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Doctor shopping with the child as proxy patient: A variant of child abuse
Abstract
Over a three-year period, we have seen in consultation four children whose mothers cited complaints referable to every organ system and which had persisted for many years. The parents had consulted a total of 99 physicians in eight states. Absence from school ranged from 40 to 200 days a year. Physical examinations of all patients and extensive and repeated laboratory studies were normal. On psychiatric examination the mothers exhibited paranoid thinking and a conviction of serious medical illness in their child which approached delusional proportions. They resisted psychiatric consultation and refused psychotherapy. The mother-child relationship was remarkably symbiotic, the two teen-age patients essentially voicing complaints which were indistinguishable from those reported by their mothers. The fathers invariably supported their wives' concerns. Subsequently, parents and children left treatment, continuing to "doctor shop." Long-standing multisystem complaints in a child with normal growth and maturation are incompatible with any known significant organic disease, but suggest a serious emotional problem within the family. Further, parents who take such children from doctor to doctor are frequently disturbed themselves and may use an offspring as a proxy patient. An accurate diagnosis depends on careful history-taking from parents, patient, health professionals, and schools.
... The third case is an example of MSbP with the subtype Bdoctor shopping with the child as proxy patient^involving a 9-year-old girl. This subtype is characterized by the mother taking the child on rigorous pilgrimages to visit outpatient clinics and emergency rooms, and involves a milder form of factitious behavior regarding the child [73]. ...
... The fourth case of MSbP also involved the Bdoctor shopping with the child as proxy patient^subtype [73]. The victim was a 9-year-old boy who was referred from pediatric nephrology due to recurrent and paroxysmal Babdominal pain^, which was often accompanied by hematuria. ...
... In both presentations, the clinical picture progressed to coma. The last two cases, involving the subtype Bdoctor shopping with the child as proxy patient^tended to have a more non-threatening appearance, although the impact on the victim with respect to various contexts, such as schooling, affective, emotional, physical, or relational, cannot be considered any less serious ( [32,73], p. 197). ...
In the factitious disorder (FD) on another, formerly called Munchausen syndrome by proxy (MSbP), one of the parents, the mother in 95% of the cases, fabricates or invents clinical symptoms in her child with the intention of convincing doctors and pediatricians that the child is sick. In the chapter on addictive disorders of the 5th Edition of Diagnostic and Statistical Manual of Mental Disorders, the gambling disorder was included, opening up the possibility of incorporating other problematic addictive risk behaviors in the same chapter. In this work, we intend to provide current data for improving the detection and treatment of MSbP as addictive disorder. Four clinical cases of MSbP studied by the authors are described. Retrospective analysis and semi-structured interviews were carried out to assess the psychopathological profile of MSbP. The four perpetrating mothers in the cases studied had a common and characteristic psychopathological profile. These mothers falsified diseases in their victimized children, obtaining rewards from the hospitalization of their children. The continuous alteration of the mother-to-child attachment with a pathological bond, which is at the basis of therapeutic intervention together with the mothers’ emotional confrontation with reality, is verified. It is proposed that the psychopathological profile of the perpetrator of FD on another corresponds to an addictive disorder, in which the hospital context is compulsively sought, providing a high degree of gratification and reward.
... 2. The mother and child appear emotionally overinvolved with one another, yet the mother seems to show little sensitivity to the child's needs as an individual apart from his or her relationship with the mother. The mother may refuse to leave the child alone, even briefly (8,9). 3. The child appears generally healthy, but the medical history is that of a long list of multiple medical complaints and unsuccessful treatments (8). ...
... The signs and symptoms occur only in the presence of the mother (9). 7. The mother seems less concerned about the child's illness than are the medical professionals (9). 8. There has been a sibling with a similar illness or death (9). ...
