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
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
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
- 15% - 20% involve
- 5% - 10% of the children die
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,
- 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
- 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
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
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
- 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
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
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
- Some offenders may fear going
home or adjusting to a normal daily routine without being the center of
- 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
- 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
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.
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
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.