Munchhausen Syndrome by Proxy

Brian W.C. Forsyth

Andrea Gottsegen Asnes

Historical Note

In 1951, Asher first used the eponym Munchhausen syndrome to describe adults who consistently fabricate symptoms of illness for themselves, leading to numerous medical investigations and frequently to surgical operations (1). The syndrome was named after Baron von Munchhausen of Hanover, who lived in the eighteenth century and was renowned for telling greatly embellished stories about his adventures in the wars against the Turks (2). In 1976, Sneed and Bell used the term “the dauphin of Munchhausen” to describe a case in which a 10-year-old boy presented with factitious recurrent urinary calculi and in which the mother was suspected of colluding with the child in fabricating the symptoms (3). The following year, Meadow coined the term Munchhausen syndrome by proxy in his report of observations of two cases in which parents repeatedly caused their children to be ill (4). Prior to this time, there had been reports in the literature of cases referred to as “nonaccidental poisoning” in which children repeatedly presented as diagnostic dilemmas and were found to have been poisoned by a parent; such cases are now considered to be variants of Munchhausen syndrome by proxy (5,6). Subsequent to Meadow’s initial report, there were other suggestions for a title for the syndrome; these included the names Meadow’s syndrome or Polle syndrome, but these have now given way to the more commonly used Munchhausen syndrome by proxy (7,8,9).

Definition

Definitional issues in Munchhausen syndrome by proxy have been pivotal in recent years. Initially it was described by Meadow as a disorder in which a person persistently fabricates symptoms of illness on behalf of another, thereby causing that person to be regarded as ill, but more recent efforts have been made to provide a more specific definition of the syndrome (4). Meadow has updated and operationalized the syndrome to include a combination of: 1) an illness fabricated in a child by a parent or someone in loco parentis; 2) the presentation of a child to doctors persistently while the perpetrator denies causing the child’s illness; 3) the illness goes away when the child is separated from the perpetrator; and 4) the perpetrator is considered to be acting out of a need to assume the sick role by proxy or as another form of attention seeking-behavior (10).

In 1998 a multidisciplinary group convened by the American Professional Society on the Abuse of Children developed definitional guidelines which have since been refined (11,12). These guidelines define the disorder as encapsulating two distinct entities: the maltreatment of a child and the motivation of the adult who perpetrates the maltreatment. The term “pediatric condition falsification” is employed to describe the form of child abuse in which an adult fabricates or directly causes symptoms and/or signs of illness in a child, resulting in a perception of that child as sick (12). The severity of the disorder and extent of the fabrication are variable. In the least severe cases mothers only report false symptoms, and the physical harm to the children is only that resulting from the medical investigations carried out in attempting to diagnose the illnesses. At the other end of the spectrum are instances in which mothers have caused severe physical harm to their children or even the death of their children in the continued pursuit of making their children appear ill. Perpetrators who act to either invent or induce illness in children to meet their own, self-serving psychological needs are diagnosed with factitious disorder by proxy, which is listed in Appendix B of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a category requiring further study (13). The following criteria are suggested:

There is intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care.
The motivation for the perpetrator’s behavior is to assume the sick role by proxy.
External incentives for the behavior (e.g., economic gain) are absent.
The behavior is not accounted for by another mental disorder.

The perpetration of pediatric condition falsification by an adult diagnosed with factitious disorder by proxy comprises Munchhausen syndrome by proxy (14,15).

Of interest is the entity of pediatric condition falsification occurring in the absence of factitious disorder by proxy in the adult. Caretakers may invent or induce illness in children to keep them from attending school or falsely allege sexual abuse as a tool in custody battles. In other forms of pediatric condition falsification the parent falsifies the illness solely to gain help with other problems, such as depression (15). This latter form has been dubbed as “help seeking” and is exemplified by the mother who puts cranberry juice in a child’s diaper as a reason to be seen by a doctor, but the behavior ceases once the mother’s own psychological needs have been identified and treated (15). In the definition proposed by the American Professional Society on the Abuse of Children, if there is absence of factitious disorder by proxy, that is, the absence of a need by the perpetrator to assume a sick role by proxy to meet his or her own psychological needs, it is not seen as comprising Munchhausen syndrome by proxy. Similarly, according to this definition, a situation in which a parent who abuses a child physically or emotionally and then invents an organic medical or psychological ailment to explain the abuse would not be characterized as Munchhausen syndrome by proxy.

