Münchhausen Syndrome by Proxy (MSBP)

Hieronymous Karl Fredrich von Münchhausen was an 18th century German baron and mercenary officer in the Russian cavalry. On his return from the Russo-Turkish wars, the baron entertained friends and neighbors with stories of his many exploits. Over time, his stories grew more and more expansive.

In 1951, Dr. Richard Asher described a pattern of self-abuse, where individuals fabricated histories of illness. These fabrications invariably led to complex medical investigations, hospitalizations, and at times, needless surgery. Remembering Baron von Münchhausen and his untrustworthy tales, Asher named this condition Münchhausen's Syndrome.

The main feature of Münchhausen's syndrome is chronic, unrelenting, factitious, physical symptoms that enable the patient to obtain repeated medical treatment or hospitalization.

A variant of this disorder, involving a child and their caregiver, has been named Münchhausen Syndrome by Proxy (MSBP).

While Münchhausen Syndrome is recognized as a psychiatric disorder, Münchhausen Syndrome by Proxy (MSBP) is classified only as a form of child abuse.

MSBP occurs when a child's caregiver falsifies illnesses or produces symptoms in the child to obtain medical treatment. The result is more attention for the caregiver.

Characteristics

Doctors who are confronted with a case of Münchhausen Syndrome by Proxy deal with a baffling and relentless illness that is difficult to diagnose and seems resistant to all forms of treatment.

The symptoms can appear to be caused by a new or rare disorder with which the doctor has little experience. Medical testing usually return results within normal clinical parameters, indicating a healthy individual. This conflicts with the physical appearance of an ill child. Throughout the medical testing the mother appears very devoted to the child, which can keep medical staff from suspecting her as the cause of the health problems.

The child who is victimized by MSBP can be brought in repeatedly for medical examinations in an attempt to isolate the problem. The person inflicting injury on the child will intentionally change the hospital or doctor that they visit in order to prevent detection. Münchhausen Syndrome by Proxy cannot be diagnosed in only one visit. It requires a careful study of the child's medical history and recognition of a pattern of abuse in order for medical authorities to intervene in an MSBP case.

The following are some statistics about MSBP:

• 50% of the children have multiple symptoms
• 15% - 20% involve non-accidental poisoning
• 5% - 10% of the children die

Profile

Münchhausen Syndrome by Proxy can be difficult to diagnose because the perpetrators appear to be someone above suspicion. The following describes the profile of a typical MSBP perpetrator:

• Often upper class, well-educated persons;
• Appears to be very knowledgeable about the victim's illness;
• Shelters the victim from participating in activities outside of the home;
• In cases involving children, the perpetrator is the mother with the father being uninvolved in the case;
• A history of marital discord;
• Lonely and isolated;
• Unusual involvement in the patient's care, to the point of trying to exclude medical staff;
• A history of Münchhausen Syndrome and/or suicide attempts;
• Socially adept and friendly around medical staff.

Most MSBP perpetrators fall into one of three types: Help Seekers, Active Inducers, and Doctor Addicts.

Help Seekers are mothers who seek medical attention for their children in order to communicate their own anxiety or inability to care for the child. They can also be suffering from depression. Help Seekers tend to come from homes studded with domestic violence, marital discord, or single parenthood. Help Seekers also tend to be open to active intervention. They acknowledge that they need help and are willing to undergo therapy in order to improve their lives.

Active Inducers induce illness in their children by dramatic methods. These mothers are anxious and depressed, and employ extreme degrees of denial and paranoid projection. They also seek acknowledgment from medical staff of their ability to be an outstanding caretaker.

Doctor Addicts are obsessed with obtaining medical treatment for nonexistent illnesses in their children. Mothers believe their children are ill, refuse to accept medical evidence to the contrary, and then develop their own treatment for their children. These mothers also tend to be distrustful, angry, and paranoid.

It is important to note that while mothers are the main inducers of MSBP, there have been cases of baby-sitters inflicting harm on the children they supervise, and even cases of fathers causing the illnesses in their children.

Warning Signs

Experts say any of the following warning signs may point to the possibility that Münchhausen Syndrome by Proxy is a factor in a child's apparent illness:

• Illness that persists in spite of traditionally effective treatments;
• Signs and symptoms that are inappropriate or do not relate to each other;
• A child with a very poor tolerance to treatments;
• A child who has been to many doctors without a clear diagnosis;
• A parent (usually the mother) who seems eager for the child to undergo additional tests, treatments, or surgeries;
• A parent who is very reluctant to have the child out of her sight;
• Another child in the same family who has had an unexplained illness or has died;
• A Parent who has a background in health care and is articulate;
• One parent (usually the father) who is absent during hospitalization;
• Symptoms that appear only when the parent is present.

If MSBP is suspected to be behind a child's illnesses, a thorough examination of the child's medical history needs to be performed before confronting the suspect. The examination should include discussions with other relatives about the child's medical history and the history of older siblings.

