Article summary of Munchausen by proxy syndrome by Moseley & Day - Chapter

What is Munchausen’s syndrome?

In 1951, Asher first labeled adult patients who present for treatment of fabricated symptoms with Munchausen’s syndrome. These people are also referred to as hospital addicts, since they continuously seek medical help and services. They do so even when they face serious risks by undergoing these (unnecessary) procedures. The reason for their behavior would be getting emotional gratification from their deceptive relationships with their doctors.

What is Munchausen by proxy syndrome?

Munchausen by Proxy Syndrome (MBP) is a form of child abuse in which a parent (usually the mother) intentionally fabricates symptoms of illness in a child, or induces the symptoms the child already suffers from. Most of the time, the fabricated or induced symptoms are consistent with life-threatening and/or chronic disorders. Parents who do this to their child are usually looking for rewards in the form of attention and support provided by family, friends and society. They want others to see them as heroes because of the way they handle the seriousness of their child’s illness.

How prevalent is Munchausen by proxy syndrome?

Because many physicians do not include the diagnosis of MBP in their discharge summaries, there is a substantial underestimate of the prevalence of the disorder. Also, only the worst cases are mentioned in saved records. There is quite a long period of time between the onset of symptoms and the diagnosis, and the diagnosis itself can take up to 6 to 15 months.

How does DSM-IV define factitious disorder?

MBP is registered in DSM-IV as factitious disorder by proxy. The disorder is defined as intentionally feigning or producing physical or psychological symptoms in another person who is under the individual’s care, with the aim of assuming the sick role. There are no external rewards present for the behavior, such as financial gain. Most of the time, the diagnosis is derived from a very lengthy process of elimination of other possible explanations for the symptoms.

What is the difference between pediatric condition falsification and factitious disorder by proxy?

This changed when Ayoub proposed a model that should improve diagnostic accuracy. A few years later, in 2002, the model was presented as a position paper by the American Professional Society on the Abuse of Children (APSAC). This model divides MBP into two functional components. The first component is labeled pediatric condition falsification (PCF), which acknowledges the falsification of the medical presentation of the child. It describes the form of child abuse in which a parent or caregiver intentionally feigns symptoms in a child. The second component is called factitious disorder by proxy (FDP). This component emphasizes the specific psychiatric diagnosis of the parent, and gives this as motivation for the behavior (missing in the original diagnosis of PCF).

What are the advantages of Ayoub’s model?

The model allows doctors to identify PCF more quickly and thereby protect the child in an earlier stage. Also, this makes it possible to leave the determination of the perpetrator’s motivation and psychopathology to qualified mental health professionals. Furthermore, this way the judicial system can be included at an earlier point in the investigation. Psychologists can provide the court with information needed for effective intervention with the family and relevant information regarding treatment, instead of using the court to ensure compliance and collaboration by the family members. All in all, using this model makes it easier for epidemiologists to more accurately identify the extent of child abuse as a result of factitious symptom presentation.

What increases the risk of misdiagnosis of MBP?

When parents deliberately manipulate medical information, the authors believe that MBP must always be considered. There is however always the risk of misdiagnosis and the following situations can increase the risk of misdiagnosing MBP:

• Overacting of symptoms by a parent whose child is recovering from a documented health crisis (for example with prematurity).
• The description of extreme symptoms which are not present at the time of the medical examination because of variability in the child’s authentic symptoms (like with asthma).
• A parent who is overanxious and therefore appears to access excessive care for the child, but is non-abusive.
• Conscious exaggeration of symptoms by the parent without any intention to deceive, but with the purpose of drawing attention to the original symptom.
• The child or parent is malingering, there is no factitious disorder.
• The child suffers from a medical disorder that has eluded detection and may be rare.
• The child’s illness threatens to become worse because of noncompliance by the parent with the prescribed medical treatment.
• The parent does fabricate symptoms and feigns the child’s illness, but shows no MBP motivation (for instance because they are suffering from a psychotic disorder and are experiencing hallucinations/delusions).
• Someone deliberately levels a false MBP accusation because of personal conflict (for example in a high-conflict divorce).

How can MBP be detected?

• Doctors and other medical staff may get suspicious and recognize the potential of a MBP case when a disproportionate number of hospitalizations and physician visits occurs, or when the symptoms reported are highly unusual or inconsistent.
• There is more medical staff to observe the child in case of hospitalization, and in combination with the collection of laboratory specimens for analysis, mother perpetrators get discovered because the specimen appears to be tampered with.
• It is likely that the amount of active induction of symptoms grows in the hospital environment, because the mother wants to convince the doctor of the necessity of more tests and procedures.
• The educational system may also be the referral source, because they detect an inordinate number of school days missed because of illness, medical procedures and doctor’s visits.
• Finally, when the medical staff gets suspicious about the role of the mother perpetrator regarding the symptoms, doctors may choose to use covert surveillance through video-taping in the hospital setting to obtain evidence.