Münchausen syndrome by proxy is a factitious disorder of childhood in which a parent fabricates medical history or produces signs of illness in a child to keep the child in a sick role. Since approximately half of all cases of Münchausen syndrome by proxy are presentations of central nervous system illness, such as excessive daytime sleepiness and near-miss sudden infant death syndrome, sleep disorders centers are likely diagnostic consultants for the evaluation of children involved in this disorder. We review characteristics that may suggest that a particular case has an increased likelihood of Münchausen syndrome by proxy. The recent presentations of two cases of Münchausen syndrome by proxy to sleep disorders centers are discussed as examples.
... 10,11 The cost of medical care of these children is extremely high. 12 When no cause for the patient's symptoms are found, physicians may order expensive or invasive tests searching for increasingly unlikely and rare diseases. 13 In these situations, the physician inadvertently contributes to the abuse of the child. ...
... Diagnosed MSBP patients were significantly more likely to be Caucasian than non-Caucasian (Table 10). We reviewed our impressions of the mother and family with regard to characteristics that have been associated with MSBP 12,17,18 (Table 11). Although many of the families fit the usual stereotypes of MSBP, such as an enthusiasm for medical testing, an emotionally or physically distant father, and unusual closeness to medical staff, these were not uniformly observed, and we were unable to predict the certainty of diagnosis using these factors. ...
In 1993, Children's Healthcare of Atlanta at Scottish Rite (formery Scottish Rite Children's Medical Center, Atlanta, GA) added facilities to perform inpatient covert video surveillance (CVS) of suspected cases of Munchausen syndrome by proxy (MSBP). Forty-one patients were monitored from 1993 to 1997. This study was performed to review our experience with these cases. How useful was video surveillance in making the diagnosis? What were the characteristics of families with children who were victims of MSBP?
Medical, social work, security, and administrative records of all children who underwent covert video monitoring at Children's Healthcare of Atlanta at Scottish Rite from 1993 through 1997 were reviewed retrospectively by a team of physicians, risk managers, and social workers.
A diagnosis of MSBP was made in 23 of 41 patients monitored. CVS was required to make the diagnosis in 13 (56.1%) of these 23, and supportive of the diagnosis in 5 (21.7%) cases. In 4 patients, this surveillance was instrumental in establishing innocence of the parents. MSBP was more common in Caucasian patients than in other ethnic groups seen at our hospital. Fifty-five percent of mothers gave a history of health care work or study, and another 25% had previously worked in day care. Although many of caretakers fit the profile of MSBP, such as excessive familiarity with medical staff, eagerness for invasive medical testing, and history of health care work, these characteristics were not sensitive indicators of MSBP in our study. Even when present, they were not sufficiently compelling to make the diagnosis.
CVS is required to make a definitive and timely diagnosis in most cases of MSBP. Without this medical diagnostic tool, many cases will go undetected, placing children at risk. All tertiary care children's hospitals should develop facilities to perform CVS in suspected cases.
... Medical child abuse (MCA) occurs when a child receives unnecessary and harmful or potentially harmful medical care due to a caregiver's instigation. 1 The abuse can take many forms including inducing direct injury to simulate disease, fabricating or exaggerating symptoms, falsifying test results, doctor shopping leading to frequent (and repeated) normal medical investigations in the setting of a seemingly well child. 2,3 Typically, the perpetrator is the mother who hyperbolizes symptoms, gives inconsistent histories, reports prior medical diagnostic possibilities as firm diagnoses, insists on invasive procedures, suffers from multiple symptoms herself, is enmeshed with the child, and obtains secondary gain from her child's medical uniqueness. [4][5][6] The above scenario is not infrequently encountered in chronic pain clinics and discerning the typical child with undiagnosed chronic pain from those with medical child abuse can be daunting. ...