Theories

Many theories exist as to why a woman would cause an illness in her child. Common to most theories is a traumatic loss earlier in the mother's life; such as maternal rejection and the lack of attention as an infant, the loss of a parent, being victimized by neglectful or abusive treatment, or even traumatic disillusionment.

Of the profile types listed earlier, Help Seekers are thought to be making an uncomplicated cry for help. Unlike the more typical MSBP parent, who will shun therapy and refuse placement of her child in a protective agency, these mothers readily acquiesce to both measures.

Active Inducers and Doctor Addicts express rage engendered by the earlier loss by devaluing and deceiving medical staff in a game of false illness. By devaluing the physician, these mothers create for themselves protection, recognition, and security, all of which they violently crave.

The perpetrators may also have one or more of the following reasons for causing harm to their child:

• Most offenders crave the attention gleaned from hospital staff, doctors, and family members;
• Offenders become more aggressive as time passes;
• Some offenders derive enjoyment from knowing what is wrong with the child while medical experts remain baffled;
• Some offenders may fear going home or adjusting to a normal daily routine without being the center of attention;
• An offender who is praised as a hero for saving a child might elect to re-create that euphoria by fabricating subsequent incidents of illness and recovery of the victim.

Successful psychotherapy for Active Inducers and Doctor Addicts is difficult to achieve. The mother's denial is often so strong that she may not admit to the act. They may also not be able to verbalize their feelings because they are accustomed to acting on them. But the most difficult part is the patient must tell the truth. For an MSBP perpetrator, the boundary between truth and non-truth is greatly blurred.

Effects on Children

The effects of MSBP on children can be quite severe. Through the course of MSBP a child may have been subjected to numerous invasive procedures ranging from daily transfusions to extremes, such as surgically implanted catheters and bone marrow sampling. Some reports have stated cases of destructive skeletal impacts, blindness, kidney damage, and mental retardation.

From a psychological standpoint, the child may view illness as being a requirement to receive love from the mother, and ultimately the child may develop Münchhausen Syndrome. Socially, they are also hindered by large amounts of time away from school and their lack of participation in group activities.

Generally, MSBP gets resolved in one of three ways:

• The child dies;
• The police apprehend the offender;
• The child grows old enough that the perpetrator feels it is too dangerous to continue and selects a new victim.

Intervention

When Münchhausen Syndrome by Proxy is suspected, professionals must intervene. Intervention must begin with a thorough examination of both the victim's and perpetrator's medical history. Other family members and relatives should be contacted to verify the presented history and to find out about any information that was purposefully omitted by the perpetrator. Relatives can both refute what the perpetrator has told medical staff and give the names of other medical facilities to which the victim may have been admitted. Questioning the victim may not provide much assistance. The child may either be too young to know if the illnesses have been induced, or the child may have grown up only knowing abuse and feel that it is normal behavior. If the victim needs to be admitted for medical care, the staff must remain vigilant in assuring the child's safety. All medications given and samples taken must be done by medical staff. The parent must not be allowed to handle any of these procedures.

If the medical staff feels they have sufficient evidence of child abuse, child protective services and the police should be notified. The perpetrator must also be confronted about the abuse. This should be handled very carefully. Confronted abusers may react in several different ways. Many will actually increase the amount of abuse to increase the severity of the illness in an attempt to prove that it is real. Other abusers may stop the abuse altogether. This is only a short-term reprieve however, because they are only waiting until they feel they are no longer in danger before starting the abuse again. Another option is that the abuser will physically relocate with the victim. They simply start over somewhere else where the medical and law enforcement personnel do not have any suspicions.

Regardless of how the offender reacts, their behavior compares to that of a drug abuser. The offender will seek to satisfy their need for attention and start abusing their child again.

Examples

Example #1

When presented at the hospital, a 15-month-old child seemed irritable and had a temperature of 104 degrees. The mother reported bloody stools. A physical exam, urinalysis, and blood work all showed the patient was normal. The child had a nasogastric tube inserted, and underwent a Meckel scan, barium enema, and an upper colonic endoscopy. The tests all came back normal. After five days the bleeding stopped and the child was discharged. At the follow-up visit further bleeding was reported and the child was admitted to the intensive care unit in another hospital. No problems were identified and the child was discharged. Later, the child was admitted into a third hospital with the same complaint. A staff member recognized the mother and confronted her. The mother admitted to cutting her own legs and disconnecting the child's intravenous line to obtain blood for the diaper and the baby's mouth. This case was caught in time, preventing a general surgical consultation for which the child had been scheduled.

Example #2

Münchhausen Syndrome by Proxy was suspected only after the second child in a family died after being admitted into the hospital. A third child was later admitted with symptoms of intractable vomiting and deteriorating mental status. An offhand comment about the family's puppies coughing and dying focused attention on the possibility of poisoning. An autopsy of the second child revealed 200 mL of arsenic in the gastric tract and arsenic in the liver. The discovery was made too late to prevent the third child from dying.