What are the characteristics of mother perpetrators?

They appear to be deceptive and manipulative about many aspects of their lives. Many details about their history in life are fabricated. They often have an education in or experience with the medical field. They insist on managing the child’s care, especially medications and medical equipment. They often suffer from post-traumatic stress syndrome or a personality disorder (especially dependent, borderline and antisocial) and in many cases they are survivors of childhood abuse themselves. They often show unusually calm behavior in the face of crises related to the child’s medical status. There are very few reported cases regarding men perpetrators.

Who are the victims of MBP?

Boys and girls are equally victims, but there are more preverbal than verbal child-victims. The average age is approximately between 3 and 4 years old. The most common (feigned) symptoms are seizures, apnea, bleeding, unconsciousness, vomiting, diarrhea, lethargy and fever. There are some consistent traits in families where MBP is present. They often lost a sibling due to an unverified or unexplained illness. Also, family history of illness behavior or family interactions that respond to illness with attention are common. In some cases there is a distant or abusive marital relationship, and a father who is described as aloof, uninvolved in the medical aspects of their children’s lives and emotionally detached. Even so, fathers are often shocked when they are faced with the allegations of MBP abuse.

How can a case of MBP be handled?

When managing a MBP case, a multidisciplinary team is necessary. These are often led by child protection teams. The investigations of cases of MBP abuse usually occur in hospitals, so that when symptoms continue unabated in the absence of the mother, the child is still in a medical setting and provided with appropriate assistance. The diagnostic model used (as discussed earlier) first examines the available medical evidence and then investigates the psychological question regarding the family members involved.

Why are victims of MBP often placed out of the home?

When the (shocked) father of the child-victim isn’t able to be protective, out of home placement is necessary for the child’s safety. When family members offer to take care of the child, psychological evaluations are necessary. This is because in some cases there is a cycle of abuse, like with sexual abuse histories. Although most of the intentions by family members are genuine, neutral and non-relative placements are more safe. When victims enter foster care, thorough medical assessments are needed. All medications should be reviewed and, if necessary, replaced. The foster parents need to take pictures of the child when it enters their home, and keep a daily log of its behavior (including food intake, behavior and sleeping patterns). A physician should see the child on a regular basis, partly because a child can be a victim of MBP, but at the same time suffer from legitimate illness.

How can the relationship between the perpetrator and the victim be re-established?

Contact between mother and child is not recommended before the mother started treatment and, at least partially, acknowledges the abuse. Extended family contact should always be supervised, just like meetings with the mother later on. Supervisors should be trained to recognize harmful behavior. No food or drinks should be served during the visits. When the mother is making progress, the supervisors may be replaced by video-taped contact.

Which kind of mother perpetrators can be identified?

Libow and Schreier identified three kinds of mother perpetrators. The ‘help seekers’ often have the purpose of obtaining help for their feelings of inadequacy as parents. They often show willingness to give up their deceptive behavior once help has been offered. In contrast, the ‘doctor addicts’ and ‘active inducers’ are motivated by some sort of emotional gratification gained from their deceptive relationships with the physician.

How can mother perpetrators be treated?

Most mother perpetrators leave treatment before finishing it and a lot continue their deceptive behavior with their therapist. Also, they often suffer from personality disorders which are difficult to treat in itself. The most well-known treatment plan can be divided in three stages:

1. The therapeutic process needs to be separated from any legal involvement, to be able to establish trust and gain insight into the patient's secret thought processes. The main goals of the first stage are establishing boundaries, strengthening coping skills, dealing with the many crises these women face, and maintaining trust between therapist and patient. Techniques used are videotaping, journaling, family photo reviews and teaching relaxation and mindfulness techniques. At the end of this stage, the patient should be able to acknowledge, at least to some extent, the abuse she has perpetrated.
2. Developing empathy for the child-victim. The traumatic memories of the mother from her own childhood will surface, and the patient will become more psychologically available to engage in appropriate therapeutic work on these issues. At the end of this stage, the mother should have established her own identity, attained vocational goals to become self-supporting, and developed a social support system.
3. Much is unknown about the final treatment stage, because most perpetrators don’t complete their treatment plan. In some known cases, the psychological evaluation was updated and completed, which confirmed no further need for treatment. Sometimes these mothers received up to 5 years of therapy.

How can the other family members be treated?

The treatment of other family members should occur simultaneously with the treatment of the mother. There should be coordination between the therapists of all of those involved. The father should engage in individual therapy to process the awareness of the wrongdoing to his child by its mother.

How can the child be treated?

Because of the age of the victim by which the MBP abuse usually appears and is discovered, the child generally internalizes the effects of victimization at a preverbal level of psychological development. The most well-known intervention to treat this is nondirective play therapy. This therapy allows children to work through the abusive parent-child dynamics they have experienced and to adjust to the dynamics of the new relationship being developed by the new caregivers.