Introduction
Background
Roy Meadow, MD, coined the term Munchausen syndrome by proxy in 1977 after observing 2 cases of mothers causing their children to be ill.
The cardinal feature of Munchausen syndrome by proxy is the production or feigning of physical or psychological symptoms in another person, usually a child or adult under the care of another. Secondary or external factors are not present. The person often lacks other mental or physical illnesses.
The caretaker simulates or induces symptoms of an illness and then takes the child or other person to seek medical attention, disavowing knowledge of the source of the problem. The deception may arise from anger or a desire for attention, which is satisfied by having a relationship with a practitioner.
Most symptoms are physical complaints, whereas feigning of mental symptoms occurs to a lesser extent. Physical presentations include vomiting, diarrhea, respiratory arrest, asthma, seizure, recurrent conjunctivitis, clumsiness, syncope, fever, infection, bleeding, failure to thrive, or electrolytic disturbance. For example, polymicrobial sepsis in a central line is extremely rare and should elicit consideration of the possibility of tampering. Another example is finding carbamazepine in the blood of a patient to whom the drug was not prescribed or finding a high level in a patient in whom it was discontinued.
Clinicians are trained to elicit the history of a sick child from his or her parents. A parent with Munchausen syndrome by proxy, usually the biologic mother, recounts serious but vague symptoms. This information may result in the performance of many laboratory tests and other procedures, including surgery. The child does not contradict the information because of fear. The outcome for the child could be serious injury or even death.
Although Munchausen syndrome by proxy is not formally listed as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),1 it can be found as factitious disorder not otherwise specified.
Many authorities consider Munchausen syndrome by proxy a lethal form of child abuse in which the action is voluntary (not impulsive) and potentially harmful to normal development.
Pathophysiology
Most cases of Munchausen syndrome by proxy are reported in the pediatric literature. Although the exact pathophysiology is unknown, a number of theories have been postulated.
Most people turn to the psychodynamic literature, which emphasizes a reaction to loss or a way to obtain attention and nurturing, a way to feel powerful, or a way of just acting out as possible explanations for this syndrome.
Some investigators offer unspecified brain dysfunction as an explanation. In this theory, the mother may have experienced abuse as a child, or she may be simply rejecting her childhood for some unknown reason.
Munchausen syndrome by proxy may be explained as a parent's pathologic relationship with a child. The mother may receive a psychological reward in the form of attention she receives from medical staff.
Frequency
United States
Frequency is unknown.2
International
Although the true prevalence is unknown, Munchausen syndrome by proxy is increasingly recognized and reported worldwide.
Mortality/Morbidity
A wide variety of morbidity, ranging from infection of unknown origin to unexplained death, is noted. The mortality rate is approximately 6%.3
Race
A racial or ethnic predilection for this condition has not been determined, but most mothers are Caucasian.
Sex
Approximately 98% of persons with Munchausen syndrome by proxy are women.4
Age
Whether a certain age group is more likely to have the condition remains unknown.
Clinical
History
Factitious disorder by proxy
The DSM-IV-TR includes the following research criteria for factitious disorder by proxy:
- The perpetrator intentionally produces or feigns physical or psychological signs or symptoms in another person who is under his or her care.
- The motivation for the perpetrator's behavior is to assume the sick role by proxy.
- External incentives for the behavior (eg, economic gain) are absent.
- Another mental disorder does not account for the behavior.
Factitious disorder not otherwise specified
The category of factitious disorder not otherwise specified includes disorders with contrived symptoms that do not meet the criteria for a factitious disorder, such as factitious disorder by proxy (ie, the intentional production or feigning of physical or psychological signs or symptoms in another person for the purpose of indirectly assuming the sick role).
- Characteristics of the mother
- Past exposure and experience with the healthcare system
- Past training or work as a nurse or medical receptionist
- Biologic mother (95% of known cases)
- Excellent interactions with all medical staff
- More concerned with appearance than with substance
- Seemingly excellent care of the child in the hospital (Eg, She never leaves the hospital and never leaves the child's side.); yet, in some cases, less concern for the child or loved one than for herself
- Inappropriate affect when discussing the child's illness
- Lack of emotion
- Possible history of Munchausen syndrome in the past (found in about 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
- Characteristics of the father
- Dependent
- High denial
- Very supportive of the spouse
- Little involvement - May never visit the hospital
- Warning signs of Munchausen syndrome by proxy
- Unexplainable, persistent, or recurrent illnesses
- Discrepancies among the history, clinical findings, and child's general health
- Working diagnosis of a rare disorder
- Symptoms and signs occurring only in the mother's presence
- Mother who is extremely attentive and always in the hospital
- Child who is frequently intolerant of treatment
- 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 occurs
- Mother with previous medical or nursing experience or with an extensive history of illness
Physical
Obtain a complete history and perform complete mental status, physical, and neurologic examinations to assist with the evaluation and to exclude other disease processes.
Causes
Research does not yet show a single cause for Munchausen syndrome by proxy.
- Major causes are thought to include the following:
- Maternal history of abuse or reported abuse
- Rejection of the child
- Use of the child to maintain control
- Pathologic relationship with the child
- Psychological reward received from the medical community because of the sick child
- The following psychiatric comorbidities may be present:
- Munchausen syndrome
- Narcissistic and borderline personality disorder
- Somatoform disorder
- Factitious disorder
- Dissociative pseudologia phantastica
- Sudden infant death syndrome
- Pediatric condition falsification
More on Munchausen Syndrome by Proxy |
 Overview: Munchausen Syndrome by Proxy |
| Differential Diagnoses & Workup: Munchausen Syndrome by Proxy |
| Treatment & Medication: Munchausen Syndrome by Proxy |
| Follow-up: Munchausen Syndrome by Proxy |
| References |
| Next Page » |
References
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Further Reading
Keywords
Münchhausen syndrome by proxy, MSBP, Munchausen syndrome, Munchausen syndrome emergency, Munchausen syndrome by proxy emergency, Asher, Baron von Munchausen, Polle syndrome, Polle's syndrome, children of Munchausen, pediatric condition falsification, PCF, FD, factitious disease, factitious disorder, factitious disorder by proxy, factitious disorder not otherwise specified, factitious disorder NOS
malingering, psychiatric disorder, pseudosickness, pseudologues, mental disorder, child abuse emergency, physical child abuse, tampering, infection of unknown origin, unexplained death, feigned illness, faked illness, hospital hobo, pathomimicry disease forgery, doctor addicts, hospital addicts, hospital hoppers, professional patients, false patients, operation addicts, peregrinating problem patients, dissociative pseudologia fantastica, hypochondriasis, hypochondriacs, black-hole patients, fabricated symptoms, invented symptoms, personality disorders, somatoform disorder, sudden infant death syndrome
