eMedicine Specialties > Emergency Medicine > Psychosocial

Munchausen Syndrome by Proxy

Author: Jon Donavon Mason, MD, FACEP, FAAP, Assistant Program Director, Associate Professor of Emergency Medicine and Pediatrics, Department of Emergency Medicine, Eastern Virginia Medical School
Coauthor(s): Michael P Poirier, MD, Associate Professor of Pediatrics, Division of Emergency Medicine, Eastern Virginia Medical School; Consulting Staff, Children's Hospital of The King's Daughters
Contributor Information and Disclosures

Updated: Sep 17, 2007

Introduction

In 1977, Englishman Roy Meadow published the first report of a new form of child abuse. He coined the term Munchausen syndrome by proxy (MSBP) after the syndrome that first had been reported by Asher in 1951. This term is applied when an adult, usually the mother, presents a false history to the physician regarding a child who is not suffering from any of the fabricated symptoms. This history causes the physician to perform unnecessary diagnostic procedures that do not result in any specific diagnosis. MSBP has been called Polle syndrome, named after Baron von Munchausen's only child. In 2002, a new terminology, pediatric condition falsification (PCF), was suggested by the American Professional Society on the Abuse by Children (APSAC).

Today, many reports of such cases are in the literature. Some mothers invent symptoms, and others induce symptoms (eg, using ipecac to induce vomiting, overdosing a child with medication, lacerating the urethra to produce hematuria). Fabricated symptoms are not observed by anyone other than the mother.

In 1995, the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) included a definition for factitious disorder by proxy, which is now the accepted psychiatric category for MSBP. The definition includes the following:

1. Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care.
2. The motivation for the perpetrator's behavior is to assume the sick role by proxy.
3. External incentives for the behavior, such as economic gain, avoiding legal responsibility, or improving physical well-being, are absent.

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

Warning Signs of Munchausen Syndrome by Proxy

Children most at risk for MSBP abuse are aged 15 months to 6 years. The emergency physician often is confronted with baffling symptoms. Frequently, the child has been taken to many care providers before the diagnosis is established. In a meta-analysis of early published cases, 75% of morbidity occurred in hospitals. In about 98% of cases, the biological mother is responsible for the event. Victims of MSBP are equally male and female. Warning signs that are suggestive of MSBP include the following:

• Illness is multisystemic, prolonged, unusual, or rare.
• Symptoms are inappropriate or incongruent.
• Patient has multiple allergies.
• Symptoms disappear when parent or caretaker is absent.
• In children, one parent, usually the father, is absent during hospitalization.
• A history of sudden infant death syndrome in siblings may be present.
• Parent is overly attached to the patient.
• Parent has medical knowledge/background.
• Patient has poor tolerance of treatment (eg, frequent vomiting, rash, problems with intravenous lines).
• Parent encourages medical staff to perform numerous tests and studies.
• General health of the patient is inconsistent with results of laboratory tests.
• Parent shows inordinate concern for feelings of the medical staff.
• Seizure activity is unresponsive to anticonvulsants and is witnessed only by parent or caretaker.

Symptoms of Munchausen Syndrome by Proxy

Typical presentations of MSBP include the following:

• Bleeding from Coumadin poisoning, phenolphthalein poisoning, exogenous blood exsanguination of child, and use of colored substances to simulate bleeding
• Seizures
• Recurrent apparent life-threatening events (ALTE)
• Poisoning with phenothiazines, hydrocarbons, salt, and imipramine
• Apnea produced via carotid sinus pressure and suffocation - Covert video surveillance in cases of suspected child abuse has demonstrated that in many cases parents were inflicting abuse by suffocation.
• CNS depression produced via drugs (eg, insulin, chloral hydrate, barbiturates, aspirin, diphenhydramine, tricyclic antidepressants, acetaminophen, hydrocarbons)
• Diarrhea and vomiting secondary to ipecac, laxatives, and salt administration
• Fever via falsification of chart records or actual temperature
• Rash from drug poisoning, scratching, caustics, or skin painting
• Hypoglycemia from insulin or hypoglycemic agents
• Hyperglycemia reports (from testing other individuals with diabetes)
• Hematuria or guaiac positive stools produced by traumatic injury to the urethra or anorectal area
• Multiple infections with varied and often unusual organisms

Diagnostic Evaluation

The emergency physician must be adept at evaluating patients with varied symptoms and limited or confusing history.

In the case of MSBP, the child may present with a truly life-threatening–induced condition or may be completely asymptomatic with a factitious history supplied by the caregiver. The challenge for the physician 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 is often necessary to aid in making this difficult diagnosis.

Physicians can do many tests in the ED to rule out life-threatening conditions, but admission and consultation usually is necessary before the diagnosis of MSBP can be proved. Hospital rooms with hidden cameras may be used to make the final diagnosis. These rooms may be used in highly suspicious cases, but careful protocols must be developed for their use. Child protective agencies, police, and hospital security coordinate the use of these surveillance systems.

Emergency evaluation of these patients must be based on symptoms, with specific tests aimed at detecting the potential method by which factitious symptoms are being induced.

Tests that emergency physicians may consider include the following:

• Urine toxicology screening
• Chemistry panels
• Electrocardiography (ECG)
• Drug levels for suspected poisoning agents (eg, aspirin, acetaminophen, anticonvulsants)
• Cultures
• Coagulation tests
• Head CT scan

The Spectrum of Munchausen Syndrome by Proxy

A study in 1992 suggested that a continuum of parental responses to children exists. At one end of the spectrum is classic neglect, in which the parent disregards symptoms in a child who is truly ill. At the other extreme is the parent who fabricates or generates factitious symptoms in an otherwise healthy child. In between are the parents who are appropriately concerned about a child's symptoms and who make appropriate efforts to seek care for a child. Parents inflicting MSBP on their children have psychological problems that require professional intervention.

In 1997, Bryk published a description of her own abuse at the hand of her mother and described in detail her prolonged and horrifying story.¹ This instructive article is recommended reading for any medical professional who may come into contact with the victims of this particularly insidious form of abuse.

Keywords

Munchausen syndrome by proxy, factitious disorder by proxy, pediatric condition falsification, PCF, MSBP, child abuse, Polle syndrome, fabricated symptoms, factitious symptoms, invented symptoms, child neglect

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