Medical child abuse (MCA), previously referred to as Munchausen by proxy, can present as chronic pain. We report the presentation of 5 children seeking treatment for chronic pain who we identified as victims of MCA. The index case had essentially not eaten for the 6 years of her life due to alleged allergies to all foods, developed severe pain, used a wheelchair for ambulation beyond a few blocks, and was alleged to have dysautonomia requiring oxygen monitoring at night. Other cases posed as arthritis that resulted in foot amputation and total body pain, fibromyalgia with alleged mutation negative Stickler syndrome who had symptoms only in her mother’s presence, severe incapacitating intermittent pains along with abdominal pain that resulted in appendectomy, cholecystectomy and pancreatectomy, and alleged disabling hypermobile Ehlers-Danlos in a non-hypermobile child for which the mother sought a power wheelchair. The unusual pattern to the pain, the presence of multiple additional, atypical symptoms and diagnoses, and a generally well appearing child are characteristic. The perpetrator is typically over-invested in the symptoms, derives tangible and intangible secondary gain from the child’s alleged illnesses, and is able to present the child in such a fashion to enlist the physician to aid in perpetuating the abuse. These children are highly over-medicalized and suffer significant morbidity. Multiple barriers exist to identifying and reporting these children to Child Protective Services, which need to be recognized and overcome in order to protect these vulnerable children.
... Additionally, increased availability of subspecialists facilitates "doctor-shopping." 25 It is often after MSP enters the differential diagnosis that questions arise regarding the appropriateness of prior medical care. Physicians understandably become defensive or feel victimized. ...
CME Educational Objectives
1. Define Munchausen syndrome by proxy (MSP) and provide a more specific classification scheme that accurately reflects the spectrum of this disorder.
2. Determine the clinical characteristics of the specific subtypes of MSP.
3. Clarify the role played by the medical provider in MSP and challenges posed by our modern health care delivery system.
Munchausen syndrome by proxy was described 35 years ago, 1 and yet it remains a complicated, controversial, and confusing condition. The term was initially limited to circumstances in which a caregiver surreptitiously injured the child or the child’s symptoms were fabricated, both leading to unnecessary or potentially harmful medical care.
... Even within the hospital setting, communication between specialists and nurses has become less verbal, more electronic, and crafted in a Twitter style or documented by checking boxes. In addition, ''doctor shopping'' can be easily pursued by families, yet missed by treating physicians (41). ...
In 1977, Roy Meadow, a pediatric nephrologist, first described a condition he subsequently coined Munchausen syndrome by proxy. The classic form involves a parent or other caregiver who inflicts injury or induces illness in a child, deceive the treating physician with fictitious or exaggerated information, and perpetrate the trick for months or years. A related form of pathology is more insidious and more common but also damaging. It involves parents who fabricate or exaggerate symptoms of illness in children, causing overly aggressive medical evaluations and interventions. The common thread is that the treating physician plays a role in inflicting the abuse upon the child. Failure to recognize the problem is common because the condition is often not included in the differential diagnosis of challenging or confusing clinical problems. We believe that a heightened "self-awareness" of the physician's role in Munchausen syndrome by proxy will prevent or reduce the morbidity and mortality associated with this diagnosis. In addition, we believe contemporary developments within the modern health care system likely facilitate this condition.
... This is amply described in other case reports and case series. 9,[44][45][46][47] Another weakness of present criteria is that they do not include the role of the health-care system in the creation of factitious disorders. The contribution of medical providers to this problem is discussed in the literature, 6,29,38 although certainly not emphasized. ...
Objectives:
Doctor shopping, double doctoring, and overlapping prescriptions are often used as synonyms for multiple physician appointments in the same disease episode. Such behaviours translate into poor patient satisfaction and patient-doctor communication as well as abuse or misuse of drugs, increasing health care costs and resulting in negative health consequences. This systematic review of the literature was conducted to identify factors that drive doctor-shopping behaviour in children's caregivers.
Methods:
The search was conducted in PubMed and grey literature and was based on the following search terms: included doctor or physician shopping, drug seeking, double doctoring, children, and combinations of those. Overall, 500 records were identified, of which 11 were selected for qualitative synthesis. Data extracted considered definitions of doctor shopping, co-morbidities, and target population characteristics.
