Transcript Munchausen’s Syndrome by Proxy

Munchausen’s Syndrome by Proxy
Marcy Rhodes
Stephen F. Austin State University
April 17, 2008
What is factitious disorder?
 Diagnostic Criteria (DSM-IV-TR)
 Intentional production or feigning of physical or
psychological signs and symptoms
 Motivation for the behavior is to assume the sick role
 External incentives for the behavior are absent
Munchausen’s Syndrome
 Karl Friedrich Hieronymus,
Baron Von Munchhausen
(18th Century)
Name given by Asher (1951)
What is Factitious Disorder BY PROXY?
 By Proxy – indirectly assumes sick role
 Listed in Appendix B in the DSM-IV-TR
 Research Criteria
 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 are absent
 The behavior is not better accounted for by another mental disorder
Munchausen’s Syndrome By Proxy
 Coined by Roy Meadow, 1977
 Pediatrician in Leeds, England
 Became convinced that many apparent “cot deaths” were
in fact the result of child abuse brought on by MSbP
 First to describe this
disorder & recognize
it as a fatal form
of child abuse.
Overview of Munchausen’s Syndrome By
Proxy (MSbP)
 Caretaker fabricates, exaggerates, or induces illness in a child,
for which he or she seeks extensive medical testing and/or
hospitalizations
 Perpetrator obtains psychological reward in the form of the
attention she receives from others
 Victimization is often lengthy
 Perpetrator is usually the biological mother (98%)
 Perpetrator presents as model parent
 Most victims are preschoolers
Overview of Munchausen’s Syndrome
By Proxy (MSbP)
 Prevalence has not been established;
considered uncommon
 Majority of cases involve the gastrointestinal,
genitourinary or central nervous system.
 More than one child in the family may be
abused
 In as many as 10% of cases, abuse leads to
death
Most common induced and simulated
illnesses
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Persistent vomiting or diarrhea
Respiratory arrest
Asthma
Central Nervous Systems dysfunctions (e.g., seizures, loss of
consciousness)
Fever
Infection – “Bacteriologically Battered Babies”
Bleeding
Failure to thrive
Hypoglycemia
Electrolyte disturbances
Rash
Attachment Representations and
MSbP
 Adshead & Bluglass (2001)
 Assessed the attachment style of 26 mothers who had
exhibited MSbP behaviors
 88% exhibited an insecure attachment style
 Most common pattern: dismissing (77%)
 Adshead & Bluglass (2005)
 Assessed attachment style of 67 mothers who had exhibited
MSbP behaviors
 Only 18% exhibited a secure attachment style
 85% rated as insecure
 Dismissing, 46%
Case Study – Kathy Bush
 Diagnosed with MSbP
 Charged with aggravated child abuse and Medicaid fraud
 Jennifer Bush, daughter
 Between August 1993 and April 1995
 Taken to the hospital more than 130 times
 Underwent 40 surgeries
 Amassed over $3 million in medical bills
Profile of MSbP Perpetrators
 Most often biological mothers
 Appear to be very knowledgeable about victim’s
illness
 Past exposure & experience with healthcare system
 Often have some previous (usually incomplete) training in
nursing or medicine
 Remain uncharacteristically calm in view of victim’s
perplexing medical symptoms
Profile of MSbP Perpetrators
 Praise medical staff excessively
 Welcome medical tests, even those that are
painful
 Increased incidence of Munchausen syndrome
 History of Abuse or at least reported history of
abuse
 Fabrication of info about perpetrator’s life
 Poor relationship skills
 Poor coping skills
Profile of MSbP Perpetrators
 Typically shelter victim from outside activities
 Maintain a high degree of attentiveness to the victim
 Often unresponsive to child when unaware of being
observed
 Find emotional satisfaction when the child is hospitalized
because of the staff’s praise of their ability to be a
superior, attentive caregiver.
