; those with mainly physical symptoms; those with both physical and
psychological symptoms; and those that do not match the conditions for the other
three types. MSP falls into the fourth category. Fortunately, it is rare (2 out
of 100,000 children).
MSP most often occurs with mothers—although it can
occur with fathers—who intentionally harm or describe non-existent symptoms in
their children to get the attention given to the family of someone who is sick.
A person with MSP uses the many hospitalizations as a way to earn praise from
others for her devotion to the child’s care, often using the sick child as a
means for developing a relationship with the doctor or other health care
provider. The adult with MSP often will not leave the bedside and will discuss
in medical detail symptoms and care provided as evidence that he or she is a
good caretaker. If the symptoms go away in the hospital, they are likely to
return when the caretaker with MSP is alone with the child or elderly parent.
People with MSP might create or exaggerate the child’s
symptoms in several ways. They might simply lie about symptoms, alter diagnostic
tests (such as contaminating a urine sample), falsify medical records, or induce
symptoms through various means, such as poisoning, suffocating, starving, and
causing infection. The presenting problem may also be psychiatric or behavioral.
What are the symptoms of Munchausen syndrome by proxy?
Certain characteristics are common in a person with MSP:
- Often is a parent, usually a mother, but can be the adult child of an elderly patient
- Might be a health care professional
- Is very friendly and cooperative with the health care providers
- Appears quite concerned (some might seem overly concerned) about the child or designated patient
- Might also suffer from Munchausen syndrome (This is a related disorder
in which the caregiver repeatedly acts as if he or she has a physical or
mental illness when he or she has caused the symptoms.)
Other possible warning signs of MSP in children include the following:
- The child has a history of many hospitalizations, often with a strange set of symptoms.
- Worsening of the child’s symptoms generally is reported by the mother and is not witnessed by the hospital staff.
- The child’s reported condition and symptoms do not agree with the results of diagnostic tests.
- There might be more than one unusual illness or death of children in the family.
- The child’s condition improves in the hospital, but symptoms recur when the child returns home.
- Blood in lab samples might not match the blood of the child.
- There might be signs of chemicals in the child’s blood, stool, or urine.
What causes Munchausen syndrome by proxy?
The exact cause of MSP is not known, but researchers believe both biological
and psychological factors play a role in the development of this disorder. Some
theories 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 MSP episode.
How common is Munchausen syndrome by proxy?
There are no reliable statistics regarding the number of people in the
United States who suffer from MSP, and it is difficult to assess how common the
disorder is because many cases go undetected. However, estimates suggest that
about 1,000 of the 2.5 million cases of child abuse reported annually are related to MSP.
In general, MSP occurs more often in women than in men.
How is Munchausen syndrome by proxy diagnosed?
Diagnosing MSP is very difficult because of the dishonesty that is involved.
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 MSP.
If a physical cause of the symptoms is not found, 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 MSP. Often, the individual with MSP
may have other comorbid psychiatric disorders. Remember, it is the adult, not
the child, who is diagnosed with MSP. Indeed, the most important or helpful part
of the workup is likely to be the review of all old records that can be
obtained. Too often, this time-consuming but critical task is forgotten and the diagnosis is missed.
How is Munchausen syndrome by proxy treated?
The first concern in cases of MSP is to ensure the safety and protection of
any real or potential victims. This might require that the child be placed in
the care of another. In fact, managing a case involving MSP often requires a
team that includes social workers, foster care organizations, and law
enforcement, as well as the health care providers.
Successful treatment of people with MSP is difficult
because those with the disorder often deny there is a problem. In addition,
treatment success is dependent on the person telling the truth, and people with
MSP tend to be such accomplished liars that they begin to have trouble telling fact from fiction.
Psychotherapy (a type of counseling) generally focuses
on changing the thinking and behavior of the individual with the disorder
(cognitive-behavioral therapy). The goal of therapy for MSP 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.
What are the complications of Munchausen syndrome by proxy ?
This disorder can lead to serious short- and long-term complications,
including continued abuse, multiple hospitalizations, and the death of the
victim. (Research suggests that the death rate for victims of MSP is about 10
percent.) In some cases, a child victim of MSP learns to associate getting
attention to being sick and develops Munchausen syndrome himself or herself.
Considered a form of child abuse, MSP is a criminal offense.
What is the prognosis (outlook) for people with Munchausen syndrome by proxy?
In generally, MSP is a very difficult disorder to treat and often requires
years of therapy and support. Social services, law enforcement, children’s
protective services, and physicians must function as a team to stop the behavior.
Can Munchausen syndrome by proxy be prevented?
There is no known way to prevent this disorder. However, it might be helpful
to begin treatment in people as soon as they begin to have symptoms. Removing
the child or other victim from the care of the person with MSP can prevent further harm to the victim.
References:
Stirling J. Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting,
Pediatrics. 2007;119:1026-1030. pediatrics.aappublications.org/cgi/content/full/119/5/1026. Accessed December 22, 2010.
Endom EE. Munchausen syndrome by proxy. uptodate.com/online/content/topic.do?topicKey=peds_soc/6036&selectedTitle=1%7E20&source=search_result. Accessed December 22, 2010.
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