Munchausen Syndrome by Proxy 

  • Author: Guy E Brannon, MD; Chief Editor: Eduardo Dunayevich, MD   more...
 
Updated: Sep 1, 2011
 

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.

Case study

A 2-year-old female was brought to the emergency department for blood in her diaper. The physician performed a complete history and physical examination, including laboratory studies. After results came back normal, the little girl was discharged home with her mother.

A couple of days later the mother returned to the emergency department again with complaint of blood in her daughter's diapers. The mother, a registered nurse, brought the bloody diaper and gave a complete medical history, including all medications used in pregnancy and Apgar scores. The daughter was admitted to the pediatric floor for observation. The mother appeared anxious but was very helpful with the staff. Every morning she was present for the attending physician's rounds and purchased donuts for the entire staff. The results returned within normal limits. The mother became agitated and insisted on a second opinion. The attending physician agreed. The next morning the nursing staff paged the physician to report that the mother took the patient and left the hospital in the middle of the night.

Sample mental status examination

The patient is a 32-year-old Caucasian female wearing street clothes, good grooming and hygiene, increased eye contact, anxious facial expression, variable motor activity, and fairly cooperative. The patient denied suicidal/homicidal ideation and audio/visual hallucinations and delusions, but appeared guarded at times. The patient was alert and oriented to person, place, and time. The patient could spell world forward and backward, perform simple calculations, and had a good fund of knowledge. Insight and judgement were decreased. Impulse control was decreased. Estimate IQ was above average. Reliability was suspect.

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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.

Bass et al suggest a chronic somatoform disorder or factitious disorder (or both) is present in mothers who cause their children to be ill. In their study, half of the mothers exhibited pathological lying; for some, this dated back to adolescence and often continued into adult life. The authors suggest that any psychiatrists who encounter women with chronic somatoform or factitious disorders should be alert to the impact of these illnesses on any dependent children, especially if evidence suggests lying from an early age,[2]

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.

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Epidemiology

Frequency

United States

Frequency is unknown.[3]

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%.[4]

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.[5]

Age

Whether a certain age group is more likely to have the condition remains unknown.

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Contributor Information and Disclosures
Author

Guy E Brannon, MD  Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center; Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company

Guy E Brannon, MD is a member of the following medical societies: American Medical Association, American Medical Writers Association, American Psychiatric Association, American Society of Addiction Medicine, Association of Clinical Research Professionals, Louisiana State Medical Society, and Southern Medical Association

Disclosure: AstraZeneca Grant/research funds Other; Janssen Grant/research funds Other; Pfizer Honoraria Speaking and teaching; Sunovion Honoraria Speaking and teaching; Eli Lilly Grant/research funds Other; Forrest Grant/research funds Other

Specialty Editor Board

Ronald C Albucher, MD  Chief Medical Officer, Westside Community Services; Consulting Staff, California Pacific Medical Center

Ronald C Albucher, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

Eduardo Dunayevich, MD  Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories

Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

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