Turkish Journal of Psychiatry 2013
A Case of Munchausen Syndrome by Proxy in the Context of Folie A
Dilşad FOTO ÖZDEMİR1, Bahar GÖKLER2, Ş. Gülin EVİNÇ3, Aysun BALSEVEN ODABAŞI4
One of the most important factors affecting the mental health
of a child is the mental state of the child’s parents. The child
is at serious risk for poor mental health when a defect or de-
viation in the parents’ reality testing manifests in delusions
surrounding the child, especially when the child becomes the
target of the parental delusions (Savvidou et al. 2002, Van der
Kolk 2005a, Van der Kolk 2005b).
Parental Munchausen and shared psychotic disorder are risk
factors for disturbed mental health in children. Munchausen
syndrome was first described by Asher in 1951. Patients with
the disorder produce physical symptoms intentionally, cause
confusion for physicians, and make frequent trips to hospitals.
In 1977, Meadow reported that Munchausen patients do not
always create symptoms for themselves but sometimes invent
symptoms for a significant other, who then needs the perpe-
trator’s nursing, care and attention; Meadow named this type
of the disorder Munchausen by proxy. According to McGuire
and Fieldman (1989), as child victims get older, they begin
to actively participate in parental deceptions. It has also been
suggested that child victims believe that their mother’s love is
dependent on their alleged illness (Sigal et al. 1989).
Though it is not common, Munchausen by proxy may also
occur with shared psychotic disorder. In 1860, Baillarger de-
fined shared psychotic disorder, referring to it as folie com-
muniquée, as the transference of delusional ideas and/or
abnormal behavior from one person to one or more others
who have been in close association with the primarily affected
patient (Gralnick 1942). In general, Munchausen by proxy
Received: 17.03.2012 - Accepted: 02.01.2013
1MD, Assist. Prof., 2MD Prof., 3PhD., Department of Child and Adolescent Psychiatry, Hacettepe University Faculty of Medicine, Ankara, Turkey., 4MD, Assoc. Prof, Department of
Forensic Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey.
The occurrence of similar psychotic symptoms in two or more people is called shared paranoid disorder. In this disease, the person who exhibits
psychotic symptoms first is the “primary patient”. The symptoms are contracted by the other people through persuasion. This disorder is seen
among people who share the same house or are emotionally bound. In some cases, shared paranoid disorder may include other diagnoses, such as
Munchausen Syndrome. This report discusses the case of a six-year-old, sexually abused boy who, when admitted to the hospital at the age of 10,
claimed to have been repeatedly sexually harassed by several different people. His family’s frequent changes in hospitals, negative perceptions of and
accusations against medical staff, and improper methods of responding to harassment led clinicians to a diagnosis of Munchausen by proxy syn-
drome. In addition, both parents believed the abuse story, suggesting a potential diagnosis of shared psychotic disorder. In the literature, Munchausen
by proxy has rarely been reported with symptoms of sexual abuse. The psychotic symptoms were shared by the family, complicating the case. This
report emphasizes that psychodynamic evaluations of Munchausen by proxy and shared psychotic disorder may be helpful in understanding underly-
Keywords: Munchausen by proxy, sexual abuse, child, shared paranoid disorder.
occurs among members of the same family or people who are
close to each other. The primarily affected patient usually has
a psychotic disorder (Howard 1994). Çetin has indicated that
the mother-child separation individuation process may lead
to folie a famille, a shared psychotic disorder among family
members (Çuhadaroğlu-Çetin 2001).
Understanding the factors underlying both of these disorders
seems to be very important in preventing and treating the
disorders. In fact, to our knowledge, no case of Munchausen
syndrome by proxy comorbid with shared psychotic disorder
has been reported in Turkey.
In the current case report, parental delusions of sexual abuse,
supposedly perpetrated on their child, are discussed within
the context of Munchausen by proxy syndrome and shared
psychosis. In the literature, there are very few reports con-
cerning similar delusions.
H, a 10-year-old boy, presented to our clinic with a pre-di-
agnosis of sexual abuse. His parents stated that H had been
raped several times and had a long history of sexual abuse.
History: According to the mother, H was raped at the age of
six by a 23-year-old boy who lived in their apartment build-
ing. The boy, who the family had known for a long time,
threatened to kill H if he told anyone. The mother had been
suspicious of the boy because she had seen him holding H
and leaving H back in an irritated manner when he realizes
her. She and her husband decided to talk to the boy only to
learn that he had already moved.
