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Munchausen Syndrome by Proxy

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
Kimberly S Carroll, MA, Clinical Research Coordinator, Brentwood Research Institute

Updated: Jan 17, 2008

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

Differential Diagnoses

Factitious Disorder
Malingering

Workup

Laboratory Studies

Standard medical workup for Munchausen syndrome by proxy is unlikely to provide useful information, other than findings that exclude medical conditions that could account for psychiatric pathology in the parent.

Laboratory tests may include these:

  • Sequential multiple analysis
  • Determination of the CBC count
  • Assays for rapid plasma reagent, thyroid-stimulating hormone, and thyroid function

Toxicologic tests and DNA typing might also be indicated.

Imaging Studies

Perform CT scanning or MRI if intracranial pathology is likely or if findings from neurologic examination are abnormal.

Other Tests

  • Psychological testing may be performed to help clarify the diagnosis.
  • A separation test removes the mother from her child for the purpose of observation. In Munchausen syndrome by proxy, the child's medical condition typically improves in the parent's absence, or the child may develop new abnormal findings or worsen after a visit with the parent.
  • If indicated, obtain an electroencephalogram.

Treatment

Medical Care

Indications for inpatient treatment include suicidal or homicidal ideations and grave disability (ie, patients who are dangerous to themselves or others or who cannot care for themselves).

Treatment of Munchausen syndrome by proxy involves treating the child (victim), the patient, and the family.

The literature provides little information regarding psychotherapy for Munchausen syndrome by proxy.

Treatment for the child

Treatment for the child comprises several areas, as follows:

  • First, the child must be placed in a safe environment where his or her symptoms can be monitored in the absence of the patient with Munchausen syndrome by proxy. There, the child can receive appropriate therapies.
  • Treatment may involve play therapy and/or individual therapy depending on his or her age.
  • Another important aspect is clarifying the child's health status.
  • A single practitioner 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.

Treatment for the patient with Munchausen syndrome by proxy

Treatment of the person with Munchausen syndrome by proxy involves thorough evaluation, individual therapy, and parenting classes, among other facets. Without treatment, the relapse rate is high. It is important not to overlook any medical and other psychiatric illnesses.

  • Clinical investigations are conducted to determine if other problems that require treatment are present. Studies include the following:
    • Physical examination
    • Laboratory evaluation
    • Psychiatric and/or psychological evaluations
  • Individual therapy is aimed at decreasing anxiety, stressors, and other problems that perpetuate the illness.
    • Identified problems must be appropriately managed.
    • Successful treatment is predicated on the patient's ability to break through denial and willingness to undergo therapy.
    • If the patient cannot overcome the issues found, his or her prognosis for recovery is poor.
  • Parenting classes are also needed to teach the patient how to parent effectively while meeting his or her needs.

Hospitalization

Hospitalization of the patient and/or child may be necessary to ensure that both the patient and the child are in safe but separate environments. The patient's condition must be understood without becoming judgmental toward him or her, as this attitude can hamper therapy.

Family therapy

Family therapy starts with education regarding Munchausen syndrome by proxy and discussions about whether reunification of the patient and child might be possible.

If other children live in the patient's home, their health status should be evaluated, and appropriate treatment given. All members of the family should receive therapy; they include parents, siblings, and the affected child.

If the family is reunited, supervision is mandatory to ensure the child's safety.

Consultations

Consultations with the following individuals may be indicated:

  • Attorney
  • Law enforcement personnel - To conduct covert video surveillance
  • Family court personnel - To terminate parental rights
  • Child welfare authorities - To arrange for foster care

Activity

Restrict activity if patients are a danger to themselves or others or if they are gravely disabled.

Medication

No information is available regarding the use of medications in the treatment of Munchausen syndrome by proxy.

Follow-up

Further Inpatient Care

Patients may require further inpatient care if they are a danger to themselves or others or if they are gravely disabled.

Further Outpatient Care

The literature provides little information regarding psychotherapy for Munchausen syndrome by proxy.

Inpatient & Outpatient Medications

No information is available.

Transfer

If patients are charged with a crime or if they have been arrested, they may be incarcerated.

Deterrence/Prevention

Deterrence and/or prevention may encompass these aspects:

  • Education
  • Legal ramifications

Complications

Complications of Munchausen syndrome by proxy and its management include the following:

  • Noncompliance with therapy
  • Difficulty in proving the syndrome

Prognosis

Patients with a good prognosis have the following characteristics:

  • They are able to assume responsibility for their behavior.
  • They can improve their coping skills.
  • They can place child's needs above their own.

Patients with a poor prognosis may exhibit the following signs:

  • They demonstrate a high degree of denial.
  • They are uncooperative with therapy.
  • They may have a personality disorder.

Patient Education

Educating the patient, family, and medical staff about Munchausen syndrome by proxy is important.

  • Patient education is directed at increasing the patient's coping and stress-management skills, among other areas.
  • Family education regarding patterns of this disorder in previous generations of the family is needed to effectively treat patients.
    • If other children are present in the home, they should be evaluated for possible abuse.
    • A helpful endeavor is instructing the patient in techniques to reduce stress and anxiety in the home to improve his or her prognosis.
    • The family should also be educated about healthy ways for the patient to express anger. The family members should allow the patient to appropriately express anger and not consider it a hindrance to the recovery process.

For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education article Munchausen Syndrome.

Miscellaneous

Medicolegal Pitfalls

  • Failure to be familiar with local laws
  • Failure to maintain or appropriately break patient confidentiality (eg, failure to report patients to the proper authorities)

Special Concerns

  • Munchausen syndrome by proxy is difficult to prove. Patients are typically not caught, and cases are usually based on circumstantial evidence.
  • A high index of suspicion is necessary to be able to detect Munchausen syndrome by proxy, eg, on the basis of the level of dishonesty a patient exhibits. One considers a diagnosis of Munchausen syndrome by proxy only after physical illnesses in the child are ruled out.
  • Review the child's medical history and the family history to look for a history of Munchausen syndrome in the patient. The adult—and not the child—is the patient in whom Munchausen syndrome by proxy is diagnosed.
  • Video surveillance may assist in confirming the diagnosis.

References

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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

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 Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Janssen Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Coauthor(s)

Kimberly S Carroll, MA, Clinical Research Coordinator, Brentwood Research Institute
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing 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.

CME Editor

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; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other; Pfizer Honoraria Speaking and teaching

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

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