Munchausen by Proxy Syndrome

By Myrna R. Nieves, MD FAAP
Originally published by The Pediatric Bulletin

Munchausen by proxy syndrome (MBPS) is one of the most harmful forms of child abuse. It is also perplexing. MBPS involves an apparent deeply caring mother who repeatedly fabricates symptoms or provokes actual illnesses in her helpless infant or child. MBPS was first described in 1977 by Meadow; since then more than 200 MBPS related articles have appeared, the majority being case descriptions. Understanding the dynamics of this disorder is of utmost importance because growing evidence indicates that it is more common than previously believed and it is devastating if not fatal for the children and infants. It is also important to mention the effects MBPS has on others who become involved in this cases, particularly nurses and physicians.

Maybe the most important aspect of this syndrome is the immense ability of the mother to fool doctors and the susceptibility of physicians to her manipulations. The hospital, which is the most common setting for MBPS cases, is where as much as 75% of the MBPS-related morbidity occurs as a consequence of attempts by physicians to diagnose and treat the affected child or infant. More than 98% of MBPS cases involve female perpetrators. Even the most experienced pediatricians often miss evident clues left by these mothers.

Although there are many case reports of MBPS, no population-based prevalence data exist. The average length of time to establish a diagnosis of MBPS generally exceeds 6 months; often a sibling has died of undiagnosed causes before the MBPS is uncovered. Jani et al found that during a 2-year period nearly 50% of patients discharged against medical advice satisfied at least three of six characteristics of MBPS.

The most common fabrications or modes of symptom inducement in MBPS involve seizures, failure to thrive, vomiting and diarrhea, asthma/allergies, and infections. Although total agreement has not yet been reached on what defines MBPS, it is believed that the syndrome requires that secondary gains from the fabrication of illness not be the prime motivation. When the definition of MBPS is limited in this way, the motivation of the mother appears to go well beyond simple attention-seeking behavior, as is often suggested both in the literature and in more popular presentations. It represents a need to be in a perverse relationship with a doctor or hospital staff, in which the mother is very dependent on them while simultaneously and purposefully causing great harm and confusion both to the child and the caretaker.

Perverse relating is used here, in the sense of recent psychoanalytic thought, as a character disorder. It entails a conscious violation of social norms and a certain gleefulness in being able to fool powerful, sought-after parental figures. Furthermore, in cases of MBPS these perverse activities are not carried out in a psychotic or dissociative state. The hallmark of perverse thought processes is the ability to carry two diametrically contradictory concepts in consciousness simultaneously. These women feel like good mothers at the very moment they are seriously harming their children. Their conceptual thought is very poor, but their perceptual abilities are quite sharp, at least in the medicine area. Even though they are constantly giving clues to their behaviors, they have an ability to organize the perceptions of doctors so that they miss or ignore such clues! In this dramatic "play" the child matters little to the mother, despite her appearance of deeply caring for the child. When left alone, they pay little attention to their sick child.

The Role of the Physician

Mothers with MBPS are so good at their charade that a group that arranges video recordings in a hospital in England recommends not disclosing the plans for video surveillance to the family doctor, because he or she may be under the sway of the mother and be likely to warn her. The physician focuses so much on what he or she is missing in the clinical picture that he or she misses the fact that the cause for the infant's deteriorating medical condition is not to be found in further clinical exploration. The talent of the mother in lying, and their ability to make the physician feel as though his or her inability to correctly diagnose the illness in the child is in some way connected with his or her sense of caring, has been the the final straw in an amazing interaction in which physicians often become the agents of actual harm to their patients.

It is not just doctors who have difficulties with these mothers. Nurses, social services agents, district attorneys, and the courts have exhibited a reluctance to believe that women who appear to be so caring can perform horrendously cruel acts on the bodies of their children. Physicians need to be aware of all these obstacles, be totally objective and learn to accept that these mothers are actually doing harm to their children. Doctors should consult health-related personnel that have experience and familiarity with MBPS in order to arrive quickly to the diagnosis.

GUIDELINES FOR SUSPECTING AND IDENTIFYING MUNCHAUSEN BY PROXY

A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling and unexplained.

Physical or laboratory findings that are highly unusual, discrepant with history, or physically or clinically impossible.

A parent, usually the mother, who appears to be medically knowledgeable and/or fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients' problems.

A highly attentive parent who is reluctant to leave her child's side and who herself seems to require constant attention.

A parent who appears to be unusually calm in the face of serious difficulties in her child's medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to other more sophisticated facilities.

The suspected parent may work in the health care field herself or profess interest in a health-related job.

The signs and symptoms of a child's illness do not occur in the parent's absence (hospitalization and careful monitoring may be necessary to establish this casual relationship).

A family history of similar sibling illness or unexplained sibling illness or death.

A parent with symptoms similar to her child's own medical problems or an illness history that itself is puzzling and unusual.

A suspected parent with an emotionally distant relationship with her spouse; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with serious illness.

A parent who reports dramatic, negative events, such as house fires, burglaries, car accidents, that affect her and her family while her child is undergoing treatment.

A parent who seems to have an insatiable need for adulation or who makes self-serving efforts at public aknowledgement of her abilities.

Copyright © Myrna R. Nieves, MD FAAP