The mother claimed that, after the 23-year-old moved, she
saw a green car approach her son, and “a man with eye-glasses
and a hat” provided him a ride. Observing the car, she felt
highly uncomfortable, but, according to her statement, she
did not understand that sexual abuse was occurring because
she was unaware of previous events. Although H was a success-
ful first grade student, he told his mother that he did not want
return for the second term. In explanation, the mother stated
that a young man had rented a house opposite H’s school and
was taking H to his house during recess. He and his friends
were forcibly raping H. Because of changes in H’s behavior,
his teacher directed the family to a child mental health clinic.
H was treated in a university clinic for a year and a half.
During this period, H’s family decided to independently solve
the harassment problem. They disguised themselves in order
to observe their son and the rapists; the mother wore a heads-
carf and an overcoat, and the father wore sunglasses. During
the first treatment period, the mother mentioned noticing
that her son was unable to sit on his hip and would come
home with dirty clothes. Her anxiety increased, so she talked
with her son.
According to the mother, H stated that he was inviting every-
one to rape him, including university clinic personnel, school
staff, teachers, neighbors, neighbors’ children, and the man-
ager of the building. All had accepted. The mother decided
to catch all the perpetrators, so she watched her son at school.
She pretended to drop her son off at class and watched the
teachers’ behavior. She observed that when the teachers want-
ed to rape H, they used jests to signal him to come near them.
Each time, H ran to them. One day she saw a member of the
school cleaning staff looking at her son, and H told her he was
one of the men who had raped him. The mother argued with
the staff member. The family called the police, and ultimately,
25 men were accused with abuse and stood trial.
Afterwards, the family moved to a new city, and their son
changed schools. However, the abuse allegations continued.
H’s parents claimed that, while the trial was underway, teach-
ers and staff at the new school also began to rape H. The fam-
ily decided not to go to the police this time because they were
highly irritated with the legal process. Instead, they placed a
camera in the school to collect evidence, but they never suc-
ceeded in obtaining any.
Assessment: The child was assessed by experts from three
different professions: psychology, psychiatry, and foren-
sic medicine. During the psychological assessment, the
Wechsler Intelligence Scale for Children-Revised (WISC-R),
the Bender Gestalt Visual-Motor Perception Test, the Beck
Depression Inventory, the Beier Sentence Completion Test
for Children, the Draw a Person Test, the Draw a Family Test,
and the Symond’s Projective Test were administered, and the
child was also observed during a play session.
At the beginning of the interview, H related the sexual abuse
he had experienced, his family’s search for treatment, and his
unavoidable sexual urges. He talked in a non-stop manner,
using words borrowed from his mother. The child’s expres-
sion was superficial, the content of his speech lacked depth,
and his behavior was thought inappropriate. Though the
mother argued that H had strong sexual urges and asked for
sex without any feelings of shame, H seemed to feel guilt
during his interview. H seemed to structure and process his
thoughts normally, but his thoughts focused on sexuality and
the theme of guilt. He was slightly depressed. He claimed that
he was not capable of controlling his sexual urges. However,
he gained satisfaction from being the center of attention.
Psychological evaluations indicated that he had a normal
level of intelligence; however, he was immature for his age
and had an active imagination. In his stories for the Symonds
Projective Test, the main themes were the “loss of a loved one”
and “problematic relationships between men and women”. In
addition, the main themes of the structured play session were
a perceived threat from a mother and the need for protection.
Clinical Progress: In the first interview, H’s mother insisted
that, if they left H alone in the waiting room, he could be
sexually assaulted by the staff of our clinic. His parents as-
serted that their son still had difficulty controlling his sexual
urges, so the father remained with his son rather than joining
the session. The mother was highly anxious, speaking fast and
repeating the same thoughts over and over without being able
to stop. The mother was manipulative and had a tendency
to devalue previous treatments and to idealize our clinic. She
also had difficulty relating what had happened in an orga-
nized manner. She had a deep affective isolation when telling
their story. She stated that her life had been affected by these
events and she had not been able to find time for herself in
the last two years. She also mentioned that her relationship
with her husband had been negatively affected. She described
her feelings using the following words: “Whenever my hus-
band touches me, I feel like something bad is happening to
my son, like he is being raped”. Her actions were observed to
be consistent with her words. She stated that the first time
they learned about the rape, they felt so desperate that they
planned to commit suicide by turning on the gas.
During the interview, the mother displayed a domineering
personality. She rejected all suggested solutions and rendered
the clinicians helpless. She also gave the impression that she
enjoyed the situation. The symptoms displayed by the child
seemed to serve the needs of the family.
