Factitious Disorder Imposed on Another (Munchausen by proxy) Clinical Presentation

Updated: Nov 11, 2015
  • Author: Guy E Brannon, MD; Chief Editor: Glen L Xiong, MD  more...
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Presentation

History

Common presentations of factitious disorder imposed on another (including Munchausen syndrome by proxy [MSBP]) include the following:

  • Bleeding from warfarin poisoning, phenolphthalein poisoning, exogenous exsanguination of a child, and use of colored substances to simulate bleeding
  • Seizures
  • Poisoning with phenothiazines, hydrocarbons, salt, or 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 [9]
  • Central nervous system (CNS) depression produced via drugs (eg, insulin, chloral hydrate, barbiturates, aspirin, diphenhydramine, tricyclic antidepressants, acetaminophen, or hydrocarbons)
  • Diarrhea and vomiting secondary to the use of ipecac, [29, 30] laxatives, [30] or salt
  • Fever, either feigned (via falsification of chart records) or actual
  • 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

Warning signs that should alert healthcare workers to the possibility of this disorder include the following:

  • Unexplainable, persistent, or recurrent illnesses
  • Discrepancies among the history, clinical findings, and child’s general health
  • A working diagnosis of a rare disorder
  • Symptoms and signs that occur only in the mother’s presence
  • A mother who is extremely attentive and always in the hospital
  • A child who is frequently intolerant of treatment
  • A mother who appears less worried about her child’s illness than about the medical staff
  • Seizures that do not respond to appropriate therapy
  • Families in which unexplained sudden infant death syndrome (SIDS) occurs
  • A mother with previous medical or nursing experience or an extensive history of illness

Characteristics of perpetrators

Individuals with factitious disorder imposed on another who perpetrate abuse are frequently described as caring, attentive, and devoted individuals. However, not all perpetrators fit this profile: Some can be hostile, emotionally labile, and obviously dishonest. Although they have no obvious psychopathology, perpetrators can be deceiving and manipulative. Their ability to convince others should not be underestimated. Their abuse is premeditated, calculated, and unprovoked.

As noted (see Pathophysiology), most reported cases involve parents and children. Although either parent may exhibit factitious disorder imposed on another, the mother is the perpetrator of the abuse in more than 95% of cases of MSBP. Typical characteristics of the mother with MSBP may be summarized as follows:

  • Biologic mother
  • Past exposure and experience with the healthcare system
  • Past training or work as a nurse or medical receptionist
  • Excellent interactions with all medical staff
  • More concerned with appearance than with substance
  • Seemingly excellent care of the child in the hospital, yet, in some cases, less concern for the child than for herself
  • Inappropriate affect when discussing the child’s illness
  • Lack of emotion
  • Possible history of factitious disorder imposed on self (including Munchausen syndrome) in the past (approximately 25% of patients)
  • Past abuse, or at least a reported story of abuse
  • Possible reporting of falsehoods about their lives (eg, earning of a law degree)
  • Poor relationship skills
  • Poor coping skills

The high frequency with which mothers with this disorder are perpetrators of abuse obviously conflicts with the commonly held view that mothers are more concerned with the well-being of their children. Saad has suggested that in some female perpetrators, motherly instincts are subverted by narcissistic attributes and enhanced need for attention. [31]

The mother may have previous healthcare knowledge or training [32] and often is fascinated by the medical field. In one study, 80% of the documented perpetrators—all of them mothers—worked in healthcare or child-care facilities. Perpetrators aspire to establish close relationships with medical staff and frequently become a source of support for staff members or the families of other patients.

The mother usually appears unexpectedly calm in the face of the perplexing problems that her child is experiencing. She tends to insist on pursuing additional diagnostic and therapeutic options, regardless of the pain and discomfort they may inflict on the child, and almost always resists discharge orders and negative diagnostic findings. If a physician becomes suspicious or reluctance to continue evaluations, she may take the child elsewhere.

Perpetrators typically recognize their wrongful behavior but take great care to conceal it, rarely admitting to their abusive activities. Relations among the mother, the child, and the primary physician may be extended and complex. This heightened level of involvement may hinder the physician from considering factitious disorder imposed on another as a differential diagnosis.

The child’s symptoms usually occur solely in the mother’s presence and subside in her absence. The mother’s partner, other family members, and healthcare workers are sometimes called to witness symptoms or a physiologically normal event (eg, mild discoloration with crying). The perpetrator later uses these witnessed events to substantiate an alleged illness of the child.