Results:
Definitions of doctor shopping were inconsistent. The frequency of doctor shopping was high for acute illnesses and ranged from 53% in children with a fever in Hong Kong to 18% at an emergency department in Canada. The incidence of this phenomenon was low when taking into account addictive drugs and was rated at 0.02% to 0.3% in the full paediatric population. This phenomenon was more prevalent in children younger than 1 year, in children with attention-deficit hyperactivity disorder (ADHD) and co-morbid psychiatric conditions, and in those whose caregivers themselves had psychiatric conditions. It was more frequent in cases with an acute disease (eg, fever, gastroenteritis, and urinary tract infection) than a chronic disease (eg, asthma).
Conclusions:
The knowledge about doctor shopping by children's caregivers is limited, despite that this is a frequent behaviour. There is a need for further research covering a broader range of diseases. The causes and consequences of doctor shopping should be sought as well to investigate its relation to health care regulations and possibility to reduce unnecessary medical resource utilization.
After defining and describing the Munchausen, syndrome by proxy (MSBP) in a review of the international literature, the authors summarize the parental characteristics which organize this form of abuse which involves medical staff members. Their descriptions and phenomenological analysis of mother/child interactions give a certain orientation to the investigation as concerns underlying psychodynamic stakes. In four detailed and annotated observations, they try to identify and elaborate narcissistic and perverse parental problem configurations. The importance of the denied or foreclosed losses, the splitting processes and the symbolization limitations involved are evidenced in transgenerational repetitions. Precocious intervention for this abnormality in the very first moments of parenting enables simultaneous treatment of morbid parental projections on the child and of projections to which the parents have themselves been exposed during childhood.
The term Munchausen is used to design patients with «expectable clínical histories full of lies and inventions» in a presumable try to find medical attention. In the Munchausen by proxy syndrome the pediatric patients are victims of their parents psychiatric pathology, who, in spite of the normal aspect that many times have, are really sick and urgently needed of psychiatric treatment. In the Spanish psychiatric bibliography we have found 25 cases of Munchausen syndrome that hurt to 20 families. 5 cases were Munchausen, and the remain 20 were Munchausen by Proxy. In this group the majority (13 cases: 65%) were non accidental drug intoxications and in the 20 cases the mother was the fraud author. We concluded remarking that statistics shows a casuistic lower than the real one. A study of the Munchansen by proxy syndrome shows that it is a type of child abuse; so that it is essential to stop the abuse as soon as possible, by a multidisciplinary work.
The authors present an approach to the Munchausen's Syndrome by Proxy. Focusing on the clinical features including psychopathological and psychosocial profile. Authors consider also family risk factors -both the parenting and the children-, developmental characteristics and Health Care Services delivery its relationship with the impact on the clients attendance. The therapeutic interventions was implemented in tow phases: the first phase Primary Care Paediatric setting, and the second phase in Child Psychiatry Services. Authors emphasize the relevance of the liaison-consultation between Paediatrician and Child Psychiatrist as a key procedure to approach Munchausen's Syndrome by Proxy treatment.
This paper proposes the idea that the story of factitious or exaggerated illness is coauthored or that symptoms may be coached through the dynamics of the family. The physician is unwittingly engaged as a coauthor by performing diagnostic tests and treatments. Children and family members may be invited to coauthor or collude in the presentation of false symptoms as well. The importance of assessing the participation of family members in illness presentation was discussed as well as the difficulty in determining intentionality of symptom production. Four cases are presented including test data which indicate that the more “active” the family may be in presentation of symptoms, the more likely they are to present a cohesive family picture and to seek outside support and the less likely they are to report Stressors. Treatment ideas include acknowledging the possibility of both conscious and unconscious production of symptoms by family members in the creation of a story of illness. Treatment suggestions included the promotion of an alternative story to illness.
Background
Unlike the so-called Munchausen syndrome by proxy, which is a form of child abuse, Munchausen syndrome is seldom reported in pediatric literature.