The family was informed that the child should be examined
in the forensic medicine and pediatric surgery units. The
mother then stated that she had treated her son with medi-
cine and lotions, and so the doctors would not be able to find
any evidence of sexual abuse. There were many inconsisten-
cies and gaps in the story, and each time the family told the
story, there were changes. The story was flexible and change-
able according to the present conditions.
The father was depressed and sometimes angry, due to feel-
ings of guilt related to H’s sexual abuse. The story he told,
although less detailed, was the same as the mother’s. He was
planning to move to an isolated town where the family could
avoid contact with others so that his son’s sexual urges would
diminish; thus, he could protect his son. He would then ver-
ify his son’s recovery by returning H to the city for a trial
period, during which he would check H’s underwear every
day. H’s father stated that he would not leave H alone and
would not send him to school for this two-year trial period.
The father had a hostile and paranoid demeanor throughout
the interview. He refused to have his son hospitalized.
Although the father introduced himself as the head of his
family, his neighbors described him as an aggressive, antiso-
cial person. In addition, the negative characteristics attributed
to him in stories told during H’s projective tests contradicted
the father’s self-description. Although the family was from a
region in which honor in sexual matters was extremely impor-
tant, similarly to the mother, the father was more concerned
with proving the truth of their story than with guarding or
protecting his son. Thus, to succeed, he was willing to re-
count the tragic experiences of his son.
During the evaluation performed at the hospital’s forensic
medicine department, no physical signs of acute or chronic
anal penetration were found. The parents were asked to bring
their other son and their daughter to the clinic as well, for a
comprehensive family assessment. However, they never com-
plied. Difficulty in gathering information about the family’s
dynamics was attributed to their psychopathology. According
to our clinic’s assessment, the child may have been sexually
abused once; however, the sexual abuse was definitely not a
continuing process. Meanwhile, the parents were trauma-
tizing and abusing the child by not sending him to school,
frequently directing him to tell fantastic abuse stories, and
not allowing him to receive treatment. Although both parents
were informed, they refused to continue treatment.
The clinic determined that, if the parents’ psychopathology
was not treated, the patient would be the victim of continu-
ing abuse. Therefore, we requested that the judicial system re-
quire the parents and their son to undergo psychotherapy. The
family was diagnosed with folie a famille. Legal proceedings
were started to ensure that the child would be protected and
would receive the necessary medical care and rehabilitation.
Serious inconsistencies and holes in the case history increased
the difficulty in diagnosing the patient. In addition to the de-
lusions and manipulative tendencies of the parents, frequent
hospital changes, hostility towards and accusations against
medical personnel, the unusual approach of the family to the
legal process, and the family’s attempts to control the sexual
harassment via inappropriate methods suggested a diagnosis
of Munchausen by proxy syndrome (MBPS) comorbid with
shared psychotic disorder.
As in the present case, MBPS mothers tend to exhibit para-
noia towards therapists, have anxiety or depression, attempt
suicide (Vennemann et al. 2006), and use primitive defense
mechanisms, such as projection, denial, and splitting (Berg
and Jones 1999, Adshead and Bluglass 2005, Pompili et al.
2003). There have been previous factitious disorder cases in-
volving a history of sexual or physical abuse (Schreier 1996,
Meadow 1993, Savvidou et al. 2002, Hornor 2001, Lipian et
al. 2004). Similar to our case, in these studies, the perpetrator
was the mother, and MBPS occurred in the period follow-
ing a divorce or marital conflict. However, child victims of
MBPS in previous studies were older than in the present case.
MBPS may originate from a dependent and hostile relation-
ship pattern, and the recipient of the emotional transference
is generally a doctor, school psychologist, social worker, or
judge (Pompili et al. 2003, Schreier 2002, Lipian et al. 2004,
Rogers R 2004). If a child also becomes part of the fabricated
fantasy, the clinical diagnosis is folie a famille.
Similarly to our case, children and adolescents with folie a
famille may be unable to distinguish between real and facti-
tious. In such families, fear of subject loss is exposed (Sigal
et al. 1989, Lipian et al. 2004, Rogers 2004), as in the pres-
ent case, and confrontation challenges familial balances and
aggravates conflicts concerning fidelity. Children subjected
to folie a famille have fears of victimization, abandonment,
and exclusion. These children regard and use fabrication as a
method for obtaining love and care. In accordance with their
mother’s insistence, they participate in their own harassment
and develop a factitious disorder. By accepting their parents’
fantasy, children not only support their parents but also estab-
lish a way to communicate with them. In the present case, the
parents were so preoccupied with their abuse story that the
only way the child could communicate with his parents and
receive their full attention was by accepting and continuously
repeating the abuse story.
