How Can I Recognize Munchausen Syndrome by Proxy?

Mary E. Muscari, PhD, CPNP, APRN-BC

Disclosures

April 08, 2008

Question
When should I suspect Munchausen syndrome by proxy in a patient?

Response from Mary E. Muscari, PhD, CPNP, APRN-BC, CFNS
Mary E. Muscari, PhD, CPNP, APRN-BC, Associate Professor and Director, O'Connor Office for Rural Studies, Decker School of Nursing, Binghamton University, Binghamton, New York

 

Munchausen Syndrome by Proxy

 

The term Munchausen syndrome by proxy (MSBP) was first coined in 1977 by pediatrician Roy Meadow when he published a report on a new form of child abuse. MSBP usually 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 usually involves a mother and young child; however, there have been cases of MSBP involving illness produced or feigned in other adults and even in pets.[1,2]

MSBP is classified as factitious disorder by proxy in Appendix B (Criteria Sets and Axes Provided for Further Study) of the Diagnostic and Statistical Manual (DSM) IV-TR.[3] Research criteria include:

  • Intentional production of or feigning of physical or psychological symptoms in a person under one's care;

  • Perpetrator motivated by assuming the sick role by proxy;

  • External incentives (such as monetary gain) are absent; and

  • Behavior is not better accounted for by another disorder.[3]

The fabrication or induction of a child's illness is a form of child abuse that carries the possibility of an extremely poor prognosis if the child is left in the home.[4] Therefore, nurse practitioners (NPs) need to know when to include MSBP in the differential diagnosis of a child's illness.

Subtypes of MSBP

Schreier and Libow[5] describe 3 subtypes of MSBP, based on the frequency and intensity of behaviors. 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. There are intervals when the person experiences symptoms of MSBP and intervals where the person lives a normal life.

In mild Munchausen by proxy, affected individuals 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 resorts to measures such as inducing 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.[5]

Presentation of MSBP

There is no single, typical presentation of MSBP; victims' symptoms are as variable as the human imagination. Victims are equally divided between male and female, and children most at risk are those aged 15 months to 72 months. Victims frequently have baffling symptoms and see multiple healthcare providers before a diagnosis of MSBP is made. In 98% of cases, the perpetrator is the biological mother.[6] Characteristics of perpetrators include female, white, experiencing marital discord, having healthcare knowledge or training, friendly and cooperative with staff, very attentive to the child, and may have a history of abuse and/or psychiatric disorders.[7]

Perpetrators of MSBP may be help-seekers who search for medical attention for their children to communicate their own exhaustion, anxiety, or depression. Others may be active inducers who create their child's illnesses through dramatic measures. These parents are typically anxious, depressed, or paranoid. And finally, some may be "doctor addicts" who are obsessed with getting treatment for their children's nonexistent illnesses.[8]

Ways that MSBP can present include[6,7]:

  • Complex pattern of illness and recurrent infection without physiologic explanation;

  • Seizure activity that does not respond to medication and that is only witnessed by the caretaker;

  • Bleeding from anticoagulants and poisons; use of caretaker's own blood or red-colored substances to simulate bleeding;

  • Vomiting precipitated by ipecac administration;

  • Diarrhea induced by laxatives or salt administration;

  • Hypoglycemia from administration of insulin or hypoglycemic agents;

  • Rashes from caustic substances applied to the skin;

  • Hematuria or rectal bleeding from trauma;

  • Recurrent apparent life-threatening events (ALTE) from purposeful suffocation; and

  • Central nervous system depression (usually from drug administration).

Diagnosis of MSBP

Diagnosis of MSBP tends to be difficult because the victim's signs and symptoms are undetectable (when exaggerated or imagined) or inconsistent (when induced or fabricated).[4] For example, signs of dehydration may be undetectable in a toddler whose caretaker exaggerates the severity of the child's diarrhea, and hypoglycemia may occur inconsistently when the caretaker is injecting insulin into the child on a sporadic basis. Confusing signs and symptoms may tempt NPs to order diagnostic tests, some of which can be painful and frightening, essentially adding to the abuse suffered by the child because of the factitious illness. Therefore, when seeing a patient with unusual symptoms, the NP should consider MSP in the differential diagnosis and investigate accordingly.[4]

Stirling and the Committee on Child Abuse and Neglect[4] suggest that providers ask themselves the following questions: (1) Are the history and signs and symptoms of disease believable? (2) Is the child receiving unnecessary, harmful, or potentially dangerous testing and medical care? (3) If so, who is prompting the evaluations and treatment?

Mason and Poirier[6] recommend looking for these warning signs:

  • Illness that is multisystemic, prolonged, unusual, or rare;

  • Symptoms that are inappropriate or incongruent;

  • Multiple allergies;

  • Symptoms that disappear when caretaker is absent;

  • One parent, usually the father, absent during the child's hospitalization;

  • History of sudden infant death syndrome (SIDS) in siblings;

  • Parent who is overly attached to the patient;

  • Parent who has medical knowledge/background;

  • Child who has poor tolerance of treatment;

  • Parent who encourages medical staff to perform numerous tests and studies; and

  • Parent who shows inordinate concern for feelings of the medical staff.

The diagnosis of MSBP cannot be made quickly; admission and consultation is usually necessary before the diagnosis can be confirmed. Hospitalization may also be warranted to keep the child safe from further abuse. Covert video surveillance in the hospital room has been recommended 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 may be used in highly suspicious circumstances, but should only be used in conjunction with carefully developed protocols that delineate the roles of child protective agencies, police, and hospital security in coordinating the use of covert surveillance systems.

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