Case report
Anthony, an 8.5-year-old child, was referred because he passed several urinary stones. Although biological findings and urinary tract ultrasonography were normal, intravenous pyelogram showed a round area of decreased density in front of the anterior urethra, which disappeared from postmicturation X-ray. For a 1 month period, the child passed 20 stones without intense pain. After undergoing an appendectomy, he was readmitted for left lumbar pain which disappeared after passage of a stone. He spent the following 10 months without any complaint. On later re-admission with similar symptoms, Munchausen syndrome was suspected because of the discrepancy arising from the emission of stones on one hand and the absence of nephritic colic, of hematuria and of urinary tract dilatation on the other hand. Diagnosis of Munchausen syndrome was confirmed by chemical analysis which reported that samples were in fact ordinary pebbles and by child's confession, during interrogation without his parents, to having introduced the pebbles into his urinary tracts.
Conclusion
When unusual clinical features are present in children, it is necessary to evoke the Munchausen syndrome which can be likened to a distress signal revealing the presence of psychological disorders.
In children examined at a child development clinic the incidence of excessive water drinking was almost exclusively confined to the foster care population. A series of 11 patients is compared with other reports of excessive water drinking as a marker for parent-child problems and inadequate nurturance. The parent-child interaction patterns were characterized as rejecting and both overprotective and overindulgent. The family adaptational styles tended to be chaotic and rigid, and the family cohesion styles disengaged or separated. Excessive water drinking can be considered a marker for problems in parenting.
The use of the term 'Munchausen by proxy '1 derives from the description of a form of adult illness behaviour, also known as 'hospital addiction', in which the patient presents to emergency departments of hospitals over a wide geographical area, named after the fabulous and extravagant adventures of the Baron von Munchausen. 2 Adult patients who exhibit this behaviour present with care- and attentionseeking behaviour and complaints of physical disease relating to any system of the body. Illness may be simulated in a range of bizarre ways and in the production of actual physical signs or symptoms these patients risk potentially serious or dangerous investigations or surgery. In most, serious personality disorder is present and the risk-taking behavior escalates, becoming entrenched and incorrigible. With the developments in the past few years of liaison psychiatry (the link between general medicine and psychiatry) it has become evident that the production of simulated, presumed or fabricated 'factitious' illness can occur with reference to any system of the body - endocrine, gynaecological, haematological, neurological and urological forms of factitious illness all exist. For example, I have documented a case of factitious (fabricated) ante-partum haemorrhage in a mother almost at term where the sudden appearance of an alarming quantity of blood (later shown to come from a self-inflicted cut in a varicose vein) led to an unnecessary emergency Caesarian section. Obstetric staff, whose basic training assumes genuine symptoms in mother and baby, are not surprisingly incensed at such risk-taking and deceptive behaviour and react negatively, yet many midwives are aware that, tired and miserable towards the end of a
Doctor shopping is defined as seeing multiple treatment providers, either during a single illness episode or to procure prescription medications illicitly. According to the available literature, prevalence rates of doctor shopping vary widely, from 6.3 to 56 percent. However, this variability is partially attributable to research methodology, including the study definition of doctor shopping as well as the patient sample. The reasons for doctor shopping are varied. Some patient explanations for this phenomenon relate to clinician factors, such as inconvenient office hours or locations, long waiting times, personal characteristics or qualities of the provider, and/or insufficient communication time between the patient and clinician. Some patient explanations relate to personal factors and include both illness factors (e.g., symptom persistence, lack of understanding or nonacceptance of the diagnosis or treatment) as well as psychological factors (e.g., somatization, prescription drug-seeking). Importantly, not all doctor shopping is driven by suspect motivations. Being aware of these various patient justifications for doctor shopping is important in understanding and managing these challenging patients in the clinical setting, whether they emerge in psychiatric or primary care environments.