Others attempting to operationalize and define Munchhausen syndrome by proxy have questioned whether the presence of psychopathology in the perpetrator, or even understanding
of the perpetrator’s motivation at all, is a prerequisite for diagnosis of Munchhausen syndrome by proxy. Rosenberg has wondered if parents who induce illness in their children are ill themselves or if they simply exhibit “nasty, self-serving cruel behavior (16).” Some diagnostic formulations, such as that in DSM-IV, require the desire of the perpetrator to assume the sick role and that other types of external gain be absent. Others point to the perpetrator’s desire to outwit medical professionals or others in perceived powerful roles. Rogers has recently addressed this confusion with a call to define carefully the diagnosis in adults by the use of systematic measures and explicit inclusion and exclusion criteria (17). Finally, two other entities that need to be distinguished from Munchhausen syndrome by proxy are those parents of chronically ill children who are perceived as “difficult” or overly demanding by medical staff, and “overanxious” parents who may display exaggerated concern for their children’s health when they feel proper medical attention is not bestowed (15).

Definitional issues play an important role in the legal aspects of suspected cases of Munchhausen syndrome by proxy. Controversy has played out in recent years over whether the term may or should be used to prosecute perpetrators of this special form of child abuse. Meadow has suggested that the term Munchhausen syndrome by proxy be used to identify a “collection of features characterizing a particular form of child abuse” and that diagnosing the adult perpetrators is the task of mental health professionals (10). These tensions carry weight when medical professionals are asked to render diagnoses to be used in court. Recent cases would suggest that pediatricians are best able to diagnose child abuse and that mental health professionals are best able to diagnose adult psychopathology. Given that current thinking about Munchhausen syndrome by proxy requires both entities to be present, making a diagnosis may require the cooperation of at least two medical professionals.

Epidemiology

Although the true prevalence remains unknown, Munchhausen syndrome by proxy is almost certainly a rare disorder. Active reporting of cases in a prospective study conducted over a 2-year period in the United Kingdom and Republic of Ireland established an annual incidence of 0.5/100,000 children aged under 16 years, and the peak incidence of 2.8/100,000 children in the first year of life (18).

To date, two comprehensive literature reviews have been published. In the first, published in 1987, Rosenberg conducted a review of the existing literature and summarized all the published reports (19). These included 117 children in 97 families. Of these cases the perpetrator was the mother in every case reviewed (98% birth mother and 2% adoptive mother). In the second, published in 2003, Sheridan conducted a similar review and found 451 cases in which 76.5% of the perpetrators were mothers (20). Fathers have previously been found to be only rarely implicated as being the perpetrator or appearing to be complicit in the fabrication of illness, although Meadow has published a series of 15 such cases occurring over a 10-year period, and in Sheridan’s review fathers were the perpetrators in 6.7% of the cases (20,21,22,23). In a review of cases published outside the United States, Canada, U.K., Australia, and New Zealand, Feldman and Brown reported on 93 cases, and in these the mother was the sole perpetrator in 86% and the father the sole perpetrator in 4% (24).

The diagnosis has been made in children of all ages from the first month of life to 21 years, with the mean age being reported as 40 months and 49 months in the Rosenberg and Sheridan reviews respectively (19,20). In the prospective British epidemiologic study, however, the median age of diagnosis was 20 months (18). The mean time interval between the onset of symptoms and time of diagnosis was found by Rosenberg to be 15 months, and by Sheridan to be 22 months. There are reports of instances in which the condition started prior to birth with mothers inducing preterm delivery (25,26). There is an approximately equal prevalence among male and female children.

Clinical Description

Medical Presentation

The variety of medical symptoms in children who present with Munchhausen syndrome by proxy is extensive and includes practically all organ systems. Generally the illness appears to be multisystem, and the children may appear to have different types of illness at different times. The four presentations that were among the most common in both Rosenberg’s and Sheridan’s reviews were seizures, apnea, diarrhea and fevers. Altogether Rosenberg listed 68 different presentations or pathologic findings, and Sheridan listed 101, highlighting the striking diversity of possible potential presentations of Munchhausen syndrome by proxy cases. The means by which the perpetrators caused the symptoms or abnormal findings are just as diverse and illustrate the severity and horrifying nature of the syndrome: One mother had put bleach in her child’s eye, causing the appearance of a periorbital infection; others had repeatedly suffocated their children so as to simulate recurrent apnea or seizures. Other mothers caused sepsis by putting fecal material into their children’s intravenous lines (19,20).

In approximately 40% of cases in Sheridan’s review, the perpetrator had simulated an illness but had not actually done anything directly to the child to cause harm (20). These were instances where the perpetrator had done something such as putting drops of her own blood in her child’s urine or contaminating the specimen. In these instances, although the perpetrator does not herself physically harm the child, she does continue to collaborate with the physicians as distressing and often painful investigations and procedures are carried out.

