Marcy RhodesStephen F. Austin State University

April 17, 2008

Munchausen’s Syndrome by Proxy

What is factitious disorder?Diagnostic Criteria (DSM-IV-TR)

Intentional production or feigning of physical or psychological signs and symptoms

Motivation for the behavior is to assume the sick role

External incentives for the behavior are absent

Munchausen’s Syndrome

Karl Friedrich Hieronymus, Baron Von Munchhausen (18th Century)

Name given by Asher (1951)

What is Factitious Disorder BY PROXY?

By Proxy – indirectly assumes sick roleListed in Appendix B in the DSM-IV-TRResearch Criteria

Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care.

The motivation for the perpetrator’s behavior is to assume the sick role by proxy

External incentives for the behavior are absent

The behavior is not better accounted for by another mental disorder

Munchausen’s Syndrome By Proxy

Coined by Roy Meadow, 1977Pediatrician in Leeds, EnglandBecame convinced that many apparent

“cot deaths” were in fact the result of child abuse brought on by MSbP

First to describe this disorder & recognize it as a fatal form of child abuse.

Overview of Munchausen’s Syndrome By Proxy (MSbP)

Caretaker fabricates, exaggerates, or induces illness in a child, for which he or she seeks extensive medical testing and/or hospitalizations

Perpetrator obtains psychological reward in the form of the attention she receives from others

Victimization is often lengthyPerpetrator is usually the biological mother

(98%)Perpetrator presents as model parentMost victims are preschoolers

Overview of Munchausen’s Syndrome By Proxy (MSbP)

Prevalence has not been established; considered uncommon

Majority of cases involve the gastrointestinal, genitourinary or central nervous system.

More than one child in the family may be abused

In as many as 10% of cases, abuse leads to death

Most common induced and simulated illnessesPersistent vomiting or diarrheaRespiratory arrestAsthmaCentral Nervous Systems dysfunctions

(e.g., seizures, loss of consciousness)FeverInfection – “Bacteriologically Battered

Babies”BleedingFailure to thriveHypoglycemiaElectrolyte disturbancesRash

Attachment Representations and MSbPAdshead & Bluglass (2001)Assessed the attachment style of 26

mothers who had exhibited MSbP behaviors88% exhibited an insecure attachment styleMost common pattern: dismissing (77%)

Adshead & Bluglass (2005)Assessed attachment style of 67 mothers

who had exhibited MSbP behaviorsOnly 18% exhibited a secure attachment

style85% rated as insecureDismissing, 46%

Case Study – Kathy BushDiagnosed with MSbP

Charged with aggravated child abuse and Medicaid fraud

Jennifer Bush, daughter

Between August 1993 and April 1995

Taken to the hospital more than 130 times

Underwent 40 surgeries

Amassed over $3 million in medical bills

Profile of MSbP PerpetratorsMost often biological mothersAppear to be very knowledgeable about

victim’s illnessPast exposure & experience with

healthcare systemOften have some previous (usually

incomplete) training in nursing or medicineRemain uncharacteristically calm in

view of victim’s perplexing medical symptoms

Profile of MSbP PerpetratorsPraise medical staff excessivelyWelcome medical tests, even

those that are painfulIncreased incidence of

Munchausen syndromeHistory of Abuse or at least

reported history of abuseFabrication of info about

perpetrator’s lifePoor relationship skillsPoor coping skills

Profile of MSbP PerpetratorsTypically shelter victim from outside

activities

Maintain a high degree of attentiveness to the victim

Often unresponsive to child when unaware of being observed

Find emotional satisfaction when the child is hospitalized because of the staff’s praise of their ability to be a superior, attentive caregiver.

Perpetrator Motivational FactorsCrave attention from medical staff,

doctors, family and friendsMight receive gratification for being able

to fool those who they perceive as having more power, status

Some offenders may fear going home or adjusting to a normal daily routine without being the center of attention

An offender who is praised as a hero for saving a child might elect to re-create that euphoria by fabricating subsequent incidents of abuse and revival of the victim.

MSbP Warning SignsUnexplained, persistent, recurring illnessRepeated hospitalizations and extensive

medical tests that fail to produce a diagnosis

Symptoms that do not make medical sense

Lab results that are inconsistent with each other or recognized diseases

Persistent failure of the victim to respond to therapy

MSbP Warning SignsSigns and symptoms that occur ONLY in

the presence of the caretakerMother who is extremely attentive and

always in the hospitalMothers who do not seem worried about

their child's illness but are constantly at the child's side while in the hospital

Mothers who have an unusually close relationship with the hospital's medical staff

MSbP Warning SignsA family history of sudden infant

death syndrome Mothers with previous medical or

nursing experience or with an extensive history of illness

A parent who welcomes medical testing of the child, even if painful

May become angry and demand further procedures, second opinions, further intervention

MSbP Warning SignsAttempts to convince the staff that the

child is still ill when advised that the child will be released from the hospital

A caregiver with a previous history of Munchausen Syndrome

A caregiver who adamantly refuses to accept the suggestion that the diagnosis is nonmedical.

Increasingly urgent visits to the same hospital or clinic.

Difficult to Confirm MSbPPractitioners may be reluctant to

diagnoseGoes against the belief that a parent or

caregiver would ever deliberately hurt his or her child.

Legal consequences of inaccurate diagnosisPersonal consequences of inaccurate

diagnosis

Sally Clark (1964 – 2007)

M.A.M.A.Mother’s Against Munchausen’s AllegationsMission: To stop the assault on innocent parents from

MSbP allegations and to reveal the ulterior motives of the accusers

These mother’s claim that they are falsely accusedDoctor or institution can evade a medical malpractice

lawsuit Doctors can rid themselves of a troublesome mom when

frustrated and unable to diagnose a child's condition The false MSBP diagnosis can be gravely detrimental;

adding deep emotional stress of maternal deprivation to an ill child

www.msbp.com

If you do suspect MSbP…Proceed with Multidisciplinary team

CPSLaw enforcementPsychologist or psychiatristProsecutorHospital social workerNurse practitionerPediatrician (especially one specialized in

MSbP)Other members of the child’s medical

team

If you do suspect MSbP…Review medical records

Entries regarding child/parent interactionsMay establish temporal relationship between

symptoms and parent’s presenceDirect monitoring of child’s hospital room

SitterDocuments time of visits, especially of suspected

perpetratorNo food or drink allowed except for the provided by

hospital staffVideo surveillance (controversial)

Completely restrict parent’s access (must be court-ordered)

Treatment - PrepetratorPsychotherapy is often ineffectiveSuccessful treatment depends upon

the patient's ability to break through denial and willingness to undergo therapy

Changes in the family systemIncreased parental sensitivity and

responsiveness to child’s needsPlan to prevent relapse

If the patient cannot overcome her issues, prognosis for recovery is poor.

Treatment – Child/VictimFirst, the child must be placed in a safe

environment Play therapy and/or individual therapy

depending on his or her age.Another important aspect is clarifying the

child's health status.A single physician who is familiar with the

case should be responsible for monitoring and treating the child.

Depending on local laws, child welfare and/or protective services may need to be notified.

Short & Long-Term Implications

Short termPain

Mother’s actionsMedical procedures

Reduced social, educational, and emotional opportunities

Long termLong term disabilityIncreased likelihood of developing Munchuasen’s

syndromeLibow (1995)

PTSDFeelings of inadequacyPoor self-esteemRelationship problems