Everybody is familiar with the symptoms of gastrointestinal stress; in Swedish we are talking about ‘ont i magen’, i.e. abdominal pain as a general expression of anxiety, ‘tappa aptiten’, i.e. loose appetite due to unpleasant feelings and ‘tentamensdiarré, i.e. examination diarrhoea as an expression of the preexamination stress. Since 100s of years man has been characterized as melancholic or choleric, representing a bad or good bile flow, respectively (18). We also talk about the well being after a good dinner including the use of aphrodisiacs to wake up emotions of love. It is very probable that all these old expressions can be related to sensations, which are primitive and possibly already generated in our mind in infancy, when we were fed by our mothers in close relationship with a life almost exclusively consisting of feeding, close warmness of our mother's body, the wordless dialogue to her and sleep (12, 13, 25, 30). It is said that it is impossible for the infant to separate the feelings from bodysensations and obviously cannot express the feelings verbally. It is thus not surprising that early psychological stress results in feeding and sleeping disturbances (10, 23). It is also natural that symptoms from the gastrointestinal tract might be dominating during depression or stress-situations during the early age period of life as well as later on (8, 9).
Selective serotonin reuptake inhibitors are globally popular antidepressants with broad clinical indications. Despite an overall favorable side-effect profile, our examination of 19 studies, one review, and one meta-analysis indicates that these unique antidepressants appear to have negative effects on bone, particularly with regard to bone mineral density and fracture risk. These risks may be enhanced by more serotonergic agents and/or longer exposure to selective serotonin reuptake inhibitors. The magnitude of this relationship is difficult to determine due to the myriad of potential confounds in available studies, but all indicate risk. In additional support of these findings, serotonin receptors have been identified on osteoclasts, osteoblasts, and osteocyte cell lines, suggesting that serotonin may be an important regulatory agent in bone. While no formal recommendations regarding the use of selective serotonin reuptake inhibitors in risk populations are available, caution is advised in individuals with potential risk (i.e., those with osteoporosis or histories of osteoporotic fractures).
Munchausen Syndrome by Proxy describes a parent who fabricates the appearance of physical illness in a child. Previous descriptions of the syndrome have focused exclusively upon medical or psychiatric assessments of the involved child and perpetrating parent. The family evaluations of two cases presented here suggest that Munchausen Syndrome by Proxy may be a systemic syndrome generated when a mother already possessing a somatoform or factitious disorder joins an enmeshed, authoritarian family system possessing a systemic history of exploitation of children. We suggest that measures instituted to protect the abused child must take into account the systemic function of the Munchausen by Proxy behavior in maintaining family stability, lest such measures be rendered ineffective by family members. When there is ongoing victimization of perpetrating parents in a similar pattern of dominance/submission within their own family of origin, disruption of these intergenerational patterns of exploitation may be a necessary component of treatment.
The goals of this study were to determine 1) the prevalence of exposure to intrafamilial violence among children attending a pediatric primary care clinic; 2) the prevalence of psychosocial distress among mothers bringing their children to the clinic; 3) the extent to which pediatricians are aware of family violence and maternal distress among their patients; and 4) whether families reporting violence are more likely to report behavioral or emotional problems with their children. The study focused on 243 mothers and their children who made scheduled visits to an inner-city, hospital-based pediatric residents' continuity clinic. The children ranged in age from 6 months to 14 years, with 69% of the children 2 years of age or younger. Parents answered questions about their own and their child's psychosocial functioning, including a modified version of the Conflict Tactics Scale, an instrument used to measure the prevalence of intrafamilial violence. Physicians independently rated parent and child psychosocial health and the likelihood of violence in the family. Forty percent of mothers said their family in the past year had experienced at least one episode of the five most serious types of violence described on the Conflict Tactics Scale. Mothers reporting these levels of violence were more likely to report psychosocial distress in their own lives as well as those of their children. Furthermore, family violence predicted maternal concern for child behavior even after accounting for the increased maternal distress associated with violence. Physicians had difficulty predicting which mothers would report violence (sensitivity 27%, specificity 81%) or which mothers would report concern about child behavior and emotional health. The authors concluded that an instrument like the Conflict Tactics Scale might both add to physicians' awareness of family violence and help explain some parental concerns about the behavior or emotional health of apparently asymptomatic children.