From a psychodynamic perspective, H is an identification ob-
ject for the mother and the only meaningful person in her
home-centered life. H’s mother never mentioned any am-
bivalent feelings she may have been experiencing towards her
son. Thus, denial is the most common defense mechanism
which could explain her psychopathology. The mother’s ego
was fragile in stressful situations, and she had developed a
psychotic disorder that prevented her from evaluating real-
ity. Therefore, she likely had basic trust problems, regressive
tendencies, and poor self-organization.
The mother reported feeling sexually distanced from her hus-
band for the previous two years as a result of a deep identifica-
tion with her son. She mentioned that sexual relations with
her husband reminded her that her son had been raped, so
she rejected her husband. The mother’s statements seemed to
support the existence of a disturbed male-female relationship.
Themes observed in the projective tests pointed to separation
anxiety, which was consistent with our marital strife hypoth-
esis. H’s drawings and his stories clearly illustrated his need
to be the center of attention. However, he could express these
needs only via tests and stories. In both his projective tests
and his role play, the father died. The following themes were
common: losing a father, having a bad father, fighting be-
tween parents, and experiencing anger towards a bad father.
These themes suggested a strong Oedipus complex. Having
the shield of a factitious abuse history would help him cope
with oedipal guilt and keep his parents together. External
danger, occurring outside the home, was always the focus of
the abuse story, also reinforcing the family’s separation anxi-
ety and tendency towards symbiosis—H was never allowed to
be alone; the mother checked H’s underwear; and H had not
been sent to school for a long time.
To meet his narcissistic needs, H needed to be at the center
of this symbiotic network, so he continued to repeat and sup-
port the story. The gains he obtained from perpetuating the
story far exceeded his losses. In his projective tests, H told
stories which included themes of aggression, death, and jail;
however, his stories also included characters that lived happily
ever after following traumatic events. Just as in these stories,
H was living happily with his family despite the tragic events
he and his family related and the restrictive and pervasive mis-
trust. Denial, repression of his emotions, and his secondary
gains explain his ability to maintain his psychopathology.
The data obtained from the projective tests conflicted with
the information provided by the mother. The mother was
deceiving herself by denying her negative feelings about her
family members, her anger, her sexual impulses, and her
anxiety about repressing her sexual impulses. The evaluations
suggested that the mother was using projection and projec-
tive identification defense mechanisms. After experiencing
a provoking event, the mother began to project her aggres-
sion, anger, and repressed sexual impulses to all men and to
her son. She thought that her son would be raped and would
invite people to rape him. The thought led to her desperate
need to control her environment and her son and allowed her
to gather satisfaction from the action of controlling. For the
mother, controlling her son meant controlling her own sexual
impulses and her unconscious tendencies related to those im-
pulses, which she feared she would be unable to repress. Her
restraint over herself and her impulses would increase as her
control over her son increased. The struggle strengthened her,
so she wanted to maintain focus on the abuse issue, and she
denied that the fabricated abuse caused real abuse to her son.
Her unconscious satisfaction surpassed her wish to protect
The father’s prior aim was to calm himself and repair his own
trauma instead of helping his son. His son’s rape had triggered
his internal conflicts. The rape, assuming that one instance
of rape did actually occur, had destroyed his sense of trust.
Rather than using more developed, mature, and realistic de-
fense mechanisms, he joined in the shared psychotic disorder.
The father’s loss of trust and perceptions of self-weakness may
have caused the father to become part of the shared psychosis.
The father ignored the traumatization that these fabricated
abuses could have on his son and overlooked the many holes
in his wife’s story. He failed to realize the importance of sup-
porting his son and the similarities between the effects of the
psychosis and those of sexual abuse.
Both parents belittled previous health centers while praising
the current health team. All three family members perceived
the inside of the home as positive, safe, and trustworthy, and
the world outside their home as dangerous and disingenuous.
Splitting and separating negative and positive emotions, as
well as denying negative emotions, was common among all
three members. Each of the family members exhibited some
form of splitting, which is one of the most common defense
mechanisms occurring in Munchausen by proxy cases.
In the literature, there are very few reports concerning
Munchausen by proxy with symptoms of sexual abuse. In the
present case, a factitious sexual abuse narrative was used to
perpetrate real child maltreatment. Munchausen symptoms
were shared by the whole family increasing the difficulty in
reaching an accurate diagnosis. The current case report and
psychodynamic evaluations are important for understanding
the factors underlying Munchausen by proxy and shared psy-
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