Perpetrator Motivational Factors
 Crave attention from medical staff, doctors, family
and friends
 Might receive gratification for being able to fool
those who they perceive as having more power, status
 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 abuse and revival
of the victim.
MSbP Warning Signs
 Unexplained, persistent, recurring illness
 Repeated hospitalizations and extensive medical
tests that fail to produce a diagnosis
 Symptoms that do not make medical sense
 Lab results that are inconsistent with each other
or recognized diseases
 Persistent failure of the victim to respond to
therapy
MSbP Warning Signs
 Signs and symptoms that occur ONLY in the
presence of the caretaker
 Mother who is extremely attentive and always in
the hospital
 Mothers who do not seem worried about their
child's illness but are constantly at the child's side
while in the hospital
 Mothers who have an unusually close relationship
with the hospital's medical staff
MSbP Warning Signs
 A family history of sudden infant death syndrome
 Mothers with previous medical or nursing
experience or with an extensive history of illness
 A parent who welcomes medical testing of the
child, even if painful
 May become angry and demand further
procedures, second opinions, further
intervention
MSbP Warning Signs
 Attempts to convince the staff that the child is
still ill when advised that the child will be
released from the hospital
 A caregiver with a previous history of
Munchausen Syndrome
 A caregiver who adamantly refuses to accept the
suggestion that the diagnosis is nonmedical.
 Increasingly urgent visits to the same hospital or
clinic.
Difficult to Confirm MSbP
 Practitioners may be reluctant to diagnose
 Goes against the belief that a parent or caregiver
would ever deliberately hurt his or her child.
 Legal consequences of inaccurate diagnosis
 Personal consequences of inaccurate diagnosis
 Sally Clark (1964 – 2007)
M.A.M.A.
 Mother’s Against Munchausen’s Allegations
 Mission: To stop the assault on innocent parents from MSbP allegations
and to reveal the ulterior motives of the accusers
 These mother’s claim that they are falsely accused
 Doctor or institution can evade a medical malpractice lawsuit
 Doctors can rid themselves of a troublesome mom when frustrated and
unable to diagnose a child's condition
 The false MSBP diagnosis can be gravely detrimental; adding deep
emotional stress of maternal deprivation to an ill child
 www.msbp.com
If you do suspect MSbP…
 Proceed with Multidisciplinary team
 CPS
 Law enforcement
 Psychologist or psychiatrist
 Prosecutor
 Hospital social worker
 Nurse practitioner
 Pediatrician (especially one specialized in MSbP)
 Other members of the child’s medical team
If you do suspect MSbP…
 Review medical records
 Entries regarding child/parent interactions
 May establish temporal relationship between symptoms and
parent’s presence
 Direct monitoring of child’s hospital room
 Sitter
 Documents time of visits, especially of suspected perpetrator
 No food or drink allowed except for the provided by hospital staff
 Video surveillance (controversial)
 Completely restrict parent’s access (must be court-ordered)
Treatment - Prepetrator
 Psychotherapy is often ineffective
 Successful treatment depends upon
 the patient's ability to break through denial and
willingness to undergo therapy
 Changes in the family system
 Increased parental sensitivity and responsiveness to
child’s needs
 Plan to prevent relapse
 If the patient cannot overcome her issues,
prognosis for recovery is poor.
Treatment – Child/Victim
 First, the child must be placed in a safe environment
 Play therapy and/or individual therapy depending on his
or her age.
 Another important aspect is clarifying the child's health
status.
 A single physician who is familiar with the case should be
responsible for monitoring and treating the child.
 Depending on local laws, child welfare and/or
protective services may need to be notified.
Short & Long-Term Implications
 Short term
 Pain
 Mother’s actions
 Medical procedures
 Reduced social, educational, and emotional opportunities
 Long term
 Long term disability
 Increased likelihood of developing Munchuasen’s syndrome
 Libow (1995)
 PTSD
 Feelings of inadequacy
 Poor self-esteem
 Relationship problems