Little attention has been paid in the literature to children's genital hygiene in recent years. We describe harmful genital care practices that produce physical and/or psychoemotional abnormalities in children. These practices comprise unusual and ritualistic handling and inspection of the child's genitals. Abnormalities produced include chronic and varied somatic complaints and behavioral anomalies, changes in genital anatomy, unnecessary medical diagnostic and therapeutic interventions, and, sometimes, overt sexual abuse. The practices need to be recognized as harmful to children, and effective intervention must be sought.
(JAMA 1989;261:577-579)
Munchausen syndrome by proxy (MSBP) is a form of child abuse wherein the mother falsifies illness in her child through simulation and/or production of illness, and presents the child for medical care, disclaiming knowledge as to etiology of the problem. From the literature, 117 cases of MSBP were reviewed. The most common presentations of MSBP were bleeding, seizures, central nervous system depression, apnea, diarrhea, vomiting, fever, and rash. Short-term morbidity rate was 100%; long-term morbidity rate was 8%. Mortality rate was 9%. Failure to thrive was associated with MSBP in 14% of cases. All perpetrators of MSBP were the mothers. The origins of this type of aberrant maternal behavior remain abstruse, as do the long-term psychological effects on the child victims. Guidelines for medical, social service, and legal management are provided.
Examples of fabrication of illness in children are described. Primarily uncomplicated cries for help are differentiated from two major subtypes (the Active Inducer and the Doctor Addict) which define the spectrum of Munchausen syndrome by proxy. Primary differences involve the form of deception, age of the victim, and maternal affect. Five histories are presented and it is suggested that doctor addiction is more common than has thus far been recognized.
Munchausen Syndrome by Proxy (the fabrication of illness by a mother in her child) is often a serious form of child abuse that has been recognized increasingly over recent years. Approximately one-half of the mothers in this study had either smothered or poisoned their child as part of their fabrications. Lifetime psychiatric histories are reported for 47 of the mothers. Thirty-four had a history of a Factitious or Somatoform disorder, 26 a history of self harm, and 10 of alcohol or drug misuse. Nine mothers had a forensic history independent of convictions related to child abuse. Nineteen of these mothers were interviewed from 1-15 years after the original fabrications. The most notable psychopathology was the presence of a personality disorder in 17 of the mothers, which were predominantly Histrionic and Borderline types. Most subjects, however, met the criteria for more than one category of personality disorder.
We believe the case of a boy whose mother insisted he was psychotic is the first report considering psychiatric illness in a child as part of the Munchausen's syndrome by proxy (MSP) complex.
Since 1977 a literature has grown describing examples of factitious illness by proxy (FIP).
The literature in English was searched using MEDLINE and supplemented by a manual search. Extracted data focused on terminology of a spectrum of behaviours, clinical features and psychopathology of perpetrators.
There has been difficulty with the use of terminology and classification of psychiatric disorders.
The spectrum of FIP is wide. Suggestions are made for the use of terminology and classification when FIP is identified.
Munchausen syndrome (MS) is characterized by patients' chronic and relentless pursuit of medical treatment for combinations of symptoms of consciously self-inflicted injury and falsely reported symptomatology. MS patients are adults, as are perpetrators of Munchausen syndrome by proxy (MSBP). MSBP is an unusual form of child abuse in which a parent, usually the mother, brings a child for medical attention with symptoms falsified or directly induced by the mother. Most reports of MSBP have been of a few cases appearing in medical and pediatric literature. Motivation in both disorders is unclear, and diagnosis and treatment present difficult problems that require more research.
Reports of pediatric condition falsification (PCF) have noted, but not emphasized, exaggerated complaints of real and common illnesses. Among the most frequent chronic childhood illnesses are asthma, allergy, drug sensitivity, and ear and sinopulmonary infections. The most common pediatric surgery is the insertion of myringotomy tubes. A computer database of 104 PCF victims from 68 families spanning from 1974 to 1998 was searched for the frequency of these conditions. Outright falsification or extreme exaggeration of severity of asthma or allergies was noted in 52 children (50%), sinopulmonary infections in 50 (48%), and drug reactions or sensitivities in 30 (29%). Forty-five children (43%) had otolaryngologic surgery, including ear tubes. In all, 71 children (68%) had at least one of these conditions. Associated victim and perpetrator characteristics are described. Children with PCF are not only subjected to induced illnesses and excessive medical diagnostic and therapeutic efforts but also victimized b) the consequences of false and exaggerated complaints of common pediatric diseases.
