Factitious Disorder Imposed on Another (Munchausen by proxy) Treatment & Management

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

Approach Considerations

Treatment of factitious disorder imposed on another (including Munchausen disease by proxy [MSBP]) involves treating the victim (most commonly, a child), the perpetrator (typically a parent, most frequently the biologic mother), and the family.

Meadow, Schreier and Libow, and others have recommended a stepwise approach to the management of this disorder, which may be summarized as follows [14, 42] :

  • Obtain and verify the victim’s and the family’s pertinent medical and social histories, previous hospitalizations, and medical records
  • Interview the other partner and any other family members alone, when the suspected perpetrator is not present
  • Admit the child to the hospital to observe the parent-child interaction, closely observe the suspected perpetrator, and determine the temporal relation between the symptoms and the perpetrator’s presence
  • Consider separating the child from the suspected perpetrator to protect the child and to confirm cessation of the child’s symptoms in the perpetrator’s absence
  • During hospitalization and under close observation, obtain the necessary body-fluid samples for toxicology screens and any other relevant investigations; if a multidisciplinary team agrees on the procedure, hidden cameras can be used to record the interactions of the child and the suspected perpetrator in the hospital setting
  • Arrange for social service, psychological, and psychiatric evaluations of the child and the suspected perpetrator
  • Assemble a team or task force to examine the records objectively before the suspected perpetrator is confronted
  • Inform the local child protection and law enforcement agencies before confronting the suspected perpetrator
  • After the suspected perpetrator has been informed of the diagnosis, remove the child and other siblings at risk; for adequate protection, relocate the child to a place that is inaccessible to the suspected perpetrator
  • Recommend short-term and long-term psychological and psychiatric treatment for the suspected perpetrator [43]
  • Verify that long-term close monitoring will be provided by the court; this is essential for ensuring the child’s safety
  • Ensure that relevant reunification criteria are met before the court considers reunification

Hospitalization of the perpetrator or the victim may be necessary to ensure that the 2 parties are both safe but are separated from each other. The clinician must attempt to understand the patient’s disorder without becoming judgmental toward him or her; such negative judgments can hamper therapy. 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).

Activity should be restricted if patients pose a danger to themselves or others or if they are gravely disabled.

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

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Treatment of the Abuse Victim

The primary concern in cases of MSBP is to ensure the safety and protection of 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 MSBP; there, the child can receive appropriate therapies
  • Treatment may involve play therapy, individual therapy, or both, depending on the child’s 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; however, managing a case involving MSBP often requires a team that includes social workers, foster care organizations, and law enforcement, in addition to healthcare providers
  • Depending on local laws, child welfare or child protective services may have to be notified
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Treatment of the Patient With MSBP

Treatment of the person with MSBP involves thorough evaluation, individual therapy, and parenting classes, among other facets. Without treatment, the relapse rate is high. However, successful treatment is difficult because those with the disorder often deny there is a problem. In addition, the success of treatment depends on the patient’s ability and willingness to tell the truth, and MSBP patients tend to be such accomplished liars that they begin to have trouble telling fact from fiction.

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 psychological evaluations

Psychotherapy generally focuses on changing the thinking and behavior of the individual with the disorder. [13] Individual therapy is aimed at decreasing anxiety, stressors, and other problems that perpetuate the illness. Elements of therapy include the following:

  • Identified problems must be appropriately managed
  • The patient must be able to break through denial and willing to undergo therapy
  • The patient must attempt to learn how to form relationships that are not associated with being ill
  • If the patient cannot overcome the issues found, the prognosis for recovery is poor
  • Parenting classes are also needed to teach the patient how to parent effectively while meeting his or her needs

No information is available regarding the use of medications in the treatment of MSBP.

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Treatment of the Family

Family therapy starts with education regarding MSBP and discussions about whether reunification of the patient and child might be possible. If the family is reunited, supervision is mandatory to ensure the child’s safety.

If other children live in the patient’s home, their health status should be evaluated, and appropriate treatment should be provided. All members of the family should receive therapy, including parents, siblings, and the affected child.

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Consultations

Many authorities feel that timely diagnosis and appropriate management of factitious disorder imposed on another (MSBP) are best achieved if professionals from multiple disciplines are involved. Consultations with the following may be indicated:

  • Psychiatrist
  • Psychologist
  • Social worker
  • Attorney
  • Law enforcement personnel (to conduct covert video surveillance)
  • Family court personnel (to terminate parental rights)
  • Child welfare authorities (to arrange for foster care)

Siegel and Fischer have summarized the roles of the key professionals needed to diagnose MSBP as follows [38] :

  • The role of the physician is to establish the pathologic healthcare-seeking behaviors that have led to medical abuse
  • The role of the psychologist is to evaluate the mother-child relationship, the mother’s psychiatric condition, and the family’s psychosocial functioning
  • The role of the child-protection worker is to ensure the child’s immediate and long-term safety
  • The role of the juvenile court is to protect the child by making a strong commitment to the child’s long-term supervision and to intervention that the family cannot refuse
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