Factitious Disorder Imposed on Another (Munchausen by proxy) Workup

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

Approach Considerations

To diagnose factitious disorder imposed on another (including Munchausen syndrome by proxy [MSBP]), clinicians must be adept at evaluating patients with varied symptoms and a limited or confusing history. Children subjected to MSBP may present with a truly life-threatening induced condition, or they may be completely asymptomatic with a factitious history supplied by the caregiver. [39]

The challenge for the physician in such cases is to put the history and physical findings together in a coherent fashion. This is particularly difficult in the child abuse victim, especially when the caretaker may not be giving a truthful history. Involving multiple medical colleagues in the evaluation may be useful. Accessing the records of previous visits and discussing the case with other physicians who have seen the child are often helpful in making this difficult diagnosis.

Many tests can be done on an emergency basis to rule out life-threatening conditions, but admission and consultation are usually necessary before the diagnosis of MSBP can be proved. [40] Hospital rooms with hidden cameras may be helpful for making the final diagnosis in highly suspicious cases, [41] but their use must follow careful protocols. Child protective agencies, police, and hospital security coordinate the use of these surveillance systems.

Standard medical workup is unlikely to provide useful information, aside from findings that exclude medical conditions that could account for psychiatric pathology in the parent. Evaluation must be based on specific symptoms, with specific tests aimed at detecting the potential method by which the factitious symptoms are being induced.

If no physical cause of the symptoms is found, a retrospective review of the child’s medical history, with careful consideration of the family history and the mother’s medical history (many perpetrators also have factitious disorder imposed on self) might provide clues suggesting MSBP. (Remember, it is the adult, not the child, who is diagnosed with MSBP.) Indeed, the most important or helpful part of the workup may be the review of all available old records. Too often, this time-consuming but critical task is forgotten, and the diagnosis is missed.

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Laboratory Studies

Laboratory tests that may be considered include the following:

  • Complete blood count (CBC)
  • Urine toxicology screening
  • Chemistry panels
  • Drug levels for suspected poisoning agents (eg, aspirin, acetaminophen, and anticonvulsants)
  • Cultures
  • Coagulation tests
  • Sequential multiple analysis
  • Assays for rapid plasma reagent, thyroid-stimulating hormone, and thyroid function
  • DNA typing
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Other Studies

Computed tomography (CT) or magnetic resonance imaging (MRI) may be warranted if intracranial pathology is likely or if findings from neurologic examination are abnormal.

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 MSBP, 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.

Electroencephalography (EEG) and electrocardiography (ECG) should be considered if warranted by the clinical circumstances.

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