The diagnosis of factitious disorder by proxy is still under investigation. Few studies have researched the psychological status and potential underlying psychopathology of the perpetrator, as well as the impact on the child's development and the pathological reactions of rearing a child within the context of a distorted reality. In this article, we present the case of a 12-year-old boy where this diagnosis was suspected. Both he and his parents brought forth false allegations of repeated physical abuse induced by his schoolteacher. The parents presented with shared psychosis and the child presented with conduct disorder, factitious disorder, and emotional problems. We suggest that this case represents a Münchausen by proxy-like syndrome involving both the legal and medical systems. Hypotheses regarding the pathogenesis of symptoms in the child are noted, underscoring the differences between Münchausen by proxy syndrome appearing in infancy with that appearing in older children.
This article presents an updated review of the literature of Munchausen Syndrome by Proxy (Factitious Disorder by Proxy, MBP).
Four hundred fifty-one cases of MBP were analyzed from 154 medical and psychosocial journal articles.
Typical victims may be either males or females, usually 4 years of age or under. Victims averaged 21.8 months from onset of symptoms to diagnosis. Six percent of victims were dead, and 7.3% were judged to have suffered long-term or permanent injury. Twenty-five percent of victims' known siblings are dead, and 61.3% of siblings had illnesses similar to those of the victim or which raised suspicions of MBP. Mothers were perpetrators in 76.5% of cases, but as knowledge of MBP grows a wider range of perpetrators is identified. In a small number of cases, MBP was found to co-exist with secondary gain or other inflicted injury.
Although published cases form a non-random sample, they add to knowledge about MBP and validate claims that it occurs. More knowledge about non-medical aspects of MBP, and more pooling of data, is desirable.
The Munchausen syndrome by proxy is a phenomenon in which symptoms of a disease are fabricated by some person other than the patient. This report describes and 8-week-old infant with repetitive bleeding episodes, presumably originating from the upper respiratory tract. Extensive investigations, including angiography, several endoscopies under general anesthesia, and reinfusion of the infant's red cells labeled with 51Cr followed by pulmonary and upper airway scanning, failed to reveal the source of bleeding. Within two weeks after initiation of the 51Cr studies, radioactivity of facial blood from two separate bleeding episodes did not exceed background counts. Simultaneous examination of the infant's capillary blood, however, showed moderate to marked radioactivity. The Rh subtype of the facial blood was cc, whereas the infant's type was Cc. These findings indicated that the facial blood was factitious in origin. No further "bleeding" occurred after this information was presented to the parents. This case represents an unusual example of the Munchausen syndrome by proxy. Awareness of this entity can prevent potentially harmful investigations. Documenting its occurrence and sharing the information with parents in a nonaccusatory manner may prevent future harm to the patient.
Reviews the research on environmental, hereditary, and physical factors in the development of psychological disorders in the "vulnerable child." It is suggested that these disorders begin in infancy and have a snowballing effect through adult life. (22 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Some patients consistently produce false stories and fabricate evidence, so causing themselves needless hospital investigations and operations. Here are described parents who, by falsification, caused their children innumerable harmful hospital procedures--a sort of Munchausen syndrome by proxy.
Folie a deux—the psychosis of association: A review of 103 cases and the entire English literature with case presentations
- Gralnick
Gralnick A: Folie a deux the psychosis of association: A review of 103 cases and the entire English literature with case presentations, Psychiatr Q 14:230, 1942.
The origin and treatment of schizophrenic disorders
- Lidz
Lidz T: The origin and treatment of schizophrenic disorders, New York, 1973, Basic Books, Inc, p 48.