Bools and associates have pointed out that there is a significant amount of comorbidity among cases of Munchhausen syndrome by proxy: In a review of 56 cases, 29% had a history of failure to thrive and 25% had a history of either nonaccidental injury or neglect (27). Siblings also might have a history of such findings or might themselves have been the subjects of fabricated illnesses. This appears to be particularly true among cases that have presented as apnea and which, in fact, are owing to suffocation (28,29,30). Of note, in Sheridan’s sample, apnea was the most common presenting symptom, representing 26.8% of all cases reviewed (20). When children present with apnea, Munchhausen syndrome by proxy should always be considered if there is a history of death of a sibling or if episodes of apnea have occurred only in the presence of one person.

Ayoub and colleagues have recently reported on a series of five families in which educational disabilities were the presenting symptom in cases ultimately diagnosed as Munchhausen syndrome by proxy. This diagnostic entity has been called educational condition or disability falsification. These cases, unlike those which present with medical problems, are played out within schools, among teachers, guidance counselors and principals, and especially within the special education system (31). Another recently recognized subcategory of Munchhausen syndrome by proxy is that in which a psychiatric or behavioral problem is the presenting complaint. These cases have involved repeated outpatient visits and hospitalizations for psychotic disorders, multiple personality disorders, attention deficit disorders, temporal lobe epilepsy with rages, Tourette’s disorder, and autistic spectrum disorders (32).

Description of the Mother

As noted previously, it is most often mothers who are fabricating illness in their children. These mothers often have had prior extensive exposure to the health care system. This, in some instances, has been from past training and work experience as a nurse, medical receptionist, or other health care professional. In Meadow’s description of 17 families, nine of the mothers had such a background, and Rosenberg reported that 27% of 97 mothers had a nursing background and another 3% had worked in medical offices (33,19). In other cases, the mother herself has had Munchhausen syndrome and therefore has brought to her experience as a mother both her own psychopathology and often a vast knowledge of medicine, hospitals, and medical practice acquired from her experiences prior to her child’s birth. In a study of covert deaths in infancy, one-half of the perpetrators had some form of abnormal illness behavior such as somatizing disorder, and 22% were reported to have Munchhausen syndrome and in Sheridan’s review, 29% of the perpetrators had some features suggestive of Munchhausen syndrome (34,20).

A striking characteristic of the mothers is that they are often considered exemplary in all their interactions with medical staff. This is in contrast to adults with Munchhausen syndrome and also to parents who provoke sickness behavior in their children and refuse to accept psychological mechanisms (35,36). Both of these groups are often described as demanding and difficult. In Munchhausen syndrome by proxy, the mothers often develop close relationships with the nurses and doctors with whom they come in frequent and continued contact. These relationships sometimes traverse the more usual boundaries between parent and medical staff and may include such things as helping the nurses in their duties, eating meals with the doctors, or maintaining social contact with the medical personnel outside of the hospital. However, these mothers tend to be unavailable for genuine interpersonal interactions, and hospital staff often report subjective feelings of uneasiness or feeling intrusive in the mother’s presence (37). Some perpetrators are thought to be motivated by a desire to manipulate or control doctors or other professionals perceived to be powerful. In this case it is the deception of medical staff, rather than a desire to somehow join their ranks or be perceived as an ideal mother, that appears to motivate the perpetrator (11).

The quality of the mother’s care for her child is also notable; they are often considered model parents who are extremely attentive to their children. They take over the care of their children to a greater degree than is usual in hospitals and often live in the hospital and remain with the child constantly. It has been noted, however, that the care given to the child can be of an excessive nature; for example, the child may be dressed in inappropriately lavish clothing, or the hospital room may be stocked with an outrageous number of toys (37). Prolonged covert videotaped observation of these mothers, however, has often revealed detached or even directly cruel behavior to children when they are not in the public view (14).

One striking quality of the mother that may be important in recognizing the syndrome is her inappropriate affect when given information about the severity of her child’s illness or discussing invasive medical investigations. There is a bland acceptance, rather than obvious distress, and she appears to be relatively at ease with medical uncertainties (37). In one report, the mother was even described as appearing euphoric as her child became sicker (38).

Besides fabrication of symptoms of illness, these mothers often fabricate extensively about other parts of their lives. An example of this is a mother who made statements that she had just completed a law degree and was working toward a master’s degree in Russian history, both of which were false (39). Certainly an important element of the syndrome is the mother’s ability to converse with the medical staff about her child’s illness in a very knowledgeable and medically sophisticated manner. The other fabrications often serve to add to the mother’s appearance as an intelligent person or as someone who has achieved despite adversity.

Only gold members can continue reading. Log In or Register to continue