The mother’s partner is often disengaged from the family. [33] Common characteristics of the father include the following:

  • Dependency
  • High level of denial
  • Tendency to be very supportive of his female partner
  • Little involvement in the child’s care; may never visit the hospital

Partners who are trusting and unsuspecting may support the perpetrators and unknowingly become passive accomplices in the ongoing abuse. Other partners are abusive or uncommitted in their relationships with the mothers. In some cases, the abusing mother may be fabricating her child’s symptoms in an attempt to bring her partner back into the family.

About 10-25% of perpetrators also induce symptoms in themselves. The pattern of lying and fabrication may extend to other aspects of their lives (eg, employment, education, marital status, and illnesses. Severe mental illness (eg, schizophrenia) is rare, though the presence of 1 or more personality disorders may be common. The perpetrator may also have a history of an excessive drive to seek attention. The family history may reveal various types of abuse, unusual diseases in multiple family members, and family interactions that reward illness.

Whether a specific physician’s profile facilitates this type of abuse is unknown. Squires and Squires discussed several factors in the modern medical environment that may prevent earlier diagnosis of this condition, such as the following [34] :

  • Medical training and practice environments that encourage pursuit of rare conditions
  • Excessive reliance on electronic medical records that are difficult to analyze
  • Health Insurance Portability and Accountability Act (HIPAA)-related barriers to accessing medical records
  • Easier access to subspecialists in some countries than in others
  • Unlimited access of perpetrators to information via the Internet
  • Pressure on healthcare workers to provide better patient satisfaction

Findings in victims

Children experiencing MSBP-related abuse usually present with an array of ailments in different organ systems. Reports from the first 20 years after the condition was identified describe 68 symptoms, signs, and laboratory findings in 117 cases of MSBP, with approximately 70% of induced or fictitious symptoms occurring in the hospital.

More than 100 symptoms have been reported, with the most common being abdominal pain, vomiting, diarrhea, weight loss, seizures, apnea, infections, fevers, bleeding, poisoning, and lethargy. One group reported multiple illnesses in 64% of 56 index children subjected to MSBP. [35] Other reports indicate that some children initially present with a single serious event (eg, a severe episode of apnea with no previous history of fabrication).

A 2004 meta-analysis showed that pediatric condition falsification (PCF) was the cause of 0.3% of all cases of ALTEs. [36] Another report suggested that intentional suffocation was the cause of about 10% of all cases of SIDS. [37] In a series of 135 cases reported by Feldman et al, 25% of the children had renal or urologic related issues. [23]

Older MSBP victims often collude with their mothers by confirming even the most unlikely stories about their medical histories, whether from fear or from persuasion. Some of them believe that they are ill with a mysterious disorder that the physicians cannot figure out; others are aware that the mother’s explanation is improbable but fail to speak, fearing punishment or disbelief. A report on MSBP cases in older children (>6 years), found induced illnesses in 57%, tampering with records or specimens in 14%, and false reporting in 62%. [22]

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Physical Examination

Complete mental status, physical, and neurologic examinations should be performed to assist with the evaluation and to exclude other disease processes.

Siegel and Fischer suggested that pediatricians ask themselves the following questions during clinical assessment of the child in a case of suspected MSBP [38] :

  • During clinical assessment, is the child’s medical status consistent with the mother’s description?
  • Does objective diagnostic evidence support the child’s reported medical condition?
  • Has any staff member, including the pediatrician, witnessed the symptoms?
  • Do negative test findings reassure the mother?
  • Is treatment being provided to the child primarily because of the mother’s persistent demands?

Physicians must remember that persistent fabrication, exaggeration, and simulation reflect pathologic seeking of healthcare and are not benign. In some cases of MSBP, fabrication of symptoms may escalate to the induction of illnesses if the perpetrator wishes to continue being involved with the medical system or perceives the physician’s response as inadequate or unsatisfactory. Finally, clinicians should remember that the presence of a real illness does not preclude the presence of MSBP.

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Complications

In its more severe forms, factitious disorder imposed on another can lead to serious complications, including continued abuse, multiple hospitalizations, and the death of the child. Research suggests that the death rate for victims of MSBP is approximately 10%. [21] MSBP is considered a form of child abuse; if suspected, it must be reported, and proper investigations must be carried out.

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